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兒童三聯(lián)截骨術(shù)后系統(tǒng)康復(fù) | DDH案例北京時(shí)間2022年7月17日17:00,一聲聲稚嫩、清脆的聲音穿透走廊,傳入康復(fù)大廳……我們的故事開始了——故事的主角、7歲的睿睿來自武漢,嘴里時(shí)常蹦出髖關(guān)節(jié)相關(guān)的專業(yè)詞匯,走到哪里都像一束光。今年4月,活潑好動(dòng)的睿睿無明顯誘因出現(xiàn)足跟痛,去醫(yī)院檢查時(shí)意外發(fā)現(xiàn)雙側(cè)髖關(guān)節(jié)發(fā)育不良。媽媽火速開啟問診之路,并于5月在天津醫(yī)院行左側(cè)三聯(lián)截骨截骨術(shù)。因?yàn)榛颊呷海n寢屃私獾叫g(shù)后康復(fù)的重要性,在術(shù)后便致電源自在康復(fù)了解術(shù)后康復(fù)的細(xì)節(jié),并約定拆除石膏后前來康復(fù)。必須強(qiáng)調(diào)的是,術(shù)后石膏期以及拆除石膏后的活動(dòng)度練習(xí)、基礎(chǔ)肌力練習(xí)非常重要。睿睿拆石膏后在天津醫(yī)院住院康復(fù),前來源自在康復(fù)時(shí),髖關(guān)節(jié)活動(dòng)度完全正常,這為之后的康復(fù)進(jìn)度奠定了良好的基礎(chǔ)——這也是要給寶媽們的第一個(gè)重要建議,術(shù)后早期康復(fù)至關(guān)重要。一旦遺留活動(dòng)度障礙,后期的功能恢復(fù)進(jìn)度都會(huì)受此影響。首次評(píng)估顯示:-術(shù)側(cè)整體肌力較弱,與右側(cè)差異較大,術(shù)側(cè)整體圍度較右側(cè)小。-術(shù)腿股外側(cè)皮神經(jīng)受損,大腿前外側(cè)有麻木感。-居家訓(xùn)練直抬腿時(shí)臀后側(cè)疼痛,側(cè)抬及直腿抬高時(shí)出現(xiàn)彈響,訓(xùn)練中存在代償。-術(shù)側(cè)下肢結(jié)構(gòu)性長1.5cm,右側(cè)待截骨。前期康復(fù)的重點(diǎn)是增加基礎(chǔ)肌力,為中后期脫拐步態(tài)奠定基礎(chǔ)。睿睿臀中肌、股四頭肌及屈髖肌力較弱,如果不提高基礎(chǔ)肌力,站立位或行走時(shí)肢體就會(huì)出現(xiàn)很多代償。首次康復(fù),在評(píng)估后我們著重檢查睿睿之前在家的訓(xùn)練動(dòng)作并做出調(diào)整,解決訓(xùn)練代償?shù)膯栴}。同時(shí)松解緊張肌肉,降低及預(yù)防訓(xùn)練過程中可能因肌肉緊張產(chǎn)生的代償或疼痛。借助Compex神經(jīng)肌肉電刺激的肌肉萎縮模式訓(xùn)練股四頭肌,并通過RedCord紅繩懸吊來激活臀肌。8月20日,術(shù)后3個(gè)月復(fù)查,睿睿骨愈合程度不佳,手術(shù)醫(yī)生建議可部分踩地負(fù)重訓(xùn)練。孩子年齡小,無法克服骨未愈合的心理壓力不敢踩地,所以,負(fù)重訓(xùn)練比預(yù)期推后。媽媽決定先回家訓(xùn)練一個(gè)月,復(fù)查骨愈合后再進(jìn)行下一階段的康復(fù)。這一階段的居家訓(xùn)練以繼續(xù)提升基礎(chǔ)力量為主,同時(shí)逐步增加左側(cè)適應(yīng)踩地感覺的訓(xùn)練動(dòng)作,為之后術(shù)腿踩地負(fù)重打下基礎(chǔ)。在這個(gè)階段康復(fù)的一個(gè)月里,從不敢站立到適應(yīng)踩地的過程,睿睿一次次在康復(fù)師的鼓勵(lì)下建立彼此的信任,沖破心理的枷鎖。他很勇敢,年僅7歲,但他能理解康復(fù)師說的每一句話,甚至在交流時(shí)可以清楚地說出人體的肌肉及關(guān)節(jié),復(fù)述正確的動(dòng)作。每次來治療他總會(huì)以自己的方式讓康復(fù)大廳充滿歡聲笑語。此后居家康復(fù)一個(gè)月,睿睿始終和我們保持聯(lián)系,堅(jiān)持訓(xùn)練。9月24日,熟悉的小身影蹦跳著進(jìn)入我們的視野。雖然步態(tài)艱難,但他歡快奔跑的樣子充滿希望。復(fù)查后手術(shù)醫(yī)生說“愈合情況良好”,可以全負(fù)重。這一階段康復(fù)重點(diǎn),改善本體感覺,讓左側(cè)腿更多地參與踩地,改善步態(tài)。術(shù)后有很多患者不敢踩地,怕影響手術(shù)位置的愈合、造成二次傷害。隨之就會(huì)出現(xiàn)身體代償,這是影響正常步態(tài)的一個(gè)重要因素。因此,此階段我們將步態(tài)拆分為屈髖、踩地、重心轉(zhuǎn)移、全負(fù)重支撐及過渡到聯(lián)合動(dòng)作進(jìn)行訓(xùn)練,讓小朋友找到正確步態(tài)的發(fā)力感,可以對(duì)自己進(jìn)行有意識(shí)的控制。這一階段他的步態(tài)改善特別明顯,媽媽陪伴著他,看著他努力走好每一步的樣子,熱淚盈眶。后期康復(fù)重點(diǎn),為適應(yīng)學(xué)校環(huán)境及突發(fā)狀況,進(jìn)一步恢復(fù)身體各項(xiàng)功能,加強(qiáng)上下樓梯、深蹲、跨越路障等貼合實(shí)際生活所需的訓(xùn)練。從踉踉蹌蹌到行走自如,從失穩(wěn)的“不倒翁”到順利上下臺(tái)階,從歪七扭八到順利跨越路障,小小身體里爆發(fā)出大大的能量。這個(gè)訓(xùn)練過程,在實(shí)現(xiàn)左側(cè)術(shù)后康復(fù)的同時(shí),也進(jìn)行著右側(cè)的術(shù)前康復(fù),一舉兩得。2022年10月16日,在脫拐22天后,睿睿順利畢業(yè)啦。因?yàn)闀r(shí)間安排緊張,睿睿的康復(fù)期由原來的1個(gè)半月壓縮至22天,遺留的蹬地不足、單腿站立穩(wěn)定性欠佳的問題,將在后期的居家訓(xùn)練中逐漸改善。我們的故事未完待續(xù)……他即將面臨下一個(gè)挑戰(zhàn)——右髖手術(shù)已提上日程。兒童康復(fù)與成人康復(fù)有很大不同,和兒骨手術(shù)一樣,兒童康復(fù)不是成人的縮小版,不同階段兒童具有不同的特質(zhì)。成人的功能早已固化,其發(fā)生的功能障礙往往是由于外傷或疼痛導(dǎo)致,也可以說成年人曾經(jīng)獲得了個(gè)體生存、生活所需的功能,但又因某種較明確的原因?qū)е缕涔δ艿耐嘶騿适?。此時(shí),對(duì)成年人的康復(fù)應(yīng)遵循“改善、代償與重建原則”。兒童的功能往往還處于發(fā)展與建立中,在這個(gè)過程中兒童因各種原因而無法建立起正常功能,對(duì)其康復(fù)在遵循“改善、代償與重建原則”的基礎(chǔ)上,應(yīng)更多關(guān)注兒童發(fā)育規(guī)律,著眼于更廣闊的未來,而非僅是當(dāng)下。期望經(jīng)過專業(yè)兒童康復(fù)干預(yù)的孩子獲得長久可用的回歸社會(huì)、回歸生活的能力。兒童康復(fù)以治療-教育-游戲相結(jié)合,同時(shí)重視家庭成員積極參與,營造一個(gè)良好的訓(xùn)練氛圍。父母是孩子最好的老師,同樣,兒童康復(fù)也離不開家庭宣教和指導(dǎo)。存在功能障礙的兒童由于身體缺陷和周圍環(huán)境的影響,常常表現(xiàn)為過于內(nèi)向、自信較差,甚至自我否定。因此,在康復(fù)過程中的信任建立與心理疏導(dǎo)對(duì)患兒尤為重要,不僅能幫助孩子盡快樹立起信心,更能促進(jìn)他們?cè)谲|體功能等方面的恢復(fù)。(解放軍總醫(yī)院骨科醫(yī)學(xué)部關(guān)節(jié)科張建立教授)
臨界髖關(guān)節(jié)發(fā)育不良Borderline DDH (2):疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH(2):疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療作者:MichaelCWyatt,MartinBeck.作者單位:KlinikfürOrthop?dieundUnfallchirurgieLuzernerKantonsspital6004Luzern,Switzerland.譯者:陶可(北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科)摘要在過去的幾十年里,影像技術(shù)的改進(jìn)和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。然而,疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然存在爭議。在這篇評(píng)論中,我們將確定相關(guān)問題并描述患者評(píng)估和治療方案。我們將提供自己的建議,并確定未來的研究領(lǐng)域。簡介在過去的幾十年里,髖關(guān)節(jié)生物力學(xué)知識(shí)的提高和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。保髖手術(shù)適應(yīng)范圍廣泛,從髖臼淺且不穩(wěn)定的髖關(guān)節(jié)到髖臼深且患有股骨髖臼撞擊(FAI)的髖關(guān)節(jié)。雖然人們普遍認(rèn)為,不穩(wěn)定髖關(guān)節(jié)發(fā)育不良的最佳治療方法是重新定位髖臼以增加覆蓋范圍,但人們同樣認(rèn)為,必須減小過度覆蓋的髖臼臨界以消除撞擊。所有這些髖關(guān)節(jié)都可能存在凸輪畸形,需要在手術(shù)矯正時(shí)加以解決[1]。在最極端的情況下,所需的治療是顯而易見的。然而,有一個(gè)過渡區(qū),很難區(qū)分不穩(wěn)定性和股骨髖臼撞擊(FAI)。過去,這些髖關(guān)節(jié)被稱為“臨界”髖關(guān)節(jié)。通常,這包括外側(cè)中心臨界(LCE)角度在20°到25°之間的髖關(guān)節(jié)[2]。然而,“臨界”一詞是有問題的,因?yàn)樗且粋€(gè)放射學(xué)定義,只涉及描述髖關(guān)節(jié)穩(wěn)定性的幾個(gè)重要參數(shù)之一。髖臼頂傾斜角、前后覆蓋和股骨前傾是應(yīng)納入髖關(guān)節(jié)穩(wěn)定性分析的其他因素。髖關(guān)節(jié)發(fā)育不良與髖關(guān)節(jié)骨關(guān)節(jié)炎之間的關(guān)聯(lián)已經(jīng)確定[3,4],有不穩(wěn)定跡象的髖關(guān)節(jié)發(fā)育不良退化速度更快[5]。臨界髖關(guān)節(jié)可能不穩(wěn)定、撞擊或兩者兼而有之。臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性很難確定,并且容易受個(gè)人主觀影響,骨科界普遍傾向于低估不穩(wěn)定性,從而導(dǎo)致不適當(dāng)?shù)闹委煛W罱难芯勘砻?,?duì)患有臨界發(fā)育不良(LCEA?>?20°)的患者進(jìn)行關(guān)節(jié)鏡髖關(guān)節(jié)手術(shù)(包括盂唇修復(fù)和關(guān)節(jié)囊折疊縫合術(shù))可能會(huì)在短期內(nèi)帶來適當(dāng)?shù)母纳芠3,4]。然而,有證據(jù)表明,之前錯(cuò)誤的髖關(guān)節(jié)鏡檢查會(huì)對(duì)此類髖關(guān)節(jié)的治療結(jié)果產(chǎn)生負(fù)面影響[6]。因此,疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然是一個(gè)極具爭議的問題。臨界性髖關(guān)節(jié)發(fā)育不良在患有髖關(guān)節(jié)疼痛的年輕人中很常見,在選定的患者群中報(bào)告的患病率為37.6%[7]。在臨界髖關(guān)節(jié)發(fā)育不良中,可能與其他不穩(wěn)定原因(如韌帶松弛癥)有顯著重疊[8]。然而,根本問題是難以正確分類潛在的病理生物力學(xué)。定義第一個(gè)問題在于定義。在前后位骨盆X線片[9](LCEA)上測(cè)量的Wiberg外側(cè)中心邊緣角傳統(tǒng)上用于將髖關(guān)節(jié)分類為正常(LCEA?>25°)、發(fā)育不良(LCEA?<20°)或臨界(LCEA20–25°),盡管這些定義值在文獻(xiàn)中差異很大[3,10]。然而,使用外側(cè)中心邊緣角(LCEA)存在兩個(gè)問題。首先是測(cè)量方法。為了測(cè)量外側(cè)中心邊緣角(LCEA),首先通過與股骨頭輪廓相符的圓來定義股骨頭的中心。角度的第一個(gè)分支垂直穿過旋轉(zhuǎn)中心。第二個(gè)分支由股骨頭的中心和股骨最外側(cè)點(diǎn)定義(圖1a)。重要的是不要使用髖臼的最外側(cè)點(diǎn)(圖1b),因?yàn)檫@不符合Wiberg的定義,并且會(huì)給出錯(cuò)誤的高值(外側(cè)中心邊緣角(LCEA)偏大)[11]。Fig.1.(a)CorrectmeasurementoftheLCEAusingtheedgeofthesourcil,indicatingmoderatedysplasia.(b)IncorrectmeasurementoftheLCEAinthesamehip.Usingthisvaluewouldfalselyclassifythishipasborderline.圖1(a)使用髖臼臨界正確測(cè)量外側(cè)中心邊緣角(LCEA),表明中度髖關(guān)節(jié)發(fā)育不良。(b)同一髖關(guān)節(jié)的外側(cè)中心邊緣角(LCEA)測(cè)量不正確。使用此值會(huì)錯(cuò)誤地將此髖關(guān)節(jié)歸類為臨界。其次,實(shí)際術(shù)語“臨界髖關(guān)節(jié)發(fā)育不良”是由Wiberg本人首次提出的,包括外側(cè)中心邊緣角(LCEA)在20°和25°之間的髖關(guān)節(jié)[2]。外側(cè)中心邊緣角(LCEA)是一種放射學(xué)測(cè)量,本身無法預(yù)測(cè)臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性,也無法完全描述股骨頭覆蓋范圍。因此,外側(cè)中心邊緣角(LCEA)無法指導(dǎo)手術(shù)決策[12–14]。部分原因是外側(cè)中心邊緣角(LCEA)本身無法涵蓋發(fā)育不良的精確位置,并且忽略了前后股骨頭覆蓋范圍。此外,髖臼指數(shù)(AI)和股骨前傾等其他參數(shù)也與髖關(guān)節(jié)穩(wěn)定性密切相關(guān)。如果外側(cè)中心邊緣角(LCEA)減少,AI可能正常,在這種情況下很難評(píng)估髖關(guān)節(jié)的穩(wěn)定性[15]。另一方面,股骨前傾過度可能會(huì)加劇髖關(guān)節(jié)前部不穩(wěn)定[16]。根本問題是什么?對(duì)于疼痛的臨界髖關(guān)節(jié)發(fā)育不良,很難僅通過二維射線測(cè)量將病理機(jī)制表征為撞擊(穩(wěn)定)或發(fā)育不良(不穩(wěn)定),尤其是僅由髖臼功能決定而不考慮股骨的測(cè)量。髖關(guān)節(jié)穩(wěn)定性的功能表征對(duì)于指導(dǎo)手術(shù)決策至關(guān)重要。不穩(wěn)定髖關(guān)節(jié)從邏輯上可以從髖臼重新定向截骨術(shù)中受益,而穩(wěn)定髖關(guān)節(jié)可以從撞擊手術(shù)(如股骨凸輪骨成形術(shù))中受益。那么關(guān)于髖關(guān)節(jié)內(nèi)病理學(xué)的了解有多少?應(yīng)該如何評(píng)估這些患者?有哪些治療方案?手術(shù)結(jié)果如何?這組患者的潛在隱患是什么?未來的發(fā)展方向是什么?在這篇敘述性綜述文章中,我們旨在解決這些問題,并闡明這組具有挑戰(zhàn)性的患者的處理方法。髖關(guān)節(jié)發(fā)育不良和臨界髖關(guān)節(jié)不穩(wěn)定的潛在病理是什么?髖關(guān)節(jié)發(fā)育不良患者的關(guān)節(jié)接觸壓力異常增高,股骨頭(軟骨損傷,導(dǎo)致軟骨下)骨質(zhì)相對(duì)暴露。髖臼通常較淺且前傾,盂唇經(jīng)常有代償性增大,但同時(shí)伴有髖臼后傾的情況也很高[17]。股骨通常呈外翻,前傾度高[10]。這些異常的解剖特征會(huì)導(dǎo)致病理性髖關(guān)節(jié)生物力學(xué),表現(xiàn)為盂唇撕裂、軟骨損傷和髖關(guān)節(jié)不穩(wěn)定,這些很容易被誤解為撞擊。由于骨穩(wěn)定性受損,軟組織穩(wěn)定器(即纖維軟骨盂唇和髖關(guān)節(jié)囊)的重要性就凸顯出來[18]。一旦軟組織約束失效,髖關(guān)節(jié)就會(huì)變得不穩(wěn)定。然而,我們必須明白,主要的潛在病理是缺乏骨性穩(wěn)定性,這會(huì)導(dǎo)致髖關(guān)節(jié)失效,而不是軟組織穩(wěn)定性失效。半脫位髖關(guān)節(jié)發(fā)育不良的自然病史預(yù)后非常差,并且必然會(huì)導(dǎo)致關(guān)節(jié)退化[5]。惡化速度與半脫位嚴(yán)重程度和患者年齡直接相關(guān),通常在癥狀出現(xiàn)后約10年,就會(huì)出現(xiàn)嚴(yán)重的退行性變化[19]。在沒有半脫位的情況下,自然病史很難預(yù)測(cè)退化速度。臨界髖關(guān)節(jié)發(fā)育不良也是如此。最近的一項(xiàng)研究強(qiáng)調(diào)了髖臼覆蓋的重要性。在一項(xiàng)為期20年的大型女性隊(duì)列研究中,研究顯示,如果外側(cè)中心邊緣角(LCE)低于28°,則每降低一度,放射學(xué)OA風(fēng)險(xiǎn)就會(huì)增加13%[20]。因此,除了短期緩解癥狀外,還必須考慮長期可能的發(fā)展。臨床表現(xiàn)臨界髖關(guān)節(jié)發(fā)育不良的臨床表現(xiàn)與其他年輕活躍成人髖關(guān)節(jié)疾?。ㄈ鏔AI綜合征[21])非常相似,因此,徹底的病史、體格檢查和放射學(xué)評(píng)估對(duì)于正確診斷這些患者至關(guān)重要。病史重點(diǎn)記錄病史。臨界髖關(guān)節(jié)發(fā)育不良患者的主要癥狀是疼痛。這通常發(fā)生在腹股溝和髖關(guān)節(jié)外側(cè),但也可能發(fā)生在臀部(臀后區(qū))。有必要記錄完整的疼痛病史。尋找特定的不穩(wěn)定和“避免疼痛”癥狀,這可能表明已經(jīng)達(dá)到因缺乏骨性穩(wěn)定性而需要的軟組織代償?shù)臉O限。咔嗒聲和卡住的癥狀也很常見。此外,還會(huì)詢問患者是否有任何跡象表明患者已經(jīng)患上髖關(guān)節(jié)炎,例如夜間疼痛。癥狀應(yīng)結(jié)合患者的功能限制和已經(jīng)接受的醫(yī)療護(hù)理,包括物理治療、藥物、其他意見和手術(shù)。檢查隨后應(yīng)進(jìn)行髖關(guān)節(jié)的合理臨床檢查,包括恐懼試驗(yàn)和撞擊測(cè)試?;颊咄ǔ?huì)表現(xiàn)出“膝內(nèi)翻”步態(tài),同時(shí)伴有髖關(guān)節(jié)內(nèi)收肌力矩增加和髖關(guān)節(jié)內(nèi)旋增加,這與股骨前傾增加一致。為了功能性地增加前覆蓋,可能存在前凸過度。應(yīng)確定大轉(zhuǎn)子處有無壓痛[22]。務(wù)必記住檢查患者的旋轉(zhuǎn)輪廓、進(jìn)行神經(jīng)血管檢查以及檢查全身關(guān)節(jié)松弛的跡象,并使用Beighton評(píng)分對(duì)此進(jìn)行量化。具體關(guān)鍵目標(biāo)包括排除(i)晚期退化過程的存在,例如表現(xiàn)為固定屈曲畸形和運(yùn)動(dòng)范圍減少,以及(ii)其他病理,例如腰椎病或L5神經(jīng)根病引起的疼痛。調(diào)查診斷成像應(yīng)從骨盆的標(biāo)準(zhǔn)化AP平片和股骨頸側(cè)位片(穿桌側(cè)位、Dunn位、假斜位)[23]開始。仔細(xì)檢查這些圖像以測(cè)量LCEA、AI、擠壓指數(shù)、股骨頸干角和FEAR指數(shù)(見下文)。應(yīng)確定骨關(guān)節(jié)炎的Tonnis等級(jí)以及是否存在凸輪形態(tài)。應(yīng)仔細(xì)檢查不穩(wěn)定的直接跡象,這些跡象包括股骨頭移位,可通過與髂坐線的距離增加、Shenton線斷裂和AP視圖上股骨頭重新定位來識(shí)別,髖關(guān)節(jié)處于外展?fàn)顟B(tài),使用MR關(guān)節(jié)造影時(shí)后關(guān)節(jié)間隙中有釓,這表明股骨頭向前移位,因此不穩(wěn)定。FEAR指數(shù)與不穩(wěn)定性有很高的相關(guān)性(見下文)。必須精確測(cè)量和記錄各種參數(shù)。有必要使用三維計(jì)算機(jī)斷層掃描(CT)進(jìn)行橫斷面成像,以獲得有關(guān)骨解剖結(jié)構(gòu)和發(fā)育不良位置的精確信息,包括髖關(guān)節(jié)周圍囊腫的存在和位置[24-26]。此外,CT還應(yīng)包括股骨前傾的評(píng)估,如果前傾過大,可能會(huì)加劇髖關(guān)節(jié)前部不穩(wěn)定。磁共振成像(MR-關(guān)節(jié)造影)應(yīng)遵循專門的髖關(guān)節(jié)檢查方案,包括徑向圖像采集或重建和關(guān)節(jié)內(nèi)造影劑應(yīng)用[27],以檢查關(guān)節(jié)內(nèi)結(jié)構(gòu)和盂唇和關(guān)節(jié)軟骨的病理。可以區(qū)分引起類似癥狀的其他原因,例如缺血性壞死、轉(zhuǎn)子滑囊炎或臀肌病變。其他測(cè)量包括盂唇大小[13,28]和髂關(guān)節(jié)囊體積[29]。對(duì)于這些患者,我們還提倡進(jìn)行非牽引性MR關(guān)節(jié)造影檢查,以檢查是否存在釓積聚,即所謂的“新月征”,這是軸向視圖上不穩(wěn)定的細(xì)微征兆[30]。這些測(cè)量值的價(jià)值是什么?在平片上,那些直接表明不穩(wěn)定的測(cè)量值是股骨頭移位,與髂坐線的距離增加,Shenton線斷裂,髖關(guān)節(jié)外展時(shí)AP視圖上股骨頭重新定位,以及FEAR指數(shù)。在MR關(guān)節(jié)造影中,后下關(guān)節(jié)間隙中釓的存在表明股骨頭移位,因此不穩(wěn)定。AI、NSA、AT、高髂囊體積和盂唇體積可能存在增加,但不能預(yù)測(cè)不穩(wěn)定性[30](表1)。表1.用于評(píng)估髖關(guān)節(jié)不穩(wěn)定性的各種參數(shù)概述TheFemoro-EpiphysealAcetabularRoof(FEAR)index:股骨骨骺髖臼頂指數(shù)Thefemoralneck-shaftangle(NSA):頸干角FEAR指數(shù)是最近描述的參數(shù),似乎對(duì)預(yù)測(cè)髖關(guān)節(jié)穩(wěn)定性具有很高的價(jià)值[27]。它是由髖臼頂與股骨生長板中央1/3處之間的角度形成的(圖2)。其依據(jù)是:在生長過程中,股骨的骨骺生長板會(huì)垂直于髖關(guān)節(jié)的關(guān)節(jié)反作用力。股骨頸的生長和方向受股骨頸下生長板的控制[31]。Pauwels和Maquet[32]提出理論,合力作用于骨骺軟骨的中心,在生長過程中,根據(jù)Heuter-Volkman原理,骨骺板會(huì)垂直于關(guān)節(jié)反作用力。Pauwels和Maquet的理論后來得到了Carter等人[33]的證實(shí),他們通過二維有限元分析研究了髖關(guān)節(jié)負(fù)荷的影響。閉合的骨骺板的角度表示跨股骨近端骨骺[34]的力的平衡,也表示跨關(guān)節(jié)力在過去的作用方式。因此,它是一個(gè)功能參數(shù),反映了髖關(guān)節(jié)在生長過程中長期的關(guān)節(jié)反作用力。如果FEAR<0°,則認(rèn)為髖關(guān)節(jié)穩(wěn)定。統(tǒng)計(jì)分析表明,5°的臨界值預(yù)測(cè)穩(wěn)定性的概率為80°。最近的研究表明,2°的臨界值預(yù)測(cè)穩(wěn)定性的概率為90%(Batailler等人,正在準(zhǔn)備發(fā)表中)。使用FEAR指數(shù)的案例如圖3a和b所示。Fig.2.TheFEARindex.Theangleismeasuredbetweenalineconnectingthemostmedialandlateralpointofthesourcilandalineconnectingthemedialandlateralendofthestraightpart(usuallycentralthird)ofthephysealscarofthefemoralhead.AnegativeFEARindex,withtheangleopeningmediallyasshowninFig.3a,indicatesastablehip.圖2.?FEAR指數(shù)。測(cè)量連接股骨最內(nèi)側(cè)和外側(cè)點(diǎn)的線與連接股骨頭骨骺直線部分(通常為中央三分之一)內(nèi)側(cè)和外側(cè)端的線之間的角度。如圖3a所示,角度向內(nèi)側(cè)打開的陰性FEAR指數(shù),表示髖關(guān)節(jié)穩(wěn)定。Fig.3.(a)CaseexamplesusingtheFEARindex.17-year-oldmale,LCEA20°,FEAR0°.Hipdeemedthereforestableandpatientmanagedwithhiparthroscopy.(b)CaseexamplesusingtheFEARindex.17-year-oldfemale,LCEA20°,FEAR8°.HipdeemedthereforeunstableandpatientmanagedwithPAO.圖3.(a)使用FEAR指數(shù)的病例。17歲男性,LCEA20°,F(xiàn)EAR0°。因此髖關(guān)節(jié)穩(wěn)定,患者接受髖關(guān)節(jié)鏡治療。(b)使用FEAR指數(shù)的病例。17歲女性,LCEA20°,F(xiàn)EAR8°。因此髖關(guān)節(jié)不穩(wěn)定,患者接受PAO截骨治療。有哪些治療方案?治療取決于髖關(guān)節(jié)的穩(wěn)定性。疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療方案包括非手術(shù)治療、解決關(guān)節(jié)內(nèi)撞擊的手術(shù)治療(通過髖關(guān)節(jié)鏡或髖關(guān)節(jié)外科脫位進(jìn)行的FAI手術(shù))和解決不穩(wěn)定性的手術(shù)治療(采用PAO和/或股骨截骨術(shù)的重新定位截骨術(shù))(見圖2)。非手術(shù)治療包括患者教育、活動(dòng)調(diào)整、簡單的止痛藥、非甾體抗炎藥和髖關(guān)節(jié)腔內(nèi)注射藥物[35]。有針對(duì)性的物理治療可以改善肌肉調(diào)節(jié)、疼痛和本體感受控制。以下段落將討論包括關(guān)節(jié)鏡和/或截骨術(shù)的臨界髖關(guān)節(jié)發(fā)育不良的手術(shù)治療方案。這組患者接受髖關(guān)節(jié)鏡檢查的結(jié)果如何?隨著髖關(guān)節(jié)鏡技術(shù)的最新發(fā)展,許多外科醫(yī)生正在使用它來治療臨界髖關(guān)節(jié)發(fā)育不良,尤其是因?yàn)槿藗冋J(rèn)為髖臼周圍截骨術(shù)等替代技術(shù)的風(fēng)險(xiǎn)更高,術(shù)后恢復(fù)時(shí)間更長。臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查還可以讓外科醫(yī)生處理髖關(guān)節(jié)內(nèi)病變,如盂唇撕裂或股骨凸輪畸形[3,12,36]。如果考慮使用PAO來解決骨穩(wěn)定性不足的問題,那么關(guān)節(jié)鏡檢查不僅可以讓外科醫(yī)生了解髖關(guān)節(jié)的關(guān)節(jié)內(nèi)狀態(tài),還可以了解患者在隨后進(jìn)行更大規(guī)模手術(shù)時(shí)的表現(xiàn)[37]。然而,關(guān)于臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查的已發(fā)表文獻(xiàn)很少,而且短期隨訪也存在局限性。在Jo等的系統(tǒng)綜述中,確定了13項(xiàng)關(guān)于髖關(guān)節(jié)發(fā)育不良的關(guān)節(jié)鏡檢查的研究[10]。這些研究各不相同,所有研究都是病例系列。僅有6項(xiàng)研究報(bào)告了主觀和/或客觀結(jié)果。關(guān)節(jié)鏡檢查的手術(shù)指征不明確,患者事先接受過多種非手術(shù)治療。此外,臨界髖關(guān)節(jié)發(fā)育不良的確切定義各不相同,只有兩項(xiàng)研究使用了Byrd和Jones的定義[36]。三項(xiàng)研究報(bào)告了髖關(guān)節(jié)鏡作為輔助工具,三項(xiàng)研究報(bào)告了髖關(guān)節(jié)鏡作為獨(dú)立治療。盂唇撕裂的總患病率為77.3%,主要位于髖臼緣的前部或前上部。髖臼軟骨病變比股骨病變更常見(59-75.2%比11-32%),并且位于盂唇病變的鄰近。僅有兩項(xiàng)研究檢查了臨界髖關(guān)節(jié)發(fā)育不良病例(LCEA20-25°)的關(guān)節(jié)鏡檢查結(jié)果,其中只有一項(xiàng)描述了患者報(bào)告的結(jié)果測(cè)量。后者是Byrd和Jones[36]的前瞻性臨床病例系列,其中66%的髖關(guān)節(jié)(32髖)患有臨界髖關(guān)節(jié)發(fā)育不良。關(guān)節(jié)鏡檢查后,平均改良Harris髖關(guān)節(jié)評(píng)分從50(差)改善到77(一般)。作者得出結(jié)論,髖關(guān)節(jié)鏡治療可能解決髖關(guān)節(jié)內(nèi)病理而不是發(fā)育不良的放射學(xué)證據(jù)的結(jié)果。對(duì)臨界髖關(guān)節(jié)發(fā)育不良進(jìn)行髖關(guān)節(jié)鏡檢查有什么危險(xiǎn)?臨界髖關(guān)節(jié)發(fā)育不良患者進(jìn)行關(guān)節(jié)鏡盂唇切除術(shù)和髖臼外側(cè)緣切除術(shù)可導(dǎo)致爆發(fā)性髖關(guān)節(jié)不穩(wěn)定[38]。即使修復(fù)了盂唇,也必須保留髂股韌帶和髖關(guān)節(jié)的其他靜態(tài)穩(wěn)定器,以防止不可逆的后果或?qū)е麦y關(guān)節(jié)不穩(wěn)定[39–41]。沒有確鑿的文獻(xiàn)支持在這些情況下進(jìn)行關(guān)節(jié)囊修復(fù),但這似乎是一種安全合理的做法[42]。關(guān)節(jié)囊復(fù)位技術(shù)可提高臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性[12]。如果髖關(guān)節(jié)在術(shù)前足夠不穩(wěn)定,那么僅通過髖關(guān)節(jié)鏡治療關(guān)節(jié)內(nèi)病變是不夠的,患者將需要進(jìn)行PAO截骨術(shù)[43,44]。必須記住,髖關(guān)節(jié)的穩(wěn)定性首先取決于髖骨幾何形狀。在輕微不穩(wěn)定(臨界發(fā)育不良)中,穩(wěn)定性可能由次級(jí)軟組織結(jié)構(gòu)來確保。一旦這些結(jié)構(gòu)因微創(chuàng)傷或大創(chuàng)傷而失效,髖關(guān)節(jié)就會(huì)變得不穩(wěn)定。恢復(fù)軟組織穩(wěn)定性可能只會(huì)在短時(shí)間內(nèi)改善髖關(guān)節(jié)穩(wěn)定性,但軟組織很可能再次磨損。因此,必須首先解決潛在的骨病理問題,才能取得良好的長期效果。最近的一份報(bào)告顯示,髖關(guān)節(jié)發(fā)育不良患者在髖關(guān)節(jié)鏡檢查失敗后,PAO的髖關(guān)節(jié)特定功能結(jié)果較差[6]。因此,對(duì)這組患者單獨(dú)進(jìn)行髖關(guān)節(jié)鏡檢查應(yīng)謹(jǐn)慎處理。但是,對(duì)于那些由于髖關(guān)節(jié)狀況不佳(即AI和股骨前傾正常)或高齡(即>40歲)而不適合進(jìn)行PAO的患者,它可能有用。重新定向髖臼周圍截骨術(shù)對(duì)這組患者有何影響?通過髖臼周圍截骨術(shù)進(jìn)行髖臼重新定向已成為髖關(guān)節(jié)發(fā)育不良最常見的治療方法,據(jù)報(bào)道術(shù)后20多年效果良好。傳統(tǒng)上,PAO時(shí)關(guān)節(jié)內(nèi)病變的處理方法是進(jìn)行前關(guān)節(jié)切開術(shù)。然而,隨著PAO微創(chuàng)技術(shù)的發(fā)展,情況已不再如此。微創(chuàng)PAO技術(shù)縮短了術(shù)后恢復(fù)時(shí)間[45]。最近的一項(xiàng)研究表明,一些可改變的因素,例如較高的體力活動(dòng)量和較高的BMI(大于30kg/m2)可導(dǎo)致PAO的發(fā)病年齡下降[46]。此外,患有較重發(fā)育不良程度的患者患PAO的年齡也較早:LCEA是手術(shù)年齡的獨(dú)立預(yù)測(cè)因素,即LCEA較低的患者往往需要在較早的年齡接受PAO手術(shù)。但是,輕度和中度發(fā)育不良患者的PAO預(yù)后沒有差異。在本研究中,輕度發(fā)育不良被歸類為15-25°,這涵蓋了我們對(duì)臨界髖關(guān)節(jié)發(fā)育不良的定義。最近的一項(xiàng)多中心前瞻性隊(duì)列研究檢查了患者報(bào)告的PAO結(jié)果指標(biāo),結(jié)果表明,雖然總體結(jié)果良好,但臨界髖關(guān)節(jié)發(fā)育不良患者和男性的改善程度低于發(fā)育較重的患者[47]。作者討論了小范圍矯正的危險(xiǎn),這可能導(dǎo)致過度矯正和醫(yī)源性FAI、股骨前傾增加和軟組織松弛。建議和未來方向在臨界髖關(guān)節(jié)中,關(guān)鍵步驟是確定穩(wěn)定性。關(guān)于髖關(guān)節(jié)的穩(wěn)定性,只有兩種情況:髖關(guān)節(jié)穩(wěn)定或不穩(wěn)定。沒有中間狀態(tài)。如果接受這個(gè)概念,治療就會(huì)變得相對(duì)簡單。不穩(wěn)定可能與其他病癥(如FAI或超負(fù)荷/過度使用和軟骨疾?。┫嘟Y(jié)合,需要同時(shí)治療。如果髖關(guān)節(jié)不穩(wěn)定,則需要髖臼重新定位。僅解決磨損的二級(jí)穩(wěn)定器并不能解決潛在的生物力學(xué)問題,最多只能產(chǎn)生令人滿意的短期結(jié)果。在穩(wěn)定的髖關(guān)節(jié)中,可以進(jìn)行開放或關(guān)節(jié)鏡關(guān)節(jié)保留手術(shù)。然而,我們必須記住,低于28°的LCE角度每減少一度,骨關(guān)節(jié)炎的發(fā)病率就會(huì)增加13%[20]。因此,如果有疑問,為了最大限度地提高獲得良好長期結(jié)果的機(jī)會(huì),我們主張進(jìn)行髖臼重新定向PAO截骨手術(shù)。重要的是要確定我們?nèi)狈χR(shí)的領(lǐng)域,以指導(dǎo)進(jìn)一步的研究。將對(duì)這些患者進(jìn)行長期隨訪研究,比較髖臼重新定向和髖關(guān)節(jié)鏡檢查,理想情況下,將記錄所有成像參數(shù)和Beighton評(píng)分。此外,還應(yīng)獲得患者報(bào)告的結(jié)果測(cè)量和恢復(fù)時(shí)間,以及包括運(yùn)動(dòng)在內(nèi)的活動(dòng)恢復(fù)時(shí)間。?TheFEARindexisarecentlydescribedparameterthatseemstohaveahighvaluetopredictstabilityofthehip[27].Itisformedbytheanglebetweentheacetabularroofandthecentralthirdofthefemoralgrowthplate(Fig.2).Itisbasedonthefactthatduringgrowththeepiphysealgrowthplateofthefemurorientsitselfperpendicularlytothejointreactingforcesofthehip.Growthandtheorientationofthefemoralneckareunderthecontrolofthesubcapitalgrowthplate[31].PauwelsandMaquet[32]theorizedthattheresultantforceactsfromthecenteroftheepiphysealcartilageandthatduringgrowth,theepiphysealplateorientsitselfperpendiculartothejointreactionforceinaccordancewiththeHeuter–Volkmanprinciple.PauwelsandMaquet’stheorylaterwasconfirmedbyCarteretal.[33]whostudiedtheinfluenceofhiploadingbybi-dimensionalfiniteelementanalysis.Theangleoftheclosedepiphysealplateindicatesthebalanceofforcesacrosstheproximalfemoralphysis[34]andindicateshowthetransarticularforcesactedinthepast.Therefore,itisafunctionalparameterthatreflectsthejointreactingforcesoveralongperiodoftimeduringgrowthofthehip.IftheFEARis?<0°thehipisconsideredstable.Statisticalanalysishasshownthatacutoffvalueof5°predictsstabilitywith80°probability.Morerecentworkhasshownthatacutoffvalueof2°predictsstabilitywith90%probability(Batailleretal.,inpreparation).CaseexamplesofusingtheFEARindexareshowninFig.3aandb.ThemanagementofthepainfulborderlinedysplastichipAbstractImprovedimagingandtheevolutionofsurgicaltechniqueshavepermittedarapidgrowthinhippreservationsurgeryoverthelastfewdecades.Themanagementofthepainfulborderlinedysplastichiphoweverremainscontroversial.Inthisreview,wewillidentifythepertinentissuesanddescribethepatientassessmentandtreatmentoptions.Wewillprovideourownrecommendationsandalsoidentifyfutureareasforresearch.INTRODUCTIONImprovedknowledgeabouthipbiomechanicsandtheevolutionofsurgicaltechniqueshavepermittedarapidgrowthinhippreservationsurgeryoverthelastfewdecades.Thespectrumcoversawiderangefromhipswithshallowacetabuli,whichareunstable,tohipswithdeepacetabulithataresufferingfromfemoro-acetabularimpingement(FAI).Whilethereisageneralagreementthatthebesttreatmentfortheunstabledysplastichipisareorientationoftheacetabulumtoincreasecover,thereisequalagreementthattherimoftheover-coveringacetabulumhastobereducedtoremoveimpingement.Onallthosehipsacamdeformitymaybepresentthatneedstobeaddressedatthetimeofsurgicalcorrection[1].Atthefarendsofthespectrumtherequisitetreatmentisobvious.However,thereisatransitionzonewhereitisdifficulttodiscriminateinstabilityfromFAI.Inthepastthesehipswerereferredtoas‘borderline’hips.Usually,thisincludedhipswithalateralcenteredge(LCE)anglebetween20°and25°[2].However,theterm‘borderline’isproblematic,becauseitisaradiographicdefinitionandonlyaddressesoneofseveralparametersimportanttodescribehipstability.Acetabularroofobliquity,anteriorandposteriorcoverandfemoralantetorsionareotherfactorsthatshouldbeincludedintoananalysisofhipstability.Theassociationofhipdysplasiawithhiposteoarthritisisestablished[3,4]anddysplastichipswithsignsofinstabilitydegenerateatahigherrate[5].Aborderlinehipcaneitherbeunstable,impingingormaybeboth.Thestabilityoftheborderlineisdifficulttodetermineandsubjecttointerpretationwithageneraltendencyintheorthopaediccommunitytounderestimateinstabilitythatthenleadstoinappropriatetreatment.Recentstudiessuggestthatarthroscopichipsurgerywithlabralrepairandcapsularplicationinpatientswithborderlinedysplasia(LCEA?>?20°)mayresultinappropriateshort-termimprovements[3,4].However,thereisevidencethatawronglydoneprevioushiparthroscopyhasanegativeimpactontheoutcomeonthetreatmentofsuchhips[6].Therefore,themanagementofthepainfulborderlinedysplastichiphoweverremainsanissueofgreatcontroversy.Borderlinehipdysplasiaiscommoninyoungadultswithhippainwithareportedprevalenceof37.6%inselectedpatientcohorts[7].Intheborderlinedysplastichiptheremaybesignificantoverlapwithothercausesofinstabilitysuchasconnectivetissuelaxity[8].However,thefundamentalissueisthedifficultyincorrectlyclassifyingtheunderlyingpatho-biomechanics.DEFINITIONThefirstproblemliesinthedefinition.TheLateralCentreEdgeAngleofWibergasmeasuredonanAntero-posteriorpelvicradiograph[9](LCEA)hastraditionallybeenusedtoclassifyhipsasnormal(LCEA?>25°),dysplastic(LCEA?<20°)orborderline(LCEA20–25°)althoughthesedefiningvaluesvarywidelyintheliterature[3,10].However,theuseoftheLCEAhastwoproblems.Firstlythemethodbywhichitshouldbemeasured.TomeasuretheLCEAthecenterofthefemoralheadisfirstdefinedbyacirclefittingthecontourofthefemoralhead.Thefirstbranchoftheanglerunsperpendicularthroughthecenterofrotation.Thesecondbranchisdefinedbythecenterofthefemoralheadandthemostlateralpointofthesourcil(Fig.1a).Itisimportantnottousethemostlateralpointoftheacetabulum(Fig.1b),becausethisdoesnotfollowthedefinitionofWiberg,andwillgivefalsehighvalues[11].Secondlytheactualterm‘Borderlinehipdysplasia’wasfirstintroducedbyWiberghimself,includinghipswithaLCEAbetween20°and25°[2].LCEAisaradiographicmeasureandpersecannotpredictstabilityintheborderlinedysplastichipnordoesfullydescribefemoralheadcoverage.ThereforetheLCEAcannotdirectsurgicaldecisionmaking[12–14].PartofthereasonisthatLCEAalonedoesnotencompassthepreciselocationofdysplasiaanddisregardsanteriorandposteriorfemoralheadcoverage.Alsootherparameterssuchasacetabularindex(AI)andfemoralantetorsionareveryrelevantforstabilityofthehip.InthepresenceofadecreasedLCEAAImaybenormalinwhichcasethestabilityofthehipisdifficulttoassess[15].Ontheotherhand,excessivefemoralanteversionmaypotentiateanteriorhipinstability[16].WHATISTHEFUNDAMENTALISSUE?Inthepainfulborderlinedysplastichipitisdifficulttocharacterizethepathologicalmechanismasimpingement(stable)ordysplasia(unstable)byatwo-dimensionalradiographicmeasurementalone,especiallyonethatissolelyafunctionoftheacetabulumandtakesnoaccountofthefemur.Thisfunctionalcharacterizationofhipstabilityisofparamountimportancetoguidesurgicaldecision-making.Anunstablehipwouldlogicallybenefitfromacetabularreorientationosteotomywhilstastablehipwouldbenefitfromimpingementsurgerysuchasfemoralcamosteoplasty.Sowhatisknownabouttheintra-articularpathology?Howshouldthesepatientsbeassessed?Whatarethetreatmentoptions?Whatarethesurgicaloutcomes?Whatarethepotentialpitfallswiththisgroupofpatients?Whatarethefuturedirections?Inthisnarrativereviewarticleweaimtoaddressthesequestionsandelucidatethemanagementofthischallenginggroupofpatients.WHATISTHEUNDERLYINGPATHOLOGYOFHIPDYSPLASIAANDUNSTABLEBORDERLINEHIPS?Inhipdysplasia,thereareabnormallyhigharticularcontactpressuresandrelativebonyuncoveringofthefemoralhead.Theacetabulumistypicallyshallowandantevertedwithanoftencompensatoryenlargedlabrum,butthereisalsoahighprevalenceofconcomitantacetabularretroversion[17].Thefemurisclassicallyinvalguswithhighantetorsion[10].Theseabnormalanatomicalfeaturescausepathologicalhipbiomechanicswhichmanifestaslabraltears,chondrallesions,andhipinstability,whichcaneasilybemisinterpretedasimpingement.Astheosseousstabilityiscompromisedtheimportanceofthesofttissuestabilisers,namelythefibrocartilaginouslabrumandthehipcapsule,isaccentuated[18].Oncethesofttissueconstraintsfailthenthehipbecomesunstable.However,onehastounderstandthattheprincipalunderlyingpathologyisthelackofosseousstability,whichleadstofailureofthehipandnotthefailingsofttissuestability.Thenaturalhistoryofthesubluxingdysplastichipisaverypoorprognosisandinvariablyleadstojointdegeneration[5].Therateofdeteriorationisdirectlyrelatedtosubluxationseverityandpatientageandusuallyabout10?yearsafteronsetofsymptomsseveredegenerativechangeshavedeveloped[19].Thenaturalhistoryintheabsenceofsubluxationismoredifficulttopredictconcerningthespeedofdegeneration.Thesameaccountsforborderlinedysplastichips.Arecentstudyhighlightstheimportanceofacetabularcover.Inalargecohortoffemales,followedfor20?years,itwasshownthateachdegreereductioninLCEbelow28°isassociatedwith13%increasedriskofradiographicOA[20].Therefore,besidesshort-termreliefofsymptoms,thelong-termpossibleevolutionhastobekeptinmind.CLINICALPRESENTATIONTheclinicalpresentationofborderlineacetabulardysplasiaisverysimilartothatofotheryoungactiveadulthipdisorders,suchasFAIsyndrome[21]soathoroughhistory,physicalexamination,andradiographicevaluationareessentialtoproperlydiagnosethesepatients.HISTORYAfocusedhistoryistaken.Theprimarysymptominpatientswithborderlinehipdysplasiaispain.Thisistypicallyperceivedingroinandlateralhipbutcanalsobeinthebuttock.Afullpainhistoryiswarranted.Particularsymptomsofinstabilityand‘givingway’aresoughtthatmayindicatethatthelimitsofsofttissuecompensationforalackofosseousstabilityhavebeenreached.Symptomsofclickingandcatchingarealsocommon.Furthermoreanyindicationsthatthepatienthasestablishedhiparthritis,suchasnightpain,areaskedfor.Thesymptomsshouldbeputintothecontextofthepatient’sfunctionallimitationsandmedicalattentionalreadyreceivedincludingphysiotherapy,medications,otheropinionsandsurgery.EXAMINATIONAlogicalclinicalexaminationofthehipshouldfollowincludingapprehensionandimpingementtests.Thepatientwilloftendisplaya‘kneeing-in’gaitinassociationwithanincreasedhipadductormomentandincreasedinternalhiprotationconsistentwithincreasedfemoralantetorsion.Hyperlordosismaybepresentinordertofunctionallyincreaseanteriorcover.Tendernessoverthegreatertrochantershouldbedetermined[22].Itiscrucialtoremembertoexaminethepatient’srotationalprofile,performaneurovascularexaminationandtocheckforsignsofgeneralizedjointlaxityandquantifythisusingBeighton’sscore.Specifickeyaimsincluderefutingthepresenceof(i)anadvanceddegenerativeprocessmanifestforexamplewithfixedflexiondeformityanddecreasedrangeofmotionand(ii)alternativepathologysuchaspainreferredfromlumbarspondylosisorL5radiculopathy.INVESTIGATIONSDiagnosticimagingshouldcommencewithstandardizedplainAPradiographofthepelvisandalateralfemoralneckviews(lateralcrosstable,Dunnview,falseprofileviews)[23].TheseimagesarescrutinizedtomeasuretheLCEA,AI,extrusionindex,femoralneck-shaftangleandFEARindex(seebelow).TheTonnisgradeofosteoarthritisshouldbedeterminedalongwithwhetherthereiscammorphology.Directsignsofinstabilityshouldbescrutinizedforandthesecomprisefemoralheadmigration,recognizedbyanincreaseddistancefromtheilioischialline,abreakinShenton’slineandrecenteringofthefemoralheadonanAPviewwiththehipinabductionandGadoliniumintheposteriorjointspacewhenusingMR-arthrography,thatindicatesanteriormigrationandthusinstabilityofthefemoralhead.TheFEARindexhasahighassociationwithinstability(seebelow).Thevariousparametershavetobemeasuredpreciselyandrecorded.Cross-sectionalimagingwiththree-dimensionalcomputerizedtomography(CT)forpreciseinformationonbonyanatomyandlocationofdysplasiaincludingthepresenceandlocationofperiarticularcystsiswarranted[24–26].FurthermoreCTshouldincludeestimationoffemoralantetorsionwhich,ifhighmaypotentiateanteriorhipinstability.Magneticresonanceimaging(MR-arthrography)shouldfollowadedicatedprotocolfortheexaminationofthehip,includingradialimageacquisitionorreconstructionandintra-articularapplicationofcontrast[27]toexamineforintra-articularstructuresandpathologyofbothlabrumandarticularcartilage.Othercausesforsimilarsymptomssuchasavascularnecrosis,trochantericbursitisorglutealpathologycanbedifferentiated.Additionalmeasurementsincludelabralsize[13,28]andiliocapsularisvolume[29].Inthesepatients,wealsoadvocatenon-tractionMRarthrographytoexamineforaaccumulationofgadoliniumknownasa‘crescentsign’whichisasubtlesignofinstabilityontheaxialview[30].WHATISTHEVALUEOFTHESEMEASUREMENTS?Onplainfilmsthosemeasurementsthataredirectsignsofinstabilityarefemoralheadmigrationwithanincreaseofthedistancefromtheilioischialline,abreakinShenton’slineandrecenteringofthefemoralheadontheAPviewwithhipsinabductionandtheFEARindex.OnMR-arthrographythepresenceofGadoliniuminthepostero-inferiorjointspaceindicatesmigrationofthefemoralheadandthusinstability.TheAI,NSA,AT,highiliocapsularisvolumeandincreasedlabralvolumemaybepresentbutarenotpredictiveofinstability[30](Table1).WHATARETHETREATMENTOPTIONS?Treatmentdependsonthestabilityofthehip.Thetreatmentalternativesforthepainfulborderlinedysplastichipincludenon-operativetreatment,surgicaltreatmenttoaddressintra-articularimpingement(FAIsurgerybyeitherhiparthroscopyorsurgicalhipdislocation)andsurgicaltreatmenttoaddressinstability(reorientationosteotomywithPAOand/orfemoralosteotomy)(seeFig.2).Non-operativemanagementincludespatienteducation,activitymodification,simpleanalgesics,non-steroidalanti-inflammatorymedications,andintra-articularinjections[35].Targetedphysiotherapycanimprovemuscularconditioning,painandproprioceptivecontrol.Thesurgicaltreatmentoptionsfortheborderlinedysplastichipwhichcomprisearthroscopyand/orosteotomywillbediscussedinthefollowingparagraphs.WHATARETHERESULTSOFHIPARTHROSCOPYINTHISGROUPOFPATIENTS?Withtherecentevolutioninhiparthroscopymanysurgeonsareusingthistoaddressborderlinedysplastichips,notleastbecauseofperceivedhigherrisksandlongerpost-operativerecoveryassociatedwithalternativetechniquessuchasperiacetabularosteotomy.Hiparthroscopyinborderlinedysplastichipspermitsthesurgeontoaddressintra-articularpathologysuchasalabraltearorfemoralcamdeformity[3,12,36].IfPAOisbeingconsideredtoaddresstheinadequatebonystabilitythenarthroscopymaygivethesurgeonvaluableinsightsnotonlyintotheintra-articularstatusofthehipbutalsohowthepatientislikelytofarewithamuchlargersubsequentoperation[37].However,thereislittlepublishedliteratureonhiparthroscopyinborderlinedysplastichipsandwhatthereislimitedbyshort-termfollow-up.InthesystematicreviewbyJoetal.,13studieslookingatarthroscopyindysplastichipswereidentified[10].Thestudieswereheterogeneousandallstudieswerecaseseries.Onlysixstudiesreportedonsubjectiveand/orobjectiveoutcomes.Thesurgicalindicationsforarthroscopywereambiguousandpatientshadreceivedvariablenon-operativemanagementapriori.FurthermoretheprecisedefinitionofborderlinehipdysplasiavariedandonlytwostudiesusedthedefinitionofByrdandJones[36].Threestudiesreportedonhiparthroscopyasanadjuvanttoolandthreeasastand-alonetreatment.Labraltearshadanoverallprevalenceof77.3%andtheseweremostlylocatedintheanteriororanterosuperiorportionoftheacetabularrim.Acetabularchondrallesionsweremorecommonthanfemorallesions(59–75.2%versus11–32%)andlocatedadjacenttothatofthelabralpathology.Therewereonlytwostudiesthatexaminedtheoutcomesofarthroscopyinborderlinehipdysplasticcases(LCEA20–25°)ofwhichonlyonedescribedpatientreportedoutcomemeasures.Thelatter,aprospectiveclinicalcaseseriesbyByrdandJones[36],had66%ofhips(32hips)withborderlinedysplasia.ThemeanmodifiedHarrisHipscoreimprovedfrom50(poor)to77(fair)followingarthroscopy.Theauthorsconcludedthatthetreatmentresponseislikelyafunctionofaddressingtheintra-articularpathologyratherthantheradiographicevidenceofdysplasia.WHATARETHEDANGERSWITHDOINGHIPARTHROSCOPYINBORDERLINEDYSPLASTICHIPS?Arthroscopiclabralresectionandremovaloflateralacetabularriminborderlinehipdysplasiacanleadtofulminantjointinstability[38].Evenifthelabrumisrepaireditisimperativetopreservetheiliofemoralligamentandotherstaticstabilizersofthehiptopreventtheirreversibleconsequencesorrenderingthehipunstable[39–41].Thereisnoconclusiveliteraturetosupportcapsularrepairinthesecasesbutthisseemsasafeandsensiblepractice[42].Capsularreductiontechniquestoimprovestabilityhavebeendescribedinborderlinedysplastichips[12].Ifthehipissufficientlyunstablepre-operativelythenaddressingtheintra-articularpathologyalonebyhiparthroscopywillbeinsufficientandthepatientwillrequireaPAO[43,44].Onehastobearinmindthatstabilityofthehipfirstlinedependsontheosseousgeometry.Insubtleinstability(borderlinedysplasia)stabilitymaybesecuredbysecondarysofttissuestructures.Oncethesefailduetomicro-ormacrotraumathehipbecomesunstable.Restoringsofttissuestabilitymayimprovehipstabilityforashortperiodoftimeonly,butitislikelythatthesofttissueswearoutagain.Thereforetheunderlyingosseouspathologyhastobeaddressedfirsttoachievegoodlong-termresults.ArecentreportshowedaninferiorhipspecificfunctionaloutcomeofPAOafterfailedhiparthroscopyinhipdysplasia[6].Hiparthroscopyaloneinthisgroupofpatientsshouldbethereforeapproachedwithcaution.However,itmayhavearoleinthosepatientswhoareeitherunsuitableforPAOeitherbecausetheirhipsareunfavourable(i.e.haveanormalAIandnormalfemoralanteversion)orbecausetheiradvancedage(i.e.>40years).WHATARETHERESULTSOFREORIENTINGPERIACETABULAROSTEOTOMYINTHISGROUPOFPATIENTS?Acetabularreorientationviatheperiacetabularosteotomyhasbecomethemostcommontreatmentforacetabulardysplasiawithgoodoutcomesreportedatover20?yearspostoperatively.Traditionallyintra-articularpathologywasaddressedatthetimeofPAObyperformingananteriorarthrotomy.HoweverwiththedevelopmentofminimallyinvasivetechniquesforPAOthisisnolongernecessarilythecase.LessinvasivePAOtechniqueshavedecreasedthetimetopostoperativerecovery[45].ArecentstudyshowedmodifiablefactorssuchashigherphysicalactivityandhigherBMIgreaterthan30?kg/m2leadtoadecreasedageofpresentationforPAO[46].FurthermorepatientsalsopresentedearlierforPAOwithworsedegreesofdysplasia:theLCEAwasindependentlypredictiveofageatsurgery,i.e.patientswithalowerLCEAtendedtorequirePAOsurgeryatanearlierage.However,therewasnodifferenceinoutcomesfollowingPAObetweenmildandmoderatedysplasia.Inthisstudymilddysplasiawasclassifiedas15–25°whichencompassesourdefinitionofborderlinehipdysplasia.Arecentmulticenterprospectivecohortstudythatexaminedpatient-reportedoutcomemeasuresofPAOshowedthat,althoughoverallresultsweregood,improvementsinborderlinehipdysplasticsandmaleswerelessthaninthosepatientswhohadmoreseveredysplasia[47].TheauthorsdiscussedthiswiththedangerofasmallcorrectionthatmayleadtoovercorrectionandiatrogenicFAI,increasedfemoralantetorsionandsofttissuelaxity.RECOMMENDATIONSANDFUTUREDIRECTIONSInborderlinehipsthecrucialstepistodefinestability.Regardingthestabilityofthehipthereareonlytwoconditions:Thehipiseitherstableorunstable.Thereisnothinginbetween.Ifthisconceptisaccepted,thetreatmentgetscomparablysimple.InstabilitymaybecombinedwithotherpathologieslikeFAIoroverload/overuseandcartilagediseasewhichneedconcomitanttreatment.Ifthehipisunstable,acetabularreorientationisnecessary.Addressingonlywornoutsecondarystabilizersdoesnotsolvetheunderlyingbiomechanicproblemandatbestwillyieldsatisfactoryshorttermresults.Instablehips,openorarthroscopicjointpreservingsurgerymaybeperformed.However,wehavetokeepinmindthateachdegreedecreaseoftheLCEanglebelow28°isassociatedwitha13%increaseofosteoarthrosis[20].Therefore,ifindoubt,inordertomaximizethechanceofgoodlong-termresults,wewouldadvocateforanacetabularreorientationoperation.Itisimportanttoidentifytheareaswherewelackknowledgeinordertoguidefurtherresearch.Longer-termfollow-upstudiescomparingacetabularreorientationandhiparthroscopyinthesepatients,ideallyinwhichallimagingparametersandBeightonscoresarerecordedwouldbeperformed.Inadditionpatient-reportedoutcomemeasuresandtimetorecoveryandresumptionofactivitiesincludingsportshouldbeattained.文獻(xiàn)出處:MichaelCWyatt,MartinBeck.Themanagementofthepainfulborderlinedysplastichip.ReviewJHipPreservSurg.2018Apr5;5(2):105-112.doi:10.1093/jhps/hny012.