髖關(guān)節(jié)脫位

髖臼發(fā)育不良：美國(guó)臨床運(yùn)動(dòng)醫(yī)學(xué)雜志2021年研究進(jìn)展作者：JoshuaDHarris,BrianDLewis,KwanJPark作者單位:TheHoustonMethodistHipPreservationProgram,HoustonMethodistOrthopedicsandSportsMedicine,6445MainStreet,Suite2500,Houston,TX77030,USA;HoustonMethodistAcademicInstitute;HoustonMethodistOrthopedics&SportsMedicine,Houston,TX,USA;WeillCornellMedicalCollege,NewYork,NY,USA;TexasA&MUniversity,CollegeStation,TX,USA.Electronicaddress:joshuaharrismd@gmail.com.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要髖臼發(fā)育不良代表與髖部疼痛、不穩(wěn)定和骨關(guān)節(jié)炎相關(guān)的結(jié)構(gòu)病理形態(tài)。廣泛的不典型增生在解剖學(xué)上是指基于3維體積和表面積的覆蓋不足，并根據(jù)覆蓋不足的程度和位置進(jìn)行分類。臨界髖臼發(fā)育不良的定義各不相同，并導(dǎo)致治療方式的不統(tǒng)一。對(duì)于有癥狀的髖臼發(fā)育不良，治療采用髖臼周圍截骨術(shù)。同步或分期髖關(guān)節(jié)鏡檢查對(duì)于解決關(guān)節(jié)內(nèi)病理學(xué)具有顯著優(yōu)勢(shì)。在非髖關(guān)節(jié)骨關(guān)節(jié)炎個(gè)體中，有證據(jù)表明PAO可以改變髖臼發(fā)育不良的自然病史，并降低髖關(guān)節(jié)骨關(guān)節(jié)炎和全髖關(guān)節(jié)置換術(shù)的風(fēng)險(xiǎn)。診所診治要點(diǎn)①髖臼發(fā)育不良是一種復(fù)雜的多平面結(jié)構(gòu)病理形態(tài)，與髖部疼痛、不穩(wěn)定和髖關(guān)節(jié)骨關(guān)節(jié)炎緊密相關(guān)。②髖臼發(fā)育不良的自然病史導(dǎo)致繼發(fā)于高度復(fù)雜的基于3-維度體積和表面積的覆蓋范圍不足軟骨損傷。③髖臼發(fā)育不良可以通過(guò)其位置來(lái)表征定位：前部、后部或外側(cè)部（或整體）。④髖臼發(fā)育不良的評(píng)估需要X線片和MRI、CT掃描，以衡量正常的覆蓋范圍和角度。⑤單純髖關(guān)節(jié)鏡檢查不應(yīng)用于治療中度或嚴(yán)重髖臼發(fā)育不良所致的髖關(guān)節(jié)解剖結(jié)構(gòu)不穩(wěn)定。⑥在正確選擇的具有過(guò)渡性髖臼覆蓋或臨界髖臼發(fā)育不良的患者中，短期和中期的隨訪可以取得良好的效果。PAO和髖關(guān)節(jié)鏡檢查可以同時(shí)或分階段一起使用，以準(zhǔn)確地糾正髖臼發(fā)育不良和FAI髖關(guān)節(jié)撞擊綜合征。⑦在非髖關(guān)節(jié)骨關(guān)節(jié)炎個(gè)體中，PAO改變了髖臼發(fā)育異常的自然病史并降低了以下風(fēng)險(xiǎn)：髖關(guān)節(jié)骨關(guān)節(jié)炎和隨后的THA全髖關(guān)節(jié)置換術(shù)。?Fig.1.Weight-bearingAPpelvisplainradiographwithfocusonlefthipin17-year-oldgirl(left)showinganLCEAof14.3°measuredtothelateralsourcil(middle)and24.6°measuredtothelateralacetabularbone(right).圖1.?17歲女孩的負(fù)重前后位(AP)骨盆X線片，左髖（左）；LCEA測(cè)量值為14.3°（中）；測(cè)量到髖臼骨性外側(cè)邊緣為24.6°（右）。Fig.2.(A)Weight-bearingAPpelvisplainradiographwithfocusonlefthipin19-year-oldwomanshowingaTonnisangleof10°.(B)Anupslopinglateralsourcil(asterisk).(C)Upslopinglateralsourcilinthesamepatientvisualizedon3-dimensionalcomputedtomographyscan;and(D)aFEARIndexof4.1°.圖2.?(A)19歲女性的負(fù)重前后位(AP)骨盆X線片，重點(diǎn)關(guān)注左髖，Tonnis角為10°。(B)向上傾斜的眉弓（星號(hào)）。(C)在3維計(jì)算機(jī)斷層掃描中顯示同一患者的向上傾斜的眉弓；(D)FEAR指數(shù)為4.1°。femoroepiphysealacetabularroof：股骨骨骺髖臼頂TheFEARindexhasvalueintheevaluationofhipinstability(femoralheadmigrationonconventionalplainradiographsorheadrecenteringonanAPabductionview)inpatientswithtransitionalacetabularcoverage.FEAR指數(shù)對(duì)于評(píng)估具有過(guò)渡性髖臼覆蓋的患者的髖關(guān)節(jié)不穩(wěn)定性（傳統(tǒng)X線片上的股骨頭移位或AP外展視圖上的股骨頭復(fù)位）具有價(jià)值。Fig.3.Falseprofileplainradiographofrighthipin21-year-oldwoman(left)showinganACEAof22°measuredtotheanteriorsourcil(middleimage)and37.9°measuredtotheanterioracetabularbone(right).圖3.?21歲女性右髖部的假斜位X線片（左）；ACEA測(cè)量到髖臼關(guān)節(jié)面前緣的角度為22°（中）；測(cè)量到髖臼前緣骨質(zhì)的角度為37.9°（右）。Fig.4.Weight-bearingAPpelvisplainradiographwithfocusonrighthipin24-year-oldmanshowingthemeasurementsneededtocalculatetheAWIandthePWI.Abest-fittingperfectcircleisdrawnaroundthefemoralhead.Alineisdrawnconnectingthefemoralneckcenterintersectingwiththeheadcenter.AWI=AW/r;PWI=PW/r.圖4.?24歲男性的負(fù)重前后位(AP)骨盆X線片，重點(diǎn)關(guān)注右髖，顯示計(jì)算AWI和PWI所需的測(cè)量值。在股骨頭周圍繪制一個(gè)最合適的完美圓。繪制一條連接股骨頸中心與股骨頭中心相交的線。AWI=AW/r；PWI=PW/r。PWI:theposteriorwallindex;AWI:anteriorwallindex.PWI：后壁指數(shù)；AWI：前壁指數(shù)。Fig.5.Weight-bearingAPpelvisplainradiographwithfocusonrighthipin31-year-oldmandemonstratingapositiveposteriorwallsign()andpositiveischialspinesign(#).圖5.?31歲男性的負(fù)重前后位(AP)骨盆X線片，重點(diǎn)關(guān)注右髖，后壁征()和坐骨棘征(#)陽(yáng)性。Fig.6.Clock-facepositionsofversionmeasurements.This3-dimensionalmodeldepictsthe3differentlocationsweusedtomeasurefocalacetabularversion(1,2,and3o’clock).(FromTannenbaumEP,ZhangP,MarattJD,etal.AComputedTomographyStudyofGenderDifferencesinAcetabularVersionandMorphology:ImplicationsforFemoroacetabularImpingement.Arthroscopy2015;31:1247–54;withpermission.)圖6.?髖臼測(cè)量的鐘面位置。這個(gè)3維模型描繪了我們用來(lái)測(cè)量髖臼局部區(qū)域的3個(gè)不同位置視圖（1點(diǎn)、2點(diǎn)和3點(diǎn)鐘方向）。Fig.7.Assessmentoffemoraltorsiononcross-sectionalimaging.Onconsecutivestrictaxialimagesovertheproximalfemur,determinethefemoralheadcenter(FHC)(yellowcircleandyellowline).Definingthefemoralneckaxis(greenline)canbedonebyseveralmethods.Leemethod(redbar):AlineisdrawnonthefirstimageonwhichtheFHCcanbeconnectedwiththemostcephalicjunctionofthegreatertrochanterandthefemoralneck;Reikerasmethod(lightbluebar):AlineconnectingtheFHCwiththefemoralneckcenterisdrawnonanimagewheretheanteriorandposteriorcorticesrunparalleltoeachother;Jarretmethod(notshown):AlineisdrawnonasingleimagethatrunsfromtheFHCtroughthecenterofthefemoralneck;Tomczakmethod(darkbluebar):TheFHCisconnectedwiththecenterofthegreatertrochanteratthebaseofthefemoralneck;andMurphymethod(orangebar):TheFHCisconnectedwiththecenterofthebaseofthefemoralneckdirectlysuperiortothelessertrochanter.Then,overthedistalfemur,drawatangenttotheposterioraspectofthefemoralcondyles(blueline;choosingtheslicewherethecondylesaremoreprominent).Theanglebetweenbothlinesrepresentsthefemoraltorsion.Althoughsomeofthesereferencepointsarelocatedondifferentadjacentslices,modernworkstationsshouldallowdrawingandmodifyingalineacrossmultipleimagesin1seriesor,alternatively,differentslicescanbesuperimposedonasingleimagewiththehelpofpostprocessingsoftware.(FromMascarenhasVV,AyeniOR,EgundN,etal.ImagingMethodologyforHipPreservation:Techniques,Parameters,andThresholds.SeminMusculoskeletRadiol2019;23:197-226;withpermission.)圖7.?橫截面成像評(píng)估股骨扭轉(zhuǎn)角度。在股骨近端的連續(xù)嚴(yán)格軸向圖像上，確定股骨頭中心(FHC)（黃色圓圈和黃線）?？梢酝ㄟ^(guò)多種方法來(lái)定義股骨頸軸（綠線）。Lee法（紅條）：在第一張圖像上畫一條線，將FHC與大轉(zhuǎn)子和股骨頸的最頭連接處連接起來(lái)；Reikeras方法（淺藍(lán)色條）：在圖像上繪制連接FHC與股骨頸中心的線，其中前皮質(zhì)和后皮質(zhì)彼此平行；Jarret方法（未顯示）：在單個(gè)圖像上繪制一條從FHC穿過(guò)股骨頸中心的線；Tomczak法（深藍(lán)色條）：FHC與股骨頸基部大轉(zhuǎn)子中心相連；墨菲法（橙色條）：FHC與小轉(zhuǎn)子正上方的股骨頸基底部中心相連。然后，在股骨遠(yuǎn)端上，繪制股骨髁后部的切線（藍(lán)線；選擇髁更突出的切片）。兩條線之間的角度代表股骨扭轉(zhuǎn)角度。盡管其中一些參考點(diǎn)位于不同的相鄰切片上，但現(xiàn)代工作站應(yīng)該允許在1系列中的多個(gè)圖像上繪制和修改一條線，或者，可以借助后處理軟件將不同的切片疊加在單個(gè)圖像上。Fig.8.PostoperativeAPpelvisplainradiographfollowingPAO(Periacetabularosteotomy)oflefthipin20-year-oldwomanwithanLCEAof34°(left)andaTonnisangleof3°?(right).圖8.?20歲女性左髖PAO（髖臼周圍截骨術(shù)）術(shù)后前后位(AP)骨盆X線片，LCEA為34°（左），Tonnis角為3°（右）。?HipDysplasiaAbstractAcetabulardysplasiarepresentsastructuralpathomorphologyassociatedwithhippain,instability,andosteoarthritis.Thewidespectrumofdysplasiaanatomicallyreferstoa3-dimensionalvolumetric-andsurfacearea-basedinsufficiencyincoverageandisclassifiedbasedonthemagnitudeandlocationofundercoverage.Borderlinedysplasiahasbeenvariablydefinedandleadstomanagementchallenges.Insymptomaticdysplasia,treatmentaddressescoveragewithperiacetabularosteotomy.Concomitantsimultaneousorstagedhiparthroscopyhassignificantadvantagestoaddressintra-articularpathology.Innonarthriticindividuals,thereisevidencePAOaltersthenaturalhistoryofdysplasiaanddecreasestheriskofhiparthritisandtotalhiparthroplasty.CLINICSCAREPOINTSAcetabulardysplasiaisacomplexmultiplanarstructuralpathomorphologyassociatedwithhippain,instability,andosteoarthritis.Thenaturalhistoryofdysplasialeadstochondralinjurysecondarytothehighlycomplex3-dimensionalvolumetric-andsurfacearea-basedinsufficiencyincoverage.Dysplasiacanbecharacterizedbyitslocation:anterior,posterior,orlateral(orglobal).EvaluationofdysplasiarequiresplainradiographsandeitherMRIorCTscan(orboth)toproperlymeasurecoverageandversion.Isolatedarthroscopyshouldnotbeusedtotreatstructuralinstabilityobservedinmoderateorseveredysplasia.Inproperlyselectedpatientswithtransitionalacetabularcoverage,orborderlinedysplasia,goodoutcomescanbeachievedatshort-andmid-termfollow-up.PAOandhiparthroscopycanbeusedtogether,eithersimultaneousorstaged,toaccuratelycorrectbothdysplasiaandFAIsyndrome.Innonarthriticindividuals,PAOaltersthenaturalhistoryofdysplasiaandreducestheriskofhiparthritisandsubsequentTHA.文獻(xiàn)出處：JoshuaDHarris,BrianDLewis,KwanJPark.HipDysplasia.ReviewClinSportsMed.2021Apr;40(2):271-288.?

專家介紹：劉萬(wàn)軍，主任醫(yī)師，醫(yī)學(xué)博士，研究生導(dǎo)師；上海交通大學(xué)醫(yī)學(xué)院附屬第六人民醫(yī)院；骨科-關(guān)節(jié)外科主任醫(yī)師，東院關(guān)節(jié)外科負(fù)責(zé)人，擅長(zhǎng)疾?。?、髖關(guān)節(jié)置換、膝關(guān)節(jié)置換手術(shù)（股骨頭壞死、嚴(yán)重骨折手術(shù)后髖關(guān)節(jié)炎、嚴(yán)重髖關(guān)節(jié)發(fā)育不良、嚴(yán)重類風(fēng)濕性髖關(guān)節(jié)炎、髖關(guān)節(jié)僵直、嚴(yán)重老年骨質(zhì)增生性膝關(guān)節(jié)炎引起的關(guān)節(jié)痛）；2、髖膝關(guān)節(jié)翻劉萬(wàn)軍+住院后可以立刻做髖關(guān)節(jié)手術(shù)嗎？修術(shù)；3、早期股骨頭壞死的保髖手術(shù)；4、早期膝關(guān)節(jié)骨性關(guān)節(jié)炎的保膝手術(shù)；5、關(guān)節(jié)置換術(shù)后假體感染及術(shù)后骨折；6、各類骨關(guān)節(jié)疼痛疾病的微創(chuàng)治療。

髖關(guān)節(jié)置換術(shù)后髖關(guān)節(jié)脫位分為前脫位和后脫位。前脫位的患者會(huì)出現(xiàn)伸直外旋動(dòng)作，表現(xiàn)為一只腳外旋畸形。髖關(guān)節(jié)的后脫位原因多半是接口在髖關(guān)節(jié)的后外側(cè)，主要表現(xiàn)在長(zhǎng)短腿，即雙下肢不等長(zhǎng)，還有局部的疼痛以及活動(dòng)障礙?；颊叱霈F(xiàn)脫位以后要積極制動(dòng)、降低繼續(xù)活動(dòng)頻率，還需要去醫(yī)院進(jìn)行X光檢查?；颊咝枰鞔_是前脫位還是后脫位、是否伴有假體周圍的骨折或者是假體的松動(dòng)等等，根據(jù)不同的情況進(jìn)行不同的治療。如果沒(méi)有骨折也沒(méi)有相應(yīng)的松動(dòng)，最好到醫(yī)院以后進(jìn)行麻醉手法復(fù)位進(jìn)行復(fù)位，重獲關(guān)節(jié)的功能。

發(fā)育性髖關(guān)節(jié)脫位（DDH）是可能導(dǎo)致兒童殘疾的重要疾病之一，也是對(duì)兒童骨科專家的重大挑戰(zhàn)！幸運(yùn)的是，目前在治療此病，我還保持開(kāi)放復(fù)位手術(shù)，從未發(fā)生再脫位。我無(wú)法確保以后手術(shù)，也一定不會(huì)發(fā)生再脫位，但是我一定會(huì)全力以赴、竭盡全力！手術(shù)效果展示：病例：黃佳X，女，2歲左DDH，行左側(cè)髖關(guān)節(jié)開(kāi)放復(fù)位（Pemberton）手術(shù)。術(shù)前X線片術(shù)后2月X線片術(shù)后1年X線片術(shù)后5年X線片

手術(shù)后10年了，這個(gè)小女孩長(zhǎng)大了，學(xué)習(xí)特別好，還是她們班的運(yùn)動(dòng)小健將呢。前兩天來(lái)復(fù)查：雙下肢等長(zhǎng)，左側(cè)髖關(guān)節(jié)功能完全正常。家長(zhǎng)說(shuō)孩子日常行走運(yùn)動(dòng)和其他孩子沒(méi)有什么不同，完全就是一個(gè)正常孩子啊?？梢则湴烈幌掳?。

展示一下，這樣的才是完美的髖關(guān)節(jié)脫位手術(shù)效果?。ㄩ_(kāi)放復(fù)位、Pemberton骨盆截骨、股骨短縮旋轉(zhuǎn)截骨手術(shù)）迄今為止，我做過(guò)的最大年齡發(fā)育性髖關(guān)節(jié)脫位（9歲1月女孩，左側(cè)發(fā)育性髖關(guān)節(jié)脫位）的全套截骨手術(shù)，手術(shù)效果完美，值得紀(jì)念！挽救了一個(gè)孩子，也就挽救了一個(gè)家庭，幸福感滿滿！那么普通公眾該如何判斷髖脫位手術(shù)效果的好壞呢？很簡(jiǎn)單，用正常側(cè)的髖關(guān)節(jié)圖像與患側(cè)手術(shù)后的髖關(guān)節(jié)圖像對(duì)比，如果看起來(lái)一樣，手術(shù)一定做得很漂亮！