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保髖截骨治療髖關(guān)節(jié)發(fā)育不良(8)：?jiǎn)闻_(tái)同時(shí)進(jìn)行無(wú)(會(huì)陰)柱髖關(guān)節(jié)鏡檢查聯(lián)合髖臼周?chē)毓切g(shù)治療DDH保髖截骨治療髖關(guān)節(jié)發(fā)育不良(8)：?jiǎn)闻_(tái)同時(shí)進(jìn)行無(wú)(會(huì)陰)柱髖關(guān)節(jié)鏡檢查聯(lián)合髖臼周?chē)毓切g(shù)治療髖關(guān)節(jié)發(fā)育不良作者：DustinWoyski,SteveOlson,BrianLewis.作者單位:DepartmentofOrthopaedicSurgery,DukeUniversity,Durham,NorthCarolina,U.S.A.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要已經(jīng)證實(shí)，關(guān)節(jié)鏡和開(kāi)放式髖關(guān)節(jié)保留技術(shù)都可以改善患者的預(yù)后并阻斷髖關(guān)節(jié)疾病的自然病程。傳統(tǒng)上，髖關(guān)節(jié)鏡檢查用于治療由盂唇撕裂、髖關(guān)節(jié)撞擊畸形和軟骨病變組成的髖關(guān)節(jié)疾病。髖臼周?chē)毓切g(shù)是治療因股骨頭對(duì)髖臼覆蓋不足或發(fā)育不良引起的髖關(guān)節(jié)不穩(wěn)定的最常用方法。由于髖臼周?chē)毓切g(shù)失敗與術(shù)后撞擊有關(guān)，且發(fā)育不良髖關(guān)節(jié)的關(guān)節(jié)內(nèi)病變發(fā)生率高，人們對(duì)將髖關(guān)節(jié)鏡檢查與髖臼周?chē)毓切g(shù)相結(jié)合產(chǎn)生了濃厚的興趣。在這里，我們描述了一種單臺(tái)、單鋪巾、無(wú)(會(huì)陰)柱聯(lián)合髖關(guān)節(jié)鏡檢查和髖臼周?chē)毓切g(shù)的技術(shù)。討論據(jù)報(bào)道，通過(guò)開(kāi)放或關(guān)節(jié)鏡檢查發(fā)現(xiàn)髖關(guān)節(jié)發(fā)育不良患者的關(guān)節(jié)內(nèi)病變發(fā)生率很高。我們的絕大多數(shù)患者也符合Warwick髖關(guān)節(jié)鏡治療標(biāo)準(zhǔn)，這體現(xiàn)在影像學(xué)、體格檢查和病史方面。由于這些因素，自2013年以來(lái)，我們一直在我們機(jī)構(gòu)的幾乎每例PAO患者身上同時(shí)進(jìn)行關(guān)節(jié)鏡檢查，并且自2018年3月以來(lái)一直采用當(dāng)前的無(wú)(會(huì)陰)柱技術(shù)。多年來(lái)，我們的髖關(guān)節(jié)鏡和PAO聯(lián)合技術(shù)已發(fā)展到本技術(shù)說(shuō)明中所述的使用1張手術(shù)臺(tái)且無(wú)需會(huì)陰柱的技術(shù)。這位資深外科醫(yī)生已經(jīng)進(jìn)行了500多例PAO手術(shù)，并發(fā)現(xiàn)同時(shí)進(jìn)行的關(guān)節(jié)鏡檢查不會(huì)增加PAO的手術(shù)時(shí)間，而且，如果有的話(huà)，由于關(guān)節(jié)鏡檢查液的水分離，使暴露更容易，出血更少，組織平面更清晰。過(guò)去20年來(lái)，PAO的長(zhǎng)期結(jié)果已得到充分描述，伯爾尼原始隊(duì)列的三分之一患者的髖關(guān)節(jié)在30年后得以保存。PAO失敗的一個(gè)已知原因是未解決股骨髖臼撞擊或通過(guò)PAO矯正造成撞擊。然而，在PAO時(shí)解決中央和外周間室病理是否會(huì)影響短期和長(zhǎng)期結(jié)果仍有待觀(guān)察。迄今為止的報(bào)告很少，并且與治療關(guān)節(jié)內(nèi)病理的選擇偏差不一致，這些選擇偏差針對(duì)的是那些有撞擊體征和癥狀或MRI發(fā)現(xiàn)盂唇病理的患者。我們堅(jiān)信，由于關(guān)節(jié)內(nèi)病理與發(fā)育不良患者的凸輪形態(tài)高度相關(guān)，因此在PAO之前對(duì)所有髖關(guān)節(jié)進(jìn)行關(guān)節(jié)鏡評(píng)估和治療是必要的。我們發(fā)現(xiàn)關(guān)節(jié)內(nèi)病變的患病率非常高，幾乎所有髖關(guān)節(jié)均出現(xiàn)PAO且需要進(jìn)行盂唇修復(fù)，超過(guò)一半的髖關(guān)節(jié)出現(xiàn)一定程度的髖臼軟骨軟化。使用一張手術(shù)臺(tái)和鋪巾使我們能夠完成高效的髖關(guān)節(jié)鏡和PAO聯(lián)合手術(shù)。在我們機(jī)構(gòu)，關(guān)節(jié)鏡和PAO均由一位外科醫(yī)生進(jìn)行。缺乏經(jīng)驗(yàn)的外科醫(yī)生不應(yīng)單獨(dú)進(jìn)行這兩種手術(shù)，因?yàn)镻AO和關(guān)節(jié)鏡髖關(guān)節(jié)手術(shù)的學(xué)習(xí)曲線(xiàn)都很陡峭。任何涉及多種復(fù)雜、困難手術(shù)和新設(shè)備組合的新技術(shù)都可能帶來(lái)潛在的缺點(diǎn)和風(fēng)險(xiǎn)。但是，如果由經(jīng)驗(yàn)豐富的外科醫(yī)生進(jìn)行，在PAO之前增加關(guān)節(jié)鏡檢查是安全的，并且不會(huì)增加并發(fā)癥發(fā)生率。?Fig1ViewofstandardHanatablesetupwithPinkHipKitandpatientdrawsheetfoldedinhalffromthe(A)sideand(B)above.(C)Viewfromaboveoftheidealpatientplacementwithperineumapproximately4to6cmfromthepostpositioninghole.圖1?標(biāo)準(zhǔn)Hana桌設(shè)置視圖，配有粉色髖關(guān)節(jié)套件和患者抽紙，從(A)側(cè)面和(B)上方折疊成兩半。(C)從上方查看理想的患者放置位置，會(huì)陰距離定位孔約4至6厘米。Fig2(A)Patientissupinewiththelefthipsterilelypreppedanddrapedandinferiormarginofiliaccrestoutlined.TheASISandGTaremarkedaswell.TheincisionoftheperiacetabularosteotomyismadefromtheGTandisconnectedtotheMAP.(B)IncisionforthePAOismadefromtheGTtotheMAP.(C)ExposureoftheEOFisimportantbeforemasking.(D)FleckosteotomyoftheASISoffoftheICusingaone-half-inchstraightosteotome.(AL,anterolateralportal;ASIS,anterosuperioriliacspine;DALA,distalanterolateralaccessoryportal;EOF,externalabdominalobliquemuscleandfascia;GT,glutealtubercle;IC,iliaccrest;MAP,mid-anteriorportal;PAO,periacetabularosteotomy.)圖2?(A)患者仰臥，左側(cè)髖關(guān)節(jié)無(wú)菌準(zhǔn)備并鋪上布，髂嵴下緣輪廓清晰。ASIS和GT也已標(biāo)記。髖臼周?chē)毓切g(shù)的切口從GT開(kāi)始，并與MAP相連。(B)PAO的切口從GT到MAP。(C)在遮蓋之前，暴露EOF非常重要。(D)使用半英寸直骨刀對(duì)IC上的ASIS進(jìn)行斑點(diǎn)截骨術(shù)。（AL，前外側(cè)入口；ASIS，髂前上棘；DALA，遠(yuǎn)端前外側(cè)副入口；EOF，腹外斜肌和筋膜；GT，髂結(jié)節(jié)；IC，髂嵴；MAP，中前入口；PAO，髖臼周?chē)毓切g(shù)。）Fig3Magneticresonanceimagingbased3-dimensionalrenderingofalefthipjointviewedanteriorlyisusedforpreoperativeplanning.Thisdemonstratestypicalfindingsoffocalfemoroacetabularimpingementfoundinthedysplastichipwithaminimalcamandpincer(),whicharelabeled.(PS,pubicsymphysis;SS,subspine.)圖3?基于磁共振成像的左側(cè)髖關(guān)節(jié)前方三維渲染圖用于術(shù)前規(guī)劃。這顯示了髖關(guān)節(jié)發(fā)育不良中發(fā)現(xiàn)的典型局灶性股骨髖臼撞擊，輕度凸輪和鉗夾畸形（），已標(biāo)記。（PS，恥骨聯(lián)合；SS，髂前下棘。）Fig4Intraoperativefluoroscopicimagesofalefthipperiacetabularosteotomy.(A)Anteroposteriorviewdemonstratingthenarrowcurvedosteotomeagainstthemedialaspectoftheanteriorischiumpriortoosteotomy.(B)Iliacobliqueviewwiththeacetabulumoutlinedinblueandposteriorcolumnincludingischialspineoutlinedingreenshowingthe(C)appropriatedepthofthecurvedosteotomeoftheincompleteischialosteotomy.(D)Anteroposteriorviewshowingthecurvedosteotome’sidealpositionbehindtheacetabulum.圖4?左側(cè)髖臼周?chē)毓切g(shù)術(shù)中透視圖像。（A）前后視圖，顯示截骨術(shù)前狹窄彎曲骨鑿抵靠前坐骨內(nèi)側(cè)。(B)髂骨斜視圖，髖臼以藍(lán)色勾勒，包括坐骨棘在內(nèi)的后柱以綠色勾勒，(C)顯示不完全坐骨截骨術(shù)的彎曲骨鑿的適當(dāng)深度。(D)前后視圖顯示彎曲骨鑿在髖臼后方的理想位置。Fig5Fluoroscopicimagesofthelefthip.(A)Widestraightosteotomeincorrectpositionontheanteroposteriorviewoverlyingtheacetabularteardrop.(B)Iliacobliqueviewwiththeiliacosteotomymadeusingtheoscillatingsawoutlinedinblue.(C)Iliacobliqueviewofthestraightosteotomecomingbehindtheacetabulumand(D)connectingwiththepreviousincompleteischialosteotomy,whichisoutlinedinblue.圖5?左髖的透視圖像。(A)寬直骨鑿在前后視圖上處于正確位置，覆蓋髖臼淚滴。(B)髂骨斜視圖，使用擺鋸進(jìn)行的髂骨截骨術(shù)以藍(lán)色勾勒。(C)髂骨斜視圖，直骨鑿位于髖臼后方，(D)與之前的不完全坐骨截骨術(shù)相連，后者以藍(lán)色勾勒。Fig6Lefthipfluoroscopiciliacobliqueviewsoftheacetabularfragment(A)beforecorrectionwiththeacetabulumoutlinedinblueand(B)postcorrectionwithprovisionalfixationusing3.2-mmdrillbits.(C)Iliacobliqueand(D)anteroposteriorfluoroscopicviewsshowingfinalpositionofacetabularfragmentfollowingperiacetabularosteotomywith4.5-mmscrewsinplace.圖6左髖關(guān)節(jié)透視髂骨斜視圖顯示髖臼塊（A）矯正前，髖臼用藍(lán)色勾勒，（B）矯正后，使用3.2毫米鉆頭進(jìn)行臨時(shí)固定。（C）髂骨斜視圖和（D）前后透視視圖顯示髖臼塊的最終位置，髖臼周?chē)毓切g(shù)后，4.5毫米螺釘固定。Fig7Anteroposteriorviewsofthepelvisshowingthelefthip(A)preoperativelyand(B)postoperatively.Increasedlateralcoverageofthefemoralheadanddecreasedinclinationoftheacetabularsourcilarenoted.圖7?骨盆前后視圖顯示左髖關(guān)節(jié)（A）術(shù)前和（B）術(shù)后。注意到股骨頭的側(cè)向覆蓋增加，髖臼底部?jī)A斜度減小。?SingleTableConcomitantPost-LessHipArthroscopyCombinedwithPeriacetabularOsteotomyforHipDysplasiaAbstractIthasbeenwellestablishedthatbotharthroscopicandopenhippreservationtechniquescanresultinimprovedpatientoutcomesandinterruptthenaturalhistoryofhipdisease.Traditionally,hiparthroscopyhasbeenusedtoaddresscentralandperipheralcompartmentdiseaseconsistingoflabraltears,impingementmorphologyandcartilagepathology.Theperiacetabularosteotomyhasbeenthemostusedtreatmentforhipinstabilitycausedbyinadequateacetabularcoverageofthefemoralheadordysplasia.Withfailuresofperiacetabularosteotomylinkedtopostoperativeimpingementandthehighincidenceofintra-articularpathologyinthedysplastichip,therehasbeenagreatinterestincombinghiparthroscopywiththeperiacetabularosteotomy.Here,wedescribeatechniqueforasingletable,singledrape,postlesscombinedhiparthroscopy,andperiacetabularosteotomy.DiscussionAhighincidenceintra-articularpathologyinpatientswithhipdysplasiawhenidentifiedbyopenorarthroscopicmeanshasbeenreported.5ThevastmajorityofourpatientsalsosatisfytheWarwickcriteriaforacceptabilityforhiparthroscopyfromtheirimaging,physicalexamination,andhistory.6Becauseofthesefactors,wehavebeenperformingconcomitantarthroscopyonnearlyeveryPAOatourinstitutionsince2013andhavebeenperformingthecurrentpostlesstechniquesinceMarch2018.OurtechniqueofcombinedhiparthroscopyandPAOhasevolvedovertheyearstowhatisdescribedinthisTechnicalNotewiththeuseof1tableandwithoutaperinealpost.Theseniorsurgeonhasperformedmorethan500PAOproceduresandhasfoundthatconcomitantarthroscopydoesnotincreasetheoperativetimeofthePAOand,ifanything,hasmadetheexposureeasierwithlessbleedingandbetter-definedtissueplanesbecauseofhydro-dissectionfromthearthroscopyfluid.TheeaseofexposurealongwithothertechnicalpearlsandbenefitsareoutlinedinTable1.Thelong-termoutcomesofPAOhavebeenwelldescribedoverthepast2decades,withone-thirdoftheoriginalBernesecohorthavingbeenpreservedat30years.7AknowncauseoffailureofthePAOisnotaddressingfemoroacetabularimpingementorcreatingimpingementwiththePAOcorrection.8However,itremainstobeseenifaddressingcentralandperipheralcompartmentpathologyatthetimeofPAOcanaffectshort-andlong-termoutcomes.Reportsthusfarhavebeensparseandinconsistentwithselectionbiasoftreatingintra-articularpathologytothosewithsignsandsymptomsofimpingementorMRIfindingsoflabralpathology.Wefirmlybelievethatwiththehighassociationofintra-articularpathologyandcammorphology9inpatientswithdysplasiathatanarthroscopicevaluationandtreatmentofthecentralandperipheralcompartmentsofthehipiswarrantedinallhipsbeforePAO.Wehavefoundaveryhighprevalenceofintra-articularpathologywithnearlyallhipspresentingforPAOrequiringalabralrepairandmorethanone-halfwithsomedegreeofchondromalaciaoftheacetabulum.TheuseofasingletableanddrapinghasallowedustocompleteanefficientcombinedhiparthroscopyandPAO(Table1).Atourinstitution,boththearthroscopyandPAOareperformedbyasinglesurgeon.NeitheroftheseproceduresaloneshouldbetakenonbytheinexperiencedsurgeonbecauseboththePAOandarthroscopichipsurgeryhaveasteeplearningcurve.10,11Anynewtechniqueinvolvingthecombinationofmultiplecomplex,difficultproceduresandnewequipmentcancarrypotentialdisadvantagesandrisks(Table2).Whenperformedbyanexperiencedsurgeon,however,theadditionofarthroscopybeforePAOcanbedonesafelyanddoesnotincreasethecomplicationrate.12文獻(xiàn)出處：DustinWoyski,SteveOlson,BrianLewis.SingleTableConcomitantPost-LessHipArthroscopyCombinedwithPeriacetabularOsteotomyforHipDysplasia.ArthroscTech.2019Nov25;8(12):e1569-e1578.doi:10.1016/j.eats.2019.08.015.eCollection2019Dec.陶可醫(yī)生的科普號(hào)
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(guò)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(zhēng)議。在這篇評(píng)論中，我們將確定相關(guān)問(wèn)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(lái)的研究領(lǐng)域。簡(jiǎn)介在過(guò)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(guò)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(jiàn)的。然而，有一個(gè)過(guò)渡區(qū)，很難區(qū)分不穩(wěn)定性和股骨髖臼撞擊(FAI)。過(guò)去，這些髖關(guān)節(jié)被稱(chēng)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(wèn)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(guān)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(lái)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(lèi)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(zhēng)議的問(wèn)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(jiàn)，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(wèn)題是難以正確分類(lèi)潛在的病理生物力學(xué)。定義第一個(gè)問(wèn)題在于定義。在前后位骨盆X線(xiàn)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(lèi)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(wèn)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(guò)與股骨頭輪廓相符的圓來(lái)定義股骨頭的中心。角度的第一個(gè)分支垂直穿過(guò)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(lèi)為臨界。其次，實(shí)際術(shù)語(yǔ)“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(wú)法預(yù)測(cè)臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性，也無(wú)法完全描述股骨頭覆蓋范圍。因此，外側(cè)中心邊緣角(LCEA)無(wú)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(wú)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(guò)度可能會(huì)加劇髖關(guān)節(jié)前部不穩(wěn)定[16]。根本問(wèn)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(guò)二維射線(xiàn)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(lái)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(wèn)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(lái)[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(méi)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(zhǎng)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(jiàn)。此外，還會(huì)詢(xún)問(wèn)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(jiàn)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。患者通常會(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(guò)度。應(yīng)確定大轉(zhuǎn)子處有無(wú)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(guò)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(kāi)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(jiàn)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(guò)與髂坐線(xiàn)的距離增加、Shenton線(xiàn)斷裂和AP視圖上股骨頭重新定位來(lái)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(jiàn)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?chē)夷[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(guò)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(zhuān)門(mén)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?？梢詤^(qū)分引起類(lèi)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(xiàn)的距離增加，Shenton線(xiàn)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(zhǎng)板中央1/3處之間的角度形成的（圖2）。其依據(jù)是：在生長(zhǎng)過(guò)程中，股骨的骨骺生長(zhǎng)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(zhǎng)和方向受股骨頸下生長(zhǎng)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(zhǎng)過(guò)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(lái)得到了Carter等人[33]的證實(shí)，他們通過(guò)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(guò)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(zhǎng)過(guò)程中長(zhǎng)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(xiàn)與連接股骨頭骨骺直線(xiàn)部分（通常為中央三分之一）內(nèi)側(cè)和外側(cè)端的線(xiàn)之間的角度。如圖3a所示，角度向內(nèi)側(cè)打開(kāi)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(guò)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(jiàn)圖2）。非手術(shù)治療包括患者教育、活動(dòng)調(diào)整、簡(jiǎn)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(lái)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?chē)毓切g(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(zhǎng)。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(lái)解決骨穩(wěn)定性不足的問(wèn)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(fǎng)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(guān)和/或客觀(guān)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(guò)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(jiàn)（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(méi)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(guò)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(lái)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?；謴?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(wèn)題，才能取得良好的長(zhǎng)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?chē)毓切g(shù)對(duì)這組患者有何影響？通過(guò)髖臼周?chē)毓切g(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(jiàn)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(kāi)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(méi)有差異。在本研究中，輕度發(fā)育不良被歸類(lèi)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(guò)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(lái)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(méi)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(jiǎn)單。不穩(wěn)定可能與其他病癥（如FAI或超負(fù)荷/過(guò)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(wèn)題，最多只能產(chǎn)生令人滿(mǎn)意的短期結(jié)果。在穩(wěn)定的髖關(guān)節(jié)中，可以進(jìn)行開(kāi)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(wèn)，為了最大限度地提高獲得良好長(zhǎng)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χR(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(zhǎng)期隨訪(fǎng)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.北大人民醫(yī)院科普號(hào)
髖關(guān)節(jié)發(fā)育不良保髖手術(shù)常見(jiàn)問(wèn)題問(wèn)：髖關(guān)節(jié)發(fā)育不良可不可以保守治療，是否必須手術(shù)？答：首先，保守治療無(wú)非控制活動(dòng)量、控制體重、吃止疼藥、加強(qiáng)肌肉鍛煉，一定程度可以緩解疼痛癥狀，但是根本的骨頭畸形并沒(méi)有改變，也就是說(shuō)，保守治療只能一定程度延緩病情進(jìn)展，無(wú)法解決根本問(wèn)題。手術(shù)的目的是為了緩解疼痛、延長(zhǎng)自身關(guān)節(jié)的使用壽命，從根本上解決問(wèn)題。如果本身關(guān)節(jié)不疼，或者疼痛非常非常輕，可以暫且保守治療。但是，如果關(guān)節(jié)疼痛比較頻繁或者比較重，手術(shù)可能是解決當(dāng)前問(wèn)題的最佳方式。?問(wèn)：保髖術(shù)后我的關(guān)節(jié)能用多少年？答：這個(gè)問(wèn)題很難回答。影響關(guān)節(jié)使用壽命的因素太多了，比如手術(shù)時(shí)關(guān)節(jié)軟骨磨損重不重、自身的軟骨耐磨程度如何、自身的關(guān)節(jié)畸形重不重、手術(shù)醫(yī)生的水平好不好、術(shù)后體重控制得好不好、術(shù)后關(guān)節(jié)保養(yǎng)的好不好。理論上講，通過(guò)手術(shù)糾正畸形可以讓關(guān)節(jié)的使用壽命盡可能延長(zhǎng)，最好的效果就是用一輩子，當(dāng)然，少術(shù)患者也有術(shù)后幾年、十幾年后出現(xiàn)關(guān)節(jié)磨損嚴(yán)重，進(jìn)而換關(guān)節(jié)的?？傮w上講，找一個(gè)靠譜的醫(yī)生，術(shù)后自己好好保養(yǎng)，剩下的就交給天意了。?問(wèn)：手術(shù)后我應(yīng)該怎么保養(yǎng)自身的關(guān)節(jié)？答：手術(shù)的目的還是希望大家回歸正常的生活。有的極端的患者，為了減少關(guān)節(jié)負(fù)重會(huì)走極端，比如坐輪椅，甚至少穿衣服，其實(shí)大可不必，該干嘛干嘛。如果可以的話(huà)，適當(dāng)避免長(zhǎng)時(shí)間重體力勞動(dòng)或者劇烈運(yùn)動(dòng)。當(dāng)然，如果你覺(jué)得運(yùn)動(dòng)是生命中不可缺少的一部分，那也不用刻意壓抑，這一點(diǎn)國(guó)外是比較積極的，很多患者手術(shù)就是為了后續(xù)運(yùn)動(dòng)時(shí)不疼。當(dāng)然，如果能把體重控制在理想的區(qū)間肯定是最好的。?問(wèn)：我想手術(shù)了，術(shù)前應(yīng)該做哪些準(zhǔn)備？答：1、異地就醫(yī)，提前進(jìn)行醫(yī)保備案，具體需要詢(xún)問(wèn)當(dāng)?shù)蒯t(yī)保部門(mén)；2、準(zhǔn)備一副拐杖，肘拐腋拐都可以，調(diào)整拐杖高度，練習(xí)拄拐單腿走路；3、術(shù)前可以按醫(yī)生的建議進(jìn)行功能鍛煉，改善肌力，加速術(shù)后康復(fù)；4、帶著之前拍的片子及病歷；5、酌情準(zhǔn)備個(gè)人生活物品。?問(wèn)：髖臼周?chē)毓鞘中g(shù)風(fēng)險(xiǎn)高不高？答：這個(gè)手術(shù)確實(shí)難度很大，被譽(yù)為骨科的珠穆朗瑪，手術(shù)的入門(mén)門(mén)檻很高，學(xué)習(xí)曲線(xiàn)很長(zhǎng)，目前全國(guó)只有為數(shù)不多的醫(yī)生可以做這類(lèi)手術(shù)。記得我在美國(guó)學(xué)習(xí)的時(shí)候，看過(guò)兩個(gè)醫(yī)生做這個(gè)手術(shù)，一個(gè)醫(yī)生平均需要三四個(gè)小時(shí)，另一個(gè)醫(yī)生需要6-8個(gè)小時(shí)。對(duì)于我們來(lái)說(shuō)，絕大多術(shù)的手術(shù)可以在1小時(shí)出頭的時(shí)間完成，手術(shù)不但做得快，質(zhì)量也是絕對(duì)有保證。?問(wèn)：手術(shù)需要輸血嗎？答：這個(gè)手術(shù)的出血確實(shí)偏多，但是隨著手術(shù)技術(shù)的提高和相關(guān)藥物的應(yīng)用，再加上手術(shù)中使用血液回收設(shè)備（可以將出血量的大概一般進(jìn)行重新回收利用），目前在我中心手術(shù)的患者，90%以上的患者不需要異體輸血。而且，我們中心現(xiàn)在術(shù)前不需要常規(guī)備自體血。?問(wèn)：術(shù)后恢復(fù)期大概多久？答：手術(shù)中我們需要將骨頭截?cái)?，調(diào)整好位置后進(jìn)行固定，截?cái)嗟墓穷^長(zhǎng)好需要大概3個(gè)月的時(shí)間。所以，術(shù)后3個(gè)月內(nèi)需要小心保護(hù)自己的髖關(guān)節(jié)，不要摔，一定要拄雙拐，拄雙拐，拄雙拐！一般我會(huì)讓患者術(shù)后6-8周內(nèi)術(shù)腿不負(fù)重，6-8周后從0開(kāi)始逐漸逐漸增加踩地的重量，注意，是勻速逐漸的增加，到3個(gè)月的時(shí)候可以負(fù)重身體重量1/3-1/2，具體以醫(yī)生通知為準(zhǔn)。過(guò)早扔拐，過(guò)早過(guò)多負(fù)重可能導(dǎo)致骨頭移位，影響手術(shù)效果。3個(gè)月后門(mén)診復(fù)查，評(píng)估骨頭生長(zhǎng)情況。?問(wèn)：術(shù)后如何進(jìn)行康復(fù)鍛煉？答：康復(fù)鍛煉很重要，鍛煉不好，走路十有八九會(huì)瘸。我的患者我一般會(huì)給每人一個(gè)康復(fù)計(jì)劃，由于每個(gè)人的手術(shù)不一樣，畸形不一樣，骨頭質(zhì)量不一樣，所以方案不會(huì)完全一樣，大家按照自己的方案去做鍛煉即可。大家認(rèn)真閱讀鍛煉資料，保證動(dòng)作做對(duì)，一旦動(dòng)作做錯(cuò)，就可能練錯(cuò)肌肉。3個(gè)月復(fù)查時(shí)人要過(guò)來(lái)，很重要，我會(huì)根據(jù)查體結(jié)果和骨頭愈合情況調(diào)整康復(fù)方案。復(fù)查方式參考：保髖術(shù)后門(mén)診復(fù)查注意事項(xiàng)航天中心醫(yī)院骨科科普號(hào)