关节镜治疗临界发育性髋关节发育不良合并凸轮型股骨髋臼撞击综合征

目的探讨应用关节镜技术治疗临界发育性髋关节发育不良合并凸轮型股骨髋臼撞击综合征的临床疗效。方法回顾性分析2017年7月至2019年12月收治的临界性髋关节发育不良合并凸轮型股骨髋臼撞击综合征并随访2年以上的患者32例, 男15例、女17例, 年龄(36.13±8.67)岁(范围20～50岁)。术前外侧中心边缘角(lateral center-edge angle, LCEA)为22.3°±1.6°(范围20.1°～24.7°)、α角为64.1°±4.6°(范围56.0°～69.8°)。术前通过超声引导下髋关节封闭试验排除髋关节外疾病, 采用髋关节镜下髋臼有限成形、盂唇缝合、头颈区充分成形、关节囊紧缩缝合术治疗。术前、术后1年、术后2年随访时应用视觉模拟评分(visual analogue scale, VAS)、改良Harris评分(modified Harris Hip Scores, mHHS)和国际髋关节评分(International Hip Outcome Tool-12, iHOT-12)评价疗效。结果 32例患者均获得随访, 平均随访时间(2.5 ±0.8)年(范围2.0...     

髋臼周围截骨治疗成人髋关节发育不良

目的 探讨髋臼周围截骨治疗成人髋关节发育不良的手术适应证及疗效.方法 25例成人髋关节发育不良患者接受经改良Smith-Peterson人路的髋臼周围截骨术,女19例,男6例;年龄18～45岁,平均25.5岁.均为单侧发病,左侧14例,右侧11例.3例有既往手术史,2例Chari截骨术、1例Salter截骨术.髋关节骨关节炎T(o)nnis 0期13例、Ⅰ期9例、Ⅱ期3例.Shenton线不连续18例.髋臼外侧CE角4.57°±7.39°,前侧CE角0.95°±6.02°,髋臼顶倾斜角32.50°±5.96°,股骨头超出指数38.11%±5.70%,Harris髋关节评分(75.32±7.51)分.结果 全部患者随访2.0～7.5年,平均4.5年.3例髋关节骨关节炎T(o)nnis Ⅰ期者改善为0期,2例T(o)nnisⅡ期者改善为Ⅰ期,1例T(o)nnis Ⅰ期者进展为Ⅱ期.Shenton线不连续减少为10例.外侧CE角29.07°±5.81°,前侧CE角29.52°±4.51°,髋臼顶倾斜角19.17°±4.95°,股骨头超出指数24.20%±4.83%,Harris髋关节评分(84.88±4.88)分,与术前比较差异均有统计学意义.16例出现股外侧皮神经支配区感觉麻木,其中9例自行恢复,7例残留永久性麻木.1例出现髋关节周围Brooker Ⅰ型异位骨化.结论 经改良Smith-Peterson人路行髋臼周围截骨治疗成人髋关节发育不良可有效增加髋臼包容,改善关节功能,阻止髋臼周围硬化和囊性变,保持关节间隙,延缓骨关节炎进展.     

股骨髋臼撞击综合征

股骨髋臼撞击综合征（ femoroacetabular impingement, FAI ）指形态有改变的髋关节（股骨或髋臼解剖学异常）在髋关节运动终末期发生股骨近端头颈交界区和髋臼的异常应力接触所产生的髋关节疾患,临床上容易被忽视,是引起中青年,尤其是运动较多者髋关节疼痛,也是引起早期骨关节炎的重要因素。FAI表现为腹股沟区疼痛,髋关节屈曲内旋受限及疼痛,可由特殊的撞击试验诱发,发生的原因主要是上述部位的骨性形态异常,股骨近端和髋臼边缘的异常碰撞,导致髋臼盂唇和髋臼软骨的损害,从而引发髋关节疼痛症状。根据发生机制可将撞击分为凸轮型和钳夹型两种类型,两者往往同时存在。x线平片显示为股骨头颈结合区异常骨性隆起、枪柄样畸形、交叉征、8字征等特异性表现,CT检查可以发现股骨近端和髋臼的骨性异常,MRI可以显示一些继发的盂唇损伤和软骨损伤,核磁关节造影（MRA）可以大大提高盂唇损伤和股骨髋臼撞击症诊断的阳性率。随着关节镜技术的发展,目前可以通过髋关节镜技术达到髋关节的中心和外周间室,对盂唇损伤进行清理或修复,并可重塑股骨近端和髋臼的形态。     

混合型髋臼撞击综合征伴髋臼缘后外侧游离体一例及文献回顾

Ganz等[1]首次提出了髋臼撞击综合征(FAI),认为FAI是由髋关节形态异常引起,根据其解剖异常分为凸轮型和钳夹型。但很多情况下是两种类型同时存在,即混合型[2]。FAI常由于髋关节局部解剖学异常而引起运动时髋臼边缘与股骨近端的反复摩擦撞击,进而导致髋关节软骨损伤,发生软骨剥离,最     

髋臼发育不良的光弹性生物力学研究

目的 从生物力学角度探讨髋臼发育不良继发骨关节炎的发病机理,为髋臼旋转截骨术提供依据。方法 用环氧树脂制作骨盆、股骨模型,其中包括４个不同Ｓｈａｒｐ角、３个不同软骨厚度及３个颈干角模型,采用二维光弹性方法进行生物力学分析。结果 随着Ｓｈａｒｐ角的增大,髋关节的合力增大,生物应力向髋臼外侧缘移动;关节软骨缺损一半时,髋关节合力未见明显变化,当关节软骨不存在时,生物应力为正常时的２．５倍;随着颈干角的增大,生物应力集中的位置没有变化,但生物应力及合力随之增大。结论 髋臼发育不良因生物力学因素可继发骨关节炎,髋臼旋转截骨术是对其有效的治疗方法。     

临界型发育性髋关节发育不良合并凸轮型髋关节撞击综合征的诊断及髋关节镜治疗研究进展

目的 总结临界型发育性髋关节发育不良（borderline developmental dysplasia of hip,BDDH）合并凸轮型股骨髋臼撞击综合征（Cam-type femoroacetabular impingement,Cam FAI）的生物力学特点、诊断及髋关节镜治疗研究进展。方法 广泛查阅近年来国内外BDDH合并Cam FAI相关研究文献并进行总结分析。结果 BDDH合并Cam FAI患者股骨颈前倾角及颈干角增大，骨盆倾斜及髋臼旋转，导致髋关节不稳定。为了维持髋关节稳定性，患者髋关节局部生物力学作用方向发生改变，进而影响了股骨近端、髋臼形态等解剖结构。临床可联合外侧中心边缘角及前中心边缘角、髋臼指数诊断BDDH合并Cam FAI。通过髋关节镜下对髋臼增生骨边缘进行打磨、切除Cam畸形，对髋关节盂唇及软骨进行微创修复，可有效治疗BDDH合并Cam FAI。结论目前有关BDDH合并Cam FAI的诊治尚无统一标准。髋关节镜下微创治疗可获得较好早中期疗效，在修复并维持盂唇完整性及缝合紧缩关节囊方面具有一定优势，但远期疗效有待进一步随访明确，手术时机、术中打磨骨边缘深度、...     

经髂腹股沟入路伯尔尼髋臼周围截骨术的中期随访

目的探讨经髂腹股沟入路伯尔尼髋臼周围截骨术的中期随访结果。方法84例96髋接受经髂腹股沟入路伯尔尼髋臼周围截骨术,男6例,女78例;年龄11～46岁,平均27.6岁。髋关节发育不良87髋,Perthes病9髋。结果随访3.8～9.0年,平均6.0年。Harris髋关节评分从术前平均76.1分增加到末次随访92.7分;外侧CE角从8.7°增加到32.7°,前方CE角从-4.2°增加到36.4°,髋臼臼顶倾斜角从27.9°减小到9.4°。术前有66髋存在Shenton线不连续,术后为31髋;术前有76髋存在软骨下骨硬化,术后为34髋;术前有41髋存在软骨下骨囊变,术后为23髋,差异有统计学意义。骨关节炎表现改善或未进展者78髋;骨关节炎表现有进展者18髋,4髋进展为T＂nnis3级,其中3髋矫正不足,1髋截骨进入关节。主要并发症包括截骨矫正不足9髋,过度矫正17髋,截骨进入关节2髋,截骨块固定失败1髋,股神经麻痹1例,切口疝4例,股外侧皮神经永久性麻木8例,BrookerⅠ期异位骨化3例。结论经髂腹股沟入路伯尔尼髋臼周围截骨术治疗成人髋关节发育不良,可获得畸形矫正与功能改善;缓解髋臼周围硬化和囊变,使髋臼周围骨质再生,保持关节间隙,延缓骨关节炎进展。手术操作正确、髋臼矫正位置准确是其技术关键。     

开放与关节镜治疗凸轮型股骨髋臼撞击症比较

[目的]比较开放与关节镜术治疗凸轮型股骨髋臼撞击症（femoroacetabular impingement, FAI）的临床疗效。[方法] 2018年1月—2019年12月，本科手术治疗凸轮型FAI患者57例。其中，27例采用开放手术治疗（开放组），30例采用髋关节镜治疗（镜下组）。比较两组患者围手术期、随访与影像资料。[结果]两组患者均顺利完成手术。镜下组患者的手术时间、手术切口长度、术中出血量及下地行走时间均显著优于开放组（P0.05）。开放组早期并发症率为18.51%，镜下组为3.33%，两组差异有统计学意义（P0.05）。末次随访时两组患者VAS评分、Harris评分、屈髋ROM和屈曲90°内旋ROM均较术前显著改善（P0.05），镜下组的VAS评分、Harris评分、屈髋ROM和屈曲90°内旋ROM均显著优于开放组（P0.05）。影像方面，术后两组患者的α角均较术前显著减少（P0.05）。末次随访时，开放组的α角显著小于镜下组（P0.05）。[结论]髋关节镜下治疗凸轮型FAI的临床效果优于开放手术。     

髋臼周围截骨治疗重度髋臼发育不良

重度髋臼发育不良的治疗方法目前还存在争论。作者采用Bernese髋臼周围截骨治疗16例，其中8例合并髋关节半脱位，8例合并继发性髋臼。6例同时行股骨近端截骨。术后摄片分析畸形矫正程度、截骨愈合和骨关节炎的发生情况。结果显示髋臼畸形矫正满意，所有截骨完全愈合。Harris评分从73．4分提高至91．3分。主要并发症为：1例髋臼固定失败需重新手术固定，     

改良髋臼旋转截骨术治疗髋臼发育不良

[目的]研究改良的髋臼旋转截骨术治疗髋臼发育不良的方法及有效性.[方法]自2002年10月～2007年8月采用改良的Ninomiya方法治疗27例髋臼发育不良的患者,其中男3例3髋,女24例27髋;平均年龄29.4岁(15～42岁).术前、术后拍摄骨盆正位、双髋侧位及外展位像,测量髋臼的CE角(中心边缘角)和AC角(臼顶倾斜角),记录髋关节旋转中心及Shenton氏线变化、骨关节炎的严重程度并进行随访,行髋关节Harris评分并进行评价.[结果]所有患者截骨术后股骨头覆盖均得到改善,CE角由术前的3.2°(-15°～15°)矫正为28.5°(20°～40°),AC角由术前的26.6°(15°～38°)矫正为3.9°(0°～12°),髋臼旋转中心内移率为63.3%(19/30),Shenton氏线不连续率由67%降为23%.平均随访4.2年(1.5～7年),1髋失随访,28髋疼痛减轻、骨关节炎得到控制,1髋疼痛加重,Harris评分由术前82.7分(67～96分)改善为97.8分(87～100分).术后2例患者出现耻骨纤维愈合,1例出现耻骨下支应力骨折,无截骨块或大粗隆不愈合病例.[结论]改良的髋臼旋转截骨术能有效地治疗髋臼发育不良,是一种有效、安全的手术方式.     

Patients with cam-type femoroacetabular impingement demonstrate increased change in bone-to-bone distance during walking: A dual fluoroscopy study

Cam-type femoroacetabular impingement (FAI) syndrome is a painful, structural hip disorder. Herein, we investigated hip joint mechanics through in vivo, dynamic measurement of the bone-to-bone distance between the femoral head and acetabulum in patients with cam FAI syndrome and morphologically screened controls. We hypothesized that individuals with cam FAI syndrome would have larger changes in bone-to-bone distance compared to the control group, which we would interpret as altered joint mechanics as signified by greater movement of the femoral head as it articulates within the acetabulum. Seven patients with cam FAI syndrome and 11 asymptomatic individuals with typical morphology underwent dual fluoroscopy imaging during level and inclined walking (upward slope). The change in bone-to-bone distance between femoral and acetabular bone surfaces was evaluated for five anatomical regions of the acetabulum at each timepoint of gait. Linear regression analysis of the bone-to-bone distance considered two within-subject factors (activity and region) and one between-subjects factor (group). Across activities, the change in minimum bone-to-bone distance was 1.38–2.54 mm for the cam FAI group and 1.16–1.84 mm for controls. In all regions except the anterior–superior region, the change in bone-to-bone distance was larger in the cam group than the control group (p ≤ 0.024). An effect of activity was detected only in the posterior–superior region where larger changes were noted during level walking than incline walking. Statement of clinical significance: Patients with cam FAI syndrome exhibit altered hip joint mechanics during the low-demand activity of walking; these alterations could affect load transmission, and contribute to pain, tissue damage, and osteoarthritis.     

Arthroskopische Behandlung des femoroazetabulären Cam-Impingements der Hüfte

Objective

Resection of the cam deformity of the femoral head-neck junction in order to avoid femoroacetabular impingement and the development of secondary damage to the anterolateral acetabular rim.

Indications

Femoroacetabular cam impingement. Initial femoroacetabular pincer impingement. Advanced femoroacetabular pincer impingement with degenerative tear of the labrum.

Contraindications

Femoroacetabular pincer impingement with significant retroversion and intact acetabular labrum, coxa profunda or circumferential ossification of the labrum. Advanced osteoarthritis.

Surgical Technique

Arthroscopy of the peripheral compartment via three portals with and without traction. The proximal anterolateral portal is used for the arthroscope, instrumentation is done via the anterior and classic anterolateral portal. After resection of the zona orbicularis and the inner parts of the iliofemoral ligament, the anterolateral cam deformity is resected without traction via the anterior portal. After distraction of the head from the acetabulum, the lateral and posterolateral cam deformity is trimmed via the classic anterolateral portal.

Postoperative Management

Pain-controlled progression to full weight bearing over 1–4 weeks, continuous passive motion therapy and stationary bike for 6 weeks in order to avoid intraarticular adhesions.

Results

From 2004 through early 2007, 72 hip arthroscopies were performed for femoroacetabular impingement. So far, 48 patients (25 men, 23 women, mean age 37 years [17–65 years]) were followed up. After a mean follow-up of 18 months, the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) was significantly improved from 65 ± 21 to 82 ± 18 and the NAHS (Non Arthritic Hip Score) from 57 ± 19 to 78 ± 19. Complications: two persistent branch lesions of the lateral femoral cutaneous nerve. One patient was surgically dislocated after 8 months for the treatment of a significant retroversion of the acetabulum; one patient underwent total hip arthroplasty after 1 year.     

The prevalence of cam-type femoroacetabular deformity in asymptomatic adults

We performed a retrospective examination of the anteroposterior pelvic CT scout views of 419 randomly selected patients between April 2004 and August 2009 in order to determine the prevalence of cam-type femoroacetabular deformity in the asymptomatic population. The CT scans had all been undertaken for conditions unrelated to disorders of the hip. The frequency of cam-type femoroacetabular deformity was assessed by measuring the α-angle of each hip on the anteroposterior images. The α-angles were classified according to the Copenhagen Osteoarthritis Study. Among 215?male hips (108?patients) the mean α-angle was 59.12° (37.75° to 103.50°). Of these, a total of 30 hips (13.95%) were defined as pathological, 32 (14.88%) as borderline and 153 (71.16%) as normal. Among 540?female hips (272 patients) the mean α-angle was 45.47° (34.75° to 87.00°), with 30 hips (5.56%) defined as pathological, 33 (6.11%) as borderline and 477?(88.33%) as normal. It appears that the cam-type femoroacetabular deformity is not rare among the asymptomatic population. These anatomical abnormalities, as determined by an increased α-angle, appear to be twice as frequent in men as in women. Although an association between osteoarthritis and femoroacetabular impingement is believed to exist, a long-term epidemiological study is needed to determine the natural history of these anatomical abnormalities.     

Clinical importance of impingement deformities for hip osteoarthritis progression in a Japanese population

Purpose

Femoroacetabular impingement is a new disease concept for hip disorders in young adults suggested as a major cause of primary hip osteoarthritis in Western countries. However, significant controversy exists regarding the prevalence and contribution of impingement deformities to osteoarthritis in Japan, owing to the higher prevalence of developmental dysplasia of the hip. Therefore, the aims of this study were to: (1) determine the prevalence of structural abnormalities associated with hip disorders in patients undergoing total hip replacement and (2) analyse the contribution of impingement deformities to osteoarthritis.

Methods

We analysed 250 patients from two different medical centres who underwent primary total hip replacement except those which were due to femoral head necrosis, posttraumatic osteoarthritis and systemic inflammatory disease. The average patient age at surgery was 64 years (range, 40–89 years), with 35 men and 215 women.

Results

Radiographic abnormality related to developmental dysplasia of the hip was associated with the majority of osteoarthritic hips (62 %). Hips with femoroacetabular impingement deformities were present within the cases categorized as unknown etiology. Cam impingement deformity was present in 22 % of unknown aetiology cases when cases with reactive osteophytes were excluded from all cam deformity cases (pistol grip deformity and aspherical femoral heads).

Conclusions

The prevalence of femoroacetabular impingement within primary osteoarthritis cases and gender predominance of impingement deformities are relatively similar to those reported previously in Western populations. This finding indicates that femoroacetabular impingement deformities are associated with osteoarthritis in the Japanese population, although it has a lower frequency among all hip failure patients.