外侧型弹响髋临床诊治的研究进展

外侧型弹响髋(external snapping hip,ESH)是指髋关节在做某一动作时引起患者感到或听到闷响声,伴或不伴局部疼痛的一种常见病。ESH的发病机制多与其特殊的解剖结构与摩擦因素有关。临床症状以活动时发出弹响为主,体格检查及X线、磁共振,动态超声等影像学技术可帮助诊断。治疗上症状轻者药物治疗、休息、理疗等即可取得好的临床疗效,保守治疗无效者国外多主张进行手术治疗,各式开放手术方式都能取得良好疗效,同时关节镜凭着创伤小、并发症少等优势,逐渐在国内外受到推广。同时有报道显示推拿、针灸、针刀等传统治疗手段在临床上亦取得了很好的疗效,值得进一步研究和推广。     

弹响髋的关节镜下手术治疗

[目的] 探讨军事训练致外侧型弹响髋的特点及关节镜治疗方法与疗效。[方法] 收治14例18髋军事训练引起的外侧型弹响髋，采用关节镜下髂胫束松解，术后早期功能锻炼。[结果] 疗效优11髋，良5髋，优良率94．1％，有效率100％，未出现感染、血肿、神经损伤等并发症。[结论] 关节镜下髂胫束松解术治疗弹响髋，只要重视围手术期处理，术后疗效满意，可取代传统切开术。     

Differential sensory block: spinalvs epidural with lidocaine

PURPOSE: In this study we sought to determine if and when a difference exists with regards to differential sensory blockade between spinal and epidural anaesthesia using lidocaine. METHODS: Ten healthy volunteers were randomly assigned to receive both spinal and epidural anaesthesia. Non-epinephrine containing solutions of lidocaine, 100 mg lidocaine 5% with 7.5% dextrose (spinal) and 600 mg lidocaine 2% (epidural), were used to establish sensory blockade. At five minute intervals, for a total of 65 min, the following sensory modalities were tested: anaesthesia (complete loss of sensation to pinprick), analgesia (loss of an equally sharp sensation to pinprick compared with that at an unblocked dermatome), cold sensation (complete loss of cold temperature discrimination). RESULTS: At all times, except at time = 0 during spinal anaesthesia, the levels of analgesia and cold sensation were more cephalad than the level of anaesthesia for both spinal and epidural anaesthesia. Multiple comparison testing among the three dermatomal response levels showed that, during epidural anaesthesia, the level of analgesia was more cephalad than the level of cold sensation at the following times: 25 min, 30 min, and from 40 to 60 min. In contrast, the level of analgesia was not different from the level of cold sensation during spinal anaesthesia. CONCLUSIONS: Spinal and epidural anaesthesia with lidocaine produce a similar degree of differential sensory blockade. Epidural anaesthesia produces a detectable difference between the level of analgesia and cold sensation at various times, whereas spinal anaesthesia did not reliably do so in this study.     

髋关节囊周神经阻滞的研究进展

髋关节囊周神经（PENG）阻滞是一种新型的神经阻滞区域麻醉方法。它最早在髋关节手术麻醉和围术期镇痛方面应用,现在已逐渐应用于下肢截肢手术、大隐静脉曲张结扎剥离术以及大腿内侧肿物切除术等下肢手术。由于PENG阻滞能操作简单且几乎完善地将闭孔神经阻滞,产生良好的围术期镇痛,减少阿片类药物需求和相关不良反应,且不影响下肢肌力,使得近几年国内外不少专家对其研究热度日益高涨。该文针对PENG阻滞的解剖基础、B超引导下麻醉技术分析及其应用于下肢手术中的效果临床研究进展予以综述。     

弹响髋病因探讨

目的　探讨弹响髋发病病因 ,为臀腿痛合并弹响髋提供一种改进术式。方法　通过 30例 35侧弹响髋的治疗观察和对儿童臀肌挛缩症导致弹响髋的分析 ,并对 3具新鲜尸体臀髋部肌肉筋膜组织的局解实验观察。结果　弹响髋大多先有臀部软组织的劳损或外伤史。臀部软组织的疼痛性痉挛和挛缩 ,致使与其有连带关系的髋部肌筋膜受牵紧张并在大转子处反复磨擦损伤 ,形成了增厚的束带而产生弹响。结论　提示弹响髋病因与臀肌筋膜组织损伤有关 ,在臀或髋部实施软组织松解术 ,既可治疗臀腿痛 ,又可治愈弹响髋     

Surgical treatment of the snapping hip

Snapping hip (Coxa saltans) is the abrupt sliding of the iliotibial tract over the greater trochanter. In the case of pain, which cannot be alleviated by a conservative treatment, an operation is advised. The methods of operation applied up to this day showed--especially because of their high recidive-quotas--great disadvantages. In a detailed post-operational check-up over the past 20 years the new method of "diagonal notching" (27 cases) developed at the Orthopedic Hospital München-Harlaching was compared to the old method of fixing the tract according to M. Lange (24 cases). After "diagonal notching" the snapping occurred again seven times less than after fixing the tract. After "diagonal notching" only 4% of the patients had to be re-operated, however, after fixing the tract a re-operation was necessary on 38% of the patients. 91% of the patients were relieved from their pain almost completely after "diagonal notching", compared to only 50% after fixing the tract. Considering that the "diagonal notching" offers simple technics of operation and better results than other methods, the "diagonal notching" should be used as method of choice to eliminate a snapping hip.     

关节镜在诊断和治疗髋关节疾患中的应用

目的：探讨关节镜在诊治髋关节疾患中的价值。方法：对54例（68髋）髋关节疾患进行了关节镜手术,其中男性36例,女性18例。年龄17-64岁,平均44岁。左侧18例,右侧22例,双侧14例。髋臼软骨肉瘤2例行关节镜下组织活检,髋臼盂辰损伤2例、髋关节感染3例、骨性关节炎21例均行关节镜清理术;股骨头缺血性坏死在关节镜监视下钻孔减压和滑膜切削清理术16例,髋关节滑膜软骨瘤病关节镜游离体取出7例,强直性脊柱炎滑膜清理术3例。结果：髋臼软骨肉瘤、关节盂唇损伤和髋关节感染经关节镜检查、活检明确了诊断并得到了有效治疗;股骨头坏死和髋骨性关节炎和强直性脊柱炎关节镜术后解除了疼痛,延缓了发展,改善了关节功能,提高了生活质量。术后Harris评分提高27分。结论：关节镜手术对髋关节疾患具有重要的诊断和治疗价值。     

Comparison of the catheter-technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery

Background: The aim of this study was to compare the intra‐ and postoperative analgesia provided by the catheter‐technique psoas compartment block and the epidural block in hip‐fractured patients. We also compared hemodynamic stability, motor blockade, ease of performing the technique, and complications. Methods: Thirty patients who underwent partial hip replacement surgery were included in this prospective single‐blind study. Subjects were randomly assigned to Group E (n=15; general anesthesia plus epidural block with 15 ml of 0.5% bupivacaine) or Group P (n=15; general anesthesia plus psoas compartment block with 30 ml of 0.5% bupivacaine). Hemodynamic parameters were recorded at 10‐min intervals intraoperatively. Regional anesthesia procedure time, number of attempts at block, intraoperative blood loss, and need for supplemental fentanyl and/or ephedrine were noted. Postoperatively, a patient‐controlled analgesia device delivered an infusion and boluses of bupivacaine/fentanyl. Pain, motor blockade, ambulation time, patient satisfaction with analgesia, and complications were recorded postsurgery. Results: The epidural required significantly more attempts than the psoas block, thus procedure time was longer in this group. Group E also showed significantly greater drops in mean arterial blood pressure from baseline at 30, 40 and 50 min after the start of general anesthesia. Significantly more Group E patients required epinephrine supplementation. The groups were similar regarding pain scores (at rest and on movement) and patient satisfaction, but Group E had higher motor blockade scores, longer ambulation time, and significantly more complications. Conclusion: The continuous psoas compartment block provides excellent intraoperative and postoperative analgesia with a low incidence of complications for partial hip replacement surgery     

Combined spinal epidural block versus spinal and epidural block for orthopaedic surgery

In a controlled study a single segment combined spinal epidural (CSE) block was compared with spinal or epidural block for major orthopaedic surgery. Seventy-five patients, age 52–86 yr, were randomly assigned to receive one of the three blocks. Bupivacaine 0.5% was used for surgical analgesia. The postoperative pain relief after 4.0 mg epidural morphine was compared with the analgesic effect of 0.2 or 0.4 mg morphine administered intrathecally. With the spinal technique good or excellent surgical analgesia and muscle relaxation were achieved rapidly (11.8 ± 1.1 min). The time taken to provide an equally effective and reliable block with the CSE technique was no longer (14.9 ± 2.2 min). For epidural block with the catheter technique more time was required (35.9 ± 3.9 min) to provide acceptable surgical conditions (P < 0.05). Perioperative sedatives and concomitant analgesics were required more frequently and in larger doses by the patients undergoing surgery with epidural block (P < 0.05) than with CSE or spinal block. Our study demonstrated that the analgesia after surgery provided by 0.2 and 0.4 mg morphine administered intrathecally was comparable to that provided by 4.0 mg of epidural morphine. It is concluded that the analgesia and surgical conditions provided by the spinal and CSE blocks were similar and were superior to those provided by an epidural block.     

Differential diagnosis of hip disease versus spine disease

Many clinicians find it difficult to differentiate between symptoms caused by a spine disorder or a hip disorder. If surgery is indicated, the order in which these operations take place is an important factor in the patient's long-term outcome. A prospective evaluation and retrospective chart review of patients with lower extremity pain was performed at the principal investigator's clinic to determine which signs and symptoms best predict the primary source of pain in patients with hip and spine disorders. Medical histories, physical examinations, and diagnostic tests were done on 97 patients with lower extremity pain to determine which signs and symptoms were the best predictors of a primary source of the pain (a hip or a spine disorder). The presence of a limp, groin pain, or limited internal rotation of the hip significantly predicted the diagnosis of a disorder as originating primarily from the hip, as opposed to originating from the spine. Patients with a limp were seven times more likely to have a hip disorder only or a hip and spine disorder than a spine only disorder. Similarly, patients with groin pain or limited internal rotation of the hips were seven and 14 times, respectively, more likely to have a hip disorder only or a hip and spine disorder than a spine only disorder. These variables are of primary importance to the clinician when making a differential diagnosis between hip disease and spine disease.     

Computed tomography and ultrasonography for diagnosis of hip joint effusion in children

Nineteen consecutive children with transient synovitis of the hip were examined for intracapsular joint effusion using computed tomography (CT) and ultrasonography (US). The two techniques were highly correlated in measurements of the anterior displacement of the joint capsule, indicating both to be reliable diagnostic tools. Such an effusion is clinically important because of the increase in intracapsular pressure with ensuing disturbance in the vascular supply to the proximal femoral epiphysis, as demonstrated experimentally and clinically in transient synovitis.