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哈尔滨医科大学附属第一医院

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公立三甲综合医院
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肢体歪斜可能从髋关节脱位开始
髋臼发育不良：美国临床运动医学杂志2021年研究进展髋臼发育不良：美国临床运动医学杂志2021年研究进展作者：JoshuaDHarris,BrianDLewis,KwanJPark作者单位: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.译者：陶可（北京大学人民医院骨关节科）摘要髋臼发育不良代表与髋部疼痛、不稳定和骨关节炎相关的结构病理形态。广泛的不典型增生在解剖学上是指基于3维体积和表面积的覆盖不足，并根据覆盖不足的程度和位置进行分类。临界髋臼发育不良的定义各不相同，并导致治疗方式的不统一。对于有症状的髋臼发育不良，治疗采用髋臼周围截骨术。同步或分期髋关节镜检查对于解决关节内病理学具有显着优势。在非髋关节骨关节炎个体中，有证据表明PAO可以改变髋臼发育不良的自然病史，并降低髋关节骨关节炎和全髋关节置换术的风险。诊所诊治要点①髋臼发育不良是一种复杂的多平面结构病理形态，与髋部疼痛、不稳定和髋关节骨关节炎紧密相关。②髋臼发育不良的自然病史导致继发于高度复杂的基于3-维度体积和表面积的覆盖范围不足软骨损伤。③髋臼发育不良可以通过其位置来表征定位：前部、后部或外侧部（或整体）。④髋臼发育不良的评估需要X线片和MRI、CT扫描，以衡量正常的覆盖范围和角度。⑤单纯髋关节镜检查不应用于治疗中度或严重髋臼发育不良所致的髋关节解剖结构不稳定。⑥在正确选择的具有过渡性髋臼覆盖或临界髋臼发育不良的患者中，短期和中期的随访可以取得良好的效果。PAO和髋关节镜检查可以同时或分阶段一起使用，以准确地纠正髋臼发育不良和FAI髋关节撞击综合征。⑦在非髋关节骨关节炎个体中，PAO改变了髋臼发育异常的自然病史并降低了以下风险：髋关节骨关节炎和随后的THA全髋关节置换术。?Fig.1.Weight-bearingAPpelvisplainradiographwithfocusonlefthipin17-year-oldgirl(left)showinganLCEAof14.3°measuredtothelateralsourcil(middle)and24.6°measuredtothelateralacetabularbone(right).图1.?17岁女孩的负重前后位(AP)骨盆X线片，左髋（左）；LCEA测量值为14.3°（中）；测量到髋臼骨性外侧边缘为24.6°（右）。Fig.2.(A)Weight-bearingAPpelvisplainradiographwithfocusonlefthipin19-year-oldwomanshowingaTonnisangleof10°.(B)Anupslopinglateralsourcil(asterisk).(C)Upslopinglateralsourcilinthesamepatientvisualizedon3-dimensionalcomputedtomographyscan;and(D)aFEARIndexof4.1°.图2.?(A)19岁女性的负重前后位(AP)骨盆X线片，重点关注左髋，Tonnis角为10°。(B)向上倾斜的眉弓（星号）。(C)在3维计算机断层扫描中显示同一患者的向上倾斜的眉弓；(D)FEAR指数为4.1°。femoroepiphysealacetabularroof：股骨骨骺髋臼顶TheFEARindexhasvalueintheevaluationofhipinstability(femoralheadmigrationonconventionalplainradiographsorheadrecenteringonanAPabductionview)inpatientswithtransitionalacetabularcoverage.FEAR指数对于评估具有过渡性髋臼覆盖的患者的髋关节不稳定性（传统X线片上的股骨头移位或AP外展视图上的股骨头复位）具有价值。Fig.3.Falseprofileplainradiographofrighthipin21-year-oldwoman(left)showinganACEAof22°measuredtotheanteriorsourcil(middleimage)and37.9°measuredtotheanterioracetabularbone(right).图3.?21岁女性右髋部的假斜位X线片（左）；ACEA测量到髋臼关节面前缘的角度为22°（中）；测量到髋臼前缘骨质的角度为37.9°（右）。Fig.4.Weight-bearingAPpelvisplainradiographwithfocusonrighthipin24-year-oldmanshowingthemeasurementsneededtocalculatetheAWIandthePWI.Abest-fittingperfectcircleisdrawnaroundthefemoralhead.Alineisdrawnconnectingthefemoralneckcenterintersectingwiththeheadcenter.AWI=AW/r;PWI=PW/r.图4.?24岁男性的负重前后位(AP)骨盆X线片，重点关注右髋，显示计算AWI和PWI所需的测量值。在股骨头周围绘制一个最合适的完美圆。绘制一条连接股骨颈中心与股骨头中心相交的线。AWI=AW/r；PWI=PW/r。PWI:theposteriorwallindex;AWI:anteriorwallindex.PWI：后壁指数；AWI：前壁指数。Fig.5.Weight-bearingAPpelvisplainradiographwithfocusonrighthipin31-year-oldmandemonstratingapositiveposteriorwallsign()andpositiveischialspinesign(#).图5.?31岁男性的负重前后位(AP)骨盆X线片，重点关注右髋，后壁征()和坐骨棘征(#)阳性。Fig.6.Clock-facepositionsofversionmeasurements.This3-dimensionalmodeldepictsthe3differentlocationsweusedtomeasurefocalacetabularversion(1,2,and3o’clock).(FromTannenbaumEP,ZhangP,MarattJD,etal.AComputedTomographyStudyofGenderDifferencesinAcetabularVersionandMorphology:ImplicationsforFemoroacetabularImpingement.Arthroscopy2015;31:1247–54;withpermission.)图6.?髋臼测量的钟面位置。这个3维模型描绘了我们用来测量髋臼局部区域的3个不同位置视图（1点、2点和3点钟方向）。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.)图7.?横截面成像评估股骨扭转角度。在股骨近端的连续严格轴向图像上，确定股骨头中心(FHC)（黄色圆圈和黄线）。可以通过多种方法来定义股骨颈轴（绿线）。Lee法（红条）：在第一张图像上画一条线，将FHC与大转子和股骨颈的最头连接处连接起来；Reikeras方法（浅蓝色条）：在图像上绘制连接FHC与股骨颈中心的线，其中前皮质和后皮质彼此平行；Jarret方法（未显示）：在单个图像上绘制一条从FHC穿过股骨颈中心的线；Tomczak法（深蓝色条）：FHC与股骨颈基部大转子中心相连；墨菲法（橙色条）：FHC与小转子正上方的股骨颈基底部中心相连。然后，在股骨远端上，绘制股骨髁后部的切线（蓝线；选择髁更突出的切片）。两条线之间的角度代表股骨扭转角度。尽管其中一些参考点位于不同的相邻切片上，但现代工作站应该允许在1系列中的多个图像上绘制和修改一条线，或者，可以借助后处理软件将不同的切片叠加在单个图像上。Fig.8.PostoperativeAPpelvisplainradiographfollowingPAO(Periacetabularosteotomy)oflefthipin20-year-oldwomanwithanLCEAof34°(left)andaTonnisangleof3°?(right).图8.?20岁女性左髋PAO（髋臼周围截骨术）术后前后位(AP)骨盆X线片，LCEA为34°（左），Tonnis角为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.文献出处：JoshuaDHarris,BrianDLewis,KwanJPark.HipDysplasia.ReviewClinSportsMed.2021Apr;40(2):271-288.?
髋脱位该何时治疗