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海军军医大学第二附属医院

简称: 上海长征医院别名: 上海长征医院
公立三甲综合医院
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保髋截骨治疗髋关节发育不良(8)：单台同时进行无(会阴)柱髋关节镜检查联合髋臼周围截骨术治疗DDH保髋截骨治疗髋关节发育不良(8)：单台同时进行无(会阴)柱髋关节镜检查联合髋臼周围截骨术治疗髋关节发育不良作者：DustinWoyski,SteveOlson,BrianLewis.作者单位:DepartmentofOrthopaedicSurgery,DukeUniversity,Durham,NorthCarolina,U.S.A.译者：陶可（北京大学人民医院骨关节科）摘要已经证实，关节镜和开放式髋关节保留技术都可以改善患者的预后并阻断髋关节疾病的自然病程。传统上，髋关节镜检查用于治疗由盂唇撕裂、髋关节撞击畸形和软骨病变组成的髋关节疾病。髋臼周围截骨术是治疗因股骨头对髋臼覆盖不足或发育不良引起的髋关节不稳定的最常用方法。由于髋臼周围截骨术失败与术后撞击有关，且发育不良髋关节的关节内病变发生率高，人们对将髋关节镜检查与髋臼周围截骨术相结合产生了浓厚的兴趣。在这里，我们描述了一种单台、单铺巾、无(会阴)柱联合髋关节镜检查和髋臼周围截骨术的技术。讨论据报道，通过开放或关节镜检查发现髋关节发育不良患者的关节内病变发生率很高。我们的绝大多数患者也符合Warwick髋关节镜治疗标准，这体现在影像学、体格检查和病史方面。由于这些因素，自2013年以来，我们一直在我们机构的几乎每例PAO患者身上同时进行关节镜检查，并且自2018年3月以来一直采用当前的无(会阴)柱技术。多年来，我们的髋关节镜和PAO联合技术已发展到本技术说明中所述的使用1张手术台且无需会阴柱的技术。这位资深外科医生已经进行了500多例PAO手术，并发现同时进行的关节镜检查不会增加PAO的手术时间，而且，如果有的话，由于关节镜检查液的水分离，使暴露更容易，出血更少，组织平面更清晰。过去20年来，PAO的长期结果已得到充分描述，伯尔尼原始队列的三分之一患者的髋关节在30年后得以保存。PAO失败的一个已知原因是未解决股骨髋臼撞击或通过PAO矫正造成撞击。然而，在PAO时解决中央和外周间室病理是否会影响短期和长期结果仍有待观察。迄今为止的报告很少，并且与治疗关节内病理的选择偏差不一致，这些选择偏差针对的是那些有撞击体征和症状或MRI发现盂唇病理的患者。我们坚信，由于关节内病理与发育不良患者的凸轮形态高度相关，因此在PAO之前对所有髋关节进行关节镜评估和治疗是必要的。我们发现关节内病变的患病率非常高，几乎所有髋关节均出现PAO且需要进行盂唇修复，超过一半的髋关节出现一定程度的髋臼软骨软化。使用一张手术台和铺巾使我们能够完成高效的髋关节镜和PAO联合手术。在我们机构，关节镜和PAO均由一位外科医生进行。缺乏经验的外科医生不应单独进行这两种手术，因为PAO和关节镜髋关节手术的学习曲线都很陡峭。任何涉及多种复杂、困难手术和新设备组合的新技术都可能带来潜在的缺点和风险。但是，如果由经验丰富的外科医生进行，在PAO之前增加关节镜检查是安全的，并且不会增加并发症发生率。?Fig1ViewofstandardHanatablesetupwithPinkHipKitandpatientdrawsheetfoldedinhalffromthe(A)sideand(B)above.(C)Viewfromaboveoftheidealpatientplacementwithperineumapproximately4to6cmfromthepostpositioninghole.图1?标准Hana桌设置视图，配有粉色髋关节套件和患者抽纸，从(A)侧面和(B)上方折叠成两半。(C)从上方查看理想的患者放置位置，会阴距离定位孔约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.)图2?(A)患者仰卧，左侧髋关节无菌准备并铺上布，髂嵴下缘轮廓清晰。ASIS和GT也已标记。髋臼周围截骨术的切口从GT开始，并与MAP相连。(B)PAO的切口从GT到MAP。(C)在遮盖之前，暴露EOF非常重要。(D)使用半英寸直骨刀对IC上的ASIS进行斑点截骨术。（AL，前外侧入口；ASIS，髂前上棘；DALA，远端前外侧副入口；EOF，腹外斜肌和筋膜；GT，髂结节；IC，髂嵴；MAP，中前入口；PAO，髋臼周围截骨术。）Fig3Magneticresonanceimagingbased3-dimensionalrenderingofalefthipjointviewedanteriorlyisusedforpreoperativeplanning.Thisdemonstratestypicalfindingsoffocalfemoroacetabularimpingementfoundinthedysplastichipwithaminimalcamandpincer(),whicharelabeled.(PS,pubicsymphysis;SS,subspine.)图3?基于磁共振成像的左侧髋关节前方三维渲染图用于术前规划。这显示了髋关节发育不良中发现的典型局灶性股骨髋臼撞击，轻度凸轮和钳夹畸形（），已标记。（PS，耻骨联合；SS，髂前下棘。）Fig4Intraoperativefluoroscopicimagesofalefthipperiacetabularosteotomy.(A)Anteroposteriorviewdemonstratingthenarrowcurvedosteotomeagainstthemedialaspectoftheanteriorischiumpriortoosteotomy.(B)Iliacobliqueviewwiththeacetabulumoutlinedinblueandposteriorcolumnincludingischialspineoutlinedingreenshowingthe(C)appropriatedepthofthecurvedosteotomeoftheincompleteischialosteotomy.(D)Anteroposteriorviewshowingthecurvedosteotome’sidealpositionbehindtheacetabulum.图4?左侧髋臼周围截骨术术中透视图像。（A）前后视图，显示截骨术前狭窄弯曲骨凿抵靠前坐骨内侧。(B)髂骨斜视图，髋臼以蓝色勾勒，包括坐骨棘在内的后柱以绿色勾勒，(C)显示不完全坐骨截骨术的弯曲骨凿的适当深度。(D)前后视图显示弯曲骨凿在髋臼后方的理想位置。Fig5Fluoroscopicimagesofthelefthip.(A)Widestraightosteotomeincorrectpositionontheanteroposteriorviewoverlyingtheacetabularteardrop.(B)Iliacobliqueviewwiththeiliacosteotomymadeusingtheoscillatingsawoutlinedinblue.(C)Iliacobliqueviewofthestraightosteotomecomingbehindtheacetabulumand(D)connectingwiththepreviousincompleteischialosteotomy,whichisoutlinedinblue.图5?左髋的透视图像。(A)宽直骨凿在前后视图上处于正确位置，覆盖髋臼泪滴。(B)髂骨斜视图，使用摆锯进行的髂骨截骨术以蓝色勾勒。(C)髂骨斜视图，直骨凿位于髋臼后方，(D)与之前的不完全坐骨截骨术相连，后者以蓝色勾勒。Fig6Lefthipfluoroscopiciliacobliqueviewsoftheacetabularfragment(A)beforecorrectionwiththeacetabulumoutlinedinblueand(B)postcorrectionwithprovisionalfixationusing3.2-mmdrillbits.(C)Iliacobliqueand(D)anteroposteriorfluoroscopicviewsshowingfinalpositionofacetabularfragmentfollowingperiacetabularosteotomywith4.5-mmscrewsinplace.图6左髋关节透视髂骨斜视图显示髋臼块（A）矫正前，髋臼用蓝色勾勒，（B）矫正后，使用3.2毫米钻头进行临时固定。（C）髂骨斜视图和（D）前后透视视图显示髋臼块的最终位置，髋臼周围截骨术后，4.5毫米螺钉固定。Fig7Anteroposteriorviewsofthepelvisshowingthelefthip(A)preoperativelyand(B)postoperatively.Increasedlateralcoverageofthefemoralheadanddecreasedinclinationoftheacetabularsourcilarenoted.图7?骨盆前后视图显示左髋关节（A）术前和（B）术后。注意到股骨头的侧向覆盖增加，髋臼底部倾斜度减小。?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文献出处：DustinWoyski,SteveOlson,BrianLewis.SingleTableConcomitantPost-LessHipArthroscopyCombinedwithPeriacetabularOsteotomyforHipDysplasia.ArthroscTech.2019Nov25;8(12):e1569-e1578.doi:10.1016/j.eats.2019.08.015.eCollection2019Dec.
临界髋关节发育不良Borderline DDH (2)：疼痛性临界髋关节发育不良的治疗临界髋关节发育不良BorderlineDDH(2)：疼痛性临界髋关节发育不良的治疗作者：MichaelCWyatt,MartinBeck.作者单位:KlinikfürOrthop?dieundUnfallchirurgieLuzernerKantonsspital6004Luzern,Switzerland.译者：陶可（北京大学人民医院骨关节科）摘要在过去的几十年里，影像技术的改进和手术技术的进步使得保髋手术得到了快速发展。然而，疼痛性临界髋关节发育不良的治疗仍然存在争议。在这篇评论中，我们将确定相关问题并描述患者评估和治疗方案。我们将提供自己的建议，并确定未来的研究领域。简介在过去的几十年里，髋关节生物力学知识的提高和手术技术的进步使得保髋手术得到了快速发展。保髋手术适应范围广泛，从髋臼浅且不稳定的髋关节到髋臼深且患有股骨髋臼撞击(FAI)的髋关节。虽然人们普遍认为，不稳定髋关节发育不良的最佳治疗方法是重新定位髋臼以增加覆盖范围，但人们同样认为，必须减小过度覆盖的髋臼临界以消除撞击。所有这些髋关节都可能存在凸轮畸形，需要在手术矫正时加以解决[1]。在最极端的情况下，所需的治疗是显而易见的。然而，有一个过渡区，很难区分不稳定性和股骨髋臼撞击(FAI)。过去，这些髋关节被称为“临界”髋关节。通常，这包括外侧中心临界(LCE)角度在20°到25°之间的髋关节[2]。然而，“临界”一词是有问题的，因为它是一个放射学定义，只涉及描述髋关节稳定性的几个重要参数之一。髋臼顶倾斜角、前后覆盖和股骨前倾是应纳入髋关节稳定性分析的其他因素。髋关节发育不良与髋关节骨关节炎之间的关联已经确定[3,4]，有不稳定迹象的髋关节发育不良退化速度更快[5]。临界髋关节可能不稳定、撞击或两者兼而有之。临界髋关节发育不良的稳定性很难确定，并且容易受个人主观影响，骨科界普遍倾向于低估不稳定性，从而导致不适当的治疗。最近的研究表明，对患有临界发育不良(LCEA?>?20°)的患者进行关节镜髋关节手术（包括盂唇修复和关节囊折叠缝合术）可能会在短期内带来适当的改善[3,4]。然而，有证据表明，之前错误的髋关节镜检查会对此类髋关节的治疗结果产生负面影响[6]。因此，疼痛性临界髋关节发育不良的治疗仍然是一个极具争议的问题。临界性髋关节发育不良在患有髋关节疼痛的年轻人中很常见，在选定的患者群中报告的患病率为37.6%[7]。在临界髋关节发育不良中，可能与其他不稳定原因（如韧带松弛症）有显著重叠[8]。然而，根本问题是难以正确分类潜在的病理生物力学。定义第一个问题在于定义。在前后位骨盆X线片[9](LCEA)上测量的Wiberg外侧中心边缘角传统上用于将髋关节分类为正常(LCEA?>25°)、发育不良(LCEA?<20°)或临界(LCEA20–25°)，尽管这些定义值在文献中差异很大[3,10]。然而，使用外侧中心边缘角(LCEA)存在两个问题。首先是测量方法。为了测量外侧中心边缘角(LCEA)，首先通过与股骨头轮廓相符的圆来定义股骨头的中心。角度的第一个分支垂直穿过旋转中心。第二个分支由股骨头的中心和股骨最外侧点定义（图1a）。重要的是不要使用髋臼的最外侧点（图1b），因为这不符合Wiberg的定义，并且会给出错误的高值(外侧中心边缘角(LCEA)偏大)[11]。Fig.1.(a)CorrectmeasurementoftheLCEAusingtheedgeofthesourcil,indicatingmoderatedysplasia.(b)IncorrectmeasurementoftheLCEAinthesamehip.Usingthisvaluewouldfalselyclassifythishipasborderline.图1(a)使用髋臼临界正确测量外侧中心边缘角(LCEA)，表明中度髋关节发育不良。(b)同一髋关节的外侧中心边缘角(LCEA)测量不正确。使用此值会错误地将此髋关节归类为临界。其次，实际术语“临界髋关节发育不良”是由Wiberg本人首次提出的，包括外侧中心边缘角(LCEA)在20°和25°之间的髋关节[2]。外侧中心边缘角(LCEA)是一种放射学测量，本身无法预测临界髋关节发育不良的稳定性，也无法完全描述股骨头覆盖范围。因此，外侧中心边缘角(LCEA)无法指导手术决策[12–14]。部分原因是外侧中心边缘角(LCEA)本身无法涵盖发育不良的精确位置，并且忽略了前后股骨头覆盖范围。此外，髋臼指数(AI)和股骨前倾等其他参数也与髋关节稳定性密切相关。如果外侧中心边缘角(LCEA)减少，AI可能正常，在这种情况下很难评估髋关节的稳定性[15]。另一方面，股骨前倾过度可能会加剧髋关节前部不稳定[16]。根本问题是什么？对于疼痛的临界髋关节发育不良，很难仅通过二维射线测量将病理机制表征为撞击（稳定）或发育不良（不稳定），尤其是仅由髋臼功能决定而不考虑股骨的测量。髋关节稳定性的功能表征对于指导手术决策至关重要。不稳定髋关节从逻辑上可以从髋臼重新定向截骨术中受益，而稳定髋关节可以从撞击手术（如股骨凸轮骨成形术）中受益。那么关于髋关节内病理学的了解有多少？应该如何评估这些患者？有哪些治疗方案？手术结果如何？这组患者的潜在隐患是什么？未来的发展方向是什么？在这篇叙述性综述文章中，我们旨在解决这些问题，并阐明这组具有挑战性的患者的处理方法。髋关节发育不良和临界髋关节不稳定的潜在病理是什么？髋关节发育不良患者的关节接触压力异常增高，股骨头（软骨损伤，导致软骨下）骨质相对暴露。髋臼通常较浅且前倾，盂唇经常有代偿性增大，但同时伴有髋臼后倾的情况也很高[17]。股骨通常呈外翻，前倾度高[10]。这些异常的解剖特征会导致病理性髋关节生物力学，表现为盂唇撕裂、软骨损伤和髋关节不稳定，这些很容易被误解为撞击。由于骨稳定性受损，软组织稳定器（即纤维软骨盂唇和髋关节囊）的重要性就凸显出来[18]。一旦软组织约束失效，髋关节就会变得不稳定。然而，我们必须明白，主要的潜在病理是缺乏骨性稳定性，这会导致髋关节失效，而不是软组织稳定性失效。半脱位髋关节发育不良的自然病史预后非常差，并且必然会导致关节退化[5]。恶化速度与半脱位严重程度和患者年龄直接相关，通常在症状出现后约10年，就会出现严重的退行性变化[19]。在没有半脱位的情况下，自然病史很难预测退化速度。临界髋关节发育不良也是如此。最近的一项研究强调了髋臼覆盖的重要性。在一项为期20年的大型女性队列研究中，研究显示，如果外侧中心边缘角(LCE)低于28°，则每降低一度，放射学OA风险就会增加13%[20]。因此，除了短期缓解症状外，还必须考虑长期可能的发展。临床表现临界髋关节发育不良的临床表现与其他年轻活跃成人髋关节疾病（如FAI综合征[21]）非常相似，因此，彻底的病史、体格检查和放射学评估对于正确诊断这些患者至关重要。病史重点记录病史。临界髋关节发育不良患者的主要症状是疼痛。这通常发生在腹股沟和髋关节外侧，但也可能发生在臀部(臀后区)。有必要记录完整的疼痛病史。寻找特定的不稳定和“避免疼痛”症状，这可能表明已经达到因缺乏骨性稳定性而需要的软组织代偿的极限。咔嗒声和卡住的症状也很常见。此外，还会询问患者是否有任何迹象表明患者已经患上髋关节炎，例如夜间疼痛。症状应结合患者的功能限制和已经接受的医疗护理，包括物理治疗、药物、其他意见和手术。检查随后应进行髋关节的合理临床检查，包括恐惧试验和撞击测试。患者通常会表现出“膝内翻”步态，同时伴有髋关节内收肌力矩增加和髋关节内旋增加，这与股骨前倾增加一致。为了功能性地增加前覆盖，可能存在前凸过度。应确定大转子处有无压痛[22]。务必记住检查患者的旋转轮廓、进行神经血管检查以及检查全身关节松弛的迹象，并使用Beighton评分对此进行量化。具体关键目标包括排除(i)晚期退化过程的存在，例如表现为固定屈曲畸形和运动范围减少，以及(ii)其他病理，例如腰椎病或L5神经根病引起的疼痛。调查诊断成像应从骨盆的标准化AP平片和股骨颈侧位片（穿桌侧位、Dunn位、假斜位）[23]开始。仔细检查这些图像以测量LCEA、AI、挤压指数、股骨颈干角和FEAR指数（见下文）。应确定骨关节炎的Tonnis等级以及是否存在凸轮形态。应仔细检查不稳定的直接迹象，这些迹象包括股骨头移位，可通过与髂坐线的距离增加、Shenton线断裂和AP视图上股骨头重新定位来识别，髋关节处于外展状态，使用MR关节造影时后关节间隙中有钆，这表明股骨头向前移位，因此不稳定。FEAR指数与不稳定性有很高的相关性（见下文）。必须精确测量和记录各种参数。有必要使用三维计算机断层扫描(CT)进行横断面成像，以获得有关骨解剖结构和发育不良位置的精确信息，包括髋关节周围囊肿的存在和位置[24-26]。此外，CT还应包括股骨前倾的评估，如果前倾过大，可能会加剧髋关节前部不稳定。磁共振成像(MR-关节造影)应遵循专门的髋关节检查方案，包括径向图像采集或重建和关节内造影剂应用[27]，以检查关节内结构和盂唇和关节软骨的病理。可以区分引起类似症状的其他原因，例如缺血性坏死、转子滑囊炎或臀肌病变。其他测量包括盂唇大小[13,28]和髂关节囊体积[29]。对于这些患者，我们还提倡进行非牵引性MR关节造影检查，以检查是否存在钆积聚，即所谓的“新月征”，这是轴向视图上不稳定的细微征兆[30]。这些测量值的价值是什么？在平片上，那些直接表明不稳定的测量值是股骨头移位，与髂坐线的距离增加，Shenton线断裂，髋关节外展时AP视图上股骨头重新定位，以及FEAR指数。在MR关节造影中，后下关节间隙中钆的存在表明股骨头移位，因此不稳定。AI、NSA、AT、高髂囊体积和盂唇体积可能存在增加，但不能预测不稳定性[30]（表1）。表1.用于评估髋关节不稳定性的各种参数概述TheFemoro-EpiphysealAcetabularRoof(FEAR)index:股骨骨骺髋臼顶指数Thefemoralneck-shaftangle(NSA):颈干角FEAR指数是最近描述的参数，似乎对预测髋关节稳定性具有很高的价值[27]。它是由髋臼顶与股骨生长板中央1/3处之间的角度形成的（图2）。其依据是：在生长过程中，股骨的骨骺生长板会垂直于髋关节的关节反作用力。股骨颈的生长和方向受股骨颈下生长板的控制[31]。Pauwels和Maquet[32]提出理论，合力作用于骨骺软骨的中心，在生长过程中，根据Heuter-Volkman原理，骨骺板会垂直于关节反作用力。Pauwels和Maquet的理论后来得到了Carter等人[33]的证实，他们通过二维有限元分析研究了髋关节负荷的影响。闭合的骨骺板的角度表示跨股骨近端骨骺[34]的力的平衡，也表示跨关节力在过去的作用方式。因此，它是一个功能参数，反映了髋关节在生长过程中长期的关节反作用力。如果FEAR<0°，则认为髋关节稳定。统计分析表明，5°的临界值预测稳定性的概率为80°。最近的研究表明，2°的临界值预测稳定性的概率为90%（Batailler等人，正在准备发表中）。使用FEAR指数的案例如图3a和b所示。Fig.2.TheFEARindex.Theangleismeasuredbetweenalineconnectingthemostmedialandlateralpointofthesourcilandalineconnectingthemedialandlateralendofthestraightpart(usuallycentralthird)ofthephysealscarofthefemoralhead.AnegativeFEARindex,withtheangleopeningmediallyasshowninFig.3a,indicatesastablehip.图2.?FEAR指数。测量连接股骨最内侧和外侧点的线与连接股骨头骨骺直线部分（通常为中央三分之一）内侧和外侧端的线之间的角度。如图3a所示，角度向内侧打开的阴性FEAR指数，表示髋关节稳定。Fig.3.(a)CaseexamplesusingtheFEARindex.17-year-oldmale,LCEA20°,FEAR0°.Hipdeemedthereforestableandpatientmanagedwithhiparthroscopy.(b)CaseexamplesusingtheFEARindex.17-year-oldfemale,LCEA20°,FEAR8°.HipdeemedthereforeunstableandpatientmanagedwithPAO.图3.(a)使用FEAR指数的病例。17岁男性，LCEA20°，FEAR0°。因此髋关节稳定，患者接受髋关节镜治疗。(b)使用FEAR指数的病例。17岁女性，LCEA20°，FEAR8°。因此髋关节不稳定，患者接受PAO截骨治疗。有哪些治疗方案？治疗取决于髋关节的稳定性。疼痛性临界髋关节发育不良的治疗方案包括非手术治疗、解决关节内撞击的手术治疗（通过髋关节镜或髋关节外科脱位进行的FAI手术）和解决不稳定性的手术治疗（采用PAO和/或股骨截骨术的重新定位截骨术）（见图2）。非手术治疗包括患者教育、活动调整、简单的止痛药、非甾体抗炎药和髋关节腔内注射药物[35]。有针对性的物理治疗可以改善肌肉调节、疼痛和本体感受控制。以下段落将讨论包括关节镜和/或截骨术的临界髋关节发育不良的手术治疗方案。这组患者接受髋关节镜检查的结果如何？随着髋关节镜技术的最新发展，许多外科医生正在使用它来治疗临界髋关节发育不良，尤其是因为人们认为髋臼周围截骨术等替代技术的风险更高，术后恢复时间更长。临界髋关节发育不良的髋关节镜检查还可以让外科医生处理髋关节内病变，如盂唇撕裂或股骨凸轮畸形[3,12,36]。如果考虑使用PAO来解决骨稳定性不足的问题，那么关节镜检查不仅可以让外科医生了解髋关节的关节内状态，还可以了解患者在随后进行更大规模手术时的表现[37]。然而，关于临界髋关节发育不良的髋关节镜检查的已发表文献很少，而且短期随访也存在局限性。在Jo等的系统综述中，确定了13项关于髋关节发育不良的关节镜检查的研究[10]。这些研究各不相同，所有研究都是病例系列。仅有6项研究报告了主观和/或客观结果。关节镜检查的手术指征不明确，患者事先接受过多种非手术治疗。此外，临界髋关节发育不良的确切定义各不相同，只有两项研究使用了Byrd和Jones的定义[36]。三项研究报告了髋关节镜作为辅助工具，三项研究报告了髋关节镜作为独立治疗。盂唇撕裂的总患病率为77.3%，主要位于髋臼缘的前部或前上部。髋臼软骨病变比股骨病变更常见（59-75.2%比11-32%），并且位于盂唇病变的邻近。仅有两项研究检查了临界髋关节发育不良病例（LCEA20-25°）的关节镜检查结果，其中只有一项描述了患者报告的结果测量。后者是Byrd和Jones[36]的前瞻性临床病例系列，其中66%的髋关节（32髋）患有临界髋关节发育不良。关节镜检查后，平均改良Harris髋关节评分从50（差）改善到77（一般）。作者得出结论，髋关节镜治疗可能解决髋关节内病理而不是发育不良的放射学证据的结果。对临界髋关节发育不良进行髋关节镜检查有什么危险？临界髋关节发育不良患者进行关节镜盂唇切除术和髋臼外侧缘切除术可导致爆发性髋关节不稳定[38]。即使修复了盂唇，也必须保留髂股韧带和髋关节的其他静态稳定器，以防止不可逆的后果或导致髋关节不稳定[39–41]。没有确凿的文献支持在这些情况下进行关节囊修复，但这似乎是一种安全合理的做法[42]。关节囊复位技术可提高临界髋关节发育不良的稳定性[12]。如果髋关节在术前足够不稳定，那么仅通过髋关节镜治疗关节内病变是不够的，患者将需要进行PAO截骨术[43,44]。必须记住，髋关节的稳定性首先取决于髋骨几何形状。在轻微不稳定（临界发育不良）中，稳定性可能由次级软组织结构来确保。一旦这些结构因微创伤或大创伤而失效，髋关节就会变得不稳定。恢复软组织稳定性可能只会在短时间内改善髋关节稳定性，但软组织很可能再次磨损。因此，必须首先解决潜在的骨病理问题，才能取得良好的长期效果。最近的一份报告显示，髋关节发育不良患者在髋关节镜检查失败后，PAO的髋关节特定功能结果较差[6]。因此，对这组患者单独进行髋关节镜检查应谨慎处理。但是，对于那些由于髋关节状况不佳（即AI和股骨前倾正常）或高龄（即>40岁）而不适合进行PAO的患者，它可能有用。重新定向髋臼周围截骨术对这组患者有何影响？通过髋臼周围截骨术进行髋臼重新定向已成为髋关节发育不良最常见的治疗方法，据报道术后20多年效果良好。传统上，PAO时关节内病变的处理方法是进行前关节切开术。然而，随着PAO微创技术的发展，情况已不再如此。微创PAO技术缩短了术后恢复时间[45]。最近的一项研究表明，一些可改变的因素，例如较高的体力活动量和较高的BMI（大于30kg/m2）可导致PAO的发病年龄下降[46]。此外，患有较重发育不良程度的患者患PAO的年龄也较早：LCEA是手术年龄的独立预测因素，即LCEA较低的患者往往需要在较早的年龄接受PAO手术。但是，轻度和中度发育不良患者的PAO预后没有差异。在本研究中，轻度发育不良被归类为15-25°，这涵盖了我们对临界髋关节发育不良的定义。最近的一项多中心前瞻性队列研究检查了患者报告的PAO结果指标，结果表明，虽然总体结果良好，但临界髋关节发育不良患者和男性的改善程度低于发育较重的患者[47]。作者讨论了小范围矫正的危险，这可能导致过度矫正和医源性FAI、股骨前倾增加和软组织松弛。建议和未来方向在临界髋关节中，关键步骤是确定稳定性。关于髋关节的稳定性，只有两种情况：髋关节稳定或不稳定。没有中间状态。如果接受这个概念，治疗就会变得相对简单。不稳定可能与其他病症（如FAI或超负荷/过度使用和软骨疾病）相结合，需要同时治疗。如果髋关节不稳定，则需要髋臼重新定位。仅解决磨损的二级稳定器并不能解决潜在的生物力学问题，最多只能产生令人满意的短期结果。在稳定的髋关节中，可以进行开放或关节镜关节保留手术。然而，我们必须记住，低于28°的LCE角度每减少一度，骨关节炎的发病率就会增加13%[20]。因此，如果有疑问，为了最大限度地提高获得良好长期结果的机会，我们主张进行髋臼重新定向PAO截骨手术。重要的是要确定我们缺乏知识的领域，以指导进一步的研究。将对这些患者进行长期随访研究，比较髋臼重新定向和髋关节镜检查，理想情况下，将记录所有成像参数和Beighton评分。此外，还应获得患者报告的结果测量和恢复时间，以及包括运动在内的活动恢复时间。?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.文献出处：MichaelCWyatt,MartinBeck.Themanagementofthepainfulborderlinedysplastichip.ReviewJHipPreservSurg.2018Apr5;5(2):105-112.doi:10.1093/jhps/hny012.
髋关节发育不良保髋手术常见问题问：髋关节发育不良可不可以保守治疗，是否必须手术？答：首先，保守治疗无非控制活动量、控制体重、吃止疼药、加强肌肉锻炼，一定程度可以缓解疼痛症状，但是根本的骨头畸形并没有改变，也就是说，保守治疗只能一定程度延缓病情进展，无法解决根本问题。手术的目的是为了缓解疼痛、延长自身关节的使用寿命，从根本上解决问题。如果本身关节不疼，或者疼痛非常非常轻，可以暂且保守治疗。但是，如果关节疼痛比较频繁或者比较重，手术可能是解决当前问题的最佳方式。?问：保髋术后我的关节能用多少年？答：这个问题很难回答。影响关节使用寿命的因素太多了，比如手术时关节软骨磨损重不重、自身的软骨耐磨程度如何、自身的关节畸形重不重、手术医生的水平好不好、术后体重控制得好不好、术后关节保养的好不好。理论上讲，通过手术纠正畸形可以让关节的使用寿命尽可能延长，最好的效果就是用一辈子，当然，少术患者也有术后几年、十几年后出现关节磨损严重，进而换关节的。总体上讲，找一个靠谱的医生，术后自己好好保养，剩下的就交给天意了。?问：手术后我应该怎么保养自身的关节？答：手术的目的还是希望大家回归正常的生活。有的极端的患者，为了减少关节负重会走极端，比如坐轮椅，甚至少穿衣服，其实大可不必，该干嘛干嘛。如果可以的话，适当避免长时间重体力劳动或者剧烈运动。当然，如果你觉得运动是生命中不可缺少的一部分，那也不用刻意压抑，这一点国外是比较积极的，很多患者手术就是为了后续运动时不疼。当然，如果能把体重控制在理想的区间肯定是最好的。?问：我想手术了，术前应该做哪些准备？答：1、异地就医，提前进行医保备案，具体需要询问当地医保部门；2、准备一副拐杖，肘拐腋拐都可以，调整拐杖高度，练习拄拐单腿走路；3、术前可以按医生的建议进行功能锻炼，改善肌力，加速术后康复；4、带着之前拍的片子及病历；5、酌情准备个人生活物品。?问：髋臼周围截骨手术风险高不高？答：这个手术确实难度很大，被誉为骨科的珠穆朗玛，手术的入门门槛很高，学习曲线很长，目前全国只有为数不多的医生可以做这类手术。记得我在美国学习的时候，看过两个医生做这个手术，一个医生平均需要三四个小时，另一个医生需要6-8个小时。对于我们来说，绝大多术的手术可以在1小时出头的时间完成，手术不但做得快，质量也是绝对有保证。?问：手术需要输血吗？答：这个手术的出血确实偏多，但是随着手术技术的提高和相关药物的应用，再加上手术中使用血液回收设备（可以将出血量的大概一般进行重新回收利用），目前在我中心手术的患者，90%以上的患者不需要异体输血。而且，我们中心现在术前不需要常规备自体血。?问：术后恢复期大概多久？答：手术中我们需要将骨头截断，调整好位置后进行固定，截断的骨头长好需要大概3个月的时间。所以，术后3个月内需要小心保护自己的髋关节，不要摔，一定要拄双拐，拄双拐，拄双拐！一般我会让患者术后6-8周内术腿不负重，6-8周后从0开始逐渐逐渐增加踩地的重量，注意，是匀速逐渐的增加，到3个月的时候可以负重身体重量1/3-1/2，具体以医生通知为准。过早扔拐，过早过多负重可能导致骨头移位，影响手术效果。3个月后门诊复查，评估骨头生长情况。?问：术后如何进行康复锻炼？答：康复锻炼很重要，锻炼不好，走路十有八九会瘸。我的患者我一般会给每人一个康复计划，由于每个人的手术不一样，畸形不一样，骨头质量不一样，所以方案不会完全一样，大家按照自己的方案去做锻炼即可。大家认真阅读锻炼资料，保证动作做对，一旦动作做错，就可能练错肌肉。3个月复查时人要过来，很重要，我会根据查体结果和骨头愈合情况调整康复方案。复查方式参考：保髋术后门诊复查注意事项