髋关节骨软骨缺损：批判性综述：髋关节骨软骨缺损的治疗和手术选择：2017年

髋关节骨软骨缺损：批判性综述：髋关节骨软骨缺损的治疗和手术选择：2017年

作者：Eric C Makhni, Austin V Stone, Gift C Ukwuani, William Zuke, Tigran Garabekyan, Omer Mei-Dan, Shane J Nho.

作者单位: Division of Sports Medicine, Department of Orthopedic Surgery, Henry Ford Health System, 6777 West Maple Road, 3rd Floor East, West Bloomfield, MI 48322, USA.

译者：陶可（北京大学人民医院骨关节科）

摘要

摘要

髋关节软骨病变的患者可能会出现疼痛和症状，这些症状的性质和发病可能病因不明。因此，应对每位出现髋部疼痛和/或残疾的患者进行全面的病史和体格检查。治疗可能是需要手术或非手术方案的。非手术治疗包括尝试休息和/或活动调整，以及抗炎药物、物理治疗和生物注射剂（玻璃酸钠注射液）。关节镜手术治疗继续降低发病率，并为微骨折、自体软骨细胞移植（ACT）和自体基质诱导的软骨再生（Autologous Matrix-Induced Chondrogenesis, AMIC）提供创新解决方案和新应用。

总结

髋关节软骨缺损的治疗仍然是快速发展的治疗策略中一个具有挑战性但非常重要的领域。随着对软骨生物学的了解不断增长，非手术和手术技术可能会涉及更大的生物学热点。关节镜技术继续降低发病率，并为微骨折、ACT和AMIC提供创新解决方案和新应用。如本文所引用和说明的，对于可能受益于关节镜下骨移植的髋臼或股骨头的骨软骨囊性病症尤其适合。软骨保留技术的适应症不断扩大，新的生物制剂提供了可能为患者带来益处的创新解决方案。

关键词：自体软骨细胞移植；软骨损伤；马赛克（骨软骨移植术）；骨软骨同种异体移植；骨软骨自体移植；粘性补充（疗法：玻璃酸钠注射液）。

表1 软骨软化的1961年Outerbridge分类系统

分级

0级 正常的软骨

1级 软骨软化、肿胀

2级 软骨部分层厚缺损，表面裂缝不扩展到软骨下骨，且缺损直径＜1.5厘米

3级 软骨部分层厚缺损，表面裂缝延伸至软骨下部骨或缺损直径＞1.5厘米

4级 全层骨软骨缺损

来自Outerbridge Re的数据。髌骨软骨软化的病因。J Bone Joint Surg Br, 1961;43-B:752–7.

Fig. 1. Incorporation of cartilage delamination (A) into labral repair construct (B, C), left hip. Note the prominent “wave sign” indicating cartilage delamination from the underlying FAI. (Courtesy of Dr Shane J. Nho, Chicago, IL.)

图1. 将软骨分层（A）掺入盂唇修复重建体（B，C），左侧髋关节。请注意突出的“波纹征”，表明软骨分层来源于股骨髋臼撞击症FAI。（由伊利诺伊州芝加哥大学的Shane J. Nho博士提供）。

Fig. 2. Microfracture of large acetabular chondral defect. Right hip with evidence of cystic and cartilage disease (A) due to femoral retro-torsion and CAM type FAI with corresponding arthroscopic appearance (B) undergoing labral reconstruction. After debridement of the unstable cartilage flap, the defect was microfractured using a drill (Stryker, Phoenix, AZ) (C), with evidence of bleeding subchondral bone indicating adequate microfracture (D). A derotational osteotomy was then performed to correct (＜15) degrees of femoral torsion to normal values (E). Corresponding images with second-look arthroscopy, demonstrating well-incorporated reconstructed labrum (tensor fascia lata [TFL] allograft) with excellent fill of the defect (F, G) in setting of prior procedure. (Courtesy of Dr Omer Mei-Dan, Boulder, CO.)

图2. 较大范围的髋臼软骨缺损的微骨折（手术过程）。（关节镜下可见）右侧髋关节具有囊性和软骨疾病的证据（a），这是由于股骨反倾（前倾角异常）和凸轮型CAM股骨髋臼撞击症FAI引起的，具有相应的关节镜外观（b），并接受了盂唇（损伤）重建术。在不稳定的软骨瓣清创术后，使用钻（Stryker，Phoenix，AZ）（C）将软骨缺损处进行了微骨折术，并查看到软骨下骨出血，以表明微骨折成功（D）。然后进行去旋转截骨术以纠正（＜15度）股骨扭转至正常值（e）。第二次关节镜检查的相应图片，盂唇重建良好（采用同种异体的小凹韧带），能很好地填充之前损伤的部位（F，G）。（由Boulder的Omer Mei-Dan博士提供）

Fig. 3. Bone grafting of a femoral head cyst using a curved shaver. Large cystic lesion noted in the femoral head on preoperative CT images (A) with intraoperative debridement and curettage pictures (B). Bone grafting delivered through curved shaver using technique referenced and described by senior author (OMD) (C, D). Final appearance of cystic lesion with bone grafting (E). (Courtesy of Dr Omer Mei-Dan, Boulder, CO.)

图3. 使用弯曲的刨刀对股骨头囊肿进行骨移植。术前CT图像显示股骨头大的囊性病变（a），术中清创和刮除术（b）。由有经验的作者（Omer Mei-Dan博士）描述的通过弯曲的刨刀进行的骨移植（c，d）。股骨头囊性病变的最终出现由骨移植物填充（E）。（由Boulder的Omer Mei-Dan博士提供）

A Critical Review: Management and Surgical Options for Articular Defects in the Hip

Abstract

Patients with articular cartilage lesions of the hip may present with pain and symptoms that may be vague in nature and onset. Therefore, a thorough history and physical examination should be performed for every patient presenting with hip pain and/or disability. The management may be operative or nonoperative. Nonoperative management includes a trial of rest and/or activity modification, along with anti-inflammatory medications, physical therapy, and biologic injections. Operative treatment in the form of arthroscopic techniques continues to decrease morbidity and offer innovative solutions and new applications for microfracture, ACT, and AMIC.

SUMMARY

The management of articular cartilage defects in the hip remains a challenging but very important area of rapidly evolving treatment strategies. As the understanding of cartilage biology continues to grow, nonoperative and operative techniques will likely involve a greater biologic focus. Arthroscopic techniques continue to decrease morbidity and offer innovative solutions and new applications for microfracture, ACT, and AMIC. This may be especially true with cystic conditions of the acetabulum or femoral head that may benefit from bone grafting arthroscopically, as referenced and illustrated in this article. The indications for cartilage-preserving techniques continue to expand and new biologics offer innovative solutions that may provide benefit to the patient.

Keywords: Autologous chondrocyte transplantation; Chondral injury; Mosaicplasty; Osteochondral allograft transplantation; Osteochondral autologous transplantation; Viscosupplementation.

文献出处：Eric C Makhni, Austin V Stone, Gift C Ukwuani, William Zuke, Tigran Garabekyan, Omer Mei-Dan, Shane J Nho. A Critical Review: Management and Surgical Options for Articular Defects in the Hip. Review Clin Sports Med. 2017 Jul;36(3):573-586. doi: 10.1016/j.csm.2017.02.010.