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：Dustin Woyski, Steve Olson, Brian Lewis.

作者单位: Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, 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。

Fig 1 View of standard Hana table setup with Pink Hip Kit and patient draw sheet folded in half from the (A) side and (B) above. (C) View from above of the ideal patient placement with perineum approximately 4 to 6 cm from the post positioning hole.

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。

Fig 2 (A) Patient is supine with the left hip sterilely prepped and draped and inferior margin of iliac crest outlined. The ASIS and GT are marked as well. The incision of the periacetabular osteotomy is made from the GT and is connected to the MAP. (B) Incision for the PAO is made from the GT to the MAP. (C) Exposure of the EOF is important before masking. (D) Fleck osteotomy of the ASIS off of the IC using a one-half-inch straight osteotome.

(AL, anterolateral portal; ASIS, anterosuperior iliac spine; DALA, distal anterolateral accessory portal; EOF, external abdominal oblique muscle and fascia; GT, gluteal tubercle; IC, iliac crest; MAP, mid-anterior portal; PAO, periacetabular osteotomy.)

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。）

Fig 3 Magnetic resonance imaging based 3-dimensional rendering of a left hip joint viewed anteriorly is used for preoperative planning. This demonstrates typical findings of focal femoroacetabular impingement found in the dysplastic hip with a minimal cam and pincer (*), which are labeled. (PS, pubic symphysis; 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。）

Fig 4 Intraoperative fluoroscopic images of a left hip periacetabular osteotomy. (A) Anteroposterior view demonstrating the narrow curved osteotome against the medial aspect of the anterior ischium prior to osteotomy. (B) Iliac oblique view with the acetabulum outlined in blue and posterior column including ischial spine outlined in green showing the (C) appropriate depth of the curved osteotome of the incomplete ischial osteotomy. (D) Anteroposterior view showing the curved osteotome’s ideal position behind the acetabulum.

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。

Fig 5 Fluoroscopic images of the left hip. (A) Wide straight osteotome in correct position on the anteroposterior view overlying the acetabular teardrop. (B) Iliac oblique view with the iliac osteotomy made using the oscillating saw outlined in blue. (C) Iliac oblique view of the straight osteotome coming behind the acetabulum and (D) connecting with the previous incomplete ischial osteotomy, which is outlined in blue.

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。

Fig 6 Left hip fluoroscopic iliac oblique views of the acetabular fragment (A) before correction with the acetabulum outlined in blue and (B) postcorrection with provisional fixation using 3.2-mm drill bits. (C) Iliac oblique and (D) anteroposterior fluoroscopic views showing final position of acetabular fragment following periacetabular osteotomy with 4.5-mm screws in place.

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。

Fig 7 Anteroposterior views of the pelvis showing the left hip (A) preoperatively and (B) postoperatively. Increased lateral coverage of the femoral head and decreased inclination of the acetabular sourcil are noted.

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。

Single Table Concomitant Post-Less Hip Arthroscopy Combined with Periacetabular Osteotomy for Hip Dysplasia

Abstract

It has been well established that both arthroscopic and open hip preservation techniques can result in improved patient outcomes and interrupt the natural history of hip disease. Traditionally, hip arthroscopy has been used to address central and peripheral compartment disease consisting of labral tears, impingement morphology and cartilage pathology. The periacetabular osteotomy has been the most used treatment for hip instability caused by inadequate acetabular coverage of the femoral head or dysplasia. With failures of periacetabular osteotomy linked to postoperative impingement and the high incidence of intra-articular pathology in the dysplastic hip, there has been a great interest in combing hip arthroscopy with the periacetabular osteotomy. Here, we describe a technique for a single table, single drape, postless combined hip arthroscopy, and periacetabular osteotomy.

Discussion

A high incidence intra-articular pathology in patients with hip dysplasia when identified by open or arthroscopic means has been reported.5 The vast majority of our patients also satisfy the Warwick criteria for acceptability for hip arthroscopy from their imaging, physical examination, and history.6 Because of these factors, we have been performing concomitant arthroscopy on nearly every PAO at our institution since 2013 and have been performing the current postless technique since March 2018. Our technique of combined hip arthroscopy and PAO has evolved over the years to what is described in this Technical Note with the use of 1 table and without a perineal post. The senior surgeon has performed more than 500 PAO procedures and has found that concomitant arthroscopy does not increase the operative time of the PAO and, if anything, has made the exposure easier with less bleeding and better-defined tissue planes because of hydro-dissection from the arthroscopy fluid. The ease of exposure along with other technical pearls and benefits are outlined in Table 1.

The long-term outcomes of PAO have been well described over the past 2 decades, with one-third of the original Bernese cohort having been preserved at 30 years.7 A known cause of failure of the PAO is not addressing femoroacetabular impingement or creating impingement with the PAO correction.8 However, it remains to be seen if addressing central and peripheral compartment pathology at the time of PAO can affect short- and long-term outcomes. Reports thus far have been sparse and inconsistent with selection bias of treating intra-articular pathology to those with signs and symptoms of impingement or MRI findings of labral pathology. We firmly believe that with the high association of intra-articular pathology and cam morphology9 in patients with dysplasia that an arthroscopic evaluation and treatment of the central and peripheral compartments of the hip is warranted in all hips before PAO.

We have found a very high prevalence of intra-articular pathology with nearly all hips presenting for PAO requiring a labral repair and more than one-half with some degree of chondromalacia of the acetabulum. The use of a single table and draping has allowed us to complete an efficient combined hip arthroscopy and PAO (Table 1). At our institution, both the arthroscopy and PAO are performed by a single surgeon. Neither of these procedures alone should be taken on by the inexperienced surgeon because both the PAO and arthroscopic hip surgery have a steep learning curve.10,11 Any new technique involving the combination of multiple complex, difficult procedures and new equipment can carry potential disadvantages and risks (Table 2). When performed by an experienced surgeon, however, the addition of arthroscopy before PAO can be done safely and does not increase the complication rate.12

文献出处：Dustin Woyski, Steve Olson, Brian Lewis. Single Table Concomitant Post-Less Hip Arthroscopy Combined with Periacetabular Osteotomy for Hip Dysplasia. Arthrosc Tech. 2019 Nov 25;8(12):e1569-e1578. doi: 10.1016/j.eats.2019.08.015. eCollection 2019 Dec.