一、正常髖關(guān)節(jié)（I型）的特點(diǎn)及治療特點(diǎn)：Ⅰ型髖關(guān)節(jié)發(fā)育正常，其中又分Ia型和Ib型。Ia型β角小于55度，Ib型β角在55-77度，兩者α角都大于60度。髖臼角30°，α角60°，β角55°。髖臼對(duì)股骨頭有良好的覆蓋，骨頂外緣銳利成角（Ⅰa型）或輕度變鈍（Ⅰb型），臼頂軟骨狹窄呈三角形1。治療：對(duì)于Ⅰ型髖關(guān)節(jié)，通常不需要特殊治療，只需定期進(jìn)行復(fù)查，觀察髖關(guān)節(jié)的發(fā)育情況。因?yàn)檫@是正常的髖關(guān)節(jié)發(fā)育狀態(tài)，在日常的生長(zhǎng)發(fā)育過(guò)程中，正常的活動(dòng)和生活不會(huì)對(duì)其產(chǎn)生不良影響。但家長(zhǎng)也需要關(guān)注孩子的一些日常行為，例如孩子的活動(dòng)是否自如等，若發(fā)現(xiàn)異常情況應(yīng)及時(shí)就醫(yī)進(jìn)一步檢查。二、髖關(guān)節(jié)發(fā)育稍差（Ⅱ型）的特點(diǎn)與治療特點(diǎn)：Ⅱ型髖關(guān)節(jié)發(fā)育稍差，分為Ⅱa、Ⅱb、Ⅱc、Ⅱd四個(gè)亞型。Ⅱa型指出生12周以?xún)?nèi)嬰兒，α角為50°-59°，β角小于55度；Ⅱb型指12周以上嬰兒髖，α角50°-59°，β角55°；Ⅱc型α角43°-49°，β角小于77度；Ⅱd型α角同Ⅱc型，β角大于77度。髖臼角在30°-43°之間，α角55°-60°，β角55°。該型髖的骨性髖臼外上緣缺少鈣化，骨頂輪廓發(fā)育缺陷的部分由軟骨頂增寬充填，覆蓋在股骨頭上25。治療：對(duì)于Ⅱ型髖關(guān)節(jié)，尤其是Ⅱa和Ⅱb型，因?yàn)樘幱隗y關(guān)節(jié)發(fā)育的臨界狀態(tài)或者骨化延遲狀態(tài)，在早期通常采取觀察和定期復(fù)查的策略。如果沒(méi)有進(jìn)一步的惡化或者有好轉(zhuǎn)的趨勢(shì)，可以繼續(xù)觀察。而對(duì)于Ⅱc和Ⅱd型髖臼發(fā)育不良的情況，可采用軟式支具矯治，如Pavlik吊帶等。通過(guò)支具將髖關(guān)節(jié)保持在合適的位置，促進(jìn)髖臼的正常發(fā)育。在使用支具期間，需要定期進(jìn)行超聲檢查來(lái)評(píng)估治療效果，并且要注意支具的佩戴是否合適，避免對(duì)孩子的皮膚等造成損傷。三、髖關(guān)節(jié)發(fā)育不良（Ⅲ型）的特點(diǎn)與治療特點(diǎn)：Ⅲ型髖關(guān)節(jié)發(fā)育不良，分為Ⅲa和Ⅲb型。Ⅲ型髖關(guān)節(jié)髖臼角43°-55°，α角40°-55°，β角55°-77°。兩類(lèi)髖中股骨頭均向上外方脫位，Ⅲa軟骨頂為無(wú)回聲結(jié)構(gòu)，是透明軟骨成分，Ⅲb的軟骨頂可見(jiàn)有程度不同回聲，說(shuō)明透明軟骨可能發(fā)生了纖維化或變性改變。在單一冠狀聲像上，脫位的股骨頭和髖臼不能同時(shí)完整顯現(xiàn)，參考測(cè)量點(diǎn)難以辨認(rèn)5。治療：對(duì)于Ⅲ型髖關(guān)節(jié)發(fā)育不良，早期（6-7個(gè)月以下）可采用保守治療，如使用Pavlik吊帶、支具等。從經(jīng)驗(yàn)和文獻(xiàn)的報(bào)道來(lái)說(shuō)，這種保守治療對(duì)于這個(gè)年齡段的孩子成功率可以達(dá)到90%以上。在使用支具或吊帶期間，需要密切關(guān)注孩子髖關(guān)節(jié)的復(fù)位情況，定期進(jìn)行超聲檢查。如果保守治療不成功，可以改用麻醉下石膏復(fù)位。經(jīng)過(guò)復(fù)位的關(guān)節(jié)對(duì)髖臼的刺激，局部發(fā)育就會(huì)逐步的改善。同時(shí)，在治療過(guò)程中，還需要關(guān)注孩子下肢的血液循環(huán)、神經(jīng)功能等情況，避免因治療導(dǎo)致其他并發(fā)癥的出現(xiàn)。四、髖關(guān)節(jié)脫位（Ⅳ型）的特點(diǎn)與治療特點(diǎn)：Ⅳ型髖關(guān)節(jié)脫位，髖臼角55°，α角40°，β角77°。此型髖的聲學(xué)特點(diǎn)是股骨頭脫位，表面只有薄層關(guān)節(jié)囊覆蓋，髖臼唇盂和軟骨頂也向原始髖臼的內(nèi)下方移位。在B超下α角甚至測(cè)量不出，屬于髖關(guān)節(jié)高位脫位的情況212。治療：對(duì)于Ⅳ型髖關(guān)節(jié)脫位，因?yàn)槊撐磺闆r較為嚴(yán)重，一般需要積極治療。對(duì)于6-7個(gè)月以下的嬰兒，如果保守治療（如Pavlik吊帶等）效果不佳，可考慮麻醉下石膏復(fù)位。而對(duì)于年齡較大的孩子（7-18個(gè)月），可能需要進(jìn)行麻醉下閉合復(fù)位或者切開(kāi)復(fù)位，然后用石膏固定。在復(fù)位過(guò)程中，要確保股骨頭準(zhǔn)確復(fù)位到髖臼內(nèi)，并且要關(guān)注復(fù)位后髖關(guān)節(jié)的穩(wěn)定性。在術(shù)后，需要長(zhǎng)期的康復(fù)隨訪(fǎng)，觀察髖關(guān)節(jié)的發(fā)育情況以及孩子的下肢功能恢復(fù)情況，預(yù)防股骨頭壞死、髖關(guān)節(jié)僵硬等并發(fā)癥的發(fā)生。五、髖關(guān)節(jié)半脫位（Ⅴ型）的特點(diǎn)與治療特點(diǎn)：Ⅴ型髖關(guān)節(jié)半脫位，髖臼角55°，α角40°，β角77°-90°。髖關(guān)節(jié)處于半脫位狀態(tài)，股骨頭部分脫離髖臼，關(guān)節(jié)的穩(wěn)定性受到影響，髖臼對(duì)股骨頭的覆蓋不完全，這會(huì)影響髖關(guān)節(jié)的正常發(fā)育和功能1。治療：對(duì)于Ⅴ型髖關(guān)節(jié)半脫位的治療與Ⅲ型髖關(guān)節(jié)發(fā)育不良類(lèi)似。在早期可嘗試保守治療，如使用Pavlik吊帶或支具，并且定期復(fù)查超聲，觀察髖關(guān)節(jié)復(fù)位情況。如果保守治療失敗，根據(jù)孩子的年齡可選擇麻醉下石膏復(fù)位（6-7個(gè)月以下）或者其他更復(fù)雜的復(fù)位手術(shù)（年齡較大時(shí)）。在整個(gè)治療過(guò)程中，同樣要關(guān)注髖關(guān)節(jié)的功能恢復(fù)和發(fā)育情況，避免出現(xiàn)并發(fā)癥。

臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH(2)：疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療作者：MichaelCWyatt,MartinBeck.作者單位:KlinikfürOrthop?dieundUnfallchirurgieLuzernerKantonsspital6004Luzern,Switzerland.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要在過(guò)去的幾十年里，影像技術(shù)的改進(jìn)和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。然而，疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然存在爭(zhēng)議。在這篇評(píng)論中，我們將確定相關(guān)問(wèn)題并描述患者評(píng)估和治療方案。我們將提供自己的建議，并確定未來(lái)的研究領(lǐng)域。簡(jiǎn)介在過(guò)去的幾十年里，髖關(guān)節(jié)生物力學(xué)知識(shí)的提高和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。保髖手術(shù)適應(yīng)范圍廣泛，從髖臼淺且不穩(wěn)定的髖關(guān)節(jié)到髖臼深且患有股骨髖臼撞擊(FAI)的髖關(guān)節(jié)。雖然人們普遍認(rèn)為，不穩(wěn)定髖關(guān)節(jié)發(fā)育不良的最佳治療方法是重新定位髖臼以增加覆蓋范圍，但人們同樣認(rèn)為，必須減小過(guò)度覆蓋的髖臼臨界以消除撞擊。所有這些髖關(guān)節(jié)都可能存在凸輪畸形，需要在手術(shù)矯正時(shí)加以解決[1]。在最極端的情況下，所需的治療是顯而易見(jiàn)的。然而，有一個(gè)過(guò)渡區(qū)，很難區(qū)分不穩(wěn)定性和股骨髖臼撞擊(FAI)。過(guò)去，這些髖關(guān)節(jié)被稱(chēng)為“臨界”髖關(guān)節(jié)。通常，這包括外側(cè)中心臨界(LCE)角度在20°到25°之間的髖關(guān)節(jié)[2]。然而，“臨界”一詞是有問(wèn)題的，因?yàn)樗且粋€(gè)放射學(xué)定義，只涉及描述髖關(guān)節(jié)穩(wěn)定性的幾個(gè)重要參數(shù)之一。髖臼頂傾斜角、前后覆蓋和股骨前傾是應(yīng)納入髖關(guān)節(jié)穩(wěn)定性分析的其他因素。髖關(guān)節(jié)發(fā)育不良與髖關(guān)節(jié)骨關(guān)節(jié)炎之間的關(guān)聯(lián)已經(jīng)確定[3,4]，有不穩(wěn)定跡象的髖關(guān)節(jié)發(fā)育不良退化速度更快[5]。臨界髖關(guān)節(jié)可能不穩(wěn)定、撞擊或兩者兼而有之。臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性很難確定，并且容易受個(gè)人主觀影響，骨科界普遍傾向于低估不穩(wěn)定性，從而導(dǎo)致不適當(dāng)?shù)闹委煛Ｗ罱难芯勘砻?，?duì)患有臨界發(fā)育不良(LCEA?>?20°)的患者進(jìn)行關(guān)節(jié)鏡髖關(guān)節(jié)手術(shù)（包括盂唇修復(fù)和關(guān)節(jié)囊折疊縫合術(shù)）可能會(huì)在短期內(nèi)帶來(lái)適當(dāng)?shù)母纳芠3,4]。然而，有證據(jù)表明，之前錯(cuò)誤的髖關(guān)節(jié)鏡檢查會(huì)對(duì)此類(lèi)髖關(guān)節(jié)的治療結(jié)果產(chǎn)生負(fù)面影響[6]。因此，疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然是一個(gè)極具爭(zhēng)議的問(wèn)題。臨界性髖關(guān)節(jié)發(fā)育不良在患有髖關(guān)節(jié)疼痛的年輕人中很常見(jiàn)，在選定的患者群中報(bào)告的患病率為37.6%[7]。在臨界髖關(guān)節(jié)發(fā)育不良中，可能與其他不穩(wěn)定原因（如韌帶松弛癥）有顯著重疊[8]。然而，根本問(wèn)題是難以正確分類(lèi)潛在的病理生物力學(xué)。定義第一個(gè)問(wèn)題在于定義。在前后位骨盆X線(xiàn)片[9](LCEA)上測(cè)量的Wiberg外側(cè)中心邊緣角傳統(tǒng)上用于將髖關(guān)節(jié)分類(lèi)為正常(LCEA?>25°)、發(fā)育不良(LCEA?<20°)或臨界(LCEA20–25°)，盡管這些定義值在文獻(xiàn)中差異很大[3,10]。然而，使用外側(cè)中心邊緣角(LCEA)存在兩個(gè)問(wèn)題。首先是測(cè)量方法。為了測(cè)量外側(cè)中心邊緣角(LCEA)，首先通過(guò)與股骨頭輪廓相符的圓來(lái)定義股骨頭的中心。角度的第一個(gè)分支垂直穿過(guò)旋轉(zhuǎn)中心。第二個(gè)分支由股骨頭的中心和股骨最外側(cè)點(diǎn)定義（圖1a）。重要的是不要使用髖臼的最外側(cè)點(diǎn)（圖1b），因?yàn)檫@不符合Wiberg的定義，并且會(huì)給出錯(cuò)誤的高值(外側(cè)中心邊緣角(LCEA)偏大)[11]。Fig.1.(a)CorrectmeasurementoftheLCEAusingtheedgeofthesourcil,indicatingmoderatedysplasia.(b)IncorrectmeasurementoftheLCEAinthesamehip.Usingthisvaluewouldfalselyclassifythishipasborderline.圖1(a)使用髖臼臨界正確測(cè)量外側(cè)中心邊緣角(LCEA)，表明中度髖關(guān)節(jié)發(fā)育不良。(b)同一髖關(guān)節(jié)的外側(cè)中心邊緣角(LCEA)測(cè)量不正確。使用此值會(huì)錯(cuò)誤地將此髖關(guān)節(jié)歸類(lèi)為臨界。其次，實(shí)際術(shù)語(yǔ)“臨界髖關(guān)節(jié)發(fā)育不良”是由Wiberg本人首次提出的，包括外側(cè)中心邊緣角(LCEA)在20°和25°之間的髖關(guān)節(jié)[2]。外側(cè)中心邊緣角(LCEA)是一種放射學(xué)測(cè)量，本身無(wú)法預(yù)測(cè)臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性，也無(wú)法完全描述股骨頭覆蓋范圍。因此，外側(cè)中心邊緣角(LCEA)無(wú)法指導(dǎo)手術(shù)決策[12–14]。部分原因是外側(cè)中心邊緣角(LCEA)本身無(wú)法涵蓋發(fā)育不良的精確位置，并且忽略了前后股骨頭覆蓋范圍。此外，髖臼指數(shù)(AI)和股骨前傾等其他參數(shù)也與髖關(guān)節(jié)穩(wěn)定性密切相關(guān)。如果外側(cè)中心邊緣角(LCEA)減少，AI可能正常，在這種情況下很難評(píng)估髖關(guān)節(jié)的穩(wěn)定性[15]。另一方面，股骨前傾過(guò)度可能會(huì)加劇髖關(guān)節(jié)前部不穩(wěn)定[16]。根本問(wèn)題是什么？對(duì)于疼痛的臨界髖關(guān)節(jié)發(fā)育不良，很難僅通過(guò)二維射線(xiàn)測(cè)量將病理機(jī)制表征為撞擊（穩(wěn)定）或發(fā)育不良（不穩(wěn)定），尤其是僅由髖臼功能決定而不考慮股骨的測(cè)量。髖關(guān)節(jié)穩(wěn)定性的功能表征對(duì)于指導(dǎo)手術(shù)決策至關(guān)重要。不穩(wěn)定髖關(guān)節(jié)從邏輯上可以從髖臼重新定向截骨術(shù)中受益，而穩(wěn)定髖關(guān)節(jié)可以從撞擊手術(shù)（如股骨凸輪骨成形術(shù)）中受益。那么關(guān)于髖關(guān)節(jié)內(nèi)病理學(xué)的了解有多少？應(yīng)該如何評(píng)估這些患者？有哪些治療方案？手術(shù)結(jié)果如何？這組患者的潛在隱患是什么？未來(lái)的發(fā)展方向是什么？在這篇敘述性綜述文章中，我們旨在解決這些問(wèn)題，并闡明這組具有挑戰(zhàn)性的患者的處理方法。髖關(guān)節(jié)發(fā)育不良和臨界髖關(guān)節(jié)不穩(wěn)定的潛在病理是什么？髖關(guān)節(jié)發(fā)育不良患者的關(guān)節(jié)接觸壓力異常增高，股骨頭（軟骨損傷，導(dǎo)致軟骨下）骨質(zhì)相對(duì)暴露。髖臼通常較淺且前傾，盂唇經(jīng)常有代償性增大，但同時(shí)伴有髖臼后傾的情況也很高[17]。股骨通常呈外翻，前傾度高[10]。這些異常的解剖特征會(huì)導(dǎo)致病理性髖關(guān)節(jié)生物力學(xué)，表現(xiàn)為盂唇撕裂、軟骨損傷和髖關(guān)節(jié)不穩(wěn)定，這些很容易被誤解為撞擊。由于骨穩(wěn)定性受損，軟組織穩(wěn)定器（即纖維軟骨盂唇和髖關(guān)節(jié)囊）的重要性就凸顯出來(lái)[18]。一旦軟組織約束失效，髖關(guān)節(jié)就會(huì)變得不穩(wěn)定。然而，我們必須明白，主要的潛在病理是缺乏骨性穩(wěn)定性，這會(huì)導(dǎo)致髖關(guān)節(jié)失效，而不是軟組織穩(wěn)定性失效。半脫位髖關(guān)節(jié)發(fā)育不良的自然病史預(yù)后非常差，并且必然會(huì)導(dǎo)致關(guān)節(jié)退化[5]。惡化速度與半脫位嚴(yán)重程度和患者年齡直接相關(guān)，通常在癥狀出現(xiàn)后約10年，就會(huì)出現(xiàn)嚴(yán)重的退行性變化[19]。在沒(méi)有半脫位的情況下，自然病史很難預(yù)測(cè)退化速度。臨界髖關(guān)節(jié)發(fā)育不良也是如此。最近的一項(xiàng)研究強(qiáng)調(diào)了髖臼覆蓋的重要性。在一項(xiàng)為期20年的大型女性隊(duì)列研究中，研究顯示，如果外側(cè)中心邊緣角(LCE)低于28°，則每降低一度，放射學(xué)OA風(fēng)險(xiǎn)就會(huì)增加13%[20]。因此，除了短期緩解癥狀外，還必須考慮長(zhǎng)期可能的發(fā)展。臨床表現(xiàn)臨界髖關(guān)節(jié)發(fā)育不良的臨床表現(xiàn)與其他年輕活躍成人髖關(guān)節(jié)疾?。ㄈ鏔AI綜合征[21]）非常相似，因此，徹底的病史、體格檢查和放射學(xué)評(píng)估對(duì)于正確診斷這些患者至關(guān)重要。病史重點(diǎn)記錄病史。臨界髖關(guān)節(jié)發(fā)育不良患者的主要癥狀是疼痛。這通常發(fā)生在腹股溝和髖關(guān)節(jié)外側(cè)，但也可能發(fā)生在臀部(臀后區(qū))。有必要記錄完整的疼痛病史。尋找特定的不穩(wěn)定和“避免疼痛”癥狀，這可能表明已經(jīng)達(dá)到因缺乏骨性穩(wěn)定性而需要的軟組織代償?shù)臉O限。咔嗒聲和卡住的癥狀也很常見(jiàn)。此外，還會(huì)詢(xún)問(wèn)患者是否有任何跡象表明患者已經(jīng)患上髖關(guān)節(jié)炎，例如夜間疼痛。癥狀應(yīng)結(jié)合患者的功能限制和已經(jīng)接受的醫(yī)療護(hù)理，包括物理治療、藥物、其他意見(jiàn)和手術(shù)。檢查隨后應(yīng)進(jìn)行髖關(guān)節(jié)的合理臨床檢查，包括恐懼試驗(yàn)和撞擊測(cè)試。患者通常會(huì)表現(xiàn)出“膝內(nèi)翻”步態(tài)，同時(shí)伴有髖關(guān)節(jié)內(nèi)收肌力矩增加和髖關(guān)節(jié)內(nèi)旋增加，這與股骨前傾增加一致。為了功能性地增加前覆蓋，可能存在前凸過(guò)度。應(yīng)確定大轉(zhuǎn)子處有無(wú)壓痛[22]。務(wù)必記住檢查患者的旋轉(zhuǎn)輪廓、進(jìn)行神經(jīng)血管檢查以及檢查全身關(guān)節(jié)松弛的跡象，并使用Beighton評(píng)分對(duì)此進(jìn)行量化。具體關(guān)鍵目標(biāo)包括排除(i)晚期退化過(guò)程的存在，例如表現(xiàn)為固定屈曲畸形和運(yùn)動(dòng)范圍減少，以及(ii)其他病理，例如腰椎病或L5神經(jīng)根病引起的疼痛。調(diào)查診斷成像應(yīng)從骨盆的標(biāo)準(zhǔn)化AP平片和股骨頸側(cè)位片（穿桌側(cè)位、Dunn位、假斜位）[23]開(kāi)始。仔細(xì)檢查這些圖像以測(cè)量LCEA、AI、擠壓指數(shù)、股骨頸干角和FEAR指數(shù)（見(jiàn)下文）。應(yīng)確定骨關(guān)節(jié)炎的Tonnis等級(jí)以及是否存在凸輪形態(tài)。應(yīng)仔細(xì)檢查不穩(wěn)定的直接跡象，這些跡象包括股骨頭移位，可通過(guò)與髂坐線(xiàn)的距離增加、Shenton線(xiàn)斷裂和AP視圖上股骨頭重新定位來(lái)識(shí)別，髖關(guān)節(jié)處于外展?fàn)顟B(tài)，使用MR關(guān)節(jié)造影時(shí)后關(guān)節(jié)間隙中有釓，這表明股骨頭向前移位，因此不穩(wěn)定。FEAR指數(shù)與不穩(wěn)定性有很高的相關(guān)性（見(jiàn)下文）。必須精確測(cè)量和記錄各種參數(shù)。有必要使用三維計(jì)算機(jī)斷層掃描(CT)進(jìn)行橫斷面成像，以獲得有關(guān)骨解剖結(jié)構(gòu)和發(fā)育不良位置的精確信息，包括髖關(guān)節(jié)周?chē)夷[的存在和位置[24-26]。此外，CT還應(yīng)包括股骨前傾的評(píng)估，如果前傾過(guò)大，可能會(huì)加劇髖關(guān)節(jié)前部不穩(wěn)定。磁共振成像(MR-關(guān)節(jié)造影)應(yīng)遵循專(zhuān)門(mén)的髖關(guān)節(jié)檢查方案，包括徑向圖像采集或重建和關(guān)節(jié)內(nèi)造影劑應(yīng)用[27]，以檢查關(guān)節(jié)內(nèi)結(jié)構(gòu)和盂唇和關(guān)節(jié)軟骨的病理。可以區(qū)分引起類(lèi)似癥狀的其他原因，例如缺血性壞死、轉(zhuǎn)子滑囊炎或臀肌病變。其他測(cè)量包括盂唇大小[13,28]和髂關(guān)節(jié)囊體積[29]。對(duì)于這些患者，我們還提倡進(jìn)行非牽引性MR關(guān)節(jié)造影檢查，以檢查是否存在釓積聚，即所謂的“新月征”，這是軸向視圖上不穩(wěn)定的細(xì)微征兆[30]。這些測(cè)量值的價(jià)值是什么？在平片上，那些直接表明不穩(wěn)定的測(cè)量值是股骨頭移位，與髂坐線(xiàn)的距離增加，Shenton線(xiàn)斷裂，髖關(guān)節(jié)外展時(shí)AP視圖上股骨頭重新定位，以及FEAR指數(shù)。在MR關(guān)節(jié)造影中，后下關(guān)節(jié)間隙中釓的存在表明股骨頭移位，因此不穩(wěn)定。AI、NSA、AT、高髂囊體積和盂唇體積可能存在增加，但不能預(yù)測(cè)不穩(wěn)定性[30]（表1）。表1.用于評(píng)估髖關(guān)節(jié)不穩(wěn)定性的各種參數(shù)概述TheFemoro-EpiphysealAcetabularRoof(FEAR)index:股骨骨骺髖臼頂指數(shù)Thefemoralneck-shaftangle(NSA):頸干角FEAR指數(shù)是最近描述的參數(shù)，似乎對(duì)預(yù)測(cè)髖關(guān)節(jié)穩(wěn)定性具有很高的價(jià)值[27]。它是由髖臼頂與股骨生長(zhǎng)板中央1/3處之間的角度形成的（圖2）。其依據(jù)是：在生長(zhǎng)過(guò)程中，股骨的骨骺生長(zhǎng)板會(huì)垂直于髖關(guān)節(jié)的關(guān)節(jié)反作用力。股骨頸的生長(zhǎng)和方向受股骨頸下生長(zhǎng)板的控制[31]。Pauwels和Maquet[32]提出理論，合力作用于骨骺軟骨的中心，在生長(zhǎng)過(guò)程中，根據(jù)Heuter-Volkman原理，骨骺板會(huì)垂直于關(guān)節(jié)反作用力。Pauwels和Maquet的理論后來(lái)得到了Carter等人[33]的證實(shí)，他們通過(guò)二維有限元分析研究了髖關(guān)節(jié)負(fù)荷的影響。閉合的骨骺板的角度表示跨股骨近端骨骺[34]的力的平衡，也表示跨關(guān)節(jié)力在過(guò)去的作用方式。因此，它是一個(gè)功能參數(shù)，反映了髖關(guān)節(jié)在生長(zhǎng)過(guò)程中長(zhǎng)期的關(guān)節(jié)反作用力。如果FEAR<0°，則認(rèn)為髖關(guān)節(jié)穩(wěn)定。統(tǒng)計(jì)分析表明，5°的臨界值預(yù)測(cè)穩(wěn)定性的概率為80°。最近的研究表明，2°的臨界值預(yù)測(cè)穩(wěn)定性的概率為90%（Batailler等人，正在準(zhǔn)備發(fā)表中）。使用FEAR指數(shù)的案例如圖3a和b所示。Fig.2.TheFEARindex.Theangleismeasuredbetweenalineconnectingthemostmedialandlateralpointofthesourcilandalineconnectingthemedialandlateralendofthestraightpart(usuallycentralthird)ofthephysealscarofthefemoralhead.AnegativeFEARindex,withtheangleopeningmediallyasshowninFig.3a,indicatesastablehip.圖2.?FEAR指數(shù)。測(cè)量連接股骨最內(nèi)側(cè)和外側(cè)點(diǎn)的線(xiàn)與連接股骨頭骨骺直線(xiàn)部分（通常為中央三分之一）內(nèi)側(cè)和外側(cè)端的線(xiàn)之間的角度。如圖3a所示，角度向內(nèi)側(cè)打開(kāi)的陰性FEAR指數(shù)，表示髖關(guān)節(jié)穩(wěn)定。Fig.3.(a)CaseexamplesusingtheFEARindex.17-year-oldmale,LCEA20°,FEAR0°.Hipdeemedthereforestableandpatientmanagedwithhiparthroscopy.(b)CaseexamplesusingtheFEARindex.17-year-oldfemale,LCEA20°,FEAR8°.HipdeemedthereforeunstableandpatientmanagedwithPAO.圖3.(a)使用FEAR指數(shù)的病例。17歲男性，LCEA20°，F(xiàn)EAR0°。因此髖關(guān)節(jié)穩(wěn)定，患者接受髖關(guān)節(jié)鏡治療。(b)使用FEAR指數(shù)的病例。17歲女性，LCEA20°，F(xiàn)EAR8°。因此髖關(guān)節(jié)不穩(wěn)定，患者接受PAO截骨治療。有哪些治療方案？治療取決于髖關(guān)節(jié)的穩(wěn)定性。疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療方案包括非手術(shù)治療、解決關(guān)節(jié)內(nèi)撞擊的手術(shù)治療（通過(guò)髖關(guān)節(jié)鏡或髖關(guān)節(jié)外科脫位進(jìn)行的FAI手術(shù)）和解決不穩(wěn)定性的手術(shù)治療（采用PAO和/或股骨截骨術(shù)的重新定位截骨術(shù)）（見(jiàn)圖2）。非手術(shù)治療包括患者教育、活動(dòng)調(diào)整、簡(jiǎn)單的止痛藥、非甾體抗炎藥和髖關(guān)節(jié)腔內(nèi)注射藥物[35]。有針對(duì)性的物理治療可以改善肌肉調(diào)節(jié)、疼痛和本體感受控制。以下段落將討論包括關(guān)節(jié)鏡和/或截骨術(shù)的臨界髖關(guān)節(jié)發(fā)育不良的手術(shù)治療方案。這組患者接受髖關(guān)節(jié)鏡檢查的結(jié)果如何？隨著髖關(guān)節(jié)鏡技術(shù)的最新發(fā)展，許多外科醫(yī)生正在使用它來(lái)治療臨界髖關(guān)節(jié)發(fā)育不良，尤其是因?yàn)槿藗冋J(rèn)為髖臼周?chē)毓切g(shù)等替代技術(shù)的風(fēng)險(xiǎn)更高，術(shù)后恢復(fù)時(shí)間更長(zhǎng)。臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查還可以讓外科醫(yī)生處理髖關(guān)節(jié)內(nèi)病變，如盂唇撕裂或股骨凸輪畸形[3,12,36]。如果考慮使用PAO來(lái)解決骨穩(wěn)定性不足的問(wèn)題，那么關(guān)節(jié)鏡檢查不僅可以讓外科醫(yī)生了解髖關(guān)節(jié)的關(guān)節(jié)內(nèi)狀態(tài)，還可以了解患者在隨后進(jìn)行更大規(guī)模手術(shù)時(shí)的表現(xiàn)[37]。然而，關(guān)于臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查的已發(fā)表文獻(xiàn)很少，而且短期隨訪(fǎng)也存在局限性。在Jo等的系統(tǒng)綜述中，確定了13項(xiàng)關(guān)于髖關(guān)節(jié)發(fā)育不良的關(guān)節(jié)鏡檢查的研究[10]。這些研究各不相同，所有研究都是病例系列。僅有6項(xiàng)研究報(bào)告了主觀和/或客觀結(jié)果。關(guān)節(jié)鏡檢查的手術(shù)指征不明確，患者事先接受過(guò)多種非手術(shù)治療。此外，臨界髖關(guān)節(jié)發(fā)育不良的確切定義各不相同，只有兩項(xiàng)研究使用了Byrd和Jones的定義[36]。三項(xiàng)研究報(bào)告了髖關(guān)節(jié)鏡作為輔助工具，三項(xiàng)研究報(bào)告了髖關(guān)節(jié)鏡作為獨(dú)立治療。盂唇撕裂的總患病率為77.3%，主要位于髖臼緣的前部或前上部。髖臼軟骨病變比股骨病變更常見(jiàn)（59-75.2%比11-32%），并且位于盂唇病變的鄰近。僅有兩項(xiàng)研究檢查了臨界髖關(guān)節(jié)發(fā)育不良病例（LCEA20-25°）的關(guān)節(jié)鏡檢查結(jié)果，其中只有一項(xiàng)描述了患者報(bào)告的結(jié)果測(cè)量。后者是Byrd和Jones[36]的前瞻性臨床病例系列，其中66%的髖關(guān)節(jié)（32髖）患有臨界髖關(guān)節(jié)發(fā)育不良。關(guān)節(jié)鏡檢查后，平均改良Harris髖關(guān)節(jié)評(píng)分從50（差）改善到77（一般）。作者得出結(jié)論，髖關(guān)節(jié)鏡治療可能解決髖關(guān)節(jié)內(nèi)病理而不是發(fā)育不良的放射學(xué)證據(jù)的結(jié)果。對(duì)臨界髖關(guān)節(jié)發(fā)育不良進(jìn)行髖關(guān)節(jié)鏡檢查有什么危險(xiǎn)？臨界髖關(guān)節(jié)發(fā)育不良患者進(jìn)行關(guān)節(jié)鏡盂唇切除術(shù)和髖臼外側(cè)緣切除術(shù)可導(dǎo)致爆發(fā)性髖關(guān)節(jié)不穩(wěn)定[38]。即使修復(fù)了盂唇，也必須保留髂股韌帶和髖關(guān)節(jié)的其他靜態(tài)穩(wěn)定器，以防止不可逆的后果或?qū)е麦y關(guān)節(jié)不穩(wěn)定[39–41]。沒(méi)有確鑿的文獻(xiàn)支持在這些情況下進(jìn)行關(guān)節(jié)囊修復(fù)，但這似乎是一種安全合理的做法[42]。關(guān)節(jié)囊復(fù)位技術(shù)可提高臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性[12]。如果髖關(guān)節(jié)在術(shù)前足夠不穩(wěn)定，那么僅通過(guò)髖關(guān)節(jié)鏡治療關(guān)節(jié)內(nèi)病變是不夠的，患者將需要進(jìn)行PAO截骨術(shù)[43,44]。必須記住，髖關(guān)節(jié)的穩(wěn)定性首先取決于髖骨幾何形狀。在輕微不穩(wěn)定（臨界發(fā)育不良）中，穩(wěn)定性可能由次級(jí)軟組織結(jié)構(gòu)來(lái)確保。一旦這些結(jié)構(gòu)因微創(chuàng)傷或大創(chuàng)傷而失效，髖關(guān)節(jié)就會(huì)變得不穩(wěn)定?；謴?fù)軟組織穩(wěn)定性可能只會(huì)在短時(shí)間內(nèi)改善髖關(guān)節(jié)穩(wěn)定性，但軟組織很可能再次磨損。因此，必須首先解決潛在的骨病理問(wèn)題，才能取得良好的長(zhǎng)期效果。最近的一份報(bào)告顯示，髖關(guān)節(jié)發(fā)育不良患者在髖關(guān)節(jié)鏡檢查失敗后，PAO的髖關(guān)節(jié)特定功能結(jié)果較差[6]。因此，對(duì)這組患者單獨(dú)進(jìn)行髖關(guān)節(jié)鏡檢查應(yīng)謹(jǐn)慎處理。但是，對(duì)于那些由于髖關(guān)節(jié)狀況不佳（即AI和股骨前傾正常）或高齡（即>40歲）而不適合進(jìn)行PAO的患者，它可能有用。重新定向髖臼周?chē)毓切g(shù)對(duì)這組患者有何影響？通過(guò)髖臼周?chē)毓切g(shù)進(jìn)行髖臼重新定向已成為髖關(guān)節(jié)發(fā)育不良最常見(jiàn)的治療方法，據(jù)報(bào)道術(shù)后20多年效果良好。傳統(tǒng)上，PAO時(shí)關(guān)節(jié)內(nèi)病變的處理方法是進(jìn)行前關(guān)節(jié)切開(kāi)術(shù)。然而，隨著PAO微創(chuàng)技術(shù)的發(fā)展，情況已不再如此。微創(chuàng)PAO技術(shù)縮短了術(shù)后恢復(fù)時(shí)間[45]。最近的一項(xiàng)研究表明，一些可改變的因素，例如較高的體力活動(dòng)量和較高的BMI（大于30kg/m2）可導(dǎo)致PAO的發(fā)病年齡下降[46]。此外，患有較重發(fā)育不良程度的患者患PAO的年齡也較早：LCEA是手術(shù)年齡的獨(dú)立預(yù)測(cè)因素，即LCEA較低的患者往往需要在較早的年齡接受PAO手術(shù)。但是，輕度和中度發(fā)育不良患者的PAO預(yù)后沒(méi)有差異。在本研究中，輕度發(fā)育不良被歸類(lèi)為15-25°，這涵蓋了我們對(duì)臨界髖關(guān)節(jié)發(fā)育不良的定義。最近的一項(xiàng)多中心前瞻性隊(duì)列研究檢查了患者報(bào)告的PAO結(jié)果指標(biāo)，結(jié)果表明，雖然總體結(jié)果良好，但臨界髖關(guān)節(jié)發(fā)育不良患者和男性的改善程度低于發(fā)育較重的患者[47]。作者討論了小范圍矯正的危險(xiǎn)，這可能導(dǎo)致過(guò)度矯正和醫(yī)源性FAI、股骨前傾增加和軟組織松弛。建議和未來(lái)方向在臨界髖關(guān)節(jié)中，關(guān)鍵步驟是確定穩(wěn)定性。關(guān)于髖關(guān)節(jié)的穩(wěn)定性，只有兩種情況：髖關(guān)節(jié)穩(wěn)定或不穩(wěn)定。沒(méi)有中間狀態(tài)。如果接受這個(gè)概念，治療就會(huì)變得相對(duì)簡(jiǎn)單。不穩(wěn)定可能與其他病癥（如FAI或超負(fù)荷/過(guò)度使用和軟骨疾?。┫嘟Y(jié)合，需要同時(shí)治療。如果髖關(guān)節(jié)不穩(wěn)定，則需要髖臼重新定位。僅解決磨損的二級(jí)穩(wěn)定器并不能解決潛在的生物力學(xué)問(wèn)題，最多只能產(chǎn)生令人滿(mǎn)意的短期結(jié)果。在穩(wěn)定的髖關(guān)節(jié)中，可以進(jìn)行開(kāi)放或關(guān)節(jié)鏡關(guān)節(jié)保留手術(shù)。然而，我們必須記住，低于28°的LCE角度每減少一度，骨關(guān)節(jié)炎的發(fā)病率就會(huì)增加13%[20]。因此，如果有疑問(wèn)，為了最大限度地提高獲得良好長(zhǎng)期結(jié)果的機(jī)會(huì)，我們主張進(jìn)行髖臼重新定向PAO截骨手術(shù)。重要的是要確定我們?nèi)狈χR(shí)的領(lǐng)域，以指導(dǎo)進(jìn)一步的研究。將對(duì)這些患者進(jìn)行長(zhǎng)期隨訪(fǎng)研究，比較髖臼重新定向和髖關(guān)節(jié)鏡檢查，理想情況下，將記錄所有成像參數(shù)和Beighton評(píng)分。此外，還應(yīng)獲得患者報(bào)告的結(jié)果測(cè)量和恢復(fù)時(shí)間，以及包括運(yùn)動(dòng)在內(nèi)的活動(dòng)恢復(fù)時(shí)間。?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.文獻(xiàn)出處：MichaelCWyatt,MartinBeck.Themanagementofthepainfulborderlinedysplastichip.ReviewJHipPreservSurg.2018Apr5;5(2):105-112.doi:10.1093/jhps/hny012.

臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH：什么時(shí)候、怎么判定為異常？作者：SarahDBixby,MichaelBMillis.作者單位:DepartmentofRadiology,BostonChildren'sHospital,Main2,300LongwoodAve.,Boston,MA,02115,USA.sarah.bixby@childrens.harvard.edu.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要臨界髖關(guān)節(jié)發(fā)育不良是指髖臼形狀和覆蓋范圍輕度低于正常范圍，可能導(dǎo)致兒童易患機(jī)械功能障礙和不穩(wěn)定。臨界發(fā)育不良通常包括外側(cè)中心邊緣角(CEA)為18-24°的兒童。一些具有臨界X線(xiàn)測(cè)量值的兒童具有正常的關(guān)節(jié)力學(xué)和功能，而其他兒童則需要進(jìn)行髖臼截骨手術(shù)。雖然臨界髖關(guān)節(jié)發(fā)育不良的X線(xiàn)檢查結(jié)果可能表明不穩(wěn)定，但最終診斷基于病史和體格檢查以及影像學(xué)相結(jié)合。患有臨界髖關(guān)節(jié)發(fā)育不良的兒童有時(shí)還需要進(jìn)行其他橫斷面成像研究，如MRI成像，以評(píng)估不穩(wěn)定的次要證據(jù)，包括沿髖臼邊緣的損傷或盂唇退化和肥大。CT也有助于描繪3-D髖臼形態(tài)，以進(jìn)行術(shù)前評(píng)估和規(guī)劃。兒童放射科醫(yī)生通常是第一個(gè)在X線(xiàn)片上發(fā)現(xiàn)邊緣性或輕度發(fā)育不良的人。兒童放射科醫(yī)生必須充當(dāng)有效的顧問(wèn)，并作為針對(duì)這一復(fù)雜患者群體的連貫多學(xué)科診療團(tuán)隊(duì)的一部分提供適當(dāng)?shù)慕ㄗh。圖1?一名16歲女孩的髖關(guān)節(jié)X線(xiàn)片顯示了外側(cè)中心邊緣角(CEA)、髖臼指數(shù)和前CEA的測(cè)量方法。a標(biāo)記了三個(gè)點(diǎn)以便進(jìn)行后續(xù)測(cè)量：點(diǎn)1位于股骨頭(旋轉(zhuǎn))中心，點(diǎn)2位于股骨髖關(guān)節(jié)(負(fù)重關(guān)節(jié)面的)內(nèi)側(cè)邊緣，點(diǎn)3位于股骨髖關(guān)節(jié)(負(fù)重關(guān)節(jié)面的)外側(cè)邊緣。b右髖關(guān)節(jié)的前后位X線(xiàn)片展示了測(cè)量外側(cè)CEA的方法。外側(cè)CEA是連接點(diǎn)1和點(diǎn)3的線(xiàn)與垂直線(xiàn)之間形成的夾角（正常為25-40°）。c髖臼指數(shù)由連接點(diǎn)2和點(diǎn)3的線(xiàn)與水平線(xiàn)之間形成的夾角決定（正常為0-10°）。d右髖關(guān)節(jié)的假斜位片顯示了確定前CEA的測(cè)量方法。前側(cè)CEA由點(diǎn)1到點(diǎn)4（在髖臼前緣）的連線(xiàn)與垂直線(xiàn)之間的角度決定（正常值為25–40°）圖2?一名19歲女性嚴(yán)重雙側(cè)髖關(guān)節(jié)發(fā)育不良。a骨盆前后位X線(xiàn)片顯示右側(cè)髖關(guān)節(jié)外側(cè)中心邊緣角(CEA)為5°，b髖臼指數(shù)為16°。左髖關(guān)節(jié)同樣發(fā)育不良。c右髖關(guān)節(jié)假斜位X線(xiàn)片顯示前方中心邊緣角為8°。圖3?一名右側(cè)髖關(guān)節(jié)疼痛的16歲女孩的外側(cè)中心邊緣角(CEA)。a前后位(AP)骨盆X線(xiàn)片顯示外側(cè)CEA為19°。左側(cè)髖關(guān)節(jié)正常。b同一女孩的假斜位X線(xiàn)片顯示前方CEA為19°。c延遲釓增強(qiáng)軟骨MRI(dGEMRIC)檢查的冠狀T1圖顯示軟骨正常。女孩沒(méi)有不穩(wěn)定的跡象，接受了腰肌勞損治療，癥狀在沒(méi)有手術(shù)的情況下得到改善。由于腰肌勞損仍然可能與潛在的微不穩(wěn)定有關(guān)，女孩在髖關(guān)節(jié)外科醫(yī)生的護(hù)理下接受長(zhǎng)期觀察。圖4?一名有髖關(guān)節(jié)發(fā)育不良家族史的11歲女性足球運(yùn)動(dòng)員的左側(cè)髖關(guān)節(jié)疼痛。a前后位(AP)X線(xiàn)片顯示為正常。b女孩現(xiàn)在13歲，仍然有左側(cè)髖關(guān)節(jié)疼痛。雙側(cè)髖關(guān)節(jié)被認(rèn)為是淺的，左側(cè)測(cè)量的外側(cè)中心邊緣角(CEA)為16°，右側(cè)為23°。左側(cè)髖臼指數(shù)也被認(rèn)為是升高的13°。陽(yáng)性恐懼測(cè)試反映了體格檢查中左側(cè)髖關(guān)節(jié)的不穩(wěn)定，右側(cè)沒(méi)有發(fā)現(xiàn)不穩(wěn)定。C假斜位X線(xiàn)片顯示前方覆蓋充分，前方CEA為27°。d左側(cè)髖臼周?chē)毓切g(shù)后前后位AP骨盆X線(xiàn)片狀態(tài)顯示側(cè)方覆蓋改善。女孩報(bào)告癥狀有所改善。e一年后的前后位AP骨盆X線(xiàn)片，癥狀緩解并恢復(fù)正?；顒?dòng)。她右側(cè)有輕微間歇性疼痛，并定期監(jiān)測(cè)癥狀。圖5?股骨骨骺髖臼頂(FEAR)指數(shù)。a與圖1中相同的16歲女孩的髖關(guān)節(jié)前后位(AP)X線(xiàn)片。FEAR指數(shù)是沿髖臼頂連接點(diǎn)2和點(diǎn)3的線(xiàn)（黑線(xiàn)）與沿股骨骨骺線(xiàn)中央三分之一繪制的線(xiàn)（白線(xiàn)）之間形成的角度。陽(yáng)性FEAR指數(shù)定義為向外側(cè)傾斜的角度，頂點(diǎn)指向內(nèi)側(cè)。這個(gè)女孩的FEAR指數(shù)小于5°。與FEAR指數(shù)<5°相比，F(xiàn)EAR指數(shù)>5°與不穩(wěn)定性具有更大的相關(guān)性。b一名13歲女孩的髖關(guān)節(jié)前后位X線(xiàn)片顯示左側(cè)髖臼外側(cè)輕微上翻（箭頭）。c一名13歲男孩的右側(cè)髖關(guān)節(jié)疼痛的左側(cè)髖關(guān)節(jié)正常前后位X線(xiàn)片顯示外側(cè)正常。黑線(xiàn)表示髖臼頂部，白線(xiàn)表示骨骺線(xiàn)的中央三分之一。此正常髖關(guān)節(jié)的FEAR指數(shù)顯示FEAR指數(shù)，角度頂點(diǎn)指向外側(cè)。圖6?一名18歲女子田徑運(yùn)動(dòng)員的右側(cè)髖關(guān)節(jié)疼痛影像。a前后位(AP)骨盆X線(xiàn)片顯示右側(cè)髖關(guān)節(jié)發(fā)育不良，左髖關(guān)節(jié)正常。b右側(cè)髖臼周?chē)毓切g(shù)后前后位(AP)骨盆狀態(tài)顯示外側(cè)覆蓋增加，但該女性報(bào)告癥狀?lèi)夯?。c術(shù)前（回顧性）進(jìn)行的右髖關(guān)節(jié)矢狀質(zhì)子密度脂肪抑制MR圖像顯示前髖臼內(nèi)有骨樣骨瘤（箭頭）。射頻消融后，該患者的癥狀得到緩解。?Theborderlinedysplastichip:whenandhowisitabnormal?AbstractBorderlineacetabulardysplasiareferstomildlysub-normalpatternsofacetabularshapeandcoveragethatmightpredisposechildrentomechanicaldysfunctionandinstability.Borderlinedysplasiagenerallyincludeschildrenwithalateralcenteredgeangle(CEA)of18-24°.Somechildrenwithborderlineradiographicmeasurementshavenormaljointmechanicsandfunctionwhileothersbenefitfromacetabularreorientingsurgery.Althoughradiographicfindingsofborderlinedysplasiamightsuggestinstability,theultimatediagnosisisbasedonhistoryandphysicalexaminadditiontoimaging.Childrenwithborderlineacetabulardysplasiasometimesbenefitfromothercross-sectionalimagingstudiessuchasMRimagingtoevaluateforsecondaryevidenceofinstability,includingdamagealongtheacetabularrim,orlabraldegenerationandhypertrophy.CTisalsohelpfulfordepictionof3-Dacetabularmorphologyforpreoperativeassessmentandplanning.Pediatricradiologistsareoftenthefirsttoidentifyborderlineormilddysplasiaonradiographs.Itisimperativethatpediatricradiologistsserveaseffectiveconsultantsandofferappropriaterecommendationsaspartofacohesivemultidisciplinaryapproachtothiscomplexpatientpopulation.Fig.1Radiographsofthehipina16-year-oldgirldemonstratemeasurementtechniqueforlateralcenteredgeangle(CEA),acetabularindex,andanteriorCEA.aThreepointsaremarkedforsubsequentmeasurements:Point1atthecenterofthefemoralhead,Point2atthemedialedgeofthesourcil,Point3atthelateraledgeofthesourcil.BAnteroposteriorpelvicradiographconeddowntotherighthipdemonstratestechniqueformeasuringlateralCEA.ThelateralCEAistheangleformedbetweenthelineconnectingPoint1toPoint3andaverticalline(normal25–40°).cAcetabularindexisdeterminedbytheangleformedbetweenalineconnectingPoint2toPoint3andahorizontalline(normal0–10°).dFalseprofileviewoftherighthipdemonstratesmeasurementtechniquefordetermininganteriorCEA.AnteriorCEAisdeterminedbytheanglebetweenalinefromPoint1toPoint4(attheanteriormarginofthesourcil)andaverticalline(normal25–40°)Fig.2Severebilateralhipdysplasiaina19-year-oldwoman.aAnteroposteriorradiographofthepelvisdemonstratesalateralcenteredgeangle(CEA)oftherighthipof5°and(b)acetabularindexof16°.Thelefthipissimilarlydysplastic.cFalseprofileradiographoftherighthipdemonstratesanteriorcenteredgeangleof8°.Fig.3Borderlinelateralcenteredgeangle(CEA)ina16-year-oldgirlwithrighthippain.aAnteroposterior(AP)pelvisradiographrevealsborderlinelateralCEAof19°.Thelefthipisnormal.bFalseprofileradiographofthesamegirlrevealsanteriorCEAof19°.cCoronalT1mapfromdelayedgadolinium-enhancedMRIofcartilage(dGEMRIC)examinationrevealsnormalcartilage.Thegirldidnothavesignsofinstability,wastreatedforpsoasstrain,andsymptomsimprovedwithoutsurgery.Becausepsoasstraincouldstillberelatedtounderlyingmicroinstability,thegirlwasunderlong-termobservationundercareofahipsurgeon.Fig.4Lefthippaininan11-year-oldfemalesoccerplayerwithafamilyhistoryofhipdysplasia.aAnteroposterior(AP)radiographinterpretedasnormal.bGirlnowisage13years,stillwithlefthippain.Bilateralhipswereconsideredshallow,withlateralcenteredgeangle(CEA)measuredat16°ontheleftand23°ontheright.Acetabularindexontheleftwasalsoconsideredelevatedat13°.Positiveapprehensiontestreflectedinstabilityofthelefthiponphysicalexamination,withnoinstabilitynotedontheright.cFalseprofileradiographrevealsadequateanteriorcoverage,withanteriorCEAof27°.dAPpelvisradiographstatuspostleft-sideperiacetabularosteotomydemonstratesimprovedlateralcoverage.Thegirlreportedimprovedsymptoms.eAPpelvisradiograph1yearlater,afterreliefofsymptomsandreturntonormalactivity.Shehadmildintermittentpainontherightandwasbeingmonitoredperiodicallyforsymptoms.Fig.5Femoro-epiphysealacetabularroof(FEAR)index.AAnteroposterior(AP)radiographofthehipinthesame16-year-oldgirlasinFig.1.TheFEARindexistheangleformedbetweenalineconnectingPoint2andPoint3alongtheacetabularroof(blacklines),andalinedrawnalongthecentralthirdofthefemoralphysealscar(whiteline).ApositiveFEARindexisdefinedbyalaterallydirectedanglewiththeapexpointingmedially.TheFEARindexinthisgirlislessthan5°.AFEARindex>5°hasagreatercorrelationwithinstabilitycomparedtoFEARindex<5°.bAPradiographofthehipina13-year-oldgirlwithmildleftacetabularsourcildemonstratesamildlyupturnedlateralsourcil(arrow).cNormalAPradiographofthelefthipina13-year-oldboywithrighthippaindemonstratesanormallateralsourcilforcomparison.Theblacklineindicatestheacetabularroofandthewhitelineindicatesthecentralthirdofthephysealscar.TheFEARindexisdemonstratedinthisnormalhiptoillustrateanegativeFEARindexwiththeapexoftheangledirectedlaterally.Fig.6Imaginginan18-year-oldfemaletrackathletewithrighthippain.aAnteroposterior(AP)pelvisradiographreportedasborderlinerightacetabulardysplasiaandnormallefthip.bAPpelvisstatuspostrightperiacetabularosteotomydemonstratesincreasedlateralcoverage,thoughthewomanhadreportedworseningsymptoms.cSagittalproton-densityfat-suppressedMRimageoftherighthipperformedpreoperatively(retrospectively)revealsanosteoidosteomawithintheanterioracetabulum(arrow).Thewoman’ssymptomsresolvedafterradiofrequencyablation.?AdvancinginvestigationTheterm“borderlinedysplasia”isalsofallingoutoffavor.Advancedimagingmodalitieshaverevealedpatternsofdysplasiathatarenotapparentonradiographs.FocalanteriorandposteriordysplasiagroupshaveanormallateralCEAontheAPradiograph[9].Refinedandupdatedradiographicmeasurementshavebeenproposedthatwouldenablebetteridentificationofchildrenwithfocaldysplasia,suchastheanteriorwallindexandposteriorwallindex[48].Earlystudiesdemonstrateddifferencesintheanteriorandposteriorwallindicesinsymptomaticdysplasticpatientscomparedtothosewithanormalacetabulum[48].Subsequentinvestigationrevealedthatevenasymptomaticpeoplehaveradiographicanteriorandposteriorwallindexmeasurementsthatoverlapthoseofpeoplewithdysplasia[49].Thisindicatesthatsomedegreeofvariationinthe3-Dmorphologyoftheacetabulumisnormal.Furthervalidationoftheseindiceswithcross-sectionalimagingandlongitudinalfollow-upisnecessarybeforethesenewreferencestandardscanbeconsideredreliableindicatorsofdisease.Inthepresenceofinstabilityrelatedtoacetabulardysplasia,thereisoftenovergrowthofsoft-tissuestructuresthatcompensatesforthedeficientbonysupport.Thisincludesenlargementoftheacetabularlabrum[50,51],evenintheabsenceoflabraltearordegeneration.Focalmuscleenlargementhasalsobeennotedinunstablepatients,specificallytheiliocapsularismuscle[52].MRImightbeusefulinidentifyingthesesecondarysignsofinstability.Still,noclearlypositivefindingsconfirmthepresenceofinstability.Femoralversionisalsoakeycomponentindetermininghipstability,asanantevertedfemurisbemoreanteriorlyuncoveredthananeutralfemur[53].Overtfeaturesofacetabularrimdamagealsosupportthediagnosisofdysplasia,includinglabraldegenerationandtearingandcartilageloss,thoughadolescentswhohaveborderlinedysplasiamightnotyethavevisiblemanifestationsofosteoarthritis,evenifinstabilityisthepaingenerator.Giventheseareasofinvestigationanduncertainty,theborderlinedysplastichiphasattractedwell-deservedattentionintheliterature.Specificconcernshavebeenraisedaroundwhethertheterm“borderlinedysplasia”isanadequatelabelandwhetherthisisasinglecondition.ItismorelikelythatchildrenwithaborderlinelateralCEAof18–24°consistofclustersofpatients,someofwhommighthavecamimpingement,andsomeofwhomhavefocalacetabulardeficiency[13].Specificpatternsofacetabulardeficiencyandfemoralmorphologyarebestcharacterizedwithcross-sectionalimagingexaminations,suchasMRIorCT,whichmightalsodetectothercausesforhippain.ItisrecommendedthatanychildinwhomthereisconcernfordysplasiaundergoanMRIaspartofacompleteevaluationbecausetheremightbeanotherfindingthatexplainsthechild’ssymptoms(Fig.6),orevidenceofintra-articulardamagethatsupportsrimloading.MRIiswellsuitedfordetectingcartilageandlabralabnormalitiesaswellasmarrowlesionsthatarepresentinthesettingofalteredbiomechanicsandearlyosteoarthritis[8].Low-dosepelvicCTisalsovaluableforpreoperativeassessmentofthehipmorphologywithprecisecharacterizationofthebonydeficienciesinthreedimensions.Itiscrucialthatthesechildrenaredirectedtoanexperiencedhipspecialistwhoisabletocontextualizetheimagingfindingswithacomprehensivephysicalexamandanappropriatehistory.Thesechildrenshouldbeinterrogatedwithrespecttothenatureandlocationoftheirpainwithspecificquestionsaroundinstability.Acomprehensivephysicalexamshouldfollow,includingattentiontothechild’sgait,pelvicpositionandrotationalprofile.ConclusionTheterm“borderlinedysplasia”referstopatternsofacetabularcoveragethatmightpredisposechildrentoinstability.Somechildrenwithborderlineradiographicmeasurementshavenormaljointmechanicsandfunction(Fig.1ShouldsayFigure3),whileothersbenefitfromacetabularreorientingsurgery(Fig.2ShouldsayFigure4)[11].Itisimportantthatradiologistsreflectthisuncertaintyintheirreportswithappropriatemanagementrecommendations.Instabilitymightbesuggestedbyradiographs,butultimatediagnosisisconfirmedonthebasisofhistoryandphysicalexamassessingforinstability.Thesechildrenshouldundergohigh-resolutionMRimagingofthehiptoevaluateforjointdamage,andCTmightbehelpfulforbetter3-Dcharacterizationofthebonyshapeandcontour.Dynamicultrasonographyhasbeenvalidatedasahelpfuladjunctinthedeterminationofinstabilitybymeasuringanteriorfemoralheadtranslationwithdynamicmaneuversreplicatingtheapprehensiontest[54].Aspediatricradiologists,weareoftenthefirsttoidentifyborderlineormilddysplasiaonthebasisofradiographs.Itisimperativethatweserveaseffectiveconsultantsandofferappropriaterecommendationsaspartofacohesivemultidisciplinaryapproachtothiscomplexpatientpopulation.?文獻(xiàn)出處：SarahDBixby,MichaelBMillis.Theborderlinedysplastichip:whenandhowisitabnormal?ReviewPediatrRadiol.2019Nov;49(12):1669-1677.doi:10.1007/s00247-019-04468-4.Epub2019Nov4.??IntroductionDevelopmentalhipdysplasia(DDH)isoneofthemostimportantandmostcommonpediatricmusculoskeletalconditions.Whileasmanyas80%ofcasesarepresentatbirth,manyremainundiagnosed.Whenpresentininfancy,DDHmightbedetectedonthebasisofphysicalexaminationfindings(i.e.BarlowandOrtolanimaneuvers)andstaticanddynamicultrasoundfeaturesoriginallydescribedbyGraf[1,2].Thelong-termimplicationsofDDHaresignificantbecausetheconditionleadstodevelopmentofosteoarthritisin25–50%ofpatientsbytheageof50years[3].Thereducedsizeandtheincreasedobliquityoftheacetabularweight-bearingsurfacecreateshearingforcesonthearticularcartilageandcausechronicoverloadingoftheanteriorandanterolateralacetabularrim[4].Thismechanicaldysfunction,ifuncorrected,leadsinadulthoodtopain,abductorfatigueandoftensymptomsofinstability,culminatingingradualfailureofthecartilageandleadingtoprogressiveosteoarthritis.Treatmentstrategiesdependonthemechanicalstabilityofthehipandthetypeanddegreeofbonydeformity.IninfantswithmildDDH,capsularlaxityandmildacetabulardysplasiaaretheissues,andsimplepositioningofthehipsinabductionandflexioninaprotectivebraceorPavlikharnessusuallyleadstotighteningofthecapsuleandresolutionofthedysplasia.Inchildrenwithfullcongenitaldislocations,particularlyifdiagnosedafterinfancy,aformalmanipulativereductionmightberequired,withspicacastingforseveralmonths.Atanyage,treatmentisfocusedonreducingandmaintainingthefemoralheadtoaconcentricpositionwithintheacetabulum.IfbonymalalignmentispresentintheolderchildwithDDH,realignmentsurgeryisoftenneededtorestorestability.Infantsandchildrenwithdevelopmentalhipdysplasiamightbetreatedtocurebyvirtueoftheseearlystrategies,ortheymighthavepersistentsubluxationthatrequiresfurthersurgerylaterinadolescenceoryoungadulthood.DysplasiainadolescentsAdolescentsandyoungadultswhohadbeenasymptomaticwithrespecttothehipmightalsohavemildformsofacetabulardysplasiadetectedonradiographsbasedoncriteriaoriginallydefinedbyWiberg(Figs.1and2)[5].Inmanychildrentheindicationforradiographsishippain,thoughforsomechildrenradiographsareperformedforotherindications.Intheabsenceofadedicatedexaminationbyahipspecialistwhocanassessforsignsorsymptomsofinstability,itisnotknownwhethermildorsubtleradiographicabnormalitiesarethesourceofthechild’ssymptoms.Radiographicmeasurementsoffemoralheadcoverageandpositionmightsuggestthepossibilityofmechanicaldysfunctionofthehip,thoughitisthemechanicsthatdefinetheunderlyingdisease,nottheradiographs.IncontrasttoinfantileDDH,adolescentdysplasiahasahighermalepredominanceandismoreoftenbilateral[6].Thedifferenceindemographicsbetweengroupshaspromptedmanytoquestionwhetheradolescentandinfantilehipdysplasiasaretwodistinctentities.Thestandinganteroposterior(AP)radiographofthepelvisremainsthegoldstandardofimagingforadolescenthipdysplasia,supplementedbyotherviewsincludingthefalseprofileradiograph[4].Anumberofradiographicmeasurementshavebeendescribedthatdefinethedysplastichip,thethreemostfundamentalincludingthelateralcenteredgeangle(CEA),theacetabularindexandtheanteriorCEA[7].ThelateralCEAandtheacetabularindexarebothmeasuredonaproperlypositionedstandingAPradiographofthepelvis,whereastheanteriorCEAismeasuredonthefalseprofileradiograph(Figs.1and2).In1939Wiberg[5]definedanormallateralCEAasbeingover25°,anabnormalangleaslessthan20°(Fig.2)andeverythinginbetweenasuncertain.Theserangeswerevalidatedinsubsequentinvestigations[8,9].SimilarcriteriaexistfortheanteriorCEAasmeasuredonafalseprofileradiograph,wherethisangleisconsiderednormalabove25°,borderlineat20–24°anddeficientbelow20°(Fig.2)[10].Incertainchildrentheanterioracetabularroofinsufficiencyismoreseverethanthelateralroofinsufficiency,andthefalseprofileviewmighthelptoidentifythesechildren,withthecaveatthattheanteriorCEAisthemostdependentonradiographictechnique[11].Theacetabularindexisconsiderednormalat0–10°[7],thoughsomehavesuggestedthatanglesupto13°arenormal[8].Valuesabovethisareconsideredindicativeofdysplasia.BorderlinemeasurementsWhilefloridacetabulardysplasiaisincontrovertiblewhenidentifiedradiographically(Fig.2),thecorrectdiagnosisbecomesmoredifficultwhenthemeasurementanglesareonlymildlyoutofthenormalrange,leadingtothecreationofan“uncertain”or“borderline”category(Figs.3and4).Thesechildrenremainasourceofconfusionandcontroversyamongradiologistsandhipspecialists.Ultimately,achildfallingintoanuncertaincategoryhaseitherahealthyoranunhealthyhip,andthisdistinctiondependsonavarietyoffactorsuniquetoeachchildthatgobeyondasimpleradiographicmeasurement.Thelabel“borderlinedysplasia”hasbeenadoptedtodefineagroupthatfallsintoanuncertainmeasurementcategorywithlateralCEAof18–24°[12–14],inwhomfurtherevaluationisnecessarybeforeadiagnosiscanbemade.Giventhemechanicalbasisforthejointdamageinacetabulardysplasia,itisareasonableassertionthathipswithslightlydiminishedcoveragearepredisposedtojointdamagerelatedtoincreasedwearontheacetabularrim.Childrenwithmilddysplasiaareknowntohaveevidenceoflabralandcartilagedamageathiparthroscopy[15].ThisdoesnotmeanthatallchildrenwithalateralCEAof18–24°developosteoarthritis.Earlystudiesevaluatingtherelationshipbetweencenteredgeangleanddysplasiafocusedprimarilyonhipfunctionratherthanspecificevidenceofjointdamage[16],thoughitislikelythatnormallyfunctionalhipsmightovertimealsohavelabraltearsandcartilagelesions.Delayedgadolinium-enhancedMRIofcartilage(dGEMRIC)measurementsDelayedgadolinium-enhancedMRIofcartilage(dGEMRIC)wasdevelopedtoidentifyhipswithearlybiomechanicaldamagetothecartilagematrixinadvanceofmorphologiccartilageloss[17].Whenintroducedviaintravenousorintraarticularinjection,ananionicmoleculesuchasgadopentetate?2(Gd-DTPA?2)distributesovertimeincartilageinverselytotheconcentrationofnegativelychargedglycosaminoglycans.TheconcentrationofGd-DTPA?2canbeindirectlydeterminedwithmeasurementsofT1andisexpectedtobelowerinnormalcartilagecomparedtodegradedcartilagewithlossofglycosaminoglycans.Thismeasurementisreferredtoasthe“dGEMRICindex”(Fig.3).EvaluationofthedGEMRICindexinpeoplewithnoormilddysplasiarevealedthatthedGEMRICindexofmildlydysplastichipsdidnotdiffersignificantlyfromthatofnormalhips[17].ItshouldbenotedthatinthisstudypeoplewithmilddysplasiaweredefinedbyalateralCEA>15°,whichislowerthanwhatwouldnowbeconsideredthethresholdofmilddysplasia.Thesedatasuggestthatchildrenwithmildorborderlinedysplasiamightnotbeatincreasedriskofdevelopingend-stageosteoarthritis,thoughbecausethesepeoplewerenotfollowedlongitudinallyovertimeitisunknownwhethercartilagedegenerationevolvedovertime.ThedGEMRICindexalsodoesnotaddresswhetherchildrenhavesignsorsymptomsofinstability,whichmightbewhatbringsthemtomedicalattention.RadiographiclandmarksMeasurementsobtainedfromconventionalradiographsrelyonidentificationofpreciselandmarks,includingthecenterofthefemoralhead,themedialmarginoftheacetabularsourcil,andthelateralmarginoftheacetabularsourcil(Fig.1).Thesourcilisnotalwayswell-defined,especiallyinchildrenyoungerthan15years.Inyoungerchildrenitisuncommonforthelateralmarginofthesourciltoalsobethelateralmarginoftheacetabulum,promptingsomeinvestigatorstodevelopa“modifiedlateralCEA”thatincludesonlythescleroticportionoftheacetabularsourcil.ThisisincontrasttothetraditionalCEA,whichismeasuredtothelateralacetabularmargin[18].Therangeofnormaldependsontechniquebecausethemodifiedanglehasalowerstandardrange(15–20°)comparedtothetraditionalangle.Withoutstrictattentiontoradiographiclandmarksthevariabilitybetweenmeasurementscanbeextreme[19–21].Themostreliablemethodistoautomatetheprocesswithcomputer-aidedsoftware,eitherbyincorporatingacomputerizedmeasurementprogram[22]orbystandardizingtheprojectionoftheradiograph[23].Unlessrigorouscriteriaarebeingusedformeasurement,amildlyabnormalmeasurementshouldnotbeconsideredamarkofdiseaseunlessthereareothercompellingimagingandclinicalfindings.Anadhocmeasurementperformedby“eyeballing”theradiographisunlikelytobeaccurate.Itisbesttomeasuremultipletimes,especiallyintheabsenceofcomputer-aidedsystems.NormalvariantsCrossoversignRadiologistsarewisetoproceedcautiouslyaroundthehip,giventhefrequencywithwhichpreviouslyreportedradiographicmeasurementsorfindingshavebeensubsequentlydeterminedtorepresentnormalvariants.AnexampleofthisisthecrossoversignontheAPpelvisradiographs.In2007itwasdemonstratedthatthepresenceofacrossoversignwasahighlyreliableindicatorofcranial(superioracetabular)anteversionoflessthan4°[24].Forreference,thesuperioraspectoftheacetabulumisantevertedapproximately10–14°.Atangleslessthan0°,theanteriorwallislateraltotheposteriorwall,leadingtothecrossoversignonradiographswherethetwowallsoverlap.ItbecamestandardforradiologistsandhipspecialiststocommentonthepresenceofacrossoversignonAPradiographsofthepelvisassuggestiveofacetabularretroversion.Inclinicalpractice,however,thesechildrendidnotalwayshavesignsorsymptomsofretroversion,nordidcross-sectionalimagingconfirmretroversion.Overtime,theliteraturerefutedanassociationbetweencrossoversignandclinicallyconfirmedacetabularretroversion.Evenasymptomaticchildrenwithouthipdiseaseorsymptomatologydemonstratedacrossoversignonawellpositionedradiograph,reflectingvariationsinpatientpositioningaswellasthevariablemorphologyoftheanteriorinferioriliacspine[25,26].CoxaprofundaInsimilarfashion,theterm“coxaprofunda”fellinandoutoffavoralmostasquickly.Coxaprofundaisdefinedaspresentiftheflooroftheacetabularfossaliesmedialtotheilioischialline.Itisconsideredanindirectsignofacetabularovercoverageofthefemoralheadandwasproposedasanimagingfeatureofpincer-typefemoroacetabularimpingementin2007[27].Withthisawareness,radiologistsreadilyofferedthisimagingfindingasevidenceofanunderlyingcondition:acetabularover-coverage.Overtime,coxaprofundawasclaimedtobeanormalradiographicfindingthatdoesnotsupportadiagnosisofpincerimpingement[28–30].CamdeformityFinally,thedefinitionof“cam”deformityinchildrenwithfemoroacetabularimpingementhasbeenasubjectofinterestanddebateformanyyears.Camlesionsarebonyprotuberancesalongthefemoralhead/neckjunctionthatimpingeagainsttheacetabularriminhipflexion.Themostobjectivemeansofmeasuringthesizeofacamdeformityisthealphaangle,anangleformedbyalineconnectingthecenterofthefemoralheadtothecenterofthefemoralneck,andalinefromthecenterofthefemoralheadtothepointatwhichthefemoralneckfallsoutsideabest-fitcirclearoundthehead.Intheearly2000sitwasacceptedthatchildrenwithanalphaangleintherangeof50°likelyhadcam-typefemoroacetabularimpingement(FAI)[31–34].OverthelastdecadetherehasbeenincreasingawarenessthatsomepreviouslydefinedcamlesionsinpeoplewithFAImightbepresentinasymptomaticpopulationswithnohipdisease[35–38].Moreoverapositiveimpingementtest,oftenassociatedwiththepresenceofanteriorFAI,hasbeendemonstratedinhealthyyoungadultswhomightnothaveFAI[39],makingthisanunreliableindicatorofdiseaseinisolationofotherevidence.RadiographictechniqueGiventhatourinterestinidentifyingandtreatingpainfulanddebilitatingdiseaseinchildrenmightoutpaceourunderstandingofnormalanatomicalvariation,radiologistsneedguidelinesforinterpretingradiographsthatrevealanuncertaindegreeoffemoralheadcoverage.Acautiousapproachwouldbetosuggestthepossibilityofborderlinehipdysplasiaandrecommendreferraltoahipspecialist.Thisrecommendationshouldbeperformedwhentheimagingfindingshavebeendeemedreliable,whichrequiresstrictadherencetoproperimagingtechnique.ThefollowingshouldbeassessedoneveryAPradiographofthepelvis:(1)Isthepelvistiltedorrotated?Asaguideline,thedistancebetweenthesuperioredgeofthepubicsymphysisandthecoccyxshouldbe1–3cm[40].(2)Howwelldefinedarethemeasurementlandmarks?Ifthereisdoubtastowherethelandmarksarelocated,themeasurementsarelikelytobeinaccurate.(3)Aremeasurementsperformedusingelectroniccalipersorwithavalidatedcomputer-assistedprogram?Ifperformedbyhand,havetheinitialmeasurementsbeenvalidatedwitharepeatattempt?(4)Isthepatientolderthan15years,andifnotisthemodifiedlateralCEAstandardbeingemployedratherthantheclassiclateralCEA?Theanswerstothesequestionshaveagreatimpactonthereportedmeasures.Iftheimagingtechniqueisadequateandthechildstillfallsintoanindeterminatecategoryoftheborderlinedysplastic(alateralCEAthatfallsbetween18°and24°),thisisstillonlythefirststepinacomplexdiagnosticprocess.Ourunderstandingofhipdiseasehasevolvedconsiderablyoverthelastdecade.Itisimpossibletoaccuratelycharacterizeallofthedifferentpatternsofinstabilityandunder-coveragewith2-Dradiographicviews.RelyingsolelyonthelateralCEAtodeterminenormalversusdeficientcoverageassumesalldysplasiaisglobal,orprimarilyinvolvesthesuperioracetabulum.Wenowknowthatatleastthreedistinctpatternsofacetabulardeficiencyexist:anterosuperior,global,andposterosuperiorinsufficiency[41],andAPradiographsarenotdesignedtodetectafocalanteriororposteriordeficiency.Thepresenceofborderlinedysplasiaonradiographsalsodoesnotconfirmthepresenceofinstability,whichisultimatelywhatleadstosymptomsandjointdamage.Thepresenceorabsenceofinstabilityorimpingementmustbedeterminedthroughcarefulhistoryandphysicalexam,aswellasfromstaticandpossiblydynamicimaging.Thefemoroepiphysealacetabularroof(FEAR)indexhasbeenproposedasausefulradiographicmarkerofinstability(Fig.5)[42].Anotherhelpfulradiographiccluetothepresenceofinstabilityistheupslopinglateralsourcilmargin[43].Alloftheseobservations,however,requirefurthervalidationbeforetheycanbeconsideredreliablemarkersofdisease.Wiberg[5]laidtheimportantgroundworkwithhisseminalarticledescribingthe“normal”lateralcoverageofthefemoralhead,andformanydecadesthoseassertionshavenotbeendisproved;subsequentinvestigationshaveonlysubstantiatedhisoriginalfindings[44–46],thoughthelowerendofthenormalthresholdhasshiftedmoretowardthedysplasticendofthespectrum.Largerpopulation-basedstudieshaverecentlysuggestedthattheserangesaregender-specificandthatmaleandfemalepatientsshouldnotbemeasuredagainstthesamestandard.UpdatedreferencestandardsproposedbyLaborieetal.[39]suggestedthatcutoffvaluesformalepatientsshouldbe21°comparedto20°infemalepatients.Updatedupperthresholdvaluesforacetabularindexaccordingtothisstudywere15°formalesand16°forfemales,comparedtopreviouspublishedthresholdof10°forbothgroups.Accordingtothesenewcriteria,manypatientswhohadpreviouslybeencharacterizedasmildlyorborderlinedysplasticmightnowbeconsiderednormal.Additionally,age,gender,heightandbodymassindex(BMI)havebeenfoundtobefactorsinwhatareconsideredtobenormalrangesofacetabularcoverage,shiftingthelowerrangeofnormalcoveragefurtherintothedysplasticrangeforcertainpopulations[47].?

問(wèn)：髖關(guān)節(jié)發(fā)育不良可不可以保守治療，是否必須手術(shù)？答：首先，保守治療無(wú)非控制活動(dòng)量、控制體重、吃止疼藥、加強(qiáng)肌肉鍛煉，一定程度可以緩解疼痛癥狀，但是根本的骨頭畸形并沒(méi)有改變，也就是說(shuō)，保守治療只能一定程度延緩病情進(jìn)展，無(wú)法解決根本問(wèn)題。手術(shù)的目的是為了緩解疼痛、延長(zhǎng)自身關(guān)節(jié)的使用壽命，從根本上解決問(wèn)題。如果本身關(guān)節(jié)不疼，或者疼痛非常非常輕，可以暫且保守治療。但是，如果關(guān)節(jié)疼痛比較頻繁或者比較重，手術(shù)可能是解決當(dāng)前問(wèn)題的最佳方式。?問(wèn)：保髖術(shù)后我的關(guān)節(jié)能用多少年？答：這個(gè)問(wèn)題很難回答。影響關(guān)節(jié)使用壽命的因素太多了，比如手術(shù)時(shí)關(guān)節(jié)軟骨磨損重不重、自身的軟骨耐磨程度如何、自身的關(guān)節(jié)畸形重不重、手術(shù)醫(yī)生的水平好不好、術(shù)后體重控制得好不好、術(shù)后關(guān)節(jié)保養(yǎng)的好不好。理論上講，通過(guò)手術(shù)糾正畸形可以讓關(guān)節(jié)的使用壽命盡可能延長(zhǎng)，最好的效果就是用一輩子，當(dāng)然，少術(shù)患者也有術(shù)后幾年、十幾年后出現(xiàn)關(guān)節(jié)磨損嚴(yán)重，進(jìn)而換關(guān)節(jié)的?？傮w上講，找一個(gè)靠譜的醫(yī)生，術(shù)后自己好好保養(yǎng)，剩下的就交給天意了。?問(wèn)：手術(shù)后我應(yīng)該怎么保養(yǎng)自身的關(guān)節(jié)？答：手術(shù)的目的還是希望大家回歸正常的生活。有的極端的患者，為了減少關(guān)節(jié)負(fù)重會(huì)走極端，比如坐輪椅，甚至少穿衣服，其實(shí)大可不必，該干嘛干嘛。如果可以的話(huà)，適當(dāng)避免長(zhǎng)時(shí)間重體力勞動(dòng)或者劇烈運(yùn)動(dòng)。當(dāng)然，如果你覺(jué)得運(yùn)動(dòng)是生命中不可缺少的一部分，那也不用刻意壓抑，這一點(diǎn)國(guó)外是比較積極的，很多患者手術(shù)就是為了后續(xù)運(yùn)動(dòng)時(shí)不疼。當(dāng)然，如果能把體重控制在理想的區(qū)間肯定是最好的。?問(wèn)：我想手術(shù)了，術(shù)前應(yīng)該做哪些準(zhǔn)備？答：1、異地就醫(yī)，提前進(jìn)行醫(yī)保備案，具體需要詢(xún)問(wèn)當(dāng)?shù)蒯t(yī)保部門(mén)；2、準(zhǔn)備一副拐杖，肘拐腋拐都可以，調(diào)整拐杖高度，練習(xí)拄拐單腿走路；3、術(shù)前可以按醫(yī)生的建議進(jìn)行功能鍛煉，改善肌力，加速術(shù)后康復(fù)；4、帶著之前拍的片子及病歷；5、酌情準(zhǔn)備個(gè)人生活物品。?問(wèn)：髖臼周?chē)毓鞘中g(shù)風(fēng)險(xiǎn)高不高？答：這個(gè)手術(shù)確實(shí)難度很大，被譽(yù)為骨科的珠穆朗瑪，手術(shù)的入門(mén)門(mén)檻很高，學(xué)習(xí)曲線(xiàn)很長(zhǎng)，目前全國(guó)只有為數(shù)不多的醫(yī)生可以做這類(lèi)手術(shù)。記得我在美國(guó)學(xué)習(xí)的時(shí)候，看過(guò)兩個(gè)醫(yī)生做這個(gè)手術(shù)，一個(gè)醫(yī)生平均需要三四個(gè)小時(shí)，另一個(gè)醫(yī)生需要6-8個(gè)小時(shí)。對(duì)于我們來(lái)說(shuō)，絕大多術(shù)的手術(shù)可以在1小時(shí)出頭的時(shí)間完成，手術(shù)不但做得快，質(zhì)量也是絕對(duì)有保證。?問(wèn)：手術(shù)需要輸血嗎？答：這個(gè)手術(shù)的出血確實(shí)偏多，但是隨著手術(shù)技術(shù)的提高和相關(guān)藥物的應(yīng)用，再加上手術(shù)中使用血液回收設(shè)備（可以將出血量的大概一般進(jìn)行重新回收利用），目前在我中心手術(shù)的患者，90%以上的患者不需要異體輸血。而且，我們中心現(xiàn)在術(shù)前不需要常規(guī)備自體血。?問(wèn)：術(shù)后恢復(fù)期大概多久？答：手術(shù)中我們需要將骨頭截?cái)?，調(diào)整好位置后進(jìn)行固定，截?cái)嗟墓穷^長(zhǎng)好需要大概3個(gè)月的時(shí)間。所以，術(shù)后3個(gè)月內(nèi)需要小心保護(hù)自己的髖關(guān)節(jié)，不要摔，一定要拄雙拐，拄雙拐，拄雙拐！一般我會(huì)讓患者術(shù)后6-8周內(nèi)術(shù)腿不負(fù)重，6-8周后從0開(kāi)始逐漸逐漸增加踩地的重量，注意，是勻速逐漸的增加，到3個(gè)月的時(shí)候可以負(fù)重身體重量1/3-1/2，具體以醫(yī)生通知為準(zhǔn)。過(guò)早扔拐，過(guò)早過(guò)多負(fù)重可能導(dǎo)致骨頭移位，影響手術(shù)效果。3個(gè)月后門(mén)診復(fù)查，評(píng)估骨頭生長(zhǎng)情況。?問(wèn)：術(shù)后如何進(jìn)行康復(fù)鍛煉？答：康復(fù)鍛煉很重要，鍛煉不好，走路十有八九會(huì)瘸。我的患者我一般會(huì)給每人一個(gè)康復(fù)計(jì)劃，由于每個(gè)人的手術(shù)不一樣，畸形不一樣，骨頭質(zhì)量不一樣，所以方案不會(huì)完全一樣，大家按照自己的方案去做鍛煉即可。大家認(rèn)真閱讀鍛煉資料，保證動(dòng)作做對(duì)，一旦動(dòng)作做錯(cuò)，就可能練錯(cuò)肌肉。3個(gè)月復(fù)查時(shí)人要過(guò)來(lái)，很重要，我會(huì)根據(jù)查體結(jié)果和骨頭愈合情況調(diào)整康復(fù)方案。復(fù)查方式參考：保髖術(shù)后門(mén)診復(fù)查注意事項(xiàng)

發(fā)育性髖關(guān)節(jié)發(fā)育不良(DDH)伯爾尼髖臼周?chē)毓切g(shù)(PAO):從其在當(dāng)?shù)氐拈_(kāi)始到在世界范圍內(nèi)的采用（2023）Berneseperiacetabularosteotomy(PAO):fromitslocalinceptiontoitsworldwideadoption?GanzR,LeunigM.Berneseperiacetabularosteotomy(PAO):fromitslocalinceptiontoitsworldwideadoption[J].JOrthopTraumatol,2023,24(1):55..?轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/37917385/?轉(zhuǎn)載文章的原鏈接2：https://jorthoptraumatol.springeropen.com/articles/10.1186/s10195-023-00734-2?AbstractThedevelopmentoftheBerneseperiacetabularosteotomy(PAO)isbasedonastructuredapproachstartingwithananalysisofthepreexistingprocedurestoimprovethecoverageofthefemoralheadandwasfollowedbyalistofadditionalgoalsandimprovements.Cadavericdissectionswithadetaileddescriptionofthevascularsupplyofacetabulumandperiacetabularbonesetthestageforanintrapelvicapproach,whichofferedthelargestacetabularcorrectionpossiblecombinedwithsafeintracapsularaccess.Thefinalcompositionofosteotomiesrequiredthedevelopmentofseveralinstrumentsandcuttingdevicesbeforethefeasibilitycouldbetestedonaseriesofcadaverichips.伯爾尼髖臼周?chē)毓切g(shù)（PAO）的發(fā)展基于一種結(jié)構(gòu)化的方法，首先對(duì)現(xiàn)有的手術(shù)方法進(jìn)行分析，以改善股骨頭的覆蓋范圍，然后列出了其他目標(biāo)和改進(jìn)措施。通過(guò)對(duì)髖臼和周?chē)堑难芄?yīng)進(jìn)行詳細(xì)描述的Cadaveric解剖，為內(nèi)盆入路奠定了基礎(chǔ)，這種入路可提供最大的髖臼矯正范圍，同時(shí)確保安全的關(guān)節(jié)囊內(nèi)入路。在對(duì)一系列cadaveric髖關(guān)節(jié)進(jìn)行可行性測(cè)試之前，需要開(kāi)發(fā)幾種器械和切割裝置來(lái)完成所需的截骨。Whilethesequenceoftheosteotomiesremainedlargelyunchangedovertime(exceptforthepubicandischialosteotomies),severalpropositionsforaneasier/lessinvasiveapproachhavebeendiscussed;somemadeitintostandardpractice.Effortswereundertakentooptimizethelearningcurveandminimizefailuresusingvideo-clips,hands-oncourses,fellowships,publications,andongoingmentoringprograms.Inretrospect,withalmost40yearsofexperience,sucheffortshavepromotedaworldwideadoptionoftheBerneseperiacetabularosteotomy.雖然骨盆截骨的順序在長(zhǎng)期內(nèi)變化不大（除了恥骨和坐骨截骨），但人們還是討論了一些更簡(jiǎn)單、更微創(chuàng)的方法。其中一些方法已納入了常規(guī)實(shí)踐。人們還通過(guò)視頻剪輯、動(dòng)手課程、研討會(huì)、出版物和持續(xù)的導(dǎo)師項(xiàng)目等方式，努力優(yōu)化學(xué)習(xí)曲線(xiàn)，減少失敗?；仡欉^(guò)去，在近40年的經(jīng)驗(yàn)基礎(chǔ)上，這些努力促進(jìn)了伯爾尼髖臼周?chē)毓切g(shù)在全球范圍內(nèi)的采用。?KeywordsHipjointpreservationsurgery,Periacetabularosteotomy,PAO,BernesePAO,Pelvicosteotomyhistory?SimilarcontentbeingviewedbyothersResultsofPeriacetabularOsteotomy(PAO)Chapter?2017BerneseperiacetabularosteotomythroughadoubleapproachArticle10August2018Mini-IncisionPeriacetabularOsteotomyChapter?2017?IntroductionAttemptstoimprovecoverageofthefemoralheaddatebacktothebeginningoflastcentury,whenAlessandroCodivilla,directorofthefamousRizzoliOrthopedicInstituteinBologna,Italy,proposedamethodtotreattheestablisheddislocationofthehip[1,2].Hesuggestedtocoverthefemoralheadcompletelybythejointcapsuleandtointroduceitintoadeepenedacetabulumattheanatomiclevel.Thetechniquewaspopularized30yearslaterbyColonnaandremainsknownunderhisname[3].Theprocedurewasexecuteduntilthelate1990s,whenBoardmanandMoseleyintheirfollow-uppaperconcluded:“wedonotsupportrevivalofthisnowobscureprocedure”[4].Nevertheless,betterunderstandingofthebloodsupplytothehipregionfavoredarevivalofamodifiedversion,nowcalledcapsulararthroplasty[5].?AcetabularaugmentationClassicaugmentationproceduresofthedeficientacetabulumaretheshelf-arthroplasty[6,7]andtheChiariosteotomy[8].Likethecapsulararthroplasty,theyrelyontransformationoftheinterposedcapsulartissuetofibrocartilage.Comparedwithhyalinecartilagethemechanicalqualityoffibrocartilageisinferior,nevertheless,thesurvivalofsucha“neo-joint”canlastuptoseveraldecades.Theexecutionoftheacetabularshelfaugmentationiscomparativelyeasy.Overtimethistechniqueunderwentseveralminormodifications;itisstillinuseinFranceandincountrieswithFrenchorthopedicinfluence[9].ThetransversejuxtaarticulariliacosteotomyofChiariistechnicallysomewhatmoredemanding.Itwasfirstdescribedintheearly1950s[8]andgainedinternationalacceptancefordecades.Despitemultiplearticlesreportinggoodlong-termresults[10,11,12,13],theprocedurelostpopularitywiththeextensionoftotalhipreplacement(THR)indicationtoyoungerpatientsandwiththeemergenceofreorientationprocedures.?AcetabularreorientationIntheseprocedurestheentireacetabularboneandhyalinecartilageisredirectedoverthefemoralhead;theglidingsurfaceofthenewarticularrelationwiththefemoralheadremainsallhyalinecartilage.Experiencehasproventhatthereisnearlyalwayssufficientacetabularcartilageavailabletoallowcorrectreorientation.LeCoeurwasthefirsttoexecutesuchanosteotomyin1939,butdidnotpublishitbefore1965[14].Today,severalareofhistoricalvalue,themajorityisusedinthecountryoftheinventor,andfewhavereachedinternationalacceptance.?SingleosteotomiesTheSalterosteotomyistheonlyonewherewithatransverseandcompletesingleosteotomyofthesupraacetabulariliumisusedtoreorienttheacetabulum[14].Itispreferredbypediatricorthopedicsurgeonsforitsrathereasyexecution.However,withitspivotpointnearthepubicsymphysis,correctionislimitedandinterlinkedwithsidecorrectionssuchaslateral,anterior,andcaudadshiftofthejoint.Thehighestclinicalrelevance,however,hasthetendencytocreateretroversionoftheacetabulum,whichinhipswithlowornoanteversionmaycreateimpingementproblemsinearlyadulthood.ThePemberton[15]andDega[16]osteotomiesareincompletesupraacetabularosteotomiescorrectingtheroofonly.ThecutissimilarasforaSalterosteotomy[14]butdoesnotseparatetheiliumcompletely.WhilethePembertoncutisstraight,theDegacutiscurvedfollowingtheacetabularroof.Thedeeperthecutpenetrates,theeasiertheacetabularpartofthebonecanbebenddownwards,decreasingtheenlargedacetabularradius.Bothtechniquesareusedalmostexclusivelyinprematurehipswithashallowacetabulum.BotharetechnicallymoredemandingcomparedwiththeSalterosteotomy[17].Comparinglong-termresults,thePembertonosteotomyseemstocreateslightlybetterresultscomparedwiththeDegaandSalterosteotomies[18,19].?DoubleosteotomiesTwodoubleosteotomiesforacetabularcorrectionwithdifferentestimateshavebeendescribedfromSutherlandandGreenfield[20]andfromHopf[21].Thefirstiscuttingthroughthebonenearthesymphysis,thesecondiscuttingthroughtheemptydistalpartofthepaleo-acetabulumincasesofseveresubluxationandsecondaryacetabulum.?TripleosteotomiesTheycanbedividedintodifferenttypes:thoseexecutedatadistancefromthejoint,whichimpliesthatthesacrospinalandsacrotuberalligamentsinsertattheacetabularfragmentandthereforelimitthecorrection,andthoseexecutedclosetothejoint,whichimpliestheligamentsarenotattachedtotheacetabularfragmentandthereforeallowahigherspatialcorrection[14,22,23,24].?SphericalosteotomiesTheseareperformedveryclosetothejoint,allowingextensivecorrectionexceptformedialshiftingoftheacetabularfragment.Theexecutionisratherdemanding,andduetotheacetabularvicinityoftheosseouscuts,thefragmentperfusionislimitedtotheobturatorandcapsularvessels.Simultaneousarthrotomyisthereforelimited[25,26,27].?TheBerneseperiacetabularosteotomy(PAO)ThemostrecentlyintroducedreorientationprocedureisthePAO[28].Incontrasttopreviousosteotomies,itisexecutedfromanteriorandfromtheinsideofthepelvis.Theprocedureistheresultofaresearchprojectwithanalysisofthelimitationsoftheexistingprocedures,followedbyextensivecadavericdissectionsofthevascularsupplyandbytrialosteotomiesforbestdirectionoftheosteotomycuts.Finally,thedefinitiveversionoftheprocedurewastestedon25cadaverhipswiththefocustotestasetofnewinstruments.Traditionally,pelvicsurgeryperformedbyorthopedicsurgeonsapproachedtheacetabularareaalmostexclusivelyfromthelateralside.Withtheprogressinsurgicaltreatmentoftraumatotheacetabulumandpelvisinthelate1970sandearly1980sbyLetournel[29],aswellaswithbetterunderstandingofthevascularsupplyofthepelvis,theinnersideofthepelvisbecameaninterestingnewsurgicalapproacharea.Additionally,knownlimitationsofthepreexistingaugmentationandreorientationprocedures(Table1[14,15,20,21,22,23,24,25,26,27,28])raisedtheambitionforamoreversatileprocedureofacetabularreorientationthatshouldfulfillseveralgoals(Table2).??Table1Characteristicsofacetabularreorientationprocedures??Table2Criteriatomeetforanewreorientationprocedure??Thefirststepoftheprojectwasacadavericstudyofthevasculartopographytothepelvisrelevanttoperiacetabularosteotomies.Hereitbecameobviousthatthemostcrucialaspectwasthepreservationofthefragmentvascularityduringtheosteotomiesandduringwideningthegapsrequiredforcorrection.Itwasbestachievedifosteotomieswereperformedfromtheinnersideofthepelvis[28](Fig.1).AfterfirstclinicalintroductionofthePAO,intraoperativelaserDopplerflowmetryoftheacetabularfragmentwasusedanddemonstratedthatthesignalsdropduringthereorientationbutreturntonormalvaluesafterseveralminutes[30].Overall,theseteststookup1year,mainlyduetolimitedavailabilityofsuitablecadavers.Forthefinalsequenceandorientationofthefivenecessaryosteotomysteps,JeffreyMast,aclinicalfellowfromtheUSAatthetime,wasaningeniouscontributortothedevelopmentofthePAO(Figs.2,3).Finally,wepracticedonseveralcadaverhipstobecomefamiliarwithtechniqueandanewsetofinstruments,whichlaterbecamecommerciallyavailable(Fig.4)fromseveralproviders.??Fig.1Periacetabularvascularsupplycadaverstudyonvascularsupplyoftheperiacetabularbone.Righthip,osteotomiesfrompelvicinside.Thebranchesfromsuperiorandinferiorglutealarterycanbepreservedduringosteotomy(left)andfragmentcorrection(right)??Fig.2PAOosteotomycutsarrangementofthefiveosteotomycuts,visibleontheleftlateralview,inthemiddleanteriorview,andontherightmedialviewofarighthemipelvis,namelyincompleteischialcut(first),pubiscut(second),supraacetabularcut(third),retroacetabularcut(fourth),andinfraacetabularcutcompletingtheischialcut(fifth)??Fig.3Pelvisplasticmodel:plasticmodelshowingseparationoftheacetabularfragmentfromposteriorcolumnincludingsacrospinalandsacrotuberalligaments.Top:anteriorview;bottom:posteriorview??Fig.4PAOinstrumentationsetofinstrumentswithspecialosteotomesandretractors??Thefirsthipwasoperatedonon13March1984.Wewerewaitingseveralweeksforan“easy”case,butDrMastcouldnolongerpostponehisflightbacktotheUSA;thiswasthereasonwhywedecidedtotreatthemosturgentcaseonthelist,whichwasaproximalfemoralfocaldeficiency(PFFD)hipwithcomplexdeformity.Thesurgeryofthis13-year-oldgirltook4hand10minandincludedafemoralvalgusosteotomytocompensateforanearliervarusosteotomy.Atotalof3monthsaftersurgery,thehipdislocatedposteriorly,acomplicationthatwassuccessfullytreatedwithaposteriorshelf.Atthattime,wedidnotknowthatPFFDhipshavesevereacetabularretroversionasacharacteristicpartofthemalformation.Thehipfunctionedwellduring33yearsbeforeTHRbecamenecessary(Fig.5).Theresultsofthefirst75hipswithratherheterogeneousformsofdysplasia,multipleprecedentsurgeries,andosteoarthrosisstageincludingT?nnisgrade2werepublished4yearslater[28];thesuccessrateofthisgroupdroppedfrom80%after10yearsto60%after20yearsandto30%after30years[31,32].Meanwhile,morehomogeneousgroupsofhipdysplasia,youngerageatsurgery,exclusionofadvancedosteoarthritis,aswellasaconcurrentarthrotomyforfemoralhead–neckshaping,haveledtofurtherincreaseofsurvival[33,34].??Fig.51984:firstoperatedcase—13-year-oldfemalewithPFFDofthelefthip.aVarusproximalfemurafterintertrochantericosteotomy3yearsearlier.bPeriacetabularosteotomyfollowedbyintertrochantericrevalgisationforbetterjointcongruity.Goodlateralcoverageofthehead.Increasedretroversionoftheacetabulumledtoposteriorsubluxation3monthsaftersurgery,whichwastreatedwithaposteriorshelf.cProgressivejointdegenerationafter36years.Plateforshelffixationstillinplace.dFollow-upradiographyofTHR2yearslater.Thepatientregainedanormalgaitpattern??TechniqueThepatientisinsupineposition,thelegtobeoperatedonisdrapedmobile.Generalanesthesiaisstandardasisbloodsalvage(cellsaver).TheapproachisamodificationofSmithPetersen’sprimarydescription[35].Thesequenceofthefivepartialcutsisdescribedelsewhereindetail[28].Someperformthepubiccutpriortothefirstischialcut,especiallywhenarectussparingapproachisused.Theclassicexposurestartswithosteotomyoftheinsertionofthesartoriusoriginattheanteriorsuperioriliacspine(ASIS).Mainlyinyoungerpatients,thesartoriusinsertionincludingtheinguinalligamentarereleasedfromtheASISwithoutanosteotomy.Byincisingthefasciaofthetensorfasciaelataeandmovingawaythemuscletothelateralside,thejointcapsuleisreached.Bydissectingtheiliacussubperiosteally,themedialflapcanbemobilized.Intheclassicapproachthereflectedandthedirectheadoftherectusfemorismusclearedividedandtheiliocapsularismuscleisdissectedfromthecapsule.Followingtheanteroinferiorcapsuletotheinferior,thegapbetweencapsuleandpsoastendonfurtherdowntotheobturatorexternusmuscleiswidenedtoreachtheischium.Thedeepbranchofthemedialfemoralcircumflexartery(MFCA)runsonthecaudadsurfaceofthismuscle,whichneedstoberespected.Initially,foranincompletecutoftheischiumattheinfracotyloidaxilla,aspeciallyangulatedosteotomeisused.Positionandpropagationcanbecontrolledwithfluoroscopy.Intherectussparingapproach,theischiumisapproachedmedialtotherectusfemoris,whichisnotreleased.Thedeepfasciaisincised,andtheischialosteotomyisperformedquitesimilartotheclassictechnique.Incomparisonwiththeclassictechniquetakingdowntheinsertionoftherectus,therectussparingapproachisnotreallyinternervous,becausethefirstbranchofthefemoralnerveiscrossingtheapproachdistally.Thepubiccut,intheclassicversionsecond,isacompleteseparationofthepubisaftersubperiostealdissection;theobturatorneurovascularbundleisprotectedusingtwobluntretractors.Thethirdcutisasupraacetabularhorizontalseparationoftheiliacbone,startingjustdistaltothesartoriusmuscleorigin.Thecutisperformedfromtheanteriorandinnersideoftheiliumwithanoscillatingsaw.Duringthisosteotomytheabductormusculatureisprotectedwithabluntretractor.Thecutstopsabout10mmbeforethepelvicbrim.Forthefourthcut,aretroacetabularcutstartsfromthereandisdirecteddownwardsatanangleof110–120°posteriortothesupraacetabularcut.Again,fluoroscopyhelpstocorrectlypropagatethiscutusinga10mmosteotome.Attheangulationbetweenthethirdandfourthcut,acurvedosteotomeisusedtocuttheoutsidecortex.Atthispointabonespreaderisinsertedjustdistaltotheangulationtoopenupthegap.Witharetractorheldagainstthequadrilateralsurfaceneartheischialspine,theareaforthefifthosteotomycanbeopened.Thecutisexecutedwithaspecialosteotomeandcutsthefinalosseousbridgebetweenthefourthandthefirstcut.Itseparatesthesacropelvicligamentsfromtheacetabularfragment(Fig.3).Whenallcutsareproperlyaccomplished,theacetabularfragmentcanbeseparatedwithacounter-rotatingmoveofthespreaderandaSchanzscrewinsertedintotheiliacpartoftheacetabularfragment.Thedesiredcorrectionistemporarilyfixedwithtwo(?3)Kirschnerwiresandiscontrolledwithfluoroscopyorastandardanteroposteriorradiographoftheentirepelvis.Thelatterispreferredbecauseitalsoguaranteesthenecessaryorthogradepositionofthepelvis.?ModificationsoftheapproachovertimeSoonaftertheinitialexperiencewith75PAOs,thedissectionoftheabductormusculaturewasabandonedandsufficientprotectionofthesemusclesduringthethirdcutcouldberealizedwithtunnelingandplacementofabluntretractor[36].Animportantinsightcamefromfollow-upstudies,showingthatsomehipsdevelopedimpingementsymptomsafteracorrectlyorientedacetabulum.Acloserlookrevealedthatconcomitantfemoralhead–neckdeformityisrelativelyfrequentandwasnotproducingsymptomsbeforethePAO-improvedanteriorcoverage.Theproblemcanbedetectedbyassessinginternalrotationinhipflexionduringsurgeryandsolvedwithadditionalarthrotomyforosteochondroplastyoftheanteriorhead–neckjunction.SomeauthorsrecommendarthroscopybeforePAO[34],whichmaycompensateformissingorinadequateMRIandmayeveninfluencetheindicationforPAO.IncomplexdeformitiesnecessitatingthecombinationofaPAOwithafemoralprocedureweareinclinedtostartwiththefemoralprocedureandapproachtheinfracotyloidaxillabetweenmuscles.gemellusinferiorandobturatorexternus.Forbetterdiscriminationitisadvantageoustoexposethisgapbeforethefemoralprocedure;itallowstoperformthefirstischialcutunderdirectviewwiththesciaticnervebeingheldaside[37](Fig.6).??Fig.6Ischialcutviafemoralapproachinhipswithcombinedacetabularandfemoralsurgery.Ontop,accesstotheinfracotyloidgroovebetweenobturatorinternusandgemellusinferiormuscles.Bottom:itallowsoptimalprotectionoftheischialnerveduringexecutionofthecut??Amorerecentmodificationoftheoriginaltechniqueistherectussparingapproach,whichallowsthefirstcuttobeperformedbyapproachingtheischiummedialtotheintactrectustendons.Acadavericstudydescribesthefeasibilityofthismodification;however,intraarticularinspectionandrevisionoftheanteriorinferioriliacspine(AIIS)mightbesomewhatrestrictedandthemostproximalbranchofthefemoralnervecanbeoverstretched[38].Anumberofproposalsdealwithmodificationsoftheapproachwithoutchangingsequenceandconfigurationoftheosteotomy.TheattemptstoexecutethePAOusingmini-invasivetechniques,includingthetranssartoriousapproach[39,40],maybeapplicableforminimalcorrectionsbuthavelimitationswithcomplexdeformities;consequentlythewidespreaduseremainslimited.AnotherpropositionistheuseofamodifiedStoppaorapararectusapproaches;bothhavebeensuccessfullyperformedforanterioracetabularfractures[41];however,theusefulnessfortheexecutionofaPAOhasnotyetbeendemonstrated.Aninguinalextensionoftheapproachmayincreasetheviewonthepubicosteotomyarea,butwasnearlycompletelyabandonedafterseveralcaseshadpostoperativedeepveinthromboses(DVTs)ofthefemoralvein.Fewareusingatwo-incisiontechnique[42],similartotheT?nnistripleosteotomy[24].Aprimaryconceptionoftheoriginaltechniquewastoavoidfluoroscopyanduseonlylocallandmarksfortheexecution.However,mostsurgeonstodayusestandardizedfluoroscopycontrolforsomeorevenallosteotomies.Computerassistancehasbeenproposedseveraltimes,butlikeforTHR,sofarithasnotfounditswayintogeneralpractice.Amostrecentversion[43]confirmsthatitmaybehelpfulforthelessexperiencedsurgeon,aconclusionwegainedalreadymorethan25yearsagousingasimilarapproach;itwasgivenupafterashortclinicaltestingperiod[44].?SpectrumoftheprocedureThefollowingselectedcasesmaydemonstratethespectrumofindicationandthereforeversatilityofthePAO.Whiletheprocedurewasoriginallyintendedasamethodforprimaryacetabulardysplasiafromdevelopmentaldislocation(DDH),itbecameusefulsoonafterasanadditionalsurgeryforothercomplexdeformitieswithacetabularparticipation,mainlyPerthesorPerthes-likedisease,butalsoincaseswithfemoralexostosisorsepticarthritiswithfemoralheadnecrosisintherareepiphysealdysplasiaandoccasionallyinearlystageofprotrusionandposttraumaticperiacetabulardeformities.Specialchallengewasconstitutedincasesafterprevioussurgery,suchasretroversionafterSalterosteotomyorwhenare-PAOwasnecessary.?Case1A16-year-oldfemalesufferingfromseverebilateralacetabulardysplasiaandcoxavalgawithhighfoveacapitishadmorepainontherightside.Therewasbilateralsubluxationwithfatiguefractureofthelateralacetabularrimontherightside(Fig.7).Thelateralviewoftherighthipshowedsubstantialintraosseousganglionformationintheroof,whiletheabductionviewfeaturedrecenteringofthefemoralheadandsomereductionoftheacetabularfragment.ThecomplexdeformityonbothhipsmadeitnecessarytocombineaPAOwithafemoralvarusosteotomy.Surgerystartedonthefemorallevelinlateraldecubitus.Beforeexecutingtheintertrochantericosteotomy,thefirstischialcutofthePAOwasperformedthroughthisapproachunderdirectview.FortheremainingPAOcuts,thepatientwasturnedintosupineposition.Theacetabularrimfracturereducedspontaneouslyanddidnotneedadditionalfixation.Thelefthipwasoperatedon6monthslater.Healingoftheosteotomies,includingtherimfracture,wasuneventful.Painofbothhipsdisappearedshortlyaftersurgery,allowingforunrestrictedage-appropriateactivities.Theprominentbendofthefemoralimplantcreatedsomediscomfort,andthiswasthereasonwhypartialmetalremovalwasexecuted2yearsaftersurgery.Afollow-upradiographyat5-yearfollow-upshowedaperfectlyreducedandhealedrimfragmentanddisappearingacetabularcysts.??Fig.7Bilateralsevereacetabulardysplasiaof16-year-oldfemale;morepainontherightside.aSeveralsubchondralbonecysts,bestvisibleinalateralview(blackarrow).Displacedrimfracturewithsomereductioninabduction(whitearrow).bPAOcombinedwithfemoralvarusosteotomy.A6-monthintervalbetweensurgeryofthehipswasobserved(rightsidefirst).SlightovercorrectionofthePAOontherightsideforbetterunloadingofthedamagedrimareawasperformed.Partialmetalremovalafter2yearswasperformed.Radiologicalresultobservedafter5years.cCloserlooktothecriticaljointareaoftherighthipbeforesurgeryandaftersugery(d)showingreducedandhealedrimfragment(doublearrow)??Case2A13-year-oldmalewithPerthesdisease(Fig.8).AfterSalterosteotomypaindidnotsubsideandlimpingincreased;bothcouldbeexplainedwithpersistentsubluxation,widenedacetabulum,followedbyadductioncontracture.Computersimulationshowedreasonablereductionofthesubluxatedfemoralheadwithintracapitalosteotomy[45]andPAO.Thepreciseexecutionofthefemoralheadosteotomywasfacilitatedbyacuttingtemplateprefabricatedonthebasisofthecomputersimulationdata.Healingoftheosteotomieswasuneventful.Painsubsidedcompletely;abductortraininghelpedtoregainawalkingpatternwithoutlimping.At1yearaftersurgery,partialmetalremovalhelpedtosettlepainfromprojectingscrewheads.At2yearsaftersurgerytheconfigurationofthehipwasclosetonormal,rangeofmotion(ROM)wasslightlylesscomparedwiththeoppositesideandfunctionwasunrestricted.??Fig.8Perthesdiseaseintherighthipofa13-year-oldmale,operatedonwithSalterosteotomy.aPersistentsubluxationandadductionwithextrusionofthehealthylateralpillarandloadingofthenecroticarea.Adaptivewideningoftheacetabularcavity.Ontheright,computersimulationshowingrelocatedheadafterresectionofthenecroticarea(redportion)andoptimalcoveragewithPAO.bIntraoperativepicturesshowingtheresectionofthenecroticcentralpartoftheheadwiththetemplateinplaceandthefinalsizeoftheheadafterscrewfixationofthemobilelateralpartoftheheadwithtwoscrews.cPostoperativesequenceswiththenewheadhealedwithoutnecrosis??Case3A21-year-oldverygracilefemalewithmultipleexostosesaroundbothhipsandconcomitantacetabulardysplasia(Fig.9).Sheonlyhadpainontheleftsideanddescribeditassudden,happeningfrequentlyduringexternalrotationinfullextension.Thephenomenoncouldbedemonstratedbyultrasoundasimpingementbetweenaposteromedialneckexostosisandtheinfracotyloidischium;thecontactwasfollowedbyfemoralheadsubluxation.Ultrasoundalsorevealedthatthecausativetumorwasbiggerthanitsradiographicappearance.Bothhipsshowedahighcoxavalgaandacetabulardysplasia.Thesurgicalplanwastoremovethenecktumor,correctthehighneckvalguswithavarusosteotomy,andtoimproveacetabularcoveragewithaPAO.Preoperativeplanningbroughtoutthatintertrochantericosteotomywouldnotsufficientlyincreasethepelvifemoralclearance.Ontheotherside,theriskofdamagetothefemoralheadvascularsupplywasestimatedtobehighduringanattempttoexcisethebigtumorviaanteriorand/orposteriorretinaculardissection.Basedontheknowledgethattheposteriorneckisfreefrombloodvessels,itwasdecidedtoexecutetheresectionthroughtheneckosteotomy,whichcouldalsobeusedtoperformtheplannedvarusosteotomy.Again,surgerystartedwithdislocationofthehip.Subperiostealanteriorandposteriordissectionoftheneck,containingthevesselstothehead,wasperformedtowardthebaseoftheexostosis.Itwasfollowedbyamediocervicalosteotomyandwideningofthegapusingaspreader.Theviewwassufficienttoallowsubperiostealpiecemillresectionofthetumorunderconstantobservationofbleedingofthehead–neckfragment.Varuspositionoftheneckwasstabilizedwithtwoscrews.PAOwasexecutedasdescribedearlier.Subluxationofthehipdisappearedimmediatelyaftersurgery.The10-yearresultshowsareasonablehipjointwithawidejointspace.ThepatientispainfreeandthehiphasanormalROM.Sheisseenregularlybyherlocaldoctorwhoconfirmedthattheotherhipisstillfunctioningwell.??Fig.9Acetabulardysplasia,multipleexostoses,andsubluxationmultipleexostosesnearbothhipswithacetabulardysplasiainaverygracile21-year-oldfemale.aPainanddiscomfortofthelefthipduringsubluxation,palpablewithrotationinfullextension.Lateralview(right)showingthecausativeexostosisattheposteriorneck.bPostoperativeresultaftersurgicaldislocation,femoralneckvarusosteotomy,andremovaloftheexostosisthroughtheneckosteotomy,followedbyPAO.cThe10-year-result.Removalofthefemoralscrewsforlocalpainsoonaftersurgery.Bothhipsarepain-free??Case4A19-year-oldrugbyplayerwithpainoftherighthip,renderinghimunabletoparticipateinhisfavoredsport(Fig.10).Historyrevealedthathewasrunoverbyatruckwhenhewas3yearsold.Hesurvivedmultiplefracturesincludingacrushinjurytothepelvicring,alltreatedconservatively.Afterfullrecoveryhehadnofurthercontroluntilrecentlywhenheexperiencedincreasingpainintherighthipduringhissportiveactivities.Radiographyrevealedatypicalposttraumaticdysplasia,apparentlyaconsequenceofthecrushinjuringthetriradiatecartilage.Thisraretypeofdysplasiaischaracterizedbythickeningoftheinnerwall,deformityofthehemipelvis,andretrotorsionoftheacetabulum.Lateralandcaudadgrowthofthephysisleadstolengtheningoftheleg.Thelargeacetabularfragmentinthiscaseisaconsequenceofchronicoverloadoftherimarea.Thesurgicalplanwastocombinetheacetabularreorientationwithexceptionalmedialshiftingofthelateralizedacetabularfragment.Concernsaboutsufficientunloadingofthefragmentinfluencedthedecisiontofixitseparatelywithtwoscrews.Thesupra-andretroacetabularosteotomycutswerelaboriousduetotheunusuallylargediameterofthesupra-andretroacetabularbone.Optimalmedializationoftheacetabulumledtominimalbonycontactbetweenacetabulumandhemipelvis,whichwasthereasonwhythecorrectionofversionwaslessthandesired.Nevertheless,consolidationwasuneventful.Thepatientresumedhisrugbyactivitiesafter9months,butalthoughpainfree,didnotregainthenecessaryaggressivityforthistypeofsportandthereforegaveitup.The2-yearresultshowedperfectconsolidationofosteotomyandrimfragmentwithalargeandcongruentjointspace.??Fig.10Posttraumaticdysplasiaina19-year-oldmale.aTypicalposttraumaticdysplasiaoftherighthipafteracaraccidentatage3.Largeacetabularrimfragment.Laboriousexecutionoftheosteotomyduetothethicksupra-andretroacetabularbone.Screwfixationofthelargerimfragment.PAOwithmaximalpossiblemedialdisplacementoftheacetabularfragment.bRadiologicalresultafter2yearswithhealedfractureandosteotomies??Case527-year-oldfemalewithosteogenesisimperfectaandbilateralprotrusio(Fig.11).Shehadincreasingandconstantpainfromglobalpincerimpingementintherighthip,whiletheleftsideremainednearlypainfree.Radiographicallythejointspaceontherightsidewasgloballynarrowed.ThepatientfavoredjointpreservationaftershehadlearnedthatthelifetimeofTHRwithsuchbonequalityislimited.Finally,sheunderstoodthatjointpreservationforherhipwouldbeelaborateandthatagoodandlastingresultcannotbeguaranteed.Thedirectionofreorientationbeingreversedtotheclassiccorrectionwouldrequirealargerimtrimmingtostartwith.Surgicaldislocationconfirmedareasonablecartilagelayerofthefemoralheadwithsomeosteophytes.Circumferentialtrimming,especiallyattheposteroinferiorrimwascombinedwithsomeosteochondroplastyattheheadneckjunction.WhileexecutionofthePAOcutswaseasy,valguscorrectionoftheacetabulumwasratherdifficult,mainlyduetotheosteoporoticbone.Tobridgethelargesupraacetabularstepasaresultofthefinalposition,astaircase-shapedplatehadtobeused.Healingoftheosteotomywasuneventful;consolidationofthefatiguefracturecouldbeobservedatthe6-weekcontrol.At2yearsaftersurgery,thepatientwaspleasedwiththeimprovedandpain-freeROM.Radiographicwideningofthejointspacewasinterpretedassignofongoingimprovement.??Fig.11Acetabularprotrusiowasobserved,withabilateralprotrusionina21-year-oldladywithosteogenesisimperfecta.Constantpainontherightsidewhiletheleftsidewaspain-freeduringmostdailyactivities.PatientrefusedtogetTHR.Onthetop,preoperativeradiographyshowingfatiguefracturethroughthebottomofthejoint(whitearrow).bResult1yearafterexcessiverimtrimmingandPAOdecoveringthehead.Fatiguefracturehealed(blackarrow)withsubstantiallyreducedpain??Case6A23-year-oldfemalewithsevereunilateralnarrowingofthepelviccavityafteraconservativelytreatedcomplexperiacetabularfractureinchildhood(Fig.12).Thejointlookedrathernormalandhippainorrestrictedmotionwereminimal;herproblemwasconnectedtothedesperatedesiretogetpregnantandastatementofhergynecologistwhoexpressedconcernswhethertheasymmetricnarrowingcouldleadtoadeviationoftheincreasinguteruswithincreasdriskofabortion.Athree-dimensional(3D)modelofthepelvisdidnotgiveaconclusiveanswertothepossibilityofuterusdeviation,butshowedthatthebirthcanalwassomewhatnarrowforanaturaldelivery.Fromanearliercasewithpelvicdeformationandsuccessfuluseofadistractor,itseemedpossibletousesuchasystemforthenecessarylateralanddistalshiftingofthemedializedjointcomplex.TestsurgeryonaplasticmodelofthedeformedpelvisrevealedthatamodifiedPAO,separatingtheposteriorcolumnproximally,wouldallowtolateralizetheacetabularfragmentsufficientlyandrecreateanormalcurvatureoftheinnerpelviccontour.Fortheverticalizedpubicramusanadditionalosteotomynearthesymphysiswasnecessary.ThebestplacefortheSchanz’screwsofthedistractorweretheoppositeiliacbonenearthesacroiliacjointandattheipsilateralfemoralhead.Bestfixationwaspossiblewithareconstructionplateplacedalongthepelvicbrim.Anilio-inguinalapproachwouldallowexposureoftheentirehemipelvis.FortheSchanz’screwneartheoppositesacroiliacjoint,ashortincisionattheiliaccrestwouldbesufficient.Thethreecutsaroundthejointandtheadditionalcutofthepubisnearthesymphysiswereexecutedastestedonthemodel.Manualtractiondidnotdispalcetheacetabularfragmentmuch.Instrumenteddistraction,however,allowedslowbutconstantdisplacementwhilealignmentcouldbeassistedwithinstruments.Theprebendedplatewasfirstfixednearthesymphysisandonthemobilepubissegment.Proximaloff-standingoftheplatecouldbesteadilyconvergedtothestableiliacbonebyalternatedrivinginthescrews.Thistechniqueallowedanoptimalfinalpositioningoftheacetabularfragment.Osteotomyhealingwasuneventful;shortlyaftershebecamepregnant.Shefinallyhadanaturaldeliveryanddidso2yearsaftersurgerywithasecondchild.Atotalof16yearsaftersurgery,thepatient,nowamotherof5children,ispainfreeandlikesoutdooractivitiesverymuch.??Fig.12Posttraumaticprotrusioobservedinpatient.aPosttraumaticprotrusioanddeformationofthehemipelvisina23-year-oldfemale.Hergynecologistdiscussedtheriskofabortionduetodeviationoftheuterus,whichwasthereasonwhyshewasaskingforcorrection.AmodifiedPAOwasfirsttestedonaplasticmodel.Correctionofprotrusioundpelvicdeformationwasassistedbyadistractor.bThenewpositionwasstabilizedwithalongrecoplateplacedalongthepelvicbrim.Ultrasoundwasperformedjustbeforenaturaldelivery.cAt16yearsaftersurgery,sheisnowthemotheroffivechildrenandisveryactiveinoutdooractivities.Thestraightlegistheoperatedone??Case7Thiscase(Fig.13)wasoperatedbyProfessorPauloRego,aformerfellow.Itispresentedtoshowthatthetechniquesarelearnablebyothers.??Fig.13Severedeformity(courtesyProf.P.Rego,HospitaldaLuz,Lisbon,Portugal)oftherighthipina16-year-oldmaleafteropenreductionattheageof1.5years,followedbyavascularnecrosis.aVarusosteotomyattheageof14years,whichdidnotimprovelimpingandpain.bPostoperativeradiographyaftercomplexsurgerywithrelativelengtheningoftheneck,intracapitalosteotomytoreducethesizeofthehead,andsubtrochantericderotationosteotomyfollowedbyPAO.cThe4-yearfollow-upresultwithgoodandpain-freefunction??Complexdeformityoftherighthipina16-year-oldmalewasobserved.HehadopenreductionforDDHattheageof1year,whichwasfollowedbyincompletenecrosisoftheepiphysis.Togetherwithongoingsubluxation,theacetabulumbecameshallowoveraPerthes-likedeformedfemoralhead.Painandlimpingdidnotimproveafterintertrochantericvarusosteotomyattheageof14years.MRIshowedareasonableconditionofthejointcartilageandcomputersimulationrevealedanimprovedheadsphericitywithintracapitalosteotomy[45].Thepreoperativeevaluationalsoexposedahighfemoralneckanteversion.Surgerywasstartedwiththefemoralside:thefirstischialcutofthePAOwasfollowedbyrelativenecklengtheningandintracapitalosteotomyandfinallysubtrochantericderotation.ThePAOwascompletedafterturningthepatientintosupineposition.Thesurgeoncommentedthattheentiresurgerywasdemandingandtimeconsuming;however,theradiographicresultwasconvincing.The6-yearfollow-upradiographyshowedaresultofcorrectionclosetoanormalhip.Thepatientispain-free,hasanormalwalkingpatternandanearlysymmetricalROM(courtesyProf.P.Rego,HospitaldaLuz,Lisbon,Portugal).?ComplicationsTechnicalcomplicationsdevelopedfirstandforemostduringthelearningcurve,whichinturnisdependentonthecaseloadovertime.Inaliteraturereviewfrom2006,inabout13publications,theincidenceofmajorcomplicationsrangedfrom6%to37%[46].Inourfirstseriesof500cases,themostfrequentcomplicationwassevereunder-,over-,andintraarticularcorrectioncountingfornearly2%ofcomplications[47].Injurytooneofthemainnerves(femoral,sciatic,orobturator)follows,makinguplessthan1%ofcomplications[48],anumberthatmayhavebeeninfluencedbystrictobservationofrecommendationsfromacadaverstudyaboutsurgicalcircumstancesleadingtosuchinjury[48].In1760casesoftheANCHORgroup,complicationincidencewas2.1%,50%(17outof36)ofwhichweretransient[49].NeuromonitoringduringPAOcanidentifythesurgicalmaneuverendangeringtraumatoanerve,butcannotpersepreventdamagewhentheblowisheavyenoughtocausealaceration[50].?InternationaladoptionoftheBernesePAOThisisprimarilytheresultofmultiplepublicationscomingfromdifferentcentersovernearly40yearssinceitsintroduction.Furtherpromotioncamefromaseriesofinstructionalcoursesindifferentcountriesandfromfellowships,mainlyorganizedinSwitzerlandandtheUSA.Also,theongoingmentorshipforcolleaguesduringtheirlearningperiodshouldberemembered[51].SwitzerlandhasprobablythehighestconcentrationoforthopedicdepartmentsperformingtheBerneseperiacetabularosteotomy,withmostoftherelevantpublicationscomingfromtheBerneseGroup[52].NextaretheUSAandCanada,whereseveralinstitutionsworktogetherintheANCHORgrouptostudyallaspectsofsurgerypreservingthenativehipjoint[53].Oneormorecentersarepracticing,andsomedoreportabouttheirresultswiththeBerneseperiacetabularosteotomyinGermany,England,Denmark,Italy,Spain,Portugal,Chile,Iran,andfinallyChina,fromwherethemostrecentreportwaspublished[54].?FutureopportunitiesandchallengesTheindicationfor(oragainst)PAOisstilloneofthemostdifficultdecisionstobemade.Thereisatendencytoperformthesurgeryevenwhenthetriradiategrowthplateisstillopen,butlittleisknownabouthowfaronecangowithoutriskingsurgery-relatedmalformationafterinjuringthegrowthplate.Interestinglyenough,deepeningoftheimmatureacetabulumforcapsulararthroplastydoesnotseemtoproduceamalformation.Maybemolecularstudiesofthetriradiatecartilagecangivesomeideasaboutitsgrowthbalance.TheindicationlimitforoldercandidatesisindirectlydefinedbytherecognitionthatPAOresultsaftertheageof40yearsarestatisticallylessfavorable.However,maybethedirectreasoncouldbetheincreaseofcartilagedegenerationwithage.However,tousedetailedinformationaboutthestatusofthejointcartilageasoftwarewouldberequiredtoquantifyandlocatethecartilagedamageoffemoralheadandacetabulumseenonanMRI.Inanycase,todaytheT?nnisclassificationofhipjointarthrosisaloneisnotagoodparameterfordecision-makingandfollow-upconclusions.WhilethegeometryofthePAOcutsdidnotchange,theapproachalreadywentthroughsomemodifications.Somerepresentaclearadvantage;oneshowedabenefittogetherwithonlyoneminorhandicapduringcadavertesting.Itwouldbehelpfultohavesuchorsimilarstudiesofcomparison,includingthepreoperativeexpenditurefortheminimallyinvasivetechniques.Furtherpropositionsofcomputerassistanceshouldbeanalyzedforexpenditureversusimpact.Progresscanbeexpectedwhenthisdemandingsurgeryisconcentratedinfewcenterswithahighcaseloadandwhenseveralsuchcentersworktogetherandcollecttheirmaterialinacentralregistry.

兒童發(fā)育性髖關(guān)節(jié)發(fā)育不良（DDH）是小兒骨科最常見(jiàn)的髖關(guān)節(jié)畸形，嚴(yán)重影響兒童的健康成長(zhǎng)。18月齡以?xún)?nèi)的DDH患兒由于重塑形的潛能大，通常可以通過(guò)吊帶或閉合復(fù)位、石膏固定的方式有效治療。隨著年齡的增大，18月齡及以上的DDH患兒病理改變進(jìn)一步加重，通常需要更大矯正幅度的截骨手術(shù)。對(duì)于學(xué)齡前（小于5-6歲）的低齡兒童髖關(guān)節(jié)畸形，Salter骨盆截骨術(shù)(SalterInnominateOsteotomy,SIO)，仍是目前使用最為廣泛的手術(shù)方式。作為小兒骨科的關(guān)鍵手術(shù)技術(shù)之一，其對(duì)于兒童的各種復(fù)雜髖關(guān)節(jié)畸形，具有強(qiáng)大的矯正能力，可以實(shí)現(xiàn)髖臼對(duì)股骨頭的良好包容、穩(wěn)定髖關(guān)節(jié)。該類(lèi)截骨手術(shù)被廣泛應(yīng)用于治療DDH等各種原因?qū)е碌膬和l(fā)育性髖關(guān)節(jié)發(fā)育不良，是目前全世界公認(rèn)的低齡兒童髖關(guān)節(jié)畸形最有效的手術(shù)方法之一。傳統(tǒng)Salter骨盆截骨術(shù)RobertSalter于1961年發(fā)明了Salter骨盆截骨術(shù)（salterinnominateosteotomy，SIO）治療發(fā)育性髖關(guān)節(jié)脫位。SIO以恥骨聯(lián)合為鉸鏈，可使髖臼向前、下、外恢復(fù)覆蓋，骨盆截骨處可通過(guò)骨塊和克氏針固定，從而得到一個(gè)穩(wěn)定復(fù)位的髖關(guān)節(jié)。SIO至今已經(jīng)沿用了50余年，治療了大量的發(fā)育性髖關(guān)節(jié)脫位病例，獲得了良好的效果！改良原創(chuàng)（Improveandoriginal）國(guó)內(nèi)著名兒童骨科專(zhuān)家李旭教授帶領(lǐng)汕頭大學(xué)廣州華新骨科醫(yī)院兒童骨科團(tuán)隊(duì)在傳統(tǒng)的Salter骨盆截骨術(shù)（SIO）基礎(chǔ)上做了進(jìn)一步的改良，并推廣應(yīng)用于臨床工作中，我們將此技術(shù)命名為Salter-Li骨盆截骨術(shù)（Salter-LiInnominateOsteotomy，SLIO)。區(qū)別于傳統(tǒng)SIO手術(shù)，優(yōu)勢(shì)明顯華新兒童骨科團(tuán)隊(duì)2015年開(kāi)始，受瑞士TheddySlongo教授的Bernese骨盆截骨術(shù)影響，李旭教授帶領(lǐng)團(tuán)隊(duì)對(duì)小兒骨科的經(jīng)典手術(shù)—Salter骨盆截骨術(shù)進(jìn)行了大幅改良，具體改進(jìn)內(nèi)容包括：（1）無(wú)需劈開(kāi)髂骨骨骺，避免了遠(yuǎn)期髂嵴的發(fā)育性畸形風(fēng)險(xiǎn)；（2）僅從髂骨內(nèi)板行骨膜外剝離，提前處理骶髂關(guān)節(jié)旁滋養(yǎng)血管，大大減少了術(shù)中失血；（3）?術(shù)中無(wú)需剝離髂骨外板的肌肉軟組織附著，避免了遠(yuǎn)期因臀肌損傷導(dǎo)致的步態(tài)異常，及髖臼緣出現(xiàn)缺血性改變的風(fēng)險(xiǎn)；（4）特殊的倒“L”形髂骨截骨設(shè)計(jì)，無(wú)需進(jìn)行髂骨取骨即可獲得較經(jīng)典手術(shù)更優(yōu)的截骨穩(wěn)定性；（5）特殊的髂骨截骨設(shè)計(jì)，可以使遠(yuǎn)端骨塊獲得更大旋轉(zhuǎn)幅度而不影響固定的穩(wěn)定性，從而獲得較經(jīng)典手術(shù)更大的髖臼指數(shù)的矯正和頭臼覆蓋改善；（6）由于手術(shù)操作大大簡(jiǎn)化，切口長(zhǎng)度、手術(shù)時(shí)間、術(shù)中失血量等均明顯優(yōu)于經(jīng)典Salter手術(shù)，手術(shù)更加微創(chuàng)，學(xué)習(xí)曲線(xiàn)亦顯著縮短。SLIO相比于傳統(tǒng)SIO更加微創(chuàng)，該術(shù)式不需要劈開(kāi)髂骨骨骺，不需要植骨，不需要?jiǎng)冸x髂骨外板的肌肉組織，不會(huì)破壞臀肌以及損傷髖臼周?chē)难?。?shí)現(xiàn)在截骨端近端和遠(yuǎn)端之間的兩點(diǎn)接觸，對(duì)髖臼畸形有更強(qiáng)大的矯正能力。更重要的是術(shù)中切口非常微創(chuàng)，不超過(guò)3cm，這也是迄今為止同類(lèi)手術(shù)中文獻(xiàn)所報(bào)道使用的最小切口?。。☆嵏材愕南胂螅褐袊?guó)最微創(chuàng)的兒童髖關(guān)節(jié)開(kāi)放復(fù)位、Salter骨盆截骨術(shù)——李旭教授改良Salter骨盆截骨術(shù)（SLIO）臨床病例Case1:馮2歲，女，右側(cè)發(fā)育性髖關(guān)節(jié)脫位，雙下肢不等長(zhǎng)手術(shù)方式：右側(cè)髖關(guān)節(jié)開(kāi)放復(fù)位、Salter骨盆截骨矯形內(nèi)固定、髖人字石膏固定術(shù)、右側(cè)闊筋膜張肌、內(nèi)收肌、腰肌松解手術(shù)時(shí)間：1.5小時(shí)手術(shù)出血量：小于100mlCase2:陸2歲，女，左側(cè)發(fā)育性髖關(guān)節(jié)脫位，雙下肢不等長(zhǎng)手術(shù)方式：左側(cè)髖關(guān)節(jié)切開(kāi)復(fù)位關(guān)節(jié)腔清理、Salter骨盆截骨矯形內(nèi)固定、左側(cè)內(nèi)收肌經(jīng)皮松解、髂腰肌松解、石膏固定手術(shù)時(shí)間：1.5小時(shí)手術(shù)出血量：80ml中國(guó)最微創(chuàng)的兒童髖關(guān)節(jié)開(kāi)放復(fù)位、Salter骨盆截骨手術(shù)李旭兒童骨科團(tuán)隊(duì)近年來(lái)開(kāi)展改良原創(chuàng)的（微創(chuàng)）骨盆截骨術(shù)——Salter-Li骨盆截骨術(shù)并大力推廣應(yīng)用于臨床，充分體現(xiàn)了團(tuán)隊(duì)不斷探索、創(chuàng)新的發(fā)展理念。上面兩個(gè)病例在手術(shù)中都使用了團(tuán)隊(duì)原創(chuàng)改良的Salter-Li骨盆截骨術(shù)，手術(shù)時(shí)間短，術(shù)中出血量小，手術(shù)切口小于3cm，這也是迄今為止同類(lèi)手術(shù)中文獻(xiàn)所報(bào)道使用的最小切口，術(shù)后患者恢復(fù)快，臨床癥狀改善明顯，滿(mǎn)意率高！“Salter骨盆截骨術(shù)”作為小兒骨科的關(guān)鍵手術(shù)技術(shù)之一，對(duì)于兒童的復(fù)雜髖關(guān)節(jié)畸形，具有強(qiáng)大的矯正能力，但由于手術(shù)難度大、學(xué)習(xí)曲線(xiàn)長(zhǎng)，目前在國(guó)內(nèi)尚只在具有兒童骨科專(zhuān)科的醫(yī)院能夠獨(dú)立開(kāi)展，大多數(shù)骨科醫(yī)師尚未能完全掌握和理解這一手術(shù)技術(shù)。這些年我們賦能提質(zhì)，髖關(guān)節(jié)手術(shù)逐步向微創(chuàng)化、創(chuàng)新化、精準(zhǔn)化高質(zhì)量發(fā)展，團(tuán)隊(duì)對(duì)該手術(shù)技術(shù)已經(jīng)處于國(guó)際領(lǐng)先水平。不再“大刀闊斧”，我院骨科手術(shù)邁入微創(chuàng)化時(shí)代工欲善其事，必先利其器。華新李旭兒童骨科團(tuán)隊(duì)在李旭教授的帶領(lǐng)下，始終秉持“復(fù)雜手術(shù)簡(jiǎn)單化、常規(guī)手術(shù)微創(chuàng)化、疑難手術(shù)個(gè)性化”的創(chuàng)新發(fā)展理念，一路披荊斬棘、技術(shù)革新，科室醫(yī)療技術(shù)得到全新的突破，從“大刀闊斧”到“精雕細(xì)琢”，華新李旭兒童骨科手術(shù)邁入微創(chuàng)化時(shí)代，為中國(guó)患兒提供更有質(zhì)量的醫(yī)療。迎難而上的勇氣，是源于團(tuán)隊(duì)加強(qiáng)技術(shù)積累和敢于業(yè)務(wù)攻關(guān)的實(shí)力和底氣。上述技術(shù)的開(kāi)展，只是我們?cè)谖?chuàng)化道路上的縮影，為了更好的服務(wù)廣大患者，我們將繼續(xù)迎難而上，往高精尖技術(shù)的道路上大步邁進(jìn)！汕頭大學(xué)廣州華新骨科醫(yī)院兒童骨科，前身為原南方醫(yī)科大學(xué)第三附屬醫(yī)院兒童骨科團(tuán)隊(duì)，由李旭博士于2011年7月份創(chuàng)建成立。2018年12月，李旭博士帶領(lǐng)兒童骨科團(tuán)隊(duì)遷移至廣州華新骨科醫(yī)院，學(xué)科建設(shè)邁上新臺(tái)階，與國(guó)際間的學(xué)術(shù)交流合作日益增多。2020年5月，美國(guó)哥倫比亞大學(xué)終身名譽(yù)教授——紐約摩根斯坦利兒童醫(yī)院前小兒骨科主任DavidP.RoyeJr.教授加盟華新兒童骨科團(tuán)隊(duì)，以謀求為中國(guó)患兒提供更有質(zhì)量的醫(yī)療，和培訓(xùn)中國(guó)兒童骨科醫(yī)生加速走向國(guó)際化。廣州華新骨科醫(yī)院李旭兒童骨科團(tuán)隊(duì)，為中國(guó)醫(yī)師協(xié)會(huì)骨科分會(huì)兒童骨科學(xué)組副主任委員單位，和廣東省醫(yī)師協(xié)會(huì)骨科分會(huì)兒童骨科學(xué)組主任委員單位。學(xué)科技術(shù)實(shí)力雄厚、特色鮮明；除常見(jiàn)的兒童創(chuàng)傷和畸形診治外，李旭兒骨團(tuán)隊(duì)對(duì)傳統(tǒng)國(guó)內(nèi)骨科界鮮少涉足的領(lǐng)域，如腦癱等神經(jīng)肌肉型疾病所涉及的四肢、脊柱畸形和運(yùn)動(dòng)功能障礙的治療，可提供世界級(jí)水平的高質(zhì)量服務(wù)；2020年9月，國(guó)內(nèi)一流的3D步態(tài)實(shí)驗(yàn)室也于我院正式落成。醫(yī)學(xué)博士后，主任醫(yī)師，碩士研究生導(dǎo)師；汕頭大學(xué)廣州華新骨科醫(yī)院院長(zhǎng)；中國(guó)著名兒童骨科專(zhuān)家。學(xué)術(shù)任職：亞太小兒骨科學(xué)會(huì)（APPOS）理事會(huì)中國(guó)執(zhí)委；華裔小兒骨科學(xué)會(huì)首任主席；中國(guó)骨科醫(yī)師協(xié)會(huì)第一、二屆小兒骨科專(zhuān)委會(huì)副主任委員；中華醫(yī)學(xué)會(huì)骨科分會(huì)小兒創(chuàng)傷與矯形學(xué)組委員；廣東省骨科醫(yī)師協(xié)會(huì)常務(wù)委員暨小兒骨科學(xué)組主任委員；SICOT中國(guó)部小兒骨科專(zhuān)委會(huì)副主任委員；中國(guó)康復(fù)醫(yī)學(xué)會(huì)修復(fù)重建外科專(zhuān)委會(huì)四肢先天畸形學(xué)組副組長(zhǎng)；Depuy-Synthes南方小兒骨科培訓(xùn)中心主任；AO中國(guó)小兒骨科講師。專(zhuān)業(yè)擅長(zhǎng)：兒童骨關(guān)節(jié)系統(tǒng)各種嚴(yán)重復(fù)雜創(chuàng)傷和后遺癥的手術(shù)治療；兒童先天性髖關(guān)節(jié)脫位(DDH)、腦癱、馬蹄內(nèi)翻足、多并指（趾）等各種兒童先天及后天性復(fù)雜肢體畸形；各種骨病后遺癥、兒童股骨頭壞死(Perthes病)、肌性斜頸、骨與軟組織腫瘤、各種肢體少見(jiàn)病及疑難雜重癥。關(guān)注我?了解更多兒童骨科相關(guān)知識(shí)！

髖關(guān)節(jié)發(fā)育不良（Developmentaldysplasiaofthehips，DDH）是兒童最常見(jiàn)的肌肉骨骼先天缺陷之一，各地報(bào)道的DDH發(fā)病率在1‰~3.4‰。DDH是導(dǎo)致髖關(guān)節(jié)骨關(guān)節(jié)炎的重要原因，延誤診治或治療不當(dāng)，都將嚴(yán)重的影響成年后生活質(zhì)量。既往文獻(xiàn)報(bào)告，近40%接受髖關(guān)節(jié)置換病人和“髖關(guān)節(jié)發(fā)育不良”有關(guān)。近年來(lái)，全髖關(guān)節(jié)置換術(shù)（THA）是當(dāng)今最成功的骨科手術(shù)之一。多種原因?qū)е碌捏y部疼痛時(shí)，THA都可緩解疼痛、恢復(fù)功能并提高生存質(zhì)量。但是，有個(gè)重大的問(wèn)題是技術(shù)本身克服不了的，那就是，“全髖關(guān)節(jié)置換”的“年限”和初次關(guān)節(jié)置換時(shí)年齡密切相關(guān)，與之相反的是，“翻修手術(shù)”難度大風(fēng)險(xiǎn)高，但效果反而不如初次置換。因此，對(duì)于髖關(guān)節(jié)發(fā)育不良這樣長(zhǎng)病程的疾患，“保髖”是“全生命周期治療”中不可或缺的一個(gè)重要環(huán)節(jié)。青少年、兒童期嚴(yán)重型髖關(guān)節(jié)發(fā)育不良/脫位，通過(guò)規(guī)范手術(shù)治療可以獲得滿(mǎn)意的中期效果。對(duì)于行走期（walkingage）及以前發(fā)現(xiàn)的髖關(guān)節(jié)脫位孩子，可以通過(guò)“閉合復(fù)位石膏褲固定”保守治療的方法，不過(guò)，存在一定的“殘余髖關(guān)節(jié)發(fā)育不良”的幾率，部分病例需行二期手術(shù)矯正。和很多與發(fā)育相關(guān)的疾病一樣，髖關(guān)節(jié)脫位同樣需要盡可能早的發(fā)現(xiàn)、診斷，及時(shí)復(fù)位，讓髖臼-股骨頭維持良好對(duì)位，才能讓兒童髖關(guān)節(jié)沿著正?！败壍馈卑l(fā)育，從而“治愈”它。而早期針對(duì)髖關(guān)節(jié)脫位/發(fā)育不良的篩查是解決“早期診斷”的唯一出路?；仡櫩磥?lái)，最早從1879年WilhelmRoser、后來(lái)Ortolani等醫(yī)生更多是通過(guò)體格檢查的方法檢查出兒童期“脫位”的髖關(guān)節(jié)。在我國(guó)，以上海新華醫(yī)院吳守義教授等為代表的小兒骨科前輩也陸續(xù)開(kāi)展了針對(duì)髖關(guān)節(jié)脫位的篩查工作。自上世紀(jì)80年代，以?shī)W地利Graf、美國(guó)Harcke、挪威的Rosendahl、Terjesen醫(yī)生為代表，開(kāi)始利用髖關(guān)節(jié)超聲技術(shù)來(lái)評(píng)估髖關(guān)節(jié)形態(tài)，并逐漸形成了早期髖關(guān)節(jié)超聲檢查技術(shù)及分型系統(tǒng)。從而，將針對(duì)DDH的早期檢出時(shí)間大大提前。并使基于這項(xiàng)技術(shù)的、針對(duì)人群的DDH篩查成為可能。奧地利是最早針對(duì)DDH實(shí)行全民篩查（universalscreeningprogram）的國(guó)家之一，他們的數(shù)據(jù)表明，早期全民篩查可以大大降低后期需手術(shù)的比例。從衛(wèi)生經(jīng)濟(jì)學(xué)角度來(lái)說(shuō)，整體上也大大降低了政府的醫(yī)療支出。我國(guó)已從政策層面高度重視，國(guó)家衛(wèi)健委在《健康兒童行動(dòng)提升計(jì)劃（2021-2025年）》中再次強(qiáng)調(diào)，要“逐步將先天性髖脫位等疾病納入篩查病種”，從而整體提升兒童骨骼發(fā)育健康。然而，西京醫(yī)院嚴(yán)亞波主任的一項(xiàng)針對(duì)兒科、兒保、婦產(chǎn)科、小兒骨科等7個(gè)專(zhuān)業(yè)醫(yī)生，共466份有效問(wèn)卷的調(diào)查發(fā)現(xiàn)，會(huì)對(duì)嬰幼兒常規(guī)進(jìn)行髖關(guān)節(jié)查體的比例為37.9%，而常規(guī)進(jìn)行髖關(guān)節(jié)超聲的比例僅為20%。理想是豐滿(mǎn)的，而現(xiàn)實(shí)是骨感的。目前，以上海、北京為代表的大城市，實(shí)行的是基于危險(xiǎn)因素的“選擇性篩查”或“區(qū)域性全民篩查”，不過(guò)，仍面臨諸如政策、運(yùn)營(yíng)協(xié)調(diào)等多方面的問(wèn)題亟待解決?？祻?fù)醫(yī)學(xué)會(huì)修復(fù)重建外科專(zhuān)委會(huì)保髖學(xué)組張洪教授、羅殿中教授、程徽和楊劼教授等，在西藏地區(qū)克服重重困難、開(kāi)展針對(duì)髖關(guān)節(jié)脫位的系統(tǒng)性早期篩查工作，星星之火已被點(diǎn)燃。在以天津醫(yī)院小兒骨科楊建平主任、天津市婦女兒童保健中心劉功姝主任為代表的兒保、小兒骨科醫(yī)生持續(xù)努力下，在上海第六人民醫(yī)院陳博昌主任等的技術(shù)支持下，新生兒期針對(duì)髖關(guān)節(jié)發(fā)育不良的早期篩查，和先心病、白內(nèi)障等一樣被納入“早期篩查項(xiàng)目”。天津市自2008年開(kāi)始實(shí)行全市范圍內(nèi)“全民篩查”，將針對(duì)髖關(guān)節(jié)發(fā)育不良的超聲篩查納入到“天津市兒童保健手冊(cè)”、“天津市預(yù)防接種手冊(cè)”（小紅本）內(nèi)，基于信息化管理，采用“2+1”的模式，確保了篩查覆蓋率及良好的質(zhì)量控制。天津市婦女兒童保健中心潘蕾主任總結(jié)了天津市2013~2020年的“天津髖篩經(jīng)驗(yàn)”，題為“天津市嬰兒發(fā)育性髖關(guān)節(jié)發(fā)育不良的篩查結(jié)果及危險(xiǎn)因素分析”的文章發(fā)表于2022年《中華骨科雜志》上。新生兒期檢出，及時(shí)規(guī)范治療，是從臨床、影像學(xué)上“治愈”髖關(guān)節(jié)脫位/發(fā)育不良的前提。有意思的是，天津市的人群數(shù)據(jù)顯示，經(jīng)超聲確診髖關(guān)節(jié)發(fā)育不良的孩子中，僅有不足12%存在例如臀位、家族史等“危險(xiǎn)因素”。上海第六人民醫(yī)院陳博昌主任、揚(yáng)州市婦幼保健院王加寬主任積極探索利用AI技術(shù)，提高髖關(guān)節(jié)超聲檢查的效率、精準(zhǔn)度和同質(zhì)化。針對(duì)髖關(guān)節(jié)發(fā)育不良的早期篩查，意義重大，但仍需多方持續(xù)努力、協(xié)作。不讓每一名孩子輸在起跑線(xiàn)上，保髖，真的需要大家一起努力、從娃娃抓起啊。

臀中肌鍛煉(2)：漸進(jìn)式臀中肌抗阻力康復(fù)訓(xùn)練，髖臼發(fā)育不良DDH/股骨頭壞死——保髖截骨術(shù)后康復(fù)指導(dǎo)作者：JayREbert,PeterKEdwards,DanielPFick,GregoryCJanes.作者單位:SchoolofSportScience,ExerciseandHealth,UniversityofWesternAustralia,Crawley,Perth,WesternAustralia.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要背景：鑒于臀中肌在骨盆和下肢穩(wěn)定性中的作用，以及臀中肌無(wú)力與許多下肢疾病之間已知的聯(lián)系，臀中肌康復(fù)至關(guān)重要。目的：系統(tǒng)地回顧文獻(xiàn)并提出一系列循證的漸進(jìn)式臀中肌負(fù)荷練習(xí)。證據(jù)獲?。?016年1月進(jìn)行了系統(tǒng)文獻(xiàn)檢索，以確定報(bào)告康復(fù)鍛煉期間臀中肌活動(dòng)占最大等長(zhǎng)收縮(MVIC)百分比的研究。其中包括調(diào)查無(wú)受傷參與者的研究。對(duì)鍛煉的類(lèi)型或方式?jīng)]有限制，但排除了無(wú)法在獨(dú)立環(huán)境中準(zhǔn)確復(fù)制或進(jìn)行的鍛煉。未將肌電活動(dòng)標(biāo)準(zhǔn)化為側(cè)臥MVIC的研究被排除。根據(jù)運(yùn)動(dòng)類(lèi)型和%MVIC對(duì)運(yùn)動(dòng)進(jìn)行分層：低（0%至20%）、中（21%至40%）、高（41%至60%）和極高（＞61%）。證據(jù)綜合：本次綜述納入了20項(xiàng)研究，報(bào)告了33項(xiàng)練習(xí)（以及同一練習(xí)的一系列變體）的結(jié)果。俯臥、四足和雙側(cè)橋式練習(xí)通常產(chǎn)生低或中等負(fù)荷。據(jù)報(bào)告，特定的髖部外展/旋轉(zhuǎn)練習(xí)為中等、高或極高負(fù)荷。存在對(duì)側(cè)肢體運(yùn)動(dòng)的單側(cè)站立練習(xí)通常是高負(fù)荷或極高負(fù)荷的活動(dòng)，而一系列功能性負(fù)重練習(xí)則存在高變異性。結(jié)論：這篇綜述概述了康復(fù)環(huán)境中常用的一系列練習(xí)，根據(jù)運(yùn)動(dòng)類(lèi)型和臀中肌激活程度進(jìn)行分層。這將有助于臨床醫(yī)生從術(shù)后早期到康復(fù)后期為患者量身定制臀中肌負(fù)荷方案。ASystematicReviewofRehabilitationExercisestoProgressivelyLoadtheGluteusMediusAbstractContext:Gluteusmediusrehabilitationisofcriticalimportancegivenitsroleinpelvicandlowerlimbstability,andtheknownlinkbetweengluteusmediusweaknessandmanylowerlimbconditions.Objective:Tosystematicallyreviewtheliteratureandpresentanevidence-basedgraduatedseriesofexercisestoprogressivelyloadgluteusmedius.Evidenceacquisition:AsystematicliteraturesearchwasconductedinJanuary2016toidentifystudiesreportinggluteusmediusmuscleactivityasapercentageofmaximalvolitionalisometriccontraction(MVIC),duringrehabilitationexercises.Studiesthatinvestigatedinjuryfreeparticipantswereincluded.Norestrictionswereplacedonthetypeormodeofexercise,thoughexercisesthatcouldnotbeaccuratelyreplicatedorperformedwithinanindependentsettingwereexcluded.StudiesthatdidnotnormalizeelectromyographicactivitytoasidelyingMVICwereexcluded.Exerciseswerestratifiedbasedonexercisetypeand%MVIC:low(0%to20%),moderate(21%to40%),high(41%to60%),andveryhigh(＞61%).Evidencesynthesis:20studieswereincludedinthisreview,reportingoutcomesin33exercises(andarangeofvariationsofthesameexercise).Prone,quadruped,andbilateralbridgeexercisesgenerallyproducedlowormoderateload.Specifichipabduction/rotationexerciseswerereportedasmoderate,high,orveryhighload.Unilateralstanceexercisesinthepresenceofcontralaterallimbmovementwereoftenhighorveryhighloadactivities,whilehighvariabilityexistedacrossarangeoffunctionalweight-bearingexercises.Conclusions:Thisreviewoutlinedaseriesofexercisescommonlyemployedinarehabilitationsetting,stratifiedbasedonexercisetypeandthemagnitudeofgluteusmediusmuscularactivation.Thiswillassistcliniciansintailoringgluteusmediusloadingregimenstopatients,fromtheearlypostoperativethroughtolaterstagesofrehabilitation.Jiànjìnshìtúnzhōngjīfùhèkāngfùxùnliàn文獻(xiàn)出處：JayREbert,PeterKEdwards,DanielPFick,GregoryCJanes.ASystematicReviewofRehabilitationExercisestoProgressivelyLoadtheGluteusMedius.ReviewJSportRehabil.2017Sep;26(5):418-436.doi:10.1123/jsr.2016-0088.視頻資料來(lái)源:Youtube，Googleimage.

髖關(guān)節(jié)發(fā)育不良（developmentaldysplasiaofthehip，簡(jiǎn)稱(chēng)DDH）是一種常見(jiàn)的骨骼畸形，指的是髖關(guān)節(jié)的形態(tài)或位置異常，導(dǎo)致股骨頭和髖臼的不穩(wěn)定或不匹配。髖關(guān)節(jié)是人體最大的球窩關(guān)節(jié)，由股骨頭和髖臼組成，正常情況下，股骨頭應(yīng)該完全覆蓋在髖臼內(nèi)，形成一個(gè)同心圓的關(guān)系，保證關(guān)節(jié)的穩(wěn)定性和功能性。髖關(guān)節(jié)發(fā)育不良的機(jī)制尚不完全清楚，可能與遺傳、環(huán)境、激素等多種因素有關(guān)。一般認(rèn)為，髖關(guān)節(jié)發(fā)育不良可以分為兩種類(lèi)型：先天性和后天性。先天性髖關(guān)節(jié)發(fā)育不良是指出生時(shí)就存在的髖關(guān)節(jié)異常，可能與胎兒在子宮內(nèi)的位置、姿勢(shì)、空間、營(yíng)養(yǎng)等有關(guān)，也可能與家族史、母親的年齡、孕期用藥等有關(guān)。后天性髖關(guān)節(jié)發(fā)育不良是指出生后由于某些原因?qū)е碌捏y關(guān)節(jié)異常，可能與嬰兒的包裹方式、抱姿、營(yíng)養(yǎng)、生長(zhǎng)速度等有關(guān)，也可能與某些疾病如神經(jīng)肌肉病、感染、創(chuàng)傷等有關(guān)。髖關(guān)節(jié)發(fā)育不良的癥狀因年齡、類(lèi)型和程度不同而異。在嬰兒期，髖關(guān)節(jié)發(fā)育不良可能沒(méi)有明顯的癥狀，或者表現(xiàn)為臀紋、大腿紋不對(duì)稱(chēng)，下肢不等長(zhǎng)，髖關(guān)節(jié)活動(dòng)受限，髖關(guān)節(jié)彈響等。在兒童期，髖關(guān)節(jié)發(fā)育不良可能表現(xiàn)為跛行、髖關(guān)節(jié)疼痛、髖關(guān)節(jié)畸形、髖關(guān)節(jié)功能障礙等。需要早期發(fā)現(xiàn)、早期治療。在成人期，髖關(guān)節(jié)發(fā)育不良可能導(dǎo)致髖關(guān)節(jié)炎的發(fā)生，表現(xiàn)為髖關(guān)節(jié)疼痛、僵硬、腫脹、活動(dòng)受限等，嚴(yán)重影響生活質(zhì)量。髖關(guān)節(jié)發(fā)育不良的分型有多種方法，常用的有以下幾種：?嬰幼兒時(shí)期，根據(jù)髖關(guān)節(jié)的穩(wěn)定性，分為不穩(wěn)定型、半脫位型和脫位型。不穩(wěn)定型指股骨頭在髖臼內(nèi)可以移動(dòng)，但不會(huì)脫出；半脫位型指股骨頭在髖臼內(nèi)部分脫出，但仍有一部分覆蓋在髖臼內(nèi)；脫位型指股骨頭完全脫出髖臼，與髖臼分離。?成人后，根據(jù)股骨頭的上移程度，分為CroweI型、II型、III型和IV型。上移越多，畸形越嚴(yán)重。CroweI型指股骨頭上移程度小于50%；CroweII型指股骨頭上移程度在50%到74%之間；CroweIII型指股骨頭上移程度在75%到100%之間；CroweIV型指股骨頭上移程度大于100%。髖關(guān)節(jié)發(fā)育不良的保守治療主要適用于早期、輕度或無(wú)癥狀的患者，目的是減輕疼痛，延緩病情進(jìn)展，保護(hù)關(guān)節(jié)功能。保守治療的方法包括：?控制體重，減少關(guān)節(jié)的負(fù)荷，避免過(guò)度的運(yùn)動(dòng)和勞累，選擇適當(dāng)?shù)倪\(yùn)動(dòng)方式，如游泳、騎自行車(chē)等。?加強(qiáng)髖周肌肉的鍛煉，增加關(guān)節(jié)的穩(wěn)定性，改善關(guān)節(jié)的血液循環(huán)，促進(jìn)軟骨的營(yíng)養(yǎng)，預(yù)防肌肉萎縮和關(guān)節(jié)僵硬。?口服或外用非甾體抗炎藥，緩解關(guān)節(jié)的炎癥和疼痛，改善關(guān)節(jié)的活動(dòng)度，注意藥物的副作用和禁忌，避免長(zhǎng)期或過(guò)量使用。?理療、按摩、熱敷等，促進(jìn)關(guān)節(jié)的血液循環(huán)，緩解肌肉的緊張和痙攣，提高關(guān)節(jié)的柔韌性，注意不要過(guò)度或不適當(dāng)?shù)牟僮?，以免加重關(guān)節(jié)的損傷。?使用輔助器具，如拐杖、支具、鞋墊等，調(diào)整雙下肢的長(zhǎng)度，減少跛行，改善步態(tài)，減輕關(guān)節(jié)的負(fù)荷，注意選擇合適的器具，定期檢查和調(diào)整。髖關(guān)節(jié)發(fā)育不良的手術(shù)治療主要適用于中晚期、重度或有癥狀的患者，目的是糾正關(guān)節(jié)的畸形，恢復(fù)關(guān)節(jié)的功能，改善生活質(zhì)量。手術(shù)治療的方法包括：?髖關(guān)節(jié)周?chē)毓鞘中g(shù)，通過(guò)對(duì)髖臼或股骨進(jìn)行截骨，改變髖關(guān)節(jié)的方向或位置，增加髖臼的覆蓋，提高關(guān)節(jié)的穩(wěn)定性，延緩關(guān)節(jié)炎的發(fā)生，適用于輕度或中度的髖關(guān)節(jié)發(fā)育不良。?髖關(guān)節(jié)置換手術(shù)，通過(guò)移除病變的股骨頭和髖臼，植入人工的假體，重建髖關(guān)節(jié)的結(jié)構(gòu)和功能，適用于重度或晚期的髖關(guān)節(jié)發(fā)育不良，股骨頭和髖臼已經(jīng)嚴(yán)重變形或壞死，關(guān)節(jié)間隙消失，年齡大于45歲的患者。髖關(guān)節(jié)置換手術(shù)的效果較好，可以明顯緩解疼痛，改善步態(tài)，提高生活質(zhì)量，但也有一定的風(fēng)險(xiǎn)和并發(fā)癥，如感染、假體松動(dòng)、脫位、下肢不等長(zhǎng)等，需要定期復(fù)查和更換。髖關(guān)節(jié)發(fā)育不良的預(yù)后取決于多種因素，如發(fā)病年齡、類(lèi)型、程度、治療方法、治療效果等。一般來(lái)說(shuō)，越早發(fā)現(xiàn)越早治療，預(yù)后越好。如果能在嬰兒期就進(jìn)行有效的保守治療，可以使髖關(guān)節(jié)發(fā)育正常，避免后期的并發(fā)癥。如果在兒童期或成人期才發(fā)現(xiàn)，需要進(jìn)行手術(shù)治療，預(yù)后就要視手術(shù)的時(shí)機(jī)、方法和效果而定。如果手術(shù)能夠成功地糾正髖關(guān)節(jié)的畸形，恢復(fù)髖關(guān)節(jié)的功能，可以延緩或防止髖關(guān)節(jié)炎的發(fā)生，提高生活質(zhì)量。如果手術(shù)不能完全糾正髖關(guān)節(jié)的畸形，或者已經(jīng)發(fā)生了髖關(guān)節(jié)炎，可能需要進(jìn)行髖關(guān)節(jié)置換手術(shù)，或者終身服用止痛藥，生活質(zhì)量會(huì)受到影響。