一、正常髖關節(jié)（I型）的特點及治療特點：Ⅰ型髖關節(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：對于Ⅰ型髖關節(jié)，通常不需要特殊治療，只需定期進行復查，觀察髖關節(jié)的發(fā)育情況。因為這是正常的髖關節(jié)發(fā)育狀態(tài)，在日常的生長發(fā)育過程中，正常的活動和生活不會對其產(chǎn)生不良影響。但家長也需要關注孩子的一些日常行為，例如孩子的活動是否自如等，若發(fā)現(xiàn)異常情況應及時就醫(yī)進一步檢查。二、髖關節(jié)發(fā)育稍差（Ⅱ型）的特點與治療特點：Ⅱ型髖關節(jié)發(fā)育稍差，分為Ⅱa、Ⅱb、Ⅱc、Ⅱd四個亞型。Ⅱa型指出生12周以內(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：對于Ⅱ型髖關節(jié)，尤其是Ⅱa和Ⅱb型，因為處于髖關節(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查的策略。如果沒有進一步的惡化或者有好轉的趨勢，可以繼續(xù)觀察。而對于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。通過支具將髖關節(jié)保持在合適的位置，促進髖臼的正常發(fā)育。在使用支具期間，需要定期進行超聲檢查來評估治療效果，并且要注意支具的佩戴是否合適，避免對孩子的皮膚等造成損傷。三、髖關節(jié)發(fā)育不良（Ⅲ型）的特點與治療特點：Ⅲ型髖關節(jié)發(fā)育不良，分為Ⅲa和Ⅲb型。Ⅲ型髖關節(jié)髖臼角43°-55°，α角40°-55°，β角55°-77°。兩類髖中股骨頭均向上外方脫位，Ⅲa軟骨頂為無回聲結構，是透明軟骨成分，Ⅲb的軟骨頂可見有程度不同回聲，說明透明軟骨可能發(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完整顯現(xiàn)，參考測量點難以辨認5。治療：對于Ⅲ型髖關節(jié)發(fā)育不良，早期（6-7個月以下）可采用保守治療，如使用Pavlik吊帶、支具等。從經(jīng)驗和文獻的報道來說，這種保守治療對于這個年齡段的孩子成功率可以達到90%以上。在使用支具或吊帶期間，需要密切關注孩子髖關節(jié)的復位情況，定期進行超聲檢查。如果保守治療不成功，可以改用麻醉下石膏復位。經(jīng)過復位的關節(jié)對髖臼的刺激，局部發(fā)育就會逐步的改善。同時，在治療過程中，還需要關注孩子下肢的血液循環(huán)、神經(jīng)功能等情況，避免因治療導致其他并發(fā)癥的出現(xiàn)。四、髖關節(jié)脫位（Ⅳ型）的特點與治療特點：Ⅳ型髖關節(jié)脫位，髖臼角55°，α角40°，β角77°。此型髖的聲學特點是股骨頭脫位，表面只有薄層關節(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角甚至測量不出，屬于髖關節(jié)高位脫位的情況212。治療：對于Ⅳ型髖關節(jié)脫位，因為脫位情況較為嚴重，一般需要積極治療。對于6-7個月以下的嬰兒，如果保守治療（如Pavlik吊帶等）效果不佳，可考慮麻醉下石膏復位。而對于年齡較大的孩子（7-18個月），可能需要進行麻醉下閉合復位或者切開復位，然后用石膏固定。在復位過程中，要確保股骨頭準確復位到髖臼內(nèi)，并且要關注復位后髖關節(jié)的穩(wěn)定性。在術后，需要長期的康復隨訪，觀察髖關節(jié)的發(fā)育情況以及孩子的下肢功能恢復情況，預防股骨頭壞死、髖關節(jié)僵硬等并發(fā)癥的發(fā)生。五、髖關節(jié)半脫位（Ⅴ型）的特點與治療特點：Ⅴ型髖關節(jié)半脫位，髖臼角55°，α角40°，β角77°-90°。髖關節(jié)處于半脫位狀態(tài)，股骨頭部分脫離髖臼，關節(jié)的穩(wěn)定性受到影響，髖臼對股骨頭的覆蓋不完全，這會影響髖關節(jié)的正常發(fā)育和功能1。治療：對于Ⅴ型髖關節(jié)半脫位的治療與Ⅲ型髖關節(jié)發(fā)育不良類似。在早期可嘗試保守治療，如使用Pavlik吊帶或支具，并且定期復查超聲，觀察髖關節(jié)復位情況。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位（6-7個月以下）或者其他更復雜的復位手術（年齡較大時）。在整個治療過程中，同樣要關注髖關節(jié)的功能恢復和發(fā)育情況，避免出現(xiàn)并發(fā)癥。

臨界髖關節(jié)發(fā)育不良BorderlineDDH(2)：疼痛性臨界髖關節(jié)發(fā)育不良的治療作者：MichaelCWyatt,MartinBeck.作者單位:KlinikfürOrthop?dieundUnfallchirurgieLuzernerKantonsspital6004Luzern,Switzerland.譯者：陶可（北京大學人民醫(yī)院骨關節(jié)科）摘要在過去的幾十年里，影像技術的改進和手術技術的進步使得保髖手術得到了快速發(fā)展。然而，疼痛性臨界髖關節(jié)發(fā)育不良的治療仍然存在爭議。在這篇評論中，我們將確定相關問題并描述患者評估和治療方案。我們將提供自己的建議，并確定未來的研究領域。簡介在過去的幾十年里，髖關節(jié)生物力學知識的提高和手術技術的進步使得保髖手術得到了快速發(fā)展。保髖手術適應范圍廣泛，從髖臼淺且不穩(wěn)定的髖關節(jié)到髖臼深且患有股骨髖臼撞擊(FAI)的髖關節(jié)。雖然人們普遍認為，不穩(wěn)定髖關節(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，但人們同樣認為，必須減小過度覆蓋的髖臼臨界以消除撞擊。所有這些髖關節(jié)都可能存在凸輪畸形，需要在手術矯正時加以解決[1]。在最極端的情況下，所需的治療是顯而易見的。然而，有一個過渡區(qū)，很難區(qū)分不穩(wěn)定性和股骨髖臼撞擊(FAI)。過去，這些髖關節(jié)被稱為“臨界”髖關節(jié)。通常，這包括外側中心臨界(LCE)角度在20°到25°之間的髖關節(jié)[2]。然而，“臨界”一詞是有問題的，因為它是一個放射學定義，只涉及描述髖關節(jié)穩(wěn)定性的幾個重要參數(shù)之一。髖臼頂傾斜角、前后覆蓋和股骨前傾是應納入髖關節(jié)穩(wěn)定性分析的其他因素。髖關節(jié)發(fā)育不良與髖關節(jié)骨關節(jié)炎之間的關聯(lián)已經(jīng)確定[3,4]，有不穩(wěn)定跡象的髖關節(jié)發(fā)育不良退化速度更快[5]。臨界髖關節(jié)可能不穩(wěn)定、撞擊或兩者兼而有之。臨界髖關節(jié)發(fā)育不良的穩(wěn)定性很難確定，并且容易受個人主觀影響，骨科界普遍傾向于低估不穩(wěn)定性，從而導致不適當?shù)闹委?。最近的研究表明，對患有臨界發(fā)育不良(LCEA?>?20°)的患者進行關節(jié)鏡髖關節(jié)手術（包括盂唇修復和關節(jié)囊折疊縫合術）可能會在短期內(nèi)帶來適當?shù)母纳芠3,4]。然而，有證據(jù)表明，之前錯誤的髖關節(jié)鏡檢查會對此類髖關節(jié)的治療結果產(chǎn)生負面影響[6]。因此，疼痛性臨界髖關節(jié)發(fā)育不良的治療仍然是一個極具爭議的問題。臨界性髖關節(jié)發(fā)育不良在患有髖關節(jié)疼痛的年輕人中很常見，在選定的患者群中報告的患病率為37.6%[7]。在臨界髖關節(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，根本問題是難以正確分類潛在的病理生物力學。定義第一個問題在于定義。在前后位骨盆X線片[9](LCEA)上測量的Wiberg外側中心邊緣角傳統(tǒng)上用于將髖關節(jié)分類為正常(LCEA?>25°)、發(fā)育不良(LCEA?<20°)或臨界(LCEA20–25°)，盡管這些定義值在文獻中差異很大[3,10]。然而，使用外側中心邊緣角(LCEA)存在兩個問題。首先是測量方法。為了測量外側中心邊緣角(LCEA)，首先通過與股骨頭輪廓相符的圓來定義股骨頭的中心。角度的第一個分支垂直穿過旋轉中心。第二個分支由股骨頭的中心和股骨最外側點定義（圖1a）。重要的是不要使用髖臼的最外側點（圖1b），因為這不符合Wiberg的定義，并且會給出錯誤的高值(外側中心邊緣角(LCEA)偏大)[11]。Fig.1.(a)CorrectmeasurementoftheLCEAusingtheedgeofthesourcil,indicatingmoderatedysplasia.(b)IncorrectmeasurementoftheLCEAinthesamehip.Usingthisvaluewouldfalselyclassifythishipasborderline.圖1(a)使用髖臼臨界正確測量外側中心邊緣角(LCEA)，表明中度髖關節(jié)發(fā)育不良。(b)同一髖關節(jié)的外側中心邊緣角(LCEA)測量不正確。使用此值會錯誤地將此髖關節(jié)歸類為臨界。其次，實際術語“臨界髖關節(jié)發(fā)育不良”是由Wiberg本人首次提出的，包括外側中心邊緣角(LCEA)在20°和25°之間的髖關節(jié)[2]。外側中心邊緣角(LCEA)是一種放射學測量，本身無法預測臨界髖關節(jié)發(fā)育不良的穩(wěn)定性，也無法完全描述股骨頭覆蓋范圍。因此，外側中心邊緣角(LCEA)無法指導手術決策[12–14]。部分原因是外側中心邊緣角(LCEA)本身無法涵蓋發(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)也與髖關節(jié)穩(wěn)定性密切相關。如果外側中心邊緣角(LCEA)減少，AI可能正常，在這種情況下很難評估髖關節(jié)的穩(wěn)定性[15]。另一方面，股骨前傾過度可能會加劇髖關節(jié)前部不穩(wěn)定[16]。根本問題是什么？對于疼痛的臨界髖關節(jié)發(fā)育不良，很難僅通過二維射線測量將病理機制表征為撞擊（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量。髖關節(jié)穩(wěn)定性的功能表征對于指導手術決策至關重要。不穩(wěn)定髖關節(jié)從邏輯上可以從髖臼重新定向截骨術中受益，而穩(wěn)定髖關節(jié)可以從撞擊手術（如股骨凸輪骨成形術）中受益。那么關于髖關節(jié)內(nèi)病理學的了解有多少？應該如何評估這些患者？有哪些治療方案？手術結果如何？這組患者的潛在隱患是什么？未來的發(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題，并闡明這組具有挑戰(zhàn)性的患者的處理方法。髖關節(jié)發(fā)育不良和臨界髖關節(jié)不穩(wěn)定的潛在病理是什么？髖關節(jié)發(fā)育不良患者的關節(jié)接觸壓力異常增高，股骨頭（軟骨損傷，導致軟骨下）骨質相對暴露。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導致病理性髖關節(jié)生物力學，表現(xiàn)為盂唇撕裂、軟骨損傷和髖關節(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節(jié)囊）的重要性就凸顯出來[18]。一旦軟組織約束失效，髖關節(jié)就會變得不穩(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，這會導致髖關節(jié)失效，而不是軟組織穩(wěn)定性失效。半脫位髖關節(jié)發(fā)育不良的自然病史預后非常差，并且必然會導致關節(jié)退化[5]。惡化速度與半脫位嚴重程度和患者年齡直接相關，通常在癥狀出現(xiàn)后約10年，就會出現(xiàn)嚴重的退行性變化[19]。在沒有半脫位的情況下，自然病史很難預測退化速度。臨界髖關節(jié)發(fā)育不良也是如此。最近的一項研究強調(diào)了髖臼覆蓋的重要性。在一項為期20年的大型女性隊列研究中，研究顯示，如果外側中心邊緣角(LCE)低于28°，則每降低一度，放射學OA風險就會增加13%[20]。因此，除了短期緩解癥狀外，還必須考慮長期可能的發(fā)展。臨床表現(xiàn)臨界髖關節(jié)發(fā)育不良的臨床表現(xiàn)與其他年輕活躍成人髖關節(jié)疾?。ㄈ鏔AI綜合征[21]）非常相似，因此，徹底的病史、體格檢查和放射學評估對于正確診斷這些患者至關重要。病史重點記錄病史。臨界髖關節(jié)發(fā)育不良患者的主要癥狀是疼痛。這通常發(fā)生在腹股溝和髖關節(jié)外側，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。此外，還會詢問患者是否有任何跡象表明患者已經(jīng)患上髖關節(jié)炎，例如夜間疼痛。癥狀應結合患者的功能限制和已經(jīng)接受的醫(yī)療護理，包括物理治療、藥物、其他意見和手術。檢查隨后應進行髖關節(jié)的合理臨床檢查，包括恐懼試驗和撞擊測試?；颊咄ǔ憩F(xiàn)出“膝內(nèi)翻”步態(tài)，同時伴有髖關節(jié)內(nèi)收肌力矩增加和髖關節(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，可能存在前凸過度。應確定大轉子處有無壓痛[22]。務必記住檢查患者的旋轉輪廓、進行神經(jīng)血管檢查以及檢查全身關節(jié)松弛的跡象，并使用Beighton評分對此進行量化。具體關鍵目標包括排除(i)晚期退化過程的存在，例如表現(xiàn)為固定屈曲畸形和運動范圍減少，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)查診斷成像應從骨盆的標準化AP平片和股骨頸側位片（穿桌側位、Dunn位、假斜位）[23]開始。仔細檢查這些圖像以測量LCEA、AI、擠壓指數(shù)、股骨頸干角和FEAR指數(shù)（見下文）。應確定骨關節(jié)炎的Tonnis等級以及是否存在凸輪形態(tài)。應仔細檢查不穩(wěn)定的直接跡象，這些跡象包括股骨頭移位，可通過與髂坐線的距離增加、Shenton線斷裂和AP視圖上股骨頭重新定位來識別，髖關節(jié)處于外展狀態(tài)，使用MR關節(jié)造影時后關節(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)定性有很高的相關性（見下文）。必須精確測量和記錄各種參數(shù)。有必要使用三維計算機斷層掃描(CT)進行橫斷面成像，以獲得有關骨解剖結構和發(fā)育不良位置的精確信息，包括髖關節(jié)周圍囊腫的存在和位置[24-26]。此外，CT還應包括股骨前傾的評估，如果前傾過大，可能會加劇髖關節(jié)前部不穩(wěn)定。磁共振成像(MR-關節(jié)造影)應遵循專門的髖關節(jié)檢查方案，包括徑向圖像采集或重建和關節(jié)內(nèi)造影劑應用[27]，以檢查關節(jié)內(nèi)結構和盂唇和關節(jié)軟骨的病理?？梢詤^(qū)分引起類似癥狀的其他原因，例如缺血性壞死、轉子滑囊炎或臀肌病變。其他測量包括盂唇大小[13,28]和髂關節(jié)囊體積[29]。對于這些患者，我們還提倡進行非牽引性MR關節(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)定的細微征兆[30]。這些測量值的價值是什么？在平片上，那些直接表明不穩(wěn)定的測量值是股骨頭移位，與髂坐線的距離增加，Shenton線斷裂，髖關節(jié)外展時AP視圖上股骨頭重新定位，以及FEAR指數(shù)。在MR關節(jié)造影中，后下關節(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，但不能預測不穩(wěn)定性[30]（表1）。表1.用于評估髖關節(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)，似乎對預測髖關節(jié)穩(wěn)定性具有很高的價值[27]。它是由髖臼頂與股骨生長板中央1/3處之間的角度形成的（圖2）。其依據(jù)是：在生長過程中，股骨的骨骺生長板會垂直于髖關節(jié)的關節(jié)反作用力。股骨頸的生長和方向受股骨頸下生長板的控制[31]。Pauwels和Maquet[32]提出理論，合力作用于骨骺軟骨的中心，在生長過程中，根據(jù)Heuter-Volkman原理，骨骺板會垂直于關節(jié)反作用力。Pauwels和Maquet的理論后來得到了Carter等人[33]的證實，他們通過二維有限元分析研究了髖關節(jié)負荷的影響。閉合的骨骺板的角度表示跨股骨近端骨骺[34]的力的平衡，也表示跨關節(jié)力在過去的作用方式。因此，它是一個功能參數(shù)，反映了髖關節(jié)在生長過程中長期的關節(jié)反作用力。如果FEAR<0°，則認為髖關節(jié)穩(wěn)定。統(tǒng)計分析表明，5°的臨界值預測穩(wěn)定性的概率為80°。最近的研究表明，2°的臨界值預測穩(wěn)定性的概率為90%（Batailler等人，正在準備發(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)。測量連接股骨最內(nèi)側和外側點的線與連接股骨頭骨骺直線部分（通常為中央三分之一）內(nèi)側和外側端的線之間的角度。如圖3a所示，角度向內(nèi)側打開的陰性FEAR指數(shù)，表示髖關節(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°。因此髖關節(jié)穩(wěn)定，患者接受髖關節(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？治療取決于髖關節(jié)的穩(wěn)定性。疼痛性臨界髖關節(jié)發(fā)育不良的治療方案包括非手術治療、解決關節(jié)內(nèi)撞擊的手術治療（通過髖關節(jié)鏡或髖關節(jié)外科脫位進行的FAI手術）和解決不穩(wěn)定性的手術治療（采用PAO和/或股骨截骨術的重新定位截骨術）（見圖2）。非手術治療包括患者教育、活動調(diào)整、簡單的止痛藥、非甾體抗炎藥和髖關節(jié)腔內(nèi)注射藥物[35]。有針對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節(jié)鏡和/或截骨術的臨界髖關節(jié)發(fā)育不良的手術治療方案。這組患者接受髖關節(jié)鏡檢查的結果如何？隨著髖關節(jié)鏡技術的最新發(fā)展，許多外科醫(yī)生正在使用它來治療臨界髖關節(jié)發(fā)育不良，尤其是因為人們認為髖臼周圍截骨術等替代技術的風險更高，術后恢復時間更長。臨界髖關節(jié)發(fā)育不良的髖關節(jié)鏡檢查還可以讓外科醫(yī)生處理髖關節(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來解決骨穩(wěn)定性不足的問題，那么關節(jié)鏡檢查不僅可以讓外科醫(yī)生了解髖關節(jié)的關節(jié)內(nèi)狀態(tài)，還可以了解患者在隨后進行更大規(guī)模手術時的表現(xiàn)[37]。然而，關于臨界髖關節(jié)發(fā)育不良的髖關節(jié)鏡檢查的已發(fā)表文獻很少，而且短期隨訪也存在局限性。在Jo等的系統(tǒng)綜述中，確定了13項關于髖關節(jié)發(fā)育不良的關節(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項研究報告了主觀和/或客觀結果。關節(jié)鏡檢查的手術指征不明確，患者事先接受過多種非手術治療。此外，臨界髖關節(jié)發(fā)育不良的確切定義各不相同，只有兩項研究使用了Byrd和Jones的定義[36]。三項研究報告了髖關節(jié)鏡作為輔助工具，三項研究報告了髖關節(jié)鏡作為獨立治療。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（59-75.2%比11-32%），并且位于盂唇病變的鄰近。僅有兩項研究檢查了臨界髖關節(jié)發(fā)育不良病例（LCEA20-25°）的關節(jié)鏡檢查結果，其中只有一項描述了患者報告的結果測量。后者是Byrd和Jones[36]的前瞻性臨床病例系列，其中66%的髖關節(jié)（32髖）患有臨界髖關節(jié)發(fā)育不良。關節(jié)鏡檢查后，平均改良Harris髖關節(jié)評分從50（差）改善到77（一般）。作者得出結論，髖關節(jié)鏡治療可能解決髖關節(jié)內(nèi)病理而不是發(fā)育不良的放射學證據(jù)的結果。對臨界髖關節(jié)發(fā)育不良進行髖關節(jié)鏡檢查有什么危險？臨界髖關節(jié)發(fā)育不良患者進行關節(jié)鏡盂唇切除術和髖臼外側緣切除術可導致爆發(fā)性髖關節(jié)不穩(wěn)定[38]。即使修復了盂唇，也必須保留髂股韌帶和髖關節(jié)的其他靜態(tài)穩(wěn)定器，以防止不可逆的后果或導致髖關節(jié)不穩(wěn)定[39–41]。沒有確鑿的文獻支持在這些情況下進行關節(jié)囊修復，但這似乎是一種安全合理的做法[42]。關節(jié)囊復位技術可提高臨界髖關節(jié)發(fā)育不良的穩(wěn)定性[12]。如果髖關節(jié)在術前足夠不穩(wěn)定，那么僅通過髖關節(jié)鏡治療關節(jié)內(nèi)病變是不夠的，患者將需要進行PAO截骨術[43,44]。必須記住，髖關節(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)定性可能由次級軟組織結構來確保。一旦這些結構因微創(chuàng)傷或大創(chuàng)傷而失效，髖關節(jié)就會變得不穩(wěn)定?；謴蛙浗M織穩(wěn)定性可能只會在短時間內(nèi)改善髖關節(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題，才能取得良好的長期效果。最近的一份報告顯示，髖關節(jié)發(fā)育不良患者在髖關節(jié)鏡檢查失敗后，PAO的髖關節(jié)特定功能結果較差[6]。因此，對這組患者單獨進行髖關節(jié)鏡檢查應謹慎處理。但是，對于那些由于髖關節(jié)狀況不佳（即AI和股骨前傾正常）或高齡（即>40歲）而不適合進行PAO的患者，它可能有用。重新定向髖臼周圍截骨術對這組患者有何影響？通過髖臼周圍截骨術進行髖臼重新定向已成為髖關節(jié)發(fā)育不良最常見的治療方法，據(jù)報道術后20多年效果良好。傳統(tǒng)上，PAO時關節(jié)內(nèi)病變的處理方法是進行前關節(jié)切開術。然而，隨著PAO微創(chuàng)技術的發(fā)展，情況已不再如此。微創(chuàng)PAO技術縮短了術后恢復時間[45]。最近的一項研究表明，一些可改變的因素，例如較高的體力活動量和較高的BMI（大于30kg/m2）可導致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是手術年齡的獨立預測因素，即LCEA較低的患者往往需要在較早的年齡接受PAO手術。但是，輕度和中度發(fā)育不良患者的PAO預后沒有差異。在本研究中，輕度發(fā)育不良被歸類為15-25°，這涵蓋了我們對臨界髖關節(jié)發(fā)育不良的定義。最近的一項多中心前瞻性隊列研究檢查了患者報告的PAO結果指標，結果表明，雖然總體結果良好，但臨界髖關節(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，這可能導致過度矯正和醫(yī)源性FAI、股骨前傾增加和軟組織松弛。建議和未來方向在臨界髖關節(jié)中，關鍵步驟是確定穩(wěn)定性。關于髖關節(jié)的穩(wěn)定性，只有兩種情況：髖關節(jié)穩(wěn)定或不穩(wěn)定。沒有中間狀態(tài)。如果接受這個概念，治療就會變得相對簡單。不穩(wěn)定可能與其他病癥（如FAI或超負荷/過度使用和軟骨疾病）相結合，需要同時治療。如果髖關節(jié)不穩(wěn)定，則需要髖臼重新定位。僅解決磨損的二級穩(wěn)定器并不能解決潛在的生物力學問題，最多只能產(chǎn)生令人滿意的短期結果。在穩(wěn)定的髖關節(jié)中，可以進行開放或關節(jié)鏡關節(jié)保留手術。然而，我們必須記住，低于28°的LCE角度每減少一度，骨關節(jié)炎的發(fā)病率就會增加13%[20]。因此，如果有疑問，為了最大限度地提高獲得良好長期結果的機會，我們主張進行髖臼重新定向PAO截骨手術。重要的是要確定我們?nèi)狈χR的領域，以指導進一步的研究。將對這些患者進行長期隨訪研究，比較髖臼重新定向和髖關節(jié)鏡檢查，理想情況下，將記錄所有成像參數(shù)和Beighton評分。此外，還應獲得患者報告的結果測量和恢復時間，以及包括運動在內(nèi)的活動恢復時間。?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.文獻出處：MichaelCWyatt,MartinBeck.Themanagementofthepainfulborderlinedysplastichip.ReviewJHipPreservSurg.2018Apr5;5(2):105-112.doi:10.1093/jhps/hny012.

臨界髖關節(jié)發(fā)育不良BorderlineDDH：什么時候、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（北京大學人民醫(yī)院骨關節(jié)科）摘要臨界髖關節(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，可能導致兒童易患機械功能障礙和不穩(wěn)定。臨界發(fā)育不良通常包括外側中心邊緣角(CEA)為18-24°的兒童。一些具有臨界X線測量值的兒童具有正常的關節(jié)力學和功能，而其他兒童則需要進行髖臼截骨手術。雖然臨界髖關節(jié)發(fā)育不良的X線檢查結果可能表明不穩(wěn)定，但最終診斷基于病史和體格檢查以及影像學相結合?；加信R界髖關節(jié)發(fā)育不良的兒童有時還需要進行其他橫斷面成像研究，如MRI成像，以評估不穩(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)，以進行術前評估和規(guī)劃。兒童放射科醫(yī)生通常是第一個在X線片上發(fā)現(xiàn)邊緣性或輕度發(fā)育不良的人。兒童放射科醫(yī)生必須充當有效的顧問，并作為針對這一復雜患者群體的連貫多學科診療團隊的一部分提供適當?shù)慕ㄗh。圖1?一名16歲女孩的髖關節(jié)X線片顯示了外側中心邊緣角(CEA)、髖臼指數(shù)和前CEA的測量方法。a標記了三個點以便進行后續(xù)測量：點1位于股骨頭(旋轉)中心，點2位于股骨髖關節(jié)(負重關節(jié)面的)內(nèi)側邊緣，點3位于股骨髖關節(jié)(負重關節(jié)面的)外側邊緣。b右髖關節(jié)的前后位X線片展示了測量外側CEA的方法。外側CEA是連接點1和點3的線與垂直線之間形成的夾角（正常為25-40°）。c髖臼指數(shù)由連接點2和點3的線與水平線之間形成的夾角決定（正常為0-10°）。d右髖關節(jié)的假斜位片顯示了確定前CEA的測量方法。前側CEA由點1到點4（在髖臼前緣）的連線與垂直線之間的角度決定（正常值為25–40°）圖2?一名19歲女性嚴重雙側髖關節(jié)發(fā)育不良。a骨盆前后位X線片顯示右側髖關節(jié)外側中心邊緣角(CEA)為5°，b髖臼指數(shù)為16°。左髖關節(jié)同樣發(fā)育不良。c右髖關節(jié)假斜位X線片顯示前方中心邊緣角為8°。圖3?一名右側髖關節(jié)疼痛的16歲女孩的外側中心邊緣角(CEA)。a前后位(AP)骨盆X線片顯示外側CEA為19°。左側髖關節(jié)正常。b同一女孩的假斜位X線片顯示前方CEA為19°。c延遲釓增強軟骨MRI(dGEMRIC)檢查的冠狀T1圖顯示軟骨正常。女孩沒有不穩(wěn)定的跡象，接受了腰肌勞損治療，癥狀在沒有手術的情況下得到改善。由于腰肌勞損仍然可能與潛在的微不穩(wěn)定有關，女孩在髖關節(jié)外科醫(yī)生的護理下接受長期觀察。圖4?一名有髖關節(jié)發(fā)育不良家族史的11歲女性足球運動員的左側髖關節(jié)疼痛。a前后位(AP)X線片顯示為正常。b女孩現(xiàn)在13歲，仍然有左側髖關節(jié)疼痛。雙側髖關節(jié)被認為是淺的，左側測量的外側中心邊緣角(CEA)為16°，右側為23°。左側髖臼指數(shù)也被認為是升高的13°。陽性恐懼測試反映了體格檢查中左側髖關節(jié)的不穩(wěn)定，右側沒有發(fā)現(xiàn)不穩(wěn)定。C假斜位X線片顯示前方覆蓋充分，前方CEA為27°。d左側髖臼周圍截骨術后前后位AP骨盆X線片狀態(tài)顯示側方覆蓋改善。女孩報告癥狀有所改善。e一年后的前后位AP骨盆X線片，癥狀緩解并恢復正?；顒?。她右側有輕微間歇性疼痛，并定期監(jiān)測癥狀。圖5?股骨骨骺髖臼頂(FEAR)指數(shù)。a與圖1中相同的16歲女孩的髖關節(jié)前后位(AP)X線片。FEAR指數(shù)是沿髖臼頂連接點2和點3的線（黑線）與沿股骨骨骺線中央三分之一繪制的線（白線）之間形成的角度。陽性FEAR指數(shù)定義為向外側傾斜的角度，頂點指向內(nèi)側。這個女孩的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性。b一名13歲女孩的髖關節(jié)前后位X線片顯示左側髖臼外側輕微上翻（箭頭）。c一名13歲男孩的右側髖關節(jié)疼痛的左側髖關節(jié)正常前后位X線片顯示外側正常。黑線表示髖臼頂部，白線表示骨骺線的中央三分之一。此正常髖關節(jié)的FEAR指數(shù)顯示FEAR指數(shù)，角度頂點指向外側。圖6?一名18歲女子田徑運動員的右側髖關節(jié)疼痛影像。a前后位(AP)骨盆X線片顯示右側髖關節(jié)發(fā)育不良，左髖關節(jié)正常。b右側髖臼周圍截骨術后前后位(AP)骨盆狀態(tài)顯示外側覆蓋增加，但該女性報告癥狀惡化。c術前（回顧性）進行的右髖關節(jié)矢狀質子密度脂肪抑制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：髖關節(jié)發(fā)育不良可不可以保守治療，是否必須手術？答：首先，保守治療無非控制活動量、控制體重、吃止疼藥、加強肌肉鍛煉，一定程度可以緩解疼痛癥狀，但是根本的骨頭畸形并沒有改變，也就是說，保守治療只能一定程度延緩病情進展，無法解決根本問題。手術的目的是為了緩解疼痛、延長自身關節(jié)的使用壽命，從根本上解決問題。如果本身關節(jié)不疼，或者疼痛非常非常輕，可以暫且保守治療。但是，如果關節(jié)疼痛比較頻繁或者比較重，手術可能是解決當前問題的最佳方式。?問：保髖術后我的關節(jié)能用多少年？答：這個問題很難回答。影響關節(jié)使用壽命的因素太多了，比如手術時關節(jié)軟骨磨損重不重、自身的軟骨耐磨程度如何、自身的關節(jié)畸形重不重、手術醫(yī)生的水平好不好、術后體重控制得好不好、術后關節(jié)保養(yǎng)的好不好。理論上講，通過手術糾正畸形可以讓關節(jié)的使用壽命盡可能延長，最好的效果就是用一輩子，當然，少術患者也有術后幾年、十幾年后出現(xiàn)關節(jié)磨損嚴重，進而換關節(jié)的?？傮w上講，找一個靠譜的醫(yī)生，術后自己好好保養(yǎng)，剩下的就交給天意了。?問：手術后我應該怎么保養(yǎng)自身的關節(jié)？答：手術的目的還是希望大家回歸正常的生活。有的極端的患者，為了減少關節(jié)負重會走極端，比如坐輪椅，甚至少穿衣服，其實大可不必，該干嘛干嘛。如果可以的話，適當避免長時間重體力勞動或者劇烈運動。當然，如果你覺得運動是生命中不可缺少的一部分，那也不用刻意壓抑，這一點國外是比較積極的，很多患者手術就是為了后續(xù)運動時不疼。當然，如果能把體重控制在理想的區(qū)間肯定是最好的。?問：我想手術了，術前應該做哪些準備？答：1、異地就醫(yī)，提前進行醫(yī)保備案，具體需要詢問當?shù)蒯t(yī)保部門；2、準備一副拐杖，肘拐腋拐都可以，調(diào)整拐杖高度，練習拄拐單腿走路；3、術前可以按醫(yī)生的建議進行功能鍛煉，改善肌力，加速術后康復；4、帶著之前拍的片子及病歷；5、酌情準備個人生活物品。?問：髖臼周圍截骨手術風險高不高？答：這個手術確實難度很大，被譽為骨科的珠穆朗瑪，手術的入門門檻很高，學習曲線很長，目前全國只有為數(shù)不多的醫(yī)生可以做這類手術。記得我在美國學習的時候，看過兩個醫(yī)生做這個手術，一個醫(yī)生平均需要三四個小時，另一個醫(yī)生需要6-8個小時。對于我們來說，絕大多術的手術可以在1小時出頭的時間完成，手術不但做得快，質量也是絕對有保證。?問：手術需要輸血嗎？答：這個手術的出血確實偏多，但是隨著手術技術的提高和相關藥物的應用，再加上手術中使用血液回收設備（可以將出血量的大概一般進行重新回收利用），目前在我中心手術的患者，90%以上的患者不需要異體輸血。而且，我們中心現(xiàn)在術前不需要常規(guī)備自體血。?問：術后恢復期大概多久？答：手術中我們需要將骨頭截斷，調(diào)整好位置后進行固定，截斷的骨頭長好需要大概3個月的時間。所以，術后3個月內(nèi)需要小心保護自己的髖關節(jié)，不要摔，一定要拄雙拐，拄雙拐，拄雙拐！一般我會讓患者術后6-8周內(nèi)術腿不負重，6-8周后從0開始逐漸逐漸增加踩地的重量，注意，是勻速逐漸的增加，到3個月的時候可以負重身體重量1/3-1/2，具體以醫(yī)生通知為準。過早扔拐，過早過多負重可能導致骨頭移位，影響手術效果。3個月后門診復查，評估骨頭生長情況。?問：術后如何進行康復鍛煉？答：康復鍛煉很重要，鍛煉不好，走路十有八九會瘸。我的患者我一般會給每人一個康復計劃，由于每個人的手術不一樣，畸形不一樣，骨頭質量不一樣，所以方案不會完全一樣，大家按照自己的方案去做鍛煉即可。大家認真閱讀鍛煉資料，保證動作做對，一旦動作做錯，就可能練錯肌肉。3個月復查時人要過來，很重要，我會根據(jù)查體結果和骨頭愈合情況調(diào)整康復方案。復查方式參考：保髖術后門診復查注意事項

發(fā)育性髖關節(jié)發(fā)育不良(DDH)伯爾尼髖臼周圍截骨術(PAO):從其在當?shù)氐拈_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..?轉載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/37917385/?轉載文章的原鏈接2：https://jorthoptraumatol.springeropen.com/articles/10.1186/s10195-023-00734-2?AbstractThedevelopmentoftheBerneseperiacetabularosteotomy(PAO)isbasedonastructuredapproachstartingwithananalysisofthepreexistingprocedurestoimprovethecoverageofthefemoralheadandwasfollowedbyalistofadditionalgoalsandimprovements.Cadavericdissectionswithadetaileddescriptionofthevascularsupplyofacetabulumandperiacetabularbonesetthestageforanintrapelvicapproach,whichofferedthelargestacetabularcorrectionpossiblecombinedwithsafeintracapsularaccess.Thefinalcompositionofosteotomiesrequiredthedevelopmentofseveralinstrumentsandcuttingdevicesbeforethefeasibilitycouldbetestedonaseriesofcadaverichips.伯爾尼髖臼周圍截骨術（PAO）的發(fā)展基于一種結構化的方法，首先對現(xiàn)有的手術方法進行分析，以改善股骨頭的覆蓋范圍，然后列出了其他目標和改進措施。通過對髖臼和周圍骨的血管供應進行詳細描述的Cadaveric解剖，為內(nèi)盆入路奠定了基礎，這種入路可提供最大的髖臼矯正范圍，同時確保安全的關節(jié)囊內(nèi)入路。在對一系列cadaveric髖關節(jié)進行可行性測試之前，需要開發(fā)幾種器械和切割裝置來完成所需的截骨。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單、更微創(chuàng)的方法。其中一些方法已納入了常規(guī)實踐。人們還通過視頻剪輯、動手課程、研討會、出版物和持續(xù)的導師項目等方式，努力優(yōu)化學習曲線，減少失敗?；仡欉^去，在近40年的經(jīng)驗基礎上，這些努力促進了伯爾尼髖臼周圍截骨術在全球范圍內(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)育性髖關節(jié)發(fā)育不良（DDH）是小兒骨科最常見的髖關節(jié)畸形，嚴重影響兒童的健康成長。18月齡以內(nèi)的DDH患兒由于重塑形的潛能大，通?？梢酝ㄟ^吊帶或閉合復位、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患兒病理改變進一步加重，通常需要更大矯正幅度的截骨手術。對于學齡前（小于5-6歲）的低齡兒童髖關節(jié)畸形，Salter骨盆截骨術(SalterInnominateOsteotomy,SIO)，仍是目前使用最為廣泛的手術方式。作為小兒骨科的關鍵手術技術之一，其對于兒童的各種復雜髖關節(jié)畸形，具有強大的矯正能力，可以實現(xiàn)髖臼對股骨頭的良好包容、穩(wěn)定髖關節(jié)。該類截骨手術被廣泛應用于治療DDH等各種原因導致的兒童發(fā)育性髖關節(jié)發(fā)育不良，是目前全世界公認的低齡兒童髖關節(jié)畸形最有效的手術方法之一。傳統(tǒng)Salter骨盆截骨術RobertSalter于1961年發(fā)明了Salter骨盆截骨術（salterinnominateosteotomy，SIO）治療發(fā)育性髖關節(jié)脫位。SIO以恥骨聯(lián)合為鉸鏈，可使髖臼向前、下、外恢復覆蓋，骨盆截骨處可通過骨塊和克氏針固定，從而得到一個穩(wěn)定復位的髖關節(jié)。SIO至今已經(jīng)沿用了50余年，治療了大量的發(fā)育性髖關節(jié)脫位病例，獲得了良好的效果！改良原創(chuàng)（Improveandoriginal）國內(nèi)著名兒童骨科專家李旭教授帶領汕頭大學廣州華新骨科醫(yī)院兒童骨科團隊在傳統(tǒng)的Salter骨盆截骨術（SIO）基礎上做了進一步的改良，并推廣應用于臨床工作中，我們將此技術命名為Salter-Li骨盆截骨術（Salter-LiInnominateOsteotomy，SLIO)。區(qū)別于傳統(tǒng)SIO手術，優(yōu)勢明顯華新兒童骨科團隊2015年開始，受瑞士TheddySlongo教授的Bernese骨盆截骨術影響，李旭教授帶領團隊對小兒骨科的經(jīng)典手術—Salter骨盆截骨術進行了大幅改良，具體改進內(nèi)容包括：（1）無需劈開髂骨骨骺，避免了遠期髂嵴的發(fā)育性畸形風險；（2）僅從髂骨內(nèi)板行骨膜外剝離，提前處理骶髂關節(jié)旁滋養(yǎng)血管，大大減少了術中失血；（3）?術中無需剝離髂骨外板的肌肉軟組織附著，避免了遠期因臀肌損傷導致的步態(tài)異常，及髖臼緣出現(xiàn)缺血性改變的風險；（4）特殊的倒“L”形髂骨截骨設計，無需進行髂骨取骨即可獲得較經(jīng)典手術更優(yōu)的截骨穩(wěn)定性；（5）特殊的髂骨截骨設計，可以使遠端骨塊獲得更大旋轉幅度而不影響固定的穩(wěn)定性，從而獲得較經(jīng)典手術更大的髖臼指數(shù)的矯正和頭臼覆蓋改善；（6）由于手術操作大大簡化，切口長度、手術時間、術中失血量等均明顯優(yōu)于經(jīng)典Salter手術，手術更加微創(chuàng)，學習曲線亦顯著縮短。SLIO相比于傳統(tǒng)SIO更加微創(chuàng)，該術式不需要劈開髂骨骨骺，不需要植骨，不需要剝離髂骨外板的肌肉組織，不會破壞臀肌以及損傷髖臼周圍的血供。實現(xiàn)在截骨端近端和遠端之間的兩點接觸，對髖臼畸形有更強大的矯正能力。更重要的是術中切口非常微創(chuàng)，不超過3cm，這也是迄今為止同類手術中文獻所報道使用的最小切口?。?！顛覆你的想象：中國最微創(chuàng)的兒童髖關節(jié)開放復位、Salter骨盆截骨術——李旭教授改良Salter骨盆截骨術（SLIO）臨床病例Case1:馮2歲，女，右側發(fā)育性髖關節(jié)脫位，雙下肢不等長手術方式：右側髖關節(jié)開放復位、Salter骨盆截骨矯形內(nèi)固定、髖人字石膏固定術、右側闊筋膜張肌、內(nèi)收肌、腰肌松解手術時間：1.5小時手術出血量：小于100mlCase2:陸2歲，女，左側發(fā)育性髖關節(jié)脫位，雙下肢不等長手術方式：左側髖關節(jié)切開復位關節(jié)腔清理、Salter骨盆截骨矯形內(nèi)固定、左側內(nèi)收肌經(jīng)皮松解、髂腰肌松解、石膏固定手術時間：1.5小時手術出血量：80ml中國最微創(chuàng)的兒童髖關節(jié)開放復位、Salter骨盆截骨手術李旭兒童骨科團隊近年來開展改良原創(chuàng)的（微創(chuàng)）骨盆截骨術——Salter-Li骨盆截骨術并大力推廣應用于臨床，充分體現(xiàn)了團隊不斷探索、創(chuàng)新的發(fā)展理念。上面兩個病例在手術中都使用了團隊原創(chuàng)改良的Salter-Li骨盆截骨術，手術時間短，術中出血量小，手術切口小于3cm，這也是迄今為止同類手術中文獻所報道使用的最小切口，術后患者恢復快，臨床癥狀改善明顯，滿意率高！“Salter骨盆截骨術”作為小兒骨科的關鍵手術技術之一，對于兒童的復雜髖關節(jié)畸形，具有強大的矯正能力，但由于手術難度大、學習曲線長，目前在國內(nèi)尚只在具有兒童骨科?？频尼t(yī)院能夠獨立開展，大多數(shù)骨科醫(yī)師尚未能完全掌握和理解這一手術技術。這些年我們賦能提質，髖關節(jié)手術逐步向微創(chuàng)化、創(chuàng)新化、精準化高質量發(fā)展，團隊對該手術技術已經(jīng)處于國際領先水平。不再“大刀闊斧”，我院骨科手術邁入微創(chuàng)化時代工欲善其事，必先利其器。華新李旭兒童骨科團隊在李旭教授的帶領下，始終秉持“復雜手術簡單化、常規(guī)手術微創(chuàng)化、疑難手術個性化”的創(chuàng)新發(fā)展理念，一路披荊斬棘、技術革新，科室醫(yī)療技術得到全新的突破，從“大刀闊斧”到“精雕細琢”，華新李旭兒童骨科手術邁入微創(chuàng)化時代，為中國患兒提供更有質量的醫(yī)療。迎難而上的勇氣，是源于團隊加強技術積累和敢于業(yè)務攻關的實力和底氣。上述技術的開展，只是我們在微創(chuàng)化道路上的縮影，為了更好的服務廣大患者，我們將繼續(xù)迎難而上，往高精尖技術的道路上大步邁進！汕頭大學廣州華新骨科醫(yī)院兒童骨科，前身為原南方醫(yī)科大學第三附屬醫(yī)院兒童骨科團隊，由李旭博士于2011年7月份創(chuàng)建成立。2018年12月，李旭博士帶領兒童骨科團隊遷移至廣州華新骨科醫(yī)院，學科建設邁上新臺階，與國際間的學術交流合作日益增多。2020年5月，美國哥倫比亞大學終身名譽教授——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隊，以謀求為中國患兒提供更有質量的醫(yī)療，和培訓中國兒童骨科醫(yī)生加速走向國際化。廣州華新骨科醫(yī)院李旭兒童骨科團隊，為中國醫(yī)師協(xié)會骨科分會兒童骨科學組副主任委員單位，和廣東省醫(yī)師協(xié)會骨科分會兒童骨科學組主任委員單位。學科技術實力雄厚、特色鮮明；除常見的兒童創(chuàng)傷和畸形診治外，李旭兒骨團隊對傳統(tǒng)國內(nèi)骨科界鮮少涉足的領域，如腦癱等神經(jīng)肌肉型疾病所涉及的四肢、脊柱畸形和運動功能障礙的治療，可提供世界級水平的高質量服務；2020年9月，國內(nèi)一流的3D步態(tài)實驗室也于我院正式落成。醫(yī)學博士后，主任醫(yī)師，碩士研究生導師；汕頭大學廣州華新骨科醫(yī)院院長；中國著名兒童骨科專家。學術任職：亞太小兒骨科學會（APPOS）理事會中國執(zhí)委；華裔小兒骨科學會首任主席；中國骨科醫(yī)師協(xié)會第一、二屆小兒骨科專委會副主任委員；中華醫(yī)學會骨科分會小兒創(chuàng)傷與矯形學組委員；廣東省骨科醫(yī)師協(xié)會常務委員暨小兒骨科學組主任委員；SICOT中國部小兒骨科專委會副主任委員；中國康復醫(yī)學會修復重建外科專委會四肢先天畸形學組副組長；Depuy-Synthes南方小兒骨科培訓中心主任；AO中國小兒骨科講師。專業(yè)擅長：兒童骨關節(jié)系統(tǒng)各種嚴重復雜創(chuàng)傷和后遺癥的手術治療；兒童先天性髖關節(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、各種肢體少見病及疑難雜重癥。關注我?了解更多兒童骨科相關知識！

髖關節(jié)發(fā)育不良（Developmentaldysplasiaofthehips，DDH）是兒童最常見的肌肉骨骼先天缺陷之一，各地報道的DDH發(fā)病率在1‰~3.4‰。DDH是導致髖關節(jié)骨關節(jié)炎的重要原因，延誤診治或治療不當，都將嚴重的影響成年后生活質量。既往文獻報告，近40%接受髖關節(jié)置換病人和“髖關節(jié)發(fā)育不良”有關。近年來，全髖關節(jié)置換術（THA）是當今最成功的骨科手術之一。多種原因導致的髖部疼痛時，THA都可緩解疼痛、恢復功能并提高生存質量。但是，有個重大的問題是技術本身克服不了的，那就是，“全髖關節(jié)置換”的“年限”和初次關節(jié)置換時年齡密切相關，與之相反的是，“翻修手術”難度大風險高，但效果反而不如初次置換。因此，對于髖關節(jié)發(fā)育不良這樣長病程的疾患，“保髖”是“全生命周期治療”中不可或缺的一個重要環(huán)節(jié)。青少年、兒童期嚴重型髖關節(jié)發(fā)育不良/脫位，通過規(guī)范手術治療可以獲得滿意的中期效果。對于行走期（walkingage）及以前發(fā)現(xiàn)的髖關節(jié)脫位孩子，可以通過“閉合復位石膏褲固定”保守治療的方法，不過，存在一定的“殘余髖關節(jié)發(fā)育不良”的幾率，部分病例需行二期手術矯正。和很多與發(fā)育相關的疾病一樣，髖關節(jié)脫位同樣需要盡可能早的發(fā)現(xiàn)、診斷，及時復位，讓髖臼-股骨頭維持良好對位，才能讓兒童髖關節(jié)沿著正?！败壍馈卑l(fā)育，從而“治愈”它。而早期針對髖關節(jié)脫位/發(fā)育不良的篩查是解決“早期診斷”的唯一出路?；仡櫩磥恚钤鐝?879年WilhelmRoser、后來Ortolani等醫(yī)生更多是通過體格檢查的方法檢查出兒童期“脫位”的髖關節(jié)。在我國，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)開展了針對髖關節(jié)脫位的篩查工作。自上世紀80年代，以奧地利Graf、美國Harcke、挪威的Rosendahl、Terjesen醫(yī)生為代表，開始利用髖關節(jié)超聲技術來評估髖關節(jié)形態(tài)，并逐漸形成了早期髖關節(jié)超聲檢查技術及分型系統(tǒng)。從而，將針對DDH的早期檢出時間大大提前。并使基于這項技術的、針對人群的DDH篩查成為可能。奧地利是最早針對DDH實行全民篩查（universalscreeningprogram）的國家之一，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的比例。從衛(wèi)生經(jīng)濟學角度來說，整體上也大大降低了政府的醫(yī)療支出。我國已從政策層面高度重視，國家衛(wèi)健委在《健康兒童行動提升計劃（2021-2025年）》中再次強調(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)院嚴亞波主任的一項針對兒科、兒保、婦產(chǎn)科、小兒骨科等7個專業(yè)醫(yī)生，共466份有效問卷的調(diào)查發(fā)現(xiàn)，會對嬰幼兒常規(guī)進行髖關節(jié)查體的比例為37.9%，而常規(guī)進行髖關節(jié)超聲的比例僅為20%。理想是豐滿的，而現(xiàn)實是骨感的。目前，以上海、北京為代表的大城市，實行的是基于危險因素的“選擇性篩查”或“區(qū)域性全民篩查”，不過，仍面臨諸如政策、運營協(xié)調(diào)等多方面的問題亟待解決。康復醫(yī)學會修復重建外科專委會保髖學組張洪教授、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、開展針對髖關節(jié)脫位的系統(tǒng)性早期篩查工作，星星之火已被點燃。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支持下，新生兒期針對髖關節(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“早期篩查項目”。天津市自2008年開始實行全市范圍內(nèi)“全民篩查”，將針對髖關節(jié)發(fā)育不良的超聲篩查納入到“天津市兒童保健手冊”、“天津市預防接種手冊”（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量控制。天津市婦女兒童保健中心潘蕾主任總結了天津市2013~2020年的“天津髖篩經(jīng)驗”，題為“天津市嬰兒發(fā)育性髖關節(jié)發(fā)育不良的篩查結果及危險因素分析”的文章發(fā)表于2022年《中華骨科雜志》上。新生兒期檢出，及時規(guī)范治療，是從臨床、影像學上“治愈”髖關節(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“危險因素”。上海第六人民醫(yī)院陳博昌主任、揚州市婦幼保健院王加寬主任積極探索利用AI技術，提高髖關節(jié)超聲檢查的效率、精準度和同質化。針對髖關節(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)：漸進式臀中肌抗阻力康復訓練，髖臼發(fā)育不良DDH/股骨頭壞死——保髖截骨術后康復指導作者：JayREbert,PeterKEdwards,DanielPFick,GregoryCJanes.作者單位:SchoolofSportScience,ExerciseandHealth,UniversityofWesternAustralia,Crawley,Perth,WesternAustralia.譯者：陶可（北京大學人民醫(yī)院骨關節(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，以及臀中肌無力與許多下肢疾病之間已知的聯(lián)系，臀中肌康復至關重要。目的：系統(tǒng)地回顧文獻并提出一系列循證的漸進式臀中肌負荷練習。證據(jù)獲?。?016年1月進行了系統(tǒng)文獻檢索，以確定報告康復鍛煉期間臀中肌活動占最大等長收縮(MVIC)百分比的研究。其中包括調(diào)查無受傷參與者的研究。對鍛煉的類型或方式?jīng)]有限制，但排除了無法在獨立環(huán)境中準確復制或進行的鍛煉。未將肌電活動標準化為側臥MVIC的研究被排除。根據(jù)運動類型和%MVIC對運動進行分層：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項研究，報告了33項練習（以及同一練習的一系列變體）的結果。俯臥、四足和雙側橋式練習通常產(chǎn)生低或中等負荷。據(jù)報告，特定的髖部外展/旋轉練習為中等、高或極高負荷。存在對側肢體運動的單側站立練習通常是高負荷或極高負荷的活動，而一系列功能性負重練習則存在高變異性。結論：這篇綜述概述了康復環(huán)境中常用的一系列練習，根據(jù)運動類型和臀中肌激活程度進行分層。這將有助于臨床醫(yī)生從術后早期到康復后期為患者量身定制臀中肌負荷方案。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文獻出處：JayREbert,PeterKEdwards,DanielPFick,GregoryCJanes.ASystematicReviewofRehabilitationExercisestoProgressivelyLoadtheGluteusMedius.ReviewJSportRehabil.2017Sep;26(5):418-436.doi:10.1123/jsr.2016-0088.視頻資料來源:Youtube，Googleimage.