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張中禮主任醫(yī)師 天津醫(yī)院 小兒骨科 這個髖關(guān)節(jié)發(fā)育不良的話，他自己內(nèi)在的發(fā)育不好，它容易一個向外移的一個趨勢，包容不住我們，那我們呢，通過一個特別的裝置，把那骨骨頭呢，重新對準(zhǔn)那個髖臼叫窩的中心的地方，這樣的話對好位才給他一個發(fā)育最好的一個創(chuàng)造最好的一個環(huán)境，否則如果不管他的話，他自己這種傾斜的情況，他自己很能好，甚至變得更不好，所以今天一會需要帶個小的吊帶，戴完之后再詳細(xì)給你講一下戴，戴完之后你注意事項好不好，我們現(xiàn)在髖骨節(jié)顧骨頭和髖節(jié)，髖節(jié)的一個管的地方最好胃，它最有利于適應(yīng)髖關(guān)節(jié)的發(fā)育，核心的是這個兩個叫前側(cè)帶，后兩個后側(cè)帶，整體的維持髖關(guān)節(jié)這樣一個最好的位置上，牽側(cè)拉的越緊，這個腿全力越高，我們要求呢，看還是在不掙扎的狀態(tài)下，這個屈髖超過90°，所以甚至是零度，越拉到到90°，再高過90°一點，但是盡量不要太大，超過90°就可以了。后側(cè)帶呢，要要松松松松的后側(cè)帶，這個輔助后側(cè)帶不要額外的給。 的太多的力量，但是孩子啊，腿蜷起來以后，他腿有重量，自然將往往撇開來，所以我們說這是兩句話，你要充分的屈髖，自然的外展，腳的地方就是輔助的，不讓它脫落就可以了，別的地方看就是這個，注意皮膚啊，不要劃著了就可以了，做好護(hù)理03月27日
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陶可主治醫(yī)師 北京大學(xué)人民醫(yī)院 骨關(guān)節(jié)科 臨界髖關(guān)節(jié)發(fā)育不良BorderlineDDH(2)：疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療作者：MichaelCWyatt,MartinBeck.作者單位:KlinikfürOrthop?dieundUnfallchirurgieLuzernerKantonsspital6004Luzern,Switzerland.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要在過去的幾十年里，影像技術(shù)的改進(jìn)和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。然而，疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然存在爭議。在這篇評論中，我們將確定相關(guān)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(lǐng)域。簡介在過去的幾十年里，髖關(guān)節(jié)生物力學(xué)知識的提高和手術(shù)技術(shù)的進(jìn)步使得保髖手術(shù)得到了快速發(fā)展。保髖手術(shù)適應(yīng)范圍廣泛，從髖臼淺且不穩(wěn)定的髖關(guān)節(jié)到髖臼深且患有股骨髖臼撞擊(FAI)的髖關(guān)節(jié)。雖然人們普遍認(rèn)為，不穩(wěn)定髖關(guān)節(jié)發(fā)育不良的最佳治療方法是重新定位髖臼以增加覆蓋范圍，但人們同樣認(rèn)為，必須減小過度覆蓋的髖臼臨界以消除撞擊。所有這些髖關(guān)節(jié)都可能存在凸輪畸形，需要在手術(shù)矯正時加以解決[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(guān)節(jié)被稱為“臨界”髖關(guān)節(jié)。通常，這包括外側(cè)中心臨界(LCE)角度在20°到25°之間的髖關(guān)節(jié)[2]。然而，“臨界”一詞是有問題的，因為它是一個放射學(xué)定義，只涉及描述髖關(guān)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(yīng)納入髖關(guān)節(jié)穩(wěn)定性分析的其他因素。髖關(guān)節(jié)發(fā)育不良與髖關(guān)節(jié)骨關(guān)節(jié)炎之間的關(guān)聯(lián)已經(jīng)確定[3,4]，有不穩(wěn)定跡象的髖關(guān)節(jié)發(fā)育不良退化速度更快[5]。臨界髖關(guān)節(jié)可能不穩(wěn)定、撞擊或兩者兼而有之。臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性很難確定，并且容易受個人主觀影響，骨科界普遍傾向于低估不穩(wěn)定性，從而導(dǎo)致不適當(dāng)?shù)闹委?。最近的研究表明，對患有臨界發(fā)育不良(LCEA?>?20°)的患者進(jìn)行關(guān)節(jié)鏡髖關(guān)節(jié)手術(shù)（包括盂唇修復(fù)和關(guān)節(jié)囊折疊縫合術(shù)）可能會在短期內(nèi)帶來適當(dāng)?shù)母纳芠3,4]。然而，有證據(jù)表明，之前錯誤的髖關(guān)節(jié)鏡檢查會對此類髖關(guān)節(jié)的治療結(jié)果產(chǎn)生負(fù)面影響[6]。因此，疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療仍然是一個極具爭議的問題。臨界性髖關(guān)節(jié)發(fā)育不良在患有髖關(guān)節(jié)疼痛的年輕人中很常見，在選定的患者群中報告的患病率為37.6%[7]。在臨界髖關(guān)節(jié)發(fā)育不良中，可能與其他不穩(wěn)定原因（如韌帶松弛癥）有顯著重疊[8]。然而，根本問題是難以正確分類潛在的病理生物力學(xué)。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(cè)中心邊緣角傳統(tǒng)上用于將髖關(guān)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(xiàn)中差異很大[3,10]。然而，使用外側(cè)中心邊緣角(LCEA)存在兩個問題。首先是測量方法。為了測量外側(cè)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(zhuǎn)中心。第二個分支由股骨頭的中心和股骨最外側(cè)點定義（圖1a）。重要的是不要使用髖臼的最外側(cè)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(cè)中心邊緣角(LCEA)偏大)[11]。Fig.1.(a)CorrectmeasurementoftheLCEAusingtheedgeofthesourcil,indicatingmoderatedysplasia.(b)IncorrectmeasurementoftheLCEAinthesamehip.Usingthisvaluewouldfalselyclassifythishipasborderline.圖1(a)使用髖臼臨界正確測量外側(cè)中心邊緣角(LCEA)，表明中度髖關(guān)節(jié)發(fā)育不良。(b)同一髖關(guān)節(jié)的外側(cè)中心邊緣角(LCEA)測量不正確。使用此值會錯誤地將此髖關(guān)節(jié)歸類為臨界。其次，實際術(shù)語“臨界髖關(guān)節(jié)發(fā)育不良”是由Wiberg本人首次提出的，包括外側(cè)中心邊緣角(LCEA)在20°和25°之間的髖關(guān)節(jié)[2]。外側(cè)中心邊緣角(LCEA)是一種放射學(xué)測量，本身無法預(yù)測臨界髖關(guān)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(cè)中心邊緣角(LCEA)無法指導(dǎo)手術(shù)決策[12–14]。部分原因是外側(cè)中心邊緣角(LCEA)本身無法涵蓋發(fā)育不良的精確位置，并且忽略了前后股骨頭覆蓋范圍。此外，髖臼指數(shù)(AI)和股骨前傾等其他參數(shù)也與髖關(guān)節(jié)穩(wěn)定性密切相關(guān)。如果外側(cè)中心邊緣角(LCEA)減少，AI可能正常，在這種情況下很難評估髖關(guān)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(guān)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(guān)節(jié)發(fā)育不良，很難僅通過二維射線測量將病理機(jī)制表征為撞擊（穩(wěn)定）或發(fā)育不良（不穩(wěn)定），尤其是僅由髖臼功能決定而不考慮股骨的測量。髖關(guān)節(jié)穩(wěn)定性的功能表征對于指導(dǎo)手術(shù)決策至關(guān)重要。不穩(wěn)定髖關(guān)節(jié)從邏輯上可以從髖臼重新定向截骨術(shù)中受益，而穩(wěn)定髖關(guān)節(jié)可以從撞擊手術(shù)（如股骨凸輪骨成形術(shù)）中受益。那么關(guān)于髖關(guān)節(jié)內(nèi)病理學(xué)的了解有多少？應(yīng)該如何評估這些患者？有哪些治療方案？手術(shù)結(jié)果如何？這組患者的潛在隱患是什么？未來的發(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(guān)節(jié)發(fā)育不良和臨界髖關(guān)節(jié)不穩(wěn)定的潛在病理是什么？髖關(guān)節(jié)發(fā)育不良患者的關(guān)節(jié)接觸壓力異常增高，股骨頭（軟骨損傷，導(dǎo)致軟骨下）骨質(zhì)相對暴露。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(dǎo)致病理性髖關(guān)節(jié)生物力學(xué)，表現(xiàn)為盂唇撕裂、軟骨損傷和髖關(guān)節(jié)不穩(wěn)定，這些很容易被誤解為撞擊。由于骨穩(wěn)定性受損，軟組織穩(wěn)定器（即纖維軟骨盂唇和髖關(guān)節(jié)囊）的重要性就凸顯出來[18]。一旦軟組織約束失效，髖關(guān)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(dǎo)致髖關(guān)節(jié)失效，而不是軟組織穩(wěn)定性失效。半脫位髖關(guān)節(jié)發(fā)育不良的自然病史預(yù)后非常差，并且必然會導(dǎo)致關(guān)節(jié)退化[5]。惡化速度與半脫位嚴(yán)重程度和患者年齡直接相關(guān)，通常在癥狀出現(xiàn)后約10年，就會出現(xiàn)嚴(yán)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(yù)測退化速度。臨界髖關(guān)節(jié)發(fā)育不良也是如此。最近的一項研究強(qiáng)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(cè)中心邊緣角(LCE)低于28°，則每降低一度，放射學(xué)OA風(fēng)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(guān)節(jié)發(fā)育不良的臨床表現(xiàn)與其他年輕活躍成人髖關(guān)節(jié)疾病（如FAI綜合征[21]）非常相似，因此，徹底的病史、體格檢查和放射學(xué)評估對于正確診斷這些患者至關(guān)重要。病史重點記錄病史。臨界髖關(guān)節(jié)發(fā)育不良患者的主要癥狀是疼痛。這通常發(fā)生在腹股溝和髖關(guān)節(jié)外側(cè)，但也可能發(fā)生在臀部(臀后區(qū))。有必要記錄完整的疼痛病史。尋找特定的不穩(wěn)定和“避免疼痛”癥狀，這可能表明已經(jīng)達(dá)到因缺乏骨性穩(wěn)定性而需要的軟組織代償?shù)臉O限。咔嗒聲和卡住的癥狀也很常見。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(guān)節(jié)炎，例如夜間疼痛。癥狀應(yīng)結(jié)合患者的功能限制和已經(jīng)接受的醫(yī)療護(hù)理，包括物理治療、藥物、其他意見和手術(shù)。檢查隨后應(yīng)進(jìn)行髖關(guān)節(jié)的合理臨床檢查，包括恐懼試驗和撞擊測試。患者通常會表現(xiàn)出“膝內(nèi)翻”步態(tài)，同時伴有髖關(guān)節(jié)內(nèi)收肌力矩增加和髖關(guān)節(jié)內(nèi)旋增加，這與股骨前傾增加一致。為了功能性地增加前覆蓋，可能存在前凸過度。應(yīng)確定大轉(zhuǎn)子處有無壓痛[22]。務(wù)必記住檢查患者的旋轉(zhuǎn)輪廓、進(jìn)行神經(jīng)血管檢查以及檢查全身關(guān)節(jié)松弛的跡象，并使用Beighton評分對此進(jìn)行量化。具體關(guān)鍵目標(biāo)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(yīng)從骨盆的標(biāo)準(zhǔn)化AP平片和股骨頸側(cè)位片（穿桌側(cè)位、Dunn位、假斜位）[23]開始。仔細(xì)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(yīng)確定骨關(guān)節(jié)炎的Tonnis等級以及是否存在凸輪形態(tài)。應(yīng)仔細(xì)檢查不穩(wěn)定的直接跡象，這些跡象包括股骨頭移位，可通過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(guān)節(jié)處于外展?fàn)顟B(tài)，使用MR關(guān)節(jié)造影時后關(guān)節(jié)間隙中有釓，這表明股骨頭向前移位，因此不穩(wěn)定。FEAR指數(shù)與不穩(wěn)定性有很高的相關(guān)性（見下文）。必須精確測量和記錄各種參數(shù)。有必要使用三維計算機(jī)斷層掃描(CT)進(jìn)行橫斷面成像，以獲得有關(guān)骨解剖結(jié)構(gòu)和發(fā)育不良位置的精確信息，包括髖關(guān)節(jié)周圍囊腫的存在和位置[24-26]。此外，CT還應(yīng)包括股骨前傾的評估，如果前傾過大，可能會加劇髖關(guān)節(jié)前部不穩(wěn)定。磁共振成像(MR-關(guān)節(jié)造影)應(yīng)遵循專門的髖關(guān)節(jié)檢查方案，包括徑向圖像采集或重建和關(guān)節(jié)內(nèi)造影劑應(yīng)用[27]，以檢查關(guān)節(jié)內(nèi)結(jié)構(gòu)和盂唇和關(guān)節(jié)軟骨的病理?？梢詤^(qū)分引起類似癥狀的其他原因，例如缺血性壞死、轉(zhuǎn)子滑囊炎或臀肌病變。其他測量包括盂唇大小[13,28]和髂關(guān)節(jié)囊體積[29]。對于這些患者，我們還提倡進(jìn)行非牽引性MR關(guān)節(jié)造影檢查，以檢查是否存在釓積聚，即所謂的“新月征”，這是軸向視圖上不穩(wěn)定的細(xì)微征兆[30]。這些測量值的價值是什么？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(guān)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(guān)節(jié)造影中，后下關(guān)節(jié)間隙中釓的存在表明股骨頭移位，因此不穩(wěn)定。AI、NSA、AT、高髂囊體積和盂唇體積可能存在增加，但不能預(yù)測不穩(wěn)定性[30]（表1）。表1.用于評估髖關(guān)節(jié)不穩(wěn)定性的各種參數(shù)概述TheFemoro-EpiphysealAcetabularRoof(FEAR)index:股骨骨骺髖臼頂指數(shù)Thefemoralneck-shaftangle(NSA):頸干角FEAR指數(shù)是最近描述的參數(shù)，似乎對預(yù)測髖關(guān)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(guān)節(jié)的關(guān)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(guān)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(guān)節(jié)負(fù)荷的影響。閉合的骨骺板的角度表示跨股骨近端骨骺[34]的力的平衡，也表示跨關(guān)節(jié)力在過去的作用方式。因此，它是一個功能參數(shù)，反映了髖關(guān)節(jié)在生長過程中長期的關(guān)節(jié)反作用力。如果FEAR<0°，則認(rèn)為髖關(guān)節(jié)穩(wěn)定。統(tǒng)計分析表明，5°的臨界值預(yù)測穩(wěn)定性的概率為80°。最近的研究表明，2°的臨界值預(yù)測穩(wěn)定性的概率為90%（Batailler等人，正在準(zhǔn)備發(fā)表中）。使用FEAR指數(shù)的案例如圖3a和b所示。Fig.2.TheFEARindex.Theangleismeasuredbetweenalineconnectingthemostmedialandlateralpointofthesourcilandalineconnectingthemedialandlateralendofthestraightpart(usuallycentralthird)ofthephysealscarofthefemoralhead.AnegativeFEARindex,withtheangleopeningmediallyasshowninFig.3a,indicatesastablehip.圖2.?FEAR指數(shù)。測量連接股骨最內(nèi)側(cè)和外側(cè)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(cè)和外側(cè)端的線之間的角度。如圖3a所示，角度向內(nèi)側(cè)打開的陰性FEAR指數(shù)，表示髖關(guān)節(jié)穩(wěn)定。Fig.3.(a)CaseexamplesusingtheFEARindex.17-year-oldmale,LCEA20°,FEAR0°.Hipdeemedthereforestableandpatientmanagedwithhiparthroscopy.(b)CaseexamplesusingtheFEARindex.17-year-oldfemale,LCEA20°,FEAR8°.HipdeemedthereforeunstableandpatientmanagedwithPAO.圖3.(a)使用FEAR指數(shù)的病例。17歲男性，LCEA20°，F(xiàn)EAR0°。因此髖關(guān)節(jié)穩(wěn)定，患者接受髖關(guān)節(jié)鏡治療。(b)使用FEAR指數(shù)的病例。17歲女性，LCEA20°，F(xiàn)EAR8°。因此髖關(guān)節(jié)不穩(wěn)定，患者接受PAO截骨治療。有哪些治療方案？治療取決于髖關(guān)節(jié)的穩(wěn)定性。疼痛性臨界髖關(guān)節(jié)發(fā)育不良的治療方案包括非手術(shù)治療、解決關(guān)節(jié)內(nèi)撞擊的手術(shù)治療（通過髖關(guān)節(jié)鏡或髖關(guān)節(jié)外科脫位進(jìn)行的FAI手術(shù)）和解決不穩(wěn)定性的手術(shù)治療（采用PAO和/或股骨截骨術(shù)的重新定位截骨術(shù)）（見圖2）。非手術(shù)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(guān)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(guān)節(jié)鏡和/或截骨術(shù)的臨界髖關(guān)節(jié)發(fā)育不良的手術(shù)治療方案。這組患者接受髖關(guān)節(jié)鏡檢查的結(jié)果如何？隨著髖關(guān)節(jié)鏡技術(shù)的最新發(fā)展，許多外科醫(yī)生正在使用它來治療臨界髖關(guān)節(jié)發(fā)育不良，尤其是因為人們認(rèn)為髖臼周圍截骨術(shù)等替代技術(shù)的風(fēng)險更高，術(shù)后恢復(fù)時間更長。臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查還可以讓外科醫(yī)生處理髖關(guān)節(jié)內(nèi)病變，如盂唇撕裂或股骨凸輪畸形[3,12,36]。如果考慮使用PAO來解決骨穩(wěn)定性不足的問題，那么關(guān)節(jié)鏡檢查不僅可以讓外科醫(yī)生了解髖關(guān)節(jié)的關(guān)節(jié)內(nèi)狀態(tài)，還可以了解患者在隨后進(jìn)行更大規(guī)模手術(shù)時的表現(xiàn)[37]。然而，關(guān)于臨界髖關(guān)節(jié)發(fā)育不良的髖關(guān)節(jié)鏡檢查的已發(fā)表文獻(xiàn)很少，而且短期隨訪也存在局限性。在Jo等的系統(tǒng)綜述中，確定了13項關(guān)于髖關(guān)節(jié)發(fā)育不良的關(guān)節(jié)鏡檢查的研究[10]。這些研究各不相同，所有研究都是病例系列。僅有6項研究報告了主觀和/或客觀結(jié)果。關(guān)節(jié)鏡檢查的手術(shù)指征不明確，患者事先接受過多種非手術(shù)治療。此外，臨界髖關(guān)節(jié)發(fā)育不良的確切定義各不相同，只有兩項研究使用了Byrd和Jones的定義[36]。三項研究報告了髖關(guān)節(jié)鏡作為輔助工具，三項研究報告了髖關(guān)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(guān)節(jié)發(fā)育不良病例（LCEA20-25°）的關(guān)節(jié)鏡檢查結(jié)果，其中只有一項描述了患者報告的結(jié)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(guān)節(jié)（32髖）患有臨界髖關(guān)節(jié)發(fā)育不良。關(guān)節(jié)鏡檢查后，平均改良Harris髖關(guān)節(jié)評分從50（差）改善到77（一般）。作者得出結(jié)論，髖關(guān)節(jié)鏡治療可能解決髖關(guān)節(jié)內(nèi)病理而不是發(fā)育不良的放射學(xué)證據(jù)的結(jié)果。對臨界髖關(guān)節(jié)發(fā)育不良進(jìn)行髖關(guān)節(jié)鏡檢查有什么危險？臨界髖關(guān)節(jié)發(fā)育不良患者進(jìn)行關(guān)節(jié)鏡盂唇切除術(shù)和髖臼外側(cè)緣切除術(shù)可導(dǎo)致爆發(fā)性髖關(guān)節(jié)不穩(wěn)定[38]。即使修復(fù)了盂唇，也必須保留髂股韌帶和髖關(guān)節(jié)的其他靜態(tài)穩(wěn)定器，以防止不可逆的后果或?qū)е麦y關(guān)節(jié)不穩(wěn)定[39–41]。沒有確鑿的文獻(xiàn)支持在這些情況下進(jìn)行關(guān)節(jié)囊修復(fù)，但這似乎是一種安全合理的做法[42]。關(guān)節(jié)囊復(fù)位技術(shù)可提高臨界髖關(guān)節(jié)發(fā)育不良的穩(wěn)定性[12]。如果髖關(guān)節(jié)在術(shù)前足夠不穩(wěn)定，那么僅通過髖關(guān)節(jié)鏡治療關(guān)節(jié)內(nèi)病變是不夠的，患者將需要進(jìn)行PAO截骨術(shù)[43,44]。必須記住，髖關(guān)節(jié)的穩(wěn)定性首先取決于髖骨幾何形狀。在輕微不穩(wěn)定（臨界發(fā)育不良）中，穩(wěn)定性可能由次級軟組織結(jié)構(gòu)來確保。一旦這些結(jié)構(gòu)因微創(chuàng)傷或大創(chuàng)傷而失效，髖關(guān)節(jié)就會變得不穩(wěn)定?；謴?fù)軟組織穩(wěn)定性可能只會在短時間內(nèi)改善髖關(guān)節(jié)穩(wěn)定性，但軟組織很可能再次磨損。因此，必須首先解決潛在的骨病理問題，才能取得良好的長期效果。最近的一份報告顯示，髖關(guān)節(jié)發(fā)育不良患者在髖關(guān)節(jié)鏡檢查失敗后，PAO的髖關(guān)節(jié)特定功能結(jié)果較差[6]。因此，對這組患者單獨進(jìn)行髖關(guān)節(jié)鏡檢查應(yīng)謹(jǐn)慎處理。但是，對于那些由于髖關(guān)節(jié)狀況不佳（即AI和股骨前傾正常）或高齡（即>40歲）而不適合進(jìn)行PAO的患者，它可能有用。重新定向髖臼周圍截骨術(shù)對這組患者有何影響？通過髖臼周圍截骨術(shù)進(jìn)行髖臼重新定向已成為髖關(guān)節(jié)發(fā)育不良最常見的治療方法，據(jù)報道術(shù)后20多年效果良好。傳統(tǒng)上，PAO時關(guān)節(jié)內(nèi)病變的處理方法是進(jìn)行前關(guān)節(jié)切開術(shù)。然而，隨著PAO微創(chuàng)技術(shù)的發(fā)展，情況已不再如此。微創(chuàng)PAO技術(shù)縮短了術(shù)后恢復(fù)時間[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(dǎo)致PAO的發(fā)病年齡下降[46]。此外，患有較重發(fā)育不良程度的患者患PAO的年齡也較早：LCEA是手術(shù)年齡的獨立預(yù)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(shù)。但是，輕度和中度發(fā)育不良患者的PAO預(yù)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(guān)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(jié)果指標(biāo)，結(jié)果表明，雖然總體結(jié)果良好，但臨界髖關(guān)節(jié)發(fā)育不良患者和男性的改善程度低于發(fā)育較重的患者[47]。作者討論了小范圍矯正的危險，這可能導(dǎo)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(guān)節(jié)中，關(guān)鍵步驟是確定穩(wěn)定性。關(guān)于髖關(guān)節(jié)的穩(wěn)定性，只有兩種情況：髖關(guān)節(jié)穩(wěn)定或不穩(wěn)定。沒有中間狀態(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(fù)荷/過度使用和軟骨疾?。┫嘟Y(jié)合，需要同時治療。如果髖關(guān)節(jié)不穩(wěn)定，則需要髖臼重新定位。僅解決磨損的二級穩(wěn)定器并不能解決潛在的生物力學(xué)問題，最多只能產(chǎn)生令人滿意的短期結(jié)果。在穩(wěn)定的髖關(guān)節(jié)中，可以進(jìn)行開放或關(guān)節(jié)鏡關(guān)節(jié)保留手術(shù)。然而，我們必須記住，低于28°的LCE角度每減少一度，骨關(guān)節(jié)炎的發(fā)病率就會增加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(jié)果的機(jī)會，我們主張進(jìn)行髖臼重新定向PAO截骨手術(shù)。重要的是要確定我們?nèi)狈χR的領(lǐng)域，以指導(dǎo)進(jìn)一步的研究。將對這些患者進(jìn)行長期隨訪研究，比較髖臼重新定向和髖關(guān)節(jié)鏡檢查，理想情況下，將記錄所有成像參數(shù)和Beighton評分。此外，還應(yīng)獲得患者報告的結(jié)果測量和恢復(fù)時間，以及包括運動在內(nèi)的活動恢復(fù)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(xiàn)出處：MichaelCWyatt,MartinBeck.Themanagementofthepainfulborderlinedysplastichip.ReviewJHipPreservSurg.2018Apr5;5(2):105-112.doi:10.1093/jhps/hny012.2024年08月14日244
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肖凱主治醫(yī)師 航天中心醫(yī)院 骨科 問：髖關(guān)節(jié)發(fā)育不良可不可以保守治療，是否必須手術(shù)？答：首先，保守治療無非控制活動量、控制體重、吃止疼藥、加強(qiáng)肌肉鍛煉，一定程度可以緩解疼痛癥狀，但是根本的骨頭畸形并沒有改變，也就是說，保守治療只能一定程度延緩病情進(jìn)展，無法解決根本問題。手術(shù)的目的是為了緩解疼痛、延長自身關(guān)節(jié)的使用壽命，從根本上解決問題。如果本身關(guān)節(jié)不疼，或者疼痛非常非常輕，可以暫且保守治療。但是，如果關(guān)節(jié)疼痛比較頻繁或者比較重，手術(shù)可能是解決當(dāng)前問題的最佳方式。?問：保髖術(shù)后我的關(guān)節(jié)能用多少年？答：這個問題很難回答。影響關(guān)節(jié)使用壽命的因素太多了，比如手術(shù)時關(guān)節(jié)軟骨磨損重不重、自身的軟骨耐磨程度如何、自身的關(guān)節(jié)畸形重不重、手術(shù)醫(yī)生的水平好不好、術(shù)后體重控制得好不好、術(shù)后關(guān)節(jié)保養(yǎng)的好不好。理論上講，通過手術(shù)糾正畸形可以讓關(guān)節(jié)的使用壽命盡可能延長，最好的效果就是用一輩子，當(dāng)然，少術(shù)患者也有術(shù)后幾年、十幾年后出現(xiàn)關(guān)節(jié)磨損嚴(yán)重，進(jìn)而換關(guān)節(jié)的?？傮w上講，找一個靠譜的醫(yī)生，術(shù)后自己好好保養(yǎng)，剩下的就交給天意了。?問：手術(shù)后我應(yīng)該怎么保養(yǎng)自身的關(guān)節(jié)？答：手術(shù)的目的還是希望大家回歸正常的生活。有的極端的患者，為了減少關(guān)節(jié)負(fù)重會走極端，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(dāng)避免長時間重體力勞動或者劇烈運動。當(dāng)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(shù)就是為了后續(xù)運動時不疼。當(dāng)然，如果能把體重控制在理想的區(qū)間肯定是最好的。?問：我想手術(shù)了，術(shù)前應(yīng)該做哪些準(zhǔn)備？答：1、異地就醫(yī)，提前進(jìn)行醫(yī)保備案，具體需要詢問當(dāng)?shù)蒯t(yī)保部門；2、準(zhǔn)備一副拐杖，肘拐腋拐都可以，調(diào)整拐杖高度，練習(xí)拄拐單腿走路；3、術(shù)前可以按醫(yī)生的建議進(jìn)行功能鍛煉，改善肌力，加速術(shù)后康復(fù)；4、帶著之前拍的片子及病歷；5、酌情準(zhǔn)備個人生活物品。?問：髖臼周圍截骨手術(shù)風(fēng)險高不高？答：這個手術(shù)確實難度很大，被譽(yù)為骨科的珠穆朗瑪，手術(shù)的入門門檻很高，學(xué)習(xí)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(shù)。記得我在美國學(xué)習(xí)的時候，看過兩個醫(yī)生做這個手術(shù)，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(shù)的手術(shù)可以在1小時出頭的時間完成，手術(shù)不但做得快，質(zhì)量也是絕對有保證。?問：手術(shù)需要輸血嗎？答：這個手術(shù)的出血確實偏多，但是隨著手術(shù)技術(shù)的提高和相關(guān)藥物的應(yīng)用，再加上手術(shù)中使用血液回收設(shè)備（可以將出血量的大概一般進(jìn)行重新回收利用），目前在我中心手術(shù)的患者，90%以上的患者不需要異體輸血。而且，我們中心現(xiàn)在術(shù)前不需要常規(guī)備自體血。?問：術(shù)后恢復(fù)期大概多久？答：手術(shù)中我們需要將骨頭截斷，調(diào)整好位置后進(jìn)行固定，截斷的骨頭長好需要大概3個月的時間。所以，術(shù)后3個月內(nèi)需要小心保護(hù)自己的髖關(guān)節(jié)，不要摔，一定要拄雙拐，拄雙拐，拄雙拐！一般我會讓患者術(shù)后6-8周內(nèi)術(shù)腿不負(fù)重，6-8周后從0開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(fù)重身體重量1/3-1/2，具體以醫(yī)生通知為準(zhǔn)。過早扔拐，過早過多負(fù)重可能導(dǎo)致骨頭移位，影響手術(shù)效果。3個月后門診復(fù)查，評估骨頭生長情況。?問：術(shù)后如何進(jìn)行康復(fù)鍛煉？答：康復(fù)鍛煉很重要，鍛煉不好，走路十有八九會瘸。我的患者我一般會給每人一個康復(fù)計劃，由于每個人的手術(shù)不一樣，畸形不一樣，骨頭質(zhì)量不一樣，所以方案不會完全一樣，大家按照自己的方案去做鍛煉即可。大家認(rèn)真閱讀鍛煉資料，保證動作做對，一旦動作做錯，就可能練錯肌肉。3個月復(fù)查時人要過來，很重要，我會根據(jù)查體結(jié)果和骨頭愈合情況調(diào)整康復(fù)方案。復(fù)查方式參考：保髖術(shù)后門診復(fù)查注意事項2024年06月30日953
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曾紀(jì)洲主任醫(yī)師 北京潞河醫(yī)院 骨關(guān)節(jié)外科 發(fā)育性髖關(guān)節(jié)發(fā)育不良(DDH)伯爾尼髖臼周圍截骨術(shù)(PAO):從其在當(dāng)?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(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/37917385/?轉(zhuǎn)載文章的原鏈接2：https://jorthoptraumatol.springeropen.com/articles/10.1186/s10195-023-00734-2?AbstractThedevelopmentoftheBerneseperiacetabularosteotomy(PAO)isbasedonastructuredapproachstartingwithananalysisofthepreexistingprocedurestoimprovethecoverageofthefemoralheadandwasfollowedbyalistofadditionalgoalsandimprovements.Cadavericdissectionswithadetaileddescriptionofthevascularsupplyofacetabulumandperiacetabularbonesetthestageforanintrapelvicapproach,whichofferedthelargestacetabularcorrectionpossiblecombinedwithsafeintracapsularaccess.Thefinalcompositionofosteotomiesrequiredthedevelopmentofseveralinstrumentsandcuttingdevicesbeforethefeasibilitycouldbetestedonaseriesofcadaverichips.伯爾尼髖臼周圍截骨術(shù)（PAO）的發(fā)展基于一種結(jié)構(gòu)化的方法，首先對現(xiàn)有的手術(shù)方法進(jìn)行分析，以改善股骨頭的覆蓋范圍，然后列出了其他目標(biāo)和改進(jìn)措施。通過對髖臼和周圍骨的血管供應(yīng)進(jìn)行詳細(xì)描述的Cadaveric解剖，為內(nèi)盆入路奠定了基礎(chǔ)，這種入路可提供最大的髖臼矯正范圍，同時確保安全的關(guān)節(jié)囊內(nèi)入路。在對一系列cadaveric髖關(guān)節(jié)進(jìn)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(dǎo)師項目等方式，努力優(yōu)化學(xué)習(xí)曲線，減少失敗?；仡欉^去，在近40年的經(jīng)驗基礎(chǔ)上，這些努力促進(jìn)了伯爾尼髖臼周圍截骨術(shù)在全球范圍內(nèi)的采用。?KeywordsHipjointpreservationsurgery,Periacetabularosteotomy,PAO,BernesePAO,Pelvicosteotomyhistory?SimilarcontentbeingviewedbyothersResultsofPeriacetabularOsteotomy(PAO)Chapter?2017BerneseperiacetabularosteotomythroughadoubleapproachArticle10August2018Mini-IncisionPeriacetabularOsteotomyChapter?2017?IntroductionAttemptstoimprovecoverageofthefemoralheaddatebacktothebeginningoflastcentury,whenAlessandroCodivilla,directorofthefamousRizzoliOrthopedicInstituteinBologna,Italy,proposedamethodtotreattheestablisheddislocationofthehip[1,2].Hesuggestedtocoverthefemoralheadcompletelybythejointcapsuleandtointroduceitintoadeepenedacetabulumattheanatomiclevel.Thetechniquewaspopularized30yearslaterbyColonnaandremainsknownunderhisname[3].Theprocedurewasexecuteduntilthelate1990s,whenBoardmanandMoseleyintheirfollow-uppaperconcluded:“wedonotsupportrevivalofthisnowobscureprocedure”[4].Nevertheless,betterunderstandingofthebloodsupplytothehipregionfavoredarevivalofamodifiedversion,nowcalledcapsulararthroplasty[5].?AcetabularaugmentationClassicaugmentationproceduresofthedeficientacetabulumaretheshelf-arthroplasty[6,7]andtheChiariosteotomy[8].Likethecapsulararthroplasty,theyrelyontransformationoftheinterposedcapsulartissuetofibrocartilage.Comparedwithhyalinecartilagethemechanicalqualityoffibrocartilageisinferior,nevertheless,thesurvivalofsucha“neo-joint”canlastuptoseveraldecades.Theexecutionoftheacetabularshelfaugmentationiscomparativelyeasy.Overtimethistechniqueunderwentseveralminormodifications;itisstillinuseinFranceandincountrieswithFrenchorthopedicinfluence[9].ThetransversejuxtaarticulariliacosteotomyofChiariistechnicallysomewhatmoredemanding.Itwasfirstdescribedintheearly1950s[8]andgainedinternationalacceptancefordecades.Despitemultiplearticlesreportinggoodlong-termresults[10,11,12,13],theprocedurelostpopularitywiththeextensionoftotalhipreplacement(THR)indicationtoyoungerpatientsandwiththeemergenceofreorientationprocedures.?AcetabularreorientationIntheseprocedurestheentireacetabularboneandhyalinecartilageisredirectedoverthefemoralhead;theglidingsurfaceofthenewarticularrelationwiththefemoralheadremainsallhyalinecartilage.Experiencehasproventhatthereisnearlyalwayssufficientacetabularcartilageavailabletoallowcorrectreorientation.LeCoeurwasthefirsttoexecutesuchanosteotomyin1939,butdidnotpublishitbefore1965[14].Today,severalareofhistoricalvalue,themajorityisusedinthecountryoftheinventor,andfewhavereachedinternationalacceptance.?SingleosteotomiesTheSalterosteotomyistheonlyonewherewithatransverseandcompletesingleosteotomyofthesupraacetabulariliumisusedtoreorienttheacetabulum[14].Itispreferredbypediatricorthopedicsurgeonsforitsrathereasyexecution.However,withitspivotpointnearthepubicsymphysis,correctionislimitedandinterlinkedwithsidecorrectionssuchaslateral,anterior,andcaudadshiftofthejoint.Thehighestclinicalrelevance,however,hasthetendencytocreateretroversionoftheacetabulum,whichinhipswithlowornoanteversionmaycreateimpingementproblemsinearlyadulthood.ThePemberton[15]andDega[16]osteotomiesareincompletesupraacetabularosteotomiescorrectingtheroofonly.ThecutissimilarasforaSalterosteotomy[14]butdoesnotseparatetheiliumcompletely.WhilethePembertoncutisstraight,theDegacutiscurvedfollowingtheacetabularroof.Thedeeperthecutpenetrates,theeasiertheacetabularpartofthebonecanbebenddownwards,decreasingtheenlargedacetabularradius.Bothtechniquesareusedalmostexclusivelyinprematurehipswithashallowacetabulum.BotharetechnicallymoredemandingcomparedwiththeSalterosteotomy[17].Comparinglong-termresults,thePembertonosteotomyseemstocreateslightlybetterresultscomparedwiththeDegaandSalterosteotomies[18,19].?DoubleosteotomiesTwodoubleosteotomiesforacetabularcorrectionwithdifferentestimateshavebeendescribedfromSutherlandandGreenfield[20]andfromHopf[21].Thefirstiscuttingthroughthebonenearthesymphysis,thesecondiscuttingthroughtheemptydistalpartofthepaleo-acetabulumincasesofseveresubluxationandsecondaryacetabulum.?TripleosteotomiesTheycanbedividedintodifferenttypes:thoseexecutedatadistancefromthejoint,whichimpliesthatthesacrospinalandsacrotuberalligamentsinsertattheacetabularfragmentandthereforelimitthecorrection,andthoseexecutedclosetothejoint,whichimpliestheligamentsarenotattachedtotheacetabularfragmentandthereforeallowahigherspatialcorrection[14,22,23,24].?SphericalosteotomiesTheseareperformedveryclosetothejoint,allowingextensivecorrectionexceptformedialshiftingoftheacetabularfragment.Theexecutionisratherdemanding,andduetotheacetabularvicinityoftheosseouscuts,thefragmentperfusionislimitedtotheobturatorandcapsularvessels.Simultaneousarthrotomyisthereforelimited[25,26,27].?TheBerneseperiacetabularosteotomy(PAO)ThemostrecentlyintroducedreorientationprocedureisthePAO[28].Incontrasttopreviousosteotomies,itisexecutedfromanteriorandfromtheinsideofthepelvis.Theprocedureistheresultofaresearchprojectwithanalysisofthelimitationsoftheexistingprocedures,followedbyextensivecadavericdissectionsofthevascularsupplyandbytrialosteotomiesforbestdirectionoftheosteotomycuts.Finally,thedefinitiveversionoftheprocedurewastestedon25cadaverhipswiththefocustotestasetofnewinstruments.Traditionally,pelvicsurgeryperformedbyorthopedicsurgeonsapproachedtheacetabularareaalmostexclusivelyfromthelateralside.Withtheprogressinsurgicaltreatmentoftraumatotheacetabulumandpelvisinthelate1970sandearly1980sbyLetournel[29],aswellaswithbetterunderstandingofthevascularsupplyofthepelvis,theinnersideofthepelvisbecameaninterestingnewsurgicalapproacharea.Additionally,knownlimitationsofthepreexistingaugmentationandreorientationprocedures(Table1[14,15,20,21,22,23,24,25,26,27,28])raisedtheambitionforamoreversatileprocedureofacetabularreorientationthatshouldfulfillseveralgoals(Table2).??Table1Characteristicsofacetabularreorientationprocedures??Table2Criteriatomeetforanewreorientationprocedure??Thefirststepoftheprojectwasacadavericstudyofthevasculartopographytothepelvisrelevanttoperiacetabularosteotomies.Hereitbecameobviousthatthemostcrucialaspectwasthepreservationofthefragmentvascularityduringtheosteotomiesandduringwideningthegapsrequiredforcorrection.Itwasbestachievedifosteotomieswereperformedfromtheinnersideofthepelvis[28](Fig.1).AfterfirstclinicalintroductionofthePAO,intraoperativelaserDopplerflowmetryoftheacetabularfragmentwasusedanddemonstratedthatthesignalsdropduringthereorientationbutreturntonormalvaluesafterseveralminutes[30].Overall,theseteststookup1year,mainlyduetolimitedavailabilityofsuitablecadavers.Forthefinalsequenceandorientationofthefivenecessaryosteotomysteps,JeffreyMast,aclinicalfellowfromtheUSAatthetime,wasaningeniouscontributortothedevelopmentofthePAO(Figs.2,3).Finally,wepracticedonseveralcadaverhipstobecomefamiliarwithtechniqueandanewsetofinstruments,whichlaterbecamecommerciallyavailable(Fig.4)fromseveralproviders.??Fig.1Periacetabularvascularsupplycadaverstudyonvascularsupplyoftheperiacetabularbone.Righthip,osteotomiesfrompelvicinside.Thebranchesfromsuperiorandinferiorglutealarterycanbepreservedduringosteotomy(left)andfragmentcorrection(right)??Fig.2PAOosteotomycutsarrangementofthefiveosteotomycuts,visibleontheleftlateralview,inthemiddleanteriorview,andontherightmedialviewofarighthemipelvis,namelyincompleteischialcut(first),pubiscut(second),supraacetabularcut(third),retroacetabularcut(fourth),andinfraacetabularcutcompletingtheischialcut(fifth)??Fig.3Pelvisplasticmodel:plasticmodelshowingseparationoftheacetabularfragmentfromposteriorcolumnincludingsacrospinalandsacrotuberalligaments.Top:anteriorview;bottom:posteriorview??Fig.4PAOinstrumentationsetofinstrumentswithspecialosteotomesandretractors??Thefirsthipwasoperatedonon13March1984.Wewerewaitingseveralweeksforan“easy”case,butDrMastcouldnolongerpostponehisflightbacktotheUSA;thiswasthereasonwhywedecidedtotreatthemosturgentcaseonthelist,whichwasaproximalfemoralfocaldeficiency(PFFD)hipwithcomplexdeformity.Thesurgeryofthis13-year-oldgirltook4hand10minandincludedafemoralvalgusosteotomytocompensateforanearliervarusosteotomy.Atotalof3monthsaftersurgery,thehipdislocatedposteriorly,acomplicationthatwassuccessfullytreatedwithaposteriorshelf.Atthattime,wedidnotknowthatPFFDhipshavesevereacetabularretroversionasacharacteristicpartofthemalformation.Thehipfunctionedwellduring33yearsbeforeTHRbecamenecessary(Fig.5).Theresultsofthefirst75hipswithratherheterogeneousformsofdysplasia,multipleprecedentsurgeries,andosteoarthrosisstageincludingT?nnisgrade2werepublished4yearslater[28];thesuccessrateofthisgroupdroppedfrom80%after10yearsto60%after20yearsandto30%after30years[31,32].Meanwhile,morehomogeneousgroupsofhipdysplasia,youngerageatsurgery,exclusionofadvancedosteoarthritis,aswellasaconcurrentarthrotomyforfemoralhead–neckshaping,haveledtofurtherincreaseofsurvival[33,34].??Fig.51984:firstoperatedcase—13-year-oldfemalewithPFFDofthelefthip.aVarusproximalfemurafterintertrochantericosteotomy3yearsearlier.bPeriacetabularosteotomyfollowedbyintertrochantericrevalgisationforbetterjointcongruity.Goodlateralcoverageofthehead.Increasedretroversionoftheacetabulumledtoposteriorsubluxation3monthsaftersurgery,whichwastreatedwithaposteriorshelf.cProgressivejointdegenerationafter36years.Plateforshelffixationstillinplace.dFollow-upradiographyofTHR2yearslater.Thepatientregainedanormalgaitpattern??TechniqueThepatientisinsupineposition,thelegtobeoperatedonisdrapedmobile.Generalanesthesiaisstandardasisbloodsalvage(cellsaver).TheapproachisamodificationofSmithPetersen’sprimarydescription[35].Thesequenceofthefivepartialcutsisdescribedelsewhereindetail[28].Someperformthepubiccutpriortothefirstischialcut,especiallywhenarectussparingapproachisused.Theclassicexposurestartswithosteotomyoftheinsertionofthesartoriusoriginattheanteriorsuperioriliacspine(ASIS).Mainlyinyoungerpatients,thesartoriusinsertionincludingtheinguinalligamentarereleasedfromtheASISwithoutanosteotomy.Byincisingthefasciaofthetensorfasciaelataeandmovingawaythemuscletothelateralside,thejointcapsuleisreached.Bydissectingtheiliacussubperiosteally,themedialflapcanbemobilized.Intheclassicapproachthereflectedandthedirectheadoftherectusfemorismusclearedividedandtheiliocapsularismuscleisdissectedfromthecapsule.Followingtheanteroinferiorcapsuletotheinferior,thegapbetweencapsuleandpsoastendonfurtherdowntotheobturatorexternusmuscleiswidenedtoreachtheischium.Thedeepbranchofthemedialfemoralcircumflexartery(MFCA)runsonthecaudadsurfaceofthismuscle,whichneedstoberespected.Initially,foranincompletecutoftheischiumattheinfracotyloidaxilla,aspeciallyangulatedosteotomeisused.Positionandpropagationcanbecontrolledwithfluoroscopy.Intherectussparingapproach,theischiumisapproachedmedialtotherectusfemoris,whichisnotreleased.Thedeepfasciaisincised,andtheischialosteotomyisperformedquitesimilartotheclassictechnique.Incomparisonwiththeclassictechniquetakingdowntheinsertionoftherectus,therectussparingapproachisnotreallyinternervous,becausethefirstbranchofthefemoralnerveiscrossingtheapproachdistally.Thepubiccut,intheclassicversionsecond,isacompleteseparationofthepubisaftersubperiostealdissection;theobturatorneurovascularbundleisprotectedusingtwobluntretractors.Thethirdcutisasupraacetabularhorizontalseparationoftheiliacbone,startingjustdistaltothesartoriusmuscleorigin.Thecutisperformedfromtheanteriorandinnersideoftheiliumwithanoscillatingsaw.Duringthisosteotomytheabductormusculatureisprotectedwithabluntretractor.Thecutstopsabout10mmbeforethepelvicbrim.Forthefourthcut,aretroacetabularcutstartsfromthereandisdirecteddownwardsatanangleof110–120°posteriortothesupraacetabularcut.Again,fluoroscopyhelpstocorrectlypropagatethiscutusinga10mmosteotome.Attheangulationbetweenthethirdandfourthcut,acurvedosteotomeisusedtocuttheoutsidecortex.Atthispointabonespreaderisinsertedjustdistaltotheangulationtoopenupthegap.Witharetractorheldagainstthequadrilateralsurfaceneartheischialspine,theareaforthefifthosteotomycanbeopened.Thecutisexecutedwithaspecialosteotomeandcutsthefinalosseousbridgebetweenthefourthandthefirstcut.Itseparatesthesacropelvicligamentsfromtheacetabularfragment(Fig.3).Whenallcutsareproperlyaccomplished,theacetabularfragmentcanbeseparatedwithacounter-rotatingmoveofthespreaderandaSchanzscrewinsertedintotheiliacpartoftheacetabularfragment.Thedesiredcorrectionistemporarilyfixedwithtwo(?3)Kirschnerwiresandiscontrolledwithfluoroscopyorastandardanteroposteriorradiographoftheentirepelvis.Thelatterispreferredbecauseitalsoguaranteesthenecessaryorthogradepositionofthepelvis.?ModificationsoftheapproachovertimeSoonaftertheinitialexperiencewith75PAOs,thedissectionoftheabductormusculaturewasabandonedandsufficientprotectionofthesemusclesduringthethirdcutcouldberealizedwithtunnelingandplacementofabluntretractor[36].Animportantinsightcamefromfollow-upstudies,showingthatsomehipsdevelopedimpingementsymptomsafteracorrectlyorientedacetabulum.Acloserlookrevealedthatconcomitantfemoralhead–neckdeformityisrelativelyfrequentandwasnotproducingsymptomsbeforethePAO-improvedanteriorcoverage.Theproblemcanbedetectedbyassessinginternalrotationinhipflexionduringsurgeryandsolvedwithadditionalarthrotomyforosteochondroplastyoftheanteriorhead–neckjunction.SomeauthorsrecommendarthroscopybeforePAO[34],whichmaycompensateformissingorinadequateMRIandmayeveninfluencetheindicationforPAO.IncomplexdeformitiesnecessitatingthecombinationofaPAOwithafemoralprocedureweareinclinedtostartwiththefemoralprocedureandapproachtheinfracotyloidaxillabetweenmuscles.gemellusinferiorandobturatorexternus.Forbetterdiscriminationitisadvantageoustoexposethisgapbeforethefemoralprocedure;itallowstoperformthefirstischialcutunderdirectviewwiththesciaticnervebeingheldaside[37](Fig.6).??Fig.6Ischialcutviafemoralapproachinhipswithcombinedacetabularandfemoralsurgery.Ontop,accesstotheinfracotyloidgroovebetweenobturatorinternusandgemellusinferiormuscles.Bottom:itallowsoptimalprotectionoftheischialnerveduringexecutionofthecut??Amorerecentmodificationoftheoriginaltechniqueistherectussparingapproach,whichallowsthefirstcuttobeperformedbyapproachingtheischiummedialtotheintactrectustendons.Acadavericstudydescribesthefeasibilityofthismodification;however,intraarticularinspectionandrevisionoftheanteriorinferioriliacspine(AIIS)mightbesomewhatrestrictedandthemostproximalbranchofthefemoralnervecanbeoverstretched[38].Anumberofproposalsdealwithmodificationsoftheapproachwithoutchangingsequenceandconfigurationoftheosteotomy.TheattemptstoexecutethePAOusingmini-invasivetechniques,includingthetranssartoriousapproach[39,40],maybeapplicableforminimalcorrectionsbuthavelimitationswithcomplexdeformities;consequentlythewidespreaduseremainslimited.AnotherpropositionistheuseofamodifiedStoppaorapararectusapproaches;bothhavebeensuccessfullyperformedforanterioracetabularfractures[41];however,theusefulnessfortheexecutionofaPAOhasnotyetbeendemonstrated.Aninguinalextensionoftheapproachmayincreasetheviewonthepubicosteotomyarea,butwasnearlycompletelyabandonedafterseveralcaseshadpostoperativedeepveinthromboses(DVTs)ofthefemoralvein.Fewareusingatwo-incisiontechnique[42],similartotheT?nnistripleosteotomy[24].Aprimaryconceptionoftheoriginaltechniquewastoavoidfluoroscopyanduseonlylocallandmarksfortheexecution.However,mostsurgeonstodayusestandardizedfluoroscopycontrolforsomeorevenallosteotomies.Computerassistancehasbeenproposedseveraltimes,butlikeforTHR,sofarithasnotfounditswayintogeneralpractice.Amostrecentversion[43]confirmsthatitmaybehelpfulforthelessexperiencedsurgeon,aconclusionwegainedalreadymorethan25yearsagousingasimilarapproach;itwasgivenupafterashortclinicaltestingperiod[44].?SpectrumoftheprocedureThefollowingselectedcasesmaydemonstratethespectrumofindicationandthereforeversatilityofthePAO.Whiletheprocedurewasoriginallyintendedasamethodforprimaryacetabulardysplasiafromdevelopmentaldislocation(DDH),itbecameusefulsoonafterasanadditionalsurgeryforothercomplexdeformitieswithacetabularparticipation,mainlyPerthesorPerthes-likedisease,butalsoincaseswithfemoralexostosisorsepticarthritiswithfemoralheadnecrosisintherareepiphysealdysplasiaandoccasionallyinearlystageofprotrusionandposttraumaticperiacetabulardeformities.Specialchallengewasconstitutedincasesafterprevioussurgery,suchasretroversionafterSalterosteotomyorwhenare-PAOwasnecessary.?Case1A16-year-oldfemalesufferingfromseverebilateralacetabulardysplasiaandcoxavalgawithhighfoveacapitishadmorepainontherightside.Therewasbilateralsubluxationwithfatiguefractureofthelateralacetabularrimontherightside(Fig.7).Thelateralviewoftherighthipshowedsubstantialintraosseousganglionformationintheroof,whiletheabductionviewfeaturedrecenteringofthefemoralheadandsomereductionoftheacetabularfragment.ThecomplexdeformityonbothhipsmadeitnecessarytocombineaPAOwithafemoralvarusosteotomy.Surgerystartedonthefemorallevelinlateraldecubitus.Beforeexecutingtheintertrochantericosteotomy,thefirstischialcutofthePAOwasperformedthroughthisapproachunderdirectview.FortheremainingPAOcuts,thepatientwasturnedintosupineposition.Theacetabularrimfracturereducedspontaneouslyanddidnotneedadditionalfixation.Thelefthipwasoperatedon6monthslater.Healingoftheosteotomies,includingtherimfracture,wasuneventful.Painofbothhipsdisappearedshortlyaftersurgery,allowingforunrestrictedage-appropriateactivities.Theprominentbendofthefemoralimplantcreatedsomediscomfort,andthiswasthereasonwhypartialmetalremovalwasexecuted2yearsaftersurgery.Afollow-upradiographyat5-yearfollow-upshowedaperfectlyreducedandhealedrimfragmentanddisappearingacetabularcysts.??Fig.7Bilateralsevereacetabulardysplasiaof16-year-oldfemale;morepainontherightside.aSeveralsubchondralbonecysts,bestvisibleinalateralview(blackarrow).Displacedrimfracturewithsomereductioninabduction(whitearrow).bPAOcombinedwithfemoralvarusosteotomy.A6-monthintervalbetweensurgeryofthehipswasobserved(rightsidefirst).SlightovercorrectionofthePAOontherightsideforbetterunloadingofthedamagedrimareawasperformed.Partialmetalremovalafter2yearswasperformed.Radiologicalresultobservedafter5years.cCloserlooktothecriticaljointareaoftherighthipbeforesurgeryandaftersugery(d)showingreducedandhealedrimfragment(doublearrow)??Case2A13-year-oldmalewithPerthesdisease(Fig.8).AfterSalterosteotomypaindidnotsubsideandlimpingincreased;bothcouldbeexplainedwithpersistentsubluxation,widenedacetabulum,followedbyadductioncontracture.Computersimulationshowedreasonablereductionofthesubluxatedfemoralheadwithintracapitalosteotomy[45]andPAO.Thepreciseexecutionofthefemoralheadosteotomywasfacilitatedbyacuttingtemplateprefabricatedonthebasisofthecomputersimulationdata.Healingoftheosteotomieswasuneventful.Painsubsidedcompletely;abductortraininghelpedtoregainawalkingpatternwithoutlimping.At1yearaftersurgery,partialmetalremovalhelpedtosettlepainfromprojectingscrewheads.At2yearsaftersurgerytheconfigurationofthehipwasclosetonormal,rangeofmotion(ROM)wasslightlylesscomparedwiththeoppositesideandfunctionwasunrestricted.??Fig.8Perthesdiseaseintherighthipofa13-year-oldmale,operatedonwithSalterosteotomy.aPersistentsubluxationandadductionwithextrusionofthehealthylateralpillarandloadingofthenecroticarea.Adaptivewideningoftheacetabularcavity.Ontheright,computersimulationshowingrelocatedheadafterresectionofthenecroticarea(redportion)andoptimalcoveragewithPAO.bIntraoperativepicturesshowingtheresectionofthenecroticcentralpartoftheheadwiththetemplateinplaceandthefinalsizeoftheheadafterscrewfixationofthemobilelateralpartoftheheadwithtwoscrews.cPostoperativesequenceswiththenewheadhealedwithoutnecrosis??Case3A21-year-oldverygracilefemalewithmultipleexostosesaroundbothhipsandconcomitantacetabulardysplasia(Fig.9).Sheonlyhadpainontheleftsideanddescribeditassudden,happeningfrequentlyduringexternalrotationinfullextension.Thephenomenoncouldbedemonstratedbyultrasoundasimpingementbetweenaposteromedialneckexostosisandtheinfracotyloidischium;thecontactwasfollowedbyfemoralheadsubluxation.Ultrasoundalsorevealedthatthecausativetumorwasbiggerthanitsradiographicappearance.Bothhipsshowedahighcoxavalgaandacetabulardysplasia.Thesurgicalplanwastoremovethenecktumor,correctthehighneckvalguswithavarusosteotomy,andtoimproveacetabularcoveragewithaPAO.Preoperativeplanningbroughtoutthatintertrochantericosteotomywouldnotsufficientlyincreasethepelvifemoralclearance.Ontheotherside,theriskofdamagetothefemoralheadvascularsupplywasestimatedtobehighduringanattempttoexcisethebigtumorviaanteriorand/orposteriorretinaculardissection.Basedontheknowledgethattheposteriorneckisfreefrombloodvessels,itwasdecidedtoexecutetheresectionthroughtheneckosteotomy,whichcouldalsobeusedtoperformtheplannedvarusosteotomy.Again,surgerystartedwithdislocationofthehip.Subperiostealanteriorandposteriordissectionoftheneck,containingthevesselstothehead,wasperformedtowardthebaseoftheexostosis.Itwasfollowedbyamediocervicalosteotomyandwideningofthegapusingaspreader.Theviewwassufficienttoallowsubperiostealpiecemillresectionofthetumorunderconstantobservationofbleedingofthehead–neckfragment.Varuspositionoftheneckwasstabilizedwithtwoscrews.PAOwasexecutedasdescribedearlier.Subluxationofthehipdisappearedimmediatelyaftersurgery.The10-yearresultshowsareasonablehipjointwithawidejointspace.ThepatientispainfreeandthehiphasanormalROM.Sheisseenregularlybyherlocaldoctorwhoconfirmedthattheotherhipisstillfunctioningwell.??Fig.9Acetabulardysplasia,multipleexostoses,andsubluxationmultipleexostosesnearbothhipswithacetabulardysplasiainaverygracile21-year-oldfemale.aPainanddiscomfortofthelefthipduringsubluxation,palpablewithrotationinfullextension.Lateralview(right)showingthecausativeexostosisattheposteriorneck.bPostoperativeresultaftersurgicaldislocation,femoralneckvarusosteotomy,andremovaloftheexostosisthroughtheneckosteotomy,followedbyPAO.cThe10-year-result.Removalofthefemoralscrewsforlocalpainsoonaftersurgery.Bothhipsarepain-free??Case4A19-year-oldrugbyplayerwithpainoftherighthip,renderinghimunabletoparticipateinhisfavoredsport(Fig.10).Historyrevealedthathewasrunoverbyatruckwhenhewas3yearsold.Hesurvivedmultiplefracturesincludingacrushinjurytothepelvicring,alltreatedconservatively.Afterfullrecoveryhehadnofurthercontroluntilrecentlywhenheexperiencedincreasingpainintherighthipduringhissportiveactivities.Radiographyrevealedatypicalposttraumaticdysplasia,apparentlyaconsequenceofthecrushinjuringthetriradiatecartilage.Thisraretypeofdysplasiaischaracterizedbythickeningoftheinnerwall,deformityofthehemipelvis,andretrotorsionoftheacetabulum.Lateralandcaudadgrowthofthephysisleadstolengtheningoftheleg.Thelargeacetabularfragmentinthiscaseisaconsequenceofchronicoverloadoftherimarea.Thesurgicalplanwastocombinetheacetabularreorientationwithexceptionalmedialshiftingofthelateralizedacetabularfragment.Concernsaboutsufficientunloadingofthefragmentinfluencedthedecisiontofixitseparatelywithtwoscrews.Thesupra-andretroacetabularosteotomycutswerelaboriousduetotheunusuallylargediameterofthesupra-andretroacetabularbone.Optimalmedializationoftheacetabulumledtominimalbonycontactbetweenacetabulumandhemipelvis,whichwasthereasonwhythecorrectionofversionwaslessthandesired.Nevertheless,consolidationwasuneventful.Thepatientresumedhisrugbyactivitiesafter9months,butalthoughpainfree,didnotregainthenecessaryaggressivityforthistypeofsportandthereforegaveitup.The2-yearresultshowedperfectconsolidationofosteotomyandrimfragmentwithalargeandcongruentjointspace.??Fig.10Posttraumaticdysplasiaina19-year-oldmale.aTypicalposttraumaticdysplasiaoftherighthipafteracaraccidentatage3.Largeacetabularrimfragment.Laboriousexecutionoftheosteotomyduetothethicksupra-andretroacetabularbone.Screwfixationofthelargerimfragment.PAOwithmaximalpossiblemedialdisplacementoftheacetabularfragment.bRadiologicalresultafter2yearswithhealedfractureandosteotomies??Case527-year-oldfemalewithosteogenesisimperfectaandbilateralprotrusio(Fig.11).Shehadincreasingandconstantpainfromglobalpincerimpingementintherighthip,whiletheleftsideremainednearlypainfree.Radiographicallythejointspaceontherightsidewasgloballynarrowed.ThepatientfavoredjointpreservationaftershehadlearnedthatthelifetimeofTHRwithsuchbonequalityislimited.Finally,sheunderstoodthatjointpreservationforherhipwouldbeelaborateandthatagoodandlastingresultcannotbeguaranteed.Thedirectionofreorientationbeingreversedtotheclassiccorrectionwouldrequirealargerimtrimmingtostartwith.Surgicaldislocationconfirmedareasonablecartilagelayerofthefemoralheadwithsomeosteophytes.Circumferentialtrimming,especiallyattheposteroinferiorrimwascombinedwithsomeosteochondroplastyattheheadneckjunction.WhileexecutionofthePAOcutswaseasy,valguscorrectionoftheacetabulumwasratherdifficult,mainlyduetotheosteoporoticbone.Tobridgethelargesupraacetabularstepasaresultofthefinalposition,astaircase-shapedplatehadtobeused.Healingoftheosteotomywasuneventful;consolidationofthefatiguefracturecouldbeobservedatthe6-weekcontrol.At2yearsaftersurgery,thepatientwaspleasedwiththeimprovedandpain-freeROM.Radiographicwideningofthejointspacewasinterpretedassignofongoingimprovement.??Fig.11Acetabularprotrusiowasobserved,withabilateralprotrusionina21-year-oldladywithosteogenesisimperfecta.Constantpainontherightsidewhiletheleftsidewaspain-freeduringmostdailyactivities.PatientrefusedtogetTHR.Onthetop,preoperativeradiographyshowingfatiguefracturethroughthebottomofthejoint(whitearrow).bResult1yearafterexcessiverimtrimmingandPAOdecoveringthehead.Fatiguefracturehealed(blackarrow)withsubstantiallyreducedpain??Case6A23-year-oldfemalewithsevereunilateralnarrowingofthepelviccavityafteraconservativelytreatedcomplexperiacetabularfractureinchildhood(Fig.12).Thejointlookedrathernormalandhippainorrestrictedmotionwereminimal;herproblemwasconnectedtothedesperatedesiretogetpregnantandastatementofhergynecologistwhoexpressedconcernswhethertheasymmetricnarrowingcouldleadtoadeviationoftheincreasinguteruswithincreasdriskofabortion.Athree-dimensional(3D)modelofthepelvisdidnotgiveaconclusiveanswertothepossibilityofuterusdeviation,butshowedthatthebirthcanalwassomewhatnarrowforanaturaldelivery.Fromanearliercasewithpelvicdeformationandsuccessfuluseofadistractor,itseemedpossibletousesuchasystemforthenecessarylateralanddistalshiftingofthemedializedjointcomplex.TestsurgeryonaplasticmodelofthedeformedpelvisrevealedthatamodifiedPAO,separatingtheposteriorcolumnproximally,wouldallowtolateralizetheacetabularfragmentsufficientlyandrecreateanormalcurvatureoftheinnerpelviccontour.Fortheverticalizedpubicramusanadditionalosteotomynearthesymphysiswasnecessary.ThebestplacefortheSchanz’screwsofthedistractorweretheoppositeiliacbonenearthesacroiliacjointandattheipsilateralfemoralhead.Bestfixationwaspossiblewithareconstructionplateplacedalongthepelvicbrim.Anilio-inguinalapproachwouldallowexposureoftheentirehemipelvis.FortheSchanz’screwneartheoppositesacroiliacjoint,ashortincisionattheiliaccrestwouldbesufficient.Thethreecutsaroundthejointandtheadditionalcutofthepubisnearthesymphysiswereexecutedastestedonthemodel.Manualtractiondidnotdispalcetheacetabularfragmentmuch.Instrumenteddistraction,however,allowedslowbutconstantdisplacementwhilealignmentcouldbeassistedwithinstruments.Theprebendedplatewasfirstfixednearthesymphysisandonthemobilepubissegment.Proximaloff-standingoftheplatecouldbesteadilyconvergedtothestableiliacbonebyalternatedrivinginthescrews.Thistechniqueallowedanoptimalfinalpositioningoftheacetabularfragment.Osteotomyhealingwasuneventful;shortlyaftershebecamepregnant.Shefinallyhadanaturaldeliveryanddidso2yearsaftersurgerywithasecondchild.Atotalof16yearsaftersurgery,thepatient,nowamotherof5children,ispainfreeandlikesoutdooractivitiesverymuch.??Fig.12Posttraumaticprotrusioobservedinpatient.aPosttraumaticprotrusioanddeformationofthehemipelvisina23-year-oldfemale.Hergynecologistdiscussedtheriskofabortionduetodeviationoftheuterus,whichwasthereasonwhyshewasaskingforcorrection.AmodifiedPAOwasfirsttestedonaplasticmodel.Correctionofprotrusioundpelvicdeformationwasassistedbyadistractor.bThenewpositionwasstabilizedwithalongrecoplateplacedalongthepelvicbrim.Ultrasoundwasperformedjustbeforenaturaldelivery.cAt16yearsaftersurgery,sheisnowthemotheroffivechildrenandisveryactiveinoutdooractivities.Thestraightlegistheoperatedone??Case7Thiscase(Fig.13)wasoperatedbyProfessorPauloRego,aformerfellow.Itispresentedtoshowthatthetechniquesarelearnablebyothers.??Fig.13Severedeformity(courtesyProf.P.Rego,HospitaldaLuz,Lisbon,Portugal)oftherighthipina16-year-oldmaleafteropenreductionattheageof1.5years,followedbyavascularnecrosis.aVarusosteotomyattheageof14years,whichdidnotimprovelimpingandpain.bPostoperativeradiographyaftercomplexsurgerywithrelativelengtheningoftheneck,intracapitalosteotomytoreducethesizeofthehead,andsubtrochantericderotationosteotomyfollowedbyPAO.cThe4-yearfollow-upresultwithgoodandpain-freefunction??Complexdeformityoftherighthipina16-year-oldmalewasobserved.HehadopenreductionforDDHattheageof1year,whichwasfollowedbyincompletenecrosisoftheepiphysis.Togetherwithongoingsubluxation,theacetabulumbecameshallowoveraPerthes-likedeformedfemoralhead.Painandlimpingdidnotimproveafterintertrochantericvarusosteotomyattheageof14years.MRIshowedareasonableconditionofthejointcartilageandcomputersimulationrevealedanimprovedheadsphericitywithintracapitalosteotomy[45].Thepreoperativeevaluationalsoexposedahighfemoralneckanteversion.Surgerywasstartedwiththefemoralside:thefirstischialcutofthePAOwasfollowedbyrelativenecklengtheningandintracapitalosteotomyandfinallysubtrochantericderotation.ThePAOwascompletedafterturningthepatientintosupineposition.Thesurgeoncommentedthattheentiresurgerywasdemandingandtimeconsuming;however,theradiographicresultwasconvincing.The6-yearfollow-upradiographyshowedaresultofcorrectionclosetoanormalhip.Thepatientispain-free,hasanormalwalkingpatternandanearlysymmetricalROM(courtesyProf.P.Rego,HospitaldaLuz,Lisbon,Portugal).?ComplicationsTechnicalcomplicationsdevelopedfirstandforemostduringthelearningcurve,whichinturnisdependentonthecaseloadovertime.Inaliteraturereviewfrom2006,inabout13publications,theincidenceofmajorcomplicationsrangedfrom6%to37%[46].Inourfirstseriesof500cases,themostfrequentcomplicationwassevereunder-,over-,andintraarticularcorrectioncountingfornearly2%ofcomplications[47].Injurytooneofthemainnerves(femoral,sciatic,orobturator)follows,makinguplessthan1%ofcomplications[48],anumberthatmayhavebeeninfluencedbystrictobservationofrecommendationsfromacadaverstudyaboutsurgicalcircumstancesleadingtosuchinjury[48].In1760casesoftheANCHORgroup,complicationincidencewas2.1%,50%(17outof36)ofwhichweretransient[49].NeuromonitoringduringPAOcanidentifythesurgicalmaneuverendangeringtraumatoanerve,butcannotpersepreventdamagewhentheblowisheavyenoughtocausealaceration[50].?InternationaladoptionoftheBernesePAOThisisprimarilytheresultofmultiplepublicationscomingfromdifferentcentersovernearly40yearssinceitsintroduction.Furtherpromotioncamefromaseriesofinstructionalcoursesindifferentcountriesandfromfellowships,mainlyorganizedinSwitzerlandandtheUSA.Also,theongoingmentorshipforcolleaguesduringtheirlearningperiodshouldberemembered[51].SwitzerlandhasprobablythehighestconcentrationoforthopedicdepartmentsperformingtheBerneseperiacetabularosteotomy,withmostoftherelevantpublicationscomingfromtheBerneseGroup[52].NextaretheUSAandCanada,whereseveralinstitutionsworktogetherintheANCHORgrouptostudyallaspectsofsurgerypreservingthenativehipjoint[53].Oneormorecentersarepracticing,andsomedoreportabouttheirresultswiththeBerneseperiacetabularosteotomyinGermany,England,Denmark,Italy,Spain,Portugal,Chile,Iran,andfinallyChina,fromwherethemostrecentreportwaspublished[54].?FutureopportunitiesandchallengesTheindicationfor(oragainst)PAOisstilloneofthemostdifficultdecisionstobemade.Thereisatendencytoperformthesurgeryevenwhenthetriradiategrowthplateisstillopen,butlittleisknownabouthowfaronecangowithoutriskingsurgery-relatedmalformationafterinjuringthegrowthplate.Interestinglyenough,deepeningoftheimmatureacetabulumforcapsulararthroplastydoesnotseemtoproduceamalformation.Maybemolecularstudiesofthetriradiatecartilagecangivesomeideasaboutitsgrowthbalance.TheindicationlimitforoldercandidatesisindirectlydefinedbytherecognitionthatPAOresultsaftertheageof40yearsarestatisticallylessfavorable.However,maybethedirectreasoncouldbetheincreaseofcartilagedegenerationwithage.However,tousedetailedinformationaboutthestatusofthejointcartilageasoftwarewouldberequiredtoquantifyandlocatethecartilagedamageoffemoralheadandacetabulumseenonanMRI.Inanycase,todaytheT?nnisclassificationofhipjointarthrosisaloneisnotagoodparameterfordecision-makingandfollow-upconclusions.WhilethegeometryofthePAOcutsdidnotchange,theapproachalreadywentthroughsomemodifications.Somerepresentaclearadvantage;oneshowedabenefittogetherwithonlyoneminorhandicapduringcadavertesting.Itwouldbehelpfultohavesuchorsimilarstudiesofcomparison,includingthepreoperativeexpenditurefortheminimallyinvasivetechniques.Furtherpropositionsofcomputerassistanceshouldbeanalyzedforexpenditureversusimpact.Progresscanbeexpectedwhenthisdemandingsurgeryisconcentratedinfewcenterswithahighcaseloadandwhenseveralsuchcentersworktogetherandcollecttheirmaterialinacentralregistry.2024年06月17日74
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李旭主任醫(yī)師 醫(yī)生集團(tuán)-廣東 小兒骨科 兒童發(fā)育性髖關(guān)節(jié)發(fā)育不良（DDH）是小兒骨科最常見的髖關(guān)節(jié)畸形，嚴(yán)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(fù)位、石膏固定的方式有效治療。隨著年齡的增大，18月齡及以上的DDH患兒病理改變進(jìn)一步加重，通常需要更大矯正幅度的截骨手術(shù)。對于學(xué)齡前（小于5-6歲）的低齡兒童髖關(guān)節(jié)畸形，Salter骨盆截骨術(shù)(SalterInnominateOsteotomy,SIO)，仍是目前使用最為廣泛的手術(shù)方式。作為小兒骨科的關(guān)鍵手術(shù)技術(shù)之一，其對于兒童的各種復(fù)雜髖關(guān)節(jié)畸形，具有強(qiáng)大的矯正能力，可以實現(xiàn)髖臼對股骨頭的良好包容、穩(wěn)定髖關(guān)節(jié)。該類截骨手術(shù)被廣泛應(yīng)用于治療DDH等各種原因?qū)е碌膬和l(fā)育性髖關(guān)節(jié)發(fā)育不良，是目前全世界公認(rèn)的低齡兒童髖關(guān)節(jié)畸形最有效的手術(shù)方法之一。傳統(tǒng)Salter骨盆截骨術(shù)RobertSalter于1961年發(fā)明了Salter骨盆截骨術(shù)（salterinnominateosteotomy，SIO）治療發(fā)育性髖關(guān)節(jié)脫位。SIO以恥骨聯(lián)合為鉸鏈，可使髖臼向前、下、外恢復(fù)覆蓋，骨盆截骨處可通過骨塊和克氏針固定，從而得到一個穩(wěn)定復(fù)位的髖關(guān)節(jié)。SIO至今已經(jīng)沿用了50余年，治療了大量的發(fā)育性髖關(guān)節(jié)脫位病例，獲得了良好的效果！改良原創(chuàng)（Improveandoriginal）國內(nèi)著名兒童骨科專家李旭教授帶領(lǐng)汕頭大學(xué)廣州華新骨科醫(yī)院兒童骨科團(tuán)隊在傳統(tǒng)的Salter骨盆截骨術(shù)（SIO）基礎(chǔ)上做了進(jìn)一步的改良，并推廣應(yīng)用于臨床工作中，我們將此技術(shù)命名為Salter-Li骨盆截骨術(shù)（Salter-LiInnominateOsteotomy，SLIO)。區(qū)別于傳統(tǒng)SIO手術(shù)，優(yōu)勢明顯華新兒童骨科團(tuán)隊2015年開始，受瑞士TheddySlongo教授的Bernese骨盆截骨術(shù)影響，李旭教授帶領(lǐng)團(tuán)隊對小兒骨科的經(jīng)典手術(shù)—Salter骨盆截骨術(shù)進(jìn)行了大幅改良，具體改進(jìn)內(nèi)容包括：（1）無需劈開髂骨骨骺，避免了遠(yuǎn)期髂嵴的發(fā)育性畸形風(fēng)險；（2）僅從髂骨內(nèi)板行骨膜外剝離，提前處理骶髂關(guān)節(jié)旁滋養(yǎng)血管，大大減少了術(shù)中失血；（3）?術(shù)中無需剝離髂骨外板的肌肉軟組織附著，避免了遠(yuǎn)期因臀肌損傷導(dǎo)致的步態(tài)異常，及髖臼緣出現(xiàn)缺血性改變的風(fēng)險；（4）特殊的倒“L”形髂骨截骨設(shè)計，無需進(jìn)行髂骨取骨即可獲得較經(jīng)典手術(shù)更優(yōu)的截骨穩(wěn)定性；（5）特殊的髂骨截骨設(shè)計，可以使遠(yuǎn)端骨塊獲得更大旋轉(zhuǎn)幅度而不影響固定的穩(wěn)定性，從而獲得較經(jīng)典手術(shù)更大的髖臼指數(shù)的矯正和頭臼覆蓋改善；（6）由于手術(shù)操作大大簡化，切口長度、手術(shù)時間、術(shù)中失血量等均明顯優(yōu)于經(jīng)典Salter手術(shù)，手術(shù)更加微創(chuàng)，學(xué)習(xí)曲線亦顯著縮短。SLIO相比于傳統(tǒng)SIO更加微創(chuàng)，該術(shù)式不需要劈開髂骨骨骺，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(yuǎn)端之間的兩點接觸，對髖臼畸形有更強(qiáng)大的矯正能力。更重要的是術(shù)中切口非常微創(chuàng)，不超過3cm，這也是迄今為止同類手術(shù)中文獻(xiàn)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(guān)節(jié)開放復(fù)位、Salter骨盆截骨術(shù)——李旭教授改良Salter骨盆截骨術(shù)（SLIO）臨床病例Case1:馮2歲，女，右側(cè)發(fā)育性髖關(guān)節(jié)脫位，雙下肢不等長手術(shù)方式：右側(cè)髖關(guān)節(jié)開放復(fù)位、Salter骨盆截骨矯形內(nèi)固定、髖人字石膏固定術(shù)、右側(cè)闊筋膜張肌、內(nèi)收肌、腰肌松解手術(shù)時間：1.5小時手術(shù)出血量：小于100mlCase2:陸2歲，女，左側(cè)發(fā)育性髖關(guān)節(jié)脫位，雙下肢不等長手術(shù)方式：左側(cè)髖關(guān)節(jié)切開復(fù)位關(guān)節(jié)腔清理、Salter骨盆截骨矯形內(nèi)固定、左側(cè)內(nèi)收肌經(jīng)皮松解、髂腰肌松解、石膏固定手術(shù)時間：1.5小時手術(shù)出血量：80ml中國最微創(chuàng)的兒童髖關(guān)節(jié)開放復(fù)位、Salter骨盆截骨手術(shù)李旭兒童骨科團(tuán)隊近年來開展改良原創(chuàng)的（微創(chuàng)）骨盆截骨術(shù)——Salter-Li骨盆截骨術(shù)并大力推廣應(yīng)用于臨床，充分體現(xiàn)了團(tuán)隊不斷探索、創(chuàng)新的發(fā)展理念。上面兩個病例在手術(shù)中都使用了團(tuán)隊原創(chuàng)改良的Salter-Li骨盆截骨術(shù)，手術(shù)時間短，術(shù)中出血量小，手術(shù)切口小于3cm，這也是迄今為止同類手術(shù)中文獻(xiàn)所報道使用的最小切口，術(shù)后患者恢復(fù)快，臨床癥狀改善明顯，滿意率高！“Salter骨盆截骨術(shù)”作為小兒骨科的關(guān)鍵手術(shù)技術(shù)之一，對于兒童的復(fù)雜髖關(guān)節(jié)畸形，具有強(qiáng)大的矯正能力，但由于手術(shù)難度大、學(xué)習(xí)曲線長，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(shù)技術(shù)。這些年我們賦能提質(zhì)，髖關(guān)節(jié)手術(shù)逐步向微創(chuàng)化、創(chuàng)新化、精準(zhǔn)化高質(zhì)量發(fā)展，團(tuán)隊對該手術(shù)技術(shù)已經(jīng)處于國際領(lǐng)先水平。不再“大刀闊斧”，我院骨科手術(shù)邁入微創(chuàng)化時代工欲善其事，必先利其器。華新李旭兒童骨科團(tuán)隊在李旭教授的帶領(lǐng)下，始終秉持“復(fù)雜手術(shù)簡單化、常規(guī)手術(shù)微創(chuàng)化、疑難手術(shù)個性化”的創(chuàng)新發(fā)展理念，一路披荊斬棘、技術(shù)革新，科室醫(yī)療技術(shù)得到全新的突破，從“大刀闊斧”到“精雕細(xì)琢”，華新李旭兒童骨科手術(shù)邁入微創(chuàng)化時代，為中國患兒提供更有質(zhì)量的醫(yī)療。迎難而上的勇氣，是源于團(tuán)隊加強(qiáng)技術(shù)積累和敢于業(yè)務(wù)攻關(guān)的實力和底氣。上述技術(shù)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(wù)廣大患者，我們將繼續(xù)迎難而上，往高精尖技術(shù)的道路上大步邁進(jìn)！汕頭大學(xué)廣州華新骨科醫(yī)院兒童骨科，前身為原南方醫(yī)科大學(xué)第三附屬醫(yī)院兒童骨科團(tuán)隊，由李旭博士于2011年7月份創(chuàng)建成立。2018年12月，李旭博士帶領(lǐng)兒童骨科團(tuán)隊遷移至廣州華新骨科醫(yī)院，學(xué)科建設(shè)邁上新臺階，與國際間的學(xué)術(shù)交流合作日益增多。2020年5月，美國哥倫比亞大學(xué)終身名譽(yù)教授——紐約摩根斯坦利兒童醫(yī)院前小兒骨科主任DavidP.RoyeJr.教授加盟華新兒童骨科團(tuán)隊，以謀求為中國患兒提供更有質(zhì)量的醫(yī)療，和培訓(xùn)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(tuán)隊，為中國醫(yī)師協(xié)會骨科分會兒童骨科學(xué)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(xué)組主任委員單位。學(xué)科技術(shù)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(tuán)隊對傳統(tǒng)國內(nèi)骨科界鮮少涉足的領(lǐng)域，如腦癱等神經(jīng)肌肉型疾病所涉及的四肢、脊柱畸形和運動功能障礙的治療，可提供世界級水平的高質(zhì)量服務(wù)；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(xué)博士后，主任醫(yī)師，碩士研究生導(dǎo)師；汕頭大學(xué)廣州華新骨科醫(yī)院院長；中國著名兒童骨科專家。學(xué)術(shù)任職：亞太小兒骨科學(xué)會（APPOS）理事會中國執(zhí)委；華裔小兒骨科學(xué)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(xué)會骨科分會小兒創(chuàng)傷與矯形學(xué)組委員；廣東省骨科醫(yī)師協(xié)會常務(wù)委員暨小兒骨科學(xué)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(fù)醫(yī)學(xué)會修復(fù)重建外科專委會四肢先天畸形學(xué)組副組長；Depuy-Synthes南方小兒骨科培訓(xùn)中心主任；AO中國小兒骨科講師。專業(yè)擅長：兒童骨關(guān)節(jié)系統(tǒng)各種嚴(yán)重復(fù)雜創(chuàng)傷和后遺癥的手術(shù)治療；兒童先天性髖關(guān)節(jié)脫位(DDH)、腦癱、馬蹄內(nèi)翻足、多并指（趾）等各種兒童先天及后天性復(fù)雜肢體畸形；各種骨病后遺癥、兒童股骨頭壞死(Perthes病)、肌性斜頸、骨與軟組織腫瘤、各種肢體少見病及疑難雜重癥。關(guān)注我?了解更多兒童骨科相關(guān)知識！2024年06月06日565
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王華副主任醫(yī)師 復(fù)旦大學(xué)附屬華東醫(yī)院 疼痛科 髖關(guān)節(jié)的發(fā)育與解剖，髖關(guān)節(jié)位于骨盆兩側(cè)，是由髖骨上凹陷的髖臼和股骨向內(nèi)上伸出的股骨頭相互嵌合而組成的多軸球窩關(guān)節(jié)。從胚胎發(fā)育上講，髖骨由髂骨、恥骨、坐骨融合而成，約16歲左右完全骨化，三骨在髖臼處匯合，共同組成髖臼窩。凹陷的髖臼窩內(nèi)有半月形的關(guān)節(jié)面。 與嵌入的股骨頭一起構(gòu)成髖關(guān)節(jié)。股骨頭位于股骨上端，股骨是人體最長、最結(jié)實的長骨，長度約為身高的1/4，分一體兩端，上端朝向內(nèi)上的股骨頸支撐著股骨頭。股骨頸與股骨干之間的夾角，醫(yī)學(xué)上稱頸干角，成年后約125°。人類出生時，頸干角大約在140°~150°，這個角度會隨著年齡慢慢降低到125°左右，主要原因是行走時對股骨頭的生物應(yīng)力。頸干角異常，醫(yī)學(xué)上被稱為股骨外翻和股骨內(nèi)翻。除冠狀面上的頸干角外，股骨頸和股骨干與股骨頸之間還有一個水平面上的扭轉(zhuǎn)角，一般約15°。前傾角異長，醫(yī)學(xué)上被稱為股骨頭前傾或后傾。出生時。 健康嬰兒的前傾角大約為40°左右，但隨著骨頭的生長，在力學(xué)承重和肌肉活動的影響下。 到16歲時大約為15°，成年后若依然過度前傾，會增加脫臼和髖關(guān)節(jié)炎風(fēng)險，表現(xiàn)出內(nèi)八字步態(tài)。2024年01月29日32
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髖關(guān)節(jié)發(fā)育不良：PAO髖臼周圍截骨術(shù)后髖關(guān)節(jié)是如何發(fā)展變化的？（不同嚴(yán)重程度的發(fā)育不良髖關(guān)節(jié)在PAO
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陶可主治醫(yī)師 北京大學(xué)人民醫(yī)院 骨關(guān)節(jié)科 髖關(guān)節(jié)發(fā)育不良：PAO髖臼周圍截骨術(shù)后髖關(guān)節(jié)是如何發(fā)展變化的？（不同嚴(yán)重程度的發(fā)育不良髖關(guān)節(jié)在PAO截骨術(shù)后能有效保髖多少年？）作者：CodyCWyles,JuanSVargas,MarkJHeidenreich,KristinCMara,ChristopherLPeters,JohnCClohisy,RobertTTrousdale,RafaelJSierra.作者單位:DepartmentofOrthopedicSurgery(C.C.W.,J.S.V.,M.J.H.,R.T.T.,andR.J.S.)andDivisionofBiomedicalStatisticsandInformatics(K.C.M.),MayoClinic,Rochester,Minnesota.譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）摘要背景：髖臼周圍截骨術(shù)（PAO）是骨骼成熟患者中癥狀性髖臼發(fā)育不良或發(fā)育性髖關(guān)節(jié)發(fā)育不良（DDH）的最常見治療方法。這項多中心隊列研究的目的是描繪髖臼周圍截骨術(shù)（PAO）后髖關(guān)節(jié)發(fā)育不良的長期放射學(xué)自然史。方法：我們評估了1996年至2012年在美國3個學(xué)術(shù)機(jī)構(gòu)接受髖臼周圍截骨術(shù)（PAO）的所有患者。納入標(biāo)準(zhǔn)是DDH的髖臼周圍截骨術(shù)（PAO）并至少進(jìn)行5年的影像學(xué)隨訪。排除標(biāo)準(zhǔn)為單純髖臼后傾、神經(jīng)源性發(fā)育不良、Legg-Calvé-Perthes病以及既往髖關(guān)節(jié)手術(shù)（包括截骨術(shù)和關(guān)節(jié)鏡檢查）的髖臼周圍截骨術(shù)（PAO）。共有288名患者，其中83%是女性；平均年齡和體重指數(shù)(BMI)分別為29歲和25kg/m。平均臨床和放射學(xué)隨訪時間為9.2年（范圍為5.0至21.1年）。對每張術(shù)前和術(shù)后髖關(guān)節(jié)X線片進(jìn)行評估，根據(jù)T?nnis分類確定骨關(guān)節(jié)炎的程度。通過多狀態(tài)建模對生存率進(jìn)行分析，從而能夠通過T?nnis等級評估進(jìn)展，而不僅僅是像Kaplan-Meier技術(shù)那樣的個體轉(zhuǎn)變。結(jié)果：截至最終隨訪時，144名患者（50%）進(jìn)展至少1T?nnis級，其中42名患者（14.6%）接受全髖關(guān)節(jié)置換術(shù)。髖臼周圍截骨術(shù)（PAO）后每個T?nnis等級的平均存留年數(shù)為：T?nnis1級為19年，T?nnis2級為8年，T?nnis3級為4年。在初始T?nnis較高的基礎(chǔ)上，進(jìn)展為全髖關(guān)節(jié)置換術(shù)的可能性顯著增加（p<0.001）。最顯著的差異發(fā)生在T?nnis0級或1級與T?nnis2級之間；對于T?nnis1級，5年和10年進(jìn)展為全髖關(guān)節(jié)置換術(shù)的概率分別為2%和11%，而T?nnis2級分別為23%和53%。結(jié)論：髖臼周圍截骨術(shù)（PAO）有效地改變了DDH的自然史?，F(xiàn)在可以使用基于T?nnis分級的精確放射學(xué)進(jìn)展來確定自然髖關(guān)節(jié)的預(yù)后。重要的是，這項研究表明，與T?nnis0級或1級骨關(guān)節(jié)炎患者相比，術(shù)前T?nnis2級骨關(guān)節(jié)炎患者在髖臼周圍截骨術(shù)（PAO）后10年內(nèi)進(jìn)展到全髖關(guān)節(jié)置換術(shù)的幾率明顯增加。表I入組隊列的患者特征在每個參與地點獲得當(dāng)?shù)貦C(jī)構(gòu)審查委員會批準(zhǔn)后，我們評估了1996年至2012年在3個學(xué)術(shù)機(jī)構(gòu)接受髖臼周圍截骨術(shù)（PAO）的所有患者，包括梅奧診所（明尼蘇達(dá)州羅徹斯特）、華盛頓大學(xué)（密蘇里州圣路易斯）和猶他州大學(xué)（猶他州鹽湖城）。納入標(biāo)準(zhǔn)為因髖關(guān)節(jié)發(fā)育不良（DDH）或髖關(guān)節(jié)發(fā)育不良（DDH）同時伴有髖臼后傾而行髖臼周圍截骨術(shù)（PAO），且至少進(jìn)行5年影像學(xué)隨訪。排除標(biāo)準(zhǔn)為包括因單純髖臼后傾、神經(jīng)源性發(fā)育不良、Legg-Calv′e-Perthes病而行髖臼周圍截骨術(shù)（PAO），以及任何先前的髖關(guān)節(jié)手術(shù)，包括關(guān)節(jié)鏡檢查和兒童截骨術(shù)。最終隊列中有288名患者，其中139名來自梅奧診所，119名來自華盛頓大學(xué)，30名來自猶他大學(xué)?？傮w而言，83%的患者為女性，平均年齡為29歲，平均體重指數(shù)（BMI）為25kg/m2（表I）。平均臨床和影像學(xué)隨訪時間為9.2年（范圍為5.0至21.1年）。137例患者在髖臼周圍截骨術(shù)（PAO）時進(jìn)行了同期其他手術(shù)，包括88例骨軟骨成形術(shù)、31例盂唇清理術(shù)、19例盂唇修復(fù)術(shù)、11例股骨截骨術(shù)和1例轉(zhuǎn)子上移術(shù)。46例患者在髖臼周圍截骨術(shù)（PAO）后進(jìn)行了其他手術(shù)，包括38例內(nèi)固定物移除、6例髖關(guān)節(jié)鏡探查、4例沖洗和清創(chuàng)、3例盂唇修復(fù)、1例血腫清除和1例腰肌腱松解。每張可用的術(shù)前和術(shù)后骨盆或髖關(guān)節(jié)前后位X線片均由2名評審員獨立評估，根據(jù)T?nnis分類（0至3級）確定骨關(guān)節(jié)炎的程度。當(dāng)評審者評估X線片上的T?nnis等級時，根據(jù)先前描述的分類系統(tǒng)標(biāo)準(zhǔn)，將患者分配到可能的最高等級。評估人員采用以下標(biāo)準(zhǔn)：T?nnis0級表示不存在退行性變化；T?nnis1級（輕度），關(guān)節(jié)間隙輕度變窄，硬化區(qū)擴(kuò)大，表現(xiàn)為輕度硬化，邊緣有小骨贅；T?nnis2級（中度），關(guān)節(jié)間隙中度變窄，股骨頭或髖臼中度硬化，股骨頭或髖臼內(nèi)存在軟骨下小的骨囊腫，股骨頭球形度中度喪失；T?nnis3級（重度），關(guān)節(jié)間隙嚴(yán)重變窄（<1mm）或關(guān)節(jié)間隙閉塞，股骨頭或髖臼上有大軟骨下骨囊腫的證據(jù)，股骨頭嚴(yán)重失去球形度，以及晚期骨壞死。對每張放射學(xué)照片的評估對于通過多狀態(tài)建模進(jìn)行生存分析至關(guān)重要。與Kaplan-Meier技術(shù)相比，該方法結(jié)合了所有單獨的放射學(xué)照相數(shù)據(jù)點來定義疾病進(jìn)展，精度更高。分析中總共納入了288名患者的2,024張X線片，每位患者中位數(shù)為7張X線片（范圍為2至17張X線片）。除了T?nnis等級評估之外，術(shù)前和術(shù)后還評估了骨盆前后位以及髖關(guān)節(jié)前后位和側(cè)位X線片，以確定如前所述的以下參數(shù)：最小關(guān)節(jié)間隙（以毫米為單位）、側(cè)向中心邊緣角(LCEA)、T?nnis角、前中心-邊緣角（ACE）和髖臼后傾（表I）。將多狀態(tài)模型確定的疾病進(jìn)展與歷史對照患者隊列進(jìn)行比較，這些患者要么患有DDH，但未接受保髖手術(shù)，要么具有正常形態(tài)的髖關(guān)節(jié)（由LCEA定義為25°至40°和T?nnis角0°至10°）。這些歷史對照采用相同的統(tǒng)計技術(shù)進(jìn)行評估，并跟蹤長達(dá)35年。BMI=體重指數(shù)，LCEA=外側(cè)中心邊緣角，ACE=前方中心邊緣角。?數(shù)值以平均值和標(biāo)準(zhǔn)差形式給出，范圍在括號內(nèi)。?數(shù)值以平均值和標(biāo)準(zhǔn)差的形式給出?！熳罱K隨訪時的T?nnis等級。圖1?研究中所有288名患者的T?nnis分級。最終隨訪時向各種T?nnis等級或全髖關(guān)節(jié)置換術(shù)(THA)的過渡用箭頭顯示。在最終隨訪時{9.2年（范圍為5.0至21.1年）}，144名患者（50%）進(jìn)展至少1個T?nnis級，其中42名患者（14.6%）接受全髖關(guān)節(jié)置換術(shù)（圖1）。具體如下：術(shù)前，150個T?nnis0級髖中，有76(50.67%)髖進(jìn)展到T?nnis1級髖，有2(1.33%)髖進(jìn)展到T?nnis2級髖，有0(0.00%)髖進(jìn)展到T?nnis3級髖，有1(0.67%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA)；191個T?nnis1級髖中，有52(27.23%)髖進(jìn)展到T?nnis2級髖，有5(2.62%)髖進(jìn)展到T?nnis3級髖，有4(2.09%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA)；75個T?nnis2級髖中，有25(33.33%)髖進(jìn)展到T?nnis3級髖，有14(18.67%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA)；32個T?nnis3級髖中，有23(71.88%)髖進(jìn)展到全髖關(guān)節(jié)置換術(shù)(THA)。?表II根據(jù)髖關(guān)節(jié)形態(tài)學(xué)和手術(shù)干預(yù)劃分的在每個T?nnis等級中停留的平均年數(shù)髖臼周圍截骨術(shù)（PAO）后每個T?nnis等級的平均年數(shù)非常接近具有正常髖關(guān)節(jié)形態(tài)的歷史隊列。然而，歷史隊列中未經(jīng)治療的髖關(guān)節(jié)發(fā)育不良（DDH）患者比形態(tài)正常的患者和當(dāng)前研究中接受髖臼周圍截骨術(shù)（PAO）的患者髖關(guān)節(jié)骨關(guān)節(jié)炎(OA)進(jìn)展更快（表II）。對于通過髖臼周圍截骨術(shù)（PAO）的髖關(guān)節(jié)發(fā)育不良（DDH）患者，在每個T?nnis等級中停留的平均年數(shù)（近似理解為：保髖術(shù)后髖關(guān)節(jié)成功存留年數(shù)）為：T?nnis1級為19年，T?nnis2級為8年，T?nnis3級為4年；對于患有髖關(guān)節(jié)發(fā)育不良（DDH）而未接受髖臼周圍截骨術(shù)（PAO）的患者，T?nnis1級髖關(guān)節(jié)存活12年，T?nnis2級髖關(guān)節(jié)存活6年，T?nnis3級髖關(guān)節(jié)存活2年；對于（股骨頭）形態(tài)正常的髖關(guān)節(jié)發(fā)育不良（DDH）且未接受髖臼周圍截骨術(shù)（PAO）的患者，分別為18、9和0年（表II）。圖2?多狀態(tài)建模分析顯示基于任何給定時間點的T?nnis等級的無全髖關(guān)節(jié)置換術(shù)(THA)的存活率。因此，當(dāng)患者進(jìn)展到更嚴(yán)重的T?nnis等級時，他們會假定指示曲線所歸因的自然歷史是從時間零開始。髖臼周圍截骨術(shù)（PAO）手術(shù)前T?nnis分級較高，進(jìn)展為全髖關(guān)節(jié)置換術(shù)的可能性顯著增加(p<0.001)（圖2）。?表III?基于當(dāng)前T?nnis等級進(jìn)展到嚴(yán)重T?nnis等級或全髖關(guān)節(jié)置換術(shù)的概率。自然史最顯著的差異發(fā)生在髖臼周圍截骨術(shù)（PAO）時T?nnis0級或1級患者與T?nnis2級患者之間。對于T?nnis1級患者，5年和10年進(jìn)展為全髖關(guān)節(jié)置換術(shù)的概率分別為2%和11%，而T?nnis2級患者則分別為23%和53%（p<0.001）（表III）。髖臼周圍截骨術(shù)（PAO）后，進(jìn)展率和模式與歷史隊列中形態(tài)正常的患者相似，但與未處理的髖關(guān)節(jié)發(fā)育不良(DDH)患者相比顯著改善（所有比較p<0.05）（表III）。表IV?Cox比例風(fēng)險回歸模型評估患者人口統(tǒng)計特征對髖臼周圍截骨術(shù)（PAO）后進(jìn)展至嚴(yán)重T?nnis等級的影響在髖關(guān)節(jié)發(fā)育不良(DDH)組中，根據(jù)形態(tài)學(xué)和/或手術(shù)干預(yù)，髖臼周圍截骨術(shù)（PAO）10年后T?nnis1級或2級患者進(jìn)展為全髖關(guān)節(jié)置換術(shù)的概率：T?nnis1級患者為11%，T?nnis2級患者為53%；沒有髖臼周圍截骨術(shù)（PAO）的髖關(guān)節(jié)發(fā)育不良(DDH)組中：T?nnis1級患者進(jìn)展為全髖關(guān)節(jié)置換術(shù)為25%，T?nnis2級患者進(jìn)展為全髖關(guān)節(jié)置換術(shù)為74%；在沒有髖臼周圍截骨術(shù)（PAO）的（股骨頭）形態(tài)正常組中，這一比例為18%和68%（表III）。Cox比例風(fēng)險回歸模型表明，年齡、性別或BMI與髖臼周圍截骨術(shù)（PAO）后進(jìn)展至更嚴(yán)重T?nnis階段之間沒有顯著的總體關(guān)系（表IV）。??NaturalHistoryoftheDysplasticHipFollowingModernPeriacetabularOsteotomy.AbstractBackground:Periacetabularosteotomy(PAO)isthemostcommontreatmentforsymptomaticacetabulardysplasia,ordevelopmentaldysplasiaofthehip(DDH),inskeletallymaturepatients.Thepurposeofthismulticentercohortstudywastodelineatethelong-termradiographicnaturalhistoryofthedysplastichipfollowingPAO.Methods:WeevaluatedallpatientsundergoingPAOfrom1996to2012at3academicinstitutionsintheUnitedStates.InclusioncriteriawerePAOforDDHwithaminimum5-yearradiographicfollow-up.ExclusioncriteriawerePAOforisolatedacetabularretroversion,neurogenicdysplasia,Legg-Calvé-Perthesdisease,andpriorhipsurgeryincludingosteotomiesandarthroscopy.Therewere288patients,83%ofwhomwerewomen;themeanageandbodymassindex(BMI)were29yearsand25kg/m,respectively.Themeanclinicalandradiographicfollow-upwas9.2years(range,5.0to21.1years).EverypreoperativeandpostoperativehipradiographwasassessedtodeterminethedegreeofosteoarthritisaccordingtotheT?nnisclassification.Survivorshipwasanalyzedbymultistatemodeling,enablingassessmentofprogressionthroughtheT?nnisgradesratherthanjustindividualtransitionsaswithKaplan-Meiertechniques.Results:Atthetimeoffinalfollow-up,144patients(50%)hadprogressedatleast1T?nnisgrade,with42patients(14.6%)undergoingtotalhiparthroplasty.ThemeannumberofyearsspentineachT?nnisgradefollowingPAOwas19forT?nnisgrade1,8forT?nnisgrade2,and4forT?nnisgrade3.TheprobabilityofprogressiontototalhiparthroplastyincreasedsignificantlyonthebasisofahigherinitialT?nnisgrade(p<0.001).ThemostmarkeddifferenceoccurredbetweenT?nnisgrade0or1andT?nnisgrade2;forT?nnisgrade1,theprobabilityofprogressiontototalhiparthroplastyat5and10yearswas2%and11%,respectively,comparedwith23%and53%,respectively,forT?nnisgrade2.Conclusions:PAOeffectivelyaltersthenaturalhistoryofDDH.PreciseradiographicprogressionbasedontheT?nnisgradecannowbeusedtoascribeprognosisforthenativehip.Importantly,thisinvestigationdemonstratesastarkincreaseinprogressiontototalhiparthroplastywithin10yearsofPAOforpatientswithpreoperativeT?nnisgrade-2osteoarthritiscomparedwiththosewithT?nnisgrade-0or1osteoarthritis.?TABLEIPatientCharacteristicsofCohortFollowinglocalinstitutionalreviewboardapprovalateachparticipatingsite,weevaluatedallpatientsundergoingPAO,from1996to2012,at3academicinstitutionsincludingtheMayoClinic(Rochester,Minnesota),WashingtonUniversity(St.Louis,Missouri),andtheUniversityofUtah(SaltLakeCity,Utah).InclusioncriteriawerePAOforDDHorforDDHandconcomitantacetabularretroversionwithaminimum5-yearradiographicfollow-up.ExclusioncriteriawerePAOforisolatedacetabularretroversion,neurogenicdysplasia,Legg-Calv′e-Perthesdisease,andanypriorsurgeryaboutthehipincludingarthroscopyandchildhoodosteotomies.Therewere288patientsinthefinalcohort,with139fromtheMayoClinic,119fromWashingtonUniversity,and30fromtheUniversityofUtah.Overall,83%ofthepatientswerewomen,themeanagewas29years,andthemeanbodymassindex(BMI)was25kg/m2(TableI).Themeanclinicalandradiographicfollowupwas9.2years(range,5.0to21.1years).ConcomitantproceduresatthetimeofPAOwereperformedin137patientsandincluded88osteochondroplasties,31labraldebridements,19labralrepairs,11femoralosteotomies,and1trochantericadvancement.AdditionalprocedureswereperformedfollowingPAOin46patientsandincluded38hardwareremovals,6arthroscopicexplorations,4irrigationanddebridements,3labralrepairs,1hematomaevacuation,and1psoastendonrelease.Everyavailablepreoperativeandpostoperativeanteroposteriorradiographofthepelvisorhipwasindependentlyassessedby2reviewerstodeterminethedegreeofosteoarthritisaccordingtotheT?nnisclassification(grade0to3).WhenthereviewersassessedforT?nnisgradesonradiographs,patientswereassignedtothehighestgradepossibleonthebasisofpreviouslydescribedcriteriafortheclassificationsystem.Thefollowingcriteriawereappliedbytheassessors:T?nnisgrade0indicatedtheabsenceofdegenerativechanges;T?nnisgrade1(mild),mildjoint-spacenarrowing,mildsclerosisevidencedbywideningofthescleroticzone,andsmallmarginalosteophytes;T?nnisgrade2(moderate),moderatejoint-spacenarrowing,moderatesclerosisofthefemoralheadoracetabulum,presenceofsmallsubchondralcystswithinthefemoralheadoracetabulum,andmoderatelossoffemoralheadsphericity;andT?nnisgrade3(severe),severejoint-spacenarrowing(<1mm)orobliterationofthejointspace,evidenceoflargesubchondralcystsonthefemoralheadoracetabulum,severelossofsphericityofthefemoralhead,andadvancedosteonecrosis.Evaluationofeveryradiographwasessentialtoenablesurvivorshipanalysisbymultistatemodeling.ThismethodincorporatesallindividualradiographicdatapointsfordefinitionofdiseaseprogressionwithenhancedprecisioncomparedwithKaplan-Meiertechniques.Atotalof2,024radiographsofthe288patientswereincludedintheanalysis,withamedianof7radiographs(range,2to17radiographs)perpatient.InadditiontoT?nnisgradeevaluation,anteroposteriorpelvicandanteroposteriorandlateralradiographsofthehipwereassessedbothpreoperativelyandpostoperativelytodeterminethefollowingparametersaspreviouslydescribed:minimumjointspaceinmillimeters,lateralcenteredgeangle(LCEA),T?nnisangle,anteriorcenter-edgeangle(ACE),andacetabularretroversion(TableI)14.ProgressionofdiseaseasdeterminedbymultistatemodelingwascomparedwithahistoricalcontrolcohortofpatientswhoeitherhadDDHanddidnotundergohippreservationsurgeryorhadahipwithnormalmorphologyasdefinedbyanLCEAbetween25°and40°andaT?nnisangleof0°to10°.Thesehistoricalcontrolswereevaluatedbythesamestatisticaltechniquesandwerefollowedforupto35years.BMI=bodymassindex,LCEA=lateralcenter-edgeangle,andACE=anteriorcenter-edgeangle.?Thevaluesaregivenasthemeanandthestandarddeviation,withtherangeinparentheses.?Thevaluesaregivenasthemeanandthestandarddeviation.§T?nnisgradeatthetimeoffinalfollow-up.Fig.1TheT?nnisgradeofall288patientsinthestudy.TransitionstovariousT?nnisgradesortotalhiparthroplasty(THA)atthetimeoffinalfollow-upareshownwitharrows.Atthetimeoffinalfollow-up,144patients(50%)hadprogressionofleast1T?nnisgrade,with42patients(14.6%)undergoingtotalhiparthroplasty(Fig.1).TABLEIIMeanYearsSpentinEachT?nnisGradebyHipMorphologyandSurgicalInterventionThemeannumberofyearsspentineachT?nnisgradefollowingPAOcloselyapproximatedahistoricalcohortwithnormalhipmorphology12.However,patientswithunmanagedDDHfromthehistoricalcohorthadmorerapidprogressionthanpatientswhohadnormalmorphologyandpatientsfromthecurrentstudywhounderwentPAO(TableII).ThemeannumberofyearsspentineachT?nnisgradebymorphologyand/orsurgicalinterventionwas19yearsinT?nnisgrade1,8yearsinT?nnisgrade2,and4yearsinT?nnisgrade3forpatientswithDDHwhohadPAO;12,6,and2years,respectively,forpatientswithDDHandnoPAO;and18,9,and0years,respectively,forpatientswithnormalmorphologyandnoPAO(TableII).Fig.2Multistatemodelinganalysisdemonstratingsurvivorshipfreeoftotalhiparthroplasty(THA)basedontheT?nnisgradeatanygivenpointintime.Thus,themomentapatienttransitionstoamoreadvancedT?nnisgrade,theyassumethenaturalhistoryascribedbytheindicatedcurve,beginningattimezero.TheprobabilityofprogressiontototalhiparthroplastyincreasedsignificantlyonthebasisofahigherT?nnisgradeatthetimeofPAO(p<0.001)(Fig.2).TABLEIIIProbabilityofTransitiontoSubsequentT?nnisGradesorTotalHipArthroplastyBasedonCurrentT?nnisGrade.ThemostmarkeddifferenceinnaturalhistoryoccurredbetweenpatientswhohadT?nnisgrade0or1andthosewhohadT?nnisgrade2atthetimeofPAO.ForpatientswithT?nnisgrade1,theprobabilityofprogressiontototalhiparthroplastyat5and10yearswas2%and11%,respectively,comparedwith23%and53%forpatientswithT?nnisgrade2(p<0.001)(TableIII).FollowingPAO,therateandpatternofprogressionapproximatedthoseforpatientswithnormalmorphologyfromthehistoricalcohortbutweresignificantlyimprovedcomparedwithpatientswithunmanagedDDH(p<0.05forallcomparisons)(TableIII).TABLEIVCoxProportionalHazardsRegressionModelsAssessingInfluenceofPatientDemographicsonProgressiontoMoreAdvancedT?nnisGradesFollowingPAOThe10-yearprobabilityofpatientswithT?nnisgrade1or2progressingtototalhiparthroplastyaccordingtomorphologyand/orsurgicalinterventionwas11%forpatientswithT?nnisgrade1and53%forthosewithT?nnisgrade2inthegroupwhohadDDHwithPAO;25%and74%,respectively,inthegroupwithDDHwithoutPAO;and18%and68%inthegroupwithnormalmorphologywithoutPAO(TableIII).Coxproportionalhazardsregressionmodelsdemonstratednosignificantoverallrelationshipofage,sex,orBMIwithprogressiontomoreadvancedT?nnisstagesfollowingPAO(TableIV).文獻(xiàn)出處：CodyCWyles,JuanSVargas,MarkJHeidenreich,KristinCMara,ChristopherLPeters,JohnCClohisy,RobertTTrousdale,RafaelJSierra.NaturalHistoryoftheDysplasticHipFollowingModernPeriacetabularOsteotomy.JBoneJointSurgAm.2019May15;101(10):932-938.doi:10.2106/JBJS.18.00983.2023年12月26日364
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陳珽副主任醫(yī)師 上海新華醫(yī)院 小兒骨科 發(fā)育性髖關(guān)節(jié)脫位呢，從理論來說，我們是都能夠治得好，因為他的終極手術(shù)呢，就是髖關(guān)節(jié)置換，但是呢，我們小兒骨科醫(yī)生所希望的呢，就是通過早期發(fā)現(xiàn)，早期干預(yù)，早期的治療來進(jìn)行避免我們后期的一個髖關(guān)節(jié)置換，那么只要能夠及時發(fā)現(xiàn)，我們會有很多很多的手術(shù)方法來進(jìn)行治療，通過我們的精細(xì)治療，我們所經(jīng)手經(jīng)手的患兒呢，都是能夠保住自己的髖關(guān)節(jié)的，那么避免了以后起的髖關(guān)節(jié)置換的一個痛苦。至于手術(shù)方式呢，我們有很多，比如說我們的骨盆結(jié)骨啦，后期的造苷手術(shù)，呃，前期的保守治療，以及后期的一個呼吸性手術(shù)治療都可以，那么我們的目的主要是為了避免我們后期的一個髖關(guān)節(jié)置換，然后這樣呢，才能夠獲得一個良好的一個生活質(zhì)量，至于我們我們髖肩脫位呢，呃，什么時候開始治療呢？我們還是希望能夠一經(jīng)發(fā)現(xiàn)，就是需要早期進(jìn)行干預(yù)，早期進(jìn)行治療。只有早期治療我們才能。 能夠獲得滿意的一個效果。2023年11月07日71
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張中禮主任醫(yī)師 天津醫(yī)院 小兒骨科 那么整體來說的話，這個治療越早期發(fā)現(xiàn)治療是相對越簡單的，那么他的手段越簡單，那么對反而效果越好，那么目前來說的話，真正能夠讓髖關(guān)節(jié)我們說呃，實現(xiàn)一個一個良好的髖棍節(jié)，就像這個照片所現(xiàn)一樣，達(dá)到一個這么好這么好的一個髖棍節(jié)的話，那么就是呃，就是個正常的髖棍節(jié)來說的話，那么什么樣的一個時間干預(yù)，什么樣一個時間點，所謂的介入治療才可以獲得這樣的髖節(jié)呢？目前認(rèn)為恐怕最多是三個月甚至四個月以內(nèi)的髖關(guān)節(jié)，如果能及時的診斷，及時的得到治療的話，那么才有可能得到這樣一個正常的髖關(guān)節(jié)，那么一個片子表現(xiàn)出來一個這樣一個正常的髖關(guān)節(jié)，才會和正常人人的關(guān)節(jié)是一樣的，我們才可從這個角度來說的話，那么髖關(guān)節(jié)，呃，這種這種問題沒有低裂，它才是根本上得到的，被我們治療了。 那么包括半歲以后的孩子才發(fā)現(xiàn)，更更別說一歲以上的孩子才發(fā)現(xiàn)的話，那么這個髖關(guān)節(jié)發(fā)育，那么就存在這樣會有那樣的一些很多的不可不可預(yù)測的因素，所以我們還是要強(qiáng)調(diào)在全國范圍以內(nèi)，要要盡可能早的來針對這部分的孩子家長呢，進(jìn)行及時的，呃，我們說有有這樣一個一個及時的，就是發(fā)現(xiàn)及時的治療。2023年08月30日620
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張中禮主任醫(yī)師 天津醫(yī)院 小兒骨科 兩歲兩個月的孩子雙側(cè)高脫位可以保守治療嗎？呃，是這樣的，首先剛才跟大家講過一點點，就是說呃，脫延越嚴(yán)重的髖關(guān)節(jié)，脫曳時間越長的髖關(guān)節(jié)，它受這個這個這個周圍的這種阻擋，它再次復(fù)位進(jìn)去的這種，呃這種東西啊，我們的雜物啊，這種阻擋，這種阻擋的東西就越越嚴(yán)重了，所以兩歲兩歲多的，兩歲兩個月的髖歡節(jié)，對呃，目前專業(yè)上角度來說的話，這個就就是屬于比較比較大齡的髖歡節(jié)了，呃，所以特別是這種高脫位的，那么其實我們這個股骨頭它離的髖臼那么那么那么遠(yuǎn)，那么那么遠(yuǎn)，這個想進(jìn)去的話，就很難進(jìn)得去了，那么我們非要勉強(qiáng)的進(jìn)進(jìn)去怎么辦呢？恐怕需要很用力的，這個這個給一個很強(qiáng)迫的體位，才能把這股骨頭呃強(qiáng)力的放。 在那個關(guān)節(jié)髖節(jié)窩里邊，但是一定也是要注意這種治療這種什么，我們說力的作用都是相互的，我們想克服這些阻擋的話，這個其實股骨頭本身，呃，特別是股骨頭本身也會受到很很大的這種反作用力，我們的這么重的這樣一個阻擋，這么嚴(yán)重的阻擋，那么對股骨頭，特別是對一個嬌嫩的股骨頭，兩歲多的股骨孩子的髖關(guān)節(jié)股骨頭啊，很嬌嫩，所以他其實承受不了那么大的一個所謂的那個這樣一個反作用力，那么很高的風(fēng)險會導(dǎo)致股骨頭缺血壞死，這個如果一2023年08月30日121
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