唯醫(yī)FM-髖關節(jié)撞擊綜合癥的診治要點

唯醫(yī)FM髖關節(jié)撞擊綜合癥的診治要點唯醫(yī)FM全新升級，強勢來襲！本期唯醫(yī)FM將為您陸續(xù)放送美國骨科醫(yī)師協(xié)會（AAOS）精編教程性書籍《AAOSEssentialsofMusculoskeletalCare5th》。中國醫(yī)師協(xié)會骨科醫(yī)師分會（CAOS）已獲授權出版中文版書籍，并已組織國內多個著名醫(yī)院的醫(yī)生完成了全文翻譯，紙質版即將刊印，電子英文原版也會陸續(xù)在唯醫(yī)網發(fā)布。歡迎老師們登陸唯醫(yī)網進行學習。本期為大家放送教程節(jié)選內容：髖關節(jié)撞擊綜合癥。長按二維碼查看完整譯文一同義詞股骨髖臼撞擊綜合癥Femoralacetabularimpingement(FAI)二定義髖關節(jié)撞擊綜合癥，又稱股骨髖臼撞擊綜合癥，是由于髖臼緣與股骨頭頸連接部骨質形態(tài)異常，在髖關節(jié)過度活動時兩者不斷的發(fā)生接觸、碰撞，導致髖臼盂唇及軟骨損傷。有研究顯示，微小的骨質結構異常導致持續(xù)不斷的微小創(chuàng)傷，逐漸發(fā)展為盂唇的撕裂。Hipimpingement,orfemoralacetabularimpingement(FAI),occurswhenareasofosseousdeformitiesontheacetabularrim,thefemoralhead-neckjunction,orbothabutatextremesofhipmotionandcauseinjurytotheacetabularlabrumandandcartilage.Studieshavedemonstratedthatmostlabraltearsoccurafterrepetitivemicrotraumaasaresultofthesesubtlestructuraldeformities.三臨床表現髖關節(jié)撞擊綜合癥多見于運動愛好者，從青少年到中年均可發(fā)病。髖關節(jié)撞擊繼發(fā)疼痛可能因某些急性誘因引起，但更多情況下，疼痛起病隱匿，隨著時間的推移逐漸加重。疼痛的位置非常重要，因為髖部關節(jié)內病損會特征性地表現為腹股溝區(qū)疼痛。髖關節(jié)撞擊綜合癥的患者常會把手卡在髖關節(jié)一側，訴拇指和其他手指之間所卡的部位有深部疼痛，這就是所謂的“C形征”。有些患者還會有髖關節(jié)外側大轉子區(qū)域疼痛，并伴有髖外展肌力減弱。其他可能的癥狀還有關節(jié)卡頓感、關節(jié)交鎖以及關節(jié)彈響。另外，許多患者在久坐、爬樓梯、上下車、穿鞋穿襪或者進行髖關節(jié)旋轉動作后，疼痛會明顯加重。Patientswithhipimpingementcanrangeinagefromteenagerstomiddle-agedweekendathletes.Painsecondarytohipimpingementmayoccurafteranacuteevent,butmoreoftenthepatientreportsaninsidiousonsetofpainthatbecomesmoreseverewithtime.Thelocationofthepainisimportantbecauseintra-articularhippathologyisclassicallyassociatedwithgroinpain.Withhipimpingement,patientsmayplaceahandoverthesideofthehipandreportthattheyfeeladeeppainlocatedbetweentheirfingersandthumb;thisisknownasthe“Csign.”Somepatientsalsomayreportpainonthelateralaspectofthehipoverthegreatertrochanter,withassociatedhipabductorweakness.Associatedcatching,locking,orclickingalsomaybepresent.Manypatientsdescribeworseningpainwithprolongedsittingorpainwithstairclimbing,gettinginandoutofacar,puttingonshoesorsocks,oractivitiesthatrequirerotationalmovement.四檢查·體格檢查髖關節(jié)撞擊綜合癥患者患側髖關節(jié)屈曲及內旋運動的幅度要比健側明顯減小。將患側髖關節(jié)置于最大屈曲內收內旋位（FADDIR），如果引出疼痛，則為髖關節(jié)撞擊征陽性（圖1）。Decreasedhipflexionandinternalrotationcomparedwiththeoppositeextremitymaybeobservedinpatientswithhipimpingement.Theclassicprovocativemaneuveristoplacethehipinmaximumflexion,adduction,andinternalrotation(FADDIR);painwiththismaneuverisapositiveimpingementsign(Figure1).圖1髖關節(jié)屈曲內收內旋檢查示意圖Figure1IllustrationoftheFADDIR(flexion,adduction,internalrotation)maneuver.·輔助檢查對于髖關節(jié)疼痛且伴有內旋受限的患者，應攝髖關節(jié)前后位及側位片。在關節(jié)間隙正常的前提下，X線的特征性表現是股骨頭頸交界區(qū)的偏心距減?。ㄒ娪赾am凸輪撞擊）和/或交叉征（見于pincer鉗形撞擊）（圖2）。在單純的股骨側凸輪撞擊時，股骨頸前側正常的凹弧面解剖形態(tài)消失，代之以異常的骨性凸起，在髖關節(jié)屈曲時撞擊髖臼前上緣，導致髖臼盂唇撕裂及鄰近軟骨剝離。APandlateralradiographsofthehipareindicatedforpatientswithpainandlimitedinternalrotationofthehip.Theclassicradiographicfeaturesarealossoffemoralhead-neckoffsetoneithertheAPorlateralview(camimpingement),acrossoversign(pincerimpingement),orboth,inthesettingofnormaljointspace(Figure2).Inpurefemoralcamimpingement,theanteriorfemoralnecklosesitsnormalconcaveanatomyandinsteadhasa“bump”thatimpingesontheanterosuperiorlabrumwithflexion,causinglabraltearsanddelaminationoftheadjacentcartilage.在鉗形撞擊時，髖臼對股骨頭呈現局部過度覆蓋（髖臼后傾）或整體過度覆蓋（髖臼過深或前突）。由于髖臼后緣較前緣更偏外，使髖臼的正常形態(tài)表現為前傾，。當髖臼前緣相對后緣外突時，即可發(fā)生鉗形髖臼撞擊，影像學表現出髖臼前緣反而位于后緣外側，稱之為交叉征。MRI和CT三維重建可以提供更詳細的髖部立體解剖信息，但由于技術水平和結果判讀的誤差，MRI對髖臼盂唇撕裂和關節(jié)軟骨損傷的診斷可能存在假陰性結果。磁共振關節(jié)造影是顯示髖臼盂唇撕裂和骨質結構異常最準確的方法（圖3）。Inpincerimpingement,theacetabulumeitherhasfocalovercoverage(focalretroversion)orglobalovercoverage(coxaprofundaorprotrusio).Themorphologyofanormalacetabulumisanteverted,inthattheposteriorrimismorelateralthantheanteriorrim.Pinceracetabularimpingementariseswhentheanterioracetabularrimisprominentrelativetotheposteriorrim,resultinginaradiographicappearanceinwhichtheanteriorwallismorelateralthantheposteriorwall.Thisisknownasthecrossoversign.EitherMRIorCTwiththree-dimensionalconstructionscanprovidefurtherinformationonthethree-dimensionalanatomyofthehip.MRImaybefalselynegativeforevidenceoflabraltearsorarticularcartilageinjurybecauseofvariabletechniqueorinterpretation.Magneticresonancearthrographyofthehipisthemostaccuratemodalityfordemonstratingassociatedlabraltearsandosseousabnormalities(Figure3).圖2髖關節(jié)撞擊患者的X線片。A，左髖關節(jié)前后位顯示，關節(jié)間隙完好，可見股骨凸輪畸形（箭頭）和髖臼交叉征（星號）。實線表示髖臼前緣，虛線表示髖臼后緣。B，騎跨式側位片顯示，股骨頭前緣正常凹弧面形態(tài)消失（箭頭）。Figure2Radiographsfromapatientwithhipimpingement.A,APviewofthelefthipdemonstratesapreservedjointspacewithacamdeformity(arrow)ofthefemurandcrossoversign(*)ontheacetabulum.Thesolidlineindicatestheanteriorwall;thedashedlineindicatestheposteriorwall.B,Cross-tablelateralviewalsodemonstratesthelossoffemoralheadconcavity(arrow).圖3磁共振關節(jié)造影冠狀位T2加權像顯示，右髖關節(jié)髖臼上緣盂唇撕裂（箭頭）。Figure3T2-weightedcoronalmagneticresonancearthrogramofarighthipdemonstratesalabraltear(arrow).五鑒別診斷運動疝（腹直肌止點及內收肌腱處疼痛）髖關節(jié)發(fā)育不良（X線檢查可明確）股部皮神經卡壓（感覺異常，有燒灼樣痛，髖關節(jié)活動正常）腹股溝拉傷（X線正常）骨關節(jié)炎（X線片可見關節(jié)間隙變窄、骨贅形成、軟骨下骨硬化及囊性變）股骨頭缺血性壞死（X線平片及MRI可明確）腰大肌撞擊綜合癥或腰大肌腱彈響（髖關節(jié)屈曲、環(huán)形運動或拉伸時，腹股溝區(qū)可聽到可重復出現的彈響）轉子滑囊炎（大轉子局部壓痛，疼痛影響髖關節(jié)外展，關節(jié)活動度正常）骨盆或脊柱腫瘤（背痛、夜間痛，髖關節(jié)活動正常）Athleticpubalgia/sportshernia(painoverrectusinsertionandadductortendons)Developmentaldysplasiaofthehip(evidentonradiographs)Femoralcutaneousnerveentrapment(sensorychanges,burningpain,normalhiprangeofmotion)Groinstrains(normalradiographs)Osteoarthritis(narrowjointspaceonradiographswithassociatedosteophytes,subchondralsclerosisandcysticchanges)Osteonecrosisofthefemoralhead(evidentonplainradiographsorMRI)Psoasimpingementorsnappingpsoastendon(audiblesnapingroinreproduciblewithflexion,circumduction,andextension)Trochantericbursitis(localtendernessofthegreatertrochanter,painwithresistedhipabduction,normalmotion)Tumorofthepelvisorspine(backpain,nightpain,normalhiprangeofmotion)六疾病的不良后果60%~80%的髖關節(jié)骨關節(jié)炎是由髖關節(jié)撞擊或其他髖關節(jié)畸形引起的。雖然還沒有系統(tǒng)性的證據證明髖關節(jié)撞擊會導致骨關節(jié)炎，但對其自然病史的長期前瞻性研究支持這一觀點。如果髖關節(jié)撞擊是導致骨關節(jié)炎的主要原因，那么對髖關節(jié)撞擊進行手術干預可能延緩甚至避免骨關節(jié)炎的發(fā)生。Hipimpingementandotherhipdeformitiesmaybetheetiologyfor60%to80%ofcasesofosteoarthritisofthehip.Theassertionthathipimpingementcanpotentiallycauseosteoarthritishasnotbeenscientificallyproved,butlong-termprospectivenaturalhistorystudiesmayprovidestrongsupportforthisidea.Ifhipimpingementisamajorcontributortohiposteoarthritis,itisthoughtthatsurgicalinterventionforhippainsecondarytohipimpingementmaydelaytheonsetorpotentiallyevenpreventhiposteoarthritis.七治療對于所有髖關節(jié)撞擊的患者首先應采用非手術治療，其內容包括應用對乙酰氨基酚及NSAIDs類藥物并限制關節(jié)活動。還應該請對處理非人工置換髖關節(jié)功能障礙有經驗的專業(yè)康復醫(yī)師會診，進行髖關節(jié)活動訓練及力量訓練，爭取恢復髖關節(jié)肌力平衡狀態(tài)。長期髖關節(jié)撞擊的患者常會伴有肌腱炎和髖關節(jié)僵硬，對于這類患者，深部組織按摩或快速放松療法等物理治療有著良好的效果。在X線透視引導下進行關節(jié)內注射局麻藥物和皮質醇激素既可以起到明確診斷的作用，又可以進行治療。如果注射后疼痛完全緩解，就可以確定疼痛的來源在關節(jié)內。經過一段時間的非手術治療，大多數患者的疼痛癥狀都可以得到緩解。Theinitialtreatmentofallpatientsisnonsurgicalandconsistsofacombinationofacetaminophen,NSAIDs,andactivitymodification.Arehabilitationspecialistfamiliarwithnonarthroplastyhipjointdysfunctionshouldbeconsultedforhiprangeofmotionandstrengthtraining,withthegoalofrestoringmuscularbalancetothehip.Modalitiessuchasdeeptissuemassageoractivereleasetherapymaybehelpfulinpatientswithassociatedtendinitisorstiffnessaboutthehipsecondarytolong-standinghipimpingement.Fluoroscopicallyguidedintra-articularhipinjectionswithacombinationofalocalanestheticandacorticosteroidarebothdiagnosticandtherapeutic,andcompletepainreliefisthemostaccuratetesttodetermineanintra-articularetiologyforhippain.Painreliefoccursinmanypatientsafteracourseofnonsurgicaltreatment.對于非手術治療效果不佳的患者應采取手術治療。髖關節(jié)撞擊的手術治療最初需要行開放手術并將髖關節(jié)脫位，以充分顯露股骨頭頸連接部以及髖臼邊緣。近來關節(jié)鏡技術已經逐漸應用于髖關節(jié)撞擊的手術治療。術后早期活動，使用CPM和固定自行車進行關節(jié)康復鍛煉，對于關節(jié)活動程度和運動能力的恢復非常重要。Patientswithhipimpingementthathasbeenrefractorytononsurgicaltreatmentarecandidatesforsurgicalintervention.Hipimpingementwasoriginallytreatedwithopensurgicalhipdislocationtosafelyprovideexposuretothefemoralhead-neckjunctionandtheacetabularrim.Morerecently,arthroscopictechniqueshavebeendevelopedtoperformsurgeryforhipimpingement.Earlypostoperativemobilizationandrangeofmotionwithacontinuouspassivemotionmachineandastationarybicycleareimportantformotionrecovery.Postoperativerehabilitationisimportantforrestorationofmotionandthereturntofunctionalaswellassportingactivities.八治療的不良后果非手術治療的不良后果主要是長期應用NSAIDs類藥物相關的胃部、腎臟或肝臟并發(fā)癥。大劑量對乙酰氨基酚延伸治療也可能會有肝臟毒性。2015年，美國FDA再次強調：非甾體類消炎藥有誘發(fā)心臟疾病和中風的可能，并指出：即便在開始使用一種非甾體類消炎藥的數周內。髖關節(jié)鏡術后并發(fā)癥包括由神經麻痹導致的腹股溝區(qū)和足背部暫時的感覺麻木。少部分患者可能出現大腿外側持續(xù)麻木，這可能是由于手術臨近股外側皮神經引起的。開放手術和關節(jié)鏡手術的其他可能并發(fā)癥還包括：異位骨化、深靜脈血栓、關節(jié)僵硬等。極少數的病例會出現術后股骨頸骨折或關節(jié)不穩(wěn)。如果不進行治療，髖關節(jié)撞擊遠期的結果是發(fā)展為骨關節(jié)炎。AdverseoutcomesofnonsurgicaltreatmentincludecomplicationsrelatedtothechronicuseofNSAIDs,suchasgastric,renal,orhepaticproblems.Extendedtreatmentwithacetaminopheninlargedosescanleadtohepatictoxicity.In2015,theFDAstrengtheneditswarninglinkingNSAIDswiththeriskofheartattackorstroke,eveninthefirstweeksofuseofanNSAID.Postoperativecomplicationsassociatedwithhiparthroscopycanincludetemporarynumbnessinthegroinorthedorsalaspectofthefootsecondarytonervepalsy.Asmallnumberofpatien