髋臼股骨撞击.ppt

股骨髋臼撞击的关节镜治疗,Femoroacetabular Impingement （FAI）,髋关节慢性疼痛的原因,关节内 关节内游离体 盂唇损伤 关节外 肌肉肌腱损伤 神经牵拉 滑囊炎 髋臼股骨撞击,常见的FAI的病因,“手枪柄形”股骨颈 髋臼后倾,a 手枪柄形股骨颈 b 正常股骨颈,“8” figure,盂唇撕裂与髋关节退化、骨性关节炎密切相关 非球面股骨头、髋臼与早期出现髋关节骨性关节炎相关 FAI是否与退化性髋关节疾病相关-目前未知,消除结构上的异常 解除疼痛 延缓退化,在极度的活动范围下 股骨颈直径增大 股骨头、颈偏移减小 均可能由于股骨颈、髋臼反复接触，产生剪式应力，造成盂唇和髋臼软骨的损伤 撞击性的盂唇损伤，绝大多数位于髋臼前上区,Murry最早将撞击的理论用于解释退化性髋关节疾病病因 Leunig等人发现髋臼边缘的退化常见于老年髋关节，并认为FAI引发了这一过程 Beck等人在手术治疗髋臼前上象限的盂唇损伤时发现损伤与股骨头、颈前外侧偏移有关,股骨头、颈偏移减小病因不清 “手枪柄”形股骨颈 亚临床型的股骨头骺滑脱 股骨近端生长障碍,病因,Ganz撞击类型,凸轮（Cam）撞击 非球面股骨头在屈髋时与髋臼接触，产生剪式应力，造成髋臼盂唇在前上象限自外向内的磨损。盂唇损伤浅，仅局限于撞击部位 钳形（Pincer）撞击 髋臼边缘与股骨头、颈结合部线状的撞击，撞击的起源在髋臼，常造成髋臼前方过度覆盖（髋臼后倾），或前方骨赘形成。盂唇磨损严重,患肢屈曲内旋时产生撞击,“8” figure,临床表现,病史,年轻病人多见 中年运动员，活动时腹股沟区疼痛 常发生在与屈髋有关的活动中 简单活动和运动时都可能引发疼痛 症状间歇发生，由轻到重 腹股沟疼痛可能造成活动受限，特别是运动员 经常误诊，保守治疗无效或加重,体检,屈髋状态下，内旋内收受限 髋关节体检时常伴随疼痛 撞击实验：被动屈曲内收髋关节，逐渐内旋，引发腹股沟区的疼痛 须鉴别排除：滑囊炎，神经牵拉痛，腹股沟疝,影像学检查,双髋正位相 骨盆正位相 穿台侧位相（A cross-table lateral radiograph） CT MRI 三维CT,X线片测量,CE角 (Wiberg) 25度: 正常 20-25度:边缘 髋臼指数 10度：髋臼发育不良 4-10度：正常 颈干角：140 发育不良,15.2%,治疗,非手术治疗 非甾体抗炎药 限制活动-屈髋 由于是机械原因，非手术治疗不能解除病源 切开手术治疗 关节镜下清创并处理盂唇、软骨损伤,软骨损伤的处理,Acetabular chondral injuries may be addressed by chondroplasty, drilling, or microfracture These lesions are not uncommon and tend to extend about 5 to 7 mm in width along the length of the impingement lesion In most cases of FAI, the femoral articular surface is intact,骨量的控制,The amount of resection that predictably ended in a fracture was greater than 30% of the femoral neck No more than approximately 20% of the width of the neck should be resected Preoperative measurement of the overall width of the neck allows the surgeon to plan for as conservative a resection as is possible,切开手术结果,open surgical dislocation approach Beck M ,2004，The open surgical dislocation approach， 14 / 19 patients for good results Murphy S,2004, 23 hips evaluation, 7 patients had been converted to total hip arthroplasty,关节镜手术结果,Christensen C, 10 patients Follow-up averaged 16 months (range, 9 to 24 months). Eight patients with evidence of FAI and no intra-articular cartilage degenerative disease did substantially better than the 2 patients who had degenerative disease diagnosed at the time of arthroscopy The McCarthy scoring averaged 75 preoperatively and 95 at follow-up Sampson has reported on a series of 90 patients treated arthroscopically for FAI. In his experience, nearly all patients had elimination of the impingement sign (pain on flexion and internal rotation) and were