唯医FM-髋关节撞击综合症的诊治要点

唯医FM髋关节撞击综合症的诊治要点唯医FM全新升级，强势来袭！本期唯医FM将为您陆续放送美国骨科医师协会（AAOS）精编教程性书籍《AAOSEssentialsofMusculoskeletalCare5th》。中国医师协会骨科医师分会（CAOS）已获授权出版中文版书籍，并已组织国内多个著名医院的医生完成了全文翻译，纸质版即将刊印，电子英文原版也会陆续在唯医网发布。欢迎老师们登陆唯医网进行学习。本期为大家放送教程节选内容：髋关节撞击综合症。长按二维码查看完整译文一同义词股骨髋臼撞击综合症Femoralacetabularimpingement(FAI)二定义髋关节撞击综合症，又称股骨髋臼撞击综合症，是由于髋臼缘与股骨头颈连接部骨质形态异常，在髋关节过度活动时两者不断的发生接触、碰撞，导致髋臼盂唇及软骨损伤。有研究显示，微小的骨质结构异常导致持续不断的微小创伤，逐渐发展为盂唇的撕裂。Hipimpingement,orfemoralacetabularimpingement(FAI),occurswhenareasofosseousdeformitiesontheacetabularrim,thefemoralhead-neckjunction,orbothabutatextremesofhipmotionandcauseinjurytotheacetabularlabrumandandcartilage.Studieshavedemonstratedthatmostlabraltearsoccurafterrepetitivemicrotraumaasaresultofthesesubtlestructuraldeformities.三临床表现髋关节撞击综合症多见于运动爱好者，从青少年到中年均可发病。髋关节撞击继发疼痛可能因某些急性诱因引起，但更多情况下，疼痛起病隐匿，随着时间的推移逐渐加重。疼痛的位置非常重要，因为髋部关节内病损会特征性地表现为腹股沟区疼痛。髋关节撞击综合症的患者常会把手卡在髋关节一侧，诉拇指和其他手指之间所卡的部位有深部疼痛，这就是所谓的“C形征”。有些患者还会有髋关节外侧大转子区域疼痛，并伴有髋外展肌力减弱。其他可能的症状还有关节卡顿感、关节交锁以及关节弹响。另外，许多患者在久坐、爬楼梯、上下车、穿鞋穿袜或者进行髋关节旋转动作后，疼痛会明显加重。Patientswithhipimpingementcanrangeinagefromteenagerstomiddle-agedweekendathletes.Painsecondarytohipimpingementmayoccurafteranacuteevent,butmoreoftenthepatientreportsaninsidiousonsetofpainthatbecomesmoreseverewithtime.Thelocationofthepainisimportantbecauseintra-articularhippathologyisclassicallyassociatedwithgroinpain.Withhipimpingement,patientsmayplaceahandoverthesideofthehipandreportthattheyfeeladeeppainlocatedbetweentheirfingersandthumb;thisisknownasthe“Csign.”Somepatientsalsomayreportpainonthelateralaspectofthehipoverthegreatertrochanter,withassociatedhipabductorweakness.Associatedcatching,locking,orclickingalsomaybepresent.Manypatientsdescribeworseningpainwithprolongedsittingorpainwithstairclimbing,gettinginandoutofacar,puttingonshoesorsocks,oractivitiesthatrequirerotationalmovement.四检查·体格检查髋关节撞击综合症患者患侧髋关节屈曲及内旋运动的幅度要比健侧明显减小。将患侧髋关节置于最大屈曲内收内旋位（FADDIR），如果引出疼痛，则为髋关节撞击征阳性（图1）。Decreasedhipflexionandinternalrotationcomparedwiththeoppositeextremitymaybeobservedinpatientswithhipimpingement.Theclassicprovocativemaneuveristoplacethehipinmaximumflexion,adduction,andinternalrotation(FADDIR);painwiththismaneuverisapositiveimpingementsign(Figure1).图1髋关节屈曲内收内旋检查示意图Figure1IllustrationoftheFADDIR(flexion,adduction,internalrotation)maneuver.·辅助检查对于髋关节疼痛且伴有内旋受限的患者，应摄髋关节前后位及侧位片。在关节间隙正常的前提下，X线的特征性表现是股骨头颈交界区的偏心距减小（见于cam凸轮撞击）和/或交叉征（见于pincer钳形撞击）（图2）。在单纯的股骨侧凸轮撞击时，股骨颈前侧正常的凹弧面解剖形态消失，代之以异常的骨性凸起，在髋关节屈曲时撞击髋臼前上缘，导致髋臼盂唇撕裂及邻近软骨剥离。APandlateralradiographsofthehipareindicatedforpatientswithpainandlimitedinternalrotationofthehip.Theclassicradiographicfeaturesarealossoffemoralhead-neckoffsetoneithertheAPorlateralview(camimpingement),acrossoversign(pincerimpingement),orboth,inthesettingofnormaljointspace(Figure2).Inpurefemoralcamimpingement,theanteriorfemoralnecklosesitsnormalconcaveanatomyandinsteadhasa“bump”thatimpingesontheanterosuperiorlabrumwithflexion,causinglabraltearsanddelaminationoftheadjacentcartilage.在钳形撞击时，髋臼对股骨头呈现局部过度覆盖（髋臼后倾）或整体过度覆盖（髋臼过深或前突）。由于髋臼后缘较前缘更偏外，使髋臼的正常形态表现为前倾，。当髋臼前缘相对后缘外突时，即可发生钳形髋臼撞击，影像学表现出髋臼前缘反而位于后缘外侧，称之为交叉征。MRI和CT三维重建可以提供更详细的髋部立体解剖信息，但由于技术水平和结果判读的误差，MRI对髋臼盂唇撕裂和关节软骨损伤的诊断可能存在假阴性结果。磁共振关节造影是显示髋臼盂唇撕裂和骨质结构异常最准确的方法（图3）。Inpincerimpingement,theacetabulumeitherhasfocalovercoverage(focalretroversion)orglobalovercoverage(coxaprofundaorprotrusio).Themorphologyofanormalacetabulumisanteverted,inthattheposteriorrimismorelateralthantheanteriorrim.Pinceracetabularimpingementariseswhentheanterioracetabularrimisprominentrelativetotheposteriorrim,resultinginaradiographicappearanceinwhichtheanteriorwallismorelateralthantheposteriorwall.Thisisknownasthecrossoversign.EitherMRIorCTwiththree-dimensionalconstructionscanprovidefurtherinformationonthethree-dimensionalanatomyofthehip.MRImaybefalselynegativeforevidenceoflabraltearsorarticularcartilageinjurybecauseofvariabletechniqueorinterpretation.Magneticresonancearthrographyofthehipisthemostaccuratemodalityfordemonstratingassociatedlabraltearsandosseousabnormalities(Figure3).图2髋关节撞击患者的X线片。A，左髋关节前后位显示，关节间隙完好，可见股骨凸轮畸形（箭头）和髋臼交叉征（星号）。实线表示髋臼前缘，虚线表示髋臼后缘。B，骑跨式侧位片显示，股骨头前缘正常凹弧面形态消失（箭头）。Figure2Radiographsfromapatientwithhipimpingement.A,APviewofthelefthipdemonstratesapreservedjointspacewithacamdeformity(arrow)ofthefemurandcrossoversign(*)ontheacetabulum.Thesolidlineindicatestheanteriorwall;thedashedlineindicatestheposteriorwall.B,Cross-tablelateralviewalsodemonstratesthelossoffemoralheadconcavity(arrow).图3磁共振关节造影冠状位T2加权像显示，右髋关节髋臼上缘盂唇撕裂（箭头）。Figure3T2-weightedcoronalmagneticresonancearthrogramofarighthipdemonstratesalabraltear(arrow).五鉴别诊断运动疝（腹直肌止点及内收肌腱处疼痛）髋关节发育不良（X线检查可明确）股部皮神经卡压（感觉异常，有烧灼样痛，髋关节活动正常）腹股沟拉伤（X线正常）骨关节炎（X线片可见关节间隙变窄、骨赘形成、软骨下骨硬化及囊性变）股骨头缺血性坏死（X线平片及MRI可明确）腰大肌撞击综合症或腰大肌腱弹响（髋关节屈曲、环形运动或拉伸时，腹股沟区可听到可重复出现的弹响）转子滑囊炎（大转子局部压痛，疼痛影响髋关节外展，关节活动度正常）骨盆或脊柱肿瘤（背痛、夜间痛，髋关节活动正常）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%的髋关节骨关节炎是由髋关节撞击或其他髋关节畸形引起的。虽然还没有系统性的证据证明髋关节撞击会导致骨关节炎，但对其自然病史的长期前瞻性研究支持这一观点。如果髋关节撞击是导致骨关节炎的主要原因，那么对髋关节撞击进行手术干预可能延缓甚至避免骨关节炎的发生。Hipimpingementandotherhipdeformitiesmaybetheetiologyfor60%to80%ofcasesofosteoarthritisofthehip.Theassertionthathipimpingementcanpotentiallycauseosteoarthritishasnotbeenscientificallyproved,butlong-termprospectivenaturalhistorystudiesmayprovidestrongsupportforthisidea.Ifhipimpingementisamajorcontributortohiposteoarthritis,itisthoughtthatsurgicalinterventionforhippainsecondarytohipimpingementmaydelaytheonsetorpotentiallyevenpreventhiposteoarthritis.七治疗对于所有髋关节撞击的患者首先应采用非手术治疗，其内容包括应用对乙酰氨基酚及NSAIDs类药物并限制关节活动。还应该请对处理非人工置换髋关节功能障碍有经验的专业康复医师会诊，进行髋关节活动训练及力量训练，争取恢复髋关节肌力平衡状态。长期髋关节撞击的患者常会伴有肌腱炎和髋关节僵硬，对于这类患者，深部组织按摩或快速放松疗法等物理治疗有着良好的效果。在X线透视引导下进行关节内注射局麻药物和皮质醇激素既可以起到明确诊断的作用，又可以进行治疗。如果注射后疼痛完全缓解，就可以确定疼痛的来源在关节内。经过一段时间的非手术治疗，大多数患者的疼痛症状都可以得到缓解。Theinitialtreatmentofallpatientsisnonsurgicalandconsistsofacombinationofacetaminophen,NSAIDs,andactivitymodification.Arehabilitationspecialistfamiliarwithnonarthroplastyhipjointdysfunctionshouldbeconsultedforhiprangeofmotionandstrengthtraining,withthegoalofrestoringmuscularbalancetothehip.Modalitiessuchasdeeptissuemassageoractivereleasetherapymaybehelpfulinpatientswithassociatedtendinitisorstiffnessaboutthehipsecondarytolong-standinghipimpingement.Fluoroscopicallyguidedintra-articularhipinjectionswithacombinationofalocalanestheticandacorticosteroidarebothdiagnosticandtherapeutic,andcompletepainreliefisthemostaccuratetesttodetermineanintra-articularetiologyforhippain.Painreliefoccursinmanypatientsafteracourseofnonsurgicaltreatment.对于非手术治疗效果不佳的患者应采取手术治疗。髋关节撞击的手术治疗最初需要行开放手术并将髋关节脱位，以充分显露股骨头颈连接部以及髋臼边缘。近来关节镜技术已经逐渐应用于髋关节撞击的手术治疗。术后早期活动，使用CPM和固定自行车进行关节康复锻炼，对于关节活动程度和运动能力的恢复非常重要。Patientswithhipimpingementthathasbeenrefractorytononsurgicaltreatmentarecandidatesforsurgicalintervention.Hipimpingementwasoriginallytreatedwithopensurgicalhipdislocationtosafelyprovideexposuretothefemoralhead-neckjunctionandtheacetabularrim.Morerecently,arthroscopictechniqueshavebeendevelopedtoperformsurgeryforhipimpingement.Earlypostoperativemobilizationandrangeofmotionwithacontinuouspassivemotionmachineandastationarybicycleareimportantformotionrecovery.Postoperativerehabilitationisimportantforrestorationofmotionandthereturntofunctionalaswellassportingactivities.八治疗的不良后果非手术治疗的不良后果主要是长期应用NSAIDs类药物相关的胃部、肾脏或肝脏并发症。大剂量对乙酰氨基酚延伸治疗也可能会有肝脏毒性。2015年，美国FDA再次强调：非甾体类消炎药有诱发心脏疾病和中风的可能，并指出：即便在开始使用一种非甾体类消炎药的数周内。髋关节镜术后并发症包括由神经麻痹导致的腹股沟区和足背部暂时的感觉麻木。少部分患者可能出现大腿外侧持续麻木，这可能是由于手术临近股外侧皮神经引起的。开放手术和关节镜手术的其他可能并发症还包括：异位骨化、深静脉血栓、关节僵硬等。极少数的病例会出现术后股骨颈骨折或关节不稳。如果不进行治疗，髋关节撞击远期的结果是发展为骨关节炎。AdverseoutcomesofnonsurgicaltreatmentincludecomplicationsrelatedtothechronicuseofNSAIDs,suchasgastric,renal,orhepaticproblems.Extendedtreatmentwithacetaminopheninlargedosescanleadtohepatictoxicity.In2015,theFDAstrengtheneditswarninglinkingNSAIDswiththeriskofheartattackorstroke,eveninthefirstweeksofuseofanNSAID.Postoperativecomplicationsassociatedwithhiparthroscopycanincludetemporarynumbnessinthegroinorthedorsalaspectofthefootsecondarytonervepalsy.Asmallnumberofpatien