黃公怡

. 述評 Editorial .

加強髖關(guān)節(jié)撞擊征的臨床與基礎(chǔ)研究

黃公怡

髖關(guān)節(jié)撞擊綜合征也稱股骨髖臼撞擊綜合征 (femoroacetabular impingement，F(xiàn)AI )，是指各種內(nèi)外因素引起髖關(guān)節(jié)解剖結(jié)構(gòu)或運動方式的改變，導致髖關(guān)節(jié)盂唇與股骨近端在活動時反復(fù)撞擊而引起相應(yīng)的臨床癥狀。臨床表現(xiàn)為間歇性腹股溝區(qū)疼痛，在活動增加或長時間受力后可轉(zhuǎn)變?yōu)槌掷m(xù)性疼痛，疼痛位于腹股溝區(qū)或轉(zhuǎn)子處，關(guān)節(jié)彈響、交鎖；髖關(guān)節(jié)活動受限，撞擊試驗陽性。而疼痛是導致患者的生活質(zhì)量嚴重下降和就診的主要原因，這不得不引起臨床醫(yī)師的關(guān)注與高度重視。

關(guān)節(jié)是軀體運動的重要解剖構(gòu)造，在生物進化過程中獲得了活動性與穩(wěn)定性的雙重特點。骨與非骨性結(jié)構(gòu)，周圍肌肉的動力裝置以及神經(jīng)系統(tǒng)精密的調(diào)控，解剖結(jié)構(gòu)與動力裝置在構(gòu)造與功能上的適配，確保了各關(guān)節(jié)完成其正常生理功能的必要條件，使之在履行正常生理功能過程中不至于發(fā)生自身構(gòu)造間的非正常接觸或意外碰撞事件。

因發(fā)育的原因或獲得性的原因?qū)е陆馄蕵?gòu)造異常，或因肌肉的動力功能失衡，抑或結(jié)構(gòu)與動力兩種異常因素兼而有之的情況下，關(guān)節(jié)撞擊才成為可能[1-5]。

肩峰下或盂肱關(guān)節(jié)內(nèi)的撞擊征，股骨髁間窩對前交叉韌帶的撞擊等早已引起了專業(yè)人員的關(guān)注。髖關(guān)節(jié)撞擊征的概念最早由 Ganz 提出[1]，在近十余年來受到了較多的注意。

目前，對髖關(guān)節(jié)撞擊征的認識是指髖關(guān)節(jié)發(fā)育不良，外傷，手術(shù)等因素致使髖關(guān)節(jié)運動過程中出現(xiàn)股骨頭頸交界部與髖臼邊緣發(fā)生的異常碰撞或卡壓并由此引發(fā)的臨床癥狀。所謂“凸輪”型[6-7]與“鉗夾”型[8]都屬于解剖結(jié)構(gòu)異常導致的撞擊。除此之外，髖關(guān)節(jié)發(fā)育不良 (DDH )，股骨頭骨骺滑脫、髖臼后傾、股骨頸骨折畸形愈合，人工髖關(guān)節(jié)置換術(shù)的髖臼位置不良 (過度外傾、內(nèi)傾或后傾 ) 均屬髖關(guān)節(jié)結(jié)構(gòu)性撞擊的原因[2-4,8-9]。

髖關(guān)節(jié)周圍肌肉組織作為動力裝置，在神經(jīng)支配與肌肉本身結(jié)構(gòu)與功能完整的條件下，肌肉間的協(xié)同與拮抗作用使關(guān)節(jié)在完成運動功能時將會避免關(guān)節(jié)自身結(jié)構(gòu)間撞擊。即使由于發(fā)育性或后天獲得的解剖結(jié)構(gòu)異常，也不一定必然會發(fā)生撞擊現(xiàn)象，或必然發(fā)展為撞擊征。

人體自身可以通過肌力的重新平衡、姿勢調(diào)整、功能的代償?shù)韧緩绞棺矒舯苊獍l(fā)生，或使已發(fā)生的撞擊減輕其發(fā)展和加重。當這種代償功能喪失時，撞擊現(xiàn)象將成為不可避免。早期的撞擊出現(xiàn)炎性反應(yīng)，如及時休息對癥治療，避免撞擊方向的運動，可以達到炎癥消除癥狀緩解[10-11]。長期的、頻繁的、反復(fù)的撞擊使關(guān)節(jié)盂唇損傷、變性、剝離進一步累及關(guān)節(jié)面軟骨，骨關(guān)節(jié)炎的發(fā)生發(fā)展將難以避免[1,4,7,12-13]。

當影像學顯示結(jié)構(gòu)異常，而尚無相應(yīng)的臨床癥狀時說明解剖結(jié)構(gòu)存在發(fā)生撞擊征的條件，但尚不能診斷為撞擊征。一旦出現(xiàn)了撞擊征典型的臨床癥狀，髖前方或髖關(guān)節(jié)周圍疼痛，激發(fā)性撞擊試驗陽性[14-18]，影像學檢查包括動態(tài)、靜態(tài) X 線片，MRI 或 CT-Scan[19-23]，從解剖結(jié)構(gòu)、病理異常等方面得到進一步證實，髖關(guān)節(jié)撞擊征診斷即可確立。

髖關(guān)節(jié)撞擊征是由多種原因?qū)е碌年P(guān)節(jié)結(jié)構(gòu)撞擊，表現(xiàn)具有相同的特征性的臨床征象，是一種典型的臨床綜合征。

關(guān)節(jié)撞擊可以發(fā)生在關(guān)節(jié)囊內(nèi)或囊外，囊內(nèi)的撞擊又可分為關(guān)節(jié)間隙間及關(guān)節(jié)周邊部位的撞擊。關(guān)節(jié)間隙間撞擊與卡壓往往與關(guān)節(jié)頭的球面和關(guān)節(jié)臼表面曲率不適配，關(guān)節(jié)內(nèi)韌帶或肌腱的病變相關(guān)聯(lián)，而以關(guān)節(jié)周邊的撞擊最為常見?！巴馆喰汀焙汀般Q夾型”的髖關(guān)節(jié)撞擊征均屬關(guān)節(jié)周邊的撞擊。

關(guān)節(jié)運動的復(fù)雜性在于每一關(guān)節(jié)均有三維方向的運動，每一方向的運動均有其固有的運動規(guī)律與特征，這種運動規(guī)律與特征又稱為關(guān)節(jié)運動的節(jié)律或韻律 (rhythm )。節(jié)律或韻律的形成取決于解剖構(gòu)造、肌肉組成、力的平衡、運動訓練以及職業(yè)和生活習慣的養(yǎng)成[24-25]。在關(guān)節(jié)出現(xiàn)撞擊現(xiàn)象時該運動方向的節(jié)律必然出現(xiàn)變化，由此也提示對關(guān)節(jié)撞擊的發(fā)生、發(fā)展進程與規(guī)律，對早期預(yù)防、代償功能的訓練的探索和研究會有助益[10-11]。

對于“凸輪型”髖關(guān)節(jié)撞擊征的股骨頭頸交界部隆突狀骨增厚，是撞擊的原因還是結(jié)果尚不十分清楚。該型病變多見于年輕人與運動員，關(guān)節(jié)的過度使用，肌肉重復(fù)損傷造成的動力失衡及肌力調(diào)控失調(diào)可能造成局部反復(fù)撞擊，其結(jié)果可導致頭頸交界部的反應(yīng)性骨增殖，這種骨增殖形成了凸輪狀畸形，結(jié)構(gòu)的異常又造成局部反復(fù)撞擊的解剖學基礎(chǔ)。對從事體育專業(yè)的青少年特定人群進行長期縱向追隨觀察，也許能從中獲得具有說服力的證據(jù)，得出客觀結(jié)論[24,26]。

因人而異的個體化診療模式，永遠是臨床工作思維與實踐的基本原則。從髖關(guān)節(jié)撞擊征的病因、病理機制，轉(zhuǎn)歸進行深入探索，積極開展多中心研究，為本病的診斷與治療積累更多循證醫(yī)學證據(jù)，以提高對本病的認識以及防治水平。

[1]Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res, 2003, (417):112-120.

[2]Smith-Petersen MN. The classic: Treatment of malum coxae senilis, old slipped upper femoral epiphysis, intrapelvic protrusion of the acetabulum, and coxa plana by means of acetabuloplasty. 1936. Clin Orthop Relat Res, 2009, 467(3):608-615.

[3]Leunig M, Casillas MM, Hamlet M, et al. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand, 2000, 71(4):370-375.

[4]Bardakos NV, Villar RN. Predictors of progression of osteoarthritis in femoroacetabular impingement: a radiological study with a minimum of ten years follow-up. J Bone Joint Surg Br, 2009, 91(2):162-169.

[5]Leunig M, Beaulé PE, Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res, 2009, 467(3):616-622.

[6]Eijer H, Myers SR, Ganz R. Anterior femoroacetabular impingement after femoral neck fractures. J Orthop Trauma, 2001, 15(7):475-481.

[7]Gosvig KK, Jacobsen S, Sonne-Holm S, et al. The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the copenhagen osteoarthritis study. Acta Radiol, 2008, 49(4):436-441.

[8]Gekeler J. Coxarthrosis with a deep acetabulum (proceedings). Z Orthop Ihre Grenzgeb, 1978, 116(4):454-454.

[9]Myers SR, Eijer H, Ganz R. Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop Relat Res, 1999, (363):93-99.

[10]Emara K, Samir W, Motasem el H, et al. Conservative treatment for mild femoroacetabular impingement. J Orthop Surg (Hong Kong), 2011, 19(1):41-45.

[11]Hunt D, Prather H, Harris Hayes M, et al. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R, 2012, 4(7):479-487.

[12]Beaulé PE, O’Neill M, Rakhra K. Acetabular labral tears. J Bone Joint Surg Am, 2009, 91(3):701-710.

[13]Beck M, Kalhor M, Leunig M, et al. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br, 2005, 87(7):1012-1018.

[14]Carvalhais VO, de Araújo VL, Souza TR, et al. Validity and reliability of clinical tests for assessing hip passive stiffness. Man Ther, 2011, 16(3):240-245.

[15]Malliaras P, Hogan A, Nawrocki A, et al. Hip fexibility and strength measures: reliability and association with athletic groin pain. Br J Sports Med, 2009, 43(10):739-744.

[16]Martin RL, Sekiya JK. The interrater reliability of4 clinical tests used to assess individuals with musculoskeletal hip pain. J Orthop Sports Phys Ther, 2008, 38(2):71-77.

[17]Philippon MJ, Maxwell RB, Johnston TL, et al. Clinical presentation of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc, 2007, 15(8):1041-1047.

[18]Clohisy JC, Knaus ER, Hunt DM, et al. Clinical presentation of patients with symptomatic anterior hip impingement. Clin Orthop Relat Res, 2009, 467(3):638-644.

[19]Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol, 2007, 188(6):1540-1552.

[20]Beaulé PE, Zaragoza E, Motamedi K. Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement. J Orthop Res, 2005, 23(6):1286-1292.

[21]Laborie LB, Lehmann TG, Enges?ter I?, et al. Prevalence of radiographic findings thought to be associated with femoroacetabular impingement in a population-based cohort of 2081 healthy young adults. Radiology, 2011, 260(2):494-502.

[22]Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am, 2008, 90(Suppl 4):47-66.

[23]Pfrrmann CW, Mengiardi B, Dora C, et al. Cam and pincer femoroacetabular impingement: characteristic MR arthrographic fndings in 50 patients. Radiology, 2006, 240(3):778-785.

[24]Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes. Sports Med, 2008, 38(10):863-878.

[25]Prather H, Hunt D, Steger-May K, et al. Inter-rater reliability of three musculoskeletal physical examination techniques used to assess motion in three planes while standing. PM R, 2009, 1(7):629-635.

[26]Siebenrock KA, Ferner F, Noble PC, et al. The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity. Clin Orthop Relat Res, 2011, 469(11):3229-3240.

(本文編輯：李貴存 )

Emphasis on clinical and basic research of femoroacetabular impingement

HUANG Gong-yi. Department of Orthopedics, Beijing Hospital, Beijing, 100730, PRC

The concept of femoroacetabular impingement (FAI ) was frst proposed by Ganz, which had been more and more concerned in recent 10 years. FAI refers to abnormal impact or entrapment in the femoral head and neck border and in the margin of the acetabulum and the related clinical symptoms in the hip movement process caused by dysplasia of the hip joint, injuries, operation and so on. Muscular tissues around the hip joint act as the powerplant. The coordination and antagonism among muscles promote the completion of movement and the avoidance of impact in the joint, when the structures and functions of the innervation and muscles are perfect. Even in the patients with developmental or acquired abnormal anatomy, the occurrence of impact or FAI is not inevitable. Due to developmental or acquired abnormal anatomy, the imbalance of motivation functions of muscles or both abnormal structures and abnormal motivation functions, the occurrence of FAI becomes possible. The long-term, frequent and repeating impact makes the articular cartilage be further involved by injures, degeneration and stripping of the glenoid labrum, and it is hard to avoid the occurrence and development of osteoarthritis. Due to the impact in the joint, the rhythm in the corresponding direction will be certainly changed. Therefore, it is supposed that the understanding of the occurrence, development course and discipline of impact is helpful for the investigation and research of early prevention and compensation training. A long-term longitudinal survey is performed in the adolescents majoring in sports, in which some persuasive evidences may be found. Individualized diagnosis and treatment will always be the basic principle of thinking and practice in the clinical work. The etiology, pathological mechanism and prognosis of FAI should be further explored and more evidences on the basis of the evidence-based medicine should be accumulated clinically, so as to improve the understanding and prevention level of this disease.

Femoracetabular impingement (FAI ); Hip joint; Joint disease

10.3969/j.issn.2095-252X.2014.06.001

R684

100730 衛(wèi)生部北京醫(yī)院骨科

2014-04-21 )