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1、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
2、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
3、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 radiogra
4、ph） 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 t
5、end 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 t
6、he 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,200
7、4, 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 patien
8、ts 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 happy with their results. One patient did sustain a nondisplaced femoral neck fracture and required screw fixation.,Thank you !,