加强髋关节撞击征的临床与基础研究

黄公怡

. 述评 Editorial .

加强髋关节撞击征的临床与基础研究

黄公怡

髋关节撞击综合征也称股骨髋臼撞击综合征 (femoroacetabular impingement，FAI )，是指各种内外因素引起髋关节解剖结构或运动方式的改变，导致髋关节盂唇与股骨近端在活动时反复撞击而引起相应的临床症状。临床表现为间歇性腹股沟区疼痛，在活动增加或长时间受力后可转变为持续性疼痛，疼痛位于腹股沟区或转子处，关节弹响、交锁；髋关节活动受限，撞击试验阳性。而疼痛是导致患者的生活质量严重下降和就诊的主要原因，这不得不引起临床医师的关注与高度重视。

关节是躯体运动的重要解剖构造，在生物进化过程中获得了活动性与稳定性的双重特点。骨与非骨性结构，周围肌肉的动力装置以及神经系统精密的调控，解剖结构与动力装置在构造与功能上的适配，确保了各关节完成其正常生理功能的必要条件，使之在履行正常生理功能过程中不至于发生自身构造间的非正常接触或意外碰撞事件。

因发育的原因或获得性的原因导致解剖构造异常，或因肌肉的动力功能失衡，抑或结构与动力两种异常因素兼而有之的情况下，关节撞击才成为可能[1-5]。

肩峰下或盂肱关节内的撞击征，股骨髁间窝对前交叉韧带的撞击等早已引起了专业人员的关注。髋关节撞击征的概念最早由 Ganz 提出[1]，在近十余年来受到了较多的注意。

目前，对髋关节撞击征的认识是指髋关节发育不良，外伤，手术等因素致使髋关节运动过程中出现股骨头颈交界部与髋臼边缘发生的异常碰撞或卡压并由此引发的临床症状。所谓“凸轮”型[6-7]与“钳夹”型[8]都属于解剖结构异常导致的撞击。除此之外，髋关节发育不良 (DDH )，股骨头骨骺滑脱、髋臼后倾、股骨颈骨折畸形愈合，人工髋关节置换术的髋臼位置不良 (过度外倾、内倾或后倾 ) 均属髋关节结构性撞击的原因[2-4,8-9]。

髋关节周围肌肉组织作为动力装置，在神经支配与肌肉本身结构与功能完整的条件下，肌肉间的协同与拮抗作用使关节在完成运动功能时将会避免关节自身结构间撞击。即使由于发育性或后天获得的解剖结构异常，也不一定必然会发生撞击现象，或必然发展为撞击征。

人体自身可以通过肌力的重新平衡、姿势调整、功能的代偿等途径使撞击避免发生，或使已发生的撞击减轻其发展和加重。当这种代偿功能丧失时，撞击现象将成为不可避免。早期的撞击出现炎性反应，如及时休息对症治疗，避免撞击方向的运动，可以达到炎症消除症状缓解[10-11]。长期的、频繁的、反复的撞击使关节盂唇损伤、变性、剥离进一步累及关节面软骨，骨关节炎的发生发展将难以避免[1,4,7,12-13]。

当影像学显示结构异常，而尚无相应的临床症状时说明解剖结构存在发生撞击征的条件，但尚不能诊断为撞击征。一旦出现了撞击征典型的临床症状，髋前方或髋关节周围疼痛，激发性撞击试验阳性[14-18]，影像学检查包括动态、静态 X 线片，MRI 或 CT-Scan[19-23]，从解剖结构、病理异常等方面得到进一步证实，髋关节撞击征诊断即可确立。

髋关节撞击征是由多种原因导致的关节结构撞击，表现具有相同的特征性的临床征象，是一种典型的临床综合征。

关节撞击可以发生在关节囊内或囊外，囊内的撞击又可分为关节间隙间及关节周边部位的撞击。关节间隙间撞击与卡压往往与关节头的球面和关节臼表面曲率不适配，关节内韧带或肌腱的病变相关联，而以关节周边的撞击最为常见。“凸轮型”和“钳夹型”的髋关节撞击征均属关节周边的撞击。

关节运动的复杂性在于每一关节均有三维方向的运动，每一方向的运动均有其固有的运动规律与特征，这种运动规律与特征又称为关节运动的节律或韵律 (rhythm )。节律或韵律的形成取决于解剖构造、肌肉组成、力的平衡、运动训练以及职业和生活习惯的养成[24-25]。在关节出现撞击现象时该运动方向的节律必然出现变化，由此也提示对关节撞击的发生、发展进程与规律，对早期预防、代偿功能的训练的探索和研究会有助益[10-11]。

对于“凸轮型”髋关节撞击征的股骨头颈交界部隆突状骨增厚，是撞击的原因还是结果尚不十分清楚。该型病变多见于年轻人与运动员，关节的过度使用，肌肉重复损伤造成的动力失衡及肌力调控失调可能造成局部反复撞击，其结果可导致头颈交界部的反应性骨增殖，这种骨增殖形成了凸轮状畸形，结构的异常又造成局部反复撞击的解剖学基础。对从事体育专业的青少年特定人群进行长期纵向追随观察，也许能从中获得具有说服力的证据，得出客观结论[24,26]。

因人而异的个体化诊疗模式，永远是临床工作思维与实践的基本原则。从髋关节撞击征的病因、病理机制，转归进行深入探索，积极开展多中心研究，为本病的诊断与治疗积累更多循证医学证据，以提高对本病的认识以及防治水平。

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(本文编辑：李贵存 )

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 卫生部北京医院骨科

2014-04-21 )