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中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (05) : 521 -534. doi: 10.3877/cma.j.issn.1674-134X.2022.05.001

所属专题： 指南共识；

专家共识

临界型发育性髋关节发育不良的诊断与治疗专家共识(2022版)
中华医学会运动医疗分会青年学组, 中华医学会运动医疗分会髋关节运动创伤工作委员会, 中国康复医学会修复重建外科委员会保髋学组, 中国医师协会骨科医师分会保髋学组, 国家骨科与运动康复临床医学研究中心, 解放军总医院骨科医学部运动医学科   
  • 收稿日期:2022-06-14 出版日期:2022-10-01
  • 基金资助:
    基础加强计划重点基础研究项目(2020-JCJQ-ZD-264-1-8); 军队课题(211-CXGC-M113-02-05-01)

Expert consensus on diagnosis and treatment of borderline developmental dysplasia of hip (2022 edition)

The Chinese Medical Association Medical Branch of Sports Medicine the Youth Group, The Chinese Medical Association Medical Branch of Hip Sports Trauma Committee, The Chinese Rehabilitation Medicine Trauma Repair Reconstruction Surgery Committee Branch of Hip Preservation Group, The Chinese Medical Doctor Association Orthopedic Surgeon Branch of Hip Preservation Group, The National Clinical Medical Research Center for Orthopaedics and Sports Rehabilitation, The Department of Sports Medicine, Senior Department of Orthopedics, the PLA General Hospital   

  • Received:2022-06-14 Published:2022-10-01
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中华医学会运动医疗分会青年学组, 中华医学会运动医疗分会髋关节运动创伤工作委员会, 中国康复医学会修复重建外科委员会保髋学组, 中国医师协会骨科医师分会保髋学组, 国家骨科与运动康复临床医学研究中心, 解放军总医院骨科医学部运动医学科. 临界型发育性髋关节发育不良的诊断与治疗专家共识(2022版)[J]. 中华关节外科杂志(电子版), 2022, 16(05): 521-534.

The Chinese Medical Association Medical Branch of Sports Medicine the Youth Group, The Chinese Medical Association Medical Branch of Hip Sports Trauma Committee, The Chinese Rehabilitation Medicine Trauma Repair Reconstruction Surgery Committee Branch of Hip Preservation Group, The Chinese Medical Doctor Association Orthopedic Surgeon Branch of Hip Preservation Group, The National Clinical Medical Research Center for Orthopaedics and Sports Rehabilitation, The Department of Sports Medicine, Senior Department of Orthopedics, the PLA General Hospital. Expert consensus on diagnosis and treatment of borderline developmental dysplasia of hip (2022 edition)[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(05): 521-534.

临界型发育性髋关节发育不良(BDDH)是介于成人发育性髋关节发育不良(DDH)和正常髋关节之间的一种特殊类型，其临床诊断和治疗一直存在争议，是运动医学和保髋外科的热点与难点。为进一步提高BDDH诊疗的规范性，由中华医学会运动医疗分会的青年学组和髋关节运动创伤工作委员会、中国康复医学会修复重建外科委员会保髋学组、中国医师协会骨科医师分会保髋学组、国家骨科与运动康复临床医学研究中心、解放军总医院骨科医学部运动医学科共同发起，采用推荐意见分级的评估、制订及评价(GRADE)体系和国际实践指南报告规范(RIGHT)遴选出临床最为关注的13个问题，最终形成38条循证医学推荐意见，旨在提高BDDH诊疗实践的科学性并最终提升以患者为中心的医疗服务质量。

关键词: 发育性髋关节发育不良, 诊断, 治疗, 多数赞同

Borderline developmental dysplasia of the hip (BDDH) is a special type in adult between developmental dysplasia of the hip (DDH) and normal hip. Its diagnosis and treatment is controversial and has always been a hot spot and difficulty in sports medicine and hip preservation. In order to further improve the standardization of diagnosis and treatment of the BDDH, this consensus was led by the Youth Group and the Sports Trauma of Hip joint Committee of Chinese Society of Sports Medicine of the Chinese Medical Association, the Hip Preservation Group of the Reparative and Reconstruction Surgery Committee of Chinese Association of Rehabilitation Medicine, the Hip Preservation Group of Chinese Association of Orthopaedic Surgeons, the National Clinical Medical Research Center for Orthopaedics and Sports Rehabilitation, and the Sports Medicin Department of Senior Department of Orthopedics, the PLA General Hospital. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist were adopted. Finally, 38 evidence-based recommendations were formulated based on 13 most concerned clinical problems. This consensus intended to improve the scientific nature of BDDH diagnosis and treatment and ultimately improve the quality of patient centered medical services.

Key words: Developmental dysplasia of the hip, Diagnosis, Therapeutics, Consensus
表1 证据质量GRADE分级
证据质量 定义 含义
高 指南制定小组对真实效应值接近效应估计值很有信心 进一步研究基本不可能改变对效应估计值的信心
中 指南制定小组对效应估计值有中等程度的信心；真实值可能接近估计值，但仍存在二者截然不同的可能性 进一步研究有可能对效应估计值的信心产生重要影响，且可能改变该估计值
低 指南制定小组对效应估计值的确信度有限；真实值可能与估计值大不相同 进一步研究很有可能对效应估计值的信心产生重要影响，且很有可能改变该估计值
极低 指南制定小组对效应估计值几乎没有信心；真实值可能与估计值大不相同 任何效应估计值都非常不确定
表2 升高或降低证据质量
升级 降级
剂量－效应关系 研究局限性
  +1剂量－效应关系证据   －1严重局限性
可能的混杂因素   －2非常严重局限性
  +1所有可能的混杂可降低效应 不一致性
  －1重大的不一致性
效应量大 间接性
  +1强，无可能的混杂因素   －1部分不确定性
  +2非常强，无重要的内部真实性和直接证据缺陷   －2重要不确定性
    不精准性
      －1不精准数据
    报告偏倚
      －1极可能存在报告偏倚
表3 共识中涉及的推荐强度分级与定义
推荐强度等级 定义
强推荐 明确显示干预措施利大于弊
弱推荐 利弊不确定或干预措施可能利大于弊
专家建议(good practice statement，GPS) 基于非直接证据或专家意见、经验形成的推荐
表4 BDDH的诊断与治疗专家共识证据推荐分级汇总表
  条目 推荐意见 推荐分级
BDDH的定义 推荐1 基于影像学检查，以站立(负重)骨盆正位(前后位)X线片测量髋臼LCEA定义BDDH 1B
推荐2 LCEA是指股骨头中心平行于身体纵轴的线与从股骨头中心到髋臼外缘连线之间的夹角，其髋臼外缘的标定点参照Wiberg法，即髋臼顶部骨性外缘 1C
推荐3 LCEA范围值为20°~25° 1C
推荐4 LCEA在20°~25°之间，且存在髋关节疼痛、关节活动受限等称为症状性BDDH 1B
症状性BDDH的诊断 推荐5 使用"关节不稳定"这一术语表述症状性BDDH的关节不稳定 1A
推荐6 临床病史采集应明确有无外伤，是否为运动员、舞蹈演员或运动业余爱好者，既往诊治经过等 1C
推荐7 症状主要表现为髋关节的疼痛、活动受限、跛行等，多由机械性损伤和/或关节不稳定引起 1B
推荐8 体格检查包括骨科髋关节一般性检查和髋关节不稳定、股骨髋臼撞击综合征、髂前下棘撞击征及多发韧带松弛等专项检查 2C
推荐9 影像学检查一般包括X线片、MRI、CT平扫和三维重建及肌肉骨骼超声，主要用于评估关节稳定性、骨性结构异常、软组织损伤、关节软骨损伤和骨关节炎程度等 1B
症状性BDDH的非手术治疗 推荐10 初次诊断症状性BDDH，未见明显关节不稳定，未行规范化保守治疗可行系统的保守治疗 1C
推荐11 症状性BDDH合并关节外疾病，症状复杂可先行保守治疗 1B
推荐12 治疗方法包括改变生活和运动习惯，应用NSAIDs和营养保护软骨补充剂，加强髋周肌群训练及物理治疗等，治疗时间以3~6个月为宜。 专家建议GPS
治疗方案的选择 推荐13 症状性BDDH的常用外科手术治疗方法包括髋关节镜和PAO，手术方案的选择取决于不同手术方式的适应证、禁忌证及患者的意愿 1B
髋关节镜手术治疗的危险因素 推荐14 性别差异不作为关节镜手术的危险因素 1C
推荐15 年龄≥42岁或BMI≥30 kg/m2是关节镜手术的危险因素 2C
推荐16 站立和直行时严重疼痛、外展肌疲劳或关节不稳定专项体格检查试验阳性是关节镜手术的危险因素 专家建议GPS
推荐17 圆韧带撕裂≥50%、关节囊及周围组织损伤或多发韧带松弛Beighton评分≥4分是关节镜手术的危险因素 1B
推荐18 髋臼Tönnis角>15°是关节镜手术的危险因素 1B
推荐19 骨关节炎Tönnis分级1级或局部轻度软骨损伤是关节镜手术的危险因素 1B
推荐20 严重的焦虑、抑郁或期望值过高是关节镜手术的危险因素 1C
髋关节镜手术适应证 推荐21 临床症状和体征主要来源于髋臼盂唇损伤、股骨髋臼撞击综合征或髂前下棘撞击等，经保守治疗无明显改善的症状性BDDH是关节镜手术治疗的适应证 1B
髋关节镜手术禁忌证 推荐22 ACEA角<20°是关节镜手术治疗的禁忌证 2C
推荐23 Shenton线不连续或髂股线IFL百分比>22%是关节镜手术治疗的禁忌证 1B
推荐24 股骨颈前倾角>35°或颈干角>140°是关节镜手术治疗的禁忌证 专家建议GPS
推荐25 骨关节炎Tönnis分级≥ 2级、关节间隙≤ 2 mm或MRI显示广泛软骨下水肿或软骨剥脱是关节镜手术治疗的禁忌证 1B
髋关节镜术中注意事项 推荐26 髋臼缘骨性结构应有限磨除，股骨头颈交界区凸轮(Cam)畸形、髋臼侧异常髂前下棘应充分成型，损伤盂唇尽可能缝合修复固定 1B
推荐27 关节囊切开后应通过缝合实现关节囊组织的闭合 1B
推荐28 谨慎行髂腰肌肌腱松解 1C
PAO手术适应证 推荐29 临床症状和体征主要来源于关节不稳定(包括关节镜术后出现持续性症状性关节不稳定)是PAO手术治疗的适应证 1B
推荐30 符合本专家共识临床问题7关节镜手术禁忌证中的第1条或第2条(髋臼前方骨性覆盖不足或股骨近端骨性结构异常)是PAO手术治疗的适应证 1B
PAO手术禁忌证 推荐31 外展内旋－功能位X线片股骨头和髋臼对合关系不良是PAO手术的禁忌证 2B
推荐32 Tönnis分级≥2级是PAO手术的禁忌证 1C
推荐33 髋关节活动明显受限是PAO手术的禁忌证 1B
PAO术中注意事项 推荐34 术中应保护坐骨神经和股神经，准确行坐骨、耻骨和髂骨关节外截骨，精准调整改善髋臼覆盖和有效固定 1B
术后康复目标和策略 推荐35 总体目标是消除疼痛和肿胀、恢复神经肌肉控制，稳定腰－骨盆－髋关节复合体，提升髋关节、躯干和下肢运动链功能，早日恢复正常生活、重返工作岗位或体育运动 1C
推荐36 基本策略是强调术后快速康复FTS理念和着重个体化、阶段性康复 1C
康复注意事项 推荐37 评估BDDH术后是否伴有医源性关节不稳定 1C
推荐38 阶段性康复应在上一阶段的基础上充分考虑患者恢复状况 1C
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