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病例漫谈107:青年人并发混合型股骨髋臼撞击综合征和非特异性髋关节滑膜炎的罕见病例—一则病例报告 [复制链接]

Acetabular labrum damage leads to loss of its function, early appearance of groin pain, loss of hip function and early hip osteoarthritis development. Numerous pathomechanism have been proposed to explain the labrum damage, including the femoroacetabular impingement (FAI). Minimal bone changes of the acetabulum and/or femoral head, reduce the distance between them, leading to premature contact-impact of the femoral head-neck junction on the edge of the acetabulum, damaging labrum and labrum adjacent cartilage, wich are early signs of hip arthritis. Three types of FAI have been described: the first one is cam type with a morphological changes at the femoral head-neck junction in the form of cam deformmity. The secoond one is pincer type, in which the patological changes are localized exclusively to the acetabulum as a global (coxa profunda, protrusio acetabuli) or local overcoverage (retroversio acetabuli) of the femoral head, where the motion of the hip leads to the impact of the femoral neck on the edge of the acetabulum and consequent damage to the acetabular labrum. The third, mixed and the most common type of FAI is the combination of the previous two. Synovitis of the hip is a reaction of the articular synovium on the systemic or local pathological substrate in the form of synovial joint fluid production or specific hypertrofic synovium reaction that is seen in pathological conditions such as pigmented villonodular synovitis, tuberculosis or rheumatoid pannus. In the literature we found no case of hypertrofic non-specific synovitis combined with any kind of FAI.

We presented a patient with nonspecific chronic hypertrofic synovitis of the hip, combined with a mixed form of FAI, who was surgically treated.

Case report
A 20-year-old male patient suffered from pain in the left groin, which lasted two years before the surgery. The patient was treated in several orthopedic institutions with non-steroid anti-inflammatory drugs, physiotherapy, skin traction, and suggested total hip replacement. Six months before the surgery, during the ultrasound examination of the hip joint, synovial fluid in the hip was asserted for which injection of corticosteroids into the joint was administered. After that, the symptoms became more pronounced, the patient began to limp visibly, walking on flat surfaces was difficult, and climbing up the stairs was practically impossible. At clinical examination the patient walked with the left leg in external rotation, with highlighted limps on that leg, Trendeleburg sign was positive on the left leg, highlighted weakness of muscles of the thigh and the left gluteal region, active flexion of the hip was possible up to 70°, internal rotation up to 5°, adduction up to 10° in the hip flexion of 70°. Impingement test was positive in the hip flexion of 30–70°. The patient brought computed tomography (CT) image of the hips and nuclear magnetic resonance (NMR) that were made before the application of corticosteroids into the joint and which showed that the bone and soft tissue structures of the hips were normal. Biochemical and laboratory tests were also within normal limits. Standardized anteroposterior radiography of the hips showed characteristics findigns for femoroacetabular impingement reported earlic in literature: (Figure 1) a strong mutual retroversion of the acetabulum 12° on the left and 11° on the right hip , mutual positive sign of ischial spine projection, the angle α was 46° on the right and 44° on the left, acetabular index, mutual 10°, mutual Wiberg angle 36°, a kolodyaphyseal angle of 126° that was asserted bilaterally.
一名20岁男性患者,左腹股沟疼痛,手术前此疼痛已持续两年。患者在多个骨科机构接受了非甾体类抗炎药治疗,物理治疗及皮牵引治疗,并被建议接受全髋关节置换术。术前六个月,超声引导下在髋关节滑液中注射皮质类固醇激素进行治疗。此后,患者症状愈加恶化,跛行明显,平地行走困难,几乎不能爬楼。临床检查显示患者行走时左腿外旋且跛行明显,左腿Trendeleburg试验呈阳性,大腿和臀部左侧的肌肉明显萎缩,髋关节主动屈曲可达70°,内旋可达5°,髋关节屈曲为70°时内收可达10°。 髋关节屈曲30-70°时,撞击实验呈阳性。关节注射皮质类固醇激素之前,患者提供的髋关节的计算机断层扫描(CT)图像和核磁共振(NMR)图像显示髋关节处的骨和软组织结构均正常。生化化验检查结果也在正常范围内。标准化的髋关节前后位X线片显示了文献中已报道的股骨髋臼撞击综合征的特征:(图1)髋关节双侧髋臼后倾明显,左侧为12°,右侧为11°,坐骨棘投影呈阳性,右侧α为46°,左侧α为44°,两者髋臼指数为10°,Wiberg角为36°,双侧kolodyaphyseal角为126°。

Fig.1 – Standardized anteroposterior x-ray of the hips showing bilaterally positive sign of the ischial spine (white arrow), and acetabular retroversion (black arrow).

图1 – 标准化的髋关节前后位X线片显示双侧坐骨棘呈阳性(白色箭头),且髋臼后倾(黑色箭头)。  

In profile, Dunn-Ripstein-Müller's radiographs of the hips, the angle α on the left was 64° (normal value of this angle is below 50°), and on the right 42° (Figure 2).
剖面上,Dunn-Ripstein-Müller 髋关节X线片显示左侧α为64°(正常值应低于50°),右侧为42°(图2)。

Fig.2 – Standardized profile Dunn-Rippstein-Müller x-ray images of the hips: the left hip (right picture) – angle α 64°; the right hip (left picture) – angle α 42°.

图2 – 髋关节标准化剖面Dunn-Rippstein-MullerX线片:左侧髋关节(右图)-α为64°;右髋关节(左图)-α为42°。

Such clinical and radiographic findings revealed the existence of mixed-type of FAI on the left hip, due to which we proposed surgical treatment to the patient. The patient was operated on. It was planned to lift the acetabular labrum from its base, to osteotomize overcovered anterior and superior edge of the acetabulum, then, reinsert acetabular labrum in a new slot, and osteotomize cam deformity at the femoral head-neck junction in its antero-superior region. Lateral hip incision and transtrohanteric flip osteotomy of the hip were done, and after anterior ''Z'' hip capsulotomy unexpected hypertrophic synovial hip reaction was asserted (Figure 3).

Fig.3 – Intraoperative image: hypertrophied synovitis of the joint capsule on the anterior and superior femoral neck and head (black arrow), and femoral head (yelow arrow).

图3 – 术中图像:股骨头颈前位和上位(黑色箭头)以及股骨头(黄色箭头)处的肥厚性关节囊滑膜炎。

Entire extra-acetabular part of the joint was filled with synovial tissue which had fully and seriously damaged the anterior and the superior part of the acetabular labrum. Partial hip synoviectomy was performed, tissue samples were sent to histopathological analysis, the damaged parts of the labrum was resected, without possibility to be reinserted, anterior and superior part of the acetabular edge were osteotomized to reduce acetabular retroversion. Osteochondroplasty of the cam prominence at the femoral head-neck junction was done (Figure 4), and thus, intraoperatively, hip flexion of 90° and internal rotation of 30° was obtained. After joint capsule reconstruction, osteotomized part of the greater trochanter was re-fixed with two cortical screws and the operational wound was closed.


Fig.4 – Intraoperative picture: osteochondroplasty of the cam deformity of the femoral head-neck junction (black arrow), and femoral head (yellow arrow).

图4 – 术中图像:股骨头颈连接处(黑色箭头)和股骨头(黄色箭头)处凸轮畸形的骨软骨成形术。

Postoperatively, the patient was reimbursed with 400 mL of blood; low molecular weight heparin thromboprophylaxis for seven days was introduced, followed by oral anticoagulant therapy for up to six weeks after the surgery. On the first post-operative day active exercises in bed started and walking on the crutches was allowed from the second day with touching the tip of toes of the operated leg for six weeks after the surgery. Histopathological findings confirmed a nonspecific chronic hypertrophic synovitis of the hip. Two years after the surgery, the patient was asymptomatic, without limping on the left leg and with normal life activities. Flexion of the operated hip was 90°, internal rotation 25°, adduction 30°, impingement test was negative. On the anteroposterior radiographs of the hips, the acetabular angle of retrovesion was reduced up to 4°, the angle α was 40° and 49° on the profile of Dunn-Rippsetin-Müller radiographs of the left hip.

Damages of the acetabular labrum cause pain and partial loss of function of the hip in young adults. There is a number of reasons for labrum lesions, such as mechanical trauma of the hip (hip dyslocations, acetabular fractures) and in patients with FAI, otherwise, it is the result of biological specific or nonspecific synovial hypertrophic pannus production  17–20 . Morphological bone changes in the area of the acetabulum and /or proximal femur in patients with FAI reduce physiological distance between these anatomical structures of the hip, lead to premature contact-impact of the femoral neck on the edge of the acetabulum, causing damage of the acetabular labrum and acetabular cartilage adjacent to it, but never lead to mechanical irritation of the articular capsule and its hypertrophic response.

We presented a patient with a clear clinical and radiographic picture of mixed form of FAI with normal biochemical, CT and NMR findings in which the subjective symptoms suddenly worsened after inta-articular application of corticosteroids in the hip joint. We found intraoperatively and verified histologically, a nonspecific reaction of the hypertrophic synovium, an unexplained etiology, that filled the hip joint, further decreasing the space between the edge of the acetabulum and the anterior and superor part of the femoral neck, with additional deterioration of the patient's subjective complaints, hip movements and irreversible damage of the acetabular labrum without the possibility to be reinserted but only partially resected. There were no reports in the literature to compare with our experience. We hypothesized, as a possible explanation, that the intraarticular administration of corticosteroids was the reason for the development of nonspecified hypertrophy of the hip synovium, but it needs furhter research.
本文报道了一例患者,临床和影像学图像清晰呈现为混合型FAI,生化检查结果正常,CT和核磁共振发现髋关节内糖皮质激素治疗后患者症状突然恶化。 我们在术中发现并经组织学证实了肥厚性滑膜的非特异性反应,其病因较难解释,此非特异性反应能填充髋关节,进一步缩小髋臼边缘和股骨颈前部与上部之间的间隙,同时还有患者主诉的其他恶化症状,髋关节移动及髋臼盂唇的不可逆性损伤,此损伤部位不能再生只能被部分切除。尚无与本文病例可进行比较的文献报道。我们认为引起髋关节滑膜非特异性肥厚性发展的可能病因是关节内注射的糖皮质激素,但这一假设还需进一步进行研究。

FAI has been, in the last 20 years, well-defined pathological and pathophysiological entity which is treated only surgically.

We believe that young adults with pain in the groin and with normal biochemical, CT and NMR parameters should not be exposed to unnecessary and inappropriate treatment (skin traction, total hip replacement or intra-articular corticosteroid application), but to be appropriately operated on.

由MediCool医库软件 王露黔 编译

原文来自Vojnosanit Pregl

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