今日の臨床サポート

股関節唇損傷

著者: 内田宗志 産業医科大学 整形外科

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2017/02/28
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 股関節唇損傷とは、臼蓋辺縁についている環状の線維軟骨組織が損傷をうけることである。多くは、臼蓋形成不全、大腿骨寛骨臼インピンジメント(股関節インピンジメント)などによる骨形態異常が原因である。
 
診断:
  1. 以下の所見を認める場合に診断となる。
  1. 鼠径部、大転子、梨状筋部分の疼痛。
  1. 最も信頼性の高い前方インピンジメントテストで陽性
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
内田宗志 : 講演料(スミス・アンド・ネフュー)[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 股関節唇は、寛骨臼の周囲を環状に付着している繊維軟骨である。大腿骨頭を環状に被覆し、シーリングすることで、股関節を安定させる機能を有する。<図表>
  1. 股関節唇損傷は、その繊維軟骨が損傷し、股関節痛や引っかかり感を呈する病気である。<図表>
  1. そのほとんどが、股関節の骨形態異常(臼蓋形成不全、Legg-Calv´ e-Perthes病、Femoroacetabular impingement 股関節インピンジメント)に起因する。MRなどの画像診断や関節鏡が発展した今もなお、診断が難しく見逃されることが多い。臼蓋縁の関節唇近傍の軟骨損傷が合併していることが多い。<図表>
  1. 多くは緩徐に症状が進行するが、頻度としては少ない(9%)ものの外傷を契機に発症することもあり、詳しい病歴の聴取が必要である[2][3]
問診・診察のポイント  
問診:
  1. 発症時期を確認する。〔いつから、どのように〕

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文献 

著者: R Stephen J Burnett, Gregory J Della Rocca, Heidi Prather, Madelyn Curry, William J Maloney, John C Clohisy
雑誌名: J Bone Joint Surg Am. 2006 Jul;88(7):1448-57. doi: 10.2106/JBJS.D.02806.
Abstract/Text BACKGROUND: The clinical presentation of a labral tear of the acetabulum may be variable, and the diagnosis is often delayed. We sought to define the clinical characteristics associated with symptomatic acetabular labral tears by reviewing a group of patients who had an arthroscopically confirmed diagnosis.
METHODS: We retrospectively reviewed the records for sixty-six consecutive patients (sixty-six hips) who had a documented labral tear that had been confirmed with hip arthroscopy. We had prospectively recorded demographic factors, symptoms, physical examination findings, previous treatments, functional limitations, the manner of onset, the duration of symptoms until the diagnosis of the labral tear, other diagnoses offered by health-care providers, and other surgical procedures that these patients had undergone. Radiographic abnormalities and magnetic resonance arthrography findings were also recorded.
RESULTS: The study group included forty-seven female patients (71%) and nineteen male patients (29%) with a mean age of thirty-eight years. The initial presentation was insidious in forty patients, was associated with a low-energy acute injury in twenty, and was associated with major trauma in six. Moderate to severe pain was reported by fifty-seven patients (86%), with groin pain predominating (sixty-one patients; 92%). Sixty patients (91%) had activity-related pain (p < 0.0001), and forty-seven patients (71%) had night pain (p = 0.0006). On examination, twenty-six patients (39%) had a limp, twenty-five (38%) had a positive Trendelenburg sign, and sixty-three (95%) had a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of a labral tear was twenty-one months. A mean of 3.3 health-care providers had been seen by the patients prior to the definitive diagnosis. Surgery on another anatomic site had been recommended for eleven patients (17%), and four had undergone an unsuccessful operative procedure prior to the diagnosis of the labral tear. At an average of 16.4 months after hip arthroscopy, fifty-nine patients (89%) reported clinical improvement in comparison with the preoperative status.
CONCLUSIONS: The clinical presentation of a patient who has a labral tear may vary, and the correct diagnosis may not be considered initially. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis.
LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

PMID 16818969  J Bone Joint Surg Am. 2006 Jul;88(7):1448-57. doi: 10.2・・・
著者: Michael Leunig, Paul E Beaulé, Reinhold Ganz
雑誌名: Clin Orthop Relat Res. 2009 Mar;467(3):616-22. doi: 10.1007/s11999-008-0646-0. Epub 2008 Dec 10.
Abstract/Text Femoroacetabular impingement (FAI) is a recently proposed mechanism causing abnormal contact stresses and potential joint damage around the hip. In the majority of cases, a bony deformity or spatial malorientation of the femoral head or head/neck junction, acetabulum, or both cause FAI. Supraphysiologic motion or high impact might cause FAI even with very mild bony alterations. FAI became of interest to the medical field when (1) evidence began to emerge suggesting that FAI may initiate osteoarthritis of the hip and when (2) adolescents and active adults with groin pain and imaging evidence of FAI were successfully treated addressing the causes of FAI. With an increased recognition and acceptance of FAI as a damage mechanism of the hip, defined standards of assessment and treatment need to be developed and established to provide high accuracy and precision in diagnosis. Early recognition of FAI followed by subsequent behavioral modification (profession, sports, etc) or even surgery may reduce the rate of OA due to FAI.

PMID 19082681  Clin Orthop Relat Res. 2009 Mar;467(3):616-22. doi: 10.・・・
著者: John C Clohisy, Evan R Knaus, Devyani M Hunt, John M Lesher, Marcie Harris-Hayes, Heidi Prather
雑誌名: Clin Orthop Relat Res. 2009 Mar;467(3):638-44. doi: 10.1007/s11999-008-0680-y. Epub 2009 Jan 7.
Abstract/Text Femoroacetabular impingement (FAI) is considered a cause of labrochondral disease and secondary osteoarthritis. Nevertheless, the clinical syndrome associated with FAI is not fully characterized. We determined the clinical history, functional status, activity status, and physical examination findings that characterize FAI. We prospectively evaluated 51 patients (52 hips) with symptomatic FAI. Evaluation of the clinical history, physical exam, and previous treatments was performed. Patients completed demographic and validated hip questionnaires (Baecke et al., SF-12, Modified Harris hip, and UCLA activity score). The average patient age was 35 years and 57% were male. Symptom onset was commonly insidious (65%) and activity-related. Pain occurred predominantly in the groin (83%). The mean time from symptom onset to definitive diagnosis was 3.1 years. Patients were evaluated by an average 4.2 healthcare providers prior to diagnosis and inaccurate diagnoses were common. Thirteen percent had unsuccessful surgery at another anatomic site. On exam, 88% of the hips were painful with the anterior impingement test. Hip flexion and internal rotation in flexion were limited to an average 97 degrees and 9 degrees, respectively. The patients were relatively active, yet demonstrated restrictions of function and overall health. These data may facilitate diagnosis of this disorder.

PMID 19130160  Clin Orthop Relat Res. 2009 Mar;467(3):638-44. doi: 10.・・・
著者: Marc Philippon, Mara Schenker, Karen Briggs, David Kuppersmith
雑誌名: Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14. doi: 10.1007/s00167-007-0332-x. Epub 2007 May 4.
Abstract/Text Femoroacetabular impingement (FAI) occurs when an osseous abnormality of the proximal femur (cam) or acetabulum (pincer) triggers damage to the acetabular labrum and articular cartilage in the hip. Although the precise etiology of FAI is not well understood, both types of FAI are common in athletes presenting with hip pain, loss of range-of-motion, and disability in athletics. An open surgical approach to decompressing FAI has shown good clinical outcomes; however, this highly invasive approach inherently may delay or preclude a high level athlete's return to play. The purpose of this study was to define associated pathologies and determine if an arthroscopic approach to treating FAI can allow professional athletes to return to high-level sport. Hip arthroscopy for the treatment of FAI allows professional athletes to return to professional sport. Between October 2000 and September 2005, 45 professional athletes underwent hip arthroscopy for the decompression of FAI. Operative and return-to-play data were obtained from patient records. Average time to follow-up was 1.6 years (range: 6 months to 5.5 years). Forty two (93%) athletes returned to professional competition following arthroscopic decompression of FAI. Three athletes did not return to play; however, all had diffuse osteoarthritis at the time of arthroscopy. Thirty-five athletes (78%) remain active in professional sport at an average follow-up of 1.6 years. Arthroscopic treatment of FAI allows professional athletes to return to professional sport.

PMID 17479250  Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908・・・
著者: Marc R Safran
雑誌名: Sports Med Arthrosc. 2010 Jun;18(2):55. doi: 10.1097/JSA.0b013e3181e13196.
Abstract/Text
PMID 20473122  Sports Med Arthrosc. 2010 Jun;18(2):55. doi: 10.1097/JS・・・
著者: Christopher M Larson, M Russell Giveans
雑誌名: Arthroscopy. 2009 Apr;25(4):369-76. doi: 10.1016/j.arthro.2008.12.014. Epub 2009 Mar 5.
Abstract/Text PURPOSE: The purpose of this study was to compare the outcomes of arthroscopic labral debridement with those of labral refixation.
METHODS: We reviewed patients who underwent labral debridement during a period before the development of labral repair techniques. Patients with labral tears deemed repairable with our current arthroscopic technique were compared with patients who underwent labral refixation with a minimum 1 of year of follow-up. To better match the 2 groups, only patients with labral pathology caused by pincer-type or combined pincer- and cam-type femoroacetabular impingement were included. In the first 36 hips the labrum was debrided (group 1); in the next 39 hips the labrum underwent refixation (group 2). Outcomes were measured preoperatively and postoperatively with the modified Harris Hip Score (HHS), Short Form 12, and visual analog scale for pain. Preoperative and postoperative radiographs were obtained to evaluate bony resection (alpha angle) and osteoarthritis (Tönnis grade).
RESULTS: The mean age was 31 years in group 1, with a mean follow-up of 21.4 months, and 27 years in group 2, with a mean follow-up of 16.5 months. Preoperative subjective outcomes scores were not significantly different between groups. At the 1-year follow-up visit, subjective outcomes were significantly improved (P < .01) in both groups. HHSs were significantly better for the refixation group (94.3) compared with the debridement group (88.9) at 1 year (P = .029). At most recent follow-up, good to excellent results were noted in 66.7% of hips in the debridement group compared with 89.7% of hips in the refixation group (P < .01).
CONCLUSIONS: Although other variables could have influenced these outcomes, these preliminary results indicate that labral refixation resulted in better HHS outcomes and a greater percentage of good to excellent results compared with the results of labral debridement in an earlier cohort.
LEVEL OF EVIDENCE: Level III, retrospective comparative study.

PMID 19341923  Arthroscopy. 2009 Apr;25(4):369-76. doi: 10.1016/j.arth・・・
著者: E Schilders, A Dimitrakopoulou, Q Bismil, P Marchant, C Cooke
雑誌名: J Bone Joint Surg Br. 2011 Aug;93(8):1027-32. doi: 10.1302/0301-620X.93B8.26065.
Abstract/Text Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade > 2, lateral sourcil height < 2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection.

PMID 21768624  J Bone Joint Surg Br. 2011 Aug;93(8):1027-32. doi: 10.1・・・
著者: Marc J Philippon, Karen K Briggs, Connor J Hay, David A Kuppersmith, Christopher B Dewing, Michael J Huang
雑誌名: Arthroscopy. 2010 Jun;26(6):750-6. doi: 10.1016/j.arthro.2009.10.016. Epub 2010 Apr 3.
Abstract/Text PURPOSE: The purpose of this study was to investigate the indications for and outcomes of arthroscopic labral reconstruction in the hip by use of iliotibial band (ITB) autograft.
METHODS: Between August 2005 and May 2008, the senior author (M.J.P.) performed 95 arthroscopic labral reconstructions using an ITB autograft in patients with advanced labral degeneration or deficiency. There were 47 patients who had undergone surgery at a minimum of 1 year previously and met the inclusion criteria. The modified Harris Hip Score (MHHS) and patient satisfaction were used to measure outcomes postoperatively. The labral autograft was harvested from the ITB through a separate incision. The graft was sutured to the intact labral remnant in the region of labral deficiency, re-establishing the suction seal of the hip joint.
RESULTS: There were 32 men and 15 women. The mean age at the time of surgery was 37 years (range, 18 to 55 years). The mean time from the onset of symptoms to labral reconstruction was 36 months (range, 1 month to 12 years). Subsequent total hip arthroplasty was performed in 4 patients (9%). Follow-up was obtained in 37 of the remaining 43 patients. The mean time to follow-up was 18 months (range, 12 to 32 months). The mean MHHS improved from 62 (range, 35 to 92) preoperatively to 85 (range, 53 to 100) postoperatively (P = .001). Median patient satisfaction was 8 out of 10 (range, 1 to 10). Patients who were treated within 1 year of injury had higher MHHSs than patients who waited longer than 1 year (93 v 81, P = .03). The independent predictor of patient satisfaction with outcome after labral reconstruction was age.
CONCLUSIONS: This study showed that patients who have labral deficiency or advanced labral degeneration had good outcomes and high patient satisfaction after arthroscopic intervention with acetabular labral reconstruction. Lower satisfaction was associated with joint space narrowing and increased age. Patients who waited longer than 1 year from the time of injury to surgery had lower function at follow-up than those treated in the first year.
LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Copyright (c) 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
PMID 20511032  Arthroscopy. 2010 Jun;26(6):750-6. doi: 10.1016/j.arthr・・・
著者: Christopher M Larson, M Russell Giveans, Mehul Taylor
雑誌名: Clin Orthop Relat Res. 2011 Jun;469(6):1667-76. doi: 10.1007/s11999-010-1741-6. Epub 2010 Dec 22.
Abstract/Text BACKGROUND: Previous studies reporting the impact of osteoarthritis (OA) on pain and function after hip arthroscopy largely predate resection of femoroacetabular impingement (FAI).
QUESTIONS/PURPOSES: We determined (1) functional improvement after resection of FAI impingement lesions in patients with preoperative radiographic joint space narrowing, and (2) identified preoperative predictors of pain, function, and failure rates in these patients.
PATIENTS AND METHODS: Between September 2004 and April 2008, we treated 210 patients (227 hips) with FAI and a minimum 12-month followup (mean, 27 months). Group FAI consisted of 154 patients (169 hips) without radiographic joint space narrowing, whereas Group FAI-OA consisted of 56 patients (58 hips) with preoperative radiographic joint space narrowing. We collected Harris hip scores (HHS), Short Form-12 (SF-12), and pain scores on a visual analog scale (VAS) preoperatively and postoperatively.
RESULTS: Score improvements were better for Group FAI compared with Group FAI-OA. The overall failure rate was greater for Group FAI-OA (52%) than for Group FAI (12%). Although patients with less than 50% joint space narrowing or greater than 2 mm joint space remaining on preoperative radiographs had improved scores throughout the study, we observed no score improvements at any time with advanced preoperative joint space narrowing. Greater joint space narrowing, advanced MRI chondral grade, and longer duration of preoperative symptoms predicted lower scores.
CONCLUSION: FAI correction with milder degrees of preoperative radiographic joint space narrowing resulted in improvements in pain and function at short-term followup. Patients with advanced radiographic joint space narrowing do not improve and we believe should not be considered for arthroscopic FAI correction.

PMID 21181460  Clin Orthop Relat Res. 2011 Jun;469(6):1667-76. doi: 10・・・

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