今日の臨床サポート

寛骨臼(臼蓋)形成不全症

著者: 中村正樹 国家公務員共済組合連合会 虎の門病院 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:2022/03/30
参考ガイドライン:
  1. 日本整形外科学会日本股関節学会 :変形性股関節症診療ガイドライン2016 改訂第2版
患者向け説明資料

概要・推奨   

  1. 寛骨臼の形成不全により、関節の安定性が障害された状態を寛骨臼(臼蓋)形成不全(acetabular dysplasia)という。
  1. 寛骨臼(臼蓋)形成不全は小児から高齢者までに認められ、変形性股関節症のリスク因子である(推奨度1)
  1. 股関節単純X線像で寛骨臼(臼蓋)形成不全があり、股関節痛がある場合は、専門医へ紹介する(推奨度1)
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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。
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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。
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※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、実際の保険適応の査定において保険適応及び保険適応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応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:
中村正樹 : 特に申告事項無し[2022年]
監修:酒井昭典 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、手術の選択やリハビリテーションプロトコール等について加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 股関節を構成する骨は大腿骨頭と寛骨臼である。このうち、寛骨臼の形成不全により、関節の安定性が障害された状態を寛骨臼(臼蓋)形成不全(acetabular dysplasia)という。
  1. 乳児期の寛骨臼(臼蓋)形成不全は発育性股関節形成不全(developmental dysplasia of the hip)に含まれる。発育性股関節形成不全は、先天性股関節脱臼(congenital dislocation of the hip)とも呼ばれる概念であり、寛骨臼(臼蓋)形成不全、亜脱臼、脱臼が含まれる。学童期、思春期、成人の寛骨臼(臼蓋)形成不全のなかには、乳児期に発育性股関節形成不全の既往歴がある場合もあるが、ない場合も多い。
  1. 女性に多く、男女比は1:5から1:9である。
  1. 寛骨臼(臼蓋)形成不全は、小児から高齢者までに認められ、成人の代表的な股関節疾患である変形性股関節症のリスク因子である[1]
問診・診察のポイント  
問診:
  1. 周産期歴の聴取が重要である。発育性股関節形成不全(寛骨臼(臼蓋)形成不全を含む)は、骨盤位に多く、羊水過少症に多く、初産に多い[2]
 
診察:
  1. 乳児期には、開排制限、あるいはAllis徴候が認められる。学童から成人では、Trendelenburg徴候が認められる場合もある。股関節に運動時痛、あるいはPatrick test陽性が認められる場合もある。

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文献 

A Chan, K A McCaul, P J Cundy, E A Haan, R Byron-Scott
Perinatal risk factors for developmental dysplasia of the hip.
Arch Dis Child Fetal Neonatal Ed. 1997 Mar;76(2):F94-100.
Abstract/Text AIMS: To identify perinatal risk factors for developmental dysplasia of the hip (DDH) and define the risk for each factor.
METHODS: In this case control study, using logistic regression analysis, all 1127 cases of isolated DDH live born in South Australia in 1986-93 and notified to the South Australian Birth Defects Register were included; controls comprised 150130 live births in South Australia during the same period without any notified congenital abnormalities.
RESULTS: Breech presentation, oligohydramnios, female sex and primiparity were confirmed as risk factors for DDH. Significant findings were an increased risk for vaginal delivery over caesarean section for breech presentation (as well as an increased risk for emergency section over elective section), high birthweight (> or = 4000 g), postmaturity and older maternal age; multiple births and preterm births had a reduced risk. There was no increased risk for caesarean section in the absence of breech presentation. For breech presentation, the risk of DDH was estimated to be at least 2.7% for girls and 0.8% for boys; a combination of factors increased the risk.
CONCLUSIONS: It is suggested that the risk factors identified be used as indications for repeat screening at 6 weeks of age and whenever possible in infancy. Other indications are family history and associated abnormalities.

PMID 9135287
S Nakamura, J Yorikawa, K Otsuka, K Takeshita, A Harasawa, T Matsushita
Evaluation of acetabular dysplasia using a top view of the hip on three-dimensional CT.
J Orthop Sci. 2000;5(6):533-9.
Abstract/Text We assessed coverage over the femoral head, using three-dimensional computed tomography (CT) imaging on 20 hips in 18 patients before rotational acetabular osteotomy, and on 18 normal hips as control. In particular, we introduced a "top view of the hip" in three-dimensional CT evaluation in order to detect posterolateral deficiency, which needs special attention in regard to rotational transfer of the acetabular fragment. We determined the horizontal plane passing through 5 mm cranial to the top of the femoral head on the coronal view of a multiplanar reconstruction image. Then, we erased the images of the ilium that were more cranial than this horizontal plane from the conventional cranial view of the pelvis and the proximal femur, and defined this view as the "top view of the hip". This top view clearly showed any uncovered area on the femoral head. Of the 20 hips, 6 were deficient anterolaterally (anterolateral type), 9 were deficient laterally (lateral type), and 5 were deficient posterolaterally (posterolateral type). On plain anteroposterior radiographs, 7 of the 20 hips had the cross-over sign of Reynolds. Five of these 7 hips with the cross-over sign were the posterolateral type in top view, while none of the 13 hips without the cross-over sign was the posterolateral type. We recommend preoperative evaluation using a top-view on three-dimensional CT images in patients who have the cross-over sign on an anteroposterior radiograph.

PMID 11180914
S Nakamura, S Ninomiya, T Nakamura
Primary osteoarthritis of the hip joint in Japan.
Clin Orthop Relat Res. 1989 Apr;(241):190-6.
Abstract/Text Diagnostic criteria for primary osteoarthritis of the hip joint in the Japanese population were determined by the roentgenographic measurements of the center-edge (CE) angle, the Sharp angle, and the acetabular roof obliquity in 254 normal hips. Primary osteoarthritis must meet the following conditions: (1) absence of femoral head deformities; (2) a CE angle of Wiberg greater than 19 degrees; (3) a Sharp angle less than 45 degrees; and (4) acetabular roof obliquity less than 15 degrees. These measurements are taken from roentgenograms during the early stage of the disease. Under these criteria, primary osteoarthritis accounted for only 0.65% of 2000 consecutive cases of osteoarthritis. Observation of the natural course of primary osteoarthritis revealed two subtypes. The superolateral type developed from the subset of normal hips with a relatively greater degree of acetabular roof obliquity.

PMID 2924462
S Ninomiya, H Tagawa
Rotational acetabular osteotomy for the dysplastic hip.
J Bone Joint Surg Am. 1984 Mar;66(3):430-6.
Abstract/Text A circumacetabular osteotomy of the acetabulum was initially done at the University of Tokyo Hospital by one of us (H. T.) in 1968. This procedure, which rotates the acetabulum, was designed to correct a dysplastic acetabulum in adolescents and adults. The surgical exposure combines both an anterior and a posterior approach. Between 1974 and 1982 this operation was performed on 103 patients (120 hips) with acetabular dysplasia, some showing early degenerative arthritis. The forty-five hips (forty-one patients) that form the basis of this report were followed for three years to eight years and ten months (average, four years and six months). Thirty hips showed only acetabular dysplasia, and fifteen were in the early stage of degenerative arthritis. The ages of the patients at the time of operation ranged from eleven to forty-two years, the majority being in the second or third decade of life. All of the forty-five hips had a preoperative center-edge angle of 10 degrees or less, but most of them had a nearly normal value after surgery. In the majority of the hips either limp or pain with exertion, or both, had disappeared, and a satisfactory range of motion had been restored.

PMID 6699061
Shiho Kanezaki, Shigeru Nakamura, Masaki Nakamura, Isao Yokota, Takashi Matsushita
Curtain osteophytes are one of the risk factors for the poor outcome of rotational acetabular osteotomy.
Int Orthop. 2017 Feb;41(2):265-270. doi: 10.1007/s00264-016-3183-6. Epub 2016 Apr 28.
Abstract/Text PURPOSE: Rotational acetabular osteotomy (RAO) is one of the surgical procedures for painful dysplastic hips. Although several risk factors for poor outcome of RAO have been reported, the presence of a curtain osteophyte in the acetabulum has not been evaluated as a possible risk factor. This study aimed to analyze the risk factors affecting the outcome of RAO and to clarify whether curtain osteophytes are one of the risk factors.
METHODS: We retrospectively analyzed 87 hips in 78 patients with a mean age of 36 (range, 13-54) years. The mean follow-up period was 8.3 (range, 2.1-19.5) years. The radiographic severity of osteoarthritis was classified into four stages: pre-arthrosis, initial stage, advanced stage, and terminal stage. The Japanese Orthopaedic Association (JOA) hip score was used for clinical evaluation. Poor outcome was defined as a hip with a JOA score < 80 points or terminal-stage osteoarthritis at final follow-up. Several factors were evaluated by logistic regression analysis.
RESULTS: At final follow-up, ten hips had a JOA score < 80 and nine hips had progressed to terminal-stage osteoarthritis. Since five hips had a JOA score < 80 as well as terminal-stage osteoarthritis, a total of 14 hips were determined to have poor outcome. An additional ten years of age at surgery, pre-operative minimal joint space < 2 mm, presence of a curtain osteophyte, and fair/poor congruency in abduction were identified as significant risk factors for poor outcome of RAO.
CONCLUSIONS: Hips with curtain osteophyte should be evaluated carefully before RAO.

PMID 27125434
Ayumi Kaneuji, Tanzo Sugimori, Toru Ichiseki, Kiyokazu Fukui, Eiji Takahashi, Tadami Matsumoto
Rotational Acetabular Osteotomy for Osteoarthritis with Acetabular Dysplasia: Conversion Rate to Total Hip Arthroplasty within Twenty Years and Osteoarthritis Progression After a Minimum of Twenty Years.
J Bone Joint Surg Am. 2015 May 6;97(9):726-32. doi: 10.2106/JBJS.N.00667.
Abstract/Text BACKGROUND: We investigated the rate of conversion to total hip arthroplasty by twenty years and radiographic findings at a minimum of twenty years after rotational acetabular osteotomy.
METHODS: Between June 1986 and August 1991, we performed 172 rotational acetabular osteotomies in 168 patients with acetabular dysplasia. Of those, ninety-three hips (ninety-one patients), including twenty-three hips with pre-osteoarthritis, twenty-nine with initial osteoarthritis, and forty-one with advanced osteoarthritis, had clinical and radiographic findings available. The mean age of the patients was 32.4 years (range, twelve to forty-nine years). The duration of follow-up was a mean of twenty-three years (range, twenty to twenty-seven years) for seventy-six hips, excluding hips that underwent conversion to total hip arthroplasty.
RESULTS: Conversion to total hip arthroplasty by twenty years after surgery was performed in one hip (4%) with pre-osteoarthritis, two hips (7%) with initial osteoarthritis, and fourteen hips (34%) with advanced osteoarthritis. The hips with advanced osteoarthritis had a significantly higher rate of conversion to total hip arthroplasty than hips in the other stages did (p = 0.0005). At the latest follow-up or at conversion to total hip arthroplasty, the disease stage had not progressed in seventeen hips (74%) with pre-osteoarthritis, nineteen (66%) with initial osteoarthritis, and twenty-six (63%) with advanced osteoarthritis.
CONCLUSIONS: The progression of osteoarthritis after rotational acetabular osteotomy was not detected for at least twenty years in most hips with either pre-osteoarthritis or initial osteoarthritis in this cohort. Rotational acetabular osteotomy may delay conversion to total hip arthroplasty in advanced osteoarthritis.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
PMID 25948519
Masatoshi Naito, Yoshinari Nakamura
Curved periacetabular osteotomy for the treatment of dysplastic hips.
Clin Orthop Surg. 2014 Jun;6(2):127-37. doi: 10.4055/cios.2014.6.2.127. Epub 2014 May 16.
Abstract/Text Curved periacetabular osteotomy (CPO) was developed for the treatment of dysplastic hips in 1995. In CPO, the exposure of osteotomy sites and osteotomy of the ischium are made in the same manner as Bernese periacetabular osteotomy, and iliac and pubic osteotomies are performed in the same manner as rotational acetabular osteotomy. We studied the dynamic instabilities of 25 dysplastic hips before and after CPO using triaxial accelerometry. Overall magnitude of acceleration was significantly decreased from 2.30 ± 0.57 m/sec(2) preoperatively to 1.55 ± 0.31 m/sec(2) postoperatively. Pain relief and improvement of acetabular coverage resulting from acetabular reorientation seem to be related with reduction of dynamic instabilities of dysplastic hips. Isokinetic muscle strengths of 24 hips in 22 patients were measured preoperatively and after CPO. At 12 months postoperatively, the mean muscle strength exceeded the preoperative values. These results seem to be obtained due to no dissection of abductor muscles in CPO. The preoperative presence of acetabular cysts did not influence the results of CPO. An adequate rotation of the acetabular fragment induced cyst remodeling. Satisfactory results were obtained clinically and radiographically after CPO in patients aged 50 years or older. CPO alone for the treatment of severe dysplastic hips classified as subluxated hips of Severin group IV-b with preoperative CE angles of up to -20° could restore the acetabular coverage, weight-bearing area and medialization of the hip joint. CPO without any other combined procedure, as a treatment for 17 hips in 16 patients with Perthes-like deformities, produced good mid-term clinical and radiographic results. We have been performing CPO in conjunction with osteochondroplasty for the treatment of acatabular dysplasia associated with femoroacetabular impingement since 2006. The combined procedure has been providing effective correction of both acetabular dysplasia and associated femoral head-neck deformities without any increased complication rate. We have encountered an obturator artery injury in one case and two intraoperative comminuted fractures. Although serious complications such as motor nerve palsy, deep infection, necrosis of the femoral head or acetabulum, and delayed union or nonunion of the ilium were reported, such complications have never occurred in our 700 cases so far.

PMID 24900892
Ayumi Kaneuji, Toshihiko Hara, Eiji Takahashi, Kiyokazu Fukui, Toru Ichiseki, Norio Kawahara
A Novel Minimally Invasive Spherical Periacetabular Osteotomy: Pelvic Ring Preservation and Patient-Specific Osteotomy by Preoperative 3-Dimensional Templating.
J Bone Joint Surg Am. 2021 Sep 15;103(18):1724-1733. doi: 10.2106/JBJS.20.00940.
Abstract/Text BACKGROUND: Spherical periacetabular osteotomy (SPO) is a novel osteotomy involving splitting the teardrop, using patient-specific preoperative planning, and requiring only a 7-cm skin incision. We report preoperative planning methods and short-term results of SPO.
METHODS: In preoperative planning, computed tomography (CT) images were imported into 3-dimensional templating software. The radius of the curved chisel was mapped to pass through the teardrop, the infracotyloid groove of the ischium, and the area between the anterior superior iliac spine and the anterior inferior iliac spine. The osteotomy height and the predicted depth of osteotome insertion were measured, and those values were reproduced during surgery. We performed a retrospective analysis of data on 52 consecutive patients (55 hips) with hip dysplasia who underwent SPO and were followed for at least 2 years: 27 hips had Tönnis grade 0, 21 had grade 1, and 7 had grade 2. The mean age at surgery was 38 years (range, 17 to 56 years). The rotated bone fragment and iliac crest were fixed with absorbable screws. Statistical analysis was performed with the paired t test.
RESULTS: The mean (range) of the lateral center-edge and sourcil angles were 6.0° (-20° to 18°) and 26.0 (13° to 38°), respectively, before surgery and 30.0° (15° to 43°) and 3.8° (-4° to 27°), respectively, after surgery (p < 0.001). However, 11 hips (20%) showed a loss of correction of bone rotation (<3 mm) or the sourcil angle (<3°). Radiographs showed bone union in all hips within 3 months after the surgery. Early second surgery related to absorbable screws was performed in 2 hips. No patient had required conversion to total hip arthroplasty at the time of writing. Clinical scores were significantly improved at the 2-year follow-up (p < 0.001). Paresthesia of the lateral femoral cutaneous nerve area was very common but had resolved in 92% of the patients at the 2-year follow-up.
CONCLUSIONS: SPO is a novel minimally invasive periacetabular osteotomy that has the potential disadvantage of early loss of correction (observed in 20% of the hips in the present study) but may provide the benefit of decreasing the risk of nonunion at the pubis osteotomy site.
LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.
PMID 33988546

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