- 學位論文
利用放射影像學觀察罹患股骨髖臼夾擠症狀之盛行率的前趨研究
Prevalence of Radiographic Findings Associated with Femoroacetabular Impingement: a pilot study
摘要
背景與目的：股骨髖臼夾擠症狀(femoroacetabular impingement, FAI)係指股骨近端和/或髖臼邊緣發生病理解剖型態學異常，而導致股骨近端經常性地衝撞到髖臼邊緣的現象。若此症狀未能及早發現並予以介入，則易提早產生髖部退化性關節炎，甚至需接受人工髖關節置換。本研究旨在了解疑似FAI的潛在性患者未被進一步檢查和診斷的比例。更進一步探討FAI篩檢和檢查方式。 研究方法：本研究檢測臺中某區域醫院2012年期間，於門診20歲至65歲所有前後側(AP view)髖部 X光片，其中X光片被診斷正常且又符合文獻FAI AP view X光診斷標準者(髖臼覆蓋角度、髖關節深度、股骨頭/頸交界角度)，則視為疑似FAI病例，以了解多少比例疑似患者未被發現。接著進一步招募三十位因髖部不適且X光片疑似為FAI的個案，安排主觀檢查(病史、修正式Harris髖關節評分表)、理學檢查(關節活動度、特殊檢測)、AP view X光、Dunn view 45° X光及核磁共振造影(MRI)，並以MRI為黃金診斷標準來判斷在X光所量測角度之敏感度及特異性。 研究結果：本研究總共檢測1174人AP view髖部 X光片，原判定為正常者共184張，經本研究重新檢視發現，其中92% (168/184)為疑似FAI病例；進一步分析所屬型態發現，pincer type佔3% (5/168)、cam type佔64% (107/168)、而mixed type佔33% (56/168)。追蹤三十位(60個髖部) FAI潛在性患者的AP view X光發現，其中51 個髖部有症狀，9個髖部無症狀，cam type佔69% (35/51)及mixed type佔31% (16/51)。從修正式Harris髖關節評分(MHHS)評分表發現，高達43%的患者會將此症狀所引起的疼痛忽略掉亦或者未注意。此外，理學檢查可發現患者的髖關節在主動屈曲、內收及內/外轉的關節角度有受限的現象，在特殊測試中的Patrick 氏測試的檢出率最高為41%。若以MRI為診斷黃金標準，則AP view X光及Dunn view 45° X光在50°切點時的敏感度及特異性最高。 結論與建議：本研究發現，在AP view X光診斷為正常者，高達92%的比例為疑似FAI潛在性患者。為提升診斷率，建議臨床首要的理學檢查可檢視患者髖關節在主動屈曲、內收及內/外轉的關節角度是否受限制，並搭配特殊檢測方法的Patrick 氏測試，初步能夠判斷此個案是否為疑似FAI的潛在性患者。並進一步接受常規的AP view X光影像學檢查之量測，並檢視其α角度是否大於50°。 臨床意義：對於有髖部不適之個案，建議臨床醫師及物理治療師注意其罹患FAI的可能性。期使早期發現，並給予適當的運動與衛教，減少髖關節早期退化。
並列摘要
Background and Purpose: Femoroacetabular Impingement (FAI) means the phenomenon of the proximal femur impacting on the edge of the acetabulum frequently, which is a symptom of the proximal femur and/or acetabulum edge pathological anatomical abnormalities. If FAI does not be diagnosed in advance, patients tend to suffer from hip osteoarthritis earlier, and even resulting in understand artificial joint replacement. The purpose of this study was to investigate the percentage of suspected FAI patients without further examination and diagnosis. We also investigate the screening and examination methods for FAI. Methods: We reviewed antero-posterior view (AP view) hip x-ray of the 20 to 65 years old outpatients in a regional hospital at Taichung in 2012. The films with normal report and fitting diagnosis standard of AP view x-ray FAI (acetabular coverage angle or coxa profunda or femoral head/neck junction) were as to be suspected FAI cases. Than, understanding how many suspected FAI patients were not be detected. Furthermore, we recruited 30 outpatients who had hip symptoms and x-ray of suspected FAI. All of them received subjective examination (history and modified Harris Hip Score), physical examination (range of motion and special test), AP view x-ray, Dunn view 45° x-ray and MRI. Calculating sensitivity and specificity of x-ray by MRI, this is as gold standard. Results: Total 1174 AP view hip x-ray were reviewed. 184 AP view films which were previously diagnosed as normal, where 168 (92%) were found to be as suspected FAI cases: including 3% pincer type (5/168), 64% cam type (107/168), and 33% mixed type (56/168). Among the recruited 30 suspected FAI patients (60 hips), 51 hips fitted the FAI criteria, while 69% cam type (35/51) and 31% mixed type (16/51). By the Modified Harris Hip Score (MHHS), it discovered that there were 43% patients who neglected or unnoted the symptom. In addition, the active hip range of motion (ROM), including flexion, adduction, internal rotation and external rotation, decreased by the physical examination and 41% cases had positive finding of the Patrick’s test (special test) . In terms of MRI as a diagnostic gold standard, the AP view x-ray and Dunn view 45° x-ray had the highest sensitivity and specificity at 50°cut-point. Conclusions and Suggestion: Our study showed 92% cases were found to be as suspected FAI patients who were previously diagnosed as normal by AP view x-ray. To enhance the diagnostic rate, the initial physical examination may include the active hip ROM and Patrick’s test (special test) and the next procedure is to check whether the alpha angle on the AP view x-ray film is over 50°. Clinical Significance: Clinicians and physical therapists should consider the FAI as a candidate disease for those patients with hip symptom. For reducing hip earlier degeneration, we hope to diagnosis FAI earlier and give them appropriate instruction on exercise and health care.