本期目錄：

1、冷凍切片和MSIS標(biāo)準(zhǔn)在假體周圍感染兩期翻修術(shù)二期再植入術(shù)時(shí)檢測(cè)可靠嗎？

2、局部使用萬古霉素粉對(duì)初次全膝關(guān)節(jié)置換術(shù)中髕骨軟骨退化以及二次髕骨表面置換術(shù)的轉(zhuǎn)化率無影響

3、關(guān)節(jié)置換術(shù)后應(yīng)用氯吡格雷作常規(guī)抗凝-與阿司匹林相比，輸血風(fēng)險(xiǎn)增加但靜脈血栓栓塞風(fēng)險(xiǎn)近似

4、膝關(guān)節(jié)單純髕股關(guān)節(jié)炎的髕股關(guān)節(jié)置換術(shù)與全膝關(guān)節(jié)置換術(shù)比較

5、異體結(jié)構(gòu)骨植骨在髖臼周圍截骨術(shù)治療嚴(yán)重髖關(guān)節(jié)發(fā)育不良的應(yīng)用

6、髖關(guān)節(jié)發(fā)育不良并發(fā)股骨骨骺外側(cè)生長(zhǎng)障礙的髖臼發(fā)育情況

7、術(shù)中計(jì)算機(jī)輔助技術(shù)進(jìn)行髖臼周圍截骨術(shù)

8、避免髖臼周圍截骨術(shù)的并發(fā)癥

9、有癥狀的塌陷前股骨頭壞死伴骨髓水腫的MRI表現(xiàn)

第一部分：關(guān)節(jié)置換及保膝相關(guān)文獻(xiàn)

文獻(xiàn)1

冷凍切片和MSIS標(biāo)準(zhǔn)在假體周圍感染兩期翻修術(shù)二期再植入術(shù)時(shí)檢測(cè)可靠嗎？

譯者 張軼超

背景：盡管其實(shí)用性有限，冷凍切片組織學(xué)依然被廣泛用于假體周圍感染兩期翻修術(shù)二期的術(shù)前檢測(cè)。然而，目前沒有明確的方法在再植術(shù)前來評(píng)估感染是否得到了控制。由于二期翻修失敗可能會(huì)產(chǎn)生嚴(yán)重后果，因此明確可能失敗的病例并在必要時(shí)推遲再植入新假體是很重要的。因此，通過一個(gè)可靠的測(cè)試來提供有關(guān)感染是否得到了控制和后續(xù)失敗風(fēng)險(xiǎn)的信息是非常有必要的。

問題/目的：(1)在二期再植入手術(shù)中，與作為金標(biāo)準(zhǔn)的肌肉骨骼感染學(xué)會(huì)（MSIS）標(biāo)準(zhǔn)相比，冷凍切片的診斷準(zhǔn)確性如何？(2) MSIS標(biāo)準(zhǔn)和冷凍切片預(yù)測(cè)再植失敗的診斷準(zhǔn)確性參數(shù)是什么？(3)再植入新假體時(shí)呈陽性的MSIS標(biāo)準(zhǔn)或冷凍切片是否預(yù)示著后續(xù)失敗的風(fēng)險(xiǎn)會(huì)增加？

方法：選取2013年診斷為假體周圍感染（PJI）而行兩期翻修的全髖關(guān)節(jié)置換術(shù)或全膝關(guān)節(jié)置換術(shù)的97名患者作為研究對(duì)象。其中11例的MSIS標(biāo)準(zhǔn)評(píng)定不完整，7例缺乏1年隨訪，剩下79例（38膝和41髖）可用于分析。再植入術(shù)時(shí)，將冷凍切片結(jié)果與作為檢測(cè)感染金標(biāo)準(zhǔn)的改良MSIS標(biāo)準(zhǔn)進(jìn)行比較。隨后，再植入假體的成功或失敗的定義是：(1)感染控制，其特征是傷口愈合無竇道、滲出或疼痛；(2)再植入術(shù)后無因?yàn)楦腥径鴮?dǎo)致的后續(xù)手術(shù)干預(yù)；(3)未發(fā)生PJI相關(guān)死亡；計(jì)算改良MSIS標(biāo)準(zhǔn)和冷凍切片預(yù)測(cè)治療失敗的診斷參數(shù)。

結(jié)果：在二期再植手術(shù)時(shí)，冷凍切片可用于判定感染，其特異性為94%(95%可信區(qū)間[CI]， 89% - 99%)；然而，排除感染的效用較小，因?yàn)槊舾行詢H為50% （CI, 13%-88%）。MSIS標(biāo)準(zhǔn)和冷凍切片在判定再植失敗方面都具有很高的特異性（MSIS標(biāo)準(zhǔn)特異性：96% [CI， 91%-100%]；冷凍切片：95% [CI， 88%-100%]），但篩查能力有限（MSIS敏感性：26% [CI， 9%-44%]；冷凍切片：22% [CI， 9%-29%]）。再植時(shí)MSIS標(biāo)準(zhǔn)陽性是術(shù)后失敗的危險(xiǎn)因素（風(fēng)險(xiǎn)比[HR]， 5.22 [1.64-16.62], p = 0.005），而冷凍切片陽性則不是（風(fēng)險(xiǎn)比[HR]， 1.16 [0.15-8.86], p = 0.883）。

結(jié)論：我們的研究結(jié)果建議在第二階段再植入術(shù)時(shí)可以采用冷凍切片和MSIS。冷凍切片和改良的MSIS標(biāo)準(zhǔn)雖然都具有高特異性，但對(duì)感染控制失敗的篩查能力有限。應(yīng)在兩期翻修術(shù)的第二階段進(jìn)行MSIS標(biāo)準(zhǔn)評(píng)估，因?yàn)樵诟腥娟栃缘年P(guān)節(jié)中進(jìn)行再植入新假體會(huì)顯著增加后續(xù)失敗的風(fēng)險(xiǎn)。

Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty?

Background：Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary.

Questions/purposes：(1) At second-stage reimplantation surgery, what is the diagnostic accuracy of frozen sections as compared with the Musculoskeletal Infection Society (MSIS) as the gold standard? (2) What are the diagnostic accuracy parameters for the MSIS criteria and frozen sections in predicting failure of reimplantation? (3) Do positive MSIS criteria or frozen section at the time of reimplantation increase the risk of subsequent failure?

Methods：A total of 97 patients undergoing the second stage of revision total hip arthroplasty or total knee arthroplasty in 2013 for a diagnosis of periprosthetic joint infection (PJI) were considered eligible for the study. Of these, 11 had incomplete MSIS criteria and seven lacked 1- year followup, leaving 79 patients (38 knees and 41 hips) available for analysis. At the time of reimplantation, frozen section results were compared with modified MSIS criteria as the gold standard in detecting infection. Subsequently, success or failure of reimplantation was defined by (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality; and diagnostic parameters in predicting treatment failure were calculated for both the modified MSIS criteria and frozen sections.

Results：At the time of second-stage reimplantation surgery, frozen section is useful in ruling in infection, where the specificity is 94% (95% confidence interval [CI], 89%– 99%); however, there is less utility in ruling out infection, because sensitivity is only 50% (CI, 13%–88%). Both the MSIS criteria and frozen sections have high specificity for ruling in failure of reimplantation (MSIS criteria specificity: 96% [CI, 91%–100%]; frozen section: 95% [CI, 88%–100%]), but screening capabilities are limited (MSIS sensitivity: 26% [CI, 9%–44%]; frozen section: 22% [CI, 9%–29%]). Positive MSIS criteria at the time of reimplantation were a risk factor for subsequent failure (hazard ratio [HR], 5.22 [1.64–16.62], p = 0.005), whereas positive frozen section was not (HR, 1.16 [0.15–8.86], p = 0.883).

Conclusions：On the basis of our results, both frozen section and MSIS are recommended at the time of the second stage of revision arthroplasty. Both frozen section and modified MSIS criteria had limited screening capabilities to identify failure, although both demonstrated high specificity. MSIS criteria should be evaluated at the second stage of revision arthroplasty because performing reimplantation in a joint that is positive for infection significantly increases the risk for subsequent failure.

文獻(xiàn)出處：George J, Kwiecien G, Klika AK, Ramanathan D, Bauer TW, Barsoum WK, Higuera CA. Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty? Clin Orthop Relat Res. 2016 Jul;474(7):1619-26. doi: 10.1007/s11999-015-4673-3. PMID: 26689583; PMCID: PMC4887348.

文獻(xiàn)2

局部使用萬古霉素粉對(duì)初次全膝關(guān)節(jié)置換術(shù)中髕骨軟骨退化以及二次髕骨表面置換術(shù)的轉(zhuǎn)化率無影響

譯者 馬云青

簡(jiǎn)介：萬古霉素粉（VP）是一種抗生素，最初用于兒童脊柱外科手術(shù)，以預(yù)防手術(shù)部位感染（SSI）。最近，其應(yīng)用范圍已擴(kuò)展到全髖關(guān)節(jié)和膝關(guān)節(jié)置換術(shù)（THA、TKA）以及前交叉韌帶重建術(shù)（ACLR）。萬古霉素的軟骨毒性是當(dāng)前研究熱點(diǎn)。此研究的目的是證明以下假設(shè)：在TKA 中局部應(yīng)用VP不會(huì)導(dǎo)致髕骨軟骨變性。 我們傳播的觀點(diǎn)是，二次髕骨表面置換的概率不受其使用的影響。

材料與方法：在 2014 年至 2021 年間，單中心的回顧性隊(duì)列研究共納入了4292個(gè)關(guān)節(jié)。所有患者均接受了TKA 治療，且未進(jìn)行原發(fā)性髕骨表面置換術(shù)。在醫(yī)院程序發(fā)生變化后，一組在術(shù)中接受了局部萬古霉素治療。另一組在手術(shù)期間未接受局部萬古霉素。其余圍手術(shù)期手術(shù)在調(diào)查期間保持不變。兩組二次髕骨表面置換率均未對(duì)適應(yīng)癥進(jìn)行區(qū)分。第二組患者由在TKA后12 個(gè)月來接受隨訪，共包含210個(gè)關(guān)節(jié)。術(shù)前、出院前和隨訪檢查時(shí)均進(jìn)行了回顧性X線評(píng)估。對(duì)髕骨軸位X線進(jìn)行了髕骨追蹤（髕骨外側(cè)傾斜、髕骨位移）和髕骨變性（斯珀納分類、髕股關(guān)節(jié)間隙）分析。

結(jié)果：二次髕骨表面置換術(shù)的概率無顯著差異（VPG 4.24%，nVPG 4.97%）。 兩組之間的髕骨追蹤和髕骨變性沒有顯著差異。

結(jié)論：VP 局部應(yīng)用不會(huì)影響二次髕骨表面置換術(shù)的概率。此外，也不會(huì)導(dǎo)致髕骨軟骨在TKA后的退化。

Topical vancomycin powder does not affect patella cartilage degeneration in primary total knee arthroplasty and conversion rate for secondary patella resurfacing

Introduction:Vancomycin powder (VP) is an antibiotic first introduced in pediatric spinal surgery to prevent surgical site infections (SSI). Recently its topical application was expanded to total hip and knee arthroplasty (THA, TKA) and anterior cruciate ligament reconstruction (ACLR). Toxicity to cartilage is the subject of current research. The aim of this study was to prove the hypothesis that topical application of VP in TKA does not result in a degeneration of patella cartilage. We propagate that the conversion rate for secondary patella resurfacing is not influenced by its use.

Materials and methods:Between 2014 and 2021, 4292 joints were included in this monocentric retrospective cohort study. All patients underwent TKA without primary patella resurfacing. After a change of the procedure in the hospital, one group (VPG) was administered VP intraoperatively. The other group (nVPG) received no VP during surgery (nVPG). The remaining perioperative procedure was constant over the investigation period. Conversion rates for secondary patella resurfacing for both groups were determined without making distinctions in the indication. A second cohort was composed of patients presenting for follow-up examination 12 months after TKA and included 210 joints. Retrospective radiographic evaluations were performed preoperatively, before discharge and at follow-up examination. Patella axial radiographs were analyzed for patella tracking (lateral patellar tilt, patellar displacement) and patella degeneration (Sperner classification, patellofemoral joint space).

Results:There was no significant difference in the conversion rate for secondary patella resurfacing (4.24% VPG, 4.97% nVPG). Patella tracking and patella degeneration did not differ significantly between both groups.

Conclusions:The topical application of VP does not influence the conversion rate for secondary patella resurfacing. Moreover, it does not result in a degeneration of patella cartilage in TK.

文獻(xiàn)出處：Jacob B, Wassilew G, von Eisenhart-Rothe R, Brodt S, Matziolis G. Topical vancomycin powder does not affect patella cartilage degeneration in primary total knee arthroplasty and conversion rate for secondary patella resurfacing. Arch Orthop Trauma Surg. 2023 Aug;143(8):5249-5254. doi: 10.1007/s00402-022-04721-w. Epub 2022 Dec 20. PMID: 36538161; PMCID: PMC10374468.

文獻(xiàn)3

關(guān)節(jié)置換術(shù)后應(yīng)用氯吡格雷作常規(guī)抗凝-與阿司匹林相比，輸血風(fēng)險(xiǎn)增加但靜脈血栓栓塞風(fēng)險(xiǎn)近似

譯者 張薔

背景：關(guān)節(jié)置換（TJA）術(shù)前長(zhǎng)期應(yīng)用氯吡格雷進(jìn)行動(dòng)脈粥樣硬化性血栓預(yù)防的病人通常在初次全膝關(guān)節(jié)置換（TKA）和全髖關(guān)節(jié)置換（THA）術(shù)后繼續(xù)將其作為靜脈血栓栓塞（VTE）預(yù)防的常規(guī)藥物。我們?cè)诒狙芯恐性噲D比較并評(píng)價(jià)TJA術(shù)后應(yīng)用氯吡格雷VS.阿司匹林作為VTE常規(guī)抗凝藥物的病例術(shù)后90天內(nèi)出血和血栓栓塞的風(fēng)險(xiǎn)。

方法：我們應(yīng)用某涵蓋全美25%住院患者的醫(yī)保數(shù)據(jù)庫資料并從中挑選出了2016年至2021年間所有施行初次擇期TKA或THA手術(shù)的成年患者。所有在術(shù)后應(yīng)用氯吡格雷作為單藥VTE預(yù)防的病例，在年齡、性別、手術(shù)類型、圍術(shù)期氨甲環(huán)酸用法和氯吡格雷應(yīng)用指證近似的基礎(chǔ)上，按照傾向性評(píng)分匹配法大約1:7的比例選擇了術(shù)后應(yīng)用阿司匹林作為單藥VET預(yù)防的病例。首要研究指標(biāo)包括術(shù)后90天內(nèi)出血和血栓栓塞性并發(fā)癥的風(fēng)險(xiǎn)。

結(jié)果：總共挑選出21273例應(yīng)用阿司匹林的病例和3078例應(yīng)用氯吡格雷的病例。匹配后，兩組間的患者一般資料、合并癥、氨甲環(huán)酸應(yīng)用率和醫(yī)院信息并無顯著性差異。與阿司匹林組相比，應(yīng)用氯吡格雷的病例在考慮潛在混淆變量后，術(shù)后緊急輸血（矯正后概率比 [aOR]: 1.69; 95%置信區(qū)間[CI]: 1.30 - 2.21; p < 0.001）和急性貧血（aOR: 1.13; 95%CI: 1.03 - 1.26; p = 0.015）的風(fēng)險(xiǎn)更高。但兩組間在深靜脈血栓栓塞、肺栓塞、中風(fēng)、急性心肌梗死、血腫或大出血風(fēng)險(xiǎn)無顯著性差異。

結(jié)論：與應(yīng)用阿司匹林相比，關(guān)節(jié)置換術(shù)后應(yīng)用單藥氯吡格雷作為術(shù)后常規(guī)VTE抗凝的患者術(shù)后出血性并發(fā)癥風(fēng)險(xiǎn)更高而血栓栓塞性并發(fā)癥風(fēng)險(xiǎn)近似。這些發(fā)現(xiàn)提醒我們：對(duì)心血管事件高風(fēng)險(xiǎn)的患者來說，我們應(yīng)謹(jǐn)慎選擇恢復(fù)應(yīng)用氯吡格雷作為術(shù)后抗凝藥物的時(shí)機(jī)，以平衡抗血小板反應(yīng)導(dǎo)致出血性并發(fā)癥的風(fēng)險(xiǎn)。

Postoperative Clopidogrel Thromboprophylaxis in?TJA Increased Risk of Transfusion but Similar Venous Thromboembolic Risk Compared with Aspirin

Background: Patients undergoing total joint arthroplasty (TJA) who are on long-term use of clopidogrel for atherothrombotic prophylaxis often continue this drug as venous thromboembolism (VTE) chemoprophylaxis following primary total knee (TKA) and total hip arthroplasty (THA). We sought to assess the 90-day bleeding and thromboembolic risk profiles of patients receiving clopidogrel monotherapy for postoperative VTE chemoprophylaxis compared with those receiving aspirin following TJA.

Methods: Utilizing a national, all-payer health-care database that captures approximately 25% of all inpatient procedures in the U.S., we identified all adult patients who underwent primary elective TKA or THA between 2016 and 2021. Patients who received clopidogrel monotherapy for postoperative VTE chemoprophylaxis were propensity-score matched in an approximately 1:7 ratio to patients who received aspirin monotherapy on the basis of age, sex, procedure type, perioperative tranexamic acid administration, and known indications for clopidogrel administration. Primary outcomes included the 90-day risks of bleeding and thromboembolic complications.

Results: A total of 21,273 patients who received aspirin were matched to 3,078 patients who received clopidogrel. After matching, there were no significant differences between the 2 cohorts with respect to patient demographics, comorbidities, rates of tranexamic acid administration, and hospital characteristics. After accounting for potential confounding variables, patients who received clopidogrel were at an increased risk for postoperative blood transfusion (adjusted odds ratio [aOR]: 1.69; 95% confidence interval [CI]: 1.30 to 2.21; p < 0.001) and acute anemia (aOR: 1.13; 95% CI: 1.03 to 1.26; p = 0.015) relative to patients receiving aspirin. No significant differences between the cohorts in the risk of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, hematoma, or hemorrhage were found.

Conclusions: Patients who received clopidogrel monotherapy for postoperative VTE chemoprophylaxis had an increased risk of postoperative bleeding complications but a similar risk of thromboembolic complications following TJA compared with patients who received aspirin. These findings suggest that the decision to resume clopidogrel for postoperative thromboprophylaxis should balance the potent antiplatelet activity with the risk of bleeding complications in high-risk cardiovascular patients.

文獻(xiàn)出處：Telang SS, Telang S, Palmer RC, Stronach BM, Stambough JB, Lieberman JR, Heckmann ND. Postoperative Clopidogrel Thromboprophylaxis in TJA: Increased Risk of Transfusion but Similar Venous Thromboembolic Risk Compared with Aspirin. J Bone Joint Surg Am. 2025 Dec 29. doi: 10.2106/JBJS.25.00930. Epub ahead of print. PMID: 41460931.

文獻(xiàn)4

單純髕股關(guān)節(jié)炎的髕股關(guān)節(jié)置換術(shù)與全膝關(guān)節(jié)置換術(shù)比較：來自一項(xiàng)采用 GRADE 評(píng)估的系統(tǒng)綜述的循證推薦

譯者 沈松坡

引言：孤立性髕股骨關(guān)節(jié)骨關(guān)節(jié)炎（PFOA）仍然是一個(gè)治療難題，其中髕股關(guān)節(jié)置換術(shù)（PFA）和全膝關(guān)節(jié)置換術(shù)（TKA）代表終末期疾病的主要手術(shù)選擇。本系統(tǒng)綜述應(yīng)用 GRADE 框架來評(píng)估 PFA 與 TKA 的比較結(jié)局，從而提供循證推薦。

材料與方法：采用 PRISMA 方法對(duì) PubMed、Cochrane Library 與 Google Scholar 進(jìn)行了系統(tǒng)檢索（2010–2025）。納入報(bào)告孤立性 PFOA 患者 PFA vs TKA 的 RCT、比較性隊(duì)列研究與注冊(cè)登記分析。主要結(jié)局為經(jīng)驗(yàn)證的患者報(bào)告結(jié)局指標(biāo)（PROMs）以及 2、5 和 10 年的假體生存率。次要結(jié)局為并發(fā)癥、患者滿意度、重返運(yùn)動(dòng)以及成本效果。偏倚風(fēng)險(xiǎn)采用 RoB 2 與 ROBINS-I 評(píng)估，證據(jù)確定性使用 GRADE 評(píng)定。

結(jié)果：共納入 10 項(xiàng)研究（4 項(xiàng) RCT、6 項(xiàng)隊(duì)列研究；約 10,000 例 PFA 來自注冊(cè)登記）。中等確定性證據(jù)顯示：與 TKA 相比，PFA 可帶來更優(yōu)的早期 PROMs 以及短期成本效果。兩組 PROMs 在中長(zhǎng)期隨訪時(shí)趨于一致。長(zhǎng)期數(shù)據(jù)以中等確定性顯示 PFA 的翻修風(fēng)險(xiǎn)持續(xù)更高：基于注冊(cè)登記的 10 年生存率為 PFA 85% vs TKA 95%，且 PFA 在 10 年后仍繼續(xù)惡化。并發(fā)癥發(fā)生率在兩組相似或 PFA 更低，尤其在全身性內(nèi)科事件方面。患者滿意度與重返運(yùn)動(dòng)在短期更偏向 PFA，但在中期與 TKA 相當(dāng)。

結(jié)論：在嚴(yán)格篩選的孤立性 PFOA 患者中，現(xiàn)代 onlay 型 PFA 可實(shí)現(xiàn)更快恢復(fù)、更優(yōu)的早期功能以及短期成本效果，且有中等確定性證據(jù)支持。但這些優(yōu)勢(shì)會(huì)被較 TKA 更高的長(zhǎng)期翻修風(fēng)險(xiǎn)所抵消，提示需要將這種權(quán)衡告知患者。對(duì)于合并脛股關(guān)節(jié)病變或不穩(wěn)定的患者，TKA 仍是參考標(biāo)準(zhǔn)，且有高確定性證據(jù)支持，并能在更異質(zhì)的患者群體中提供持久、可預(yù)測(cè)的長(zhǎng)期結(jié)局。

證據(jù)等級(jí)：II 級(jí)：系統(tǒng)性 GRADE（Grading of Recommendations, Assessment, Development and Evaluation）綜述，納入 RCT 與觀察性研究。

關(guān)鍵詞：孤立性髕股骨關(guān)節(jié)骨關(guān)節(jié)炎;髕股關(guān)節(jié)置換術(shù);全膝關(guān)節(jié)置換術(shù);全膝關(guān)節(jié)置換（total knee replacement）;假體生存率;患者報(bào)告結(jié)局指標(biāo)（PROMs）

Patellofemoral vs. total knee arthroplasty for isolated patellofemoral osteoarthritis: evidence-based recommendations from a systematic review with GRADE assessment

Introduction: Isolated patellofemoral osteoarthritis (PFOA) remains a therapeutic challenge, with patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) representing the main surgical options for end-stage disease. This systematic review applies the GRADE framework to evaluate comparative outcomes of PFA and TKA, providing evidence-based recommendations.

Materials and methods: A PRISMA systematic search of Pubmed, Cochrane Library, and Google Scholar was conducted (2010–2025). RCTs, comparative cohort studies, and registry analyses reporting on PFA versus TKA for isolated PFOA were included. Primary outcomes were validated PROMs and implant survival at 2, 5, and 10 years. Secondary outcomes were complications, patient satisfaction, return to sport, and cost-effectiveness. Risk of bias was assessed with RoB 2 and ROBINS-I, and certainty of evidence using GRADE.

Results: Ten studies were included (4 RCTs, 6 cohort studies; approximately 10,000 PFAs comprising registries). Moderate-certainty evidence indicated that PFA provides superior early PROMs, and short-term cost-effectiveness compared with TKA. PROMs converged between groups at mid- to long-term follow-up. Long-term data demonstrated a consistently higher revision risk for PFA with moderate certainty, with registry-based 10-year survival of 85% for PFA vs. 95% for TKA, continuing to worsen for PFA after 10 years. Complication rates were similar or lower after PFA, particularly for systemic medical events. Patient satisfaction and return to sport favored PFA short term but became comparable to TKA at mid-term.

Conclusion: In carefully selected patients with isolated PFOA, modern onlay PFA yields faster recovery, superior early function, and short-term cost-effectiveness, supported by moderate-certainty evidence. These advantages are offset by a higher long-term revision risk compared with TKA, highlighting the need to inform patients of this trade-off. TKA remains the reference standard for patients with tibiofemoral disease or instability, supported by high-certainty evidence, and offers durable, predictable long-term outcomes in more heterogeneous patient populations.

Level of evidence, II: Systematic GRADE (Grading of Recommendations, Assessment, Development and Evaluation) review of RCTs and observational studies.

Keywords: Implant survival; Isolated patellofemoral osteoarthritis; Patellofemoral arthroplasty; Patient-reported outcome measures.; Total knee arthroplasty; Total knee replacement.

第二部分：保髖相關(guān)文獻(xiàn)

文獻(xiàn)1

異體結(jié)構(gòu)骨植骨在髖臼周圍截骨術(shù)治療嚴(yán)重髖關(guān)節(jié)發(fā)育不良的應(yīng)用

譯者 張振東

本研究擬明確髖臼弧形旋轉(zhuǎn)截骨術(shù)聯(lián)合使用結(jié)構(gòu)性同種異體骨植骨治療嚴(yán)重髖關(guān)節(jié)發(fā)育不良的中期效果。研究回顧了1998年至2019年期間接受髖臼弧形旋轉(zhuǎn)截骨與結(jié)構(gòu)性骨植骨治療的嚴(yán)重DDH患者，嚴(yán)重DDH定義是Severin 分級(jí)為IVb或V級(jí)（即外側(cè)中心-邊緣角（LCEA）< 0°）。通過病歷回顧提取了人口統(tǒng)計(jì)學(xué)數(shù)據(jù)、與截骨術(shù)相關(guān)的并發(fā)癥以及改良髖關(guān)節(jié)Harris評(píng)分（mHHS）。髖關(guān)節(jié)發(fā)育不良的影像學(xué)參數(shù)通過術(shù)前和術(shù)后的X光片進(jìn)行測(cè)量。采用Kaplan-Meier生存分析估算截骨失?。ㄟM(jìn)展至T?nnis 3級(jí)骨關(guān)節(jié)炎或轉(zhuǎn)為全髖關(guān)節(jié)置換術(shù)）的累積概率，并采用多變量Cox比例危險(xiǎn)模型確定了失敗的預(yù)測(cè)因素。

本研究共納入 64 例患者（76 髖）。隨訪時(shí)間的中位數(shù)為 10 年（四分位數(shù)間距為 5 至 14 年）。中位 mHHS 從術(shù)前的 67（IQR 56 至 80）提高到最近隨訪時(shí)的 96（IQR 85 至 97）（p < 0.001）。術(shù)后影像學(xué)參數(shù)均有所改善（p < 0.001），42% 到 95% 的髖關(guān)節(jié)的影像學(xué)參數(shù)在正常范圍內(nèi)。10年的存活率為95%，15年的存活率為80%。術(shù)前T?nnis 2級(jí)是TOA失敗的獨(dú)立風(fēng)險(xiǎn)因素。

本研究表明，對(duì)于沒有晚期骨關(guān)節(jié)炎的青少年和年輕成年人，TOA 和結(jié)構(gòu)性骨異體移植是矯正嚴(yán)重發(fā)育不良髖臼的可行手術(shù)方案，而且中期療效良好。

Clinical results of periacetabular osteotomy with structural bone allograft for the treatment of severe hip dysplasia

Aims:To clarify the mid-term results of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, combined with structural allograft bone grafting for severe hip dysplasia.

Methods:We reviewed patients with severe hip dysplasia, defined as Severin IVb or V (lateral centre-edge angle (LCEA) < 0°), who underwent TOA with a structural bone allograft between 1998 and 2019. A medical chart review was conducted to extract demographic data, complications related to the osteotomy, and modified Harris Hip Score (mHHS). Radiological parameters of hip dysplasia were measured on pre- and postoperative radiographs. The cumulative probability of TOA failure (progression to T?nnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method, and a multivariate Cox proportional hazard model was used to identify predictors for failure.

Results:A total of 64 patients (76 hips) were included in this study. The median follow-up period was ten years (interquartile range (IQR) five to 14). The median mHHS improved from 67 (IQR 56 to 80) preoperatively to 96 (IQR 85 to 97) at the latest follow-up (p < 0.001). The radiological parameters improved postoperatively (p < 0.001), with the resulting parameters falling within the normal range in 42% to 95% of hips. The survival rate was 95% at ten years and 80% at 15 years. Preoperative T?nnis grade 2 was an independent risk factor for TOA failure.

Conclusion:Our findings suggest that TOA with structural bone allografting is a viable surgical option for correcting severely dysplastic acetabulum in adolescents and young adults without advanced osteoarthritis, with favourable mid-term outcomes.

文獻(xiàn)出處：Fujii M, Kawano S, Ueno M, Sonohata M, Kitajima M, Tanaka S, Mawatari D, Mawatari M. Clinical results of periacetabular osteotomy with structural bone allograft for the treatment of severe hip dysplasia. Bone Joint J. 2023 Jul 1;105-B(7):743-750. doi: 10.1302/0301-620X.105B7.BJJ-2023-0056.R1. PMID: 37399069.

文獻(xiàn)2

髖關(guān)節(jié)發(fā)育不良并發(fā)股骨骨骺外側(cè)生長(zhǎng)障礙的髖臼發(fā)育情況

譯者 任寧濤

背景:股骨頭骨骺外側(cè)生長(zhǎng)障礙是髖關(guān)節(jié)發(fā)育不良治療過程中最常見的骨骺生長(zhǎng)障礙類型。雖然這種類型的骨骺生長(zhǎng)障礙被認(rèn)為可導(dǎo)致髖臼發(fā)育不良，但這種生長(zhǎng)障礙模式對(duì)髖關(guān)節(jié)發(fā)育不良影響的自然史尚不清楚。為了探討這一問題，我們對(duì)48名DDH患者治療后發(fā)生股骨頭骨骺外側(cè)生長(zhǎng)障礙的58例髖臼發(fā)育情況進(jìn)行了回顧性研究。

方法:58例髖關(guān)節(jié)中，36例行閉合復(fù)位，22例行切開復(fù)位。復(fù)位時(shí)患者平均年齡為22個(gè)月(范圍，3 ~ 97個(gè)月)，最近一次隨訪評(píng)估時(shí)為21歲(范圍，10 ~ 55歲)。隨訪時(shí)Severin I級(jí)(優(yōu))或II級(jí)(良)為臨床效果滿意， Severin III級(jí)(可)或IV級(jí)(差)的被認(rèn)為是臨床效果不滿意。在連續(xù)的影像學(xué)上觀察股骨頭的特定變化，在后期隨訪期間，測(cè)量髖關(guān)節(jié)的各種影像學(xué)參數(shù)，包括股骨骨骺的側(cè)傾程度，并在四個(gè)時(shí)間節(jié)點(diǎn)(復(fù)位前、復(fù)位后兩年、6至8歲和最終隨訪時(shí))對(duì)劃分為滿意和不滿意的髖關(guān)節(jié)進(jìn)行比較。

結(jié)果:平均10歲(4 ~ 14歲)首次出現(xiàn)股骨頭骨骺外側(cè)生長(zhǎng)發(fā)育障礙。在骨骺、骨骺或干骺端中沒有一致的早期變化模式與骨骺外翻傾斜的后期發(fā)展有關(guān)。末次隨訪時(shí)34例髖(59%)滿意，24例髖不滿意。不滿意的髖關(guān)節(jié)平均在7歲時(shí)表現(xiàn)為髖臼發(fā)育不良。隨著時(shí)間的推移，骨骺板的傾斜逐漸變得更水平甚至倒置; 然而，連續(xù)測(cè)量的傾斜度并不是Severin分類的顯著預(yù)測(cè)因子。

結(jié)論：股骨頭骨骺外側(cè)生長(zhǎng)障礙并不一定與髖臼發(fā)育不良有關(guān)，因?yàn)楫?dāng)發(fā)育不良確實(shí)發(fā)生時(shí)，通常在確定骨骺生長(zhǎng)障礙之前就很明顯了。重要的是監(jiān)測(cè)復(fù)位后髖臼的發(fā)育，而不是尋找骨骺生長(zhǎng)發(fā)育的影像學(xué)變化，這在幼兒中很難發(fā)現(xiàn)。

圖1 25個(gè)月大小患兒，右髖高脫位，行內(nèi)收肌松解閉合復(fù)位

圖2 該患者9歲時(shí)，股骨近端骨骺外側(cè)傾斜，股骨頸上外側(cè)可見向外延續(xù)的“骨板”。股骨頭部略扁平，髖臼發(fā)育不良。

圖3 該患者11歲時(shí)，股骨頭嚴(yán)重外翻畸形，伴有殘余髖臼發(fā)育不良，淚滴形態(tài)異常，右髖關(guān)節(jié)半脫位。

Acetabular development in developmental dysplasia of the hip complicated by lateral growth disturbance of the capital femoral epiphysis

Background: Lateral growth disturbance of the capital femoral epiphysis is the most common type of physeal arrest complicating the treatment of developmental hip dysplasia. Although this type of physeal damage has been assumed to result in poor acetabular development, the natural history of dysplastic hips affected by this pattern of growth disturbance is still unclear. To investigate this issue, we evaluated acetabular development in a retrospective study of fifty-eight hips in forty-eight patients who had lateral physeal arrest after management of developmental hip dysplasia.

Methods: Of the fifty-eight hips, thirty-six were reduced closed and twenty-two were reduced open. The average age of the patients was twenty-two months (range, three to ninety-seven months) at the time of the reduction and twenty-one years (range, ten to fifty-five years) at the time of the latest follow-up evaluation. Hips rated as Severin class I (an excellent result) or II (a good result) were defined as having a satisfactory result, and those rated as Severin class III (a fair result) or IV (a poor result) were considered to have an unsatisfactory result. Specific femoral head changes were sought in the complete radiographic files on all hips. Various radiographic parameters of hip integrity, including the degree of lateral tilt of the capital femoral epiphysis, were measured over time, and comparisons were made between hips classified as satisfactory and those classified as unsatisfactory at four time-points: before the reduction, at two years after the reduction, at six to eight years of age, and at the time of the final follow-up.

Results: Lateral growth disturbance of the capital femoral epiphysis was first evident by an average of ten years of age (range, four to fourteen years of age). There was no consistent early pattern of changes in the epiphysis, physis, or metaphysis related to later development of valgus tilt of the epiphysis. Thirty-four hips (59 percent) were rated as satisfactory and twenty-four were rated as unsatisfactory at the latest follow-up evaluation. Hips classified as unsatisfactory exhibited poor acetabular development by an average age of seven years. The inclination of the epiphyseal plate became progressively more horizontal or even reversed over time; however, serial measurements of inclination were not significant predictors of Severin classification.

Conclusions: Lateral growth disturbance of the capital femoral epiphysis is not necessarily associated with poor acetabular development, as when dysplasia does occur it is generally evident prior to the identification of the physeal arrest. It is important to monitor acetabular development after reduction rather than search for radiographic changes of physeal arrest, which are difficult to detect in young children.

文獻(xiàn)出處：Kim HW, Morcuende JA, Dolan LA, Weinstein SL. Acetabular development in developmental dysplasia of the hip complicated by lateral growth disturbance of the capital femoral epiphysis. J Bone Joint Surg Am. 2000 Dec;82(12):1692-700. doi: 10.2106/00004623-200012000-00002. PMID: 11130642.

文獻(xiàn)3

術(shù)中計(jì)算機(jī)輔助技術(shù)進(jìn)行髖臼周圍截骨術(shù)：一項(xiàng)系統(tǒng)綜述

譯者 李勇

術(shù)中計(jì)算機(jī)輔助技術(shù)在髖臼周圍截骨術(shù)（PAO）中的作用，以及這些技術(shù)的圍手術(shù)期和術(shù)后結(jié)果，目前仍缺乏明確的定義。本系統(tǒng)綜述旨在評(píng)估術(shù)中計(jì)算機(jī)輔助技術(shù)在PAO中的應(yīng)用技術(shù)及臨床結(jié)果。檢索了三個(gè)數(shù)據(jù)庫（PubMed、CINAHL/EBSCOHost和Cochrane），以獲取報(bào)告計(jì)算機(jī)輔助技術(shù)用于PAO的臨床研究。排除標(biāo)準(zhǔn)包括：小規(guī)模病例系列（患者數(shù)<10）、非英文文獻(xiàn)以及未提供計(jì)算機(jī)輔助技術(shù)描述的研究。數(shù)據(jù)提取內(nèi)容包括所使用的計(jì)算機(jī)輔助技術(shù)、手術(shù)技術(shù)、人口學(xué)特征、影像學(xué)結(jié)果、圍手術(shù)期結(jié)果、患者報(bào)告結(jié)局（PROs）、并發(fā)癥及二次手術(shù)情況。九項(xiàng)研究符合納入標(biāo)準(zhǔn)，共涉及208名患者，平均年齡范圍為26至38歲。其中七項(xiàng)研究采用了術(shù)中導(dǎo)航，一項(xiàng)研究使用了患者特異性導(dǎo)板，另一項(xiàng)研究同時(shí)使用了這兩種技術(shù)。三項(xiàng)研究報(bào)告稱，與常規(guī)PAO相比，計(jì)算機(jī)輔助PAO的術(shù)中輻射暴露顯著減少（P < 0.01）。計(jì)算機(jī)輔助組與常規(guī)組在手術(shù)時(shí)間和估計(jì)失血量方面通常觀察到相似的結(jié)果（P > 0.05）。接受計(jì)算機(jī)輔助PAO的患者術(shù)后平均外側(cè)中心邊緣角范圍為27.8°至37.4°，其中六項(xiàng)研究報(bào)告稱該值與常規(guī)PAO相比無顯著差異（P > 0.05）。在所有報(bào)告了接受計(jì)算機(jī)輔助PAO患者術(shù)前和術(shù)后PROs值的六項(xiàng)研究中，均觀察到PROs得到改善。用于PAO的計(jì)算機(jī)輔助技術(shù)包括對(duì)游離髖臼碎片和手術(shù)器械的導(dǎo)航追蹤，以及患者特異性截骨導(dǎo)板和旋轉(zhuǎn)模板。與常規(guī)技術(shù)相比，計(jì)算機(jī)輔助PAO可減少術(shù)中輻射暴露，且手術(shù)時(shí)長(zhǎng)相似，但由于手術(shù)技術(shù)和手術(shù)設(shè)置的異質(zhì)性，這些結(jié)果應(yīng)謹(jǐn)慎解讀。

Periacetabular osteotomy with intraoperative computer-assisted modalities: a systematic review

The role of intraoperative computer-assisted modalities for periacetabular osteotomy (PAO), as well as the perioperative and post-operative outcomes for these techniques, remains poorly defined. The purpose of this systematic review was to evaluate the techniques and outcomes of intraoperative computer-assisted modalities for PAO. Three databases (PubMed, CINAHL/EBSCOHost and Cochrane) were searched for clinical studies reporting on computer-assisted modalities for PAO. Exclusion criteria included small case series (<10 patients), non-English language and studies that did not provide a description of the computer-assisted technique. Data extraction included computer-assisted modalities utilized, surgical techniques, demographics, radiographic findings, perioperative outcomes, patient-reported outcomes (PROs), complications and subsequent surgeries. Nine studies met the inclusion criteria, consisting of 208 patients with average ages ranging from 26 to 38 years. Intraoperative navigation was utilized in seven studies, patient-specific guides in one study and both modalities in one study. Three studies reported significantly less intraoperative radiation exposure (P < 0.01) in computer-assisted versus conventional PAOs. Similar surgical times and estimated blood loss (P > 0.05) were commonly observed between the computer-assisted and conventional groups. The average post-operative lateral center edge angles in patients undergoing computer-assisted PAOs ranged from 27.8° to 37.4°, with six studies reporting similar values (P > 0.05) compared to conventional PAOs. Improved PROs were observed in all six studies that reported preoperative and post-operative values of patients undergoing computer-assisted PAOs. Computer-assisted modalities for PAO include navigated tracking of the free acetabular fragment and surgical instruments, as well as patient-specific cutting guides and rotating templates. Compared to conventional techniques, decreased intraoperative radiation exposure and similar operative lengths were observed with computer-assisted PAOs, although these results should be interpreted with caution due to heterogeneous operative techniques and surgical settings.

文獻(xiàn)出處：Curley AJ, Bruning RE, Padmanabhan S, Jimenez AE, Laude F, Domb BG. Periacetabular osteotomy with intraoperative computer-assisted modalities: a systematic review. J Hip Preserv Surg. 2023 Apr 20;10(2):104-118. doi: 10.1093/jhps/hnad005. PMID: 37900886; PMCID: PMC10604052.

文獻(xiàn)4

避免髖臼周圍截骨術(shù)的并發(fā)癥

譯者 陶可

髖臼周圍截骨術(shù)最常見的并發(fā)癥包括（按發(fā)生頻率遞減順序排列）：淺表傷口并發(fā)癥、異位骨化、股外側(cè)皮神經(jīng)感覺異常、截骨部位延遲愈合或不愈合、深部血腫以及后柱、坐骨或恥骨的術(shù)后骨折。

為降低髖臼周圍截骨術(shù)并發(fā)癥發(fā)生率，術(shù)前措施包括：選擇合適的患者、在學(xué)習(xí)曲線期間接受手術(shù)指導(dǎo)以及優(yōu)化可控風(fēng)險(xiǎn)因素。

為降低并發(fā)癥發(fā)生率，術(shù)中措施包括：精細(xì)處理軟組織、適當(dāng)擺放下肢位置、在截骨時(shí)保護(hù)神經(jīng)血管結(jié)構(gòu)、術(shù)中透視以評(píng)估截骨碎片位置并觀察截骨與髖關(guān)節(jié)的關(guān)系，以及考慮采用血液保護(hù)策略以減少出血量和輸血需求。

術(shù)后措施包括：術(shù)后保護(hù)性負(fù)重直至X線片顯示截骨愈合，以及預(yù)防深靜脈血栓形成和異位骨化。

圖1 顯示了坐骨截骨術(shù)中，骨鑿在髖臼下溝內(nèi)的正確起始位置和角度。圖1A為骨盆模型的前后位圖像，圖1B為50°側(cè)位透視圖像；術(shù)中，我們使用透視確認(rèn)該起始點(diǎn)的前后位圖像（圖1C）和50°側(cè)位透視圖像（圖1D），以避免醫(yī)源性髖臼穿透。外科醫(yī)生應(yīng)確認(rèn)從坐骨內(nèi)側(cè)到外側(cè)的截骨已完成，以便于截骨塊調(diào)整移動(dòng)。

圖2 50°假側(cè)位透視可為外科醫(yī)生提供后柱截骨起始點(diǎn)的標(biāo)志，并輔助外科醫(yī)生將骨鑿指向髖臼和坐骨大切跡之間的遠(yuǎn)端。骨盆模型（圖2A）和術(shù)中采用50°假側(cè)位透視（圖2B）顯示了后柱截骨的正確骨鑿位置。

Avoiding Complications in Periacetabular Osteotomy

The most common complications that have been described in association with periacetabular osteotomy include, in decreasing order of cumulative frequency, superficial wound complications, heterotopic ossification, lateral femoral cutaneous nerve dysesthesias, delayed union or nonunion of the osteotomy site, deep hematoma, and postoperative fracture of the posterior column, ischium, or pubis.

Preoperative measures to reduce complication rates for periacetabular osteotomy include appropriate patient selection, surgical mentoring during the learning curve, and optimization of modifiable risk factors.

Intraoperative measures to reduce complication rates include meticulous soft-tissue handling, appropriate lower-limb positioning and protection of neurovascular structures when performing osteotomy cuts, intraoperative fluoroscopy to evaluate osteotomy fragment positioning and to visualize osteotomies in relation to the hip joint, and consideration of using blood conservation strategies to reduce blood loss and need for transfusion.

Postoperative measures include protected weight-bearing in the postoperative period until evidence of osteotomy healing is seen on radiographs and prophylaxis for deep venous thrombosis and heterotopic ossification.

文獻(xiàn)出處：Ishaan Swarup, Benjamin F Ricciardi, Ernest L Sink. Avoiding Complications in Periacetabular Osteotomy. JBJS Rev. 2015 Nov 24;3(11):e4. doi: 10.2106/JBJS.RVW.O.00023.

文獻(xiàn)5

有癥狀的塌陷前股骨頭壞死伴骨髓水腫的MRI表現(xiàn)：軟骨下骨折的組織病理學(xué)證實(shí)

譯者 邱興

目的：在塌陷前股骨頭壞死的磁共振成像中出現(xiàn)的骨髓水腫被認(rèn)為是隱匿性軟骨下骨折的征象；然而，據(jù)我們所知，尚無組織病理學(xué)研究證實(shí)這一點(diǎn)。本研究旨在通過組織病理學(xué)方法，驗(yàn)證在MRI上表現(xiàn)為骨髓水腫的癥狀性塌陷前股骨頭壞死中，外側(cè)壞死邊界處是否存在軟骨下骨折。

材料與方法：在2019年1月至2024年6月于我院行全髖關(guān)節(jié)置換術(shù)切除的149例連續(xù)壞死股骨頭中，納入13例術(shù)前X線片未見明顯塌陷但MRI顯示骨髓水腫的股骨頭。對(duì)每個(gè)股骨頭的連續(xù)冠狀切片蘇木精-伊紅染色標(biāo)本進(jìn)行檢查，以確認(rèn)軟骨下骨折的存在。使用顯微計(jì)算機(jī)斷層掃描圖像測(cè)量軟骨下骨折周圍的骨微結(jié)構(gòu)。

結(jié)果：在所有股骨頭中，組織病理學(xué)均證實(shí)修復(fù)區(qū)與壞死區(qū)外側(cè)交界處存在軟骨下骨折。顯微CT顯示，鄰近軟骨下骨折的修復(fù)區(qū)骨體積分?jǐn)?shù)、骨小梁厚度和骨礦物質(zhì)密度均顯著高于鄰近軟骨下骨折的壞死區(qū)。

結(jié)論：在塌陷前股骨頭壞死中，當(dāng)MRI上出現(xiàn)骨髓水腫時(shí)，必然存在軟骨下骨折。當(dāng)MRI觀察到骨髓水腫時(shí)，即使X線片上股骨頭塌陷不明顯，也應(yīng)意識(shí)到軟骨下骨折已經(jīng)發(fā)生。

關(guān)鍵詞：骨髓水腫；股骨頭壞死；軟骨下骨折。

圖1 軟骨下骨折鄰近的修復(fù)區(qū)與壞死區(qū)骨微結(jié)構(gòu)評(píng)估。在這兩個(gè)區(qū)域中，選取3毫米體素作為感興趣區(qū)。外側(cè)的紅色立方體對(duì)應(yīng)鄰近軟骨下骨折的修復(fù)區(qū)；內(nèi)側(cè)的黃色立方體對(duì)應(yīng)鄰近軟骨下骨折的壞死區(qū)。

圖2 一例55歲男性患者術(shù)前1天股骨頭X線平片。正側(cè)位X線片未見明顯塌陷，但可見修復(fù)區(qū)硬化改變（白色箭頭），提示JIC 2期。JIC：日本健康福利部調(diào)查研究委員會(huì)。

圖3 術(shù)前MRI：患者，55歲，術(shù)前1個(gè)月股骨頭影像。T1加權(quán)像可見低信號(hào)帶（白色箭頭），伴彌漫性低信號(hào)區(qū)（白色三角），對(duì)應(yīng)骨髓水腫。脂肪抑制T2加權(quán)像可見高信號(hào)區(qū)（白色三角），亦對(duì)應(yīng)骨髓水腫。MRI，磁共振成像

圖4 該55歲男性患者股骨頭組織病理學(xué)檢查。a 全股骨頭蘇木精-伊紅染色切片（×20，標(biāo)尺=5 mm）。股骨頭頂端可見一條清晰穿過壞死區(qū)的骨小梁骨折線（黑色三角）。b 黑方框區(qū)域放大圖像（×40，標(biāo)尺=1 mm）。外側(cè)修復(fù)區(qū)與壞死區(qū)之間的軟骨下骨板可見不連續(xù)（黑色箭頭）。

圖5 一名75歲男性患者的組織病理學(xué)檢查。a 全股骨頭蘇木精-伊紅染色切片（×20，標(biāo)尺=5 mm）。股骨頭內(nèi)未見明顯骨小梁骨折線。b 圖a黑方框區(qū)域顯微圖像（×40，標(biāo)尺=1 mm）。外側(cè)修復(fù)區(qū)與壞死區(qū)之間的軟骨下骨板可見不連續(xù)（黑色箭頭）。

Histopathologic confirmation of subchondral fracture in symptomatic pre-collapse osteonecrosis of the femoral head with bone marrow edema on magnetic resonance imaging

Objective: The presence of bone marrow edema on magnetic resonance imaging (MRI) in pre-collapse osteonecrosis of the femoral head is suggested to be a sign of occult subchondral fracture; however, to our knowledge, there are no histopathological studies verifying this. This study aimed to histopathologically verify the presence of subchondral fracture at the lateral necrotic boundary in symptomatic pre-collapse osteonecrosis of the femoral head with bone marrow edema on MRI.

Materials and methods: Of 149 consecutive necrotic femoral heads resected during total hip arthroplasty at our hospital from January 2019 to June 2024, we included 13 femoral heads that did not show apparent collapse on preoperative radiographs and exhibited bone marrow edema on MRI. Continuous coronal-slice hematoxylin and eosin-stained specimens of each femoral head were examined for the presence of subchondral fracture. Bone microarchitectures around subchondral fractures were measured using micro-computed tomography (CT) images.

Results: In all femoral heads, subchondral fractures were histopathologically confirmed at the lateral junction between the reparative and the necrotic zone. On micro-CT, bone volume fraction, trabecular thickness, and bone mineral density of the reparative zone adjacent to the subchondral fracture were all significantly higher than those of the necrotic zone adjacent to the subchondral fracture.

Conclusion: Subchondral fracture invariably existed when bone marrow edema was present on MRI during pre-collapse osteonecrosis of the femoral head. When bone marrow edema is observed on MRI, it should be known that subchondral fracture has already occurred, even if femoral head collapse is unclear on radiographs.

Keywords: Bone marrow edema; Osteonecrosis of the femoral head; Subchondral fracture.

文獻(xiàn)出處：Ayabe, Y., Motomura, G., Yamaguchi, R., Utsunomiya, T., Sakamoto, K., & Nakashima, Y. (2025). Histopathologic confirmation of subchondral fracture in symptomatic pre-collapse osteonecrosis of the femoral head with bone marrow edema on magnetic resonance imaging. Skeletal Radiology, 54(6), 1275-1281.

來源：304關(guān)節(jié)學(xué)術(shù)

作者：304關(guān)節(jié)團(tuán)隊(duì)

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