本期目錄：

1、在PJI二期翻修術(shù)中，哪些指標(biāo)最能指導(dǎo)二期再植入術(shù)的時(shí)機(jī)

2、當(dāng)股骨T值＞-2.5時(shí)，術(shù)前骨密度（BMD）不影響非骨水泥型全髖關(guān)節(jié)置換術(shù)（THA）中股骨柄的下沉

3、術(shù)前步速可以作為全髖關(guān)節(jié)置換術(shù)后患者自評(píng)量表的預(yù)測指標(biāo)

4、不同骨水泥應(yīng)用技術(shù)對全膝關(guān)節(jié)置換術(shù)中脛骨假體固定的比較

5、機(jī)器人輔助全膝關(guān)節(jié)置換術(shù)是否較傳統(tǒng)全膝關(guān)節(jié)置換術(shù)帶來更好的結(jié)局評(píng)分或長期生存率

6、DDH患兒髖關(guān)節(jié)重建術(shù)后早期活動(dòng)

7、年輕人股骨頭軟骨下疲勞性骨折的轉(zhuǎn)歸不同于一般骨折愈合的普遍結(jié)果

8、髖臼周圍截骨術(shù)后遲發(fā)性坐骨神經(jīng)麻痹

9、Y形軟骨閉合前進(jìn)行伯爾尼髖臼周圍截骨術(shù)（PAO）的放射學(xué)結(jié)果

10、年輕成人非手術(shù)治療的臨界髖關(guān)節(jié)發(fā)育不良的自然史及與功能結(jié)局不良相關(guān)因素

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

文獻(xiàn)1

在PJI二期翻修術(shù)中，哪些指標(biāo)最能指導(dǎo)二期再植入術(shù)的時(shí)機(jī)？系統(tǒng)回顧和薈萃分析

譯者 張軼超

背景：對于假體周圍感染（PJI）的兩期翻修術(shù)后使用哪種標(biāo)志物決定進(jìn)行再植入新假體更合適尚無共識(shí)。

問題/目的：哪些測試指標(biāo)提供可接受的診斷價(jià)值，以指導(dǎo)PJI兩期翻修術(shù)中適當(dāng)?shù)脑僦踩胄g(shù)時(shí)機(jī)？

方法：檢索在線數(shù)據(jù)庫（MEDLINE， EMBASE， OVID和Cochrane數(shù)據(jù)庫），其中包含準(zhǔn)確預(yù)測髖關(guān)節(jié)和/或膝關(guān)節(jié)再植入時(shí)機(jī)的敏感性和特異性值的文章。12篇文章納入最終分析，其中包括1047名患者的數(shù)據(jù)。對描述再植入術(shù)時(shí)標(biāo)志物診斷的準(zhǔn)確性的數(shù)據(jù)進(jìn)行評(píng)估并根據(jù)診斷方法（血清學(xué)、滑膜、組織和診斷影像學(xué)）分為四個(gè)主要部分。檢測血清紅細(xì)胞沉降（ESR）率、血清C反應(yīng)蛋白（CRP）、血清白細(xì)胞（WBC）計(jì)數(shù)、滑液革蘭氏染色、滑液培養(yǎng)、滑液超聲裂解培養(yǎng)、滑液WBC、滑液多形核細(xì)胞百分比（PMN%）、組織革蘭氏染色、組織培養(yǎng)、正電子發(fā)射斷層掃描、白細(xì)胞掃描等12項(xiàng)指標(biāo)。每篇納入的文章均采用QUADAS-2獨(dú)立分析偏倚風(fēng)險(xiǎn)和適用性。采用Cochran Q檢驗(yàn)計(jì)算統(tǒng)計(jì)異質(zhì)性，a = 0.10被認(rèn)為是顯著異質(zhì)性。

結(jié)果：組織培養(yǎng)(敏感性0.82[0.72-0.90]，特異性0.91[0.89-0.95]，診斷優(yōu)勢比（DOR） 46.87[95%可信區(qū)間{CI}， 22.03-99.69]），滑液PMN%（敏感性0.77[0.46-0.95]，特異性0.74 [0.67-0.81],DOR 11.27 [95% CI, 2.89-43.61]）和滑液培養(yǎng)（敏感性0.64[0.52-0.74]，特異性0.96 [0.93-0.98],DOR 27.07 [95% CI, 2.55- 288.00]）具有較高的診斷價(jià)值。其他參數(shù)的診斷準(zhǔn)確性較差：ESR（敏感性0.56[0.40-0.72]，特異性0.60 [0.53-0.66],DOR 2.41 [95% CI, 0.60-9.72）， CRP（敏感性0.53[0.39-0.67]，特異性0.72 [0.66-0.78],DOR 2.25 [95% CI, 0.09-4.63），滑液WBC計(jì)數(shù)（敏感性0.37[0.19-0.58]，特異性0.49 [0.41-0.57],DOR 0.94 [95% CI, 0.06-14.74）。然而，文中解釋其原因是有限的，因?yàn)槊總€(gè)合并分析只有兩到三個(gè)研究可用。在QUADAS-2評(píng)估的四個(gè)領(lǐng)域中，偏倚風(fēng)險(xiǎn)和適用性問題都很低。

結(jié)論：該薈萃分析表明，沒有單一的標(biāo)記物優(yōu)于所有其他標(biāo)記物，并且在PJI的兩階段方案的第一階段后，沒有一個(gè)（單獨(dú)使用時(shí)）可能足以確認(rèn)感染得到了控制。因此，目前使用多種檢測工具而不是單一標(biāo)記的方法是必要的。此外，必須進(jìn)行進(jìn)一步的研究，以便使用多個(gè)研究進(jìn)行匯總分析，以確定再植入前確定感染得到控制的理想標(biāo)記物。

What Markers Best Guide the Timing of Reimplantation in Twostage Exchange Arthroplasty for PJI? A Systematic Review and Meta-analysis

Background：There is no consensus on the appropriate marker to use when deciding to perform reimplantation after two-stage exchange arthroplasty for periprosthetic joint infection (PJI).

Questions/purposes：What tests provide acceptable diagnostic value to guide appropriate timing of reimplantation in two-stage exchange arthroplasty for PJI?

Methods：A search of online databases (MEDLINE, EMBASE, OVID, and Cochrane database) was performed containing articles that provided sensitivity and specificity values for accuracy for predicting reimplantation of the hip and/or knee. Twelve articles were included for final analysis, which included data from 1047 patients. Data that described the diagnostic accuracy of markers for reimplantation were evaluated and categorized into four main entities according to diagnostic method (serologic, synovial, tissue, and diagnostic imaging). Twelve parameters were examined, including serum erythrocyte sedimentation (ESR) rate, serum C-reactive protein (CRP), serum white blood cell (WBC) count, synovial fluid Gram stain, synovial fluid culture, synovial fluid sonication culture, synovial fluid WBC, synovial fluid polymorphonucleocyte percentage (PMN%), tissue Gram stain, tissue culture, positron emission tomography scan, and leukocyte scan. Each of the included articles was independently analyzed for risk of bias and applicability by using QUADAS-2. Statistical heterogeneity was calculated by using the Cochran Q test, and an a of 0.10 was considered significant for heterogeneity.

Results：Tissue culture (sensitivity 0.82 [0.72-0.90], specificity 0.91 [0.89-0.95], diagnostic odds ratio (DOR) 46.87 [95% confidence interval {CI}, 22.03-99.69], synovial fluid PMN% (sensitivity 0.77 [0.46-0.95], speci- ficity 0.74 [0.67-0.81], DOR 11.27 [95% CI, 2.89-43.61]), and synovial fluid culture (sensitivity 0.64 [0.52-0.74],specificity 0.96 [0.93-0.98], DOR 27.07 [95% CI, 2.55- 288.00]) showed relatively high diagnostic performance. Other parameters had poorer diagnostic accuracy: ESR (sensitivity 0.56 [0.40-0.72], specificity 0.60 [0.53-0.66], DOR 2.41 [95% CI, 0.60-9.72), CRP (sensitivity 0.53 [0.39-0.67], specificity 0.72 [0.66-0.78], DOR 2.25 [95% CI, 0.09-4.63), and synovial fluid WBC count (sensitivity 0.37 [0.19-0.58], specificity 0.49 [0.41-0.57], DOR 0.94 [95% CI, 0.06-14.74). However, interpretation is limited, because only two to three studies were available for each pooled analysis. Both risks of bias and applicability concerns were low in the four domains assessed in QUADAS-2.

Conclusions：This meta-analysis suggests that no single marker was superior to all the others, and none (when used alone) is likely sufficient to confirm control of infection after the first stage of a two-stage protocol for PJI. Therefore, the current approach using multiple tools rather than a single marker is essential. Additionally, further studies must be conducted so that pooled analysis can be performed using multiple studies to determine ideal markers for reimplantation.

文獻(xiàn)出處：Lee YS, Fernando N, Koo KH, Kim HJ, Vahedi H, Chen AF. What Markers Best Guide the Timing of Reimplantation in Two-stage Exchange Arthroplasty for PJI? A Systematic Review and Meta-analysis. Clin Orthop Relat Res. 2018 Oct;476(10):1972-1983. doi: 10.1097/01.blo.0000534680.87622.43. PMID: 30794241; PMCID: PMC6259852.

文獻(xiàn)2

當(dāng)股骨T值＞-2.5時(shí)，術(shù)前骨密度（BMD）不影響非骨水泥型全髖關(guān)節(jié)置換術(shù)（THA）中股骨柄的下沉

譯者 馬云青

背景與目的：普遍認(rèn)為，在初次非骨水泥型全髖關(guān)節(jié)置換術(shù)（THA）中，股骨柄的固定效果取決于股骨骨密度（BMD）水平。這也是業(yè)內(nèi)廣泛認(rèn)同，骨質(zhì)疏松患者或年齡＞75歲患者應(yīng)選用骨水泥型假體的原因之一。本研究旨在探討術(shù)前股骨骨密度是否與非骨水泥型全髖關(guān)節(jié)置換術(shù)后股骨柄移位相關(guān)。

患者與方法：本研究納入62例擬行非骨水泥型全髖關(guān)節(jié)置換術(shù)的患者，平均年齡64歲（范圍49～74歲），其中男性34例。術(shù)前對患者股骨近端行雙能X線吸收法（DEXA）檢查，計(jì)算股骨頸T值和Z值。采用放射立體測量分析（RSA）評(píng)估股骨柄移位情況，隨訪時(shí)間為24個(gè)月。最終56例患者完成術(shù)前DEXA檢查及術(shù)后24個(gè)月RSA隨訪。

結(jié)果：所有患者T值均不低于-2.5。術(shù)后3個(gè)月及24個(gè)月時(shí)，術(shù)前骨密度與股骨柄下沉之間均無統(tǒng)計(jì)學(xué)相關(guān)性。將患者按T值＞-1與T值≤-1分為兩組，RSA測量結(jié)果顯示，兩組術(shù)后3個(gè)月及24個(gè)月的股骨柄平均下沉量均無統(tǒng)計(jì)學(xué)差異。

結(jié)論：在年齡≤75歲、股骨局部T值＞-2.5的患者人群中，術(shù)前骨密度與非骨水泥型全髖關(guān)節(jié)置換術(shù)后股骨柄下沉無相關(guān)性。

Preoperative BMD does not influence femoral stem subsidence of uncemented THA when the femoral T-score is > -2.5

Background and purpose - It is believed that in uncemented primary total hip arthroplasty (THA) the anchorage of the stem is dependent on the level of bone mineral density (BMD) of the femoral bone. This is one of the reasons for the widely accepted agreement that a cemented solution should be selected for people with osteoporosis or age > 75 years. We evaluated whether preoperative BMD of the femur bone is related to femoral stem migration in uncemented THA.Patients and methods - We enrolled 62 patients (mean age 64 years (range 49-74), 34 males) scheduled for an uncemented THA. Before surgery we undertook DEXA scans of the proximal femur including calculation of the T- and Z-scores for the femoral neck. Evaluation of stem migration by radiostereometric analysis (RSA) was performed with 24 months of follow-up. In 56 patients both preoperative DEXA data and RSA data were available with 24 months of follow-up.Results - None of the patients had a T-score below -2.5. We found no statistically significant relationship between preoperative BMD and femoral stem subsidence after 3 or 24 months. When comparing the average femoral stem subsidence between 2 groups with T-score > -1 and T-score ≤ -1, respectively, we found no statistically significant difference after either 3 or 24 months when measured with RSA.Interpretation - In a cohort of people ≤ 75 years of age and with local femur T-score > -2.5 we found no relationship between preoperative BMD and postoperative femoral stem subsidence of a cementless THA.

Background and purpose - It is believed that in uncemented primary total hip arthroplasty (THA) the anchorage of the stem is dependent on the level of bone mineral density (BMD) of the femoral bone. This is one of the reasons for the widely accepted agreement that a cemented solution should be selected for people with osteoporosis or age > 75 years. We evaluated whether preoperative BMD of the femur bone is related to femoral stem migration in uncemented THA.Patients and methods - We enrolled 62 patients (mean age 64 years (range 49-74), 34 males) scheduled for an uncemented THA. Before surgery we undertook DEXA scans of the proximal femur including calculation of the T- and Z-scores for the femoral neck. Evaluation of stem migration by radiostereometric analysis (RSA) was performed with 24 months of follow-up. In 56 patients both preoperative DEXA data and RSA data were available with 24 months of follow-up.Results - None of the patients had a T-score below -2.5. We found no statistically significant relationship between preoperative BMD and femoral stem subsidence after 3 or 24 months. When comparing the average femoral stem subsidence between 2 groups with T-score > -1 and T-score ≤ -1, respectively, we found no statistically significant difference after either 3 or 24 months when measured with RSA.Interpretation - In a cohort of people ≤ 75 years of age and with local femur T-score > -2.5 we found no relationship between preoperative BMD and postoperative femoral stem subsidence of a cementless THA.

文獻(xiàn)出處：Dyreborg K, S?rensen MS, Flivik G, Solgaard S, Petersen MM. Preoperative BMD does not influence femoral stem subsidence of uncemented THA when the femoral T-score is > -2.5. Acta Orthop. 2021 Oct;92(5):538-543. doi: 10.1080/17453674.2021.1920163. Epub 2021 May 12. PMID: 33977827; PMCID: PMC8522811.

文獻(xiàn)3

術(shù)前步速可以作為全髖關(guān)節(jié)置換術(shù)后患者自評(píng)量表的預(yù)測指標(biāo)來自患者可接受狀態(tài)和K均值聚類分析

譯者 張薔

背景：全髖關(guān)節(jié)置換（THA）術(shù)是治療髖骨關(guān)節(jié)炎（OA）的成熟術(shù)式。然而，其臨床效果具有一定可變性，最佳的手術(shù)時(shí)間并不明確。確定能影響患者術(shù)后中期隨訪時(shí)自評(píng)量表結(jié)果（PROMs）的術(shù)前因素可以幫助改善術(shù)后療效。

方法：本回顧性研究納入了274例2012年至2018年間因OA而接受初次THA手術(shù)的亞裔患者。所有患者均有術(shù)前一般狀態(tài)評(píng)估結(jié)果和術(shù)后郵寄式隨訪結(jié)果。術(shù)前變量包括癥狀期、疼痛強(qiáng)度、髖關(guān)節(jié)活動(dòng)度、下肢肌力和10米行走步速。PROMs包括牛津髖關(guān)節(jié)評(píng)分（OHS）和關(guān)節(jié)遺忘評(píng)分（FJS-12）。另外，我們應(yīng)用患者可接受狀態(tài)（PASS）分析法評(píng)估患者有意義的臨床療效，定義為OHS評(píng)分≥42和FJS-12評(píng)分≥50。最后，我們應(yīng)用K均值聚類分析法依據(jù)患者PROMs結(jié)果將其分為極佳療效組和對照組。

結(jié)果：多變量回歸分析顯示術(shù)前步速對術(shù)后OHS和FJS-12評(píng)分有顯著的預(yù)測效果（p < 0.01）。此外，髖關(guān)節(jié)屈曲活動(dòng)度和屈髖肌力均與術(shù)前步速有顯著相關(guān)性（p < 0.01）。然后，我們應(yīng)用受試者工作特征曲線分析法（ROC）確定為了獲得OHS評(píng)分PASS（可接受狀態(tài)）步速閾值為0.7m/s（曲線下面積[AUC]: 0.69; p < 0.01），為了獲得FJS-12評(píng)分PASS步速閾值為1.0m/s（AUC: 0.60; p = 0.01）。K均值聚類分析顯示術(shù)前步速是術(shù)后獲得極佳療效的唯一顯著預(yù)測因素（概率比，5.85；p < 0.01）。ROC曲線分析顯示患者分入極佳療效組的步速閾值為1.0m/s（AUC: 0.64; p < 0.01）。

結(jié)論：術(shù)前步速，由于髖關(guān)節(jié)功能障礙而顯示行動(dòng)能力下降的指標(biāo)，是THA術(shù)后中期PROMs的顯著預(yù)測因素。無論患者具體年齡，保持術(shù)前步速在1.0m/s是獲得優(yōu)異術(shù)后療效的關(guān)鍵閾值。

Preoperative?Gait?Speed?as?a?Predictor?of Patient-Reported?Outcomes?after?Total Hip?Arthroplasty-Insights from Patient Acceptable Symptom State and K-Means Clustering Analyses

Background: Total hip arthroplasty (THA) is a well-established procedure for hip osteoarthritis (OA); however, its clinical outcomes are variable, and the optimal timing for surgery remains unclear. Identifying the preoperative predictors that influence midterm patient-reported outcome measures (PROMs) could improve patient outcomes.

Methods: This retrospective cohort study included 274 Asian patients who underwent primary THA for OA between 2012 and 2018, who completed preoperative physical assessments, and who responded to a postoperative mail survey. Preoperative variables included symptom duration, pain intensity, hip range of motion, lower-limb muscle strength, and 10-m free gait speed. PROMs were assessed using the Oxford Hip Score (OHS) and the Forgotten Joint Score-12 (FJS-12). Clinically meaningful outcomes were assessed using the Patient Acceptable Symptom State (PASS), defined as a score of ≥42 for the OHS and a score of ≥50 for the FJS-12. Additionally, K-means clustering was applied to categorize patients into an excellent outcome group and a control group on the basis of their PROMs.

Results: Multivariable regression analysis revealed that preoperative gait speed significantly predicted both the OHS and FJS-12 outcomes (p < 0.01). Furthermore, hip flexion range of motion and hip flexion strength were significantly associated with preoperative gait speed (p < 0.01). A receiver operating characteristic (ROC) curve analysis identified a gait speed cutoff value of 0.7 m/s for achieving the PASS for the OHS (area under the curve [AUC]: 0.69; p < 0.01) and a cutoff value of 1.0 m/s for achieving the PASS for the FJS-12 (AUC: 0.60; p = 0.01). K-means clustering identified preoperative gait speed as the sole significant predictor of classification into the excellent outcome group (odds ratio, 5.85; p < 0.01). The ROC curve analysis revealed a gait speed cutoff value of 1.0 m/s for classification into the excellent group (AUC: 0.64; p < 0.01).

Conclusions: Preoperative gait speed, which reflects decreased mobility due to hip joint dysfunction, was a significant predictor of midterm PROMs after THA. Maintaining a preoperative gait speed of 1.0 m/s could serve as a critical threshold for achieving favorable postoperative outcomes, regardless of patient age.

文獻(xiàn)4

不同骨水泥應(yīng)用技術(shù)對全膝關(guān)節(jié)置換術(shù)中脛骨假體固定的比較

譯者 丁云鵬

目的：脛骨假體的無菌性松動(dòng)仍然是全膝關(guān)節(jié)置換術(shù)（TKA）中翻修手術(shù)的主要原因。研究表明，實(shí)現(xiàn)脛骨假體的初始穩(wěn)定固定可減少假體微動(dòng)，這對長期性能可能具有決定性影響。文獻(xiàn)中描述了多種脛骨表面骨水泥應(yīng)用技術(shù)，但結(jié)果存在爭議。目前尚無支持特定操作方法的指南。

方法：本研究對比了脈沖灌洗后僅表面指壓骨水泥（配對人類脛骨樣本，四組，n=24）與三種常用骨水泥技術(shù)（分層填入、假體柄填注、骨水泥槍）的效果。所有標(biāo)本均接受計(jì)算機(jī)斷層掃描以實(shí)現(xiàn)骨水泥滲透的三維分析，并進(jìn)行力學(xué)測試以評(píng)估界面強(qiáng)度。

結(jié)果：骨水泥滲透隨骨密度（BMD）增加而降低（R2=0.18，p=0.023），而界面強(qiáng)度隨BMD增加而升高（R2=0.56，p<0.001）。各組中均未發(fā)現(xiàn)骨水泥技術(shù)對水泥滲透（p≥0.069）或界面強(qiáng)度（p=0.180）的顯著影響。

結(jié)論：充分的表面準(zhǔn)備（使用脈沖灌洗并充分干燥脛骨表面）似乎具有壓倒性的重要性，從而限制了任何特定技術(shù)對改善植入物固定的影響。本研究強(qiáng)調(diào)了表面準(zhǔn)備和脈沖灌洗在全膝關(guān)節(jié)置換術(shù)中的根本重要性。

Comparison of different cement application techniques for tibial component fixation in TKA

Purpose: Aseptic loosening of the tibial component remains a major cause for revision surgery in total knee arthroplasty (TKA). A stable initial fixation of the tibial implant has been suggested to reduce micromotion of the implant and could be decisive regarding its long-term performance. Different techniques for applying cement to the tibial surface have been described in the literature, with controversial results. No guidelines in favour of any particular approach are available.

Methods: In this study, we compared three commonly used cementing techniques (layered application, stem cementation, cement gun) with surface-only fingerpacking cementation following pulsed lavage (paired human tibiae, four groups, n = 24). Specimens underwent computed tomography scanning for three-dimensional analysis of cement penetration and mechanical testing for assessing interface strength.

Results: Bone cement penetration decreased with increasing bone mineral density (BMD) (R (2) = 0.18, p = 0.023), while interface strength increased with BMD (R (2) = 0.56, p < 0.001). No significant effect of cementation techniques on cement penetration (p ≥ 0.069) or interface strength (p = 0.180) was found in any group.

Conclusion: Adequate surface preparation using pulsed lavage and copious drying of the tibial surface appears to be of overruling importance, thus limiting the effect of any particular technique applied to improve implant fixation. This study emphasises the fundamental importance of surface preparation and pulsed lavage in TKA.

文獻(xiàn)出處:Ulf J Schlegel , Nicholas E Bishop, Klaus Püschel,Comparison of different cement application techniques for tibial component fixation in TKA.Int Orthop. 2015 Jan;39(1):47-54. doi: 10.1007/s00264-014-2468-x. Epub 2014 Aug 1.

文獻(xiàn)5

機(jī)器人輔助全膝關(guān)節(jié)置換術(shù)是否較傳統(tǒng)全膝關(guān)節(jié)置換術(shù)帶來更好的結(jié)局評(píng)分或長期生存率？——一項(xiàng)隨機(jī)對照試驗(yàn)

譯者 沈松坡

背景： 機(jī)器人輔助全膝關(guān)節(jié)置換術(shù)（TKA）被引入，旨在提高骨準(zhǔn)備和假體對線的精確性，以期改善TKA的臨床結(jié)果和生存率。盡管大量報(bào)道提示，利用機(jī)器人輔助可改善骨準(zhǔn)備和膝關(guān)節(jié)假體對線，但目前尚無機(jī)器人輔助TKA的長期隨機(jī)試驗(yàn)表明，這是否會(huì)帶來更好的臨床功能或TKA生存率。

問題/目的： 在這項(xiàng)隨機(jī)試驗(yàn)中，我們在長期隨訪時(shí)將機(jī)器人輔助TKA與手工對線技術(shù)進(jìn)行了比較，比較內(nèi)容包括：（1）基于Knee Society評(píng)分、WOMAC評(píng)分和UCLA活動(dòng)評(píng)分的功能結(jié)果；（2）包括假體對線和下肢對線在內(nèi)的多項(xiàng)影像學(xué)參數(shù)；（3）Kaplan-Meier生存率；以及（4）機(jī)器人輔助相關(guān)的特異性并發(fā)癥，包括針道感染、腓總神經(jīng)麻痹、針點(diǎn)骨折或髕骨相關(guān)并發(fā)癥。

方法： 本研究是一項(xiàng)已注冊的前瞻性隨機(jī)對照試驗(yàn)。2002年1月至2008年2月，一名術(shù)者在850例患者中實(shí)施了975例機(jī)器人輔助TKA，在849例患者中實(shí)施了990例傳統(tǒng)TKA。根據(jù)預(yù)先設(shè)定的納入標(biāo)準(zhǔn)，其中1406例患者符合本研究入組條件。所有患者均同意參加并被隨機(jī)分組，其中700例患者（750膝）接受機(jī)器人輔助TKA，706例患者（766膝）接受傳統(tǒng)TKA。平均隨訪13（±5）年時(shí)，機(jī)器人輔助TKA組96%（674例患者）和傳統(tǒng)TKA組95%（674例患者）獲得隨訪。由于預(yù)期進(jìn)行長期隨訪，兩組中均未將65歲以上患者納入隨機(jī)分組。我們對兩組各674例患者（724膝）的臨床和影像學(xué)結(jié)局進(jìn)行了評(píng)估，并以無菌性松動(dòng)或翻修為終點(diǎn)進(jìn)行了Kaplan-Meier生存分析。臨床評(píng)價(jià)在術(shù)前及末次隨訪時(shí)采用原始Knee Society膝評(píng)分、WOMAC評(píng)分和UCLA活動(dòng)評(píng)分。我們還通過普通X線片評(píng)估松動(dòng)（定義為假體位置的改變），并在末次隨訪時(shí)通過CT評(píng)估骨溶解，通過機(jī)械軸位片評(píng)估假體和下肢對線。為盡量減少Ⅱ類錯(cuò)誤并提高研究效能，我們假設(shè)Knee Society評(píng)分差異為5分，以匹配其最小臨床重要差異（MCID），并設(shè)定檢驗(yàn)效能為0.99，據(jù)此計(jì)算每組需要628例患者。

結(jié)果： 平均隨訪13年時(shí)，兩組在末次隨訪時(shí)的臨床測量指標(biāo)方面無差異，包括Knee Society膝評(píng)分（機(jī)器人輔助TKA組平均93±5分，傳統(tǒng)TKA組92±6分［95% CI 90～98］；p = 0.321）、Knee Society功能評(píng)分（83±7分比85±6分［95% CI 75～88］；p = 0.992）、WOMAC評(píng)分（18±14分比19±15分［95% CI 16～22］；p = 0.981）、膝關(guān)節(jié)活動(dòng)范圍（125°±6°比128°±7°［95% CI 121～135］；p = 0.321）和UCLA活動(dòng)評(píng)分（兩組均為7分［95% CI 5～10］；p = 1.000）。兩組的影像學(xué)參數(shù)也無差異，包括股脛角（機(jī)器人輔助TKA組平均2°±2°外翻，傳統(tǒng)TKA組3°±3°外翻［95% CI 1～5］；p = 0.897）、股骨假體位置（冠狀面：98°比97°［95% CI 96～99］；p = 0.953；矢狀面：3°比2°［95% CI 1～4］；p = 0.612）和脛骨假體位置（冠狀面：90°比89°［95% CI 87～92］；p = 0.721；矢狀面：87°比86°［95% CI 84～89］；p = 0.792）、關(guān)節(jié)線（16 mm比16 mm［95% CI 14～18］；p = 0.512）以及股骨后髁偏距（24 mm比24 mm［95% CI 21～27］；p = 0.817）（均p > 0.05）。兩組無菌性松動(dòng)率均為2%，差異無統(tǒng)計(jì)學(xué)意義。以翻修或假體無菌性松動(dòng)為終點(diǎn)時(shí)，兩組TKA假體的15年Kaplan-Meier生存率均為98%（95% CI 94～100；p = 0.972）。兩組并發(fā)癥發(fā)生頻率也無差異。兩組各有2%的膝關(guān)節(jié)（15膝）發(fā)生淺表感染，經(jīng)靜脈抗生素治療2周后治愈。上述膝關(guān)節(jié)均未發(fā)生深部感染。傳統(tǒng)TKA組有0.8%的膝關(guān)節(jié)（6膝）出現(xiàn)活動(dòng)受限（<60°）。

結(jié)論： 在至少10年的隨訪時(shí)，我們發(fā)現(xiàn)機(jī)器人輔助TKA與傳統(tǒng)TKA在功能結(jié)局評(píng)分、無菌性松動(dòng)、總體生存率和并發(fā)癥方面均無差異。考慮到機(jī)器人輔助TKA增加了額外的時(shí)間和費(fèi)用，我們不推薦其廣泛使用。

Does Robotic-assisted TKA Result in Better Outcome Scores or Long-Term Survivorship Than Conventional TKA? A Randomized, Controlled Trial

Background: Robotic-assisted TKA was introduced to enhance the precision of bone preparation and component alignment with the goal of improving the clinical results and survivorship of TKA. Although numerous reports suggest that bone preparation and knee component alignment may be improved using robotic assistance, no long-term randomized trials of robotic-assisted TKA have shown whether this results in improved clinical function or survivorship of the TKA.

Questions/purposes: In this randomized trial, we compared robotic-assisted TKA to manual-alignment techniques at long-term follow-up in terms of (1) functional results based on Knee Society, WOMAC, and UCLA Activity scores; (2) numerous radiographic parameters, including component and limb alignment; (3) Kaplan-Meier survivorship; and (4) complications specific to robotic-assistance, including pin-tract infection, peroneal nerve palsy, pin-site fracture, or patellar complications.

Methods: This study was a registered prospective, randomized, controlled trial. From January 2002 to February 2008, one surgeon performed 975 robotic-assisted TKAs in 850 patients and 990 conventional TKAs in 849 patients. Among these patients 1406 patients were eligible for participation in this study based on prespecified inclusion criteria. Of those, 100% (1406) patients agreed to participate and were randomized, with 700 patients (750 knees) receiving robotic-assisted TKA and 706 patients (766 knees) receiving conventional TKA. Of those, 96% (674 patients) in the robotic-assisted TKA group and 95% (674 patients) in the conventional TKA group were available for follow-up at a mean of 13 (± 5) years. In both groups, no patient older than 65 years was randomized because we anticipated long-term follow-up. We evaluated 674 patients (724 knees) in each group for clinical and radiographic outcomes, and we examined Kaplan-Meier survivorship for the endpoint of aseptic loosening or revision. Clinical evaluation was performed using the original Knee Society knee score, the WOMAC score, and the UCLA activity score preoperatively and at latest follow-up visit. We also assessed loosening (defined as change in the position of the components) using plain radiographs, osteolysis using CT scans at the latest follow-up visit, and component, and limb alignment on mechanical axis radiographs. To minimize the chance of type-2 error and increase the power of our study, we assumed the difference in the Knee Society score to be 25 points to match the MCID of the Knee Society score with a SD of 5; to be able to detect a difference of this size, we calculated that a total of 628 patients would be needed in each group in order to achieve 80% power at the α = 0.05 level.

Results: Clinical parameters at the latest follow-up including the Knee Society knee scores (93 ± 5 points in the robotic-assisted TKA group versus 92 ± 6 points in the conventional TKA group [95% confidence interval 90 to 98]; p = 0.321) and Knee Society knee function scores (83 ± 7 points in the robotic-assisted TKA group versus 85 ± 6 points in the conventional TKA group [95% CI 75 to 88]; p = 0.992), WOMAC scores (18 ± 14 points in the robotic-assisted TKA group versus 19 ± 15 points in the conventional TKA group [95% CI 16 to 22]; p = 0.981), range of knee motion (125 ± 6° in the robotic-assisted TKA group versus 128 ± 7° in the conventional TKA group [95% CI 121 to 135]; p = 0.321), and UCLA patient activity scores (7 points versus 7 points in each group [95% CI 5 to 10]; p = 1.000) were not different between the two groups at a mean of 13 years' follow-up. Radiographic parameters such as the femorotibial angle (mean 2° ± 2° valgus in the robotic-assisted TKA group versus 3° ± 3° valgus in the conventional TKA group [95% CI 1 to 5]; p = 0.897), femoral component position (coronal plane: mean 98° in the robotic-assisted TKA group versus 97° in the conventional TKA group [95% CI 96 to 99]; p = 0.953; sagittal plane: mean 3° in the robotic-assisted TKA group versus 2° in the conventional TKA group [95% CI 1 to 4]; p = 0.612) and tibial component position (coronal plane: mean 90° in the robotic-assisted TKA group versus 89° in the conventional TKA group [95% CI 87 to 92]; p = 0.721; sagittal plane: 87° in the robotic-assisted TKA group versus 86° in the conventional TKA group [95% CI 84 to 89]; p = 0.792), joint line (16 mm in the robotic-assisted TKA group versus 16 mm in the conventional TKA group [95% CI 14 to 18]; p = 0.512), and posterior femoral condylar offset (24 mm in the robotic-assisted TKA group versus 24 mm in the conventional TKA group [95% CI 21 to 27 ]; p = 0.817) also were not different between the two groups (p > 0.05). The aseptic loosening rate was 2% in each group, and this was not different between the two groups. With the endpoint of revision or aseptic loosening of the components, Kaplan-Meier survivorship of the TKA components was 98% in both groups (95% CI 94 to 100) at 15 years (p = 0.972). There were no between-group differences in terms of the frequency with which complications occurred. In all, 0.6% of knees (four) in each group had a superficial infection, and they were treated with intravenous antibiotics for 2 weeks [corrected]. No deep infection occurred in these knees. In the conventional TKA group, 0.6% of knees (four) had motion limitation (< 60°) [corrected].

Conclusions: At a minimum follow-up of 10 years, we found no differences between robotic-assisted TKA and conventional TKA in terms of functional outcome scores, aseptic loosening, overall survivorship, and complications. Considering the additional time and expense associated with robotic-assisted TKA, we cannot recommend its widespread use.

第二部分：保髖相關(guān)文獻(xiàn)

文獻(xiàn)1

DDH患兒髖關(guān)節(jié)重建術(shù)后早期活動(dòng)

譯者 任寧濤

背景：針對DDH患兒髖關(guān)節(jié)重建術(shù)后，絕大多數(shù)小兒骨科醫(yī)生喜歡石膏制動(dòng)4-12周，石膏制動(dòng)可引起石膏固定相關(guān)并發(fā)癥，對DDH患兒髖關(guān)節(jié)重建術(shù)后不選擇石膏制動(dòng)，選擇早期活動(dòng)的研究甚少。

方法：對行髖關(guān)節(jié)重建手術(shù)（Dega、股骨近端截骨、切開復(fù)位）的患兒進(jìn)行回顧性研究，共納入27名患兒（3.4±2.0歲），包括33例髖關(guān)節(jié)，涵蓋發(fā)育不良和脫位（T?nnis1-4），術(shù)后患兒放置在泡沫殼內(nèi)，保持髖關(guān)節(jié)中立位屈曲外展30度，手術(shù)后幾天內(nèi)進(jìn)行早期被動(dòng)活動(dòng)，術(shù)后3-4周完全負(fù)重，記錄患兒術(shù)前和術(shù)后查體和影像學(xué)評(píng)估情況，隨訪時(shí)間12.3±2.9月。

結(jié)果：術(shù)后AI從36.9°降低到21.7°，CE角從9.9°增加到28.6°，終末隨訪時(shí)所有的髖關(guān)節(jié)復(fù)位達(dá)到了T?nnis 1，未發(fā)現(xiàn)骨塊移位、股骨頭或髖臼缺血壞死、不愈合和神經(jīng)損傷。

結(jié)論：此隊(duì)列研究發(fā)現(xiàn)，髖關(guān)節(jié)重建術(shù)后早期活動(dòng)不影響臨床和影像學(xué)效果，DDH髖關(guān)節(jié)重建術(shù)后可進(jìn)行早期活動(dòng)。

圖1 泡沫殼，保持髖關(guān)節(jié)中立位屈曲外展。

Outcome after early mobilization following hip reconstruction in children with developmental hip dysplasia and luxation

Background: Most orthopedic surgeons prefer spica cast immobilization in children for 4 to 12 weeks after surgical hip reconstruction in children with developmental hip dysplasia. This challenging treatment may be associated with complications. Studies are lacking that focus on early mobilization without casting for postoperative care after hip reconstruction.

Methods: Twenty-seven children (3.4±2.0 years), including 33 hips with developmental hip dysplasia (DDH) and dislocation of the hip (T?nnis grade 1 to 4), who underwent hip reconstruction (Dega acetabuloplasty, varisation-derotation osteotomy and facultative open reduction) were retrospectively included in this study. Postoperatively the patients were placed in an individual foam shell with 30 degrees of hip abduction, hip extension, and neutral rotation. Early mobilization physiotherapy was performed within the first few days after the surgery under epidural anaesthesia. Full weight bearing was allowed after 3-4 weeks. All children received a clinical examination and radiographic evaluation before and after surgical intervention. The follow-up period was 12.3±2.9 months.

Results: On average, the postoperative acetabular index decreased significantly from 36.9 to 21.7 degrees and the center-edge angle increased from 9.9 to 28.6 degrees. All hips had reached T?nnis grade 1 at the time of the last follow-up. No complications such as dislocation of the bone wedge, avascular necrosis of the acetabulum or femur, lack of non-union, or nerve injury, were reported.

Conclusions: In this cohort study, hip reconstruction was successful according to clinical and radiographic outcome parameters after early mobilization without cast therapy. Early mobilization may be used as an alternative treatment option after hip reconstruction in DDH.

文獻(xiàn)出處：Katharina Susanne Gather, Eva von Stillfried, Sebastien Hagmann Sebastian Müller, Thomas Dreher. Outcome after early mobilization following hip reconstruction in children with developmental hip dysplasia and luxation. World J Pediatr. 2018 Apr;14(2):176-183.

文獻(xiàn)2

年輕人股骨頭軟骨下疲勞性骨折的轉(zhuǎn)歸不同于一般骨折愈合的普遍結(jié)果

譯者 李勇

目的： 本研究旨在報(bào)告年輕健康成年人中股骨頭疲勞型軟骨下骨折的臨床病程。

材料與方法： 我們回顧性分析了28例連續(xù)患者（共34髖），這些患者均有明確的無外傷情況下髖部和骨盆區(qū)域體力活動(dòng)突然增加的歷史，并被診斷為股骨頭疲勞型軟骨下骨折。診斷主要基于連續(xù)的X光平片和磁共振成像（MRI）結(jié)果。

結(jié)果： 在34髖中，19髖未發(fā)生骨塌陷的患者在發(fā)病數(shù)月后主觀疼痛逐漸消失，且無復(fù)發(fā)。另外2髖雖出現(xiàn)骨塌陷但保留了關(guān)節(jié)面邊緣，也未出現(xiàn)明顯的塌陷惡化或關(guān)節(jié)炎性改變，無需手術(shù)干預(yù)。其余13髖伴有骨塌陷及關(guān)節(jié)面邊緣破壞或關(guān)節(jié)炎性改變者，髖部疼痛逐漸加重，最終需要手術(shù)治療。

結(jié)論： 當(dāng)前研究結(jié)果表明，股骨頭軟骨下疲勞性骨折隨時(shí)間推移可能表現(xiàn)出不同程度的軟骨下?lián)p傷嚴(yán)重性。對于已發(fā)生塌陷的軟骨下疲勞性骨折，尤其是合并股骨頭不匹配時(shí)，髖部疼痛會(huì)加劇到必須接受手術(shù)干預(yù)的程度。

Fate of subchondral fatigue fractures of femoral head in young adults differs from general outcome of fracture healing

Abstract: Purpose: The purpose of this study is to report the clinical course of fatigue-type subchondral fractures of the femoral head in young healthy adults. Materials/Methods: We retrospectively reviewed 28 consecutive patients (34 hips) who had a clear history of a sudden increase in physical activity without trauma on the hip and pelvis, and were diagnosed as having a fatigue-type subchondral fracture of the femoral head. The diagnosis was made primarily on the basis of sequential plain radiographs and magnetic resonance images. Results: Of the 34 hips, 19 hips with no bony collapse experienced gradual disappearance of subjective pain a few months after onset, and there were no recurrences. Other 2 hips that showed bony collapse, but preserved the articular margin, also experienced no definite deterioration of collapse or arthritic change and did not need surgical intervention. In the remaining 13 hips with bony collapse and destroyed articular margin or arthritic change, hip pain gradually worsened necessitating surgery. Conclusions: The current findings suggest that a subchondral fatigue fracture of the femoral head could show a different severity of subchondral injury over time. In the collapsed subchondral fatigue fractures, especially when combined with head incongruency, the hip pain was aggravated enough to require surgical intervention.

文獻(xiàn)出處：Kim SM, Oh SM, Cho CH, Lim SJ, Moon YW, Choi SH, Park YS. Fate of subchondral fatigue fractures of femoral head in young adults differs from general outcome of fracture healing. Injury. 2016 Dec;47(12):2789-2794. doi: 10.1016/j.injury.2016.10.014. Epub 2016 Oct 18. PMID: 27771040.

文獻(xiàn)3

髖臼周圍截骨術(shù)后遲發(fā)性坐骨神經(jīng)麻痹

譯者 陶可

病例：一名青少年患者因嚴(yán)重的髖關(guān)節(jié)發(fā)育不良需要進(jìn)行較大的手術(shù)矯正，并伴有遲發(fā)性坐骨神經(jīng)損傷。髖臼碎片外側(cè)的皮質(zhì)碎骨塊造成了間接損傷，在患者活動(dòng)時(shí)出現(xiàn)癥狀。

結(jié)論：在髖關(guān)節(jié)伸髖外展、屈膝位的體位下進(jìn)行髖臼周圍截骨術(shù)，可減輕坐骨神經(jīng)張力，此時(shí)坐骨神經(jīng)直接損傷的風(fēng)險(xiǎn)很低。已報(bào)道的損傷病例均歸因于過度軟組織牽拉造成的直接損傷，或骨性坐骨截骨術(shù)、髖臼上截骨術(shù)和/或髖臼后截骨術(shù)造成的損傷。

圖1 骨盆正位X線片顯示雙側(cè)髖關(guān)節(jié)發(fā)育不良。髖臼淺，右側(cè)T?nnis角為29°，左側(cè)為26°；右側(cè)外側(cè)中心邊緣角為7°，左側(cè)為9°；雙側(cè)股骨頭均向外側(cè)移位，Shenton線斷裂，提示嚴(yán)重的髖關(guān)節(jié)發(fā)育不良伴股骨頭前外側(cè)移位。

圖2-A和2-B 術(shù)后X線片。圖2-A為術(shù)后即刻骨盆正位X線片（第二次手術(shù)后），顯示雙側(cè)股骨頭復(fù)位良好，覆蓋范圍足夠，Shenton線完整。左髖可見骨折塊固定良好。右髖截骨術(shù)（6個(gè)月前進(jìn)行）已完全愈合。圖2-B 術(shù)后3年，雙側(cè)截骨均已愈合，股骨頭居中良好。雙側(cè)關(guān)節(jié)吻合度良好。

圖3-A和3-B CT圖像。圖3-A股骨頭軸位CT切面圖像，顯示向外側(cè)突出的髖臼骨折塊。兩個(gè)小箭頭指向后柱；一個(gè)大箭頭指向邊緣銳利的后側(cè)骨折塊。圖3-B三維CT重建圖像，顯示髖臼骨折塊向后外側(cè)移位（白色矩形框所示區(qū)域與圖4-A所示區(qū)域相同）。

圖4-A和4-B 術(shù)中照片。圖4-A經(jīng)Gibson入路拍攝的圖像，顯示坐骨神經(jīng)(*)和壓迫神經(jīng)的骨折塊后緣。神經(jīng)未見結(jié)構(gòu)性改變，且神經(jīng)連續(xù)性良好。箭頭指示截骨碎片的帳篷狀邊緣。圖4-B照片顯示了翻修手術(shù)中為減輕神經(jīng)張力而切除的骨塊。大的骨碎片長度約為25毫米。

Delayed-Onset Sciatic Nerve Palsy After Periacetabular Osteotomy: A Case Report

Case: A large surgical correction was required for severe hip dysplasia, which was associated with a delayed-onset sciatic nerve injury in an adolescent patient. A cortical bone spur on the outside of the acetabular fragment produced an indirect injury that became symptomatic during mobilization of the patient.

Conclusion: The risk of direct injury to the sciatic nerve during a periacetabular osteotomy is quite low when the osteotomy is executed in extension with abduction of the hip and flexion of the knee to reduce tension on the sciatic nerve. Reported injuries have been attributed to direct damage from excessive soft-tissue retraction or during osseous ischial, supra-acetabular, and/or retroacetabular osteotomies.

文獻(xiàn)出處：Michael Leunig, Jonathan M Vigdorchik, Aidin Eslam Pour, Silvia Willi-D?hn, Reinhold Ganz. Delayed-Onset Sciatic Nerve Palsy After Periacetabular Osteotomy: A Case Report. Case Reports JBJS Case Connect. 2017 Jan-Mar;7(1):e9. doi: 10.2106/JBJS.CC.16.00084.

文獻(xiàn)4

Y形軟骨閉合前進(jìn)行伯爾尼髖臼周圍截骨術(shù)（PAO）的放射學(xué)結(jié)果

譯者 邱興

目的：伯爾尼髖臼周圍截骨術(shù)（PAO）通常需待青春期晚期生長板閉合后方可實(shí)施，因該術(shù)式截骨線跨越Y(jié)形軟骨后支，可能引發(fā)類似兒童期骨盆骨折后觀察到的創(chuàng)傷后發(fā)育不良畸形。本研究旨在通過影像學(xué)回顧性分析，評(píng)估在生長板未閉合兒童中實(shí)施PAO對髖臼發(fā)育的影響。

方法：我們回顧性分析了23例髖關(guān)節(jié)（20例患者）的放射學(xué)結(jié)果，平均年齡10.7歲（標(biāo)準(zhǔn)差1.8；范圍5.7至12.7歲）。測量并比較術(shù)前、術(shù)后3個(gè)月及末次隨訪（生長板閉合后）的以下參數(shù)：外側(cè)中心邊緣角（LCE）、髖臼指數(shù)（AI）、股骨頭突出指數(shù)（HE）、股骨頭外側(cè)移位程度及淚滴厚度。同時(shí)對比手術(shù)側(cè)與非手術(shù)側(cè)Y形軟骨閉合年齡。

結(jié)果：平均隨訪時(shí)間5.2年（標(biāo)準(zhǔn)差3.7；范圍0.6至12.7年）。術(shù)前超過80%的髖關(guān)節(jié)呈現(xiàn)病理性測量值，PAO術(shù)后顯著改善，所有髖關(guān)節(jié)術(shù)后測量值均恢復(fù)正常范圍。PAO術(shù)后各髖臼角度指標(biāo)均顯著改善（LCE從14°（標(biāo)準(zhǔn)差8°）增至38°（標(biāo)準(zhǔn)差11°）；AI從20°（標(biāo)準(zhǔn)差8°）降至7°（標(biāo)準(zhǔn)差4°）；HE指數(shù)從32°（標(biāo)準(zhǔn)差9°）降至8°（標(biāo)準(zhǔn)差8°））。髖臼塑形過程符合生理特征，股骨頭外側(cè)移位程度輕微（從9°（標(biāo)準(zhǔn)差9°）變?yōu)?1.7°（標(biāo)準(zhǔn)差4.8°）），淚滴寬度輕度增加（4.7 mm（標(biāo)準(zhǔn)差1）增至8.2 mm（標(biāo)準(zhǔn)差4.4））。并發(fā)癥發(fā)生率低：骨關(guān)節(jié)炎1例；一過性坐骨神經(jīng)刺激癥狀1例（自行緩解）；內(nèi)固定物干擾1例（行取出術(shù)）；需附加股骨轉(zhuǎn)子間外翻截骨1例。所有并發(fā)癥均獲解決且無后遺影響。

結(jié)論：本組生長板未閉合患者接受PAO治療的數(shù)據(jù)令人鼓舞，術(shù)后髖臼覆蓋參數(shù)恢復(fù)正常，髖臼發(fā)育僅出現(xiàn)輕微改變，研究結(jié)果支持該術(shù)式應(yīng)用于6歲及以上兒童。

圖1、2.5歲女性患兒，高能量損傷致右側(cè)Y形軟骨撕裂傷（箭頭所示）。創(chuàng)傷后僅兩個(gè)月，可見髖臼窩及淚滴區(qū)域明顯增厚（白色T形標(biāo)記）。十七年后隨訪時(shí)呈現(xiàn)創(chuàng)傷性髖臼發(fā)育不良，典型表現(xiàn)為淚滴增厚（白色T形標(biāo)記）、髖臼向遠(yuǎn)端移位及后傾，繼發(fā)股骨頭外側(cè)移位，符合創(chuàng)傷性髖關(guān)節(jié)發(fā)育不良的特征性改變。AP：前后位。

圖2、 Y形軟骨未閉合的半骨盆示意圖，顯示伯爾尼髖臼周圍截骨術(shù)（PAO）的后柱截骨線（紅色標(biāo)示）與Y形軟骨髂坐骨支交匯。改編自Dong等的研究。

圖3、 髖臼覆蓋參數(shù)測量示意圖。圖中上半部分展示了以下指標(biāo)的量化標(biāo)準(zhǔn)：a) 外側(cè)中心邊緣角（LCE）、b) 髖臼傾斜角（AI）、c) 股骨頭突出指數(shù)。d) 至 f) 為上述測量指標(biāo)的箱線圖統(tǒng)計(jì)結(jié)果，顯示術(shù)前所有參數(shù)均呈病理性異常，術(shù)后恢復(fù)正常并維持至末次隨訪（FUP）。***表示p < 0.001，ns表示無統(tǒng)計(jì)學(xué)意義。箱線圖展示中位數(shù)和四分位距（IQR）；須狀線表示數(shù)據(jù)范圍（排除異常值），異常值以獨(dú)立數(shù)據(jù)點(diǎn)顯示。

圖4、示意圖展示a) 股骨頭位置（股骨頭外側(cè)移位）及b) 淚滴形態(tài)（淚滴厚度），這些指標(biāo)在創(chuàng)傷性發(fā)育不良中通常表現(xiàn)為數(shù)值升高。c) 股骨頭外側(cè)移位程度從術(shù)前至末次隨訪（FUP）保持穩(wěn)定。d) 術(shù)后僅出現(xiàn)輕度淚滴增厚，且至末次隨訪未見進(jìn)一步進(jìn)展。*表示p < 0.05，ns表示無統(tǒng)計(jì)學(xué)意義。箱線圖展示中位數(shù)和四分位距（IQR）；須狀線表示數(shù)據(jù)范圍（排除異常值），異常值以獨(dú)立數(shù)據(jù)點(diǎn)顯示。

圖5、 10歲男性患兒，既往因重度Perthes'病伴鉸鏈?zhǔn)酵庹够?，接受股骨?cè)內(nèi)翻截骨術(shù)。為使股骨頭納入髖臼，通過外科脫位入路聯(lián)合實(shí)施髖臼周圍截骨術(shù)（PAO）與股骨頭縮小截骨術(shù)（HRO）。術(shù)后六周X線片顯示股骨頭于髖臼內(nèi)對位良好，HRO固定螺釘、轉(zhuǎn)子截骨內(nèi)固定物及PAO固定螺釘位置滿意。術(shù)后兩年行部分內(nèi)固定物取出（轉(zhuǎn)子及髂骨部）后，髖關(guān)節(jié)仍保持中心性對位，未見繼發(fā)性創(chuàng)傷后髖關(guān)節(jié)發(fā)育不良征象。AP：前后位。

Radiological results of the Bernese periacetabular osteotomy performed before closure of the triradiate cartilage

Aims: The Bernese periacetabular osteotomy (PAO) is typically not performed until after the growth plates have closed in late adolescence, as the osteotomy crosses the posterior branch of the triradiate cartilage, which could potentially cause deformities similar to post-traumatic dysplasia, a condition observed following pelvic fractures in childhood. The aim of this study was to retrospectively analyze on radiographs whether the PAO, when performed in children with open growth plates, affects acetabular development.

Methods: We retrospectively reviewed the radiological outcomes of 23 hips (20 patients) with a mean age of 10.7 years (SD 1.8; 5.7 to 12.7). Preoperative, three-months postoperative, and latest follow-up measurements (after growth plate closure) were assessed for the following parameters: lateral centre-edge angle (LCE), acetabular index (AI), head extrusion (HE) index, femoral head (FH) lateralization, and teardrop thickness. We also compared the age at triradiate cartilage closure between the operated and nonoperated hips.

Results: The mean follow-up was 5.2 years (SD 3.7; 0.6 to 12.7). Preoperatively, over 80% of the hips showed pathological measurements, which improved significantly post-PAO. None of the hips had pathological measurements after surgery. All acetabular angles showed significant improvement post-PAO (LCE from 14° (SD 8°) to 38° (SD 11°); AI from 20° (SD 8°) to 7° (SD 4°); and HE index from 32° (SD 9°) to 8° (SD 8°)). Acetabular moulding was physiological with little FH lateralization (from 9° (SD 9°) to 11.7° (SD 4.8°)), and a small increase in teardrop width (4.7 mm (SD 1) to 8.2 mm (SD 4.4)). Few complications were observed: one case of osteoarthritis (OA); one case of transient sciatic nerve irritation that resolved; one case of interfering osteosynthesis material that was removed; and one case requiring an additional valgus intertrochanteric osteotomy. All complications resolved without further issues.

Conclusion: Our data on the use of PAO in patients with an open growth plate are encouraging with normalization of acetabular coverage parameters and only minor alterations of acetabular development, and may support its use in children six years old and older.

文獻(xiàn)出處：Ganz, Reinhold, Stefan Blümel, Alisa Schleicher, Felix ?ttl, Vincent A. Stadelmann, and Michael Leunig. "Radiological results of the Bernese periacetabular osteotomy performed before closure of the triradiate cartilage." Bone & Joint Open 6, no. 6 Supple B (2025): 24-32.

文獻(xiàn)5

年輕成人非手術(shù)治療的臨界髖關(guān)節(jié)發(fā)育不良的自然史及與功能結(jié)局不良相關(guān)因素

譯者 徐子茵

背景： 年輕人中非手術(shù)治療的臨界髖關(guān)節(jié)發(fā)育不良（BHD）的長期結(jié)果尚未被探索。本研究旨在調(diào)查非手術(shù)治療的BHD在至少10年隨訪期間的自然病程。

假設(shè)： 大多數(shù)接受非手術(shù)治療的BHD患者在至少10年內(nèi)會(huì)表現(xiàn)出持續(xù)的癥狀和髖關(guān)節(jié)骨關(guān)節(jié)炎（OA）的影像學(xué)證據(jù)。

研究設(shè)計(jì)： 病例系列研究（預(yù)后）；證據(jù)等級(jí)，4級(jí)。

方法： 回顧性分析了2005年1月至2012年12月期間因髖部疼痛就診的14至39歲BHD患者的病歷和X光片。BHD定義為外側(cè)中心邊緣角（LCEA）為18°至25°。接受非手術(shù)治療的患者在至少10年的隨訪期后返回進(jìn)行臨床檢查、骨盆X光檢查和髖關(guān)節(jié)磁共振成像（MRI）。同時(shí)，回顧性分析了接受手術(shù)的臨界髖關(guān)節(jié)患者（手術(shù)方式包括針對股骨髖臼撞擊綜合征[FAI]的髖關(guān)節(jié)鏡手術(shù)[HAS]或髖臼周圍截骨術(shù)[PAO]）的病歷、骨盆X光片和MR圖像。

結(jié)果： 在非手術(shù)治療的45個(gè)髖關(guān)節(jié)（30名患者，平均年齡23 ± 7歲）中，平均隨訪15 ± 1年后，有4個(gè)髖關(guān)節(jié)（9%）進(jìn)展為1級(jí)骨關(guān)節(jié)炎。末次隨訪時(shí)的平均改良Harris髖關(guān)節(jié)評(píng)分（mHHS）為88 ± 12分，僅1名患者評(píng)分低于70分。手術(shù)組包括19個(gè)髖關(guān)節(jié)（15名患者），手術(shù)方式包括PAO（5個(gè)髖關(guān)節(jié)）和HAS（14個(gè)髖關(guān)節(jié)）。髖臼后傾（比值比 [OR] 為13 [95% CI, 1.4-122.9]; P = .02）和盂唇肥大（OR為17.9 [95% CI, 1.4-228.1]; P = .03）與較低的mHHS相關(guān)，但與骨關(guān)節(jié)炎的進(jìn)展無關(guān)。

結(jié)論： 在平均15年的隨訪中，90個(gè)臨界髖關(guān)節(jié)中有19個(gè)（21%）需要保髖手術(shù)。在45個(gè)非手術(shù)髖關(guān)節(jié)中，4個(gè)（9%）表現(xiàn)出輕度骨關(guān)節(jié)炎進(jìn)展，其中3個(gè)（75%）保持了極佳的功能結(jié)果。髖臼后傾和盂唇肥大與功能較差相關(guān)，但不能預(yù)測骨關(guān)節(jié)炎的進(jìn)展。在接受FAI髖關(guān)節(jié)鏡手術(shù)后，盂唇肥大的患者常見持續(xù)癥狀。

關(guān)鍵詞： 臨界髖臼發(fā)育不良；髖關(guān)節(jié)鏡；自然病程；髖臼周圍截骨術(shù)；治療。

Natural History of Nonoperatively Treated Borderline Acetabular Dysplasia in Young Adults and Factors Associated With Inferior Functional Outcome

Background: The long-term outcomes of nonoperatively treated borderline acetabular dysplasia (BHD) in young adults remain unexplored. This study aimed to investigate the natural history of nonoperatively treated borderline hips over a minimum 10-year follow-up.

Hypothesis: Most patients with nonoperatively treated BHD would exhibit persistent symptoms and radiological evidence of hip osteoarthritis (OA) for at least 10 years.

Study design: Case series (prognosis); Level of evidence, 4.

Methods: Medical records and radiographs of patients aged 14 to 39 years with BHD, defined as a lateral center-edge angle (LCEA) of 18° to 25°, who presented with hip pain between January 2005 and December 2012, were retrospectively reviewed. Patients treated nonoperatively returned for clinical examination, pelvic radiograph, and hip magnetic resonance imaging (MRI) at a minimum of 10-year follow-up. Medical records, pelvis radiographs, and MR images of patients with borderline hips who underwent surgery, either hip arthroscopy (HAS) for predominantly femoroacetabular impingement (FAI) or periacetabular osteotomy (PAO), were retrospectively reviewed.

Results: Among 45 hips (30 patients) treated nonoperatively (mean age, 23 ± 7 years), 4 hips (9%) showed progression to OA grade 1 at a mean of 15 ± 1 years of follow-up. The mean modified Harris Hip Score (mHHS) was 88 ± 12 at the last follow-up, with only 1 patient scoring <70. Of the surgical group (19 hips, 15 patients), procedures included PAO (5 hips) and HAS (14 hips). Acetabular retroversion (odds ratio [OR], 13 [95% CI, 1.4-122.9]; P = .02) and labrum hypertrophy (OR, 17.9 [95% CI, 1.4-228.1]; P = .03) correlated with lower mHHS but not with OA progression.

Conclusion: At a mean 15-year follow-up, 19 of 90 (21%) of borderline hips required preservation surgery. Of the 45 nonsurgical hips, 4 (9%) exhibited mild OA progression, and 3 of 4 hips (75%) maintained excellent functional outcomes. Acetabular retroversion and labrum hypertrophy were associated with poorer function but did not predict OA progression. Persistent symptoms were common in patients with labrum hypertrophy after HAS for FAI.

Keywords: borderline acetabular dysplasia; hip arthroscopy; natural history; periacetabular osteotomy; treatment.

文獻(xiàn)出處：Dimitriou D, Marcus R, Kaiser D, Hoch A, Zingg P. Natural History of Nonoperatively Treated Borderline Acetabular Dysplasia in Young Adults and Factors Associated With Inferior Functional Outcome. Orthop J Sports Med. 2026;14(2):23259671251410199. Published 2026 Feb 17. doi:10.1177/23259671251410199

來源：304關(guān)節(jié)學(xué)術(shù)

作者：304關(guān)節(jié)團(tuán)隊(duì)

聲明：本文內(nèi)容及圖片均為轉(zhuǎn)載內(nèi)容，如涉及版權(quán)問題請相關(guān)權(quán)利人及時(shí)與我們聯(lián)系，我們會(huì)立即處理配合采取保護(hù)措施，以保障雙方利益。

為什么要投稿？是為了記錄自己的醫(yī)學(xué)之路！是為了與更多的骨科同道交流分享！是為了讓更多的人看到而受益！讓傳播知識(shí)成為一種習(xí)慣，是“玖玖骨科”讓你投稿的理由！