髋膝关节文献精译荟萃（第163期）
本期目录：
1、机器人全膝置换与传统全膝置换的对比：一个全国性数据库研究
2、机器臂辅助与全手动全髋关节置换的对比研究
3、新型机器人辅助技术与传统手术技术在膝关节内侧单间室关节置换术中应用的对比研究：疗效与影像学比较
4、机械臂辅助膝关节手术:经济性分析
5、膝关节牵张和胫骨高位截骨术后软骨厚度和裸露骨面积的变化——两项随机对照试验的事后分析
6、美国支付系统中DDH筛查与发病率
7、早期超声检测髋关节发育不良
8、在治疗稳定性髋关节发育不良时再次超声检查的时机
9、3-D超声评估婴幼儿发育性髋关节发育不良的可靠性
10、DDH早期筛查早期诊断的重要性
11、儿童髋关节超声：检查的不确定性和治疗的选择
第一部分：关节置换及保膝相关文献
文献1
机器人全膝置换与传统全膝置换的对比：
一个全国性数据库研究
译者：张轶超
全膝关节置换（TKA）是解决终末期膝关节骨关节炎的一个效果良好的手术方法。其良好的效果正是得益于它的长期生存率（10-15年的生存率超过90%）和满意度（70-93%）。在既往几十年中膝关节置换方面的进步主要表现在新的假体设计及个体化假体、材料学的进步、基于CT或MRI的截骨模板设计、围手术期治疗方法的改进及计算机导航技术的应用等。21世纪末以来，机器人辅助手术逐渐被引入到外科领域的各个方面。首次使用机器人辅助完成手术的是1985年的可编程通用操作臂系统（PUMA），使用这个设备做了一台神经外科的活检。而真正获得批准上市的是用于腹腔镜手术的达芬奇手术机器人系统。直到上世纪80年代末手术机器人系统才被引入骨科领域。最早是使用ROBODOC手术机器人进行全髋置换手术，而随着期推广，目前已经完成超过15，000例的全膝置换。随后，越来越多的手术机器人系统被使用到全关节置换领域。这些年又出现了很多主动、半主动和被动控制系统（如机器人辅助臂、机器人截骨导板及机器人切削系统等）被引入到临床中。
很多文献报告了全关节置换手术中使用机器人辅助系统后提高了手术的精度和拥有更好的假体位置及下肢力线。但同时也会令我们担心手术成本和时间的增加，以及是否真的能够提高准确性和减少术后并发症尚不可知。美国杜兰大学医学院的Sione A. Ofa等报道了一组从数据库中获得的从2010年到2017年行初次TKA的病例，一组是使用机器人完成的（n=5228），另一组没有使用机器人（n=750，122）。主要观察了术后并发症及阿片类药物使用量。结果观察到未用机器人组出院1年内假体翻修率高（P<0.05），出院90天和1年内的手法松解率高（P<0.05）。而且未使用机器人组在院期间和出院90天内的深静脉血栓和肺栓塞、精神疾病、贫血、急性肾衰、脑血管事件、肺炎、肝衰竭和尿路感染的发生率均高（均P<0.05）。在所有时间段里未用机器人手术的病例的阿片药物摄入量均较使用机器人手术病例高（P<0.001）。从这些观察指标来看，使用机器人手术可以降低翻修率及麻醉下手法松解的发生率，减少术后并发症和阿片类药物的使用量。但作者认为还需要进行长期的观察。
Robotic Total Knee Arthroplasty vs Conventional Total Knee Arthroplasty: A Nationwide Database Study
Background: As robot-assisted equipment is continuously being used in orthopaedic surgery, the past few decades have seen an increase in the usage of robotics for total knee arthroplasty (TKA). Thus, the purpose of the present study is to investigate the differences between robotic TKA and nonrobotic TKA on perioperative and postoperative complications and opioid consumption.
Methods: An administrative database was queried from 2010 to Q2 of 2017 for primary TKAs performed via robot-assisted surgery vs non-robot-assisted surgery. Systemic and joint complications and average morphine milligram equivalents were collected and compared with statistical analysis.
Results: Patients in the nonrobotic TKA cohort had higher levels of prosthetic revision at 1-year after discharge (P < .05) and higher levels of manipulation under anesthesia at 90 days and 1-year after discharge (P < .05). Furthermore, those in the nonrobotic TKA cohort had increased occurrences of deep vein thrombosis, altered mental status, pulmonary embolism, anemia, acute renal failure, cerebrovascular event, pneumonia, respiratory failure, and urinary tract infection during the inpatient hospital stay (all P < .05) and at 90 days after discharge (all P < .05). All of these categories remained statistically increased at the 90-days postdischarge date, except pneumonia and stroke. Patients in the nonrobotic TKA cohort had higher levels of average morphine milligram equivalents consumption at all time periods measured (P < .001).
Conclusions: In the present study, the use of robotics for TKA found lower revision rates, lower incidences of manipulation under anesthesia, decreased occurrence of systemic complications, and lower opiate consumption for postoperative pain management. Future studies should look to further examine the long-term outcomes for patients undergoing robot-assisted TKA.
文献出处：Ofa SA, Ross BJ, Flick TR, Patel AH, Sherman WF. Robotic Total Knee Arthroplasty vs Conventional Total Knee Arthroplasty: A Nationwide Database Study. Arthroplast Today. 2020 Nov 7;6(4):1001-1008.e3. doi: 10.1016/j.artd.2020.09.014. PMID: 33385042; PMCID: PMC7772451.
文献2
机器臂辅助与全手动全髋关节置换的对比研究
译者：马云青
虽然传统人工全髋关节置换术(THA)可以为髋关节疾病的患者提供良好的术后功能和满意率，但近年来普遍认为机器人辅助全髋关节置换术存在进一步提高手术疗效的可能。机器人辅助髋关节置换术取得了快速进展，从最初的1992年推出的ROBODOC 外科手术系统(THINK Surgical, Fremont, California, USA),到后期CASPAR (Universal Robot Systems, Rastatt, Germany)的应用，这些系统都是可以独立于主刀医生外，单独完成手术，近年来Mako交互式矫形外科系统(Stryker, Kalamazoo, Michigan, USA)应用于临床，与ROBODOC和CASPAR不同，因为它是一个半自动的手术系统(需要外科医生参与手术)。自2015年通过FDA认证应用，随着病例数量的增加越来越多的证据表明机器人辅助全髋关节置换术（rTHA） 与手工全髋关节置换术(mTHA)相比提高了假体位置的准确性，但不清楚rTHA是否比mTHA 有任何术后功能上的提高。此研究的主要目的是比较(rTHA)与(mTHA)的骨关节炎患者的髋关节特异性功能结果。同时也比较了rTHA 和 rTHA间患者一般健康改善、患者满意度、假体影像学位置和下肢长度恢复情况。
Clement等将40例接受 rTHA 的髋关节OA患者与80例接受mTHA的患者相匹配。比较术前和术后随访时牛津髋关节评分(OHS）、Forgotten Joint Score (FJS)和 EuroQol-5D问卷调查表(EQ-5D)。rTHA组术后平均10个月，mTHA组术后平均12个月，同时记录术后患者满意度在术后影像学资料上准确测量双下肢长度和假体Lewinnek 和 Callanan安全区范围。
结果显示rTHA组术后OHS和FJS明显高于mTHA组。然而只有FJS有临床意义。
术后EQ-5D无统计学意义，rTHA组无患者不满意，mTHA 组6人不满意，但两组没有统计学差异。rTHA组假体位置和家督处于安全区内比例和下肢长度恢复满意率较高。
接受rTHA治疗的患者与接受mTHA治疗的髋关节骨关节患者相比，术后早期有更好的髋关节功能这些可能与假体位置更加准确和肢体长度恢复更好有关。但患者术后一般健康状态和患者满意率没有差异。
Robotic arm-assisted versus manual total hip arthroplasty
Aims: The primary aim of this study was to compare the hip-specific functional outcome of robotic assisted total hip arthroplasty (rTHA) with manual total hip arthroplasty (mTHA) in patients with osteoarthritis (OA). Secondary aims were to compare general health improvement, patient satisfaction, and radiological component position and restoration of leg length between rTHA and mTHA.
Methods: A total of 40 patients undergoing rTHA were propensity score matched to 80 patients undergoing mTHA for OA. Patients were matched for age, sex, and preoperative function. The Oxford Hip Score (OHS), Forgotten Joint Score (FJS), and EuroQol five-dimension questionnaire (EQ-5D) were collected pre- and postoperatively (mean 10 months (SD 2.2) in rTHA group and 12 months (SD 0.3) in mTHA group). In addition, patient satisfaction was collected postoperatively. Component accuracy was assessed using Lewinnek and Callanan safe zones, and restoration of leg length were assessed radiologically.
Results: There were no significant differences in the preoperative demographics (p ≥ 0.781) or function (p ≥ 0.383) between the groups. The postoperative OHS (difference 2.5, 95% confidence interval (CI) 0.1 to 4.8; p = 0.038) and FJS (difference 21.1, 95% CI 10.7 to 31.5; p < 0.001) were significantly greater in the rTHA group when compared with the mTHA group. However, only the FJS was clinically significantly greater. There was no difference in the postoperative EQ-5D (difference 0.017, 95% CI -0.042 to 0.077; p = 0.562) between the two groups. No patients were dissatisfied in the rTHA group whereas six were dissatisfied in the mTHA group, but this was not significant (p = 0.176). rTHA was associated with an overall greater rate of component positioning in a safe zone (p ≤ 0.003) and restoration of leg length (p < 0.001).
Conclusion: Patients undergoing rTHA had a greater hip-specific functional outcome when compared to mTHA, which may be related to improved component positioning and restoration of leg length. However, there was no difference in their postoperative generic health or rate of satisfaction.
文献出处：Clement ND, Gaston P, Bell A, Simpson P, Macpherson G, Hamilton DF, Patton JT. Robotic arm-assisted versus manual total hip arthroplasty. Bone Joint Res. 2021 Jan;10(1):22-30. doi: 10.1302/2046-3758.101.BJR-2020-0161.R1. PMID: 33380216; PMCID: PMC7845457.
文献3
新型机器人辅助技术与传统手术技术在
膝关节内侧单间室关节置换术中应用的
对比研究：疗效与影像学比较
译者：张蔷
众所周知，膝关节骨关节炎是一种常见的慢性疾病，45岁以上人群中发病率超过19%，它会导致长期的慢性疼痛、关节功能丧失，并严重影响患者的生活质量。单间室膝关节置换（也被成为单髁置换，UKA）是一种高效费比的治疗股胫关节单间室骨关节炎的方法。全世界多个国家的关节登记中心在近些年发表的数据显示UKA手术占比迅速攀升。与全膝关节置换手术（TKA）相比，单髁置换的并发症率更低，恢复更快，患者满意度更高。尽管如此，单髁置换依然存在挑战，其中尤为重要的一点即是，与全膝相比，单髁置换术中准确的安放假体难度更大，而假体位置不佳又是早期无菌性松动的重要原因。机器人辅助手术技术可以使手术更加精准，因此它也可以在预防单髁置换术中假体安放位置不佳方面发挥更大的作用，进而提升临床疗效并保证假体长期生存。本篇文章通过五种影像学指标比较了使用NAVIO（Blue Belt Technologies, Plymouth, MN, USA）机器人辅助手术技术和传统手术技术的内侧单间室膝关节置换手术的假体安放准确性。
作者选择单一医疗中心（康迪斯诊所）2017年4月至2019年3月间共34例内侧间室单髁置换的病例进行队列研究。患者被随机分入传统手术组（UKA-C，16例）或机器人辅助组（UKA-R，18例）。研究的基础指标包括年龄、性别、术侧、住院时长、手术时间等。影像学指标包括股骨远端内侧角（aMDFA），胫骨近端内侧角（aMPTA），胫骨后倾角，股骨矢状角和假体型号（见下图）。作者为所有影像学测量指标规定了目标范围，只有达到至少四项指标的目标值，单髁手术才能被认定为成功。此外，患者自评量表包括牛津膝关节评分表（OKS）评价功能和数字化评分表（NRS）评价疼痛。
结果显示机器人辅助组的成功率为87%，而传统手术组仅为28%，组间存在显著统计学差异（确切概率法，p=0.001；1-β=0.95）。此外，机器人辅助组的中位OKS评分也比传统手术组高5分（p=0.01），而机器人辅助组的术后中位NRS评分也比传统手术组低，差距存在显著统计学差异（p<0.000）。
本研究显示机器人辅助技术单髁关节置换比传统技术置换的术后影像学指标更为精准，术后短期随访显示机器人辅助手术术后OKS关节功能评分更高，NRS疼痛评分更低。但作者也强调：为了证明这一趋势，我们在未来还需要更多更大样本量的研究以及更长时间的随访结果。
膝关节术后正侧位片：图中显示了以下指标的测量方法：aMDFA，股骨远端内侧角；aMPTA，胫骨近端内侧角；Tibial Slope，胫骨后倾角；SFA，股骨矢状角。
Robotic-assisted vs conventional surgery in medial unicompartmental knee arthroplasty: a clinical and radiological study
Background: The use of unicompartmental knee arthroplasty (UKA) has increased and new technologies have been developed to improve patient survival and satisfaction, soft tissue balance, alignment, and component size. Robot-assisted systems offer an increase in surgical precision and accuracy. The purpose of this study is to evaluate the precision of component position using five radiological parameters in conventional and robotic-assisted medial UKA using the NAVIO system.
Methods: A cohort study was designed for patients who underwent medial UKA between April 2017 and March 2019 in a single center. Patients were allocated in the conventional (UKA-C) or robotic-assisted (UKA-R) group. The variables analyzed were age, gender, affected knee side, length of hospital stay, surgical time, and radiological measurements such as anatomical medial distal femoral angle (aMDFA), anatomical medial proximal tibial angle (aMPTA), tibial slope, the sagittal femoral angle, and the component size. A target was defined for each measurement, and a successful UKA was defined if at least four radiological measures were on target after surgery. Also, patients' reported outcomes were evaluated using the Oxford Knee Score (OKS) and a numeric rating scale (NRS) for pain.
Results: Thirty-four patients were included, 18 of them underwent UKA-R. The success rate for UKA in the UKA-R group was 87%; meanwhile, in the UKA-C group this was 28%, this difference was significant and powered (Fisher's exact test, p = 0.001; 1 - β = 0.95). Also, a 5-point difference in favor of the UKA-R group in the median OKS (p = 0.01), and a significantly lower median NRS for pain (p < 0.000) were found after surgery.
Conclusions: UKA-R achieved more precision in the radiological parameters' measure in this study. Also, UKA-R has a trend towards a better OKS and a lower NRS for pain at short-term follow-up.
文献出处：Negrín R, Duboy J, Iñiguez M, Reyes NO, Barahona M, Ferrer G, Infante C, Jabes N. Robotic-assisted vs conventional surgery in medial unicompartmental knee arthroplasty: a clinical and radiological study. Knee Surg Relat Res. 2021 Feb 12;33(1):5. doi: 10.1186/s43019-021-00087-2. PMID: 33579393; PMCID: PMC7879692.
文献4
机械臂辅助膝关节手术:经济性分析
译者：沈松坡
目前全球全膝关节置换术（TKA）的数量逐年增长，2014年仅在美国就进行了70万例TKA手术，预计至2030年年手术量将达到125万。与之相对应的是手术相关花费剧增，达到了250亿美元。为了应对医疗成本的不断攀升，医保系统按诊断组付费（DRG）不断研究如何优化TKA手术，实现在不影响治疗的前提下，降低医保支付成本。随着机器人辅助手术在人工膝关节置换中应用的不断优化，研究人员趋于相信使用机械臂辅助TKA手术能够在一定程度上节约医保支出。
根据先前对医疗保险人群的研究表明，机械臂辅助全膝关节置换术(RATKA)改善了术后结果，并降低了90天的治疗成本。研究人员本使用OptumInsight公司的数据库评估65岁以下人群RATKA后的医保支出和医疗服务使用情况，共纳入357例RATKA手术和1785例MTKA手术进行分析，按评分1：5匹配进行。结果发现，术后90天内，RATKA患者使用住院服务 (2.24% vs 4.37%;P = .0444)和专业护理机构(1.68% vs 6.05%;P <0.0001) 的可能性较小。RATKA组中没有患者去康复机构住院，而MTKA组中0.90%的患者去康复机构住院。RATKA组中使用家庭健康助手的患者使用家庭健康指导天数显著减少(5.33天和6.36天;P = .0037)。在RATKA组，与术后总支出相关的成本减少了1332美元(6857美元vs 8189美元;P = .0018)。RATKA组90天的全球支出(包括术后指数)减少了4049美元(28,204美元vs 32253美元;P <0.0001)。RATKA组术后住院时间减少了近1天(1.80 vs 2.72天;P <0.0001)。
因此作者认为，与MTKA相比，RATKA与更短的住院时间、更低的医疗服务使用率和更低的90天支付成本相关，机械臂辅助TKA手术相比于传统TKA手术，在一定程度上能够降低医疗系统的总体花费。
Robotic arm-assisted knee surgery: an economic analysis
Objectives: Previous studies on Medicare populations have shown improved outcomes and decreased 90-day episode-of-care costs with robotic arm-assisted total knee arthroplasty (RATKA). The purpose of this study was to evaluate expenditures and utilization following RATKA in the population younger than 65 years.
Study design: This is a retrospective longitudinal analysis of a commercial claims data set.
Methods: TKA procedures were identified using the OptumInsight Inc database. The procedures were stratified in 2 groups: the RATKA and manual TKA (MTKA) cohorts. Propensity score matching was performed at 1:5. Utilization and associated costs were analyzed for 90 days following the index procedure. A total of 357 RATKA and 1785 MTKA procedures were included in this analysis.
Results: Within 90 days post surgery, patients who had RATKA were less likely to utilize inpatient services (2.24% vs 4.37%; P = .0444) and skilled nursing facilities (1.68% vs 6.05%; P < .0001). No patients in the RATKA group went to inpatient rehabilitation, whereas 0.90% of the MTKA arm went to an inpatient rehabilitation facility. Patients who utilized home health aides in the RATKA arm utilized significantly fewer home health days (5.33 vs 6.36 days; P = .0037). Costs associated with overall postsurgery expenditures were $1332 less in the RATKA arm ($6857 vs $8189; P = .0018). The 90-day global expenditures (index plus post surgery) were $4049 less in the RATKA arm ($28,204 vs $32,253; P < .0001). Length of stay after surgery was nearly a day less for the RATKA arm (1.80 vs 2.72 days; P < .0001).
Conclusions: RATKA was associated with shorter length of stay, reduced utilization of services, and reduced 90-day payer costs compared with MTKA.
文献出处：Pierce J, Needham K, Adams C, Coppolecchia A, Lavernia C. Robotic arm-assisted knee surgery: an economic analysis. Am J Manag Care. 2020 Jul 1;26(7):e205-e210. doi: 10.37765/ajmc.2020.43763. PMID: 32672918.
文献5
膝关节牵张和胫骨高位截骨术后软骨厚度和
裸露骨面积的变化：两项随机对照试验的事后分析
译者：张峻
膝骨关节炎（OA）是最常见的OA形式，也是全世界最常见的致残原因之一。它造成了全球经济负担，并且患病人数预计在未来会持续增加。在较年轻和较活跃的患者中，保留关节的手术可能是某些病人理想的选择。对于病变主要在单间室膝的OA患者，单间室膝关节置换术（UKA），高胫骨截骨术（HTO）和膝关节牵开术（KJD）可被视为（部分）保留关节的治疗选择。与UKA相比，HTO和KJD完全保留了天然的关节组织。HTO通过(过度)矫正腿部力线实现软骨修复，KJD通过使用外固定架暂时卸载两个间室应力来促进软骨修复，两种方法都有良好的长期生存率。本研究的主要目的是比较KJD和HTO治疗期间两年的磁共振观察下软骨厚度和裸露关节表面积（dABp）的变化。
荷兰乌得勒支大学Jansen MP等从两个不同的随机对照实验纳入病人，KJD vs. HTO和KJD vs. TKA。治疗2年后，以x线片关节间隙宽度（JSW）为参考，MRI显示易受影响的间室（MAC）软骨平均厚度和dABp百分比发生变化。治疗后，KJDHTO患者（n=18）没有显著变化。HTO患者（n=33）显示MAC软骨厚度减少，并且dABp增加，但JSW增加。KJDTKA（n=18）显示MAC软骨厚度增加，JSW，dABp下降。骨关节炎的严重程度是软骨修复的最强预测因子，Kellgren-Lawrence分级≥3级病人经KJD治疗后显示恢复显著（p<0.01）；≤2级恢复不好。经KJD和HTO治疗的重度患者在MAC MRI软骨厚度（d=1.09；p=0.005）和dABp（d=1.13；p=0.003）方面效应量较大，但不包括影放射学JSW。
总之，对于纳入同一试验的患者（KJD vs. HTO），两种治疗在MAC软骨修复方面显示出相似的结果。在轻度膝关节OA患者中，经HTO和KJD治疗两年以上均不能实现显著的软骨修复，反而都有轻微的软骨退变，这可能是骨关节炎自然发展的结果。两种处理对较少受影响的间室的变化没有差异。基于亚组分析的结果表明，在重度膝关节OA患者中，KJD可能比HTO更有效地恢复软骨厚度。研究表明，对于重度膝关节OA，KJD作为保留关节的手术是一个很好的选择。但这需要设计大样本的试验来进一步证实。
Changes in Cartilage Thickness and Denuded Bone Area after Knee Joint Distraction and High Tibial Osteotomy-Post-Hoc Analyses of Two Randomized Controlled Trials
High tibial osteotomy (HTO) and knee joint distraction (KJD) are joint-preserving treatments that unload the more affected compartment (MAC) in knee osteoarthritis. This post-hoc study compares two-year cartilage-thickness changes after treatment with KJD vs. HTO, and identifies factors predicting cartilage restoration. Patients indicated for HTO were randomized to KJD (KJDHTO) or HTO treatment. Patients indicated for total knee arthroplasty received KJD (KJDTKA). Outcomes were the MRI mean MAC cartilage thickness and percentage of denuded bone area (dABp) change two years after treatment, using radiographic joint space width (JSW) as the reference. Cohen's d was used for between-group effect sizes. Post-treatment, KJDHTO patients (n = 18) did not show significant changes. HTO patients (n = 33) displayed a decrease in MAC cartilage thickness and an increase in dABp, but an increase in JSW. KJDTKA (n = 18) showed an increase in MAC cartilage thickness and JSW, and a decrease in dABp. Osteoarthritis severity was the strongest predictor of cartilage restoration. Kellgren-Lawrence grade ≥3 showed significant restoration (p < 0.01) after KJD; grade ≤2 did not. Effect sizes between severe KJD and HTO patients were large for MAC MRI cartilage thickness (d = 1.09; p = 0.005) and dABp (d = 1.13; p = 0.003), but not radiographic JSW (d = 0.28; p = 0.521). This suggests that in knee osteoarthritis patients with high disease severity, KJD may be more efficient in restoring cartilage thickness.
文献出处：Jansen MP, Maschek S, van Heerwaarden RJ, Mastbergen SC, Wirth W, Lafeber FPJG, Eckstein F. Changes in Cartilage Thickness and Denuded Bone Area after Knee Joint Distraction and High Tibial Osteotomy-Post-Hoc Analyses of Two Randomized Controlled Trials. J Clin Med. 2021 Jan 19;10(2):368. doi: 10.3390/jcm10020368. PMID: 33478012; PMCID: PMC7835945.
第二部分：保髋相关文献
文献1
美国支付系统中DDH筛查与发病率
译者：罗殿中
DDH是导致肌肉骨骼系统病残的主要因素之一，DDH筛查不同策略的效率存在争议。当前美国采用超声进行DDH筛查的模式尚不明确。该研究来源于一个商业和医疗进步的数据库（Optum’s de-identified Clinformatics® Data Mart）。从2007年至2017年，依据支付受益人记录，大约共有290万DDH筛查和超声检查，共有6806例DDH患儿得到确诊，新生儿年平均发病率为千分之1.7，在研究期间保持稳定。筛查和诊断DDH患儿中，72%为女性，比值比OR为2.55（95%置信区间为2.42～2.69），P<0.001。美国平均约0.9%的新生儿得到超声筛查，从2007年的0.4%上升至2017年的2.2%；多数账单诊断为髋关节畸形（27.4%）、臀位分娩（20.4%）、查体异常（17.7%）。所有筛查儿童中，平均影像诊断费用为108.94美元。美国保险业的声明反映了当前美国的DDH筛查模式为选择性筛查，与基于诊断报告的《美国儿科指南》一致。虽然DDH筛查数量大幅度增加，但DDH发病率并未增长。我们的调查结果显示，扩大DDH超声筛查范围，并不能有效提升DDH的检出率，需要进一步深入研究来明确恰当的筛查策略以改善患者预后。
图1. 超声筛查频率与DDH患病率，2007-2017
2007年至2017年美国儿童DDH患病率维持稳定，最高位是2013年的千分之2.02，最低位是2016年的千分之1.04。新生儿超声筛查频率由2007年的0.4%提升至2017年的2.1%。整体的趋势图显示，在美国人口中增加筛查未能增加DDH检出率。
Developmental hip dysplasia and hip ultrasound frequency in a large American payer database
Developmental dysplasia of the hip (DDH) is an important contributor to musculoskeletal morbidity, but effective strategies to screen for DDH remain controversial. The current utilization of hip ultrasound (US) screening for DDH in the United States is not defined. This study utilized Optum's de-identified Clinformatics® Data Mart, a large commercial and Medicare Advantage claims database. The frequency of DDH and hip US utilization was estimated using billing data on an average of 2.9 million relevant beneficiaries included annually from 2007 through 2017. A total of 6806 DDH cases were identified with an average annual prevalence of 1.7 per 1000 infants, which was stable during the study period. Girls were more likely to be screened and diagnosed with DDH, comprising 72% of DDH cases with an OR of 2.55 (95% CI 2.42-2.69), p < 0.001. Hip US screening was employed in 0.9% of the infant population on average but increased substantially from 2007 (0.4%) to 2017 (2.2%). Most common billing diagnoses included hip deformity (27.4%), breech delivery (20.4%), and physical exam abnormality (17.7%). The average imaging costs per patient for all screened children was $108.94. Insurance claims reflect the current American practice of selective hip US with relative adherence to American Academy of Pediatrics guidelines based on reported diagnoses. While hip US utilization increased during the study period, prevalence of DDH diagnoses did not increase. Our results suggest that expansion of hip US screening may not effectively increase DDH detection although further investigation is needed to ascertain optimal screening strategies to improve patient outcomes.
文献出处：Degnan AJ, Hemingway J, Otero HJ, Hughes DR. Developmental hip dysplasia and hip ultrasound frequency in a large American payer database. Clin Imaging. 2021 May 5;76:213-216. doi: 10.1016/j.clinimag.2021.04.023. Epub ahead of print. PMID: 33965847.
文献2
早期超声检测髋关节发育不良
译者：程徽
目的：探讨早期超声(US)普筛诊断髋关节发育不良(DDH)的有效性。
研究设计：本研究是一项前瞻性研究。纳入了2012年到2013年，在赛格德大学妇产科出生的所有足月新生儿；1636例新生儿(3272髋)在出生后3天内进行了临床手法检查和Graf髋关节超声检查。评估了DDH的患病率、危险因素、临床检查的敏感性和特异性。
结果：在第1次超声检查中， 3272髋中有70髋(2.14%)检查结果为阳性。Graf分型：IIC型21髋(30.0%)；D型24髋(34.28%)；III型24髋(34.28%)；IV型1髋(1.44%)。在危险因素方面，女性、臀位产和阳性家族史具有显著意义。有趣的是，55例患有DDH的新生儿中有28例(50.90%)既没有阳性体征，也没有除性别以外的任何危险因素。手法检查的敏感性为20.0%和特异性为98.34%。
图1 超声阳性髋关节的分型情况
结论：我们为期1年的研究发现，患有DDH的新生儿50.9%既没有任何阳性体征，也没有除性别以外的任何危险因素。早期超声髋关节筛查有助于诊断所有髋关节发育不良。髋关节超声检查能有效的预防髋关节发育不良，但需要进一步的研究来比较选择性筛查和普遍筛查模式的手术率。
Early detection of developmental dysplasia of hip by ultrasound
Objective: To assess the effectiveness of early universal ultrasound (US) screening of developmental dysplasia of the hip (DDH).
Study design: A prospective study of universal hip screening of all mature neonates was conducted from 2012 to 2013, at the Department of Obstetrics and Gynaecology, University of Szeged; 1636 newborns (3272 hips) had clinical examinations and hip ultrasound by the Graf method within the1st 3 days of life. Prevalence of DDH, risk factors, sensitivity and specificity of clinical examinations were evaluated.
Results: At the 1st US, 70 of the examined 3272 hips (2.14%) were found to be positive. According to Graf categories, the following distribution was observed: type II C, 21 hips (30.0%); D, 24 hips (34.28%); III, 24 hips (34.28%); IV, 1 hip (1.44%). Regarding the risk factors, female gender, breech presentation and positive family history proved to be significant. Interestingly, 28 (50.90%) of the 55 newborns with DDH had neither positive physical signs nor any risk factors, except being female. The physical examination was calculated for sensitivity (20.0%) and specificity (98.34%).
Conclusions: In our 1-year period study, 50.9% of the newborns with DDH had neither any positive physical signs nor any risk factors, except being a female. In contrast, early universal US screening of the hip facilitated to diagnose all cases with hip dysplasia. Hip sonography is an effective mode of prevention in orthopaedics, however further studies are needed to compare the rates of operative procedures in selective versus universal screening models.
文献出处：Zita Gyurkovits, Gellért Sohár, Anna Baricsa, Gábor Németh, Hajnalka Orvos, Beat Dubs. Early detection of developmental dysplasia of hip by ultrasound. Hip Int. 2021 May;31(3):424-429. doi: 10.1177/1120700019879687. Epub 2019 Sep 30.
文献3
在治疗稳定性髋关节发育不良时再次超声检查的时机
译者：肖凯
Pavlik吊带常用于婴儿发育性髋关节发育不良（developmental dysplasia of the hip，DDH）的治疗，其具有较高的治疗有效率，但较长时间的佩戴也可能导致股骨头骺坏死及骨神经麻痹等并发症。全球范围内，Pavlik吊带对于6个月以内稳定性DDH患儿的治疗持续时间存在很大差异。主流认为在治疗后的12周进行复查超声。为了明确缩短治疗后首次超声检查的时间是否会缩短整体的治疗时间，以及这是否影响1岁时的放射学预后，同时也为了调查了患儿1岁时髋臼指数较高的预测因素。
Wesley等进行了一项回顾性研究，对2015年至2017年间诊断及治疗的222名稳定性DDH（Graf IIb和IIc）患儿进行了研究。他们将患儿分为两组：第一组在使用Pavlik吊带治疗12周后进行常规超声检查，第二组则在Pavlik吊带治疗6周后进行超声检查。之后两组患儿均继续Pavlik吊带治疗，并每6周进行一次常规超声检查，直至超声显示髋关节形态正常才停止治疗。在患儿1岁时进行骨盆正位X线片检查，并根据Tönnis分级评估残余畸形。
第一组患儿Pavlik吊带治疗的中位时间为12周（四分位间距为11.9至12.3周），而第二组治疗中位时间为6.1周（四分位间距为6.0至7.5周）（P <0.001）。第一组中有20名患儿（16.8％）1岁时发现有残余发育不良，而第二组中有11名患儿（10.7％）有残余发育不良（P = 0.189）。多变量预测模型显示，DDH家族史和较低的α角与1岁时X线片上显示较高的髋臼指数相关。作者认为，可以将稳定性DDH患儿接受Pavlik吊带治疗后的首次超声检查时间由12周安全地调整至6周，这样可以缩短总的治疗时间，使患儿及家庭受益。
Timing of Repeat Ultrasound Examination in Treatment of Stable Developmental Dysplasia of the Hip
Background: Worldwide a wide variation exists in duration of Pavlik harness treatment for infants up to 6 months with stable developmental dysplasia of the hip (DDH). The purpose of this study was to evaluate whether shortening the time to first routine follow-up ultrasound after initiation of Pavlik harness treatment would reduce treatment duration and whether this influenced radiologic outcome at 1 year of age. Furthermore, predictors of higher acetabular index (AI) at 1 year of age were investigated.
Methods: A retrospective study was conducted in infants with stable DDH (Graf IIb and IIc) diagnosed and treated between 2015 and 2017. Two groups were identified: first routine follow-up ultrasound at 12 weeks after Pavlik harness initiation (group I) and first routine follow-up ultrasound at 6 weeks after Pavlik harness initiation (group II). In both groups, treatment was continued until repeat ultrasound measurements (every 6 wk) showed a normalized hip. Radiologic outcome at 1 year of age was defined as residual dysplasia measured on an anteroposterior hip radiograph according to the Tönnis table.
Results: A total of 222 infants were included. The median time of Pavlik harness treatment was 12 weeks (interquartile range, 11.9 to 12.3) in group I compared with 6.1 weeks (interquartile range, 6.0 to 7.5) in group II (P<0.001). Residual dysplasia at 1 year of age was detected in 20 infants (16.8%) in group I compared with 11 infants (10.7%) in group II (P=0.189). The multivariable prediction model showed that positive family history and lower baseline alpha angle correlate with a higher AI at 1 year of age.
Conclusions: First routine follow-up ultrasound can be safely brought forward from 12 to 6 weeks after Pavlik harness initiation. Furthermore, infants with a positive family history for DDH and an initial low alpha angle are at higher risk to have a higher AI at 1 year of age.
文献出处：Theunissen WWES, van der Steen M, van Douveren FQMP, Witlox AMA, Tolk JJ. Timing of Repeat Ultrasound Examination in Treatment of Stable Developmental Dysplasia of the Hip. J Pediatr Orthop. 2021 Apr 1;41(4):203-208. doi: 10.1097/BPO.0000000000001766. PMID: 33655899; PMCID: PMC8048726.
文献4
3-D超声评估婴幼儿发育性髋关节发育不良的可靠性
译者：张振东
发育性髋关节发育不良(Developmental dysplasia of the hip,DDH)在婴幼儿髋关节疾患中最为常见，包括轻度髋关节发育不良以及不同程度的髋关节脱位。目前二维超声在婴幼儿DDH筛查中广泛应用，虽然测量简便易行，但其结果可变性大，即多次测量可能存在较大的差异性。本文作者在2018年曾对二维超声测量DDH指标α角进行系统评价，结果显示测量指标α角存在7°标准差。测量结果的不准确会误导临床决策：不早期治疗会延误最佳治疗时机而需要接受昂贵且创伤大的截骨手术；过度治疗则可能导致股骨头坏死、髋关节生物力学异常等并发症。因此选择可靠性高的DDH超声筛查方法至关重要。
针对这个问题，加拿大不列颠哥伦比亚大学Quader N等人对使用三维超声获取的DDH指标进行分析，并与二维指标比较，验证了三维B超测量指标可重复性高的特点。引人注目的是，作者提出了自动化获取三维测量数据得方法。首先由计算机在各测量层面中去除非骨性结构干扰，提取三维骨性边界，并确定出同时包含髂骨的垂直皮质层及髋臼顶的层面，三维重建股骨头后通过函数公式计算出相应的DDH指标。
作者使用该方法获取了25例婴幼儿（40例髋）的三维B超测量数据，包括α角及股骨头覆盖率，同时还进行了二维超声的常规测量。结果显示，三维B超测量的α角及股骨头覆盖率均较二维数据更为可靠，其测量易变性分别较二维数据降低75%、65%。因此更推荐使用3D超声进行DDH筛查，以使测量更加规范和准确。
3-D Ultrasound Imaging Reliability of Measuring Dysplasia Metrics in Infants
Developmental dysplasia of the hip is a hip abnormality that ranges from mild acetabular dysplasia to irreducible femoral head dislocations. While 2-D B-mode ultrasound (US)-based dysplasia metrics or disease metrics are currently used clinically to diagnose developmental dysplasia of the hip, such estimates suffer from high inter-exam variability. In this work, we propose and evaluate 3-D US-derived dysplasia metrics that are automatically computed and demonstrate that these automatically derived dysplasia metrics are considerably more reproducible. The key features of our automatic method are (i) a random forest-based learning technique to remove regions across the coronal axis that do not contain bone structures necessary for dysplasia-metric extraction, thereby reducing outliers; (ii) a bone segmentation method that uses rotation-invariant and intensity-invariant filters, thus remaining robust to signal dropout and varying bone morphology; (iii) a novel slice-based learning and 3-D reconstruction strategy to estimate a probability map of the hypoechoic femoral head in the US volume; and (iv) formulae for calculating the 3-D US-derived dysplasia metrics. We validate our proposed method on real clinical data acquired from 40 infant hip examinations. Results show a considerable (around 70%) reduction in variability in two key 3-D US-derived dysplasia metrics compared with their 2-D counterparts.
文献出处：Quader N, Hodgson AJ, Mulpuri K, Cooper A, Garbi R. 3-D Ultrasound Imaging Reliability of Measuring Dysplasia Metrics in Infants. Ultrasound Med Biol. 2021 Jan;47(1):139-153. doi: 10.1016/j.ultrasmedbio.2020.08.008. Epub 2020 Oct 24. PMID: 33239155.
文献5
DDH早期筛查早期诊断的重要性
译者：任宁涛
髋关节超声筛查可分为普遍性筛查和选择性筛查，普遍性筛查是对所有的新生儿就行髋关节检查，选择性筛查仅对有危险因素的新生儿进行髋关节超声检查，由于澳大利亚采用的是选择性髋关节筛查，因此其晚期DDH发生率逐年递增，来自悉尼韦斯特米德儿童医院骨科的Justine St George等通过对DDH早期和晚期诊断随访5年后的影像学结果进行比较，旨在强调早期普遍性筛查的必要性。
Justine St George等人对2000年至2010年就诊患有髋关节脱位的患儿进行了病例对照研究，总共纳入115名患儿，按照诊断时间和治疗方式分为三组：早期诊断并行Pavlik吊带治疗组（SP），早期诊断未行Pavlik吊带治疗组（FP）和晚期诊断组（LD），随访时间不短于4年。
结果发现晚期诊断组（LP）需要切开复位、髋臼截骨和股骨近端截骨的概率明显增加（P < 0.001），并且有很高的生长紊乱率，可高达46.3%（P < 0.001），早期诊断未行Pavlik吊带治疗组（FP）为20.6%，早期诊断并行Pavlik吊带治疗组（SP）为5%。随访影像学结果发现早期诊断并行Pavlik吊带治疗组（SP）优良率为100%，早期诊断未行Pavlik吊带治疗组（FP）为79.4%，晚期诊断组（LP）为58.5%。
选择性髋关节超声筛查可导致较高的晚期DDH发生率，虽然晚期DDH随访的影像学结果尚可接受，但是大部分后期需进行手术干预，并且可导致较高的生长紊乱率，因此普遍性髋关节筛查是非常重要的。
图1 早期诊断并行Pavlik吊带治疗组（SP），早期诊断未行Pavlik吊带治疗组（FP）和晚期诊断组（LD）影像学结果，采用改良Severin分型。
图2 晚期诊断DDH病例，2岁时才诊断为DDH，13岁时影像学检查可见左髋生长紊乱，残余发育不良。
Importance of early diagnosis for developmental dysplasia of the hip: A 5-year radiological outcome study comparing the effect of early and late diagnosis
Aim: Australia utilises a selective ultrasound screening programme. The rate of late diagnosis of developmental dysplasia of the hip (DDH) in Australia is increasing. The aim of this study is to quantify the treatment required and compare the 5-year radiological outcomes between early and late diagnosis in children with DDH with frank dislocation.
Methods: We performed a case-matched control study of children with frank DDH dislocations from 2000 to 2010 comparing three groups: children with an early diagnosis successfully treated in a Pavlik harness (SP), children with an early diagnosis who failed Pavlik harness treatment (FP) and children with a late diagnosis (LD). Minimum follow-up was 4 years.
Results: A total of 115 hips were included. Patients in the LD group required significantly more open reductions (P < 0.001), acetabular osteotomies (P < 0.001) and femoral osteotomies (P < 0.001). LD was also associated with significantly higher rates of growth disturbance at 46.3%, compared to 20.6% in the FP group and 5% in the SP group (P < 0.001). Overall, there were excellent radiological outcomes in 58.5% of the LD group compared to 79.4% in the FP group and 100% in the SP group.
Conclusion: In Australia, high rates of LD in DDH persist in the context of selective ultrasound screening. While good radiological outcomes are achievable, a significantly greater level of surgical intervention is required and this is associated with significantly higher rates of growth disturbance. Optimisation of screening in Australia is vital.
文献出处：St George J, Kulkarni V, Bellemore M, Little DG, Birke O. Importance of early diagnosis for developmental dysplasia of the hip: A 5-year radiological outcome study comparing the effect of early and late diagnosis. J Paediatr Child Health. 2021 Jan;57(1):41-45. doi: 10.1111/jpc.15111. Epub 2020 Aug 9. PMID: 32772467.
文献6
儿童髋关节超声：检查的不确定性和治疗的选择
译者：张利强
先天性髋脱位的发病率为0.5%~1%。早期诊断和治疗可显著降低长期并发症。Graf超声为早期DDH诊断的重要辅助检查。在德国，新生儿在出生后4至5周由会诊医生采用Graf方法进行髋关节超声检查，如果有任何不确定因素则转诊到专门的骨科。但在日常诊疗过程中我们发现有越来越多的儿童因为髋关节发育不良来就诊咨询，但使用外展支具和和石膏固定的患儿似乎没有增加。本研究评估了门诊超声筛查的质量和转诊儿童的治疗要求。
回顾性分析2016年4月至2019年4月期间进行会诊的384例新生儿资料。共有74%（n=284）的新生儿髋关节为Ia/b型。32%（n=122）的病例需要治疗（外展支具或石膏）。治疗时长与初次诊断的年龄显著相关（Pearson's r=0.678；p=0.001）。初次确诊年龄>200天患儿的治疗时长是初次确诊年龄为100天患儿的两倍。有公共健康保险的病人需要由会诊医师转诊。在转诊诊断为发育性髋关节发育不良的患儿中，64%（n=132）的患儿再次检查时证实为正常髋关节。在有公共健康保险的儿童中，97%（n=200）儿童通过儿科会诊医生转诊。
我们发现临床工作中使用和解释Graf超声检查方法的不足。在我们的再次检查中，共有64%的病理髋关节是正常髋关节。未来的工作目标应该是增加新生儿髋关节的解剖学知识，并确保正确使用Graf超声方法。建议开展必要的高级培训课程。
带支架和探头导向系统的检查台；超声装置
Paediatric hip ultrasound: uncertainties in examination and choice of treatment
Purpose: In Germany, neonates undergo hip sonography examination using the Graf method during the routine U3 screening examination, performed by consultant physicians four to five weeks after birth, and are referred to specialized orthopaedic departments if there are any uncertainties. This study evaluated the quality of sonographic screening in the outpatient sector and the treatment requirements of referred children.
Methods: We performed a retrospective analysis of the patient data of 384 neonates collected in consultations performed between April 2016 and April 2019.
Results: In total, 74% (n = 284) of neonates presented a hip type Ia/b. Treatment (abduction brace or Fettweis cast) was required in 32% (n = 122) of cases. The treatment duration was significantly correlated with age at first presentation (Pearson's r = 0.678; p = 0.001). The treatment duration for patients aged > 200 days old at first presentation was twice as long as those aged 100 days at first presentation. Patients with public health insurance require referral by a consultant. Developmental dysplasia of the hip as referral diagnosis could not be confirmed in control examination in 64% (n = 132) of cases. Of the public health insured children, 97% (n = 200) were referred through a consultant paediatrician.
Conclusion: We identified deficits in performing and interpreting the Graf method of ultrasound examination. A total of 64% of referred pathological hips turned out to be physiological configurations in our control examination. The future goal should be to increase anatomical knowledge of the newborn hip and ensure the correct use of Graf ultrasound method. Advanced training courses are recommended and necessary.
文献出处：Bucher F, Görg C, Weber S, Peterlein CD. Paediatric hip ultrasound: uncertainties in examination and choice of treatment. J Child Orthop. 2021 Feb 1;15(1):42-47. doi: 10.1302/1863-2548.15.200084. PMID: 33643457; PMCID: PMC7907771.