髋膝关节文献精译荟萃（第167期）
本期目录：
1、采用 CR假体结合高匹配胫骨垫片的Persona假体的TKA术后的步态及效果
2、美国人工髋关节翻修调查
3、抗生素骨水泥与初次骨水泥型全膝关节置换术后翻修风险降低有关:使用国家关节登记处数据对731,214例患者的分析
4、综述：髋膝关节置换术后的静脉血栓栓塞预防措施新进展
5、全膝关节翻修术中多孔干骺端袖套和钽金属柄锥的无菌性松动：系统评价
6、单间室置换与全膝关节置换术的病人相关结果：系统回顾和荟萃分析
7、三分法能充分检测髋臼覆盖不足和过度吗?
8、髋关节发育不良患者关节镜手术失败的放射影像学预测因素的多中心研究：注意 Tönnis 角
9、评估发育性髋关节发育不良儿童的父母无症状发育不良的风险
10、印度襁褓方法调查：关于儿科医生、护士和婴儿护理员襁褓方法的调查
11、手术时年龄不能预测髋臼周围截骨术后患者早期报告结果
12、诊断性髋关节注射后的效果
13、髋臼周围截骨术后体能测试与患者报告的结果相关：一项前瞻性研究
第一部分：关节置换及保膝相关文献
文献1
采用 CR假体结合高匹配胫骨垫片的
Persona假体的TKA术后的步态及效果
译者：张轶超
背景：对于治疗晚期症状性膝骨关节炎，全膝关节置换（TKA）是一个可靠的方法。目前，在临床上应用的不同设计类型的假体显示出了相似的临床效果。假体表面几何形状的改进是为了获得更好的效果。本文的目的是观察两种不同的胫骨垫片（CR胫骨垫片Persona CR和高匹配胫骨垫片Persona UC）(Zimmer-Biomet, Warsaw, IN)在术后功能效果方面的差异。
方法：本研究为前瞻性单盲随机对照研究，有105名（66名女性和39名男性）同时行双侧TKA的患者被纳入，均采用Persona假体(Zimmer-Biomet)，一侧膝关节采用CR垫片而另一侧采用UC垫片。由一位不了解分组的评估员定期对患者的功能和步态进行评估。采用西安大略和麦克马斯特大学骨关节炎指数（WOMAC）和改良膝关节协会评分（mKSS）对膝关节功能进行评估。使用足的蹬舵力和步长来评估步态。
结果：研究期间没有病例失访及做了翻修手术。所有105名患者术后6个月、1年和2年时的WOMAC评分、mKSS评分及关节活动度与术前比较，UC组均存在统计学上的优势(P < .05)。但是在术后2年时，在步态方面两组间没有显著性差异。
结论：在术后2年时，UC垫片较CR垫片存在更好的功能效果。但是，本研究发现在步态上两组并没有明显差异。
Gait Parameters and Functional Outcomes After Total Knee Arthroplasty Using Persona Knee System With Cruciate Retaining and Ultracongruent Knee Inserts
Background: Total knee arthroplasty is a well-established treatment for managing end-stage symptomatic knee osteoarthritis. Currently, different designs of prostheses are available with majority ensuring similar clinical outcomes. Altered surface geometry is introduced to strive toward gaining superior outcomes. We aimed to investigate any differences in functional outcomes between 2 different polyethylene designs namely the Persona CR (cruciate retaining) and Persona UC (ultracongruent) tibial inserts (Zimmer-Biomet, Warsaw, IN).
Methods: This prospective single blind, single-surgeon randomized controlled trial reports on 105 patients, (66 female and 39 male), who underwent simultaneous bilateral total knee arthroplasty using the Persona knee system (Zimmer-Biomet) UC inserts in one side and CR inserts in the contralateral side. By a blind assessor, at regular time intervals patients were assessed in terms of function and gait. The functional knee scoring scales used were the Western Ontario and McMaster Universities Osteoarthritis Index and Modified Knee Society Score. The gait parameters evaluated were foot pressure and step length.
Results: During the study period, no patient was lost to follow-up or underwent revision surgery for any cause. Western Ontario and McMaster Universities Osteoarthritis Index scores, Modified Knee Society Score, and knee range of motion of all 105 patients assessed preoperatively and postoperatively at 6 months, 1 year, and 2 years showed statistically better results (P < .05) for UC inserts. Gait analysis measuring foot pressures and step length, however, did not show any statistically significant differences at 2-year follow-up.
Conclusion: Ultracongruent tibial inserts show significantly better functional outcomes as compared to CR inserts during a 2-year follow-up period. However, in this study these findings were not shown to be attributed to differences in gait parameters.
文献出处：Rajgopal A, Aggarwal K, Khurana A, Rao A, Vasdev A, Pandit H. Gait Parameters and Functional Outcomes After Total Knee Arthroplasty Using Persona Knee System With Cruciate Retaining and Ultracongruent Knee Inserts. J Arthroplasty. 2017 Jan;32(1):87-91. doi: 10.1016/j.arth.2016.06.012. Epub 2016 Jun 23. PMID: 27436502.
文献2
美国人工髋关节翻修调查
译者：罗殿中
背景：深入了解人工髋关节失败翻修的原因和类型对今后研究方向、假体设计、临床决策及保健政策都有重要意义。本文基于新近执行的ICD-9-CM编码系统（国际疾病分类，第九版，临床版）、对美国诊断和手术编码为髋关节翻修的大样本、全美范围的病例进行研究，明确髋关节置换失败机制、和翻修的类型。
方法：利用全美健康消费与应用病案系统，对2005年10月1日至2006年12月31日进行的51345例髋关节翻修病例的临床资料、人口学特征、和经济数据进行分析。根据美国人口学亚群，对年龄、性别、诊断、人口区域、一级支付方、医院类别等进行分层分析，对不同类型的髋置换失败原因、住院时间、总费用等进行汇总。
结果：髋关节翻修中最常见的手术类型是所有部件的全翻修（41.1%），最常见的翻修原因是不稳/脱位（22.5%），机械松动（19.7%），和感染（14.8%）。翻修手术最常应用于75-84岁、有医保、大型城区非教学医院。所有类别的髋关节翻修平均住院时间为6.2天，平均总费用为54553美元。然而，平均住院时间、平均总费用、手术频次等随不同的人口区域、医院类别、翻修手术类型有较大差异。
结论：在美国，髋关节不稳和机械性松动是髋关节翻修的主要原因；随着对髋关节翻修相关的新的疾病诊断与手术编码系统的应用，这些信息对今后的研究方向、假体设计、和临床决策等具有重要意义。
表1. ICD-9-CM与髋关节翻修相关的诊断和手术分类，2005年10月1日启用
|
ICD-9-CM诊断编码 |
ICD-9-CM手术编码 |
|
996.41关节假体机械性松动 996.42关节假体脱位 996.43假体关节部件失效/破裂 996.44关节假体周围骨折 996.45关节假体周围骨溶解 996.46关节假体表面磨损 996.47其它关节假体机械并发症 |
00.70髋臼与股骨柄假体均翻修 00.71髋臼侧翻修（包括股骨头） 00.72股骨侧翻修（包括臼衬） 00.73仅翻修股骨头/臼衬 84.56植入骨水泥占位器 84.57取出骨水泥占位器 |
The epidemiology of revision total hip arthroplasty in the United States
Background: Understanding the causes of failure and the types of revision total hip arthroplasty performed is essential for guiding research, implant design, clinical decision-making, and health-care policy. The purpose of the present study was to evaluate the mechanisms of failure and the types of revision total hip arthroplasty procedures performed in the United States with use of newly implemented ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis and procedure codes related specifically to revision total hip arthroplasty in a large, nationally representative population.
Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was used to analyze clinical, demographic, and economic data from 51,345 revision total hip arthroplasty procedures performed between October 1, 2005, and December 31, 2006. The prevalence of revision procedures was calculated for population subgroups in the United States that were stratified according to age, sex, diagnosis, census region, primary payer class, and type of hospital. The cause of failure, the average length of stay, and total charges were also determined for each type of revision arthroplasty procedure.
Results: The most common type of revision total hip arthroplasty procedure performed was all-component revision (41.1%), and the most common causes of revision were instability/dislocation (22.5%), mechanical loosening (19.7%), and infection (14.8%). Revision total hip arthroplasty procedures were most commonly performed in large, urban, nonteaching hospitals for Medicare patients seventy-five to eighty-four years of age. The average length of hospital stay for all types of revision arthroplasties was 6.2 days, and the average total charges were $54,553. However, the average length of stay, average charges, and procedure frequencies varied considerably according to census region, hospital type, and type of revision total hip arthroplasty procedure performed.
Conclusions: Hip instability and mechanical loosening are the most common indications for revision total hip arthroplasty in the United States. As further experience is gained with the new diagnosis and procedure codes specifically related to revision total hip arthroplasty, this information will be valuable in directing future research, implant design, and clinical decision-making.
文献出处：Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009 Jan;91(1):128-33. doi: 10.2106/JBJS.H.00155. PMID: 19122087.
文献3
抗生素骨水泥与初次骨水泥型全膝关节置换
术后翻修风险降低有关:使用国家
关节登记处数据对731,214例患者的分析
译者：马云青
研究目的: 抗生素骨水泥(ALBCs)可以在关节置换术后早期预防细菌生物膜形成从而提供保护作用。ALBC在髋关节置换术中应用已被广泛接受，但在全膝关节置换术(TKA)中应用仍缺乏证据。本研究的目的是评价ALBC在大样本量TKA患者中的应用结果。
材料和方法: 2003年3月至2016年7月期间，从英格兰和威尔士国家联合关节置换登记系统(NJR)获得的所有初次骨水泥型TKA的数据，包括患者自身相关因素、假体植入物和手术相关变量。采用 Cox 风险模型评估ALBC对翻修风险的影响。采用体重指数(BMI)的数据对患者进一步的分组分析。
结果: 731,214例TKA中，普通水泥15295例(2.1%) ，ALBC 715919例(97.9%)。13391例术后翻修，感染原因2391例。在对其他变量进行调整后，ALBC对任何原因的导致翻修的风险都显著降低(HR 0.85, 95%CI 0.77-0.93; p<0.001)。ALBC与所有无菌原因导致的翻修风险(HR 0.85,95% CI 0.77-0.95; p<0.001)和感染翻修风险(HR 0.84,95% CI 0.67-1.01; p= 0.06)降低相关。当以BMI分组进行分析时，结果是相似的。在研究中，如果外科医生在整个研究期间只使用ALBC将被排除。ALBC组患者假体10年生存率为96.3% (95% CI 96.3-96.4)，普通水泥组假体10年生存率为95.5% (95% CI为95.0-95.9)。在人口水平上分析，如果每年100,000 TKA，这个差异意味着在ALBC组10年内减少了870次翻修。
结论: ALBC在基于全国登记系统的初次骨水泥型膝关节置换术的数据中显著降低了翻修的风险。同时使用ALBC并不会增加中期假体失败率。
Antibiotic-loaded bone cement is associated with a lower risk of revision following primary cemented total knee arthroplasty: an analysis of 731,214 cases using National Joint Registry data
Aims: Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients.
Materials and methods: Data from the National Joint Registry (NJR) of England and Wales were obtained for all primary cemented TKAs between March 2003 and July 2016. Patient, implant, and surgical variables were analyzed. Cox proportional hazards models were used to assess the influence of ALBC on risk of revision. Body mass index (BMI) data were available in a subset of patients.
Results: Of 731 214 TKAs, 15 295 (2.1%) were implanted with plain cement and 715 919 (97.9%) with ALBC. There were 13 391 revisions; 2391 were performed for infection. After adjusting for other variables, ALBC had a significantly lower risk of revision for any cause (hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77 to 0.93; p < 0.001). ALBC was associated with a lower risk of revision for all aseptic causes (HR 0.85, 95% CI 0.77 to 0.95; p < 0.001) and revisions for infection (HR 0.84, 95% CI 0.67 to 1.01; p = 0.06). The results were similar when BMI was added into the model, and in a subanalysis where surgeons using only ALBC over the entire study period were excluded. Prosthesis survival at ten years for TKAs implanted with ALBC was 96.3% (95% CI 96.3 to 96.4) compared with 95.5% (95% CI 95.0 to 95.9) in those implanted with plain cement. On a population level, where 100 000 TKAs are performed annually, this difference represents 870 fewer revisions at ten years in the ALBC group.
Conclusion: After adjusting for a range of variables, ALBC was associated with a significantly lower risk of revision in this registry-based study of an entire nation of primary cemented knee arthroplasties. Using ALBC does not appear to increase midterm implant failure rates.
文献出处：Jameson SS, Asaad A, Diament M, Kasim A, Bigirumurame T, Baker P, Mason J, Partington P, Reed M. Antibiotic-loaded bone cement is associated with a lower risk of revision following primary cemented total knee arthroplasty: an analysis of 731,214 cases using National Joint Registry data. Bone Joint J. 2019 Nov;101-B(11):1331-1347. doi: 10.1302/0301-620X.101B11.BJJ-2019-0196.R1. PMID: 31674244.
文献4
综述：髋膝关节置换术后的静脉血栓
栓塞预防措施新进展
译者：张蔷
选择静脉血栓栓塞（VTE）的预防措施是在效力与安全性之间寻求平衡。我们的目标是在尽可能降低出血风险的基础上预防系统性静脉血栓栓塞。
VTE的最佳预防方法并没有最终定论。美国胸科医师协会（ACCP）的指南推荐：全髋或全膝关节置换术后，患者接受10-14天的至少一种以下预防措施的治疗：阿司匹林、维生素K拮抗剂、阿哌沙班、达比加群、磺达肝癸钠、低分子肝素、低剂量普通肝素、利伐沙班或便携式肢体加压装置。
由于其高效、口服剂型无需监测的优势，阿司匹林在近十年间获得越来越广泛的应用。但其真正的效力需要未来多中心大样本量随机对照试验的结果来验证。
为每位患者选择最安全有效VTE预防措施的关键是规范化的风险分级制度。而最佳的风险分级方法也没有定论，因此选择哪一种方法应该由医生和患者进行共同决策，平衡出血与血栓的风险。
房颤并正在接受长期华法林或其他口服抗凝药治疗的患者应在停药3-5天后手术。而无需在术前对患者进行特殊的过渡治疗。
Venous Thromboembolic Prophylaxis After Total Hip and Knee Arthroplasty
The selection of an agent for prophylaxis against venous thromboembolism (VTE) is a balance between efficacy and safety. The goal is to prevent symptomatic VTE while limiting the risk of bleeding.
The optimal agent for VTE prophylaxis has not been identified. The American College of Chest Physicians guidelines recommend that, after total hip or total knee arthroplasty, patients receive at least 10 to 14 days of 1 of the following prophylaxis agents: aspirin, adjusted-dose vitamin K antagonist, apixaban, dabigatran, fon-daparinux, low-molecular-weight heparin, low-dose unfractionated heparin, rivaroxaban, or portable home mechanical compression.
The use of aspirin for VTE prophylaxis has increased in popularity over the past decade because it is effective, and it is an oral agent that does not require monitoring. The true efficacy of aspirin needs to be determined in multicenter randomized clinical trials.
Validated risk stratification protocols are essential to identify the safest and most effective regimen for VTE prophylaxis for individual patients. There is no consensus regarding the optimal method for risk stratification; the selection of a prophylaxis agent should be determined by shared decision-making with the patient to balance the risk of thrombosis versus bleeding.
Patients with atrial fibrillation being treated with chronic warfarin therapy or direct oral anticoagulants should stop the agent 3 to 5 days prior to surgery. Patients do not typically require bridging therapy prior to surgery.
文献出处：Lieberman JR, Bell JA. Venous Thromboembolic Prophylaxis After Total Hip and Knee Arthroplasty. J Bone Joint Surg Am. 2021 Jun 16. doi: 10.2106/JBJS.20.02250. Epub ahead of print. PMID: 34133395.
文献5
全膝关节翻修术中多孔干骺端袖套和
钽金属柄锥的无菌性松动：系统评价
译者：沈松坡
骨缺损是全膝关节翻修术(TKA)的常见并发症。干骺端骨缺损的处理各不相同，没有明显的优越技术。处理干骺端缺损的两种常用方法包括多孔涂层干骺端袖套和钽金属柄锥。我们根据系统评价和meta分析的国际首选报告项目(PRISMA)准则进行了系统评价。根据PRISMA的建议，我们在多个数据库中将搜索词“全膝关节置换术”和/或“袖套”、“柄锥”作为关键词或医学主题标题(MeSH)词表。所有检索到的文章均采用明确的纳入和排除标准进行评审和评估。共纳入27项翻修TKA的研究(12项使用袖套和15项使用钽金属柄锥)。在12项关于TKA翻修术使用袖套植入的研究中，1025例患者的1133例翻修TKA中植入了1617个袖套。再手术的总发生率为110/ 1133(9.7%)，每个袖套无菌性松动的总发生率为13/ 1617(0.8%)。在15项TKA翻修中植入钽金属柄锥的研究中，612例患者的620例翻修TKA中植入了701个钽金属柄锥。再次手术的总发生率为116/620(18.7%)，钽金属柄锥无菌性松动的总发生率为12/701(1.7%)。两种假体组件的无菌性松动率相似，而使用钽金属柄锥的翻修TKA其再手术率几乎是使用袖套的两倍。所选研究的可变性和可能的失败的多因素性质不允许做出任何确定的结论。这篇综述阐明了补充文献检查翻修TKA植入物种类的必要性。
Aseptic Loosening of Porous Metaphyseal Sleeves and Tantalum Cones in Revision Total Knee Arthroplasty: A Systematic Review
Bone loss often complicates revision total knee arthroplasty (TKA). Management of metaphyseal defects varies, with no clearly superior technique. Two commonly utilized options for metaphyseal defect management include porous-coated metaphyseal sleeves and tantalum cones. A systematic review was conducted according to the international Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We combined search terms 'Total knee arthroplasty' AND/OR 'Sleeve,' 'Cone' as either keywords or medical subject heading (MeSH) terms in multiple databases according to PRISMA recommendations. All retrieved articles were reviewed and assessed using defined inclusion and exclusion criteria. A total of 27 studies (12 sleeves and 15 cones) of revision TKAs were included. In the 12 studies on sleeve implantation in revision TKAs, 1,617 sleeves were implanted in 1,133 revision TKAs in 1,025 patients. The overall rate of reoperation was 110/1,133 (9.7%) and the total rate of aseptic loosening per sleeve was 13/1,617 (0.8%). In the 15 studies on tantalum cone implantation in revision TKAs, 701 cones were implanted into 620 revision TKAs in 612 patients. The overall rate of reoperation was 116/620 (18.7%), and the overall rate of aseptic loosening per cone was 12/701 (1.7%). Rates of aseptic loosening of the two implants were found to be similar, while the rate of reoperation was nearly double in revision TKAs utilizing tantalum cones. Variability in the selected studies and the likely multifactorial nature of failure do not allow for any definitive conclusions to be made. This review elucidates the necessity for additional literature examining revision TKA implants.
文献出处：Roach RP, Clair AJ, Behery OA, Thakkar SC, Iorio R, Deshmukh AJ. Aseptic Loosening of Porous Metaphyseal Sleeves and Tantalum Cones in Revision Total Knee Arthroplasty: A Systematic Review. J Knee Surg. 2020 Feb 19. doi: 10.1055/s-0040-1701434. Epub ahead of print. PMID: 32074656.
文献6
单间室置换与全膝关节置换术的病人相关结果：
系统回顾和荟萃分析
译者：张峻
目的：将关于单间室膝关节置换术（UKA）和全膝关节置换术（TKA）已发表文献数据进行清晰的和全面的分析总结，把对于病人和医生都认为重要的功能结果进行对比，以便能够做出明智的决策。
设计：对随机对照实验，全国数据库或关节注册中心和大型队列研究系统综述。
数据来源：时间限定为1997年1月至2018年12月31日，在Medline, Embase, Cochrane对照实验注册(CENTRAL)和 Clinical Trials.gov搜索。
选择研究的纳入标准：过去20年比较成人初次UKA和TKA功能结果已发表的研究。排除少于50例病例的研究和不是英文的研究。
结果：将符合条件的60项研究分为3个方法学组：7篇文献来自6项随机对照试验、17项全国关节注册中心和全国数据库研究，以及36项队列研究。由于数据水平不同，每项结果都不同，并且研究结果并不总是有显著性。三组分析显示UKA较TKA住院时间更短（分别为-1.20天（95%CI 1.67至-0.73），-1.43（-1.53至-1.33），-1.73（-2.30至-1.16））。根据病人报告的结果测量（PROMs），疼痛无显著差异，但两个非试验组UKA的功能性PROM评分明显优于TKA（平均差异分别为-0.58（-0.88至-0.27）和-0.32（-0.48至-0.15））。关于主要并发症，试验和队列研究没有显著结果，但TKA后的死亡率在注册中心和大型数据库研究中显著较高（风险比为0.27（0.16至0.45）），静脉血栓栓塞事件（0.39（0.27至0.57））和主要心脏事件（0.22（0.06至0.86））也是如此。无论何种原因，TKA术后早期再手术率均高于UKA术后，但在所有三个研究组中，UKA术后5年的翻修率仍然较高（风险比分别为5.95（1.29-27.59）、2.50（1.77-3.54）和3.13（1.89-5.17））。
结论：对于局限在单间室的膝关节骨关节炎，TKA和UKA都是切实可行的方案。通过直接比较两种治疗方法，本研究显示UKA在好几方面有更佳的结果。但是，TKA被翻修的风险较低。这些信息应该作为选择治疗方案共同决策过程的一部分提供给病人。
Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis
Objective: To present a clear and comprehensive summary of the published data on unicompartmental knee replacement (UKA) or total knee replacement (TKA), comparing domains of outcome that have been shown to be important to patients and clinicians to allow informed decision making.
Design: Systematic review using data from randomised controlled trials, nationwide databases or joint registries, and large cohort studies.
Data sources: Medline, Embase, Cochrane Controlled Register of Trials (CENTRAL), and Clinical Trials.gov, searched between 1 January 1997 and 31 December 2018.
Eligibility criteria for selecting studies: Studies published in the past 20 years, comparing outcomes of primary UKA with TKA in adult patients. Studies were excluded if they involved fewer than 50 participants, or if translation into English was not available.
Results: 60 eligible studies were separated into three methodological groups: seven publications from six randomised controlled trials, 17 national joint registries and national database studies, and 36 cohort studies. Results for each domain of outcome varied depending on the level of data, and findings were not always significant. Analysis of the three groups of studies showed significantly shorter hospital stays after UKA than after TKA (-1.20 days (95% confidence interval -1.67 to -0.73), -1.43 (-1.53 to -1.33), and -1.73 (-2.30 to -1.16), respectively). There was no significant difference in pain, based on patient reported outcome measures (PROMs), but significantly better functional PROM scores for UKA than for TKA in both non-trial groups (mean difference -0.58 (-0.88 to -0.27) and -0.32 (-0.48 to -0.15), respectively). Regarding major complications, trials and cohort studies had non-significant results, but mortality after TKA was significantly higher in registry and large database studies (risk ratio 0.27 (0.16 to 0.45)), as were venous thromboembolic events (0.39 (0.27 to 0.57)) and major cardiac events (0.22 (0.06 to 0.86)). Early reoperation for any reason was higher after TKA than after UKA, but revision rates at five years remained higher for UKA in all three study groups (risk ratio 5.95 (1.29 to 27.59), 2.50 (1.77 to 3.54), and 3.13 (1.89 to 5.17), respectively).
Conclusions: TKA and UKA are both viable options for the treatment of isolated unicompartmental osteoarthritis. By directly comparing the two treatments, this study demonstrates better results for UKA in several outcome domains. However, the risk of revision surgery was lower for TKA. This information should be available to patients as part of the shared decision making process in choosing treatment options.
文献出处：Wilson HA, Middleton R, Abram SGF, Smith S, Alvand A, Jackson WF, Bottomley N, Hopewell S, Price AJ. Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis. BMJ. 2019 Feb 21;364:l352. doi: 10.1136/bmj.l352. Erratum in: BMJ. 2019 Apr 2;365:l1032. PMID: 30792179; PMCID: PMC6383371.
第二部分：保髋相关文献
文献1
三分法能充分检测髋臼覆盖不足和过度吗?
译者：程徽
背景：髋臼前覆盖和后覆盖的评估，对于选择正确的手术指征和预判保髋手术预后至关重要。前后覆盖的量化具有挑战性，需要特别的X线片、CT、MRI或特殊的测量软件，这些方法比较繁琐，不能广泛使用，或者会造成额外的辐射暴露。我们引入“三分法”作为一种有前途的替代方法，以提供一种更适用、更简单的方法来检测前后覆盖率过度或不足。该方法将前(后)壁在股骨头上的投影位置作为评判标准，内侧三分之一为不足，外侧三分之一为过度。
（本文所述的详细方法详见我们髋膝关节文献精粹144期）
问题/目的： 与之前建立的以Hip2Norm为金标准，用三分法检测(1)过度和(2)前后覆盖不足的有效性如何？检测指标包括曲线下面积[AUC]，敏感性，特异性，阳性/阴性似然比[LR(+)/LR(-)]，阳性/阴性预测值[PPV，NPV]。
方法：我们回顾性评估了2003年至2015年我们的机构数据库中所有因髋关节疼痛在我院住院并拟行保髋手术的患者。我们根据各自的髋臼前覆盖和后覆盖将研究组分为6个亚组，包括发育不良组、过度覆盖组、严重过度覆盖组、髋臼过度前倾组、髋臼后倾组、全髋臼后倾组。从该患者队列中随机选取161髋进行分析。使用Hip2Norm(一种已经验证过准确性的髋臼形态评估软件)确定髋臼前后覆盖。前、后壁指数在标准化的骨盆平片上测量，采用三分法。
图1 分组情况：A.发育不良组，B.过度覆盖组，C.严重过度覆盖组，D.髋臼过度前倾组，E.髋臼后倾组，F.全髋臼后倾组
结果：采用三分法检测髋臼前、后壁过度，AUC曲线下面积分别为0.945和0.933。采用三分法检测髋臼前后壁缺损，AUC曲线下面积分别为0.962和0.876。用三分法评估髋臼前后覆盖，特异性和阳性预测值较高，但敏感性和阴性预测值较低。
结论：我们发现当此髋臼前后壁位于外侧(内侧)三分之一时，髋臼壁过度(缺陷)的可能性很高，适合手术矫正。另一方面，如果髋臼前后壁不在外侧(内侧)三分之一，不能明确地排除髋臼壁的过度(缺陷)。因此，三分法特异性非常好，但敏感性差强人意。
Does the Rule of Thirds Adequately Detect Deficient and Excessive Acetabular Coverage?
Background: Assessment of AP acetabular coverage is crucial for choosing the right surgery indication and for obtaining a good outcome after hip-preserving surgery. The quantification of anterior and posterior coverage is challenging and requires either other conventional projections, CT, MRI, or special measurement software, which is cumbersome, not widely available and implies additional radiation. We introduce the 'rule of thirds' as a promising alternative to provide a more applicable and easy method to detect an excessive or deficient AP coverage. This method attributes the intersection point of the anterior (posterior) wall to thirds of the femoral head radius (diameter), the medial third suggesting deficient and the lateral third excessive coverage.
Question/purpose: What is the validity (area under the curve [AUC], sensitivity, specificity, positive/negative likelihood ratios [LR(+)/LR(-)], positive/negative predictive values [PPV, NPV]) for the rule of thirds to detect (1) excessive and (2) deficient anterior and posterior coverages compared with previously established radiographic values of under-/overcoverage using Hip2Norm as the gold standard?
Methods: We retrospectively evaluated all consecutive patients between 2003 and 2015 from our institutional database who were referred to our hospital for hip pain and were potentially eligible for joint-preserving hip surgery. We divided the study group into six specific subgroups based on the respective acetabular pathomorphology to cover the entire range of anterior and posterior femoral coverage (dysplasia, overcoverage, severe overcoverage, excessive acetabular anteversion, acetabular retroversion, total acetabular retroversion). From this patient cohort, 161 hips were randomly selected for analysis. Anterior and posterior coverage was determined with Hip2Norm, a validated computer software program for evaluating acetabular morphology. The anterior and posterior wall indices were measured on standardized AP pelvis radiographs, and the rule of thirds was applied by one observer.
Results: The detection of excessive anterior and posterior acetabular wall using the rule of thirds revealed an AUC of 0.945 and 0.933, respectively. Also, the detection of a deficient anterior and posterior acetabular wall by applying the rule of thirds revealed an AUC of 0.962 and 0.876, respectively. For both excessive and deficient anterior and posterior acetabular coverage, we found high specificities and PPVs but low sensitivities and NPVs.
Conclusion: We found a high probability for an excessive (deficient) acetabular wall when this intersection point lies in the lateral (medial) third, which would qualify for surgical correction. On the other hand, if this point is not in the lateral (medial) third, an excessive (deficient) acetabular wall cannot be categorically excluded. Thus, the rule of thirds is very specific but not as sensitive as we had expected.
文献出处：era M Stetzelberger, Angela M Moosmann, Guoyan Zheng, Joseph M Schwab, Simon D Steppacher, Moritz Tannast. Does the Rule of Thirds Adequately Detect Deficient and Excessive Acetabular Coverage? Clin Orthop Relat Res. 2021 May 1;479(5):974-987.
文献2
髋关节发育不良患者关节镜手术失败的放射影像学
预测因素的多中心研究：注意 Tönnis 角
译者：肖凯
背景：先前已证明髋关节镜是治疗成人轻度髋关节发育不良的有效方法。有许多影像学参数用于对髋关节发育不良进行分类，但迄今为止，很少有研究明确哪些参数对于预测手术预后最重要。
目的：确定与成人轻度髋关节发育不良关节镜治疗预后相关的术前影像学参数。
研究设计：病例对照研究；证据级别，3。
方法：对 2009 年至 2015 年间接受关节镜手术的轻度髋关节发育不良患者进行影像学分析。术前影像学测量包括外侧中心边缘角、Tönnis 角、颈干角、前中心边缘角、α 角、股骨头外排指数和髋臼深宽比。手术失败被定义为改良Harris髋关节评分未能达到最小临床重要差异 (MCID) 或需要二次手术。应用等方差 t 检验分析放射影像学参数，将P 值0.05确定统计显着性。
结果：共有 373 髋纳入分析，平均随访时间为 41 个月（范围，24-102 个月）。其中，46 髋（12%）需要二次手术，95 髋（25%）未达到 MCID。总失败率为 32.4%。没有单一的或组合测量指标与未达到 MCID 相关。术前较高的 Tönnis 角与二次手术相关，二次手术组的平均值为 6.7°（95% CI，5.3°-8.1°），而非二次手术组为 4.8°（95% CI，4.4°-5.3°）组（P = .006）。OR值为1.12（95% CI，1.0-1.2；P = .05）。在 Tönnis 角 >10° 的患者中，84% 需要二次手术。
结论：较高的 Tönnis 角预示着翻修手术的风险较高。Tönnis 角每增加 1 度，二次手术的概率就会增加 1.12 倍。在 Tönnis 角 >10° 的患者中，84% 需要二次手术。
A Multicenter Study of Radiographic Measures Predicting Failure of Arthroscopy in Borderline Hip Dysplasia: Beware of the Tönnis Angle
Background: Hip arthroscopy has been previously demonstrated to be an effective treatment for adult mild hip dysplasia. There are many radiographic parameters used to classify hip dysplasia, but to date few studies have demonstrated which parameters are of most importance for predicting surgical outcomes.
Purpose: To identify preoperative radiographic parameters that are associated with poor outcomes in the arthroscopic treatment of adult mild hip dysplasia.
Study design: Case-control study; Level of evidence, 3.
Methods: Radiographic analysis was performed in patients with mild hip dysplasia who underwent arthroscopic surgery between 2009 and 2015. Preoperative radiographic measurements included lateral center edge angle, Tönnis angle, neck shaft angle, anterior center edge angle, alpha angle, femoral head extrusion index, and acetabular depth-to-width ratio. Failure was defined as failure to achieve the minimal clinically important difference (MCID) utilizing the modified Harris Hip Score or as the need for secondary operation. The equal variance t test was used to analyze radiographic parameters. Statistical significance was determined using a P value of .05.
Results: A total of 373 hips underwent analysis with an average follow-up of 41 months (range, 24-102 months). Of these, 46 hips (12%) required secondary operation, and 95 (25%) failed to meet the MCID. The overall failure rate was 32.4%. There was no single measurement or combination thereof associated with failure to reach the MCID. Higher preoperative Tönnis angles were associated with secondary operation, with a mean of 6.7° (95% CI, 5.3°-8.1°) in the secondary operation group versus 4.8° (95% CI, 4.4°-5.3°) in the nonsecondary operation group (P = .006). The odds ratio was 1.12 (95% CI, 1.0-1.2; P = .05) per degree increase in Tönnis angle for secondary operation. In patients with a Tönnis angle >10°, 84% required secondary operation.
Conclusion: Higher Tönnis angles portend a higher risk for revision surgery. The probability of secondary operation was increased by a magnitude of 1.12 with each degree increase in the Tönnis angle. In patients with a Tönnis angle >10°, 84% required a secondary operation.
文献出处：McQuivey KS, Secretov E, Domb BG, Levy BA, Krych AJ, Neville M, Hartigan DE. A Multicenter Study of Radiographic Measures Predicting Failure of Arthroscopy in Borderline Hip Dysplasia: Beware of the Tönnis Angle. Am J Sports Med. 2020 Jun;48(7):1608-1615. doi: 10.1177/0363546520914942. Epub 2020 Apr 28. PMID: 32343594.
文献3
评估发育性髋关节发育不良儿童的父母
无症状发育不良的风险
译者：张振东
发育性髋关节发育不良（DDH）的原因有多种，包括韧带松弛、宫内原因、产前和产后的位置、遗传原因、种族差异和环境因素等。既往较多研究对遗传因素进行报道，已经证明有DDH成员的家庭，其他成员患有DDH的风险是其他家庭的五倍。因此患有DDH的儿童，其父母也属于高危发病群体。本研究的目的是探讨作为发育性髋关节发育不良儿童的父母是否为无症状髋关节发育不良的危险因素。
经超声筛查诊断为DDH的儿童，通过检查他们无症状父母的骨盆正位X线片来评估其是否亦存在髋关节发育不良。共纳入研究组43人86髋，对照组49人98髋。通过分析骨盆正位片Wiberg角、臼顶倾斜角、髋臼深度/宽度指数、股骨头覆盖率( femoral head coverage ratio，FHCR)和股骨颈干角。
研究组平均髋臼深度/宽度指数为44.3%，对照组为53.5%。研究组的平均FHCR为80%，对照组为82%。两组髋臼深度/宽度指数(p < 0.05)、FHCR (p < 0.05)差异均有统计学意义。另外，研究组21例及对照组2例参与者髋臼深度/宽度指数明显异常；而FHCR异常者在研究组有22人，在对照组有13人。两组髋臼深度/宽度指数或FHCR异常者所占比例均有统计学差异。
结果表明，父母患有DDH是儿童髋关节发育不良的一个明确的危险因素。此外，作为DDH儿童的父母，患有无症状髋关节发育不良的风险要高于普通人群，这些父母应该行x线检查。
Assessing the risk of asymptomatic dysplasia in parents of children with developmental hip dysplasia
Objective: The aim of this study was to investigate whether being the parents of children with developmental hip dysplasia (DDH) is a risk factor for asymptomatic dysplasia.
Methods: Asymptomatic parents of children who were diagnosed with DDH were assessed for presence of dysplasia by examining their anteroposterior pelvis radiographs at the neutral position. Eighty-six hips of 43 participants were included in the study group and 98 hips of 49 participants were included in the control group. Presence of hip dysplasia over the anteroposterior pelvis radiographs was analyzed for Wiberg's angle, acetabular index of the weight-bearing zone (the Tönnis angle), acetabular depth/width index, femoral head coverage ratio (FHCR) and femoral neck/shaft angle.
Results: The mean acetabular depth/width ratio was 44.3% in the study group and 53.5% in the control group. And, the mean FHCR was 80% in the study group and 82% in the control group. There was a statistically significant difference between the two groups in terms of mean acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05). In addition, 21 participants in the study group and 2 in the control group had a pathological acetabular depth/width ratio. And, the number of participants with a pathological FHCR was 22 in the study group and 13 in the control group. A statistically significant difference was found between the two groups regarding the number of pathological measurements of acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05).
Conclusion: Having a parent with DDH is a definitive risk factor for the development of hip dysplasia in childhood. In addition, being a parent of a child with DDH is a risk factor for asymptomatic dysplasia. These parents should be screened by roentgenogram.
文献出处：Ayanoglu T, Ataoglu MB, Tokgöz N, Ersöz E, Atalar H, Turanlı S. Assessing the risk of asymptomatic dysplasia in parents of children with developmental hip dysplasia. Acta Orthop Traumatol Turc. 2019 Sep;53(5):346-350. doi: 10.1016/j.aott.2019.07.002. Epub 2019 Aug 7.
文献4
印度襁褓方法调查：关于儿科医生、
护士和婴儿护理员襁褓方法的调查
译者：任宁涛
目的：传统的襁褓方法蜡烛包保持髋膝关节后伸，是导致DDH的危险因素，而安全的襁褓方法髋膝关节屈曲，可降低此风险。我们进行了一项调查，以确定印度襁褓的流行方法；为什么母亲要练习襁褓，谁教她们；以及儿科医生、护士和婴儿护理员是否了解髋关节安全的襁褓方法。
方法：在三级护理中心、城市的、妇幼保健医院，对三组（儿科医生、护士和婴儿护理员）进行了匿名一次性调查。
结果：对55名儿科医生，219名护士和100名婴儿护理员进行调查研究，90%的婴儿护理员采用的是传统襁褓方法，生后即进行襁褓，每天平均襁褓10.2小时，襁褓最长可至生后4.2个月，99% 的护士和 53% 的儿科医生提倡传统襁褓方法，原因为传统襁褓方法有助于睡眠、保暖，并且错误的认为传统的襁褓方法可使下肢避免弓形弯曲，相反仅有8%的母亲不选择传统襁褓方法。婴儿母亲学习襁褓方法主要来源为亲戚（94%）和护士（64%），大多数护士 (70%) 在护理培训期间学习襁褓方法。只有 6.6% 的儿科医生、4% 的婴儿护理员和 0% 的护士知道“髋关节安全襁褓方法”。
结论：传统的婴儿襁褓方法是一种根深蒂固的做法，源于错误的认识，并因缺乏认识而广为传播。针对护士和儿科医生的髋关节安全襁褓方法培训将是提高母亲意识和改变其做法的有效措施。
图1 a 传统襁褓方法保持下肢伸直，限制下肢活动；b 髋关节安全的襁褓方法，可保持髋膝关节屈曲，下肢活动不受限。
Swaddling Practices in an Indian Institution Are they Hip‑SafeA Survey of Paediatricians, Nurses and Caregivers
Purpose: Traditional infant swaddling or binding with hips and knees extended is a known risk factor for Developmental Dysplasia of the Hip (DDH), while 'hip-safe swaddling' with hips and knees flexed is believed to eliminate this risk. We conducted a survey to determine the prevalent practices for infant swaddling in India; why mothers practice swaddling and who teaches them; and whether Paediatricians, nurses and caregivers are aware of hip-safe swaddling.
Methods: Anonymous one-time surveys were conducted in three groups-Paediatricians, Nurses and caregivers - at a tertiary-care, urban based, paediatric and maternity hospital.
Results: Forty-five paediatricians, 219 nurses and 100 caregivers were surveyed. Ninety percent caregivers practiced traditional swaddling, for on average 10.2 hours a day, starting soon after birth, up to 4.2 months of life. Traditional swaddling was advocated by 99% nurses and 53% Paediatricians. Reasons for swaddling included sleep, warmth and the misbelief that the child's legs would remain bowed if not bound straight; contrarily few mothers (8%) avoided swaddling out of superstition. Mothers learnt swaddling mainly from relatives (94%) and nurses (64%). Most nurses (70%) had learnt the practice during nursing training. Only 6.6% Paediatricians, 4% caregivers and 0% nurses were aware of 'hip-safe swaddling'.
Conclusion: Traditional swaddling of infants is a practice deeply rooted in India, born out of misbeliefs, and propagated by lack of awareness. Training in hip-safe swaddling targeted at nurses and Paediatricians would be an effective initial step in creating awareness among mothers and changing their practices.
文献出处：Deepika A Pinto , Alaric Aroojis, Rujuta Mehta. Swaddling Practices in an Indian Institution Are they Hip‑SafeA Survey of Paediatricians, Nurses and Caregivers. Indian J Orthop. 2020 Jul 8;55(1):147-157.
文献5
手术时年龄不能预测髋臼周围截骨术后患者早期报告结果
译者：张利强
背景：大量文献显示髋臼周围截骨术（PAO）治疗有症状的髋臼发育不良获得临床成功。关于年龄与临床结果的相关性存在相互矛盾的证据。HOOSglobal是最近认可的测量PAO术后患者报告结果。本研究的目的是根据PAO时的年龄评估早期随访时的HOOSglobal和WOMAC评分。
方法：确定了一个由391名接受PAO的患者组成的前瞻性多中心队列，随访时间至少为2年（平均4.71年）。患者分为4个年龄组：<20岁（N=131），20-29岁（N=102），30-39岁（N=65），和≥40岁（N=34）。采用4×2重复测量方差分析（年龄组×时间）比较各年龄组之间术前、术后HOOSgloba评分和WOMAC评分。采用多元线性回归分析确定术后HOOSgloba评分的预测因素。
结果：各年龄组的HOOSglobal评分和WOMAC评分均升高；然而，在这些患者中，≥40岁组术前和术后的HOOSglobal评分和WOMAC评分在统计学上与<20岁（P≤0.002）组、20-29岁（P=0.01）组和30-39岁（P=0.02）组有更大的增加。术前HOOSglobal评分越高，术后HOOSglobal评分越高（P<0.001），但年龄（P=0.065）、性别（P=0.80）、体重指数（P=0.50）和Tönnis分类（P=0.07）不是1年预后的独立预测因素。
结论：不同年龄段早期术后患者报告结果没有差异，这说明无论患者年龄大小PAO治疗症状性髋臼发育不良是成功的。因此，在行PAO的术前评估时，年龄本身可能不是一个合适的选择标准。
Age at the Time of Surgery Is Not Predictive of Early Patient-Reported Outcomes After Periacetabular Osteotomy
Background: The clinical success of periacetabular osteotomy (PAO) for the treatment of symptomatic acetabular dysplasia is well-documented. Conflicting evidence exists regarding the correlation of age with clinical outcomes. Hip disability and Osteoarthritis Outcome Score-global (HOOSglobal) is a recently validated patient-reported outcome measure following PAO. The purpose of this study is to asses HOOSglobal and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at early follow-up based on age at the time of PAO.
Methods: A prospective multicenter cohort of 391 patients undergoing PAO with minimum 2-year follow-up (average 4.71 years) were identified. Patients were categorized into 4 age groups: <20 years (N = 131), 20-29 (N = 102), 30-39 (N = 65), and !40 (N = 34). A 4 × 2 repeated measures analysis of variance (Age Group × Time) was used to compare preoperative and postoperative HOOSglobal and WOMAC scores between age groups. A multiple linear regression was used to identify predictors of postoperative HOOSglobal scores.
Results: HOOSglobal and WOMAC scores increased across all age groups; however, a statistically greater increase in preoperative to postoperative HOOSglobal and WOMAC scores was found in those ≥ 40 years compared to those <20 (P ≤ 0.002), 20-29 (P = 0.01), and 30-39 years (P = 0.02). Higher preoperative HOOSglobal scores were predictive of greater postoperative HOOSglobal scores (P < 0.001) but age (P = .065), gender (P = 0.80), body mass index (P = 0.50), and Tönnis Classification (P = 0.07) were not independent predictors of 1-year outcomes.
Conclusion: The absence of differences in early postoperative patient-reported outcomes across multiple age ranges emphasizes that PAO in the setting of symptomatic acetabular dysplasia can be successful regardless of patient age alone. Therefore, age alone might not be an appropriate selection criterion when evaluating surgical candidates for PAO.
文献出处：Muffly BT, Zacharias AJ, Jochimsen KN, Duncan ST, Jacobs CA; ANCHOR Study Group, Clohisy JC. Age at the Time of Surgery Is Not Predictive of Early Patient-Reported Outcomes After Periacetabular Osteotomy. J Arthroplasty. 2021 May 25:S0883-5403(21)00511-8. doi: 10.1016/j.arth.2021.05.029. Epub ahead of print. PMID: 34120795.
文献6
诊断性髋关节注射后的效果
译者：陶可、李儒军（北京大学人民医院骨关节科）
目的：全面回顾与局部麻醉 (LA) 或 LA 联合皮质类固醇 (CS) 相关的诊断性髋关节注射的效果与反应，以预测随后的手术成功率。
方法：从数据库（PubMed、Medline、Scopus、Embase）检索至到2015 年 1 月的主要患者数据的英文文献进行了系统评价，排除了 >50% 潜在骨关节炎的研究。研究由 2 位收集相关数据的审查员进行评估。
结果：包括7项研究，报告了总共 337 名接受诊断性髋关节注射的患者。平均年龄为 34.4 岁，其中 5 项研究报告了 94 (35.2%) 名男性和 173 (64.8%) 名女性。一项研究检查了 LA 的疼痛缓解率 (92.5%)；2 项 CS 研究报告了从 0% 到 100%（没有到完全缓解）的缓解，范围从 61% 到 82.3%；3 项研究使用 10 点疼痛量表，其中一项 CS 研究的疼痛评分为1.0，一项 LA 研究的评分为3.03，1 项研究使用 CS 或 LA 评分为3 至5.6。疼痛缓解持续时间为 9.8 (CS) 和 2.35 天 (LA)。根据病理学，髋臼软骨损伤（93.3%）和凸轮型撞击（81.6%）的缓解最大，临床和影像学发现不是可靠的缓解预测指标。1项研究表明，无反应是股骨髋臼撞击症非手术效果的有力预测因素。
结论：诊断性髋关节注射为各种髋关节病变患者提供了显着的疼痛缓解，但有限的数据表明对软骨损伤患者的缓解作用最大。临床和影像学发现是注射反应的不可靠预测因素，注射无反应是手术效果的强烈负面预测因素。未来的研究应侧重于阐明潜在病理学的差异并预测未来的手术成功。
Outcomes After Diagnostic Hip Injection
Purpose: To provide a comprehensive review of outcomes associated with local anesthetic (LA) or LA and corticosteroid (CS) diagnostic hip injections, and how well response predicts subsequent operative success.
Methods: A systematic review from database (PubMed, Medline, Scopus, Embase) inception to January 2015 for English-language articles reporting primary patient outcomes data was performed, excluding studies with >50% underlying osteoarthritis. Studies were assessed by 2 reviewers who collected pertinent data.
Results: Seven studies were included, reporting on a total 337 patients undergoing diagnostic hip injection. The mean age was 34.4 years, with 5 studies reporting 94 (35.2%) males and 173 (64.8%) females. One study examined the rate of pain relief with LA (92.5%); 2 CS studies reported relief on a scale from 0% to 100% (no to complete relief), ranging from 61% to 82.3%; and 3 studies used 10-point pain scales, with a CS study noting a pain score of 1.0, an LA study with a score of 3.03, and 1 study using either CS or LA scores of 3 to 5.6. Duration of pain relief was 9.8 (CS) and 2.35 days (LA). By pathology, greatest relief was achieved in acetabular chondral injury (93.3%) and least in cam impingement (81.6%), with clinical and imaging findings being unreliable predictors of relief. One study showed nonresponse to be a strong predictor of negative surgical outcome for femoroacetabular impingement.
Conclusions: Diagnostic hip injections provide substantial pain relief for patients with various hip pathologies, with limited data to suggest greatest relief for those with chondral injury. Clinical and imaging findings are unreliable predictors of injection response, and nonresponse to injection is a strong negative predictor of surgical outcome. Future research should focus on elucidating differences by underlying pathology and predicting future operative success.
文献出处：T Sean Lynch, Michael E Steinhaus, Charles A Popkin, Christopher S Ahmad, James Rosneck. Outcomes After Diagnostic Hip Injection. Arthroscopy. 2016 Aug;32(8):1702-11. doi: 10.1016/j.arthro.2016.02.027. Epub 2016 May 18.
文献7
髋臼周围截骨术后体能测试与患者报告的结果相关：一项前瞻性研究
译者：孙维
髋臼周围截骨术（PAO）是用于治疗髋臼发育不良的一种成熟的手术方式。患者通常年轻而活跃，希望恢复到高水平的运动功能。通常用专门用于评价髋关节功能的各种患者报告结果（PRO）来衡量功能缺陷。体能测试（PPMs）可以对损伤和恢复进行客观评估，并为PROs提供补充信息，已在运动员的损伤中广泛应用，但对术后非炎症性髋关节的情况评估还未有广泛报道。以下四项体能测试方法（图1）已在近期被用于评价髋关节撞击和髋关节发育不良：5次坐立试验（STS5）、四方步测试（FSST）、自选步行速度测试（SSWS）和定时上楼梯测试（TSA）。这些体能测试方法检测功能改善的能力以及与现在流行的几种PAO术后患者报告结果（PRO）的相关性尚不清楚。本研究的目的是评价PAO术后长达1年的四种体能测试的反应度，并与相应时间节点的PRO评估结果相比，报告PPMs用于评估PAO术后结果的接受度和实用性。
本研究是一项前瞻性研究，从2018年5月至2019年1月共入组22例患者（年龄在15-39岁之间），行PAO手术治疗，分别在术前、术后6个月和术后1年进行评估，包括7项PRO和4项PPM。其中PRO包括：VAS评分评估疼痛程度、简明国际髋关节结果工具（iHOT-12）、简明髋关节残疾和骨关节炎结果评分（HOOS PS）和疼痛分量表（HOOS Pain）、躯体功能和疼痛干扰适应性测试（PROMIS PF和PROMIS PI）以及改良Harris髋关节评分（mHHS）。Wilcoxon秩和检验和非配对t检验用于评估时间点之间的差异；Spearman相关性和广义线性模型用于确定PPM和PRO测量值之间的关系。
结果显示，PAO术后6个月后，患者在所有7种PRO（P<0.001）和 STS5（P = 0.01）上均表现出显著改善。1年后，这些改善得以保持，并且TSA也有所改善（P = 0.03）。其他PPMs项目的改善没有达到显著性（P = 0.07和0.08）。STS5测试证明与所有PRO项目具有中到强相关性（|r| = 0.43到0.76，P<0.05），而 TSA 测试证明与几乎所有测量都有中到强相关（|r|= 0.43到0.58，P<0.05）。对单侧受累的患者（n=11）进行亚组分析，相关性更强（|r|= 0.56到0.94，P<0.05）。尽管有残疾，但所有患者都认为PPM测试是可以接受的；25%的人更喜欢PPMs而不是PRO，而75%的患者觉得它们的实用性相同。因此我们建议，这些测试可作为功能结果用作PAO术后PRO结果的补充。
图1 5次坐立试验（STS5）：从坐在椅子上开始，双手胸前交叉，受试者用最快速度重复5次完整的起立、坐下，记录所用时间。四方步试验（FSST）：两根杆子十字交叉放在地上。受试者从左下象限开始，逆时针围绕杆子迈步一圈，然后再顺时针迈一圈回到原点。自选步行速度试验（SSWS）：受试者在长10米的垫子上用自己正常的速度行走，只记录中间6米的用时。定时上楼梯测试（TSA）：在一个至少有连续12节台阶的地方进行测试。受试者用最快速度登上12节台阶，测试过程中不能扶扶手。
Physical Performance Tests Correlate With Patient- reported Outcomes After Periacetabular Osteotomy: A Prospective Study
Introduction: Individuals with hip dysplasia report significant functional disability that improves with periacetabular osteotomy (PAO). Four physical performance measures (PPMs) have been recently validated for use with nonarthritic hip conditions; however, their ability to detect functional improvement and correlate with improvements in popular hip-specific patient-reported outcome (PRO) instruments after PAO is unknown. The purpose of this study was to evaluate the responsiveness of four PPMs up to 1 year after PAO, compare PPMs with established PRO measures at these time points, and report the acceptability and utility of PPMs for assessing outcomes after PAO.
Methods: Twenty-two participants aged 15 to 39 years completed the timed stair ascent (TSA), sit-to-stand five times (STS5), self- selected walking speed, four-square-step test, and seven hip- specific PRO measures before surgery and at approximately
6 months and 1 year after PAO. They completed questions regarding acceptability and utility of both types of testing. Wilcoxon rank sum test and unpaired Student t-tests were used to assess differences between time points; Spearman correlation and generalized linear modeling were used to determine the relationship between PPMs and PRO measures.
Results: Six months after PAO, participants showed significant improvements on all seven PRO instruments (P , 0.001) and on the STS5 (P = 0.01). At one year, these improvements were maintained and TSA also improved (P = 0.03). Improvement in other PPMs did not reach significance (P = 0.07 and 0.08). The STS5 test demonstrated moderate to strong correlation (jrj = 0.43 to 0.76, P , 0.05) with all PRO measures, and the TSA test demonstrated moderate to strong correlation with almost all measures (jrj = 0.43 to 0.58, P , 0.05). Correlations strengthened on subanalysis of participants with unilateral disease (n = 11) (jrj = 0.56 to 0.94, P , 0.05). All participants (100%) found PPM testing acceptable despite disability; 25% preferred PPMs to PRO measures, whereas 75% of participants found them equal in usefulness.
Discussion: The STS5 and TSA tests demonstrated moderate to very strong correlation with PRO measures at six and 12 months after PAO for dysplasia. These tests could be used as a functional outcome to supplement PRO instruments after PAO.
文献出处：Elizabeth JS, Michael CW, John CD, Robert WW, Amanda CP, Jason MW. Physical Performance Tests Correlate With Patient- reported Outcomes After Periacetabular Osteotomy: A Prospective Study. JAAOS Glob Res Rev 2021;5:1-10. DOI: 10.5435/JAAOSGlobal-D-21-00100.
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