髋膝关节文献精译荟萃（第122期）
本期目录：
1、髌骨厚度对全膝关节置换术后髌骨轨迹和髌股关节接触特性的影响
2、全髋关节置换术治疗Charcot关节病临床症状改善明显但并发症发生率较高
3、直接前入路全髋关节置换术后出现的异位骨化对患者自评量表的影响
4、全膝关节置换术后僵硬：是脊柱畸形的结果吗？
5、病态肥胖对门诊关节置换术患者住院过夜及早期并发症的影响
6、新兵股骨头软骨下疲劳骨折
7、髋臼周围截骨术治疗医源性髋关节不稳的早期预后
8、危险因素与DDH和超声髋关节分型的关系：一项回顾性病例对照研究
9、症状性髋臼发育不良的Ottawa分类：观察者间和观察者内可靠性的评估
10、Legg-Calvé-Perthes病的股骨近端截骨术的长期结果
第一部分：关节置换及保膝相关文献
文献1
髌骨厚度对全膝关节置换术后
髌骨轨迹和髌股关节接触特性的影响
译者：张轶超
尽管全膝关节置换术（TKA）已经是一种很常见的手术，但髌骨的问题一直是影响手术效果的主要不利因素。髌骨的厚度是一个非常具有挑战性的因素。我们对髌骨厚度对于髌骨关节的运动学和接触特性的影响进行了研究。研究了7个未采用防腐措施处理的尸体全下肢样本。采用一种磁力轨迹装置测量了运动学指标（3维追踪系统，Polhemus导航科学部，科尔切斯特，佛蒙特州）。通过测量的运动学数据和基于理论性方法获得的数字化表面几何分布来计算髌股关节接触区域。通过一种单轴力传感器来测量髌股关节接触应力。运动学测量可见髌骨厚度对于髌骨屈曲、旋转和远近的移动没有明显的影响。骨科医生经常认为解决髌股关节紊乱问题是一个很大的挑战，尤其是在TKA术后。一般认为恢复髌骨原有厚度是非常合理的。薄的髌骨固然可以降低髌股关节的接触应力，但也可以造成髌骨应力骨折和关节前后不稳的潜在风险。厚的髌骨可以在膝关节轻度屈曲时增加股四头肌力臂的效能，但可能会降低膝关节的活动度及导致髌骨的半脱位。无论厚的还是薄的髌骨都会比正常厚度的髌骨与股骨接触面更小。因此，在TKA术中置换髌骨时恢复髌骨的原有厚度是很重要的。
Influence of patellar thickness on patellar tracking and patellofemoral contact characteristics after total knee arthroplasty
Although total knee arthroplasty (TKA) has become a very common procedure, patellar problems remain a major cause of disability. Patellar thickness is one of the most challenging factors. The influence of patellar thickness on patellofemoral kinematics and contact characteristics following TKA was investigated. Seven unembalmed whole-lower-extremity cadaveric specimens were used. The kinematics was measured with a magnetic tracking device (3Space Tracker System, Polhemus Navigation Sciences Division, Colchester, VT). Contact area was calculated from the kinematic data and the digitized joint surface geometrics based on a theoretical method. The patellofemoral joint contact force was measured directly using a uniaxial force transducer. Kinematically, the influence of patellar thickness on patellar flexion, rotation, and proximodistal shift was not significant. Orthopaedic surgeons are often challenged by derangement of the patellofemoral joint, especially following TKA. It is commonly assumed that restoration of overall patellar thickness is most desirable. A thin patella can reduce the contact force, but it also poses the potential risks of stress fracture and anteroposterior instability. Increasing patellar thickness might be expected to increase the effective quadriceps moment arm at low flexion angles of the knee, but potentially reduces the range of motion of the knee and predisposes to patellar subluxation. Either a thicker or a thinner patella had a smaller contact area than intact and normal-thickness patella. Therefore, the surgical technique of patellar resurfacing during TKA should attempt to reproduce the original patellar thickness.
文献出处：Hsu HC, Luo ZP, Rand JA, An KN. Influence of patellar thickness on patellar tracking and patellofemoral contact characteristics after total knee arthroplasty. J Arthroplasty. 1996;11(1):69-80. doi:10.1016/s0883-5403(96)80163-x
文献2
全髋关节置换术治疗Charcot关节病
临床症状改善明显但并发症发生率较高
译者：马云青
背景：髋部神经病变(Charcot)导致的关节病很少见，但会导致关节破坏、骨缺损严重和关节功能障碍。虽然全髋关节置换术(THA)是一种可选择的治疗方案，但所获得的相关临床数据非常有限，仅以病例报告的形式出现。本研究的目的是分析Charcot关节病病例接受初次THA治疗的结果，重点是假体存活率、围手术并发症和临床结果的改善情况。
方法：回顾性分析2007～2014年11例Charcot关节病患者共12髋的临床资料。所有患者均有严重的潜在神经病变和明确的Charcot关节病的放射学诊断证据。平均年龄54岁，4例为女性。平均随访5年。
结果：以任何原因翻修为终点的2年和5年假体生存率为75%。3例THAs（3/12）接受翻修：2例为反复脱位，1例原于股骨假体松动。在术后2年和5年，没有再手术的占67%。除以上翻修原因外另1例再手术的THA病例为B1假体周围骨折的接受了切开复位内固定。最终，总的并发症发生率（包括翻修和再手术）高达58%，3例复发脱位，2例假体周围骨折，1例股骨假体松动，1例伤口延迟愈合。Harris髋关节评分从术前平均43分提高到术后平均81分(P<0.001)。
结论：在这项病例数量最大的研究中，作者发现初次THA治疗Charcot关节病的患者在临床结果上有显著的改善，但早期并发症和假体翻修的风险很高，主要与复发性脱位有关。为避免早期并发症发生，考虑应用能提供初始和长期稳定性的假体和能增加髋关节稳定性的措施。
Primary Total Hip Arthroplasty for Charcot Arthropathy is Associated With High Complications but Improved Clinical Outcomes
Background: Neuropathic (Charcot) arthropathy of the hip is rare but can lead to joint destruction, bone loss, and dysfunction. While total hip arthroplasty (THA) may be considered a treatment option, only very limited data in the form of case reports are available on the results of THA. The goal of this study was to analyze the outcomes of primary THA for Charcot arthropathy with emphasis on implant survivorship, complications, and clinical outcomes.
Methods: Eleven patients undergoing 12 primary THAs for Charcot arthropathy from 2007 to 2014 were retrospectively reviewed. All patients had a severe underlying neuropathy and clear radiographic evidence of Charcot arthropathy. Mean age was 54 years with 4 patients being female. Mean follow-up was 5 years.
Results: Survivorship free of any revision was 75% at both 2 and 5 years. Three THAs (3/12) were revised: 2 for recurrent instability and 1 for femoral component loosening. Survivorship free of any reoperation was 67% at both 2 and 5 years. One additional THA underwent open reduction and internal fixation of a Vancouver B1 periprosthetic fracture. The overall complication rate (including revisions and reoperations) was high at 58% with 3 recurrent dislocations, 2 periprosthetic fractures, 1 femoral component loosening, and 1 delayed wound healing. Harris Hip Scores improved from a mean of 43 preoperatively to 81 postoperatively (P < .001).
Conclusion: In this study, the largest to date, we found that patients undergoing primary THA for Charcot arthropathy have a significant improvement in clinical outcomes but that there was a high risk of early complications and revisions, mostly related to recurrent instability. Specific precautions to avoid early complications, namely utilization of components that provide robust fixation and strategies that provide enhanced hip stability, should be considered.
文献出处：Chalmers BP, Tibbo ME, Trousdale RT, Lewallen DG, Berry DJ, Abdel MP. Primary Total Hip Arthroplasty for Charcot Arthropathy is Associated With High Complications but Improved Clinical Outcomes. J Arthroplasty. 2018;33(9):2912-2918. doi:10.1016/j.arth.2018.04.002
文献3
直接前入路全髋关节置换术后出现的
异位骨化对患者自评量表的影响
译者：张蔷
背景：异位骨化（HO）是一项被大家熟知的常见于全髋关节置换（THA）术后可能会对临床疗效有潜在影响的并发症。异位骨化的发生与许多因素相关，包括软组织创伤、术后用药、手术入路和术者经验等。近些年，直接前入路（DAA）逐步流行，因此我们的目标是（1）明确DAA-THA术后异位骨化的发生率（2）评估异位骨化对患者自评量表（PROs）的影响。
方法：我们回顾性入组了401例全髋关节置换病例（67±10岁，210男）。异位骨化的确诊和分级在骨盆前后位片上通过Brooker分型来确定。PROs包括牛津髋关节评分（OHS）与核心自评指数（COMI）-髋关节。我们还将这些自评量表结果与异位骨化分级进行了相关性回归分析。
Brooker分级：1级：异位骨化骨块包裹在髋关节周围软组织中，与股骨近端和骨盆分离；2级：起自股骨近端或骨盆的骨块，距离对侧骨面至少1cm以上；3级：起自股骨近端或骨盆的骨块，距离对侧骨面不足1cm；4级：骨块连接骨盆和股骨近端，髋关节强直。
结果：骨盆前后位片上显示异位骨化的发生率为29.9%（Brooker 1级，14.5%；2级，11.1%；3级，2.7%；4级，0.57%）；侧位片可以再多发现9%的异位骨化（Brooker 1级，8%和2级，1%）。异位骨化在男性患者中更为常见。美国麻醉医师协会分级（ASA）、女性年龄和男性BMI与异位骨化分级呈正相关性。与纵行切口（12%）相比，横行bikini切口导致的Brooker 3级和4级异位骨化（4%）发生率更低。Brooker 0级-3级异位骨化并不会影响患者自评结果。只有Brooker 4级异位骨化与更差的患者自评结果相关。而且，异位骨化分级也不会影响疼痛。
正位片上显示异位骨化骨块与骨距分离（Brooker 1级），而侧位片上显示骨块与骨距相连（Brooker 2级），因此侧位片的缺失会使异位骨化被低估。
结论：DAA-THA术后低等级异位骨化并不罕见，而如果评价时只有正位没有侧位片，其发生率会被进一步低估。我们的实验队列中发生异位骨化的危险因素包括ASA分级超过3级、男性（尤其是高BMI的患者）、女性高龄和使用纵行切口。使用bikini切口会降低患者出现严重异位骨化的风险，但这种切口通常被更有经验的高年资医生使用。年龄、ASA分级、术者经验以及Brooker 4级都对患者自评结果有显著性影响。在临床上，DAA-THR术后很少见到显著的异位骨化（Brooker 4级）。
The Impact of Heterotopic Ossification on Self-Reported Outcomes After Total Hip Arthroplasty Using the Direct Anterior Approach
Background: Heterotopic ossification (HO) is a known finding after total hip arthroplasty (THA) that potentially affects clinical outcomes. The incidence of HO is related to various factors, including soft-tissue trauma, postoperative medication, surgical approach, and the surgeon’s experience. Because use of the direct anterior approach (DAA) is gaining popularity, we aimed (1) to determine the incidence of HO after DAA-THA and (2) to evaluate the impact of HO on patient reported outcomes (PROs).
Methods: We retrospectively reviewed 401 THAs (67 ± 10 years old, 210 men). The incidence and grade of HO were evaluated using the Brooker classification with anteroposterior and lateral radiographs. PROs were collected with use of the Oxford Hip Score (OHS) and the Core Outcome Measures Index (COMI)-Hip and were correlated with HO grades using generalized multiple regression models.
Results: The incidence of HO was 29.9% on the anteroposterior radiographic views (Brooker grade 1, 14.5%; grade 2, 11.1%; grade 3, 2.7%; and grade 4, 0.57%); the lateral radiographic views detected 9% additional HO when compared with the anteroposterior radiographs alone (Brooker grade 1, 8%, and grade 2, 1%). HO was more frequent in men. The American Society of Anesthesiologists (ASA) grade, age in women, and higher body mass index (BMI) in men were associated with higher HO grades. A transverse “bikini” incision was associated with a lower rate (4%) of Brooker grades 3 and 4 HO when compared with a longitudinal incision (12%). A Brooker grade of 0 to 3 HO did not impact outcomes. Only Brooker grade-4 HO was associated with significantly worse PROs; however, pain was not affected.
Conclusions: Low-grade HO after DAA-THA is not uncommon, and its rate is underestimated when anteroposterior radiographic views are evaluated without lateral views. The risk factors for developing HO in our cohort were an ASA grade of >3, male sex (especially with a high BMI), older age in women, and use of longitudinal incisions. With use of the bikini incision, patients had lower rates of severe HO, but mostly senior surgeons with more experience performed their surgery. Age, ASA grade, experience level of the surgeon, and Brooker grade-4 HO all had a significant influence on PROs. Clinically important HO (Brooker grade 4) remains rare after DAA-THR.
文献出处：Rüdiger HA, Dittrich M, Robinson J, et al. The Impact of Heterotopic Ossification on Self-Reported Outcomes After Total Hip Arthroplasty Using the Direct Anterior Approach [published online ahead of print, 2020 Jun 10]. J Bone Joint Surg Am. 2020;10.2106/JBJS.20.00071. doi:10.2106/JBJS.20.00071
文献4
全膝关节置换术后僵硬：
是脊柱畸形的结果吗？
译者：李睿
背景：迄今为止，尚无研究分析脊柱畸形对全膝关节置换术（TKA）结局的影响。众所周知，膝关节屈曲是一种对脊柱畸形的补偿机制，以保持矢状面平衡。这项研究的目的是确定部分TKA术后活动范围（ROM）不良的患者是否存在未识别的脊柱畸形，从而使他们出现膝关节屈曲挛缩和僵硬。
方法：我们回顾性评估了一系列连续的，由于TKA术后ROM不良而接受在麻醉下手法松解（MUA）的患者。使用站立位双平面全长片，测量膝关节的对线和脊柱骨盆参数。根据骨盆入射角减去腰椎前凸来对患者进行分层，以衡量脊柱矢状位对线，不匹配≥10°定义为异常，并计算了矢状位脊柱畸形的发生率。
结果：MUA之前的平均ROM为伸展3°，屈曲83°。约有62％的患者骨盆入射角减腰椎前凸不匹配≥10°。在脊柱畸形组中，MUA后仅屈曲而得到改善，而在非畸形组中，屈曲和伸展都得到了改善。
结论：由于矢状位脊柱畸形而导致的代偿性膝关节屈曲可能是TKA后ROM不良的原因。对于临床上有怀疑的患者，应在术前进行检查并给予相应的沟通建议。
Stiffness After Total Knee Arthroplasty: Is It a Result of Spinal Deformity?
Background: There are no studies to date analyzing the effect of spinal malalignment on outcomes of total knee arthroplasty (TKA). Knee flexion is a well-described lower extremity compensatory mechanism for maintaining sagittal balance with increasing spinal deformity. The purpose of this study was to determine whether a subset of patients with poor range of motion (ROM) after TKA have unrecognized spinal deformity, predisposing them to knee flexion contractures and stiffness.
Methods: We retrospectively evaluated a consecutive series of patients who underwent manipulation under anesthesia (MUA) for poor ROM after TKA. Using standing full-length biplanar images, knee alignment and spinopelvic parameters were measured. Patients were stratified by pelvic incidence minus lumbar lordosis as a measure of spinal sagittal alignment with a mismatch of ≥10° defined as abnormal, and we calculated the incidence of sagittal spinal deformity.
Results: Average ROM before MUA was extension 3° and flexion 83°. About 62% of patients had a pelvic incidence minus lumbar lordosis mismatch of ≥10°. In the spinal deformity group, post-MUA ROM was improved for flexion only, whereas both flexion and extension were improved in the nondeformity group.
Conclusion: Compensatory knee flexion because of sagittal spinal deformity may predispose to poor ROM after TKA. Patients with clinical suspicion should be worked up preoperatively and counseled accordingly.
文献出处：Vigdorchik JM, Sharma AK, Feder OI, et al. Stiffness After Total Knee Arthroplasty: Is It a Result of Spinal Deformity?. J Arthroplasty. 2020;35(6S):S330-S335. doi:10.1016/j.arth.2020.02.031
文献5
病态肥胖对门诊关节置换术
患者住院过夜及早期并发症的影响
译者：沈松坡（同仁医院）
背景：门诊人工关节置换术的人数正在迅速增加，但对于是否应将某些患者排除在当日出院的人工关节置换术之外仍存在担忧。本研究的目的是评估病态肥胖是否是门诊关节置换术后围手术期并发症的危险因素。
方法：回顾性分析了2013年至2017年门诊手术的初次全髋关节、全膝关节、部分膝关节置换和髋、膝关节翻修的病例，共4863例(5988例关节置换手术)。根据非病态肥胖(NMO) (BMI < 40 kg/m2)和病态肥胖(MO) (BMI >40 kg / m2)。NMO组有4870例关节置换，MO组有1118例关节置换。对两组间住院过夜、医疗并发症和早期围手术期并发症的差异进行评估。
结果：5.4%的NMO患者和9.1%的MO患者发生住院过夜(P < .001)， 3.2%的NMO患者和6.4%的MO患者发生因医疗因素的住院过夜 (P < .001)。在4%的MO患者和0.8%的NMO患者中，呼吸/睡眠呼吸暂停是导致留宿的主要医学原因(P < .001)。在90天内，两组在直接转院、急诊/入院或医疗并发症方面没有显著差异。两组间伤口再修复、非翻修手术或90天内翻修率均有显著性差异。
结论：MO患者在门诊关节置换术后发生90天并发症、再入院或翻修的风险没有增加。然而，MO患者的过夜发生率明显较高。
Impact of Morbid Obesity on Overnight Stay and Early Complications With Outpatient Arthroplasty
Background: The shift toward outpatient joint arthroplasty is rapidly growing, but concerns still remain on whether certain patients should be excluded from same-day discharge arthroplasty. The purpose of this study is to evaluate whether morbid obesity is a risk factor for perioperative complications after outpatient joint arthroplasty.
Methods: A retrospective review was performed from 2013 to 2017 of all outpatient primary total hip, total knee, partial knee, and revision hip and knee arthroplasties, yielding a cohort of 4863 patients (5988 arthroplasty procedures). Patients were separated and analyzed based on 2 groups: nonmorbidly obese (NMO) (BMI < 40 kg/m2) and morbidly obese (MO) (BMI>40 kg/m2). The NMO group consisted of 4870 arthroplasties and the MO group consisted of 1118 arthroplasties. Overnight stays, medical com- plications, and early perioperative complications were assessed between groups.
Results: Overnight stays occurred in 5.4% of NMO patients and 9.1% of MO patients (P < .001), with medical reasons for the overnight stay occurring in 3.2% of NMO and 6.4% of MO patients (P < .001). Respiratory/sleep apnea was the leading medical reason leading to overnight stay occurring in 4% of MO patients and 0.8% of NMO patients (P < .001). There was no significant difference between groups in direct facility transfers, emergency room visits/admissions, or medical complications within 90 days. Wound revisions, nonrevision surgery, or revisions within 90 days were significant between groups.
Conclusion: MO patients did not have an increased risk of 90-day medical complications, readmission, or revisions after outpatient arthroplasty. However, MO patients did have a significantly higher incidence of overnight stay.
文献出处：Crawford DA, Hurst JM, Morris MJ, Hobbs GR, Lombardi AV Jr, Berend KR. Impact of Morbid Obesity on Overnight Stay and Early Complications With Outpatient Arthroplasty [published online ahead of print, 2020 May 11]. J Arthroplasty. 2020;S0883-5403(20)30486-1. doi:10.1016/j.arth.2020.04.098
第二部分：保髋相关文献
文献1
新兵股骨头软骨下疲劳骨折
译者：罗殿中
背景：股骨头软骨下应力骨折是一种较为罕见的疾病，通常发生于骨质较差的患者，表现为股骨头不完全的骨折。我们对年轻健康的新兵发生的股骨头软骨下疲劳性骨折的临床特征进行评估。
方法：在1998年1月至2001年11月之间，共有5例患（7髋）因股骨头软骨下疲劳骨折接受治疗。疾病的诊断基于患者的临床病史、X线片、骨扫描和磁共振图像。
结果：所有患者均为二十多岁的男性新兵，在入伍后五个月内出现髋关节疼痛。在3例患者（4髋）的髋关节初次X线片上观察到明确的异常，并且这其中2髋的股骨头已经出现明显塌陷。四名患者（5髋）的骨扫描均显示股骨头中放射性核素的吸收增加。磁共振显示所有患者的股骨头和/或股骨颈均有局部或弥漫性骨髓水肿。所有受累髋关节的X线片均有软骨下骨折线（磁共振新月征）。在没有股骨头塌陷的患者中，疼痛逐渐减轻并在六个月内完全消失，之后的磁共振也表现出显著改善。股骨头塌陷的患者接受了全髋关节置换术或髂骨支撑植骨术治疗。
结论：当新兵或运动员出现髋关节疼痛时，应考虑到发生股骨头软骨下疲劳骨折的可能。
一名21岁男性新兵，训练1个月后出现有髋关节疼痛。症状出现6周后X线片显示右股骨头塌陷。骨扫描显示有股骨头放射性浓聚
磁共振显示右侧股骨头塌陷区（箭头）信号异常，对侧股骨头信号轻度改变（星号）
Subchondral fatigue fracture of the femoral head in military recruits
Background: Subchondral stress fracture of the femoral head is a rare condition that usually occurs as an insufficiency fracture in people with poor bone quality. We evaluated the clinical characteristics of subchondral fatigue fractures of the femoral head that occurred in young, healthy military recruits.
Methods: Between January 1998 and November 2001, seven subchondral fatigue fractures of the femoral head were treated in five patients. The characteristics of this condition were ascertained by assessing the clinical course as well as radiographs, bone scintigrams, and magnetic resonance images.
Results: All patients were male military recruits in their early twenties in whom pain had developed within five months after recruitment. Definite abnormal findings were observed on the initial radiographs of four hips in three patients, and the femoral head was markedly collapsed in two of these four hips. Bone scintigrams were made of five hips in four patients, and all of them showed increased radionuclide uptake in the femoral head. In all affected hips, magnetic resonance images demonstrated a localized or diffuse bone-marrow-edema pattern in the femoral head and/or neck. A subchondral fracture line (a magnetic resonance crescent sign) was identified in all hips. In the patients who did not have collapse of the femoral head, the pain decreased gradually and disappeared completely within six months, with correspondingly improved findings on sequential magnetic resonance images. The patients with femoral head collapse were treated with total hip arthroplasty or an iliac bone strut graft.
Conclusions: When a military recruit or an athlete reports hip pain, a diagnosis of subchondral fatigue fracture of the femoral head should be considered.
文献出处：Song WS, Yoo JJ, Koo KH, Yoon KS, Kim YM, Kim HJ. Subchondral fatigue fracture of the femoral head in military recruits. J Bone Joint Surg Am. 2004;86(9):1917-1924. doi:10.2106/00004623-200409000-00009
文献2
髋臼周围截骨术治疗医源性髋关节不稳的早期预后
译者：肖凯
背景：髋臼周围截骨术（PAO）可减轻髋关节发育不良患者的疼痛并改善其生活质量。目前还没有研究评估PAO对传统影像学指标显示无发育不良患者的治疗效果，PAO可能用于治疗髋关节镜手术后不能改善的关节不稳，或髋关节镜手术导致的关节不稳。
方法：研究对象选择了单中心同一名医生诊治的患者，所有患者外侧中心边缘角（LCEA）≥24°且Tönnis角<10°，因髋关节镜术后疼痛或关节不稳而接受PAO治疗。收集并分析患者的人口统计资料，LCEA的平均变化情况以及患者报告的至少术后6个月的预后评分（包括改良的Harris髋关节评分（mHHS）和国际髋关节预后评分-33（iHOT-33）。
结果：共有25例患者纳入研究，平均年龄27.3±6.9岁，均为女性，患者平均LCEA从术前的27.2°（范围：24°至37°）增加到术后的39.0°±5.1°（净增加，11.8°± 4.5°）。总体而言，mHHS平均提高了11.5±16.9（术前59.4±11.6；术后70.9±20.6），iHOT-33平均提高了23.8±23.6（术前32.2±17.2；术后56.0±30.0） ）。18名患者（72％）的mHHS（平均提高了17.4±12.9）和iHOT-33（平均提高了32.4±19.1）的改善达到了最小临床显著性。与7例未显示改善的患者相比，另外18例的末次功能评分明显高于基线水平。
结论：据我们所知，本研究首次对髋关节镜术后髋关节疼痛的患者进行PAO治疗，而根据传统影像学指标，这些患者并不符合髋关节发育不良的诊断。短期随访的良好临床预后表明PAO可以用于某些特定患者的挽救性治疗。我们仍需要长期随访。
Periacetabular Osteotomy as a Salvage Procedure: Early Outcomes in Patients Treated for Iatrogenic Hip Instability
Background: A periacetabular osteotomy (PAO) can reduce pain and improve quality of life in patients with hip dysplasia. While its utility for patients without traditional radiographic parameters for hip dysplasia has not been previously established, the PAO may help treat patients with hip instability that does not improve following single or multiple hip arthroscopic procedures, or when such procedures lead to hip instability.
Methods: A single-surgeon registry of patients at a single institution was queried to identify patients with a lateral center-edge angle (LCEA) of ≥24° and a Tönnis angle of <10° who underwent PAO because of hip pain and/or instability that failed treatment with hip arthroscopy. Descriptive summary statistics were reported on patient demographics, mean change in LCEA, and patient-reported outcome measures, including the modified Harris hip score (mHHS) and the International Hip Outcome Tool-33 (iHOT-33), at a minimum of 6 months of follow-up.
Results: Among 25 patients (mean age, 27.3 ± 6.9 years; 100% women), the mean LCEA increased from 27.2° (range, 24° to 37°) preoperatively to 39.0° ± 5.1° postoperatively (net increase, 11.8° ± 4.5°). Overall, the mean improvement in the mHHS was 11.5 ± 16.9 (preoperative, 59.4 ± 11.6; postoperative, 70.9 ± 20.6) and the mean improvement in the iHOT-33 was 23.8 ± 23.6 (preoperative, 32.2 ± 17.2; postoperative, 56.0 ± 30.0). Eighteen patients (72%) achieved a minimal clinically important improvement in mHHS (mean improvement, 17.4 ± 12.9) and iHOT-33 (mean improvement, 32.4 ± 19.1) scores. In comparison with 7 patients who did not show improvement, the 18 patients who showed improvement had significantly greater mean baseline patient-reported outcome scores.
Conclusions: To our knowledge, these findings provide the first report on outcomes of PAO in patients with hip pain following arthroscopy who do not meet the traditional criteria for acetabular dysplasia. Early benefits in clinical outcomes suggest a novel surgical indication for PAO as a potential salvage option for selected patients; however, longer-term studies are needed.
文献出处：Brusalis CM, Peck J, Wilkin GP, et al. Periacetabular Osteotomy as a Salvage Procedure: Early Outcomes in Patients Treated for Iatrogenic Hip Instability [published online ahead of print, 2020 Jun 9]. J Bone Joint Surg Am. 2020;10.2106/JBJS.20.00087. doi:10.2106/JBJS.20.00087
文献3
危险因素与DDH和超声髋关节分型的关系：
一项回顾性病例对照研究
译者：任宁涛
目的：我们旨在回顾先前定义的危险因素与DDH发生的相关性，并根据Graf分型评估这些因素对DDH超声类型的影响。
方法：健康婴儿（平均年龄33天）双侧成熟（正常）髋关节（Graf I型）的数据与因单侧或双侧DDH（Graf IIa型及更差）而使用外展支具治疗的婴儿（平均年龄105天）的数据进行比较。
结果：至少有一个危险因素的婴儿DDH发生率显著高于无危险因素的婴儿（p<0.001）。同样，有一个以上危险因素的婴儿的DDH发生率明显高于只有一个危险因素的婴儿（p=0.008）。家族史、臀位和襁褓是DDH发生的三个重要危险因素。家族史、襁褓和羊水过少是DDH患者髋关节不稳定/脱位（Graf类型D/III/IV）发生率较高的三个重要危险因素。
结论：如果婴儿有一个以上的DDH危险因素，则DDH的风险显著增加。有家族史和产后传统的襁褓是导致DDH的病因和更严重的髋关节发育不良的两个主要因素。此外，臀位增加了发生DDH的风险，羊水过少可导致发生更严重的髋关节发育不良。通过将这四个变量作为DDH的绝对危险因素引入选择性新生儿髋关节筛查项目，可以优化这些项目的敏感性和特异性，降低延误诊断的风险。
表1 危险因素对评价人群DDH发生率影响的单因素分析
表2 DDH患者超声分型危险因素的单因素分析
Associations Between Risk Factors and Developmental Dysplasia of the Hip and Ultrasonographic Hip Type A Retrospective Case Control Study
Purpose: We aimed to revisit the correlation between the previously defined risk factors and the occurrence of developmental dysplasia of the hip (DDH) and to assess the influence of these factors on the ultrasonographic type of hip dysplasia according to the Graf's classification in patients with DDH.
Methods: Data of healthy infants (mean age 33 days) who had bilateral mature (normal) hips (Graf type I) were compared with the data of infants (mean age 105 days) who were treated by abduction brace due to unilateral or bilateral DDH (Graf type IIa- and worse hips).
Results: Infants with at least one risk factor had a significantly higher rate of DDH than those with no risk factors (p < 0.001). Likewise, infants with more than one risk factor had a significantly higher rate of DDH than those with only one risk factor (p = 0.008). Family history, breech presentation and swaddling were found to be the three significant risk factors related to the development of DDH. Family history, swaddling and oligohydramnios were found to be the three significant risk factors correlated with a higher rate of unstable/decentred hip(s) (Graf types D/III/IV) in patients with DDH.
Conclusion: The risk of DDH significantly increases in infants who have more than one risk factor for DDH. Positive family history and postnatal traditional swaddling are the two main factors both in the aetiology of DDH and in development of a more severe hip dysplasia in patients with DDH. Besides, breech presentation increases the risk of development of DDH and oligohydramnios leads to development of a more severe hip dysplasia in patients with DDH. By introducing these four variables as 'absolute risk factors for DDH' to the selective newborn hip screening programmes, the sensitivity and specificity of these programmes may be optimized and the risk of delayed diagnosis may be lessened.
文献出处：H Ömeroğlu, A Akceylan, N Köse. Associations Between Risk Factors and Developmental Dysplasia of the Hip and Ultrasonographic Hip Type A Retrospective Case Control Study. J Child Orthop. 2019 Apr 1;13(2):161-166.
文献4
症状性髋臼发育不良的Ottawa分类：
观察者间和观察者内可靠性的评估
译者：张利强
目的：本研究的目的是评估Ottawa分类评价症状性髋臼发育不良的可靠性。
方法：使用软件（Hip2Norm）将134例接受髋臼周围截骨术的髋关节分为四类：正常、外侧/整体缺损、前方或后方缺损。选取74例进行可靠性分析，其中髋关节发育不良患者44例，正常髋关节30例。掌握分类标准的6名研究员使用标准的放射测量方法在两个不同的时间点对这些髋关节进行了分类。此后，在4名研究员分别对74张X片进行第三次阅片之前，召开会议制定了修改后的流程图。
结果：研究员第1次和第2次测量的观察者内一致性从中度可靠到几乎完美（kappa=0.416到0.873）。关于研究员观察者间的一致性，第1次和第2次测量的一致性相似（第1次kappa=0.619，第2次kappa=0.623）。后壁缺损和前壁缺损kappa评分在第1次（后kappa=0.557；前kappa=0.438）和第2次测量（后kappa=0.506；前kappa=0.250）的观察者间一致性分别为中度和一般。在第3次测量时，总体（kappa=0.687）和前后壁缺损（后kappa=0.579；前kappa=0.521）的可靠性比第1次和第2次测量有所提高。
结论：Ottawa分类系统提供了一个可靠的方法来识别三种类型的髋臼发育不良，这三种类型的髋臼发育不良与手术治疗是一致的。“临界发育不良”一词不应再使用。
一位22岁女性的术前骨盆前后位片，右髋关节正常，外侧中心边缘角（LCEA）约为28°，髋臼指数（AI）约为2。
一位21岁女性的术前骨盆前后位片，左髋关节后壁有明显缺陷，外侧中心边缘角（LCEA）约为30°，髋臼指数（AI）约为-2
一位24岁男性的术前骨盆前后位片，右髋关节整体/外侧缺陷，外侧中心边缘角（LCEA）约为5°，髋臼指数（AI）约为2
一位19岁女性的术前骨盆前后位片，右髋关节前方缺陷，外侧中心边缘角约22°，髋臼指数约7
Ottawa classification for symptomatic acetabular dysplasia: assessment of interobserver and intraobserver reliability
Aims: The aim of the current study was to assess the reliability of the Ottawa classification for symptomatic acetabular dysplasia.
Methods: In all, 134 consecutive hips that underwent periacetabular osteotomy were categorized using a validated software (Hip2Norm) into four categories of normal, lateral/global, anterior, or posterior. A total of 74 cases were selected for reliability analysis, and these included 44 dysplastic and 30 normal hips. A group of six blinded fellowship-trained raters, provided with the classification system, looked at these radiographs at two separate timepoints to classify the hips using standard radiological measurements. Thereafter, a consensus meeting was held where a modified flow diagram was devised, before a third reading by four raters using a separate set of 74 radiographs took place.
Results: Intrarater results per surgeon between Time 1 and Time 2 showed substantial to almost perfect agreement among the raters (kappa = 0.416 to 0.873). With respect to inter-rater reliability, at Time 1 and Time 2 there was substantial agreement overall between all surgeons (Time 1 kappa =0.619; Time 2 kappa = 0.623). Posterior and anterior rating categories had moderate and fair agreement at Time 1 (posterior kappa = 0.557; anterior kappa = 0.438) and Time 2 (posterior kappa = 0.506; anterior kappa = 0.250), respectively. At Time 3, over-all reliability (kappa = 0.687) and posterior and anterior reliability (posterior kappa = 0.579; anterior kappa = 0.521) improved from Time 1 and Time 2.
Conclusion: The Ottawa classification system provides a reliable way to identify three categories of acetabular dysplasia that are well-aligned with surgical management. The term 'borderline dysplasia’ should no longer be used.
文献出处：Bali K, Smit K, Ibrahim M, et al. Ottawa classification for symptomatic acetabular dysplasia assessment of interobserver and intraobserver reliability. Bone Joint Res. 2020;9(5):242-249. Published 2020 Jun 8. doi:10.1302/2046-3758.95.BJR-2019-0155.R1
文献5
Legg-Calvé-Perthes病的股骨近端截骨术的长期结果
译者：陶可（北京大学人民医院骨关节科）
背景：Legg-Calvé-Perthes病是一种儿童时期的髋关节疾病，可能导致髋关节畸形和功能低下。本研究的目的是评估骨骼成熟时髋关节畸形与退行性骨关节炎之间的相关性，并提出Legg-Calvé-Perthes病进行股骨近端内翻去旋转截骨术的长期随访结果。
方法：我们分析了1959年至1983年间因Legg-Calvé-Perthes病接受股骨近端内翻去旋转截骨术的40例患者（43髋）的结果。所有可随访到的患者均接受了一次长期随访检查。采用Stulberg分类系统对髋关节进行分类；使用Tönnis分类评估髋骨关节炎。最终，评估了平均随访33年后的长期预后。
结果：使用Stulberg分类系统检查终末结果时，有8髋为Stulberg I型（19.5%），15髋为Stulberg II型36.6%），8髋为Stulberg III型（19.5%），9髋为Stulberg IV型（22%），和1髋为Stulberg V型（2.4%）。一位患有双侧Legg-Calvé-Perthes病的患者因髋骨关节炎接受了全髋关节置换术治疗。7例患者的临床随访结果较差。
结论：股骨近内翻去旋转截骨术可为Legg-Calvé-Perthes病提供良好的长期效果。Stulberg分类是患者预后的良好预测指标。
图1. 显示了从1959年至1983年的24年间，我们中心接受股骨近内翻去旋转截骨术(PFPD)手术治疗Legg-Calvé-Perthes病(LCPD)的患者分布。
图2. A，一位12岁男孩的骨盆术前前后位(AP)X线片显示了双侧LCPD，形成了明显不规则的股骨头和较差的股骨头覆盖率。B，患者44岁（36岁的随访）的术后AP位骨盆X线片显示头部变宽，有中等程度的骨关节炎迹象。
图3. A，一位6岁男孩的骨盆术前AP位X线片显示了左髋LCPD。B，在随访中，当患者为42岁时，髋关节无疼痛或骨关节炎的迹象。但是，我们认为该患者按照目前诊断标准应不会接受手术。
Long-term Results of Proximal Femoral Osteotomy in Legg-Calvé-Perthes Disease
Background: Legg-Calvé-Perthes disease is a childhood hip disorder that may result in a deformed and poorly functioning hip. The purpose of this study was to evaluate the correlation between hip deformity at skeletal maturity and degenerative osteoarthritis and to present the long-term results of proximal femoral varus derotational osteotomy in Legg-Calvé-Perthes disease.
Methods: We analyzed the results of 40 patients (43 hips), who underwent proximal femoral varus derotational osteotomy for Legg-Calvé-Perthes disease in our institution between 1959 and 1983. All available patients underwent a single long-term follow-up examination. Hips were classified with the classification system of Stulberg. Osteoarthritis was evaluated using the Tönnis classification. The long-term outcomes were evaluated after a mean follow-up period of 33 years.
Results: When examining the outcome using the Stulberg classification system, there were 8 Stulberg class I hips (19.5%), 15 Stulberg class II hips (36.6%), 8 Stulberg class III hips (19.5%), 9 Stulberg class IV hips (22%), and 1 Stulberg class V hip (2.4%). One patient, who had a bilateral Legg-Calvé-Perthes disease, underwent total hip replacement for osteoarthritis. Seven patients had poor clinical results.
Conclusions: Proximal femoral varus derotational osteotomy provides good long-term results for Legg-Calvé-Perthes disease. The Stulberg classification is a good predictor for patient outcome.
文献出处：Yiftah Beer, Yossi Smorgick, Amir Oron, Yigal Mirovsky, Danny Weigl, Gabriel Agar, Reuven Shitrit, Leonel Copeliovitch. Long-term Results of Proximal Femoral Osteotomy in Legg-Calvé-Perthes Disease. J Pediatr Orthop. 2008 Dec;28(8):819-824.
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