髋膝关节文献精译荟萃（第327期）

本期目录：

1、既往骨折导致创伤后骨关节炎行全膝关节置换术后并发症发生率高和患者报告的预后较差

2、既往股骨截骨术对后续全髋关节置换的影响

3、全血细胞计数百分比可以鉴别从围术期地塞米松治疗中获益的关节置换患者

4、切口外侧局部应用非甾体抗炎药（洛索洛芬钠）对单室膝关节置换术后疼痛的影响

5、全膝关节置换术与单髁膝关节置换术在疼痛、功能和心理轨迹上的比较

6、双切口改良骨盆三联截骨治疗残余髋关节发育不良

7、髋臼周围截骨术联合结构性同种异体骨移植治疗严重髋关节发育不良的的临床预后

8、印度发育性髋关节发育不良（DDH）的发病率、诊断和治疗

9、外部验证临界发育性髋关节发育不良患者的FEAR指数

10、临界髋关节发育不良患者的髋臼周围截骨术和髋关节镜联合髋关节囊紧缩缝合术的患者报告结果

第一部分：关节置换及保膝相关文献

文献1

既往骨折导致创伤后骨关节炎行全膝关节置换术后并发症发生率高和患者报告的预后较差：一项系统综述

译者 张轶超

目的：本研究旨在介绍现有文献中关于创伤后骨关节炎（PTOA）患者行全膝关节置换术（TKA）与因原发性骨关节炎（OA）患者行全膝关节置换术（TKA）患者报告的预后指标（PROMs）和并发症的比较。

方法：通过检索PubMed、Scopus、Cochrane Library和EMBASE等数据库中的现有文献，根据PRISMA指南进行系统性回顾和综合。根据PECO使用了搜索字符串。在对2781项研究进行分析后，18项研究（5729例PTOA患者/ 149,843例OA患者）被纳入最终分析。分析显示，12项（67%）为回顾性队列研究，4项（22%）为登记研究，其余2项（11%）为前瞻性队列研究。关键评估技能计划（CASP）的平均得分为23.6分（满分28分），表明研究质量中等。

结果：最常报道的结果指标是术后并发症，在所有18项研究中均有报道。10项研究（4165个PTOA /124,511个OA）报告了术中并发症，6项研究（210个toa /2768个OA）报告了患者报告的效果测量指标（PROMs）。总共评估了9种不同的PROMs。就PROMs而言，PTOA组得分较低，但与OA组没有统计学差异，只有一项研究偏向OA组。在所有的研究中，PTOA组的术后并发症更高，感染是最常见的并发症。此外，据报道，PTOA组的翻修率更高。

结论：PROM分析表明，两组患者在功能效果和缓解疼痛方面都受益于TKA，然而，患者报告的结果PTOA患者效果不好。有一致的证据表明，PTOA TKA术后并发症发生率高。应该告知骨折治疗后因PTOA而行TKA的患者其存在效果不佳的风险，避免患者将其术后膝关节功能与OA行TKA术后患者进行比较。外科医生应该意识到PTOA TKA带来的挑战。

Increased complications rates and inferior patient reported outcomes following total knee arthroplasty due to post‑traumatic osteoarthritis with previous fracture treatment: a systematic review

Purpose：This study aims to present the existing literature relating to patient-reported outcome measures (PROMs) and complications in patients undergoing total knee arthroplasty (TKA) due to posttraumatic osteoarthritis (PTOA) with prior fracture treatment around the knee compared with patients who underwent TKA because of primary osteoarthritis (OA).

Methods：A systematic review was undertaken and synthesised in accordance with the PRISMA guidelines by searching existing literature in the following databases: PubMed, Scopus, Cochrane Library and EMBASE. A search string according to the PECO was used. After analysing 2781 studies, 18 studies (5729 PTOA patients/149,843 OA patients) were included for a fnal review. An analysis revealed that 12 (67%) were retrospective cohort studies, four (22%) were register studies and the remaining two (11%) were prospective cohort studies. The mean Critical Appraisal Skills Programme (CASP) score was 23.6 out of 28, signifying studies of moderate quality.

Results：The most frequently reported outcome measure were postoperative complications, reported in all eighteen studies. Intraoperative complications were reported in ten (4165 PTOA/124.511 OA) and patient-reported outcome measures (PROMs) in six studies (210 PTOA/2768 OA). A total of nine diferent PROMs were evaluated. As far as PROMs were concerned, the scores were inferior for PTOA but did not difer statistically from OA, except for one study, which favoured the OA group. Across all studies, postoperative complications were higher in the PTOA group, reporting infections as the most common complication. Furthermore, a higher revision rate was reported in the PTOA group.

Conclusion：PROM analysis suggests that both patient groups beneft from a TKA in terms of functional outcome and pain relief, however, patient-reported outcomes could be inferior for PTOA patients. There is consistent evidence for increased complication rates following PTOA TKA. Patients undergoing TKA due to PTOA after fracture treatment should be informed about the risk for inferior results and refrain from comparing their knee function to patients with TKA after OA. Surgeons should be aware of the challenges that PTOA TKA poses.

文献出处：Syrikas I, Engbäck C, Tsikandylakis G, Karikis I, Desai N. Increased complications rates and inferior patient reported outcomes following total knee arthroplasty due to post-traumatic osteoarthritis with previous fracture treatment: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2023 Oct;31(10):4124-4141. doi: 10.1007/s00167-023-07407-x. Epub 2023 Apr 25. PMID: 37097470; PMCID: PMC10471648.

文献2

既往股骨截骨术对后续全髋关节置换的影响，系统性综述研究

译者 马云青

背景: 股骨截骨术已被广泛用于治疗各种发育性和退行性髋关节疾病。为此，不同类型的股骨近端截骨术: 在股骨颈部以及在转子间或转子下的水平。很少有研究评估既往的股骨截骨术对全髋关节置换术的影响; 因此，以前的股骨截骨术是否以及如何影响全髋关节置换术的术后结果仍然存在争议。

问题/目的: 在综述中，作者首先提出问题: (1)接受股骨截骨术的患者在全髋关节置换术后最常见的并发症是什么，这些并发症发生的率是多少？(2)股骨截骨术后全髋关节置换术的生存率如何？(3)内固定取出的时机是否与 THA 并发症和生存率有关？

方法: 在 PubMed、 Cochrane 数据库、 Scopus 和 Embase 数据库中，使用以下关键词“ THA”、“total hip arthroplasty”和“total hip replacement”结合以下至少一个关键词“股骨截骨术”或“转子间截骨术”进行系统综述检索，为实现搜索策略的最大灵敏度。纳入标准为: (1)报告了股骨截骨术后进行的 THA 的数据; (2)记录了 THA 随访; (3)股骨截骨术后接受 THA 的患者构成实验组或对照组; (4)描述了手术和临床并发症和 THA 的存活率。数据库共检索出了383项研究，作者对其进行了初步评估。在去除重复并完成纳入标准的全文评估后，15项研究(7项历史对照研究，8项病例系列研究)被纳入最终评估。从最终分析中包含的每个研究中检索特定信息。每项研究的质量用非随机研究方法学指数(MINORS)问卷进行评估。历史对照研究的 MINORS 平均评分为24分中的14分(范围10-17) ，而病例系列研究为16分中的8.1分(范围5-10)。

结果: 全髋置换术中发生并发症的患者比例为0% -17% 。最常见的术中并发症是股骨骨折，其他术中并发症是内固定取出困难和神经麻痹，在15项研究报告的并发症中提到了以上问题。在13项回答这个问题的研究中，股骨截骨术后 THA 的存活率从43.7% 到100% ，随访时间从2年到20年不等。五项研究描述了内固定取出的时机，其中三项研究详细描述了全髋置换时内固定取出的更多并发症。

结论: 这个综述表明股骨截骨术后的全髋关节置换术在技术上要求更高，并且可能比直接全髋关节置换术后并发症的风险更高。阶段性内固定取出可以降低术中骨折和感染的高风险，但是没有明确的证据支持这一论点。尽管股骨截骨术后 THA 的存活率普遍较高，但评估它的研究通常是回顾性病例系列研究，具有实质性偏倚，包括选择偏倚和转移偏倚(失访) ，因此在既往股骨截骨术后 THA 的存活率可能低于报道。

文献出处：Gallazzi E, Morelli I, Peretti G, Zagra L. What Is the Impact of a Previous Femoral Osteotomy on THA? A Systematic Review. Clin Orthop Relat Res. 2019 May;477(5):1176-1187. doi: 10.1097/CORR.0000000000000659. PMID: 30998636; PMCID: PMC6494317.

文献3

全血细胞计数百分比可以鉴别从围术期地塞米松治疗中获益的关节置换患者

译者 张蔷

背景：全血细胞计数百分比（CBRs）包括中性粒细胞-淋巴细胞比值（NLR）和单核细胞-淋巴细胞比值（MLR），这些炎症指标均与术后不良事件相关。考虑到手术应激反应与关节置换（TJA）术后并发症的明确关系，这项研究的主要目的是评估术前CBR升高能否鉴别关节置换术后应用地塞米松治疗后获益明显的患者。

方法：我们搜索了初级医保数据库中所有初次全髋或全膝关节置换（THA或TKA）的病例。我们应用以地塞米松治疗情况和CBRs数值作为独立变量的多元回归方程模型评估术后90天内并发症情况和超过3天的住院时长。首先我们比较了应用地塞米松组和未应用地塞米松组每个CBR四分区间下的研究指标。最终在每个CBR四分区间比较了所有概率差异。

结果：最终入组了2016年至2021年间共32849例初次择期关节置换病例（12788例THA[38.93%]，20061例TKA[61.07%]），其中22282例（67.83%）接受了围术期地塞米松治疗。NLR>1.00的患者中，应用地塞米松的病例术后并发症率更低（p<0.05）。相比NLR最低四分区间的病例（NLR<1.84），NLR最高四分区间的病例（NLR≥4.67）中应用地塞米松与LOS≥3天呈负相关性（p=0.002）。在MLR值≥0.36的病例中，接受地塞米松治疗的病例术后并发症率显著更低。而相比于MLR值<0.24（最低的四分区间）的病例，MLR值≥0.33（最高的两个四分区间）的病例中应用地塞米松与住院时长≥3天的概率更低相关（p=0.039）。

结论：NLR值和MLR值更高与围术期应用地塞米松后更高的临床获益相关，而这也更新了我们对关节置换术围术期炎症反应与术后不良事件相关性的认知。

Complete Blood Cell Count-Based Ratios Identify Total Joint Arthroplasty Patients Likely to Benefit from Perioperative Dexamethasone

Background: Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization.

Methods: The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles.

Results: A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of >1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p < 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR <1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of <0.24 (the lowest quartile) (p = 0.039).

Conclusions: Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA.

文献4

切口外侧局部应用非甾体抗炎药（洛索洛芬钠）对单室膝关节置换术后疼痛的影响：一项双盲随机对照试验

译者 丁云鹏

目的：如何减少膝关节置换术后的疼痛一直是一个巨大的挑战。本研究旨在评估在切口外侧局部应用非甾体类抗炎药对单室膝关节置换术（UKA）术后疼痛（NSAID）的影响。

方法：从2023年8月至2024年1月，随机对照试验纳入100例患者。100名接受UKA的患者被随机分为两组。干预组术后在切口外侧局部使用非甾体抗炎药，对照组术后在切口外侧使用安慰剂。外用非甾体抗炎药是洛索洛芬钠贴剂（LSP），每片含有100毫克洛索洛芬钠。对照组试验安慰剂为包含了与LSP相同的成分，并具有LSP相同的物理特性。主要观察指标为阿片类药物用量和视觉模拟评分（VAS）评分（术后12、24、36、48和72 h）。次要观察指标为美国膝关节学会评分（AKSS，术前及术后1个月随访）、首次镇痛需求时间、阿片类药物副作用、手术时间、术后住院时间、手术相关并发症、术后切口愈合等级。采用独立样本t检验和配对样本t检验对连续数据进行比较。分类数据的分析采用卡方检验和Fisher精确概率检验。

结果：98例患者(干预组48例；对照组50例)进行分析。干预组术后前12 h、12 ~ 24 h、24 ~ 48 h阿片类药物消耗均显著低于对照组（p < 0.05）。干预组术后72 h疼痛VAS评分明显低于对照组（p < 0.05）。两组患者在AKSS、手术时间、术后停留时间、并发症、术后切口愈合等级等方面均无显著差异。干预组患者首次自控镇痛需求时间明显晚于对照组（p < 0.05）。干预组阿片类药物副作用发生率（8.3%）低于对照组（18.0%）。

结论：术后切口外侧局部应用非甾体抗炎药是一种有效、安全的治疗UKA术后疼痛的方法，有助于降低疼痛评分，减少术后阿片类药物的消耗，且未增加副作用。

Effect of Topical Application of an NSAID Lateral to the Incision on Postoperative Pain Following Unicompartmental Knee Arthroplasty: A Double-Blind Randomized Controlled Trial

Objective: How to minimize postoperative pain following knee replacement surgery has been a great challenge. This study was performed to evaluate the effect of applying a topical nonsteroidal anti-inflammatory drug (NSAID) lateral to the incision for postoperative pain following unicompartmental knee arthroplasty (UKA).

Methods: The randomized controlled trial enrolled 100 patients from August 2023 to January 2024. One hundred patients who underwent UKA were randomized into two groups. The intervention group received a topical NSAID lateral to the incision postoperatively, and the control group received a placebo lateral to the incision postoperatively. The primary outcome measures were the amount of opioid consumption and the visual analogue scale (VAS) score (12, 24, 36, 48, and 72 h after operation) for pain. The secondary outcome measures were the American Knee Society Score (AKSS, preoperation and 1-month follow-up after operation), the time of first analgesic demand, side effects of opioids, operation time, postoperative stay, surgery-related complications, and postoperative incision healing grade. Independent sample t test and paired sample t test were used to compare continuous data. Chi-square test and Fisher's precision probability tests were used to analyze the categorical data.

Results: Ninety-eight patients (intervention group, 48 patients; control group, 50 patients) were analyzed. Opioid consumption was significantly lower in the intervention group than in the control group during the first 12 h, 12 to 24 h, and 24 to 48 h postoperatively (p < 0.05). The VAS score for pain within 72 h postoperatively was significantly lower in the intervention group than in the control group (p < 0.05). There was no significant difference in the AKSS, operation time, postoperative stay, complications, or postoperative incision healing grade between the two groups. The time of first analgesic demand for patient-controlled analgesia was significantly later in the intervention group than in the control group (p < 0.05). There were fewer side effects of opioids in the intervention group (8.3%) than in the control group (18.0%).

Conclusion: Postoperative application of topical NSAIDs lateral to the incision is an effective and safe method for pain management after UKA, helping to decrease the pain score and reduce opioid consumption postoperatively with no increase in side effects.

文献出处 Chao Li , Lei Li , Yifan Li , Effect of Topical Application of an NSAID Lateral to the Incision on Postoperative Pain Following Unicompartmental Knee Arthroplasty: A Double-Blind Randomized Controlled Trial.Orthop Surg. 2024 Jul;16(7):1555-1561. doi: 10.1111/os.14084. Epub 2024 May 28.

文献5

全膝关节置换术与单髁膝关节置换术在疼痛、功能和心理轨迹上的比较：

一项6个月前瞻性观察研究的二次分析

译者 沈松坡

背景

单髁膝关节置换术（UKA）用于治疗膝关节单间室的骨关节炎，而全膝关节置换术（TKA）则针对所有间室。围绕UKA和TKA的争议在于UKA的快速恢复和较少的并发症与TKA较低的长期修复率之间的平衡，这突显了对手术后结果进行全面评估的重要性。本研究旨在描述并比较全膝关节置换术与单髁膝关节置换术在术后6个月康复期间疼痛、功能和心理轨迹的差异。

方法

共招募了115名接受TKA或UKA的参与者，分别在术后1周、4周、12周和24周进行了结果评估。测量内容包括疼痛强度（视觉模拟评分）、关节活动度、步行速度（4米步行测试）、身体功能表现（30秒椅子起立测试）、健康功能（Western Ontario和McMaster大学骨关节炎指数）、疼痛灾难化（疼痛灾难化量表）、对运动的恐惧（Tampa恐惧运动量表）以及焦虑和抑郁（医院焦虑和抑郁量表）。通过混合效应模型分析手术类型对疼痛、功能和心理轨迹的影响。

结果

TKA和UKA组均在6个月康复期间显著改善，唯TKA组的焦虑症状以及UKA组的运动恐惧和抑郁未显著改善。两组在术后早期（急性期）表现出差异：UKA患者活动度较好，而TKA患者步行速度较快但运动恐惧更高。总体而言，手术类型未显著影响整个康复期间的疼痛、功能和心理轨迹。

结论

尽管在急性期存在差异，TKA和UKA在6个月康复期间的疼痛、功能和心理轨迹无显著差异。这些结果有助于更好地向患者提供信息并优化围手术期的患者教育。

Comparison of pain, functional and psychological trajectories between total and unicompartmental knee arthroplasties: secondary analysis of a 6-month prospective observational study

Introduction: Unicompartmental knee arthroplasty (UKA) treats osteoarthritis in one knee compartment, while total knee arthroplasty (TKA) addresses all compartments. The debate focuses on UKA's advantages of quicker recovery and fewer complications versus TKA's lower long-term revision rates, emphasizing the need for thorough outcome evaluations. The aim of the present study is to describe and compare the pain, functional and psychological trajectories during a 6-month postoperative rehabilitation period between total and unicompartmental knee arthroplasties.

Materials and methods: 115 participants who had undergone either TKA or UKA were recruited. Outcome measurements were performed at 1, 4, 12 and 24 weeks post-surgery. Measurements included pain intensity (Visual Analog Scale), range of motion, walking speed (4 m walking test), physical performance (30-s chair stand test), health functioning (Western Ontario and McMaster Universities Osteoarthritis Index), pain catastrophizing (pain catastrophizing scale), fear of movement (Tampa Scale of Kinesiophobia), anxiety and depression (Hospital Anxiety and Depression Scale). A mixed-effects model was used to estimate the influence of type of surgery (either unicompartmental or total knee arthroplasty) to pain, function, and psychological trajectories.

Results: Both TKA and UKA groups showed significant improvements across the six-month rehabilitation period except for anxiety symptoms in the TKA group, and fear of movement and depression in the UKA group. Between group analysis revealed that in the acute phase UKA patients showed improved range of motion and TKA patients displayed faster walking speed but higher fear of movement. Overall, the type of surgery does not significantly influence the overall rehabilitation pain, functional and psychological trajectories.

Conclusions: Despite differences in the acute phase, there are no differences in pain, functional and psychological trajectories throughout the six-month rehabilitation period. These results should be acknowledged to better inform patients and to improve patient education during the perioperative period.

文献出处：Terradas-Monllor M, Rierola-Fochs S, Merchan-Baeza JA, Parés-Martinez C, Font-Jutglà C, Hernández-Hermoso JA, Ochandorena-Acha M. Comparison of pain, functional and psychological trajectories between total and unicompartmental knee arthroplasties: secondary analysis of a 6-month prospective observational study. Arch Orthop Trauma Surg. 2024 Dec 12;145(1):32. doi: 10.1007/s00402-024-05710-x. PMID: 39666075; PMCID: PMC11638299.

第二部分：保髋相关文献

文献1

双切口改良骨盆三联截骨治疗残余髋关节发育不良

译者 罗殿中

目的：评估改良入路骨盆三联截骨（TPO）治疗残余髋关节发育不良的可靠性、安全性、和有效性。

方法：该回顾性研究纳入2019年至2023年有15患15髋残余髋关节发育不良，进行Tonnis描述的双切口改良三联截骨手术治疗。第一个改良是采用内侧切口行耻骨和坐骨截骨（Vladimirov改良），第二个改良是坐骨截骨靠近髋臼，以便髋臼骨块自由选择、充分覆盖股骨头（Li氏改良）。手术时平均年龄为11.85岁（8-23岁），10位男性（66.7%）、5位女性（33.3%）。平均随访36.533个月（20-60月）。

结果：我们的结果显示临床和影像显著改善。中心边缘角（CE角）由术前的10°（2°-17°）提高到术后的32.785°（18°-40°），髋臼指数（AI）由术前的平均32°降低为术后的平均13.89°，HHS由术前的平均74.80分提高到术后的平均90.67分。同样，髋关节活动度（ROM）也得到显著改善（外展和内旋），下肢不等长由术前的平均2.6cm改善为术后的平均0.37cm。在我们的临床病例研究中，出现3例延迟愈合，无骨坏死和神经并发症。

结论：采用双切口改良骨盆三联截骨术（TPO）安全、有效，对髋关节发育不良患者可提供恰当的股骨头覆盖，手术时间短，功能恢复满意，并发症少。

图1. 坐骨支截骨示意图。我们采用髋臼下截骨（红色线条），位于骶棘韧带、骶结节韧带外侧（黑色线段）。

图2. （a）9.2岁女孩右侧髋关节发育不良；（b）3D重建显示髋臼外侧壁缺损；（c）术前临床检查显示屈膝时右髋屈髋外展受限；（d）伸膝时右髋外展受限；（e）右髋内旋受限；（f）术后即刻骨盆片；（g）术后1个月复查；（h）术后完全愈合并重建。

图3. （a）13岁男孩术前骨盆蛙氏位片显示右髋关节发育不良；（b）站立位下肢全长片显示继发于右侧髋关节半脱位的下肢不等长；（c,d）右侧TPO+股骨短缩截骨术后即刻正位片和侧位片。

Modified triple pelvic osteotomy for residual acetabular dysplasia through double incisions: Technical note and review of short-term results

Purpose:To assess validity, safety, and efficacy of the modified triple pelvic osteotomy (TPO) approach for correction of residual acetabular dysplasia.

Methods:This is a retrospective case series conducted on 15 hips in 15 patients from 2019 to 2023 with residual acetabular dysplasia treated by modified TPO as described by Tonnis with two modifications. The first modification is using a single medial incision for pubic and ischial cuts (the Vladimirov modification). The second modification is having the ischial cut closer to the acetabulum (Li modification) allowing free movement of the acetabular fragment for better femoral head coverage. The mean age at the time of surgery was 11.85 years, (range 8-23). Cases presenting were 10 males (66.7%) and 5 females (33.3%). The mean follow-up period was 36.533 months (24-60 months).

Results:Our study revealed significant clinical and radiological improvement. The CE angle improved from a mean value of 10° (range 2-17) pre-operatively to 32.785° (range 18°-40°) post-operatively. The AI improved from a mean value of 32° pre-operatively to a mean value of 13.89° post-operatively. HHS increased from a preoperative mean value of 74.80° to a post-operative mean value of 90.67°. Also, there was a significant improvement in ROM (abduction and internal rotation). LLD improved from a mean value of 2.60 cm preoperatively to a mean value of 0.37 cm postoperatively. Delayed union was found in 3 cases. No cases of osteonecrosis or neurovascular complication were encountered in our study.

Conclusion:The modified TPO technique using dual incisions can be considered safe and effective, providing adequate coverage of the femoral head in acetabular dysplasia with less surgical time, satisfactory functional outcomes, and minimal complications.

文献出处：Aly AS, Fayyad TA, El-Beshry SS, Elhusseiny KT, El Ghazawy AK. Modified triple pelvic osteotomy for residual acetabular dysplasia through double incisions: Technical note and review of short-term results. SICOT J. 2024;10:14. doi: 10.1051/sicotj/2024012. Epub 2024 Apr 30. PMID: 38687149; PMCID: PMC11060049.

文献2

髋臼周围截骨术联合结构性同种异体骨移植治疗严重髋关节发育不良的的临床预后

译者 肖凯

目的：明确一种球形髋臼周围截骨术（TOA，髋臼转位截骨术）联合结构性同种异体骨移植治疗严重髋关节发育不良的中期疗效。

方法：我们回顾性分析了1998年至2019年间接受TOA联合结构性同种异体骨移植治疗的严重髋关节发育不良患者。严重髋关节发育不良定义为Severin IVb或V级（外侧中心边缘角（LCEA）< 0°）。通过病历回顾提取患者的人口学数据、与截骨相关的并发症以及改良Harris髋关节评分（mHHS）。在术前及术后影像学中测量髋关节发育不良的放射学参数。采用Kaplan-Meier生存分析法估算TOA失败（进展至Tönnis 3级或需要行全髋关节置换术）的累积概率，并通过多变量Cox比例风险模型分析预后不良的危险因素。

结果：本研究共纳入64名患者（76髋）。中位随访时间为10年（四分位距：5至14年）。mHHS由术前的中位67分（IQR：56至80分）提高至术后随访时的中位96分（IQR：85至97分）（p < 0.001）。术后放射学参数显著改善（p < 0.001），其中42%至95%的髋关节参数达到正常范围。手术生存率在10年时为95%，在15年时为80%。术前Tönnis 2级是TOA失败的独立危险因素。

结论：我们的研究表明，对于青少年及年轻成人的严重髋臼发育不良但未伴有晚期骨关节炎的病例，TOAst联合结构性同种异体骨移植是一种可行的手术选择，且具有良好的中期预后。

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

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

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

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

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

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

文献3

印度发育性髋关节发育不良（DDH）的发病率、诊断和治疗：一项范围系统综述

译者 任宁涛

目的：鉴定印度髋关节发育不良（DDH）的发病率、诊断和治疗方面的差异和知识差距的文献。

方法：按照标准方法和PRISMA-ScR指南，对印度DDH发病率、诊断和治疗的文献进行系统性综述。1975年至2021年3月期间在印度进行的、发表在索引或非索引期刊上的研究也包括在搜索中。

结果：共纳入57篇文献，其中33篇（57.8%）符合纳入标准。28项研究（49%）发表在骨科期刊上，大多数以骨科医生为第一作者（59.6%）。16项研究主要是流行病学研究，20项报告了筛查/诊断，21项报告了DDH的治疗。根据研究中的证据水平，几乎90%的研究（51项）是4或5级。髋关节发育不良的定义和筛查/诊断指南尚不明确。据报道，印度髋关节发育不良的发病率为0-75 /1000活产，真正的DDH在0- 2.6/1000之间。迟发性DDH在印度很常见，大多数研究报告就诊儿童的平均年龄为＞20个月。治疗也是多种多样的，而且没有明确的循证方法来选择各种治疗方案，缺乏长期的研究。

结论：这一范围系统综述突出了印度DDH诊断和治疗方面的各种知识差距。未来需要在确定的空白领域开展高质量、多中心的研究，并进行长期随访。

The Incidence, Diagnosis, and Treatment practices of Developmental Dysplasia of Hip (DDH) in India: A Scoping Systematic Review

Purpose: To identify literature on variations and knowledge gaps in the incidence, diagnosis, and management of developmental dysplasia of hip (DDH) in India.

Methods: Following standard methodology and PRISMA-ScR guidelines, a scoping systematic review of literature on incidence, diagnosis, and treatment of DDH in India was conducted. Studies conducted in India, published in indexed or non-indexed journals between 1975 and March 2021, were included in the search.

Results: Of 57 articles which met the inclusion criteria, only 33 studies (57.8%) were PubMed-indexed. Twenty-eight studies (49%) were published in Orthopaedic journals and majority had orthopaedic surgeon as the lead author (59.6%). Sixteen studies were mainly epidemiological, 20 reported screening/diagnosis, and 21 reported treatment of DDH. Almost 90% of the studies (51) were Level 4 or 5 according to the levels of evidence in research. There is lack of clarity in the definition of hip dysplasia and screening/diagnostic guidelines to be used. The incidence of hip dysplasia in India is reported to be 0-75 per 1000 live births, with true DDH between 0 and 2.6/1000. Late-presenting DDH is common in India, with most studies reporting a mean age of > 20 months for children presenting for treatment. The treatment is also varied and there is no clear evidence-based approach to various treatment options, with lack of long-term studies.

Conclusion: This systematic scoping review highlights various knowledge gaps pertaining to DDH diagnosis and management in India. High-quality, multicentric research in identified gap areas, with long-term follow-up, is desired in future.

文献出处: Chand S, Aroojis A, Pandey RA, Johari AN. The Incidence, Diagnosis, and Treatment practices of Developmental Dysplasia of Hip (DDH) in India: A Scoping Systematic Review. Indian J Orthop. 2021 Sep 24;55(6):1428-1439. doi: 10.1007/s43465-021-00526-y. PMID: 35003534; PMCID: PMC8688615.

文献4

外部验证临界发育性髋关节发育不良患者的FEAR指数

译者 张利强

背景：鉴于缺乏确定的、外部验证的髋关节不稳定诊断标准，股骨头骨骺臼顶指数（FEAR）已作为识别临界发育性髋关节发育不良髋关节稳定性的有用工具。

目的：（1）确定FEAR指数在鉴别临界发育性髋关节发育不良临床诊断为不稳定髋关节的外部表现，以及（2）评估FEAR指数单独与臼顶倾斜或骨骺角比较的性能。

方法：作者回顾了176例临界发育性髋关节发育不良患者（外侧中心边缘角，20°-25°）。定义阳性FEAR指数为≥5°。还评估了≥2°的替代阈值。高年资外科医生根据患者和影像学特征的组合确定严重的不稳定；不稳定髋关节采用髋臼周围截骨术（有或没有髋关节镜）治疗，稳定髋关节采用单独髋关节镜治疗。

结果：只有18%的临界发育不良髋关节FEAR指数阳性。FEAR指数阳性阈值≥5°在预测临床诊断不稳定方面的敏感性为33%（23/70），特异性为92%（98/106）。≥2°FEAR指数阈值在预测临床诊断不稳定方面的敏感性为39%（27/70），特异性为89%（94/106）。FEAR指数无其他阈值可表现出高水平的敏感性和特异性。当阈值为-5°时才能达到74%的足够灵敏度。即使在控制了髋顶倾斜度（比值比1.12；P<0.001）或骨骺角（比值比1.6；P<0.001）后，FEAR指数仍然是髋关节不稳定的重要预测因素。

结论：在目前的研究中，FEAR指数阳性通常表明存在临床不稳定性，但单独使用FEAR指数仍不足以完全确定给定髋关节的不稳定性，因为它在外部验证中的敏感性较低（仅33%）。恐惧指数最好用于其他临床和影像学特征一起使用。

关键词：临界发育不良；不稳定；FEAR指数

左髋FEAR指数（绿线）为5.12°。右髋FEAR指数为髋臼眉弓（髋臼倾斜度，蓝线）和骺线角（红线）之间形成的角度。

临床诊断为不稳定的两例髋关节：(A) FEAR指数 <5°（阴性）和(B) FEAR指数＞5°（阳性）。

External Validation of the FEAR Index in Borderline Acetabular Dysplasia

Background: Given the lack of established, externally validated criteria for the diagnosis of unstable hips, the Femoro-Epiphyseal Acetabular Roof (FEAR) index has been proposed as a useful tool for identifying hips with instability in the setting of borderline acetabular dysplasia.

Purposes: To (1) determine the external performance of the FEAR index in identifying hips with a clinical diagnosis of instability in the setting of borderline dysplasia and (2) assess the performance of the FEAR index compared with acetabular inclination or physeal scar angle alone.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: The authors reviewed 176 patients with borderline acetabular dysplasia (lateral center-edge angle, 20°-25°). A positive FEAR index was defined as ≥ 5°. An alternative threshold ≥ 2° was also assessed. Significant instability was determined by the senior surgeon based on the combination of patient and radiographic features; unstable hips were treated with periacetabular osteotomy (with or without hip arthroscopy), and stable hips were treated with isolated hip arthroscopy.

Results: Only 18% of borderline hips had a positive FEAR index. The ≥ 5° positive FEAR index threshold had a sensitivity of 33% (23/70) and specificity of 92% (98/106) in predicting the clinical diagnosis of instability. The ≥ 2° FEAR index threshold had a sensitivity of 39% (27/70) and specificity of 89% (94/106) in predicting the clinical diagnosis of instability. No alternative threshold for the FEAR index resulted in high levels of sensitivity and specificity. A threshold of –5 was required to reach an adequate sensitivity of 74%. The FEAR index remained a significant predictor of hip instability even after controlling for acetabular inclination (odds ratio, 1.12; P < 0.001) or physeal scar angle (odds ratio, 1.6; P < 0.001).

Conclusion: In the current study, a positive FEAR index was generally indicative of the presence of clinical instability, but the FEAR index alone remained inadequate to fully define the instability of a given hip, as it demonstrated low sensitivity (only 33%) in the external validation. The FEAR index is best used in the context of other clinical and radiographic features.

Keywords: borderline dysplasia; instability; FEAR index

文献出处：Schwabe MT, Clohisy JC, A Graesser E, Pascual-Garrido C, Nepple JJ. External Validation of the FEAR Index in Borderline Acetabular Dysplasia. Orthop J Sports Med. 2022 Aug 11;10(8):23259671221113837. doi: 10.1177/23259671221113837. PMID: 35990876; PMCID: PMC9382071.

文献5

临界髋关节发育不良患者的髋臼周围截骨术和髋关节镜联合髋关节囊紧缩缝合术的患者报告结果

译者 陶可

目的：比较临界髋关节发育不良患者接受髋关节镜检查(HA)和髋臼周围截骨术(PAO)后的最低5年患者报告结果。

方法：从2家机构中选出接受髋臼周围截骨术(PAO)或髋关节镜检查(HA)且外侧中心边缘角(LCEA)在18°至小于25°之间的髋关节患者。排除标准如下：外侧中心边缘角(LCEA)小于18°、Tönnis骨关节炎分级大于1、既往髋关节手术、活动性炎症性疾病、工伤赔偿和同期手术。患者根据年龄、性别、体重指数和Tönnis骨关节炎分级进行倾向匹配。患者报告的结果测量包括改良的Harris髋关节评分，以及计算最小临床重要差异、患者可接受的症状状态和最大结果改善满意度阈值。术前X线预测因素包括股骨-骨骺髋臼Roof指数和圆韧带损伤的比较。

结果：共有28名髋臼周围截骨术(PAO)患者与49名髋关节镜检查(HA)患者进行了倾向匹配。两组在平均年龄、性别、术前体重指数和外侧中心边缘角(LCEA)方面相似。髋臼周围截骨术(PAO)组的平均随访期较长（95.8个月 vs 81.3个月，P = .001）。髋关节镜检查(HA)组术前股骨-骨骺髋臼Roof指数平均显著较低（P < .001）。从术前到最新随访，两组的平均改良Harris髋关节评分均显示出相似且显著的改善（P < .001）。髋臼周围截骨术(PAO)组后续手术的相对风险为3.49（P = .024），主要归因于内固定螺钉的移除（25%）。髋臼周围截骨术(PAO)组和髋关节镜检查(HA)组的翻修率为3.6%和8.2% (P = .65)。髋臼周围截骨术(PAO)组中的一名患者因关节内粘连而需要髋关节镜检查(HA)翻修。髋关节镜检查(HA)组中需要翻修的患者中有三名因持续疼痛而接受髋臼周围截骨术(PAO)，一名仅接受翻修髋关节镜检查(HA)。髋关节镜检查(HA)组中有1名患者需要转为全髋关节置换术，而髋臼周围截骨术(PAO)组中没有患者需要转为全髋关节置换术。

结论：髋臼周围截骨术(PAO)和髋关节囊紧缩缝合术的髋关节镜检查(HA)均可为边缘性髋关节发育不良患者带来临床显著改善，术后至少5年翻修率较低。

Femoral osteotomy for osteonecrosis of the femoral head

Purpose: To compare minimum 5-year patient-reported outcome measures after hip arthroscopy (HA) and periacetabular osteotomy (PAO) for borderline hip dysplasia.

Methods: Hips with a lateral center-edge angle (LCEA) between 18° and less than 25° that underwent either PAO or HA were selected from 2 institutions. The exclusion criteria were as follows: LCEA less than 18°, Tönnis osteoarthritis grade greater than 1, prior hip surgical procedures, active inflammatory disease, Workers' Compensation, and concomitant surgery. Patients underwent propensity matching based on age, sex, body mass index, and Tönnis osteoarthritis grade. Patient-reported outcome measures included the modified Harris Hip Score, as well as calculation of the minimal clinically important difference, patient acceptable symptom state, and maximum outcome improvement satisfaction threshold. Preoperative radiographic predictors included comparison of the Femoro-epiphyseal Acetabular Roof index and ligamentum teres lesions.

Results: A total of 28 PAO patients underwent propensity matching to 49 HA patients. The 2 groups were similar in terms of mean age, sex, preoperative body mass index, and LCEA. The PAO group had a longer mean follow-up period (95.8 months vs 81.3 months, P = .001). The mean Femoro-epiphyseal Acetabular Roof index was significantly lower preoperatively in the HA group (P < .001). The 2 groups showed similar and significant improvements in the mean modified Harris Hip Score from preoperatively to latest follow-up (P < .001). The relative risk of subsequent surgery in the PAO group was 3.49 (P = .024), mostly attributed to hardware removal (25%). The revision rate was 3.6% in the PAO group and 8.2% in the HA group (P = .65). One patient in the PAO group required revision HA for intra-articular adhesions. Three of the patients requiring revision in the HA group underwent PAO because of persistent pain, and one underwent revision HA alone. Conversion to total hip arthroplasty was required in 1 patient in the HA group and no patients in the PAO group.

Conclusions: Both PAO and HA with capsular plication provide borderline hip dysplasia patients with clinically significant improvements and low revision rates at a minimum of 5 years postoperatively.

文献出处：Octavian Andronic 1, Edwin O Chaharbakhshi 2, Patrick O Zingg 3, Christoph Germann 4, Stefan Rahm 3, Ajay C Lall 5, Benjamin G Domb 2. No Difference in Patient-Reported Outcomes for Periacetabular Osteotomy and Hip Arthroscopy With Capsular Plication in the Setting of Borderline Hip Dysplasia: A Propensity-Matched Multicenter Study With Minimum 5-Year Follow-Up. Multicenter Study, Arthroscopy. 2024 Mar;40(3):754-762. doi: 10.1016/j.arthro.2023.06.045.

来源：304关节学术

作者：304关节团队

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