髋膝关节文献精译荟萃（第348期）

本期目录：

1、机器人辅助膝关节重建的有效性和安全性

2、经典适应证以外的内侧单间室膝关节置换病例获得近似疗效

3、全膝关节置换术后膝关节对线判断的机器学习模型开发

4、基于CT三维统计建模的骨盆环不对称性评估

5、Perthes病患者限制负重和运动与生活质量的关系

6、机器人辅助增强现实（AR）引导的髋臼周围截骨手术导航

7、切开复位治疗挛缩型髋关节是否会导致关节僵硬

8、股骨前倾角增大导致内八字步态受试者行走时的关节接触力研究

9、盂唇内翻是DDH患儿行挽具治疗失败的预测因素

第一部分：关节置换及保膝相关文献

文献1

机器人辅助膝关节重建的有效性和安全性：系统回顾和荟萃分析

译者 张轶超

目的：机器人辅助手术越来越多地应用于髋关节和膝关节重建。然而，与传统手术相比，机器人辅助全膝关节置换术（RATKR）的相对疗效和安全性仍不确定。本研究旨在系统回顾当前文献，比较RATKR与传统手术的效果。

材料与方法：在主要数据库中进行全面的文献检索，找出比较RATKR与传统手术的研究。主要比较结果是功能评分和术后并发症。采用随机效应模型计算95%置信区间（CIs）的合并平均差（MDs）。

结果：共纳入12项研究。两组间的西安大略和麦克马斯特大学骨关节炎指数（WOMAC）、膝关节协会评分（KSS）、特种外科医院 （HSS）评分、疼痛视觉模拟评分(VAS) 的合并功能评分差异无统计学意义（MD = -0.99, 95% CI -2.32 ~ 0.34， p值= 0.14）。髋关节和膝关节重建的亚组分析也显示在功能评分方面没有显著差异。然而，对于术后并发症，虽然两组在失血量方面无显著差异（MD = -1.62, 95% CI -4.42 ~ 1.17， p值= 0.25），但RATKR组的再入院率明显高（MD = 0.94, 95% CI 0.77 ~ 1.11， p值< 0.00001）。总体异质性非常高（I²= 93%），特别是在术后并发症的分析中。

结论：研究结果表明，与传统手术相比，机器人辅助膝关节重建并没有显著改善功能预后。除了RATKR后再入院率更高外，安全性大体相似。考虑到高度的异质性，需要进一步的大规模、精心设计的随机对照试验来最终确定机器人辅助髋关节和膝关节重建的有效性和安全性。

Efficacy and safety of robotic-assisted knee reconstruction: a systematic review and meta-analysis

OBJECTIVE: Robotic-assisted surgery is increasingly being utilized in hip and knee reconstruction. However, the relative efficacy and safety of robotic-assisted total knee replacement (RATKR) compared to traditional surgery remained uncertain. This study aimed to systematically review the current literature comparing the outcomes of RATKR to traditional procedures.

MATERIALS AND METHODS: Comprehensive literature searches were conducted in major databases to identify studies comparing RATKR with traditional surgeries. The primary outcomes were functional scores and post-operative complications. Pooled mean differences (MDs) with 95% confidence intervals (CIs) were calculated using a random effects model.

RESULTS: A total of 12 studies were considered for inclusion. The pooled functional scores of The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Society Score (KSS), hospital for Special Surgery (HSS) score, visual analogue score (VAS) pain score showed no significant differences between the two groups (MD = -0.99, 95% CI -2.32 to 0.34, p-value = 0.14). The subgroup analysis for hip and knee reconstructions also revealed no significant difference in terms of functional scores. However, for post-operative complications, while there was no significant difference in terms of blood loss (MD = -1.62, 95% CI -4.42 to 1.17, p-value = 0.25), the readmission rates were significantly higher in the RATKR group (MD = 0.94, 95% CI 0.77 to 1.11, p-value < 0.00001). The overall heterogeneity was extremely high (I² = 93%), particularly in the analyses of post-operative complications.

CONCLUSIONS: The findings suggested that robotic-assisted knee reconstruction did not significantly improve functional outcomes compared to traditional surgery. The safety profile was similar except for a higher readmission rate following RATKR. Given the high heterogeneity, further large-scale, well-designed, randomized controlled trials are needed to conclusively determine the efficacy and safety of robotic-assisted hip and knee reconstruction.

文献出处：Alshahrani AH. Efficacy and safety of robotic-assisted knee reconstruction: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2024 Mar;28(6):2250-2262. doi: 10.26355/eurrev_202403_35729. PMID: 38567588.

文献2

经典适应证以外的内侧单间室膝关节置换病例获得近似疗效

译者 张蔷

背景：单间室膝关节置换（UKA）手术的适应证有多条。本研究的目的是探究经典UKA适应证以外病例UKA术后的疗效。

方法：本研究纳入了197例2017年-2020年间因内侧间室骨关节炎而接受UKA手术治疗的病例。病例分两组进行比较：一组为满足经典适应证的病例，另外一组为至少有一条禁忌证的病例（如年龄≥75岁，BMI≥30kg/m2或内翻畸形>8°）。所有病例均采用了同一款现代固定平台假体。最短随访3年。首要研究指标为关节功能，包括膝关节协会评分（KSS），次要研究指标为并发症情况及翻修率。

结果：最终经典适应证组有100例，适应证以外组有97例。两组间的身高、性别比例、术侧或骨关节炎阶段均无显著性差异（p > 0.05）。两组间的KSS评分也没有显著性差异（p = 0.96）。在3年随访时，经典适应证组的生存率为100%，而适应证以外组为95.38%（p = 0.57）。经典适应证组的并发症率为12.9%而适应证以外组为8.96%（p = 0.47）。

结论：至少包含一项禁忌证（BMI≥30kg/m2，年龄≥75岁或内翻畸形>8°）的内侧间室膝骨关节炎病例在UKA术后获得了与经典适应证病例近似的关节功能，且术后3年随访时的并发症率或翻修率也没有显著性变化。

Similar Functional Results in Patients outside the Classical Criteria for Medial Unicompartmental Knee Arthroplasty

Background: The indications for unicompartmental knee arthroplasty (UKA) are restricted by multiple criteria. The aim of this study was to explore the functional results of UKA in a population of patients outside the classical criteria.

Methods: This study included a population of 197 patients who underwent UKA for medial osteoarthritis between 2017 and 2020. Two groups of patients were compared: those meeting the classical criteria and those presenting with ≥1 contraindication (e.g., age of ≥75 years, body mass index [BMI] of ≥30 kg/m2, or coronal limb deformity of >8°). The implant that was used was a modern fixed-bearing primary medial UKA component. The minimal follow-up was 3 years. The primary outcome was the functional results, including the Knee Society Score (KSS), and the secondary outcomes were the complication and revision rates.

Results: There were 100 patients in the indication group and 97 in the off-indication group. No significant differences were observed between the 2 groups for height, sex ratio, operated side, or osteoarthritis stage (p > 0.05). There was no significant difference in the KSS between the 2 groups (p = 0.96). At 3 years of follow-up, the survival rate without revision was 100% in the indication group and 95.38% in the off-indication group (p = 0.57). The rate of complications was 12.9% in the indication group and 8.96% in the off-indication group (p = 0.47).

Conclusions: UKA for medial osteoarthritis yielded the same functional results for patients presenting with ≥1 theoretical contraindication, including a BMI of ≥30 kg/m2, age of ≥75 years, and coronal limb deformity of >8°, without altering the complication or revision rates at 3 years of follow-up.

文献3

全膝关节置换术后膝关节对线判断的机器学习模型开发

译者 沈松坡

引言：对线异常仍然是全膝关节置换术（TKA）后植入物失败的主要原因之一。大规模手动图像分析不可行，而机器学习（ML）模型或许是判断TKA术后对线的有用工具，并能帮助识别有失败风险的患者。我们旨在开发一款能从全长髋-膝-踝影像中准确判断TKA对线的ML模型。

方法：收集了550位接受初次TKA的患者的长腿X线片（LLR），其中440例用于训练ML模型以识别用于测量对线的标志点。包括股骨头、转子间区域、股骨干中段、股骨假体内外侧髁远端、胫骨托板上缘内侧1/3与外侧1/3、胫骨干中段、胫骨平台底面等位置。基于这些标志点计算力线膝角（mHKA）、股骨远端外侧角（LDFA）、胫骨平台近端内侧角（MPTA）与关节线倾斜度（JLO）。另外110例LLR用于测试模型的准确性。

结果：ML模型可在小于0.1秒内分析一张影像。ML模型与人工测量的平均角度误差为：mHKA误差0.08º（标准差SD = 0.8），LDFA误差0.7º（SD = 0.9），MPTA误差0.4º（SD = 0.3），JLO误差0.7º（SD = 0.8）。

结论：我们开发的ML模型在TKA术后对线判断中展现出高度准确性，显示出人工智能技术在提升关节置换术临床工作流程和科研效率方面的巨大潜力。

Development of a Machine Learning Model for Determining Alignment in Knees Following Total Knee Arthroplasty

Introduction: Malalignment remains a major reason for implant failure following total knee arthroplasty (TKA). Manual analysis of images at a large scale is untenable, and machine learning (ML) models may be a useful tool for determining alignment following TKA and can help identify patients who are at risk for failure. We aimed to develop an ML model that can accurately determine TKA alignment from full-length hip-to-ankle films.

Methods: Long-leg radiographs (LLR) from 550 patients who had undergone primary TKA were collected, of which 440 were utilized to train an ML model to identify landmarks used for alignment measurement. These landmarks included the femoral head, the intertrochanteric region, the femoral midshaft, the distal aspects of the medial and lateral implant femoral condyle, the medial third and lateral third of the superior border of the tibial base plate, the tibial midshaft, and the tibial plafond. Following identification of these landmarks, mechanical hip-knee-ankle angle (mHKA), lateral distal femoral angle (LDFA), medial tibial plateau angle (MPTA), and joint line obliquity (JLO) were calculated. A separate random sample of 110 LLR was utilized to test the accuracy of the ML model.

Results: The ML model was effective in analyzing one image in less than 0.1 seconds. The mean angle error between human-measured and ML model-measured mHKA was 0.08º (standard deviation [SD = 0.8), the mean error for LDFA was 0.7º (SD = 0.9), the mean error for MPTA was 0.4º (SD = 0.3), and the mean error for JLO was 0.7º (SD = 0.8).

Conclusions: We describe an ML model that demonstrates high accuracy in determining alignment following TKA and demonstrates the vast potential of applying artificial intelligence technology to improving clinical workflow and increasing research productivity in total joint arthroplasty.

第二部分：保髋相关文献

文献1

基于CT三维统计建模的骨盆环不对称性评估

译者 罗殿中

人类骨盆是由无名骨、骶骨和尾骨组成的复杂解剖结构，共同构成骨盆环。尽管通常被视为对称实体，但骨盆环不对称（APR）可能改变其解剖结构、功能或生物力学特性，并影响临床病例的评估与治疗。由于骨盆环解剖结构复杂，APR及其评估具有挑战性。目前对APR的认知有限，且缺乏标准化评估方法。本研究旨在采用基于CT的三维统计建模与分析技术，在骨盆环复杂解剖结构内评估APR，以期深化对APR的理解，并将相关知识与应用转化至人体解剖学、研发课题及临床实践。研究对150例欧亚男女患者（64±15岁（20-90岁）的常规盆腔CT影像进行后处理，构建了基于性别和种族的骨盆环三维统计模型。通过主成分分析（PCA）评估尺寸、形态及不对称模式变异，最终建立四个不同族群与性别的骨盆环三维统计模型。PCA主要呈现尺寸与形态变异，而扩展模式分析识别出六种典型不对称区域：骶骨、髂嵴、骨盆界线、耻骨联合、耻骨下支及髋臼邻近区。研究表明骨盆环并非完全对称，其不对称性评估极具挑战。基于CT三维统计建模与PCA，我们确定了分布于不同解剖区域的六种APR类型，这些区域更易发生不对称。需区分轻微不对称模式与典型APR，并考虑尺寸、形态和/或位置的侧别差异。APR可能源于脊柱或下肢传递的负荷机制，亦或是局部负荷作用。当前亟需开发更简便高效且可靠的方法，并常规应用于人体解剖学、相关研发课题及临床实践。

图1. 典型欧洲女性（上面一排）和男性（下面一排）CT 3D统计学模型。中间灰色为平均模型，左侧黄色为-3.0SD模型，右侧黄色为+3.0SD模型。

图2. 典型亚洲女性（上面一排）和男性（下面一排）CT 3D统计学模型。中间灰色为平均模型，左侧黄色为-3.0SD模型，右侧黄色为+3.0SD模型。

图3. 典型欧洲女性（上面一排）CT 3D统计学模型，及六种不对称情形和位置。灰色为平均模型，黄色为-3.0SD模型，红色为+3.0SD模型。(a) -3.0SD模型前后观，红色箭头显示骶骨不对称；(b) +3.0SD模型前后观，红色箭头显示髂骨嵴不对称；(c) -3.0SD模型入盆观，红色箭头显示骨盆内缘不对称；(d) +3.0SD模型出盆观，红色箭头显示髋臼不对称；(e) -3.0SD模型入盆观，红色箭头显示耻骨联合不对称；(f) +3.0SD模型入盆观，红色箭头显示耻骨下支不对称。

图4. 6种不同类型骨盆不对称示例：(a) 一位88岁亚洲女性，骶骨不对称；(b) 一位27岁亚洲男性，髂骨嵴不对称；(c) 一位54岁欧洲女性，骨盆入口边缘不对称；(d) 一位65岁欧洲女性骨盆侧面半透明透视观，髋臼不对称；(e) 一位86岁欧洲女性骨盆出口位观，耻骨联合不对称；(f) 一位62岁亚洲女性骨盆入口观，耻骨下肢不对称。

文献出处：Handrich K, Kamer L, Mayo K, Sawaguchi T, Noser H, Arand C, Wagner D, Rommens PM. Asymmetry of the pelvic ring evaluated by CT-based 3D statistical modeling. J Anat. 2021 May;238(5):1225-1232. doi: 10.1111/joa.13379. Epub 2020 Dec 31. PMID: 33382451; PMCID: PMC8053576.

文献2

Perthes病患者限制负重和运动与生活质量的关系

译者 任宁涛

背景:在Perthes病的活动期通常采用限制负重和运动。这些限制，从免负重的石膏或支架治疗，到完全负重的运动限制，都可能对儿童的身体、心理和社会健康产生重大影响。然而，它们对患者生活质量的影响尚未得到很好的研究。

问题/目的:在控制混杂变量后，我们提出以下问题:(1)负重和运动的限制是否与Perthes病活动期儿童的身体健康指标(通过患者报告的结局测量信息系统[Patient-Reported Outcome Measurement Information System, PROMIS]的活动能力、PROMIS疼痛干扰和PROMIS疲劳表示)相关?(2)这些限制是否与较差的心理健康测量分数(PROMIS抑郁症状和PROMIS焦虑)有关?(3)这些限制是否与较差的社会健康指标(PROMIS同伴关系)分数有关?

方法:2013年至2020年，对某一机构的211名Perthes患者进行了6项PROMIS分析，以评估其身体、心理和社会健康状况。对符合以下入选标准的患者进行分析:年龄8 - 14岁，完成了6项PROMIS测量，会说英语，Perthes病处于活跃期(Waldenstrom期I、II或III)。在Perthes病的初始到早期骨化阶段，当患者出现疼痛加重、髋关节活动差或受限、股骨头畸形进展、髋关节滑膜炎加重时，临床推荐患者限制负重和运动时，以及MRI显示股骨头受累或有无手术史。根据负重和运动限制情况将患者分为4个干预组。我们排除了111例不符合纳入标准的患者。评估了以下六种PROMIS分析:活动能力、疼痛干扰、疲劳、抑郁症状、焦虑和同伴关系。100例患者中，其中无限制负重和运动者36例，轻度限制者27例，中度限制者25例，重度限制者12例，诊断时的中位年龄(范围)为8岁(范围2至13岁)。其中，男85例，女15例;11例患者的髋关节处于Waldenstrom I期，10例处于II期，79例处于III期。外侧柱B型44例，外侧柱C型47例。9例未达到碎裂中期，无法进行合适的外侧柱分型。方差分析用于比较这些负重/运动方案的平均PROMIS t评分之间的差异。结果以p < 0.05 有显著性差异;采用多因素回归分析Waldenstrom分期、性别、诊断年龄和手术史之间的关系。

结果:在控制混杂变量后，轻度- β回归系数为-15 [95% CI为-19 ~ -10];p < 0.001)，中度- (β -19 [95% CI -24 ~ -14];p < 0.001)，重度的- (β -25 [95% CI -30 ~ 19];p < 0.001)与无限制组相比，限制组的活动能力t评分较差，但未发现疼痛干扰或疲劳的关联。负重和活动限制与心理健康指标(抑郁症状和焦虑)无关。负重和活动限制与社会健康指标(同伴关系)无关。Waldenstrom分期与疼痛干扰 (β 10 [95% CI 2~17];p = 0.01)和同伴关系评分(β -8 [95% CI -15~-1];P = 0.03)有关;女性与更严重的抑郁症状 (β 7 [95% CI 2 ~ 12];p = 0.005)和更差的同伴关系评分(β -6 [95% CI -12 ~ 0];P = 0.04) 相关;诊断年龄越早与同伴关系评分越差相关(β 1 [95% CI 0 ~ 2];P = 0.03)。大手术史与6项PROMIS指标均无关联。

结论:我们发现，在控制Waldenstrom分期、性别、诊断年龄和手术史后，负重和运动限制治疗与Perthes病活动期患者报告的较差的活动能力相关。然而，负重/运动限制与疼痛干扰、疲劳、抑郁症状、焦虑和同伴关系无关。了解这些治疗如何与Perthes疾病患者的生活质量相关联，可以帮助医生做出决策，帮助为患者及其父母设定期望，并提供更好的教育和准备机会。由于Perthes病为慢性病，未来的研究可能关注患者报告结局的纵向趋势，以更好地了解该病及其治疗的总体影响。

Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease

Background: Weightbearing and activity restrictions are commonly prescribed during the active stages of Perthes disease. These restrictions, ranging from cast or brace treatment with nonweightbearing to full weightbearing with activity restrictions, may have a substantial influence on the physical, mental, and social health of a child. However, their impact on the patient's quality of life is not well-described.

Questions/purposes: After controlling for confounding variables, we asked (1) are restrictions on weightbearing and activity associated with physical health measures (as expressed by the Patient-Reported Outcome Measurement Information System [PROMIS] mobility, PROMIS pain interference, and PROMIS fatigue) of children in the active stages of Perthes disease? (2) Are these restrictions associated with poorer scores for mental health measures (PROMIS depressive symptoms and PROMIS anxiety)? (3) Are these restrictions associated with poorer scores for social health measures (PROMIS peer relationships)?

Methods: Between 2013 and 2020, 211 patients with Perthes disease at a single institution were assigned six PROMIS measures to assess physical, mental, and social health. Patients who met the following eligibility criteria were analyzed: age 8 to 14 years old, completion of six PROMIS measures, English-speaking, and active stage of Perthes disease (Waldenstrom Stage I, II, or III). Weightbearing and activity restrictions were clinically recommended to patients in the initial through early reossification stages of Perthes disease when patients had increasing pain, loss of hip motion, loss of hip containment, progression of femoral head deformity, increased hip synovitis, and femoral head involvement on MRI or as a postoperative regimen. Patients were categorized into four intervention groups based on weightbearing and activity regimen. We excluded 111 patients who did not meet the inclusion criteria. The following six pediatric self-report PROMIS measures were assessed: mobility, pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Of the 100 patients, 36 were categorized into the no-restriction regimen, 27 into the mild-restriction regimen, 25 into the moderate-restriction regimen, and 12 into the severe-restriction regimen at the time of PROMIS administration. The median (range) age at diagnosis was 8 years old (range 2 to 13 years). There were 85 boys and 15 girls. Eleven patients had hips in Waldenstrom Stage I, 10 were in Stage II, and 79 were in Stage III. Forty-four patients had hips classified as lateral pillar B and 47 patients as lateral pillar C. Nine patients had not reached the mid-fragmentation stage for appropriate lateral pillar classification by the time they took the PROMIS survey. ANOVA was used to compare differences between the mean PROMIS T-scores of these weightbearing/activity regimens. Results were assessed with a significance of p < 0.05 and adjusted for Waldenstrom stage, gender, age at diagnosis, and history of major surgery using multivariate regression analysis.

Results: After controlling for confounding variables, the mild- (β regression coefficient -15 [95% CI -19 to -10]; p < 0.001), moderate- (β -19 [95% CI -24 to -14]; p < 0.001), and severe- (β -25 [95% CI -30 to -19]; p < 0.001) restriction groups were associated with worse mobility T-scores compared with the no-restriction group, but no association was detected for the pain interference or fatigue measures. Weightbearing and activity restrictions were not associated with mental health measures (depressive symptoms and anxiety). Weightbearing and activity restrictions were not associated with social health measures (peer relationships). Earlier Waldenstrom stage was associated with worse pain interference (β 10 [95% CI 2 to 17]; p = 0.01) and peer relationships scores (β -8 [95% CI -15 to -1]; p = 0.03); female gender was linked with worse depressive symptoms (β 7 [95% CI 2 to 12]; p = 0.005) and peer relationships scores (β -6 [95% CI -12 to 0]; p = 0.04); and earlier age at diagnosis was associated with worse peer relationships scores (β 1 [95% CI 0 to 2]; p = 0.03). History of major surgery had no connection to any of the six PROMIS measures.

Conclusion: We found that weightbearing and activity restriction treatments are associated with poorer patient-reported mobility in the active stages of Perthes disease after controlling for Waldenstrom stage, gender, age at diagnosis, and history of surgery. Weightbearing/activity restrictions, however, are not associated with pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Understanding how these treatments are associated with quality of life in patients with Perthes disease can aid in decision-making for providers, help set expectations for patients and their parents, and provide opportunities for better education and preparation. Because of the chronic nature of Perthes disease, future studies may focus on longitudinal trends in patient-reported outcomes to better understand the overall impact of this disease and its treatment.

文献出处：Do DH, McGuire MF, Jo CH, Kim HKW. Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease. Clin Orthop Relat Res. 2021 Jun 1;479(6):1360-1370. doi: 10.1097/CORR.0000000000001608. PMID: 33394755; PMCID: PMC8133300.

文献3

机器人辅助增强现实（AR）引导的髋臼周围截骨手术导航

译者 李勇

髋臼周围截骨术(PAO)是治疗髋关节发育不良（DDH)的有效手术方法。然而,由于髋关节周围解剖结构复杂且术中视野(FoV)受限,医生实施PAO手术极具挑战性。为此,我们提出一种用于PAO的机器人辅助增强现实(AR)引导手术导航系统。该系统主要由机械臂、光学追踪器和微软HoloLens 2头显(一种前沿的光学穿透式头戴显示器, OST HMD)组成。在AR引导方面,我们提出一种基于光学标记的AR配准方法,用于估算从光学追踪器坐标系(COS)到虚拟空间坐标系的变换矩阵,从而实现虚拟模型与对应实体结构的精准叠加。此外,为引导截骨操作,系统可自动将骨锯与术前影像规划的截骨平面对齐,并为医生提供双重支持:一方面通过虚拟约束限制骨锯移动范围,另一方面通过AR引导提供无需视线转移的视觉反馈,从而提高手术精度与安全性。通过综合实验评估了该导航系统的AR配准精度与截骨精度:所提出的AR配准方法实现了1.96 ± 0.43毫米的平均绝对距离误差(mADE) ;机器人系统达到0.96 ±0.23毫米的平均中心平移误差,1.31 ± 0.20毫米的平均最大距离误差及 3.77 ± 0.85。的平均角度偏差。实验结果验证了该系统在AR配准与截骨操作上的精确性。

Robot-Assisted Augmented Reality (AR)-Guided Surgical Navigation for Periacetabular Osteotomy

Periacetabular osteotomy (PAO) is an effective approach for the surgical treatment of developmental dysplasia of the hip (DDH). However, due to the complex anatomical structure around the hip joint and the limited field of view (FoV) during the surgery, it is challenging for surgeons to perform a PAO surgery. To solve this challenge, we propose a robot-assisted, augmented reality (AR)-guided surgical navigation system for PAO. The system mainly consists of a robot arm, an optical tracker, and a Microsoft HoloLens 2 headset, which is a state-of-the-art (SOTA) optical see-through (OST) head-mounted display (HMD). For AR guidance, we propose an optical marker-based AR registration method to estimate a transformation from the optical tracker coordinate system (COS) to the virtual space COS such that the virtual models can be superimposed on the corresponding physical counterparts. Furthermore, to guide the osteotomy, the developed system automatically aligns a bone saw with osteotomy planes planned in preoperative images. Then, it provides surgeons with not only virtual constraints to restrict movement of the bone saw but also AR guidance for visual feedback without sight diversion, leading to higher surgical accuracy and improved surgical safety. Comprehensive experiments were conducted to evaluate both the AR registration accuracy and osteotomy accuracy of the developed navigation system. The proposed AR registration method achieved an average mean absolute distance error (mADE) of 1.96 ± 0.43 mm. The robotic system achieved an average center translation error of 0.96 ± 0.23 mm, an average maximum distance of 1.31 ± 0.20 mm, and an average angular deviation of 3.77 ± 0.85°. Experimental results demonstrated both the AR registration accuracy and the osteotomy accuracy of the developed system.

文献出处：Ding H, Sun W, Zheng G. Robot-Assisted Augmented Reality (AR)-Guided Surgical Navigation for Periacetabular Osteotomy. Sensors (Basel). 2024 Jul 22;24(14):4754. doi: 10.3390/s24144754. PMID: 39066150; PMCID: PMC11280818.

文献4

切开复位治疗挛缩型髋关节是否会导致关节僵硬？

译者 张利强

背景：尽管已有相关研究报道了切开复位治疗先天性脱位髋关节的积极效果，但对于患有多关节挛缩症的先天性髋关节脱位患者进行切开复位手术后是否会出现关节僵硬的问题仍存在担忧。我们对52名患有多关节挛缩症的患者进行了回顾性研究，这些患者接受了75次先天性髋关节脱位的切开复位手术，且术后随访时间至少为2年。我们比较了术前和术后的髋关节活动度，并评估了接受该手术患者的行走能力。

方法：在10年的时间里，52名患有多关节挛缩症的患者进行了75次先天性髋关节脱位的切开复位手术，且术后随访时间至少为2年。手术时患者的平均年龄为23个月。术前、术后以及最后一次随访时均记录了髋关节活动度数据，同时记录了患者的行走能力。对髋关节状态和缺血性坏死进行了X线评估。

结果：平均随访时间为68个月；59%的患者同时行股骨缩短。术前，34个髋关节的平均屈曲挛缩度为33度，随访时改善了22度；59个髋关节的蛙式外展角度小于45度，术前为11度和10度，分别改善了11度和10度（所有P≤ 0.001）。从术前到术后，关节的屈伸总活动范围仅减少了1度（P=0.733）。单侧脱位患者（n=29）在最终随访时，脱位侧与未脱位侧髋关节的总活动范围无显著差异。术前屈曲度小于90度的髋关节在复位后未见明显改善。平均随访时间为68个月（24至152个月），31名患者能够独立行走，15名患者依靠轮椅但仍在改善，6 名患者仍无法行走。约一半的髋关节出现了缺血性坏死（AVN），但在随访时并未影响屈伸总活动范围；AVN病例中55%为2型，仅为短期变化（延迟骨化）。

结论：对于关节挛缩型髋关节脱位的切开复位术能够保持关节的活动性而不造成僵硬。虽然术前髋关节的总活动范围略有恶化（约 1 至 5 度），但下肢位置得到了改善，尤其是在髋关节伸直和外展方面，从而增强了行走能力。大多数患者能够实现独立行走。

证据级别：IV 级 - 病例系列。

关键词：先天性多关节挛缩症、关节挛缩症、先天性髋关节脱位、切开复位、行走能力

Does Open Reduction of Arthrogrypotic Hips Cause Stiffness?

Background: Concerns of potential hip stiffness following open reduction for congenitally dislocated hips in arthrogryposis multiplex congenita (arthrogryposis) persist, despite published accounts of positive outcomes. We retrospectively compared preoperative and postoperative hip motion and evaluated the ambulatory abilities of patients who underwent the procedure.

Methods: Over a 10-year period, 52 patients with arthrogryposis had 75 open reductions for congenitally dislocated hips with a minimum follow-up of 2 years. The mean patient age at surgery was 23 months. Hip range of motion data was recorded preoperatively, postoperatively, and at last follow-up, as was ambulatory ability. Radiographs were assessed for hip station and avascular necrosis.

Results: The average follow-up was 68 months; 59% had concurrent femoral shortenings. Preoperatively, 34 hips had a mean flexion contracture of 33 degrees, improving 22 degrees at follow up; 59 hips had <45 degree frogleg abduction and 39 hips had <30 degree abduction preoperatively, improving by 11 and 10 degrees, respectively (all P≤ 0.001). The flexion-extension total arc of motion decreased by only 1 degree from preoperative to follow-up (P= 0.733). Patients with unilateral dislocation (n = 29) had no significant difference in the total arc of motion between the dislocated and nondislocated hips at the final follow up. Hips with <90 degrees of flexion preoperatively showed no improvement following reduction. At a mean follow-up of 68 months (24 to 152 mo), 31 patients were independently ambulatory, 15 were walker-dependent but still progressing, and 6 remained nonambulatory. Avascular necrosis (AVN) was seen in approximately half the hips but without affecting flexion-extension total arc of motion at follow-up; 55% of AVN cases were type 2, with only transient changes (delayed ossification).

Conclusions: Open reduction for arthrogrypotic hip dislocations maintains mobility without causing stiffness. While pre-existing hip total arc of motion slightly worsened (∼1 to 5 degree), lower limb positioning improved, especially in hip extension and abduction, enhancing ambulation. Most achieved independent ambulation.

Level of Evidence: Level IV—case series.

Key Words: arthrogryposis multiplex congenita, arthrogryposis, congenital hip dislocation, open reduction, ambulation

文献出处：Teytelbaum DE, Bijanki V, Samuel SP, Silva S, Israel H, van Bosse HJP. Does Open Reduction of Arthrogrypotic Hips Cause Stiffness? J Pediatr Orthop. 2025 Jul 1;45(6):e581-e589. doi: 10.1097/BPO.0000000000002940. Epub 2025 Apr 30. PMID: 40304381.

文献5

股骨前倾角增大导致内八字步态受试者行走时的关节接触力研究
译者 邱兴

内八字步态是一种病理现象，表现为儿童行走时足部内旋（即呈“内八字”）而非指向前方。此病症会改变下肢结构排列，增加膝髋关节骨关节炎发病率。本研究旨在探究内八字步态受试者的运动学特征与关节负荷。实验选取两组受试者：正常组与股骨前倾角增大导致内八字步态组（每组15人）。采用Qualisys运动分析系统和Kistler测力台记录行走时的下肢运动及受力数据，并通过OpenSim软件（3.3版）分析两组受试者的关节活动度、力矩、肌力及关节接触力。

正常组步长均值（1.1±0.141米）与内八字步态组（0.94±0.183米）差异显著。内八字步态组的地面反作用力内外侧分量较正常组显著降低（p值=0.05）。与正常组相比，内八字步态组大部分髋关节肌肉的峰值肌力显著增加（p值<0.05）。研究结果表明：因股骨前倾角增大形成的内八字步态仅引起骨盆与髋关节的旋转变化。两组在步行速度及大部分地面反作用力分量上无显著差异。由于内八字步态组髋关节多数肌肉的峰值肌力显著升高，导致关节接触力增大（尤以髋关节前后向分量与膝关节内外侧分量为主），最终可能增加髋膝关节骨关节炎的发病风险。

Investigation of joint contact forces during walking in the subjects with toe in gait due to increasing in femoral head anteversion angle

Toe-in gait is a pathology in which the child walks and turns the foot inward instead of pointing straight ahead. The alignment of the lower limb structure changes in this disease, increasing the incidence of knee and hip osteoarthritis. This study aimed to determine the kinematic and joint loading in subjects walking with a toe-in gait pattern. This study selected two groups of subjects: normal subjects and those with toe-in gait due to an increased femoral head anteversion angle (each group consisted of 15 subjects). A Qualisys motion analysis system and a Kistler force plate were used to record the motions and forces applied to the leg while walking. OpenSim software (version 3.3) was used to analyze the range of motion, moments, muscle forces, and joint contact forces in both groups of subjects. The mean values of stride length for normal subjects (1.1 ± 0.141 m) and those with toe-in gait (0.94 ± 0.183 m) differed significantly. The mediolateral component of the ground reaction force decreased significantly in the toe-in gait group compared to normal subjects (p-value = 0.05). The peak force of most of the hip joint muscles increased significantly in those with toe-in gait compared to normal subjects (p-value < 0.05). The results of this study showed that those with toe-in gait, due to an increase in femoral head anteversion angle, only had a change in rotation of the pelvic and hip joint. There was no significant difference between walking speed and most ground reaction force components between normal subjects and those with toe-in gait. As the peaks of most of the hip joint muscles increased significantly in the toe-in gait group, this increased joint contact forces (especially the anteroposterior component of the hip joint and the mediolateral component of the knee joint), which may ultimately increase the incidence of hip and knee joint osteoarthritis.

文献出处：Karimi, Mohammad Taghi, et al. "Investigation of joint contact forces during walking in the subjects with toe in gait due to increasing in femoral head anteversion angle." Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 238.7 (2024): 755-763.

文献6

盂唇内翻是DDH患儿行挽具治疗失败的预测因素

译者 张振东

背景：髋关节发育不良（DDH）行Pavlik挽具治疗失败率高达55%。本研究目的是明确盂唇内翻对该治疗结果的影响。

方法：对一家三级儿科医院 2004 年至 2016 年接受治疗的 DDH 患儿进行回顾性研究。纳入的DDH患儿均接受过Pavlik挽具治疗，且随访至少12个月。对患儿的人口统计学、治疗和结果进行了回顾性分析。比较了有内翻盂唇的患者和没有内翻盂唇的患者的治疗效果差异。

结果：共纳入156例患者（229髋）诊断为髋关节发育不良。开始使用Pavlik治疗的平均年龄为（1.9±1.4）个月，平均随访时间为（37.7±23.0）个月。46%的患者（73/156）被诊断为双侧DDH。共有37%（75/229）的髋关节未行Pavlik治疗。Pavlik治疗失败的患者中，91%的患者（68/75）再采用硬质髋关节外展支架进行治疗，5%的患者（4/75）再采用闭合复位治疗，另外4%的患者（3/75）再采用切开复位治疗。在所有髋关节中，10%（22/229）的髋关节存在内翻盂唇。内翻盂唇患者中Pavlik治疗失败率为91%（20/22），而对照组为27%（55/207）（P<0.001）。内翻盂唇患者中，86%（15/22）的髋关节需要二次手术，包括闭合或切开复位，而对照组仅为3%（7/207）（P<0.001）。此外，盂唇内翻的患者中，股骨头坏死发生率为18%（4/22），而对照组为0.4%（1/207）（P<0.001）。

结论：在使用Pavlik 治疗的 DDH 患儿中，盂唇内翻是治疗失败的重要预测指标。与无内翻盂唇的患儿相比，有内翻盂唇的DDH患儿需要闭合或切开复位、以及发生股骨头缺血坏死的风险也明显更高。

An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia

Introduction: The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH.

Methods: A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum.

Results: A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P<0.001). Closed or open reduction was required in 86% (15/22) of the inverted labrum group compared with 3% (7/207) of hips in the control group (P<0.001). The incidence of avascular necrosis was 18% (4/22) in hips with an inverted labrum compared with 0.4% (1/207) in the control group (P<0.001).

Conclusions: In children with DDH undergoing index treatment in a Pavlik harness, the presence of an inverted acetabular labrum is strongly predictive of treatment failure. Dysplastic hips with an inverted labrum also have a significantly higher risk of requiring closed or open reduction and developing avascular necrosis compared with those without an inverted labrum.

文献出处：Lin AJ, Siddiqui AA, Lai LM, Goldstein RY. An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia. J Pediatr Orthop. 2021 Sep 1;41(8):479-482.

来源：304关节学术

作者：304关节团队

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