髋膝关节文献精译荟萃（第353期）

本期目录：

1、度洛西汀能够减少全髋关节或全膝关节置换术后阿片类药物的用量和术后疼痛

2、与全髋关节置换术后假体周围感染相关的长期病死率

3、在初次髋关节或膝关节置换术中局部使用万古霉素是否可以预防感染

4、创伤后骨关节炎行全膝关节置换术中的微生物学取样

5、类固醇性骨坏死:类固醇剂量风险分析

6、冠状面髋臼矫正对髋臼周围截骨术中关节接触压力的影响

7、利用人工韧带对临界发育性髋关节发育不良进行关节镜下关节囊修复术

8、髋臼周围截骨术治疗成人髋关节发育不良的手术进展

9、髋臼旋转截骨术后骨关节炎进展的影响因素

第一部分：关节置换及保膝相关文献

文献1

度洛西汀能够减少全髋关节或全膝关节置换术后阿片类药物的用量和术后疼痛：随机对照试验的荟萃分析

译者 张轶超

目的：目前文献对度洛西汀在全髋关节置换术（THA）或全膝关节置换术（TKA）后的镇痛作用尚未达成共识。因此，我们设计了这项荟萃分析，以证明度洛西汀在TKA或THA治疗过程中的镇痛效果和安全性。

方法：截至到2022年10月，由两位作者（L.C.和w.q.j）独立检索了五个主要数据库（EMBASE、Web of Science、PubMed、Cochrane Library和谷歌学术搜索）以查找相关研究。将关于度洛西汀与安慰剂对TKA或THA术后镇痛疗效的随机对照试验（RCTs）研究纳入本研究。我们将围手术期阿片类药物总消耗量作为主要指标。次要指标包括静息或活动时的疼痛评分、胃肠道不良事件、神经系统不良事件和其他不良反应。

结果：本研究纳入了8项随机对照试验中的695名患者。本荟萃分析表明，高证据表明度洛西汀可有效减少围手术期阿片类药物的消耗量（标准平均差[SMD]= - 0.50, 95%可信区间[CI]: - 0.70至- 0.31，P<0.00001），低至中等证据表明度洛西汀可在术后三周内减轻疼痛。从低到高的证据表明，两组在大多数不良事件方面没有差异。大量证据表明度洛西汀可减少术后恶心呕吐（风险比[RR]=0.69, 95% CI: 0.50 ~ 0.95， P=0.02, I2=4%）。然而，中度证据表明度洛西汀可能与术后嗜睡增加有关（RR=1.83, 95% CI: 1.08 ~ 3.09， P=0.02, I2=0%）。

结论：度洛西汀可减少围手术期阿片类药物的总体消耗量，减轻术后3周内的疼痛，且不会增加药物不良事件的风险。度洛西汀可作为TKA和THA患者多模式镇痛治疗方案的一部分。

Duloxetine reduces opioid consumption and pain after total hip or knee arthroplasty: a meta-analysis of randomized controlled trials

Purpose： There is no consensus in the current literature on the analgesic role of duloxetine after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Thus, we designed this meta-analysis to reveal the analgesic effectiveness and safety of duloxetine in TKA or THA.

Methods： As of October 2022, two authors (L.C. and W.Q.J.) independently searched five main databases (EMBASE, Web of Science, PubMed, Cochrane Library, and Google Scholar) to find relevant studies. Duloxetine vs. placebo in randomized controlled trials (RCTs) for THA or TKA were included. We set perioperative total opioid consumption as the primary outcome. Secondary outcomes included resting or dynamic pain scores over time, gastrointestinal adverse events, neurological adverse events, and other adverse reactions.

Results： Eight RCTs with 695 patients were incorporated in our study. This meta-analysis showed high evidence that duloxetine was effective in reducing perioperative opioid consumption (Standard mean difference [SMD]=−0.50, 95% confidence intervals [CI]: −0.70 to −0.31, P<0.00001) and low to moderate evidence that duloxetine could reduce pain within three weeks after surgery. Low to high evidence showed no differences between the two groups for most adverse events. Substantial evidence suggests that duloxetine can reduce nausea and vomiting after surgery (Risk ratio [RR]=0.69, 95% CI: 0.50 to 0.95, P=0.02, I2=4%). However, moderate evidence suggested that duloxetine might be associated with increased postoperative drowsiness (RR=1.83, 95% CI: 1.08 to 3.09, P=0.02, I2=0%).

Conclusion： Duloxetine reduced overall opioid consumption in the perioperative period and relieved pain within three weeks after surgery without increasing the risk of adverse drug events. Duloxetine can be part of a multimodal management regimen in patients with THA and TKA.

文献出处：Lin Y, Jiang M, Liao C, Wu Q, Zhao J. Duloxetine reduces opioid consumption and pain after total hip or knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2024 Mar 13;19(1):181. doi: 10.1186/s13018-024-04648-5. PMID: 38481321; PMCID: PMC10936099.

文献2

与全髋关节置换术后假体周围感染相关的长期病死率：一项包含了4651例感染翻修病例的数据库研究

译者 张蔷

背景：与全髋关节翻修术（THA）或假体周围感染（PJI）相关的病死率已在多篇文献中被详细探讨，但与病死率相关的危险因素却鲜有涉及。在本篇文章中，我们希望能够明确与全髋翻修手术或假体周围感染相关的长期病死率以及相关危险因素。

方法：我们选择了澳洲骨科协会国家关节登记库（AOANJRR）中自1999年9月至2022年12月间因骨关节炎而施行的THA手术以及后续的翻修病例。我们使用Kaplan-Meier曲线和基于澳洲时期生命表的标准死亡比（SMRs）来总结并计算初次THA和首次翻修后的总体生存率。最后，我们使用配平了年龄和性别之后的Cox比例风险模型来确定与病死率相关的危险因素。

结果：共有548061例因骨关节炎而施行的初次THA手术病例；有4651例因感染而施行的初次翻修手术病例和15891例非感染与骨折原因而施行的初次翻修手术病例。在术后5年、10年和15年的三个时间点上，因PJI而施行翻修手术的累计病死率分别为14.5%、34.7%和57.5%。感染翻修手术病例的病死率显著高于一般人群，且对应的SMR（1.31; 95%置信区间[CI]: 1.24 - 1.39）也高于初次THA（0.81; 95% CI: 0.81 - 0.82）或无菌性松动翻修（0.95; 95% CI: 0.92 - 0.99）的病例。年龄小于65岁病例和女性病例的感染翻修后SMR更高，且此后15年逐年升高。处置假体周围感染的手术无论大小，病死率均近似。

结论：与普通大众、初次THA患者或无菌性松动翻修患者相比，感染翻修患者的病死率更高。且这种风险在术后15年中持续存在，特别是相对年轻的病例。

Long-Term Mortality Associated with Periprosthetic Infection in Total Hip Arthroplasty Infection in Total Hip Arthroplasty A Registry Study of 4,651 Revisions for Infection

Background: While the morbidity associated with revision total hip arthroplasty (THA) or periprosthetic infection (PJI) has been well characterized, less is known about the risk of mortality. With this study, we aimed to determine the long-term mortality associated with revision THA for PJI and associated risk factors.

Methods: Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were used to study mortality associated with THA procedures for osteoarthritis and subsequent revisions from September 1999 through December 2022. Kaplan-Meier estimates of survivorship and standardized mortality ratios (SMRs) based on Australian period life tables were used to summarize the overall survival following the primary and first revision THA. Risk factors associated with mortality were identified using Cox proportional hazards models, adjusted for age and gender.

Results: There were 548,061 primary THA procedures for osteoarthritis; 4,651 first revision procedures for infection and 15,891 first revisions for reasons other than infection and fracture were recorded. At 5, 10, and 15 years, the cumulative mortality rate for revision for PJI was 14.5%, 34.7%, and 57.5%, respectively. Patients who underwent revision for PJI had higher mortality rates than expected compared with the general population, and the corresponding SMR (1.31; 95% confidence interval [CI]: 1.24 to 1.39) was greater than that for patients undergoing primary THA (0.81; 95% CI: 0.81 to 0.82) or aseptic revision (0.95; 95% CI: 0.92 to 0.99). A higher SMR following revision for PJI was observed in patients <65 years of age and in female patients, and continued to increase beyond 15 years. There were no differences in mortality rates according to whether a major or minor revision was performed to manage PJI.

Conclusions: Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary THA or aseptic revision. This excess risk persisted beyond 15 years, especially in younger patients.

文献3

在初次髋关节或膝关节置换术中局部使用万古霉素是否可以预防感染？

译者 丁云鹏

背景： 感染是髋关节和膝关节置换术的主要并发症之一。局部应用万古霉素预防脊柱外科术后感染是有效的，并在关节置换手术中得到推广。然而，其临床相关性和安全性仍存在争议。因此，我们进行了本研究，以（1）评估局部使用万古霉素是否会降低假体周围感染率，以及（2）研究其对手术伤口并发症的影响。

假设：我们的假设是关节置换术中局部使用稀释万古霉素可以降低术后第1年的感染率。

材料和方法：2014年至2021年间，在同一家医院共进行了1900例髋关节和膝关节置换术。2018年7月至2021年12月，910例关节置换应用万古霉素和氨甲环酸。2014年11月至2018年6月，990例关节置换不应用万古霉素。在至少12个月的随访中，记录术后第1年发生的假体周围感染，以及万古霉素引起的全身或皮肤并发症。

结果：对照组9/990例（0.91%）假体周围感染，万古霉素组10/910例（1.1%）假体周围感染（p = 0.82）。同时，我们观察到对照组和万古霉素组分别有19/990例（1.9%）和10/910例（1.1%）出现创面并发症（红斑、血肿、血肿、裂开和创面愈合延迟）（p = 0.19）。万古霉素的应用没有引起一般并发症。

讨论：局部稀释万古霉素不能降低假体周围感染风险，对手术伤口并发症的发生无影响。考虑到目前的研究结果，在目前的实践中不推荐使用万古霉素来预防髋关节和膝关节置换术后的感染。最后，它的使用不会引起任何特定的并发症，无论是局部（瘢痕）还是全身（与耳毒性或肾毒性有关）。

Does the use of topical vancomycin during primary hip or knee arthroplasty protect from infections?

Background: Infection is one of the main complications of hip and knee arthroplasties. Topical application vancomycin to prevent postoperative infections is efficient in spine surgery, and is spreading in prosthetic surgery. However, its clinical relevance and safety are still under debate. Thus, we conducted the present study to (1) assess whether topical vancomycin reduces peri-prosthetic infection rate, and (2) investigate its influence on surgical wound complications.

Hypothesis: Our hypothesis was that topical administration of diluted vancomycin during arthroplasty would reduce infection rate within the first postoperative year.

Material and methods: In total, 1900 hip and knee arthroplasties were performed between 2014 and 2021 in a single hospital. From July 2018 and December 2021, 910 prostheses were implanted with intra-articular instillation of vancomycin and tranexamic acid. From November 2014 to June 2018, 990 prostheses were set up without vancomycin. During a follow-up of minimum 12 months, we reported periprosthetic infections occurring during the first postoperative year, as well as vancomycin-induced general or cutaneous complications.

Results: We observed periprosthetic infections in 9/990 cases (0.91%) of the control group and 10/910 cases (1.1%) of the vancomycin group (p = 0.82). In parallel, we observed wound complications (erythema, seroma, hematoma, dehiscence and delay in wound healing) in 19/990 (1.9%) and 10/910 cases (1.1%) of the control and vancomycin group, respectively (p = 0.19). There were no general complications resulting from the application of vancomycin.

Discussion: Topical diluted vancomycin does not reduce periprosthetic infection risk, and has no effect on the occurrence of surgery wound complications. Considering the present findings, the use of vancomycin cannot be recommended in current practice to prevent infections following hip and knee arthroplasties. Finally, its use does not induce any specific complications, whether local (cicatrisation) or general (related to ototoxicity or nephrotoxicity).

文献出处：François Laudet , Alice Gay , Hervé Dutronc ,Does the use of topical vancomycin during primary hip or knee arthroplasty protect from infections? Orthop Traumatol Surg Res. 2025 Feb;111(1):103984.doi: 10.1016/j.otsr.2024.103984. Epub 2024 Sep 3.

文献4

创伤后骨关节炎行全膝关节置换术中的微生物学取样：假体周围关节感染发生率及对取样于无明显异常组织的争议

译者 沈松坡

背景： 胫骨近端骨折可导致创伤后骨关节炎（PTOA），此类患者后续接受全膝关节置换术（TKA）时并发症发生率升高。推荐采用分期手术策略，先择期移除内固定材料，再行TKA。术中对肉眼无异常组织进行微生物学取样的价值仍存在争议。

目的： 回顾性评估PTOA后TKA的假体周围关节感染（PJI）发生率，并探讨术中微生物学取样的潜在价值。次要目标是评估受累病例中内固定材料的潜在细菌定植情况。

患者与方法： 回顾性筛查医院数据库中2008年至2022年间AO/OTA 41-B与41-C型骨折病例。患者被分为取样组（TKA术中进行微生物学取样）与对照组（未取样）。所有患者均接受术后随访，以评估并发症。

结果： 共纳入40例患者。取样组（n=29）中，17.24%的患者需要再次手术，PJI发生率为3.45%。对照组（n=11）中，18.14%的患者接受了翻修手术，PJI发生率为9.09%。平均随访时间为4.35年（范围2–11.6年）。

讨论： PTOA患者接受TKA的并发症风险较高。本研究观察到系统性术中微生物取样可能与较低的PJI发生率相关。尽管样本量较小无法明确因果关系，但结果支持术中一致性取样的潜在价值。

Microbiological Sampling in Total Knee Arthroplasty After Post-Traumatic Osteoarthritis: Rate of Periprosthetic Joint Infection and the Debate Around Sampling Unremarkable Tissue

Background: Proximal tibial fractures can lead to post-traumatic osteoarthritis (PTOA), and subsequent total knee arthroplasty (TKA) in such patients is associated with elevated complication rates. A two-stage approach, involving the elective removal of osteosynthetic hardware prior to TKA, is recommended. The utility of microbiological sampling from macroscopically unremarkable tissue during TKA implantation remains controversial.

Objective: To retrospectively evaluate the rate of periprosthetic joint infection (PJI) following TKA after PTOA and to assess the potential benefit of intraoperative microbiological sampling. The secondary objective was to evaluate the presence of prior colonization in osteosynthetic hardware among the affected cases.

Patients and methods: A retrospective screening of the hospital database was conducted between 2008 and 2022, including only AO/OTA type 41-B and 41-C fractures. Patients were assigned to a sampling group (with microbiological sampling during TKA) or a control group (without sampling). All patients received structured follow-up to assess postoperative complications.

Results: A total of 40 patients met the screening criteria. In the sampling group (n = 29), 17.24% required surgical revision, and the rate of PJI was 3.45%. In the control group (n = 11), 18.14% underwent revision surgery, with a PJI rate of 9.09%. The average follow-up period was 4.35 years (range 2-11.6 years).

Discussion: TKA in patients with PTOA is associated with a heightened risk of complications. A noteworthy possible correlation between systematic microbiological sampling and reduced PJI incidence was observed. While the small sample size limits definitive conclusions regarding causality, the findings support the potential value of consistent intraoperative sampling.

第二部分：保髋相关文献

文献1

类固醇性骨坏死:类固醇剂量风险分析

译者 任宁涛

骨坏死是一种涉及骨破坏的严重疾病，通常需要手术治疗来重建受损的关节。虽然有大量文献记录了皮质类固醇相关的骨坏死，但对于类固醇经非肠道、口服、外用、吸入和其他途径给药后发生骨坏死的相对风险还没有共识，这种风险是一个重要的预后指标,因为识别和保守的干预可以降低发病率与过度手术治疗骨坏死发生率，这篇文章是基于使用皮质类固醇导致发生骨坏死风险指南上的见解。对不同皮质类固醇和不同剂量的人类进行了病例研究、回顾性研究和前瞻性研究。大多数骨坏死病例继发于全身给药皮质类固醇和/或每日高剂量治疗，特别是伴有结缔组织疾病、高脂血症或既往创伤等潜在合并症的患者。以往报告的与吸入或局部使用类固醇相关的骨坏死病例，由于在绝大多数病例中，患者在发生骨坏死之前也接受了全身性类固醇治疗，因此变得复杂。基于文献，我们制定了一套关于使用类固醇的患者发生骨坏死风险的建议。

1. 开药者应意识到接受皮质类固醇治疗的患者，特别是肠外或口服制剂，以及具有某些特定潜在疾病状态的患者发生骨坏死的潜在风险。

2. 通过其他途径接受类固醇治疗的患者，如内注射、吸入或鼻内注射，发生骨坏死的风险很低，但并非为零。当使用高剂量吸入性皮质类固醇时，如严重持续性哮喘或嗜酸性食管炎，有可能发生骨坏死。

3. 无论何时使用类固醇，都应告知患者发生骨坏死的风险。

Steroid induced osteonecrosis An analysis of steroid dosing risk

Osteonecrosis is a serious condition involving bone destruction that frequently requires surgical treatment to rebuild the joint. While there is an abundance of literature documenting corticosteroid related osteonecrosis, there is no consensus as to the relative risk of osteonecrosis after administration of steroids via parenteral, oral, topical, inhaled and other routes. This risk is an important prognostic indicator because identification and conservative intervention can potentially reduce morbidity associated with aggressive surgical treatment of osteonecrosis. This paper provides insight into establishing guidelines related to the risk of developing osteonecrosis as a result of corticosteroid use. Case studies, retrospective studies and prospective studies in humans on different corticosteroids and varied dosages were assessed. Most cases of osteonecrosis are secondary to systemically administered corticosteroids and/or high dose daily therapy, particularly in patients with underlying comorbidities including connective tissue diseases, hyperlipidemia, or previous trauma. Previous case reports of osteonecrosis related to inhaled or topical use of steroids are complicated by the fact that in the great majority of cases, the patients are also treated with systemic steroids prior to the development of osteonecrosis. Based on the literature, a set of recommendations regarding the risk of osteonecrosis in patients on steroids was formulated.

文献出处：Powell C, Chang C, Naguwa SM, Cheema G, Gershwin ME. Steroid induced osteonecrosis: An analysis of steroid dosing risk. Autoimmun Rev. 2010 Sep;9(11):721-43. doi: 10.1016/j.autrev.2010.06.007. Epub 2010 Jul 9. PMID: 20621176; PMCID: PMC7105235.

文献2

冠状面髋臼矫正对髋臼周围截骨术中关节接触压力的影响：有限元分析
译者 李勇

背景：在髋臼周围截骨术（PAO）中，优化髋关节生物力学的理想髋臼位置仍不明确。本研究旨在确定冠状面髋臼矫正与关节接触压力（CP）之间的关系，并识别矫正后仍存在异常CP的形态学因素。
方法：通过使用44名髋关节发育不良患者的CT图像，我们在患者特定的3D髋关节模型上进行了三种虚拟PAO模式，其中髋臼向外旋转至30°、35°和40°的外侧中心缘角（LCEA）。使用有限元分析计算单腿站立时髋臼软骨的CP。
结果：将LCEA矫正为30°时，最大CP的中位数较术前减少了0.5倍（p < 0.001）。将LCEA进一步矫正为40°时，CP在15个髋关节（34%）中进一步减少，但在29个髋关节（66%）中反而增加。CP的增加与较大的术前外翻指数（p = 0.030）和圆度指数（p = 0.038）相关。总体而言，虚拟PAO未能在11个髋关节（25%）中正常化CP，且小的前壁指数（p = 0.049）和大的圆度指数（p = 0.003）与残余异常CP相关。
结论：在冠状面髋臼矫正中，CP最小化的髋臼矫正程度因患者而异。单独的冠状面矫正未能使本研究中25%的患者CP正常化。在患有前髋臼缺损（前壁指数<0.21）和非球形股骨头（圆度指数>53.2%）的患者中，单纯的冠状面矫正可能无法使CP正常化。需要进一步研究以明确包括矢状面和轴向面在内的多平面矫正对优化髋关节接触力学的有效性。

图：一个髋关节发育不良经虚拟髋臼周围截骨术后的代表性有限元模型，并显示弹性模量的分布。骨模型采用2毫米四面体单元和表面0.4毫米三角形壳单元构建。髋臼和股骨头的软骨以1.8毫米的恒定厚度创建，并在髋臼软骨的承重区域采用局部细化的0.5毫米至2.0毫米四面体单元进行网格划分。为了可视化髋臼软骨上承受的接触压力，在其表面放置了厚度为0.0005毫米的三节点壳单元。载荷情景基于单腿站立姿态，髋关节接触力作用于股骨头中心的节点。载荷施加过程中，髂嵴和耻骨区完全固定，而股骨远端仅在Z轴方向自由，但在X和Y轴方向受限。分别在软骨-骨界面和软骨-软骨界面设置了绑定接触和滑动接触约束。髋臼碎片通过绑定接触重新连接到骨盆，以模拟完全骨性愈合。接触关节面之间的摩擦剪应力被忽略。

Effect of Coronal Plane Acetabular Correction on Joint Contact Pressure in Periacetabular Osteotomy: A Finite-Element Analysis

Background: The ideal acetabular position for optimizing hip joint biomechanics in periacetabular osteotomy (PAO) remains unclear. We aimed to determine the relationship between acetabular correction in the coronal plane and joint contact pressure (CP) and identify morphological factors associated with residual abnormal CP after correction.
Methods: Using CT images from 44 patients with hip dysplasia, we performed three patterns of virtual PAOs on patient-specific 3D hip models, where the acetabulum was rotated laterally to the lateral center-edge angles (LCEA) of 30°, 35°, and 40°. Finite-element analysis was used to calculate the CP of the acetabular cartilage during a single-leg stance.
Results: Coronal correction to the LCEA of 30° decreased the median maximum CP by 0.5-fold compared to preoperatively (p < 0.001). Additional correction to the LCEA of 40° further decreased CP in 15 hips (34%) but conversely increased CP in 29 hips (66%). The increase in CP was associated with a greater preoperative extrusion index (p = 0.030) and roundness index (p = 0.038). Overall, virtual PAO failed to normalize CP in 11 hips (25%), and a small anterior wall index (p = 0.049) and a large roundness index (p = 0.003) were associated with residual abnormal CP.
Conclusions: The degree of acetabular correction in the coronal plane where CP is minimized varied among patients. Coronal plane correction alone failed to normalize CP in 25% of patients in this study. In patients with an anterior acetabular deficiency (anterior wall index <0.21) and an aspherical femoral head (roundness index > 53.2%), coronal plane correction alone may not normalize CP. Further studies are needed to clarify the effectiveness of multiplanar correction, including in the sagittal and axial planes, in optimizing the hip joint's contact mechanics.

文献出处：Kitamura K, Fujii M, Iwamoto M, Ikemura S, Hamai S, Motomura G, Nakashima Y. Effect of coronal plane acetabular correction on joint contact pressure in Periacetabular osteotomy: a finite-element analysis. BMC Musculoskelet Disord. 2022 Jan 14;23(1):48. doi: 10.1186/s12891-022-05005-5. PMID: 35031030; PMCID: PMC8760799.

文献3

利用人工韧带对临界发育性髋关节发育不良进行关节镜下关节囊修复术

译者 张利强

鉴于髂股韧带在维持髋关节稳定性方面具有积极作用，尤其是在患有临界发育性髋关节发育不良的患者中，一些外科医生建议通过保守的关节囊切开术并最终缝合来恢复其原始结构。在各种不同的关节囊切开术中，纵向关节囊切开术是一种能够减少对髂股韧带损伤的技术。这种保护作用足以使患有股骨髋臼撞击症的患者恢复髋关节稳定性，但对于患有临界发育性髋关节发育不良的患者而言，由于其关节囊松弛和不稳定，这种保护作用可能不够充分。因此，我们提出了一种手术技术，即在纵向关节囊切开术后利用人工韧带对前关节囊进行增强修复。

右侧髋关节的关节镜图像展示使用30度关节镜进行加强手术的关键步骤。患者仰卧于牵引床上，术侧下肢置于旋转中立和轻度屈曲位。(A)通过前内侧入路，关节囊纵向切开向上延伸至盂唇，向下延伸至股骨颈。(B、C)用射频探针识别并标记髂股韧带内侧束和外侧束的固定点。(D)预钻近端隧道。(E)通过远端外侧辅助入路将装有LARS缝合线带的锚钉置入近端隧道。(F)在伸直位固定并拉紧LARS。(G)缝线穿过切开的关节囊两侧。(H)最终关节镜图像显示关节囊完全闭合。(C，关节囊；FM，股骨头；IH，反折头；L，盂唇；LARS，韧带高级加强系统；LD，髂股韧带外侧束；MD，髂股韧带内侧束。)

准备韧带高级加强系统线带。（A、B）将韧带高级加强系统线带穿过锚钉的孔并折叠。（C）在近端隧道置入第一枚锚钉后，从前中间切口牵出线带两端，并穿过第二枚和第三枚锚钉的孔。

右髋关节示意图展示从中前侧切口进行加强术的主要步骤。（A）采用纵向“由外向内”的关节囊切开技术切开。（B）确定固定点：髂前下极下方区域、髂股韧带的外侧束以及内侧束的末端。（C）将韧带高级加强系统固定在3个固定点上以增强髂股韧带，随后对纵向切口进行端端缝合。

Arthroscopic Augmentation of the Anterior Capsule Using Artificial Tape for Borderline Developmental Dysplasia of the Hip

With the recognition of the positive effect of the iliofemoral ligament in maintaining hip stability, particularly in patients with borderline developmental dysplasia of the hip, some surgeons recommend restoring its native anatomy through conservative capsulotomy and final closure. In the many different kinds of capsulotomy, longitudinal capsulotomy is a technique that can reduce damage to the iliofemoral ligament. This protective effect is sufficient to restore hip stability in patients with femoroacetabular impingement but may be inadequate for patients with borderline developmental dysplasia of the hip because of the laxity and capsular instability. Therefore, we propose a surgical technique that utilizes artificial tape to augment the anterior capsule under longitudinal capsulotomy.

文献出处：Zhang J, Sha SY, Liang T, Liu Y, Yin QF. Arthroscopic Augmentation of the Anterior Capsule Using Artificial Tape for Borderline Developmental Dysplasia of the Hip. Arthrosc Tech. 2025 Apr 3;14(6):103534. doi: 10.1016/j.eats.2025.103534. PMID: 40656720; PMCID: PMC12255451.

文献4

髋臼周围截骨术治疗成人髋关节发育不良的手术进展

译者 陶可

引言：髋关节发育不良的特征是髋臼过度倾斜且臼窝较浅，股骨头覆盖不足。它是年轻人髋关节疼痛和早期骨关节炎发展的已知原因。髋臼周围截骨术是年轻成人出现症状性髋关节发育不良的首选保髋治疗方法。这项手术旨在重新定向髋臼，以改善覆盖范围并消除病理性髋关节应力集中。因此，术中对已实现的髋臼重新定向进行评估至关重要。髋臼周围截骨术的“经典”手术入路会对组织造成广泛的创伤，有些甚至会导致肌肉脱离。手术入路的类型可能会影响并发症的发生、手术时间、术中失血量、输血需求和住院时间。本博士论文旨在：I）评估一种新型经髋臼周围微创入路截骨术的效果；II）比较该微创入路与以往使用的“经典”髂腹股沟入路差异；III）评估一种用于术中评估髋臼复位效果的新型装置的可靠性。

方法：本博士论文包含三项研究。在研究I和II中，通过数据库查询和影像学资料评估，回顾性地评估了微创入路和髂腹股沟入路的经验。患者人口统计学信息、病史、术中测量和并发症数据均记录在经过验证的数据库中。在术前和术后骨盆X线片中测量外侧中心边缘角和髋臼指数角，以评估术前发育不良和髋臼复位效果。在研究I和II中，明确定义的研究组分别包含94例和263例髋臼周围截骨术。在研究三中，前瞻性地对35例髋臼周围截骨术进行了术中角度测量。将获得的测量值（外侧中心边缘角和髋臼指数角）与术后骨盆X线片的测量值进行比较。此外，还进行了一项尸体研究，以评估该装置的观察者内和观察者间变异性，并评估骨盆位置是否影响测量值的变异性。对所应用的方法进行了严格审查。

结果：研究一——微创手术的结果如下。平均手术时间为73分钟，术中失血量中位数为250毫升。3%的手术后需要输血。没有出现中度或重度技术和神经血管并发症，所获得的中心边缘角和髋臼指数角表明可以实现最佳的重新定位。以全髋关节置换术为终点的髋关节存活率为98%，随访时间为4.3年。

研究二——与髂腹股沟入路的结果相比，采用微创入路进行的手术具有统计学上显著的手术时间更短、术中失血量和血红蛋白降低更少以及输血需求更少的特点。两组之间实现的重新定位效果相当。微创组无中度或重度并发症病例，髂腹股沟组有3例（3%）动脉血栓形成病例。在髋关节手术后4.9年的随访中，微创组的生存率为97%，髂腹股沟组的生存率为93%。

研究三——术中测量的角度与术后骨盆X线片上的测量值相差不到 +/- 5度，并且该装置的观察者内和观察者之间的差异均在 +/- 5度以内。除了观察者内的装置差异外，定位对角度测量差异的影响并不大。

解读：新的微创经髋臼入路似乎是一种安全的技术，可实现最佳的髋臼复位，并似乎可最大限度地减少组织创伤。此外，短期髋关节成活率令人鼓舞。其结果与髂腹股沟入路相比更为有利，并且结果支持继续使用微创入路进行髋臼周围截骨术。在髋臼周围截骨术中，髋臼的最佳复位至关重要。这种新型测量装置是术中评估外侧中心边缘和髋臼指数角度的潜在有用工具。它使用简单，便于在髋臼复位期间重复可靠的角度测量，从而无需术中拍摄X线片。这种新的微创入路和新型测量装置代表了当代髋臼周围截骨术的重要手术进展。

图 改良 Smith-Petersen入路（绿色）和髂腹股沟入路（蓝色）的切口。髂前上棘标记为ASIS。

图. 测量装置在前后位透视下使用。它安装在双侧髂前上棘上。通过插入克氏针固定。为了确保骨盆与角度测量的对齐，一根杆连接上述固定的克氏针。测量装置在手术过程中与用于测量外侧中心边缘角的角度测量盘链接在一起。

图 用于测量外侧中心边缘角的角度测量盘。通过识别股骨头中心和硬化髋臼顶的外侧边界作为标志（蓝色箭头）来定位。0°标记已标记。本例中测量的角度为35°（黄色箭头）。

图. 以全髋关节置换术为终点的髋臼周围截骨术后的Kaplan-Meier髋关节存活曲线。彩色区域（微创=红色；髂腹股沟=蓝色）表示存活率的95%置信区间。x轴下方给出了每组随访年数的剩余髋关节数量。请注意，y轴并非从“0”开始。随访4.9年，微创组髋关节存活率为97%，髂腹股沟组髋关节存活率为93%（图11）。

Surgical advances in periacetabular osteotomy for treatment of hip dysplasia in adults

Introduction: Hip dysplasia is characterized by an excessively oblique and shallow acetabulum with insufficient coverage of the femoral head. It is a known cause of pain and the development of early osteoarthritis in young adults. The periacetabular osteotomy is the joint-preserving treatment of choice in young adults with symptomatic hip dysplasia. The surgical aim of this extensive procedure is to reorient the acetabulum to improve coverage and eliminate the pathological hip joint mechanics. Intraoperative assessment of the achieved acetabular reorientation is therefore crucial. The "classic" surgical approaches for the periacetabular osteotomy inflict extensive trauma to the tissues and some involve detachment of muscles. The type of surgical approach may affect the occurrence of complications, duration of surgery, intraoperative blood loss, transfusion requirements, and length of hospital stay. The aims of the PhD thesis were I) to assess the outcome of a new, minimally invasive transsartorial approach for periacetabular osteotomy; II) to compare the minimally invasive approach with the previously used "classic" ilioinguinal approach; and III) to assess the reliability of a novel device for intraoperative assessment of the achieved acetabular reorientation.

Methods: Three studies underly this PhD thesis. In studies I and II, the experience with the minimally invasive and ilioinguinal approaches was retrospectively assessed by database inquiry and evaluation of radiographic material. Data regarding patient demographics, patient history, intraoperative measures and complications was recorded in a validated database. Center-edge and acetabular index angles were measured in preoperative and postoperative pelvic radiographs to assess preoperative dysplasia and the achieved acetabular reorientation. The well-defined study groups consisted of 94 and 263 periacetabular osteotomies in studies I and II, respectively. In study III, intraoperative angle measurements were carried out prospectively in 35 periacetabular osteotomies. The obtained measures (center-edge and acetabular index angles) were compared with those of postoperative pelvic radiographs. Furthermore, a cadaver study was conducted to evaluate intra- and interobserver variability of the device and to assess whether pelvic positioning influenced the variability of measurements. The applied methodology was critically reviewed.

Results: Study I--The minimally invasive approach had the following outcome. The mean duration of surgery was 73 min and the median intraoperative blood loss was 250 ml. Blood transfusion was required following 3% of the procedures. There were no cases of moderate or severe technical and neurovascular complications, and the achieved center-edge and acetabular index angles suggest that optimal reorientation can be achieved. Hip joint survival with total hip arthroplasty as the end point was 98% at 4.3 years. Study II--When compared with the outcome of the ilioinguinal approach, the procedures performed by using the minimally invasive approach had a statistically significant shorter duration of surgery, less intraoperative blood loss and hemoglobin reduction, and fewer transfusion requirements. The achieved reorientation was comparable between groups. There were no cases of moderate or severe complications in the minimally invasive group and three cases (3%) of arterial thrombosis in the ilioinguinal group. At follow-up 4.9 years after hip joint surgery, survival rates were 97% in the minimally invasive group and 93% in the ilioinguinal group. Study III--Intraoperatively obtained angle measures differed less than +/- 5 degrees from measurements on postoperative pelvic radiographs, and the intra- and interobserver variability of the device was confined well within +/-5 degrees. Positioning did not influence the variation of angle measurements beyond intraobserver variability of the device.

Interpretation: The new minimally invasive transsartorial approach appears to be a safe technique, allowing optimal acetabular reorientation, and seems to minimize tissue trauma. In addition, short-term hip joint survival rate is encouraging. The outcome compares favorably with that of the ilioinguinal approach, and the results support continued use of the minimally invasive approach for periacetabular osteotomy. Optimal reorientation of the acetabulum is crucial in periacetabular osteotomy. The novel measuring device is a potentially helpful tool for intraoperative assessment of center-edge and acetabular index angels. It is simple to use and facilitates repeated reliable angle measurements during acetabular reorientation, making intraoperative radiographs unnecessary. The new, minimally invasive approach and the novel measuring device represent important surgical advances in contemporary periacetabular osteotomy.

文献出处：Anders Troelsen. Surgical advances in periacetabular osteotomy for treatment of hip dysplasia in adults. Acta Orthop Suppl. 2009 Apr;80(332):1-33. doi: 10.1080/17453690610046585.

文献5

髋臼旋转截骨术后骨关节炎进展的影响因素：183例髋关节中位随访期14年的研究

译者 徐子茵

背景：髋臼旋转截骨术（RAO）是一种保髋手术，可改善股骨头覆盖。该手术有望减缓髋关节发育不良（DDH）的年轻患者继发骨性关节炎（OA）的进展。然而，由于多种因素，术后OA进展仍会发生。因此，我们的目的是使用患者队列数据研究术后OA进展的因素，RAO手术后的中位随访期为14年，无严重OA的DDH。

方法：回顾性分析因DDH接受RAO的患者的记录，这些患者的T€onnis分级为0和1。我们通过将全髋关节置换术和进展至Tonnis 2级OA作为终点来计算生存率。研究患者术前OA分期、术后髋臼覆盖率和OA进展之间的关系。最终分析共纳入160例患者和183例髋关节（Tonnis 0级，112例髋关节; 1级，71例髋关节）。中位随访时间为14年。

结果：以全髋关节置换术为终点，Tonnis 0级和1级OA组的20年生存率相似，均为86.4%。然而，在这些组中，以进展至Tonnis 2级OA为终点的生存率分别为74.6%和49.3%。在单变量分析中，RAO时的年龄、术前OA分期和体重指数（BMI）是OA进展的预测因素。在多变量分析中，BMI是OA进展的唯一独立预测因素。

结论：我们的RAO队列的中位随访期为14年，在骨关节炎前期和DDH发病初期的患者中显示出良好的生存率。在多变量分析中，高BMI与RAO后OA进展独立相关。

Factors Contributing to the Progression of Osteoarthritis After Rotational Acetabular Osteotomy: A Study of 183 Hips With a Median Follow-Up Period of 14 Years

Background: Rotational acetabular osteotomy (RAO) is a joint-preserving procedure that improves femoral head coverage. This procedure is expected to counteract the progression of secondary osteo­ arthritis of the hip (OA) in young patients who have developmental dysplasia of the hip (DDH). How­ever, postoperative OA progression still occurs owing to multiple factors. Therefore, we aimed to investigate the factors contributing to postoperative OA progression using patient cohort data with a median follow-up period of 14 years after RAO surgery for DDH without severe OA.

Methods: The records of patients who underwent RAO for DDH who had T€onnis grades 0 and 1 were retrospectively reviewed. We calculated the survival rates by setting total hip arthroplasty and pro­ gression to T€onnis grade 2 OA as the endpoints. The associations between patient background, preop­ erative OA stage, postoperative acetabular coverage, and OA progression were investigated. A total of 160 patients and 183 hips (Tonnis grade 0, 112 hips; grade 1, 71 hips) were included in the final analysis. The median follow-up time was 14 years.

Results: The 20-year survival rates with total hip arthroplasty as the endpoint were similarly good at 86.4% in both Tonnis grade 0 and 1 OA groups. However, in these groups, the survival rates with pro­ gression to T€onnis grade 2 OA as the endpoint were 74.6 and 49.3%, respectively. Age at the time of RAO, preoperative OA stage, and body mass index(BMI) were predictive factors for OA progression in the univariate analysis. In the multivariate analysis, BMI was the only independent predictive factor for OA progression.

Conclusions: Our RAO cohort with a median follow-up period of 14 years demonstrated good survival rates in patients at the preosteoarthritis stage and in patients at the initial stage of DDH. In the multivariate analysis, high BMI was independently associated with OA progression after RAO.

文献来源：Yoshikawa Y, Okano I, Usui Y, Nishi M, Nakamura S, Kudo Y. Factors Contributing to the Progression of Osteoarthritis After Rotational Acetabular Osteotomy: A Study of 183 Hips With a Median Follow-Up Period of 14 Years. J Arthroplasty. Published online June 11, 2025. doi:10.1016/j.arth.2025.06.021

来源：304关节学术

作者：304关节团队

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