髋膝关节文献精译荟萃（第361期）

本期目录：

1、单髁置换术：什么是获得手术成功的最佳力线？运动对线的作用

2、初次膝关节置换术中非骨水泥与骨水泥型假体疗效相当，但配对随机对照试验发现非骨水泥型髌骨组件出现移位

3、全膝关节置换胫骨侧假体周围骨折300例病例分析

4、无影像导航机器人手术与个体化方法：优化前交叉韧带重建术后全膝关节置换术

5、髋关节外展肌无力对正常行走中关节负荷的影响

6、大转子截骨术：对臀中肌功能的影响

7、股骨旋转截骨术与凸轮切除可改善股骨前倾角不足型髋关节撞击综合征患者的髋关节功能及内旋活动度

8、反向髋臼周围截骨术治疗症状性髋臼过度覆盖的早期效果如何

9、亚洲髋关节发育不良女性半脱位百分比与髋臼宽度的关系

第一部分：关节置换及保膝相关文献

文献1

单髁置换术：什么是获得手术成功的最佳力线？运动对线的作用

译者 张轶超

单室膝关节置换术（UKA）在许多方面都是一种终极的运动学手术，因为其明确的目标是进行关节病变侧表面置换，并在保持前后交叉韧带完整性的同时恢复关节病变前的力线和平衡。越来越多的知识将UKA的结果与关节炎前的关节解剖联系在一起，而不是随意定义的中立位。膝关节冠状面力线（CPAK）分型为计算关节炎前肢体力线（演算髋关节-膝关节-踝关节角度（aHKA））和关节线倾斜角（JLO）提供了一种有效的技术，并将使人们更好地理解关节炎前解剖、假体位置选择和效果之间的相互作用关系。如果没有考虑到关节炎前的下肢力线，那么术后对于内侧UKA的轻至中度内翻力线和外侧UKA的中度外翻的肢体力线似乎可以达到最好的结果。当考虑到关节炎前的解剖结构时，有报道认为当术后恢复到关节炎前的肢体力线和关节线倾斜度会有更好的结果。在应用这种新方式时，胫骨侧假体冠状角和髋-膝-踝关节（HKA）角的标准尚未被明确定义，但现有证据表明，胫骨冠状角的内翻限制为6°可能是一个合理的标准。外侧UKA在胫骨假体的位置和韧带平衡方面具有固有的差异。移动平台UKA需要对影响垫片稳定性的假体位置有一个三维理解。改良技术是必要的，通过手术器械的设计改进使得胫骨假体角度达到解剖机械对线。机器人技术可以准确地重建关节炎前的解剖结构，精确地再现患者个性化的虚拟规划，同样精确地达到软组织平衡，未来使用这些平台的研究可以进一步阐明理想的患者个性化假体和肢体对线目标。

Unicompartmental Knee Arthroplasty: What is the optimal alignment correction to achieve success? The role of kinematic alignment

Unicompartmental knee arthroplasty (UKA) is in many ways the ultimate kinematic operation, as the express aim is to resurface the diseased side of the joint and restore pre-arthritic alignment and balance while maintaining integrity of both cruciate ligaments. An increasing body of knowledge relates the outcomes of UKA to pre-arthritic anatomy rather than an arbitrarily defined neutral. The Coronal Plane Alignment of the Knee (CPAK) classification provides a validated technique for calculating pre-arthritic limb alignment (the arithmetic hip-knee-ankle angle (aHKA)) and joint line obliquity (JLO) and will enable a greater understanding of the interactions between pre-arthritic anatomy, choice of prosthetic position and outcomes. When pre-arthritic alignment is not taken into consideration a post-operative limb alignment of mild to moderate varus for medial UKA and moderate valgus for lateral UKA appears to produce the best outcomes. When pre-arthritic anatomy is taken into account, superior results have been reported with restoration of pre-arthritic limb alignment and joint line obliquity. Restriction boundaries have yet to be clearly defined for tibial component coronal and hip-knee-ankle (HKA) angles when applying this new paradigm, but existing evidence would suggest a 6 varus limit for the tibial coronal angle may be a reasonable starting point. Lateral UKA has inherent differences in terms of tibial component positioning and ligament balance targets. Mobile bearing UKA demands a three-dimensional understanding of the effect of implant position on bearing stability. Modification of technique is necessary to produce anatomic tibia component angles with equipment designed for mechanical alignment. Robotic technology allows accurate understanding of pre-arthritic anatomy, precise reproduction of patient specific virtual planning, equally precise manipulation of soft tissue balance, and future research using these platforms is likely to further clarify in terms of ideal patientspecific component and limb alignment targets.

文献出处：McEwen P, Omar A, Hiranaka T. Unicompartmental Knee Arthroplasty: What is the optimal alignment correction to achieve success? The role of kinematic alignment. J ISAKOS. 2024 Dec;9(6):100334. doi: 10.1016/j.jisako.2024.100334. Epub 2024 Oct 16. PMID: 39419311.

文献2

初次膝关节置换术中非骨水泥与骨水泥型假体疗效相当，但配对随机对照试验发现非骨水泥型髌骨组件出现移位

译者 马云青

背景：非骨水泥型全膝关节置换术（TKA）日益普及，但部分外科医生对其术后疼痛、假体稳定性及金属底座髌骨组件存活率存在顾虑。本研究通过双侧同期置换病例对比非骨水泥型与骨水泥型TKA的临床效果。

方法：研究纳入40例双侧骨关节炎患者（共80膝），均在单次麻醉下接受双侧TKA，并行髌骨表面置换。所有患者一侧膝关节植入非骨水泥型假体，对侧植入骨水泥型假体。评估指标包括：遗忘关节评分、改良WOMAC骨关节炎指数、膝关节活动度、疼痛程度、手术时间、影像学结果及并发症。所有病例均完成至少2年（2-3年）随访。

结果：两组在功能结局方面无显著差异：遗忘关节评分（97±5分 vs 98±3分，P=0.52）、改良WOMAC评分（3±4分 vs 3±2分，P=0.96）及关节活动度（134±7° vs 134±7°，P=0.16）。术后疼痛程度亦无统计学差异（P>0.05）。非骨水泥组中4例髌骨组件出现平均3.5mm（范围1.77-4.16mm）的上方位移，但无松动征象，移位均发生于术后4周（范围2-6周）。

结论：非骨水泥型TKA可获得与骨水泥型TKA相似的功能结局及恢复轨迹，但需关注非骨水泥髌骨组件的移位风险。

Cementless and Cemented Total Knee Arthroplasties Have Similar Outcomes but Cementless Patellar Component Migration was Observed in a Paired Randomized Control Trial

Background:Cementless total knee arthroplasty (TKA) has become increasingly popular. Some surgeons are concerned about pain, implant stability, and metal-backed patellar component survivorship. This study investigated the outcomes of cementless compared with cemented TKA in bilateral cases.

Methods:We randomized 80 knees in 40 osteoarthritic knee patients who underwent bilateral TKA with patellar resurfacing under one anesthesia. All participants received cementless prostheses in one knee and cemented prostheses in the other. The outcomes were knee function measured by the forgotten joint scores, modified Western Ontario and McMaster Universities Osteoarthritis Index, knee ranges of motion, pain levels, operative times, radiographic outcomes, and complications. All knees were followed for a minimum of 2 years (2 to 3 years).

Results:Cementless and cemented TKA had similar functional outcomes in forgotten joint score (97 ± 5 versus 98 ± 3 points, P = .52), modified Western Ontario and McMaster Universities Osteoarthritis Index score (3 ± 4 versus 3 ± 2 points, P = .96), and ranges of motion (134 ± 7° versus 134 ± 7°, P = .16). The postoperative pain was also similar (P > .05). There were 4 cementless patellar components had superior migration for an average of 3.5 mm (range, 1.77 to 4.16) without loosening. The mean time of migration was 4 (range, 2 to 6) weeks.

Conclusions:Cementless TKA had similar functional outcomes and recovery patterns compared with cemented TKA. However, there was concern of cementless component migration at patellae.

文献出处：Tanariyakul Y, Kanitnate S, Tammachote N. Cementless and Cemented Total Knee Arthroplasties Have Similar Outcomes but Cementless Patellar Component Migration was Observed in a Paired Randomized Control Trial. J Arthroplasty. 2024 May;39(5):1266-1272. doi: 10.1016/j.arth.2023.10.055. Epub 2023 Nov 2. PMID: 37924989.

文献3

全膝关节置换胫骨侧假体周围骨折300例病例分析

单一医学中心的病例分类及疗效分析

译者 张蔷

背景：全膝关节置换（TKR）胫骨侧假体周围骨折是一项处理起来十分具有挑战性的并发症，既往文献中鲜有相关治疗指导。本篇文章的目的是回顾单一医学中心迄今为止最大样本量的一组胫骨侧假体周围骨折病例，分析其疾病分型并总结治疗经验。

方法：我们选择了本医疗中心自1996年至2020年共300例（285位患者）全膝关节置换（43%为初次全膝，57%为全膝翻修）胫骨侧假体周围骨折病例。根据Felix等人的分型标准，I型为累及平台的骨折，II型为累及假体的骨折，III型为假体远端的骨折和IV型为胫骨结节的骨折，亚型A为假体牢固固定，亚型B为假体松动，亚型C为术中骨折。本研究的病例中，53%为I型，24%为II型，16%为III型，8%为IV型。有46%的骨折发生于术中，其余54%发生于术后（61%为亚型A，39%为亚型B）。骨折时平均年龄为67岁，64%为女性。平均随访时间为6年。

I型：累及平台的骨折。II型：累及假体的骨折。III型：假体远端的骨折。IV型：胫骨结节的骨折。

亚型A为术后骨折，胫骨假体固定牢靠。亚型B为术后骨折，胫骨假体松动。亚型C为术中骨折。

结果：全膝翻修术中骨折的概率为1.40%，初次全膝术中骨折的概率为0.10%。术中骨折的病例中，术后2年除外胫骨假体再翻修的生存率最高为I型（100%），最低为IV型（67%）（P < 0.001）。术后骨折的病例中，术后2年除外任意再手术的生存率为29%，术后2年除外胫骨假体再翻修的生存率为51%。I型术后骨折术后2年除外胫骨假体再翻修的生存率最低（10%），而III型的生存率最高（88%）（P < 0.001）。

结论：全膝翻修病例术中胫骨侧假体周围骨折的概率是初次全膝病例的14倍。在所有术中骨折病例中，I型骨折的耐受性最好，术后2年除外胫骨假体翻修的生存率为100%。而相反的，I型术后骨折术后2年生存率仅为10%。

Three Hundred Periprosthetic Tibial Fractures around a Total Knee Replacement

Classification and Outcomes from a Single Institution

Background: Periprosthetic tibial fractures around a total knee replacement (TKR) remain challenging to manage, with little published information for guidance. The purpose of this study was to review the types, management techniques, and outcomes of periprosthetic tibial fractures in the largest series to date.

Methods: We identified 300 periprosthetic tibial fractures (285 patients) around a TKR (43% in primary TKRs and 57% in revision TKRs) sustained between 1996 and 2020. Fractures were classified according to Felix et al. as Type I (tibial plateau), Type II (adjacent to stem), Type III (distal to stem), or Type IV (tibial tubercle), with subtypes A (well-fixed component), B (loose component), and C (intraoperative fracture). Of the fractures in this study, 53% were Type I, 24% were Type II, 16% were Type III, and 8% were Type IV. A total of 46% of fractures occurred intraoperatively, and 54% of fractures occurred postoperatively (61% subtype A, 39% subtype B). The mean patient age at fracture was 67 years, and 64% of patients were female. The mean follow-up was 6 years.

Results: The intraoperative fracture incidence was 1.40% in revision TKRs and 0.10% in primary TKRs. Among intraoperative fractures, the 2-year survivorship free from tibial component revision was highest in Type I (100%) and lowest in Type IV (67%) (P < 0.001). For postoperative fractures, the 2-year survivorship free from any reoperation was 29% and the 2-year survivorship free from tibial component revision was 51%. Type-I postoperative fractures had the lowest 2-year survivorship free from tibial component revision (10%), whereas Type-III fractures had the highest survivorship (88%) (P < 0.001).

Conclusions: Intraoperative periprosthetic fracture of the tibia was fourteen-fold more likely in revision TKRs compared with primary TKRs. Among all intraoperative fractures, Type-I fractures were well-tolerated, with 100% survivorship free from tibial component revision at 2 years. Conversely, Type-I postoperative fractures had only 10% survivorship at 2 years.

文献4

无影像导航机器人手术与个体化方法：优化前交叉韧带重建术后全膝关节置换术

译者 沈松坡

背景：前交叉韧带重建（ACLR）会增加膝关节骨关节炎（OA）及全膝关节置换术（TKA）的发生风险，并伴随更高的并发症发生率。本前瞻性研究的目的，是评估无影像导航机器人手术及个体化方法在既往ACLR患者接受TKA时的作用。

方法：本前瞻性研究纳入70例接受初次TKA的患者：其中35例为既往ACLR组，35例为原发性OA组。所有手术均采用无影像导航机器人系统实施。分析患者的人口学资料、术中及术后数据，包括膝关节功能（活动度ROM、膝关节评分KSS、西安大略和麦克马斯特大学骨关节炎指数WOMAC）、并发症及影像学结果。

结果：尽管ACLR组术前在最大屈曲角度（p=0.021）、KSS-膝关节评分（p=0.041）、KSS-功能评分（p=0.032）、WOMAC-僵硬度（p=0.017）及WOMAC-功能（p=0.035）方面均显著低于原发OA组，但术后两组总体疗效相当，仅在ACLR组膝关节屈曲角仍有残余下降（114.41° vs 128.61°，p<0.001）。术中调整在ACLR组更为频繁，其胫骨再次截骨率显著更高（20% vs 2.8%，p=0.017）。三年随访期内未报告重大并发症或翻修病例。

结论：无影像导航机器人手术结合个体化方法，可使ACLR术后接受TKA的患者与原发性OA患者获得相当的术后疗效，同时减少ACLR病史患者TKA常见的手术问题。总体结果表明，机器人辅助手术的TKA对该类患者是一种安全且有效的治疗选择。

证据等级： II级。

关键词（Keywords） 前交叉韧带重建、全膝关节置换术、个体化对线、无影像导航、机器人手术、全膝关节置换术

图1. 一名 51岁男性患者 的术前X线片，其右膝患有骨关节炎，并于29年前接受过前交叉韧带重建术。术前膝关节活动范围（ROM）为0–105°，伴有外侧推力表现。

图2. 与图1为同一名患者的术中截图，来自 ROSA 膝关节机器人系统（Zimmer Biomet，美国印第安纳州华沙）。在图(a)中，可见伸直位存在11°的内翻畸形（varus deformity），同时在伸直位与90°屈曲位均存在明显的关节松弛，分别为5 mm与4 mm。在图(b)中，可观察到关节运动学得到改善，冠状面畸形得到矫正，并且在伸直位与90°屈曲位均实现了良好的平衡。

图3. 与图1和图2为同一名患者的术后X线片。手术中使用了 Persona® 型人工膝关节假体（Zimmer Biomet，美国印第安纳州华沙），配有后稳定型（Posterior-Stabilized）衬垫和14 × 30 mm的胫骨延长柄。术中胫骨端的固定装置已被移除，而股骨端的固定装置则保留原位。

Imageless robotic surgery and a personalized approach: optimizing TKA after ACL reconstruction

Background: Anterior cruciate ligament reconstruction (ACLR) increases the risk of knee osteoarthritis (OA) and the need for total knee arthroplasty (TKA), with an increased rate of complications. The aim of this prospective study is to evaluate the role of imageless robotic surgery and a personalized approach in TKA after prior ACLR.

Methods: This prospective study involved 70 patients who underwent primary TKA: 35 with prior ACLR and 35 with primary OA. All surgeries were performed using an imageless robotic system. Demographic, intraoperative, and postoperative data were analyzed, including knee function (ROM, KSS, WOMAC), complications, and radiographic outcomes.

Results: Despite significantly lower preoperative values in the ACLR group for maximum flexion (p = 0.021), KSS-knee (p = 0.041), KSS-function (p = 0.032), WOMAC-stiffness (p = 0.017), and WOMAC-function (p = 0.035), postoperative outcomes were comparable between the two groups, except for a residual reduction in knee flexion in the ACLR group (114.41° vs 128.61°, p < 0.001). Intraoperative adjustments were more frequent in the ACLR group, with a significantly higher rate of tibial recuts (20 % vs 2.8 %, p = 0.017). No major complications or revisions were reported at the three-year follow-up.

Conclusions: The use of imageless robotic surgery combined with a personalized approach can achieve comparable postoperative outcomes between patients undergoing TKA after ACLR and those with primary OA, while also reducing common issues associated with TKA in patients with a history of ACLR. The overall results indicate that robotic-assisted TKA is a safe and effective option for these patients.

Level of evidence: Level II.

Keywords: Anterior cruciate ligament reconstruction; Imageless; Personalized alignment; Robotic surgery; TKA.

文献出处：Andriollo L, Picchi A, Demattia G, Marescalchi M, Sangaletti R, Benazzo F, Rossi SMP. Imageless robotic surgery and a personalized approach: optimizing TKA after ACL reconstruction. Knee. 2025 Oct 8;57:353-360. doi: 10.1016/j.knee.2025.09.007. Epub ahead of print. PMID: 41067207.

第二部分：保髋相关文献

文献1

髋关节外展肌无力对正常行走中关节负荷的影响: 建模之概率模型

译者 任宁涛

髋关节外展肌无力与下肢关节骨关节炎相关，关节超负荷可能增加疾病进展风险。肌力、结构性关节退化和关节负荷之间的关系使后者成为研究疾病发生和随访的重要参数。由于髋关节外展肌无力和关节负荷之间的关系仍然是一个悬而未决的问题，本研究的目的是采用概率建模的方法，以了解在正常步态的情况下，髋关节外展肌无力如何影响同侧关节负荷。将一个通用的肌肉骨骼模型缩放到研究中的每个健康受试者，并对模型中每个髋关节外展肌的最大发力能力进行调整，以评估髋关节外展肌无力在生理学上可能的因素如何影响行走时的关节负荷。一般来说，肌肉系统能够补偿髋关节外展肌无力。外展肌发力能力的降低对关节负荷的影响程度较轻，第50分位的平均差异可达0.5 BW(最大1.7 BW)。膝关节负荷峰值比髋关节或踝关节负荷增加更大。臀中肌，尤其是前间室，是对髋、膝关节负荷影响最大的外展肌。进一步的研究应该评估这些关节负荷的增加是否会影响骨关节炎的发生和进展。

Influence of weak hip abductor muscles on joint contact forces during normal walking： probabilistic modeling analysis

The weakness of hip abductor muscles is related to lower-limb joint osteoarthritis, and joint overloading may increase the risk for disease progression. The relationship between muscle strength, structural joint deterioration and joint loading makes the latter an important parameter in the study of onset and follow-up of the disease. Since the relationship between hip abductor weakness and joint loading still remains an open question, the purpose of this study was to adopt a probabilistic modeling approach to give insights into how the weakness of hip abductor muscles, in the extent to which normal gait could be unaltered, affects ipsilateral joint contact forces. A generic musculoskeletal model was scaled to each healthy subject included in the study, and the maximum force-generating capacity of each hip abductor muscle in the model was perturbed to evaluate how all physiologically possible configurations of hip abductor weakness affected the joint contact forces during walking. In general, the muscular system was able to compensate for abductor weakness. The reduced force-generating capacity of the abductor muscles affected joint contact forces to a mild extent, with 50th percentile mean differences up to 0.5 BW (maximum 1.7 BW). There were greater increases in the peak knee joint loads than in loads at the hip or ankle. Gluteus medius, particularly the anterior compartment, was the abductor muscle with the most influence on hip and knee loads. Further studies should assess if these increases in joint loading may affect initiation and progression of osteoarthritis.

文献出处：Valente G, Taddei F, Jonkers I. Influence of weak hip abductor muscles on joint contact forces during normal walking: probabilistic modeling analysis. J Biomech. 2013 Sep 3;46(13):2186-93. doi: 10.1016/j.jbiomech.2013.06.030. Epub 2013 Jul 24. PMID: 23891175.

文献2

大转子截骨术：对臀中肌功能的影响

译者 李勇

目的： 大转子前移会改变臀中肌的功能。然而，除临床研究和生物力学力臂研究外，目前尚无出版物分析大转子前移对肌肉功能的影响。本研究旨在实验室环境下分析大转子截骨术后臀中肌的力学变化。

方法： 对四个髋关节进行了臀中肌起源和插入的解剖学研究。基于解剖，开发了将肌肉分为五个部分的弦模型。测量每 10° 屈曲、内旋和外旋以及外展，转子处于解剖、近端和远端位置，肌纤维长度的变化。

结果： 转子远移导致肌肉动作不平衡，肌肉的等长部分向前移动，屈曲时活跃的肌肉部分较多，伸展时活动的肌肉部分较少。肌肉的拉伸增加了被动力，但降低了肌肉的发力能力，同时增加的肌纤维偏移可能需要更多的能量消耗，这可以解释转子远移后外展肌组织的早期疲劳。对于外展，肌肉附着的远端化导致收缩模式从等长变为等渗。当大转子的尖端与髋关节旋转中心齐平时，肌肉的最佳平衡和偏移是肌肉的最佳平衡和偏移。

结论： 对于存在高位大转子的髋关节，其最佳位置是与髋关节旋转中心齐平。应避免过度远移。由于该结论及相关考量基于实验室环境得出，因此未必能直接应用于临床实践。

Osteotomy of the greater trochanter: effect on gluteus medius function

Purpose: Advancement of the greater trochanter alters the function of the gluteus medius muscle. However, with the exception of clinical studies and biomechanical lever arm studies, no publications that analyze the consequences of advancement of the greater trochanter on the muscle function exist. The aim of the study was to analyze the mechanical changes of gluteus medius after osteotomy of the greater trochanter in a lab setting.

Methods: An anatomical study of origin and insertion of the gluteus medius was carried out on four hips. Based on the dissections, a string model was developed dividing the muscle into five sectors. Changes in muscle fiber length were measured for every 10° of flexion, internal and external rotation and abduction with the trochanter in anatomic, proximalized and distalized positions.

Results: Distalization of the trochanter leads to an imbalance of muscle action, moving the isometric sector of the muscle anteriorly with more muscle sectors being active during flexion and less during extension. Stretching of the muscle increases passive forces but decreases the force generation capacity of the muscle and at the same time increased muscle fiber excursion may require more energy consumption, which may explain earlier fatigue of the abductor musculature after distalization of the trochanter. For abduction, distalization of the muscle attachment leads to a change in contraction pattern from isometric to isotonic. Optimal balancing and excursion of the muscle is when the tip of the greater trochanter is at level with the hip rotation center.

Conclusions: In hips with high riding trochanter, the optimal position is at the level of the center of hip rotation. Excessive distalization should be avoided. As the conclusions and considerations are based on a lab setting, transfer to clinical practice may not necessarily apply.

文献出处：Beck M, Krüger A, Katthagen C, Kohl S. Osteotomy of the greater trochanter: effect on gluteus medius function. Surg Radiol Anat. 2015 Aug;37(6):599-607. doi: 10.1007/s00276-015-1466-z. Epub 2015 Apr 1. PMID: 25828839.

文献3

股骨旋转截骨术与凸轮切除可改善股骨前倾角不足型髋关节撞击综合征患者的髋关节功能及内旋活动度

译者 邱兴

目前针对股骨前倾角（FV）减小的股骨髋臼撞击综合征（FAI）患者的研究尚不充分。本研究旨在评估：（i）接受股骨旋转截骨术的有症状患者的髋关节疼痛及活动范围；（ii）主观满意度；（iii）后续手术情况。研究采用回顾性病例系列分析，纳入2014-2018年间18例（23髋）因股骨前倾角减小伴髋前疼痛接受股骨旋转截骨术的患者。术前平均年龄25±6岁（男性占57%），所有患者股骨前倾角均<10°且完成至少1年随访（平均随访时间2±1年）。手术指征包括：前撞击试验阳性、屈曲90°时内旋（IR）受限（平均10±8°）、伸直位内旋受限（平均24±11°）、磁共振关节造影显示前上侧软骨盂唇损伤、CT测量确认股骨前倾角减小（平均5±3°，采用Murphy测量法）且无骨关节炎（Tönnis分级0级）。多数患者存在关节内与关节外髂前下棘撞击（基于患者特异性三维撞击模拟）。通过转子下股骨旋转截骨术增加股骨前倾角（矫正角度20±4°），并联合实施凸轮切除（78%）和外科髋关节脱位（91%）。（i）前撞击试验阳性率从术前至术后显著下降（100%降至9%，P<0.001）；屈曲90°时内旋角度显著增加（10±8°增至31±10°，P<0.001）。（ii）主观满意度从术前至术后显著提升（33%上升至77%，P<0.001）；Merle d'Aubigné-Postel评分从术前14±2分（范围8-15）显著提高至17±1分（范围13-18，P<0.001）。85%患者在随访中表示愿意再次接受该手术。（iii）末次随访时所有23髋均获得保留（未转为全髋关节置换术），其中1髋（4%）接受内固定翻修术。结论：对于股骨前倾角减小的FAI患者，近端股骨旋转截骨术联合凸轮切除在短期随访中可有效改善髋部疼痛及内旋功能。增加股骨前倾角的旋转截骨术安全可靠。

图1. 一名20岁男性患者的术前影像资料：正位X光片（A）、股骨前倾角测量（B）及基于三维CT的骨盆与近端股骨模型（C），其中显示存在关节内与关节外髋关节前撞击；该患者后续接受了转子下股骨旋转截骨术联合外科髋关节脱位术（D）以增大股骨前倾角。

Rotational femoral osteotomies and cam resection improve hip function and internal rotation for patients with anterior hip impingement and decreased femoral version

Femoroacetabular impingement (FAI) patients with reduced femoral version (FV) are poorly understood. The aim of this study is to assess (i) hip pain and range of motion, (ii) subjective satisfaction and (iii) subsequent surgeries of symptomatic patients who underwent rotational femoral osteotomies. A retrospective case series involving 18 patients (23 hips, 2014-2018) with anterior hip pain that underwent rotational femoral osteotomies for treatment of decreased FV was performed. The mean preoperative age was 25 ± 6 years (57% male), and all patients had decreased FV < 10° and minimum 1-year follow-up (mean follow-up 2 ± 1 years). Surgical indication was the positive anterior impingement test, limited internal rotation (IR) in 90° of flexion (mean 10 ± 8°) and IR in extension (mean 24 ± 11°), anterosuperior chondrolabral damage in Magnet resonance (MR) arthrography, CT-based measurement of decreased FV (mean 5 ± 3°, Murphy method) and no osteoarthritis (Tönnis Grade 0). Most patients had intra- and extra-articular subspine FAI (patient-specific 3D impingement simulation). Subtrochanteric rotational femoral osteotomies to increase FV (correction 20 ± 4°) were combined with cam resection (78%) and surgical hip dislocation (91%). (i) The positive anterior impingement test decreased significantly (P < 0.001) from pre- to postoperatively (100% to 9%). IR in 90° of flexion increased significantly (P < 0.001, 10 ± 8° to 31 ± 10°). (ii) Subjective satisfaction increased significantly (P < 0.001) from pre- to postoperatively (33% 77%). The mean Merle d'Aubigné and Postel score increased significantly (P < 0.001) from 14 ± 2 (8-15) points to 17 ± 1 (13-18, P < 0.001) points. Most patients (85%) reported at follow-up that they would undergo surgery again. (iii) At follow-up, all 23 hips were preserved (no conversion to total hip arthroplasty). One hip (4%) underwent revision osteosynthesis. Proximal rotational femoral osteotomies combined with cam resection improve hip pain and IR in most FAI patients with decreased FV at short-term follow-up. Rotational femoral osteotomies to increase FV are safe and effective.

文献出处：Lerch, T. D., Meier, M. K., Hanke, M. S., Boschung, A., Schmaranzer, F., Siebenrock, K. A., ... & Steppacher, S. D. (2024). Rotational femoral osteotomies and cam resection improve hip function and internal rotation for patients with anterior hip impingement and decreased femoral version. Journal of Hip Preservation Surgery, 11(2), 85-91.

文献4

反向髋臼周围截骨术治疗症状性髋臼过度覆盖的早期效果如何？

译者 陶可

背景：髋臼过度覆盖与钳夹型股骨髋臼撞击综合征(FAI)有关。髋臼过度覆盖的一个亚型是由于髋臼深且髋臼顶倾斜引起的，在这种情况下，髋臼重新定向可能是比单纯修整边缘以暴露股骨头更好的替代方案。我们于2003年引入了真正的反向髋臼周围截骨术(PAO)，与前倾式PAO不同，它还能使髋臼相对于完整的髂骨屈曲和外展，以减少股骨头前后侧覆盖并纠正髋臼顶的负倾斜。据我们所知，真正的反向PAO的临床结果尚未得到评估。

问题/目的：针对一组接受反向PAO的患者，(1)接受反向PAO的患者是否在短期内表现出疼痛、功能和髋关节活动度的改善，以及髋臼覆盖度（以外侧和前方中心边缘角以及Tönnis角定义）的降低？(2)是否存在与反向PAO成功或不良结局（以再次手术、转为全髋关节置换术或患者报告结果评分不佳定义）相关的可识别因素？(3)是否存在与早期并发症相关的可识别因素？

方法：2003年至2017年间，两名外科医生为37例患者实施了49例反向PAO。其中25例患者为单侧反向PAO，12例患者为分期双侧反向PAO。为了确保每个髋关节作为独立的数据点进行统计分析，我们选择仅纳入接受双侧反向PAO的患者的第一髋。在研究期间，我们将该手术的一般适应症定义为：有症状的髋臼外侧和前侧覆盖过度导致的FAI，且既往保守或手术治疗无效。本回顾性研究纳入了37例患者，共37个髋关节，中位年龄（范围）为18岁（12至41岁；四分位距16至21岁），随访时间最短为2年（中位时间6年；范围2至17年）。34例患者完成了问卷调查，24例患者接受了X线评估，23例患者接受了髋关节ROM临床检查。然而，7例患者已超过5年未复诊。我们从纵向维护的机构数据库中选取了37例接受反向PAO治疗的髋关节患者，并对其术前和术后临床和X线参数进行了回顾性研究。不良结局定义为术后至少2年转为全髋关节置换术（THA）或WOMAC疼痛评分大于10。术前及最近一次随访时，根据情况使用配对t检验或McNemar检验评估患者报告的结局、X线测量值和髋关节活动度（ROM）。采用线性回归分析评估与临床结局相关的可识别因素。采用逻辑回归分析评估与不良结局和手术并发症相关的可识别因素。所有检验均为双侧检验，p值小于0.05被认为具有显著差异。

结果：术后至少2年，患者的WOMAC疼痛评分（-7 [95% CI -9至-5]；p < 0.001）、僵硬评分（-2 [95% CI -3至-1]；p < 0.001）、功能评分（-18 [95% CI -24至-12]；p < 0.001）和改良Harris髋关节评分（mHHS）（20 [95% CI 13至27]；p < 0.001）均有所改善。术后髋关节平均内旋活动度（8° [95% CI 2°至14°]；p = 0.007）均有所改善。髋臼覆盖度（以外侧中心边缘角(LCEA)、前中心边缘角(ACEA) 和 Tönnis 角定义）LCEA改善-8°（95% CI -12° 至 -5°；p < 0.001），ACEA改善 -12°（95% CI -15° 至 -9°；p < 0.001），Tönnis角改善9°（95% CI 6° 至 13°；p < 0.001）。术后放射学关节炎的严重程度与较差的WOMAC功能评分相关，因此，术后每个Tönnis等级，WOMAC功能评分都会增加12分（95% CI 2 至 22；p = 0.03）。术后Tönnis分级越高，mHHS越差，平均每增加一个Tönnis分级，mHHS就会下降12 分（95% CI -20 至 -4；p = 0.008）。术后前撞击试验阳性与随访时mHHS评分下降相关，mHHS平均下降23 分（95% CI -34 至 -12；p = 0.001）。19%（37例中的7例）的髋关节出现了手术相关并发症。4例髋关节在最终随访中出现不良反应，其中2例患者随后接受了THA，2例患者的WOMAC疼痛评分大于10分。我们没有发现与并发症或不良反应相关的因素。

结论：真正的反向PAO的早期临床和影像学结果与钳状FAI的其他外科治疗方法相比具有优势，提示反向PAO是治疗钳状FAI（由于广泛的髋臼超覆盖造成的）的一种有效的方法。然而，该手术技术复杂，需要熟悉标准PAO的外科医生进行大量的培训和准备，并且必须向患者仔细讲解该手术的潜在风险和益处。未来需要进一步研究以进一步完善反向PAO的适应症并确定其长期疗效。

图1 A-C (A)这张术前X线片来自一名18岁女性，因髋臼过度覆盖导致右髋疼痛。术前，她的外侧中心边缘角(LCEA)为36°，前方中心边缘角(ACEA)为50°。(B)反向PAO术后，她的LCEA 为21°，ACEA为35°。(C)反向PAO术后9年的最终随访X线片显示，与术前相比，股骨头外侧和前方覆盖减少，关节间隙得以维持。

图2 A-K这些插图展示了反向PAO的手术技巧。(A)坐骨、耻骨上支和髂骨截骨术按常规方式进行。(B)后柱截骨术呈曲线形，并向前凹入坐骨截骨术。(C) 5号截骨术是在完整的髂骨上开一个小口，以进一步稳定截骨。6号截骨术是髂骨成形术，在内侧突出的髂前下棘和髋臼碎片的髂前缘进行，以减轻股骨神经血管结构的压力。(D)将骨撑开器放置在髂骨和后柱截骨处，以帮助释放髋臼。(E)使用有角度的Ganz凿子沿远端和外侧方向直接切开坐骨。(F)用反向Hohmann牵开器的下钝尖端在骨盆内向前外侧推压髋臼碎片的前下缘，有助于完成坐骨截骨处的移位。(G)在髋臼相对于完整髂骨进行屈曲、外展和内旋的联合矫正操作期间，使用Schanz螺钉、T型手柄和Weber骨夹来控制髋臼碎片。(H)髋臼碎片的另一个视图，显示矫正操作期间产生的髋臼屈曲。(I)应对内侧突出的髂骨进行广泛的髂骨成形术，以减少该突出对髂腰肌和股神经血管结构的术后压力。(J)使用多个螺钉实现最终固定。髂骨成形术中切除的骨骼可用作自体骨移植，以填补截骨术中的任何间隙。(K)髋臼碎片的最终位置显示髋臼相对于完整髂骨的内旋和外展。经儿童骨科手术基金会许可发表。

What Are the Early Outcomes of True Reverse Periacetabular Osteotomy for Symptomatic Hip Overcoverage?

Background: Acetabular overcoverage is associated with pincer-type femoroacetabular impingement (FAI). A subtype of acetabular overcoverage is caused by a deep acetabulum with a negatively tilted acetabular roof, in which acetabular reorientation may be a preferable alternative to rim trimming to uncover the femoral head. We introduced the true reverse periacetabular osteotomy (PAO) in 2003, which in contrast to an anteverting PAO, also flexes and abducts the acetabulum relative to the intact ilium to decrease anterior and lateral femoral head coverage and correct negative tilt of the acetabular roof. To our knowledge, the clinical results of the true reverse PAO have not been evaluated.

Questions/purposes: For a group of patients who underwent reverse PAO, (1) Do patients undergoing reverse PAO demonstrate short-term improvement in pain, function, and hip ROM, and decreased acetabular coverage, as defined by lateral and anterior center-edge angle and Tönnis angle? (2) Are there identifiable factors associated with success or adverse outcomes of reverse PAO as defined by reoperation, conversion to THA, or poor patient-reported outcome scores? (3) Are there identifiable factors associated with early complications?

Methods: Between 2003 and 2017, two surgeons carried out 49 reverse PAOs in 37 patients. Twenty-five patients had unilateral reverse PAO and 12 patients had staged, bilateral reverse PAOs. To ensure that each hip was an independent data point for statistical analysis, we chose to include in our series only the first hip in the patients who had bilateral reverse PAOs. During the study period, our general indications for this operation were symptomatic lateral and anterior acetabular overcoverage causing FAI that had failed to respond to previous conservative or surgical treatment. Thirty-seven hips in 37 patients with a median (range) age of 18 years (12 to 41; interquartile range 16 to 21) were included in this retrospective study at a minimum follow-up of 2 years (median 6 years; range 2 to 17). Thirty-four patients completed questionnaires, 24 patients had radiographic evaluation, and 23 patients received hip ROM clinical examination. However, seven patients had not been seen in more than 5 years. The clinical and radiographic parameters of all 37 hips that underwent reverse PAO in 37 patients from a longitudinally maintained institutional database were retrospectively studied preoperatively and postoperatively. Adverse outcomes were considered conversion to THA or a WOMAC pain score greater than 10 at least 2 years postoperatively. Patient-reported outcomes, radiographic measurements, and hip ROM were evaluated preoperatively and at most recent follow-up using a paired t-test or McNemar test, as appropriate. Linear regression analysis was used to assess for identifiable factors associated with clinical outcomes. Logistic regression analysis was used to assess for identifiable factors associated with adverse outcomes and surgical complications. All tests were two-sided, and p values less than 0.05 were considered significant.

Results: At a minimum of 2 years after reverse PAO, patients experienced improvement in WOMAC pain (-7 [95% CI -9 to -5]; p < 0.001), stiffness (-2 [95% CI -3 to -1]; p < 0.001), and function scores (-18 [95% CI -24 to -12]; p < 0.001) and modified Harris Hip Score (mHHS) (20 [95% CI 13 to 27]; p < 0.001). The mean postoperative hip ROM improved in internal rotation (8° [95% CI 2° to 14°]; p = 0.007). Acetabular coverage, as defined by lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), and Tönnis angle, improved by -8° (95% CI -12° to -5°; p < 0.001) for LCEA, -12° (95% CI -15° to -9°; p < 0.001) for ACEA, and 9° (95% CI 6° to 13°; p < 0.001) for Tönnis angle. The postoperative severity of radiographic arthritis was associated with worse WOMAC function scores such that for each postoperative Tönnis grade, WOMAC function score increased by 12 points (95% CI 2 to 22; p = 0.03). A greater postoperative Tönnis grade was also correlated with worse mHHS, with an average decrease of 12 points (95% CI -20 to -4; p = 0.008) in mHHS for each additional Tönnis grade. Presence of a positive postoperative anterior impingement test was associated with a decrease in mHHS score at follow-up, with an average 23-point decrease in mHHS (95% CI -34 to -12; p = 0.001). Nineteen percent (7 of 37) of hips had surgery-related complications. Four hips experienced adverse outcomes at final follow-up, with two patients undergoing subsequent THA and two with a WOMAC pain score greater than 10. We found no factors associated with complications or adverse outcomes.

Conclusion: The early clinical and radiographic results of true reverse PAO compare favorably to other surgical treatments for pincer FAI, suggesting that reverse PAO is a promising treatment for cases of pincer FAI caused by global acetabular overcoverage. However, it is a technically complex procedure that requires substantial training and preparation by a surgeon who is already familiar with standard PAO, and it must be carefully presented to patients with discussion of the potential risks and benefits. Future studies are needed to further refine the indications and to determine the long-term outcomes of reverse PAO.

文献出处：Stephanie Y Pun, Shayan Hosseinzadeh, Roya Dastjerdi, Michael B Millis. What Are the Early Outcomes of True Reverse Periacetabular Osteotomy for Symptomatic Hip Overcoverage? Clin Orthop Relat Res. 2021 May 1;479(5):1081-1093. doi: 10.1097/CORR.0000000000001549.

文献5

亚洲髋关节发育不良女性关节半脱位百分比与髋臼宽度的关系

译者 徐子茵

背景： 将髋臼杯假体植入髋臼的“真实”位置是全髋关节置换术的基本原则，用于治疗因髋关节发育不良 （DDH） 引起的继发性骨关节炎。由于准确放置需要了解髋臼形态，因此我们研究了髋臼宽度与髋关节半脱位百分比的 Crowe 分类之间的关系。我们还分析了与髋臼宽度比 （AWR） 相关的因素，AWR 定义为发育不良髋关节的髋臼宽度除以未受影响的对侧髋关节的髋臼宽度。

方法： 我们完成了对 207 名因单侧 DDH 接受初次全髋关节置换术的女性患者的术前标准前后位 X 光片和计算机断层扫描 （CT） 扫描的回顾性评价。每次 CT 重建中的“真正”髋臼平面被定义为垂直于骨盆前平面、平行于泪滴线并穿过未受影响的对侧股骨头中心的平面。在真正的髋臼平面上测量受影响髋关节和对侧参考髋关节的髋臼宽度，髋臼宽度定义为髋臼前壁和后壁边缘之间的距离。所有髋关节均根据发育不良髋关节的半脱位百分比根据 Crowe 分组进行分类;半脱位百分比从I组增加到IV组，IVb组出现关节脱位。

结果： 髋臼宽度从 Crowe 组 I 减小到 IVb，AWR 与半脱位百分比之间呈负相关（Spearman 相关系数，ρ = -0.404;p < 0.001）。多因素回归分析确定半脱位百分比和股骨颈干角是与 AWR 相关的独立因素。

结论： 半脱位百分比和股骨颈干角，将指导外科医生在 DDH 患者的全髋关节置换术期间正确植入髋臼杯假体。

The Relationship Between Subluxation Percentage of the Femoroacetabular Joint and Acetabular Width in Asian Women with Developmental Dysplasia of the Hip

Background: Implantation of the acetabular cup insert in the "true" location of the acetabulum is a fundamental principle of total hip arthroplasty for the treatment of secondary osteoarthritis due to developmental dysplasia of the hip (DDH). As knowledge of the morphology of the acetabulum is required for accurate placement, we investigated the relationship between acetabular width and the Crowe classification of subluxation percentage of the hip. We also analyzed factors associated with the acetabular width ratio (AWR), defined as the acetabular width of the dysplastic hip divided by that of the unaffected, contralateral hip.

Methods: We completed a retrospective review of the preoperative standard anteroposterior radiographs and computed tomography (CT) scans of 207 female patients who underwent primary total hip arthroplasty for unilateral DDH. The "true" acetabular plane was defined on each CT reconstruction as a plane perpendicular to the anterior pelvic plane, parallel to the teardrop line, and passing through the center of the femoral head on the unaffected, contralateral side. The acetabular width was measured for both the affected hip and the contralateral, reference hip on the true acetabular plane, with the acetabular width defined as the distance between the edges of the anterior and posterior walls of the acetabulum. All hips were classified according to the Crowe groupings on the basis of the subluxation percentage of the dysplastic hip; the subluxation percentage increased from groups I to IV, with group IVb showing joint dislocation.

Results: The acetabular width decreased from Crowe groups I to IVb, with a negative correlation found between the AWR and the subluxation percentage (Spearman correlation coefficient, ρ = -0.404; p < 0.001). Multivariate regression analysis identified subluxation percentage and femoral neck-shaft angle as independent factors associated with the AWR.

Conclusions: Characterization of factors associated with the AWR, namely subluxation percentage and femoral neck-shaft angle, will guide surgeons in correctly implanting the acetabular cup insert during total hip arthroplasty in patients with DDH.

文献来源：Okuzu Y, Goto K, Kawata T, So K, Kuroda Y, Matsuda S. The Relationship Between Subluxation Percentage of the Femoroacetabular Joint and Acetabular Width in Asian Women with Developmental Dysplasia of the Hip. J Bone Joint Surg Am. 2017;99(7):e31. doi:10.2106/JBJS.16.00444

来源：304关节学术

作者：304关节团队

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