髋膝关节文献精译荟萃（第363期）

本期目录：

1、全膝关节置换术中的非骨水泥固定：目前的证据和未来的展望

2、哪些术前因素与全膝关节置换术后未能达到可接受的疼痛和功能水平相关

3、应用叠放式锥形补块处理膝翻修手术中胫骨侧广泛骨缺损

4、以基尼指数量化的收入不平等可作为全膝关节置换术不良结局的指标

5、指甲-髌骨综合征影像学表现

6、术后髋臼壁指数对髋关节发育不良患者行髋臼转位截骨术后患者报告结局的影响

7、股骨头坏死治疗的预后因素

8、髋臼周围截骨术治疗严重髋关节发育不良-手术技术

9、股骨头软骨下不全骨折

第一部分：关节置换及保膝相关文献

文献1

全膝关节置换术中的非骨水泥固定：目前的证据和未来的展望

译者 张轶超

介绍：非骨水泥固定在全膝关节置换术（TKA）中扮演着越来越重要的角色。这篇综述文章的目的是分析非骨水泥TKA的功能效果和生存率。

材料和方法：对非骨水泥TKA的预后和生存率进行了全面的文献检索。该检索基于PRISMA 2020指南，使用PubMed、Medline和Embase数据库。由两名独立观察员筛选出纳入的研究文献。

结果：搜索从2010 - 2022年间的文献，有15项被纳入研究。11项研究比较了非水泥TKA和水泥TKA。四项研究仅涉及非骨水泥假体。非骨水泥TKA的生存率和功能结果至少与骨水泥TKA相当。

结论：随着制造技术的进步和手术工具的精确交付，以及机器人辅助TKA和3D打印植入物的使用，由于更多的生物固定技术的开展，获得更好的生存率和结果，可以预期非骨水泥TKA的使用会逐渐增加。

Cementless fixation in total knee arthroplasty: current evidence and future perspective

Introduction：Cementless fixation plays an increasing role in total knee arthroplasty (TKA). The objective of this review article is to analyze functional outcomes and survivorship of cementless TKA.

Materials and Methods：A comprehensive literature search for studies reviewing the outcome and survivorship of cementless TKA was conducted. This search was based on the PRISMA 2020 guidelines using PubMed, Medline, and Embase. The included studies were screened by two independent observers.

Results：From 2010 to 2022, fifteen studies were included. Eleven studies compared cementless and cemented TKA. Four studies only covered cementless implants. Survivorship and functional outcomes of cementless TKA are at least comparable to those of cemented implants.

Conclusion：With improvement in manufacturing, and surgical tools for more precise delivery, such as robotic assisted TKA and 3D-printed implants, one can expect increase in usage of cementless TKA, due to a more biological fixation, better survivorship, and outcomes.

文献出处：Haslhofer DJ, Kraml N, Stadler C, Gotterbarm T, Klotz MC, Klasan A. Cementless fixation in total knee arthroplasty: current evidence and future perspective. Arch Orthop Trauma Surg. 2024 Dec 28;145(1):101. doi: 10.1007/s00402-024-05670-2. PMID: 39731597; PMCID: PMC11682007.

文献2

哪些术前因素与全膝关节置换术后未能达到可接受的疼痛和功能水平相关？一项国际多中心研究的发现

译者 马云青

背景：尽管全膝关节置换术（TKA）是治疗终末期膝关节骨关节炎的常见可靠的术式，但仍有少数患者无法获得满意的疼痛缓解和功能改善。尽管已有研究试图找出会影响临床结果不佳的原因，但很少有研究从患者可接受的症状状态（PASS）这一角度来探讨此问题。PASS定义为患者自评疗效指标量表上的一个阈值，高于此阈值表明患者认为其当前的治疗状态是可以接受的。

目的： (1) 在TKA术后1年时，未达到疼痛和功能PASS的患者比例是多少？(2) 哪些术前患者因素与TKA术后1年未达到疼痛PASS相关？(3) 哪些术前患者因素与TKA术后1年未达到功能PASS相关？

方法：本研究是一项回顾性研究，是对一项关于单一TKA系统的前瞻性、国际性、多中心研究的1年随访数据进行的二次分析。原研究的纳入标准为：诊断为原发骨关节炎或创伤后关节炎、且能够进行10年随访的患者；排除标准为：存在感染、骨髓炎以及既往关节置换失败。在2011年至2014年间，共有449名患者在5个国家的10个中心接受了TKA。在1年时，13%（58/449）的患者失访，2%（8/449；缺失1年KOOS数据）无法进行分析，剩下85%（383/449）的患者纳入本次分析。主要结局指标是未达到证据推导出的膝关节损伤和骨关节炎结局评分（KOOS）疼痛分量表及日常生活活动（ADL）分量表的PASS阈值。研究构建了多变量二元逻辑回归模型，考虑术前人口统计学、影像学及患者报告结局指标数据，并采用前向逐步剔除算法来得到最简化的最佳拟合回归模型。

结果：在TKA术后1年，38%（145/383）的患者未达到KOOS疼痛的PASS，36%（139/383）未达到KOOS ADL的PASS，29%（110/383）未达到KOOS疼痛或ADL中任一指标的PASS。在控制了性别、年龄、BMI和合并症评分等潜在混杂变量后，我们发现，男性（比值比 2.09；p = 0.01）以及影像学显示非严重骨关节炎的患者（比值比 2.09；p = 0.01）与未达到疼痛PASS显著相关。在控制了相同的潜在混杂变量后，我们发现，影像学显示非严重骨关节炎的患者（比值比 2.09；p = 0.01）也与未达到功能PASS显著相关。

结论：我们发现，骨关节炎严重程度较轻的患者在TKA术后1年达到疼痛和功能PASS的可能性要低得多，并且男性在TKA术后1年达到疼痛PASS的可能性也低得多。基于这些发现，外科医生应强烈考虑对于骨关节炎严重程度较轻的患者延迟手术，并对男性患者给予额外谨慎。外科医生应就患者的期望及其获得有意义的疼痛和功能改善的机会向其提供咨询。未来的地区和国家注册研究应评估TKA术后达到疼痛和功能PASS患者的真实比例，并验证本研究中确定的术前因素在更大型、更多样化的患者群体中是否仍然显著。

Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study

Background:Although TKA is a common and proven reliable procedure for treating end-stage knee osteoarthritis, a minority of patients still do not achieve satisfactory levels of pain relief and functional improvement. Even though several studies have attempted to identify patients at risk of having poor clinical outcomes, few have approached this issue by considering the outcome of the patient-acceptable symptom state (PASS), defined as the value on a patient-reported outcome measure scale above which the patient deems their current symptom state acceptable.

Questions/purposes:(1) What is the proportion of patients who do not attain the PASS in pain and function at 1 year after TKA? (2) Which preoperative patient factors are associated with not achieving the PASS in pain at 1 year after TKA? (3) Which preoperative patient factors are associated with not achieving the PASS in function at 1 year after TKA?

Methods:This retrospective study is a secondary analysis of the 1-year follow-up data from a prospective, international, multicenter study of a single TKA system. Inclusion criteria for that study were patients diagnosed with primary osteoarthritis or post-traumatic arthritis and who were able to return for follow-up for 10 years; exclusion criteria were infection, osteomyelitis, and failure of a previous joint replacement. Between 2011 and 2014, 449 patients underwent TKA at 10 centers in five countries. At 1 year, 13% (58 of 449) were lost to follow-up, 2% could not be analyzed (eight of 449; missing 1-year KOOS), leaving 85% (383 of 449) for analysis here. The primary outcomes were not surpassing evidence-derived PASS thresholds in the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain and Activities in Daily Living (ADL) sub-scores. Multivariate binary logistic regressions considering preoperative demographic, radiographic, and patient-reported outcome measure data were constructed using a forward stepwise elimination algorithm to reach the simplest best-fit regression models.

Results:At 1 year after TKA, 38% of the patients (145 of 383) did not reach the PASS in KOOS Pain, 36% (139 of 383) did not reach the PASS in KOOS ADL, and 29% (110 of 383) did not achieve the PASS in either KOOS Pain or ADL. After controlling for potentially confounding variables such as gender, age, BMI, and comorbidity scores, we found that men (odds ratio 2.09; p = 0.01), and patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were strongly associated with not achieving the PASS in pain. After controlling for the same potentially confounding variables, we found that patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were also strongly associated with not achieving the PASS in function.

Conclusions:We found that patients with less severe osteoarthritis were much less likely to attain the PASS in pain and function at 1 year after TKA, and that men were much less likely to achieve the PASS in pain at 1 year after TKA. Based on these findings, surgeons should strongly consider delaying surgery in patients who present with less-than-severe osteoarthritis, with increased caution in men. Surgeons should counsel their patients on their expectations and their chances of achieving meaningful levels of pain and functional improvement. Future regional and national registry studies should assess the true proportion of patients attaining PASS in pain and function after TKA and confirm if the preoperative factors identified in this study remain significant in larger, more diverse patient populations.

文献出处：Connelly JW, Galea VP, Rojanasopondist P, Nielsen CS, Bragdon CR, Kappel A, Huddleston JI 3rd, Malchau H, Troelsen A. Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study. Clin Orthop Relat Res. 2020 May;478(5):1019-1028. doi: 10.1097/CORR.0000000000001162. Erratum in: Clin Orthop Relat Res. 2020 Dec;478(12):2955. doi: 10.1097/CORR.0000000000001565. Erratum in: Clin Orthop Relat Res. 2021 Jul 1;479(7):1641-1643. doi: 10.1097/CORR.0000000000001831. PMID: 32039954; PMCID: PMC7170689.

文献3

应用叠放式锥形补块处理膝翻修手术中胫骨侧广泛骨缺损

译者 张蔷

背景：在处理膝翻修手术中胫骨近端广泛骨缺损时，高孔隙率干骺端锥形补块涌现为备受青睐的固定选择。尽管既往关于叠放式锥形补块的文献稀少，这种方法却逐步流行。本篇文章主要报道了全膝（TKA）翻修手术中应用叠放式锥形补块的早期结果。

方法：我们选择2010年1月至2022年12月间所有接受叠放式锥形补块治疗的病例，进行了一项单中心回顾性观察研究。收集的资料包括一般资料、手术信息、影像学数据等。我们应用Kaplan-Meier曲线评估了全因再手术或胫骨侧翻修的假体生存率，终末点均为影像学可观察的假体松动。最终，共入组了22例叠放式锥形补块的病例：其中，15例（68.2%）为男性；平均年龄64.1岁（范围，42.8-87.8岁），BMI 34.2kg/m2（范围，20.4-51.9kg/m2），既往手术中位数为4台（范围，1-12台），平均随访时间为22.6个月（范围，6.8-79.1个月）。

评估骨缺损的方法：在距离腓骨头近端15mm的位置画一条垂直于胫骨轴线的水平线标记原始关节线，内外侧平台皮质骨向关节线做垂线，估算骨缺损。

77岁老年男性，既往应用铰链膝的二期膝翻修病史（A），因假体周围感染行再翻修手术，一期应用含有抗生素的静态间隔器（B），二期手术时可见AORI 3型的胫骨侧广泛非包容性骨缺损，分别应用远端3D打印的多孔钛金属锥形补块和近端高孔隙率钽金属锥形补块叠放的技术处理骨缺损，术后1年随访时显示假体结构稳定（C）。

结果：有20例应用了两块叠放的锥形补块，而另外2例应用了三块叠放的锥形补块。应用叠放式锥形补块的适应证包括：假体周围感染（n = 11），无菌性松动（n = 9），胫骨侧疼痛（n = 1）和假体周围骨折（n = 1）。在术后中位数2.9个月后（范围，0.4-37.3个月），5例病例接受了再手术，原因包括：伸膝装置失效（n = 2），股骨假体松动（n = 1），浅表伤口开裂（n = 1）和术后血肿（n = 1）。在术后3年随访时，未出现因胫骨侧假体松动而翻修的病例（有一例在术后15个月随访时片子显示松动迹象，但最终未接受翻修治疗）。

结论：在全膝翻修手术中遇到广泛干骺端骨缺损时，叠放式锥形补块是一种安全有效的治疗选择。

Stacked Cone Constructs for the Treatment of Extensive Tibial Bone Loss in Revision Total Knee Arthroplasty-A Series of 22 Patients

Background: Highly porous metaphyseal cones have emerged as a promising fixation strategy to address extensive proximal tibial bone loss in the multiply revised knee. Despite a paucity of literature regarding stacked cone constructs, they have gained popularity. This study reports on the early outcomes of stacked tibial cone constructs that are used during revision total knee arthroplasty (TKA).

Methods: A single-institution retrospective observational study was performed to identify patients who had been treated with a stacked cone construct during revision TKA between January 2010 and December 2022. Demographic, operative, clinical, and radiographic data were collected and assessed. Kaplan-Meier estimates were used to assess survival with all-cause reoperation, tibial-sided revision, and radiographic loosening as end points. In total, 22 stacked cone constructs were identified: 15 (68.2%) of the patients were men; the demographics included a mean age of 64.1 years (range, 42.8 to 87.8 years), a body mass index of 34.2 kg/m2 (range, 20.4 to 51.9 kg/m2), a median of 4 prior surgeries (range, 1 to 12 prior surgeries), and a mean follow-up of 22.6 months (range, 6.8 to 79.1 months).

Results: Twenty patients received 2-cone constructs, and 2 patients received 3-cone constructs. Patients received the stacked cone constructs during revision TKA for the following indications: periprosthetic joint infection (n = 11), aseptic loosening (n = 9), tibial stem pain (n = 1), and periprosthetic fracture (n = 1). At a median time of 2.9 months (range, 0.4 to 37.3 months), 5 patients underwent reoperation for the following indications: extensor mechanism failure (n = 2), femoral component loosening (n = 1), superficial wound dehiscence (n = 1), and postoperative hematoma (n = 1). At the 3-year follow-up, no patients had undergone revision for tibial component loosening (1 patient had radiographic evidence of loosening at the 15-month follow-up but did not undergo revision).

Conclusions: Stacked cone constructs are a viable option during revision TKA when extensive metaphyseal bone loss is encountered.

文献4

以基尼指数量化的收入不平等可作为全膝关节置换术不良结局的指标

译者 沈松坡

背景：全膝关节置换术（TKA）术后结局可能因非医疗因素（包括健康的社会决定因素，SDOH）而有所差异。虽然区域贫困指数（ADI）和社会脆弱性指数（SVI）等复合指标已将社区劣势与不良结局联系起来，但收入不平等在骨科领域中的作用尚未得到充分研究。基尼指数（GI）作为衡量收入差距的指标，可能为评估社会经济因素对手术结果的影响提供一种更聚焦的方法。本研究旨在探讨患者所处地区的GI是否与TKA术后短期并发症相关。

方法：利用大型全国数据库，通过国际疾病分类第10版（ICD-10）代码筛选2017年至2021年接受原发性TKA的成年人。根据GI将患者分为低（<0.40）、中（0.40–0.49）和高（≥0.50）三组。结局指标包括术后一年内的翻修率、机械性并发症和感染性并发症。采用倾向评分匹配以控制人口学差异。

结果：高GI组患者的全因翻修率显著高于中GI组，术后90天（0.9% vs 0.6%，比值比OR=1.42，P=0.01）及一年（1.5% vs 1.1%，OR=1.46，P<0.01）。高GI组脱位率亦较高，术后90天（2.6% vs 1.7%，OR=1.54，P<0.001）及一年（3.3% vs 2.1%，OR=1.58，P<0.001）。低GI组的翻修率及机械性并发症与中GI组无显著差异。感染率在各GI组间无差别。

结论：GI高于全国平均水平的患者TKA并发症风险更高，而GI低于平均水平者无显著差异。社区收入不平等程度可能是影响骨科结局的重要社会决定因素。

Income Inequality Quantified by the Gini Index Is an Indicator for Adverse Total Knee Arthroplasty Outcomes

Background: Postoperative outcomes following total knee arthroplasty (TKA) may vary due to non-medical factors, including social determinants of health (SDOH). While composite indices such as the Area Deprivation Index and Social Vulnerability Index link community disadvantage to adverse outcomes, the role of income inequality is underexplored in orthopaedics. The Gini Index (GI), a measure of income disparity, may provide a focused approach to assess socioeconomic influence on surgical outcomes. This study investigates whether a patient's GI is associated with short-term complications after TKA.

Methods: A large national database was queried to identify adults who underwent primary TKA from 2017 to 2021 via International Procedural Code - 10th Edition (ICD-10) codes. Patients were categorized by GI into low (< 0.40), average (0.40 to 0.49), and high (≥ 0.50) groups. Outcomes included revision rates, mechanical complications, and infectious complications within one year postoperatively. Propensity score matching was performed to control for demographic differences.

Results: Patients in the high-GI cohort had significantly increased rates of all-cause revision at 90 days (0.9 versus 0.6%, odds ratio (OR) 1.42, P = 0.01) and one year (1.5 versus 1.1%, OR 1.46, P < 0.01) compared to the average-GI group. Dislocation rates were also elevated at 90 days (2.6 versus 1.7%, OR 1.54, P < 0.001) and one year (3.3 versus 2.1%, OR 1.58, P < 0.001 in the high-GI group. There were no differences observed in revisions or mechanical complications in the low-GI group. Infection rates were similar across all GI categories.

Conclusion: Patients assigned a GI index greater than the national average demonstrated a higher risk for TKA complications, while there were no differences in patients who had a GI lower than the national average. The degree of income inequality in a community may be an influential SDOH driving variance in orthopaedic outcomes.

第二部分：保髋相关文献

文献1

指甲-髌骨综合征影像学表现

译者 任宁涛

指甲-髌骨综合征（NPS）是一种罕见的常染色体显性遗传病，发病率1/50,000，NPS 是 LMX1B突变的结果。NPS典型的特征是指甲发育不全或发育不全、髌骨发育不良或发育不全、肘部发育不良和髂骨犄角。髂骨犄角被认为是特有的，与发育不全或发育不良的髌骨与指甲异常相结合是诊断此病的主要特征。早在70年前，Captain Fong就报道了髂骨犄角，髂骨犄角是该综合征的特征，但并非在所有情况下都会出现。大多数情况下都存在肘关节发育不良，并且可以表现出该综合征的典型特征。除了骨骼和关节异常外，NPS 患者的肌肉质量低，体型偏瘦，他们通常很难在中年之前增加体重。在此，我们展示了一名患有指甲-髌骨综合征的女性的肘部、膝盖和骨盆的影像学表现。

图1 髂骨犄角

图2 双髌骨发育不良

图3 肘关节发育不良，桡骨小头后脱位

Radiographic findings in the nail-patella syndrome

Nail-patella syndrome is a rare disorder characterized classically by the tetrad of nail hypoplasia or aplasia, aplastic or hypoplastic patellae, elbow dysplasia, and the presence of iliac horns. Iliac horns are considered pathognomonic, and the presence of hypoplastic or aplastic patellae in conjunction with nail abnormalities is a cardinal feature of diagnosis. Elbow dysplasia is present in most cases and can exhibit features typical of the syndrome. Herein we present the radiographic findings of the elbows, knees, and pelvis of a woman with nail-patella syndrome.

文献出处：James A West , Thomas H Louis. Radiographic findings in the nail-patella syndrome. Proc (Bayl Univ Med Cent) . 2015 Jul;28(3):334-6.

文献2

术后髋臼壁指数对髋关节发育不良患者行髋臼转位截骨术后患者报告结局的影响

译者 李勇

引言： 本研究旨在确定术前变量和三维髋臼矫正对髋臼转位截骨术（TOA）（一种球形髋臼周围截骨术）后患者报告结局（PROMs）的影响。

方法： 我们回顾性分析了1998年至2019年间接受TOA治疗的442例（582髋）髋关节发育不良患者，他们均完成了有效的问卷调查，包括疼痛和满意度的视觉模拟评分（VAS）以及髋关节残疾和骨关节炎结果评分（HOOS）。中位随访时间为12年。我们分析了患者报告结局与术前变量及术后髋臼覆盖率（外侧中心边缘角、前壁指数和后壁指数）之间的关联。

结果： 年龄较大与HOOS-ADL（日常生活活动）呈负相关（r = -0.26, P < 0.001），与HOOS-运动/娱乐呈负相关（r = -0.25, P < 0.001）。男性患者报告的HOOS-QOL（生活质量）中位数低于女性患者（P = 0.038）。Tönnis分级为0级的患者，其满意度-VAS中位数高于2级患者（P = 0.031），且其HOOS-ADL、运动/娱乐和QOL子量表的中位数均高于1级或2级患者。对于术后前壁指数，（前壁）缺陷组的VAS-疼痛评分较高（P = 0.045），而HOOS-疼痛评分较低（P = 0.047）。对于术后后壁指数，（后壁）过度组的HOOS-疼痛评分低于正常组（P = 0.029）。

结论： 即使在TOA术后保留的髋关节中，髋臼的矢状面矫正也会影响术后疼痛，而年龄、性别和Tönnis分级则会影响患者满意度、功能能力和生活质量。这些见解对于优化手术适应证和髋臼重新定向策略，以及改善术后患者体验具有重要意义。

Impact of Postoperative Acetabular Wall Index on Patient-Reported Outcomes After Transposition Osteotomy of the Acetabulum in Patients With Hip Dysplasia

Introduction: This study aimed to determine the effect of preoperative variables and three-dimensional acetabular correction on patient-reported outcome measures after transposition osteotomy of the acetabulum (TOA), a spherical periacetabular osteotomy.

Methods: We retrospectively reviewed 442 patients (582 hips) with hip dysplasia who underwent TOA between 1998 and 2019 and completed validated questionnaires, including the visual analog scale (VAS) for pain and satisfaction and the Hip disability and Osteoarthritis Outcome Score (HOOS). The median follow-up was 12 years. Associations between patient-reported outcome measures and preoperative variables and postoperative acetabular coverage (lateral center-edge angle, anterior wall index, and posterior wall index) were analyzed.

Results: Older age was negatively correlated with HOOS-ADL (r = -0.26, P < 0.001) and HOOS-sports/recreation (r = -0.25, P < 0.001). Male patients reported lower median HOOS-QOL than female patients (P = 0.038). Patients with Tönnis grade 0 had higher median satisfaction-VAS than those with grade 2 (P = 0.031), and higher median HOOS-ADL, sports/recreation, and QOL subscales than those with grade 1 or 2. For postoperative anterior wall index, the deficient group had higher VAS-pain (P = 0.045) and lower HOOS-pain (P = 0.047) than the normal group. For postoperative posterior wall index, the excessive group had lower HOOS-pain than the normal group (P = 0.029).

Conclusion: Even in preserved hips after TOA, sagittal plane acetabular correction influenced postoperative pain, whereas age, sex, and Tönnis grade affected satisfaction, functional capacity, and QOL. These insights have implications for refining surgical indications and acetabular reorientation strategies, improving postoperative patient experience.

文献出处：Tanaka, Shiori MD; Fujii, Masanori MD, PhD; Kawano, Shunsuke MD, PhD; Ueno, Masaya MD, PhD; Nagamine, Satomi MD, PhD; Mawatari, Masaaki MD, PhD. Impact of Postoperative Acetabular Wall Index on Patient-Reported Outcomes After Transposition Osteotomy of the Acetabulum in Patients With Hip Dysplasia. JAAOS: Global Research and Reviews 9(10):e25.00154, October 2025. | DOI: 10.5435/JAAOSGlobal-D-25-00154

文献3

股骨头坏死治疗的预后因素：一项系统综述

译者 张利强

背景：多种保髋技术描述用于治疗股骨头坏死（ONFH）。本系统综述旨在确定与治疗失败及转为全髋关节置换术（THA）相关的治疗股骨头坏死预后因素。

材料与方法：本研究遵循PRISMA指南。于2021年11月进行文献检索。获取所有比较两种或两种以上股骨头坏死治疗方法的临床试验。通过多元分析来探究基线特征与手术结果之间的关联。采用皮尔逊积矩相关系数（r）进行多元线性回归分析。

结果：共检索到88篇文章（6112例手术）。女性患者与转为全髋关节置换术的时间延长（P = 0.03）和全髋关节置换率降低（P = 0.03）相关。治疗前症状持续时间越长，治疗失败时间越短（P = 0.03）。治疗前的视觉模拟评分（VAS）升高与失败间隔缩短（P = 0.03）和全髋关节置换术（THA）间隔时间缩短（P = 0.04）相关。治疗前髋关节功能降低与全髋关节置换术率升高（P = 0.02）和失败率升高（P = 0.005）相关。患者年龄、体重指数（BMI）、病因、术后完全负重时间以及患侧均未显示出与手术结果有统计学显著关联的证据。

结论：男性、治疗前症状持续时间较长、VAS评分较高以及HHS评分较低均为股骨头坏死治疗的不良预后因素。

Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review

Background: Several hip preserving techniques have been described for the management of osteonecrosis of the femoral head (ONFH). This systematic review identified prognostic factors in the treatment of ONFH that are associated with treatment failure and conversion to total hip arthroplasty (THA).

Material and methods: This study followed the PRISMA guidelines. The literature search was conducted in November 2021. All clinical trials comparing two or more treatments for femoral head osteonecrosis were accessed. A multivariate analysis was performed to investigate the association between baseline characteristics and the surgical outcome. A multiple linear model regression analysis through the Pearson Product-Moment Correlation Coefficient (r) was used.

Results: Data from 88 articles (6112 procedures) were retrieved. Female gender was associated with increased time to THA (P = 0.03) and reduced rate of THA (P = 0.03). Longer symptom duration before treatment was associated with shorter time to failure (P = 0.03). Increased pre-treatment VAS was associated with reduced time to failure (P = 0.03) and time to THA (P = 0.04). Reduced pre-treatment hip function was associated with increased rate of THA (P = 0.02) and failure (P = 0.005). Patient age and BMI, aetiology, time from surgery to full weight bearing and the side did not show evidence of a statistically significant association with the surgical outcome.

Conclusion: Male gender, longer symptom duration before treatment, higher VAS scores, and lower HHS scores were negative prognostic factors after treatment for osteonecrosis of the femoral head.

文献出处：Migliorini F, Maffulli N, Baroncini A, Eschweiler J, Tingart M, Betsch M. Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review. Surgeon. 2023 Apr;21(2):85-98. doi: 10.1016/j.surge.2021.12.004. Epub 2022 Jan 4. PMID: 34991986.

文献4

髋臼周围截骨术治疗严重髋关节发育不良-手术技术

译者 陶可

背景：严重髋关节发育不良伴股骨头半脱位或继发性髋臼（解剖结构异常）的最佳治疗方法仍存在争议。本研究的目的是分析手术矫正的程度和使用伯尔尼髋臼周围截骨术治疗青少年和年轻成人患者的严重髋关节发育不良所获得的早期临床结果。

方法：平均年龄为17.6岁（范围，13.0至31.8岁）的13名患者（16髋）被归类为严重髋关节发育不良（根据Severin分类为IV型或V型）。8髋存在半脱位，8髋存在继发髋臼（解剖结构异常）。术前，所有患者均出现髋关节疼痛，且X线片上的髋关节（股骨头与髋臼）形合度完全一致，可考虑进行截骨术。所有16髋均接受了伯尔尼髋臼周围截骨术，其中6个髋关节同时接受了股骨近端截骨术。术后，髋关节进行放射学评估，以评估畸形的矫正、截骨部位的愈合和骨关节炎的进展。术后采用Harris髋关节评分测量临床结果和髋关节功能，平均随访4.2年。

结果：术前和随访X线片比较显示Wiberg外侧中心边缘角平均改善44.6度（从-20.5度到24.1度），假斜位片上的前方中心边缘角平均改善51.0度（从-25.4度到25.6度），及髋臼顶倾斜角平均改善25.9度（从37.3度到11.4度）。髋关节中心向内侧平均平移10毫米（范围，0至31毫米）。所有髂骨截骨部位均愈合。平均Harris髋关节评分从术前的73.4分提高到最近一次随访时的91.3分。13例患者中有11例（16髋中的14例）对手术结果表示满意，14髋临床效果良好或优良。主要并发症包括一名患者的髋臼固定丢失，这需要额外的手术治疗；另一名患者的髋臼过度矫正和相关的坐骨骨不连。在最近一次随访时，两名患者的临床结果都很好。没有严重的神经血管损伤或关节内骨折。

结论：髋臼周围截骨术是一种有效的手术矫正青少年和年轻成人严重髋关节发育不良的技术。本系列早期临床效果非常好，平均术后4.2年；两大并发症并没有影响良好的临床效果。

图1-A 患者仰卧位于可透射线的手术台上。在受影响的髋关节下方放置一个小凸起衬垫，并将足部固定在手术台上。放置神经监测导线以进行持续的周围神经监测。

图1-B 演示了改良Smith-Petersen入路的髋关节切口。ASIS = 髂前上棘。

图2-A 图 2-A改良的Smith-Petersen方法的示意图。

图2-B和 2-C 改良的Smith-Petersen方法的示意图。

图3-A 髋臼下坐骨切口。使用Metzenbaum剪刀（长弯组织剪）在髋关节前囊上方和腰大肌腱下方形成一个平面。

图3-B 该平面向下，再向后进入前坐骨（坐骨体，髋臼下沟），进行第一次截骨。

图3-C和 3-D 截骨的位置可以通过前后（图3-C）和45°髂骨斜位（图3-D）透视图来确认。

图3-E 注意因为靠近坐骨神经，而不要过度伸展切口的后外侧。

图4-A、4-B和 4-C 耻骨上支截骨术。图4-A将窄、钝、弯曲的牵开器前后放置，然后用尖头Homan牵开器暴露耻骨上支。

图4-B和4-C大部分截骨切口是用小摆锯（图4-B）完成的，深层皮质切开采用半英寸（1.27厘米）带角度的骨刀完成（图4-B和4-C)。

图5-A 髂骨截骨术从髂前上棘直接朝向坐骨切迹进行，并在骨盆边缘上外侧约1cm处停止。高速磨钻用于为髂骨切口而制作目标打孔。

5-B和5-C 使用摆锯进行截骨术。ASIS =髂前上棘。

图6-A 后柱切口与髂骨切口成120°角。图6-B可以通过45°髂骨斜透视评估该切口的方向。

图6-C 使用45°角骨刀完成截骨。

图7-A至7-E 严重髋关节发育不良的髋臼周围切口和髋臼复位的假骨模型。重要的是要注意，这个假骨模型中描述的复位是指矫正严重髋臼发育不良所需的积极复位的类型。具体而言，由于需要大量重新定位，髂骨间隙可能缺乏髋臼碎片和髂骨之间的骨与骨接触（图7-C）。此外，模型中明显过度的前方矫正（图7-E）不会出现在髋臼前方严重不足的髋关节。图7-A、7-B和7-C重新定位的目标是增加股骨头前外侧的覆盖范围，保持或获得髋臼前倾，并在需要时向内侧平移髋关节（旋转）中心。我们通过：(1)内旋（外侧覆盖和前倾）、（2）前倾或伸展（前覆盖）和（3）内侧平移（关节中心的内侧化）进行髋臼复位。图7-B和7-C展示了髋臼周围的切口。图7-D和7-E截骨部位通常用四枚螺钉固定，将切除的突出的髂前上棘移植入髂骨间隙。

图8 髋臼截骨骨块暂时用克氏针固定，最终用4.5毫米螺钉从髂嵴插入截开的髋臼（骨块）。

9-A、9-B和9-C股骨头颈交界处的股骨成形术。图9-A髋臼周围截骨术后中度髋关节发育不良的术中蛙式位片，显示在前外侧头颈交界处存在非球形股骨头（箭头）。

图9-B 这种畸形与关节切开术中观察到的屈曲100°时的股骨髋臼前方撞击有关。

图9C 进行头颈部交界处的骨成形术，以实现髋关节在运动范围内无撞击。

图10 髋关节重建后检查被动髋关节屈曲运动，以确保髋关节屈曲至少为90°（最好>100°）。

图11-A至11-D 一名患有严重髋臼发育不良的16岁男孩的髋关节X线片。图11-A和11-B前后位（图11-A）和假斜位（图11-B）X线片显示严重的髋关节发育不良。该患者采用髋臼周围截骨术和股骨近端内翻截骨术联合治疗。

图11-C和11-D 术后3年拍摄X线片，显示重建后实现了广泛的重新定向、最小的骨盆变形和完全的骨愈合。该患者的临床效果极佳。

Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique

Background: The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients.

Methods: Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively.

Results: Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures.

Conclusions: The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

文献出处：John C Clohisy, Susan E Barrett, J Eric Gordon, Eliana D Delgado, Perry L Schoenecker. Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique. Review J Bone Joint Surg Am. 2006 Mar;88 Suppl 1 Pt 1:65-83.

文献5

股骨头软骨下不全骨折

译者 邱兴

股骨头软骨下不全骨折（SIF）是近期（2012）提出的一个概念，需与骨坏死相鉴别。临床上，SIF常见于患有骨质疏松的老年女性或肾移植术后患者。早期影像学改变不明显，但部分病例可出现软骨下塌陷（新月征）。在T1加权磁共振图像上，低信号带是其特征性影像表现之一，组织学上对应骨折线及相关的骨折修复组织。因此，低信号带的形态通常呈不规则、不连续且凸向关节面的特点。SIF的预后尚未明确，部分病例通过保守治疗症状可缓解，而另一些病例则出现快速塌陷进展，如快速进展性髋关节病。

关键词：股骨头；骨坏死；骨质疏松；软骨下不全骨折

图1、一名68岁女性患者，患有右股骨头软骨下不全骨折。（A）于发病8周后拍摄的X线片显示股骨头外侧部分出现软骨下塌陷，并可见关节间隙狭窄。（B）在侧位视图中，可清晰观察到新月征（箭头所示）。该病例的最终组织病理学诊断为软骨下不全骨折。

图2、68岁女性，右股骨头软骨下不全骨折。（A）发病后4周拍摄的X光片显示股骨头未见明显异常。（B、C）发病后4周进行MRI，存在弥漫性骨髓水肿模式，T1加权像呈低信号强度（B），T2加权像呈高信号强度（C）。同时可见一条与关节面平行的极低信号强度带（箭头所示）。（D）切除的股骨头截面显示，关节面正下方可见一条发白的线（箭头所示）。（E）标本X光片显示一条骨硬化线（箭头所示），该硬化线由沿骨折线形成的骨痂构成（箭头所示）。（F）线性硬化区域的组织学检查显示，原有的骨小梁骨折，伴有骨折骨痂形成，并且骨髓腔内有肉芽组织。未见既往存在的骨坏死证据（苏木精-伊红染色，×100）。

图3、软骨下不全骨折（A）与骨坏死（B）的带状影像比较。在软骨下不全骨折中，该带状影像对应于骨折线，因此通常形态不规则、不连续、呈凸形且与软骨表面平行。相比之下，骨坏死中的带状影像对应于坏死区域周围形成的修复组织，其形态往往光滑、边界清晰且呈凹形。

Subchondral insufficiency fractures of the femoral head

A subchondral insufficiency fracture (SIF) of the femoral head is a recently proposed concept, which needs to be differentiated from osteonecrosis. Clinically, SIF has generally been observed in the osteoporotic elderly women or renal transplant recipients. Radiographical changes are not obvious in its early phase, however, some cases undergo subchondral collapse (crescent sign). On the T1-weighted magnetic resonance images, a low intensity band is one of the characteristic imaging appearances, which corresponds histologically to the fracture line and associated fracture repair tissue. Therefore, the shape of the low intensity band generally tends to be irregular, disconnected, and convex to the articular surface. The prognosis of SIF is not clearly established. Some cases show resolution of the symptoms by the conservative treatments, while other cases show rapid progression of the collapse such as rapidly progressive arthrosis of the hip.

Keywords: Femoral head; Osteonecrosis; Osteoporosis; Subchondral insufficiency fracture.

文献出处：Yamamoto, Takuaki. "Subchondral insufficiency fractures of the femoral head." Clinics in orthopedic Surgery 4, no. 3 (2012): 173.

来源：304关节学术

作者：304关节团队

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