髋膝关节文献精译荟萃（第365期）

本期目录：

1、膝骨关节炎患者全膝关节置换术后生活质量的决定因素

2、膝关节置换手术病人的心理测量学特性和可行性评估

3、机器人辅助关节置换手术：欧洲关于外科医生采用与应用趋势的观点

4、髋关节疼痛患者通常存在两种或以上的撞击或不稳定畸形

5、髋臼周围截骨术是否改变脊柱骨盆矢状面序列

6、保髋手术后患者报告结局的演变轨迹

7、欧洲国家发育性髋关节发育不良筛查与治疗指南概述及质量评估

8、髋臼周围截骨术治疗伴有严重股骨头非球形畸形的髋关节发育不良临床研究

9、股骨头坏死中软骨下骨折始于骨吸收区：一项显微计算机断层扫描研究

第一部分：关节置换及保膝相关文献

文献1

膝骨关节炎患者全膝关节置换术后生活质量的决定因素：一项系统综述

译者 张轶超

目的：系统回顾、总结和评价影响膝骨关节炎患者全膝关节置换术后生活质量（QoL）的因素。

方法：通过检索PubMed、Scopus、Web of Science、CINAHL、EMBASE、ProQuest等6个数据库，采用合适的检索词检索TKA术后影响生活质量的因素的相关文献。两名审稿人独立对研究进行筛选和纳入。如有异议就咨询第三位审稿人。纳入研究的方法学质量采用改良Downs和Black指数检查表进行评估。本综述已在PROSPERO注册（CRD42022352887），并根据PRISMA核对表要求进行报告。

结果：我们共搜索到8517项研究，其中29项被纳入。高龄;女性;身体质量指数（BMI）的增加；存在合并症，如糖尿病；对侧膝关节疼痛；术前状态差；心理和疼痛相关因素，如对疼痛过度敏感；中枢性敏感;运动恐惧症;焦虑;抑郁症;慢性疼痛;悲痛;乐观程度低；和降低的患者满意度被用来作为确定TKA术后的生活质量评分内容。在这些研究中，高BMI和抑郁是最常见的因素。总体而言，纳入研究的方法学质量从高到低不等。

结论：经TKA治疗后，患者总体生活质量评分有所提高。然而，有一些生理、行为和心理因素会影响生活质量。确定这些因素可以帮助临床医生和卫生专业人员在患者的治疗和康复过程中改善TKA患者的预后。

Factors determinant of quality of life after total knee arthroplasty in knee osteoarthritis: A systematic review

Objective: To systematically review, summarize and appraise evidence on the factors determining quality of life (QoL) after total knee arthroplasty (TKA) in individuals with knee osteoarthritis.

Methods: We searched six databases (PubMed, Scopus, Web of Science, CINAHL, EMBASE, and ProQuest) using appropriate search terms to identify the relevant literature published on the factors determining QoL following TKA. Two reviewers independently performed the study screening and study selection. A third reviewer was consulted in case of any disagreement. The methodological quality of the included studies was assessed using the Modified Downs and Black Index checklist. This review was registered in PROSPERO (CRD42022352887) and reported according to the PRISMA checklist.

Results: We identified a total of 8517 studies, 29 of which were included. Advanced age; female sex; increased body mass index (BMI); the presence of comorbidities such as diabetes; contralateral knee pain; poor preoperative status; psychological and pain-related factors such as the presence of pain catastrophizing; central sensitization; kinesiophobia; anxiety; depression; chronic pain; psychological distress; low level of optimism; and reduced patient satisfaction were used to determine post-TKA QoL scores. High BMI and depression were the most common factors evaluated in these studies. Overall, the methodological quality of the included studies varied from high to low.

Conclusion: After TKA, the overall QoL score improved. However, there are a few physical, behavioral, and psychological factors that influence QoL. Identifying these factors could aid clinicians and health professionals in treating and rehabilitating patients by helping them improve patient prognosis after TKA.

文献出处：Shetty S, Maiya GA, Rao Kg M, Vijayan S, George BM. Factors determinant of quality of life after total knee arthroplasty in knee osteoarthritis: A systematic review. J Bodyw Mov Ther. 2024 Oct;40:1588-1604. doi: 10.1016/j.jbmt.2024.08.013. Epub 2024 Aug 23. PMID: 39593495.

文献2

应用患者自评结果测量系统-计算机自适应测试工具VS.疾病特异性评价工具对膝关节置换手术病人的心理测量学特性和可行性评估

译者 张蔷

背景：相比于常用的疾病特异性评价工具，通用性极佳的患者自评结果测量系统-计算机自适应测量（PROMIS CATs）工具可以帮助我们更有效的评价膝关节置换手术患者的健康状态。本研究旨在比较不同的PROMIS-CATs工具（包括疼痛[PROMIS-PI-CAT, v1.1]、功能[PROMIS-PF-CAT, v2.0]、行动能力[PROMIS Mob-CAT, v2.0]、参与社会角色与活动能力[PROMIS-AS-CAT, v2.0]和对社会角色与活动能力的满意度[PROMIS-SS-CAT, v2.0]）与传统的膝关节疼痛和骨关节炎评分（KOOS），包括KOOS功能短表（KOOS-PS）和KOOS关节置换（KOOS-JR）以及WOMAC评分在评价膝关节置换手术患者疗效方面的心理测量学特性和可行性。

方法：在AZ Alma（Eeklo，比利时）医院接受单侧或双侧初次或翻修全膝关节置换手术的患者（n=193；平均年龄，64.4±10.1岁；56%为女性；平均BMI，29.6±5.2 kg/m2）分别在术前6周、术后6周、术后3个月、术后6个月和术后12个月随访时完成了评测。本研究分别评估了评测的准确性（百分标准差[SE%]）、反应性（假定相关性和标准反应均数[SRM]）、地板和天花板效应（最差和最佳所占百分比）和可行性（完成时间以及完成项目数）。

结果：与传统的KOOS/WOMAC评价系统相比，PROMIS-PI-CAT和PROMIS-PF-CAT显示出更为优秀的准确性（SE%, 4.6 vs 7.1/9.3和3.6 vs 4.4/4.4），但在术后12个月随访时准确性变差（SE %, 6.8 vs 4.8/5.5和3.6 vs 3.0/3.0）。所有的PROMIS CATs评测工具都有很好的反应性（75% - 100% 的设定未拒绝; 术后12个月随访时SRMs: PROMIS-PI-CAT = 21.35 vs KOOS 疼痛 = 1.78 和 WOMAC 疼痛 = 21.59; PROMIS-PFCAT = 1.14 vs KOOS-ADL/WOMAC-PF = 1.43/21.44; PROMIS-AS-CAT = 0.93 和 PROMIS-SS-CAT = 0.93）。PROMIS-PF-CAT在术后12个月随访时没有显现出天花板效应，与KOOS-ADL/WOMAC-PF正相反（17.5%）。与KOOS和WOMAC评分相比，PROMIS CATs评测工具可行性更佳。

结论：PROMIS-CATs评测工具能有效的评价膝关节置换患者的疗效，显示出优秀的心理测量学特性和可行性，支持其在以疗效主导的诊疗过程中发挥更大的作用。

Psychometric Properties and Feasibility of PROMIS Computerized Adaptive Tests Compared with Disease-Specific Measures in Knee Arthroplasty

Background: The efficient assessment of health outcomes in knee arthroplasty may benefit from universally applicable Patient-Reported Outcomes Measurement Information System computerized adaptive tests (PROMIS CATs), rather than disease-specific measures. This study aimed to evaluate and compare some psychometric properties and the feasibility of various PROMIS CATs (Pain Interference [PROMIS-PI-CAT, v1.1], Physical Function [PROMIS-PF-CAT, v2.0], Mobility [PROMIS Mob-CAT, v2.0], Ability to Participate in Social Roles and Activities [PROMIS-AS-CAT, v2.0], and Satisfaction with Social Roles and Activities [PROMIS-SS-CAT, v2.0]), with the Knee Injury and Osteoarthritis Outcome Score (KOOS) scales, including the KOOS Physical Function Short-form [KOOS-PS] and KOOS for Joint Replacement [KOOS-JR], and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scales.

Methods: Patients (n = 193; mean age [and standard deviation], 64.4 ± 10.1 years; 56% female; mean body mass index, 29.6 ± 5.2 kg/m2 ) undergoing unilateral or bilateral primary or revision knee arthroplasty at AZ Alma (Eeklo, Belgium) completed the measures 6 weeks before and 6 weeks and 3, 6, and 12 months after surgery. The study evaluated precision (standard error as a percentage of scale range [SE%]), responsiveness (hypothesized correlations and standardized response mean [SRM]), floor and ceiling effects (percentage with the worst and the best scores), and feasibility (completion time and number of items).

Results: The PROMIS-PI-CAT and PROMIS-PF-CAT showed better precision at baseline compared with corresponding KOOS/WOMAC scales (SE%, 4.6 versus 7.1/9.3 and 3.6 versus 4.4/4.4), but less precision at 12 months of follow-up (SE %, 6.8 versus 4.8/5.5 and 3.6 versus 3.0/3.0). All PROMIS CATs had good responsiveness (75% to 100% of hypotheses not rejected; SRMs at 12 months: PROMIS-PI-CAT = 21.35 versus KOOS Pain = 1.78 and WOMAC Pain = 21.59; PROMIS-PFCAT = 1.14 versus KOOS-ADL/WOMAC-PF = 1.43/21.44; PROMIS-AS-CAT = 0.93 and PROMIS-SS-CAT = 0.93). The PROMIS-PF-CAT did not show ceiling effects at 12 months, unlike the KOOS-ADL/WOMAC-PF (17.5%). PROMIS CATs were more feasible at baseline and follow-ups compared with KOOS and WOMAC scales.

Conclusions: PROMIS-CATs effectively assess health outcomes in knee arthroplasty patients, showing strong psychometric properties and favorable feasibility, supporting their role in value-based health care.

文献3

机器人辅助关节置换手术：欧洲关于外科医生采用与应用趋势的观点

译者 沈松坡

背景： 机器人辅助全关节置换术（TJA）提升了手术精度和假体定位的准确性，然而外科医生对其认知及采用模式仍未被充分理解。本研究聚焦三个关键问题：（1）不同地区在机器人技术使用及兴趣方面的当前趋势如何？（2）不同手术类型的机器人使用情况有何差异？外科医生对各类机器人系统的熟悉程度如何？（3）哪些因素最能影响外科医生在关节置换手术中选择或避免使用机器人辅助？

方法： 本研究于2023年10月在欧洲范围内开展了一项横断面匿名调查。符合条件的参与者需具有至少两年的独立执业经验，并且每年完成的关节置换手术量不少于100例。有主要植入物制造商财务关联的外科医生被排除在外。网络问卷收集了人口统计学信息、手术量、2018年至2023年的机器人系统使用情况，以及外科医生对采用因素和主要机器人平台熟悉程度的评分。所得数据采用描述性方法进行分析。

结果： 从2019年至2023年，欧洲使用机器人辅助TJA的外科医生比例从1%上升至14%，而对该技术感兴趣的外科医生比例则从32%上升至50%。机器人技术应用最多的手术类型为部分膝关节置换术（PKA），其次为全膝关节置换术（TKA），再次为全髋关节置换术（THA）。外科医生认为“手术效率”和“术前计划执行力”是使用机器人辅助的两大关键驱动因素。

结论： 在过去五年中，欧洲地区对机器人辅助技术的兴趣与使用率均显著增长。外科医生普遍认为提高手术效率和计划执行力是采用该技术的主要动因。未来仍需进一步研究，以评估未来十年内该技术的使用模式。

关键词： 髋关节；膝关节；机器人；问卷调查；技术；全关节置换术。

Robotic-Assisted Joint Arthroplasty: European Perspectives on Surgeon Adoption and Utilization Trends

Background: Robotic-assisted total joint arthroplasty (TJA) has improved surgical precision and implant positioning, yet surgeon perceptions and adoption patterns remain incompletely understood. This study addresses three key questions: (1) What are the current trends in robotic technology use and interest across regions? (2) How does utilization vary by procedure type, and how familiar are surgeons with different robotic systems? and (3) Which factors most influence surgeons' decisions to adopt or avoid robotic assistance in arthroplasty?

Methods: A cross-sectional, anonymous survey was conducted in October 2023 among orthopaedic surgeons in Europe. Eligible participants had at least two years of independent practice and an arthroplasty volume of at least 100 cases annually. Surgeons who had financial ties to major implant manufacturers were excluded. The web-based survey collected demographic data, procedure volumes, robotic system usage from 2018 to 2023, and surgeon ratings of adoption factors and familiarity with key robotic platforms. Data were analyzed descriptively.

Results: From 2019 to 2023, the percentage of European surgeons utilizing robotic-assisted TJA rose from 1 to 14%, while the number of surgeons interested in the technology increased from 32 to 50%. The greatest utilization of robotic technology was seen in partial knee arthroplasty (PKA), followed by total knee arthroplasty (TKA), then total hip arthroplasty (THA). Surgeons rated efficiency and plan execution as the two most important factors for utilizing robotics assistance.

Conclusion: Interest and utilization of robotic assistance have grown tremendously over the past five years in Europe. Surgeons view efficiency and plan execution as motivators for using this technology. Further studies are needed to evaluate usage patterns over the next decade.

Keywords: Hip; Knee; Robotics; Survey; Technology; Total joint arthroplasty

第二部分：保髋相关文献

文献1

髋关节疼痛患者通常存在两种或以上的撞击或不稳定畸形

译者 张振东

由于股骨和髋臼前倾角、颈干角、α角和外侧中心边缘角等解剖因素造成的撞击或不稳定可导致髋关节损伤。这些解剖因素之间的关联以及它们在疼痛的髋关节中发生的频率尚不清楚，但如果不加以解决，可能会导致保髋手术失败。

研究拟确定性别对撞击相关或不稳定相关因素的影响；这些因素之间的关联；以及撞击和/或不稳定因素在同一髋关节中发生的频率。

研究对因任何原因接受髋关节磁共振的 170 髋（145 患者）进行了回顾性分析。 排除了58例严重发育不良、Perthes病后遗症、既往手术史或影像学信息不完整的髋关节，剩下112例髋关节（96患者）纳入本研究。在核磁共振上测量了股骨前倾角和α角。骨盆X光片上测量了髋臼前倾角、外侧CEA和颈干角。

结果显示，研究观察到性别与α角之间存在相关性。其他五个参数之间的相关性较弱或没有相关性。在 66% 的髋关节中发现了五个参数中的两个或两个以上符合撞击征的指标，在 51% 的髋关节中发现了两个或两个以上符合髋关节不稳定的指标。

结论：髋关节疼痛患者通常有多种可能导致软骨髋臼损伤的解剖因素。要解决由于撞击和/或不稳定造成的病理性髋关节负荷增加，就必须了解所有的解剖影响因素。由于本研究没有发现解剖因素之间存在关联，因此建议对每个疼痛的髋关节进行个体化评估。

Two or more impingement and/or instability deformities are often present in patients with hip pain

Background:Damage to the hip can occur due to impingement or instability caused by anatomic factors such as femoral and acetabular version, neck-shaft angle, alpha angle, and lateral center-edge angle (CEA). The associations between these anatomic factors and how often they occur in a painful hip are unclear but if unaddressed might explain failed hip preservation surgery.

Questions/purposes:We determined (1) the influence of sex on the expression of impingement-related or instability-related factors, (2) the associations among these factors, and (3) how often both impingement and/or instability factors occur in the same hip.

Methods:We retrospectively reviewed a cohort of 170 hips (145 patients) undergoing MR arthrography of the hip for any reason. We excluded 58 hips with high-grade dysplasia, Perthes' sequelae, previous surgery, or incomplete radiographic information, leaving 112 hips (96 patients). We measured femoral version and alpha angles on MR arthrograms. Acetabular anteversion, lateral CEA, and neck-shaft angle were measured on pelvic radiographs.

Results:We observed a correlation between sex and alpha angle. Weak or no correlations were observed between the other five parameters. In 66% of hips, two or more (of five) impingement parameters, and in 51% of hips, two or more (of five) instability parameters were found.

Conclusions:Patients with hip pain frequently have several anatomic factors potentially contributing to chondrolabral damage. To address pathologic hip loading due to impingement and/or instability, all of the anatomic influences should be known. As we found no associations between anatomic factors, we recommend an individualized assessment of each painful hip.

文献出处：Tibor LM, Liebert G, Sutter R, Impellizzeri FM, Leunig M. Two or more impingement and/or instability deformities are often present in patients with hip pain. Clin Orthop Relat Res. 2013 Dec;471(12):3762-73.

文献2

髋臼周围截骨术是否改变脊柱骨盆矢状面序列

译者 任宁涛

背景:目前关于髋臼周围截骨术对脊柱骨盆矢状面序列影响的数据很少。先前的研究试图通过在AP 位X线片上进行测量和使用数学模型来确定术后骨盆倾斜的变化来描述两者之间的关系。这些信息对外科医生在术中评估髋臼/骨盆位置和了解术后脊柱-骨盆矢状面序列变化具有临床意义;因此，应更详细地描述PAO引起的影像学变化。

问题/目的:在本研究中，我们的问题是:(1) 根据EOS X线片测量，PAO术后是否会导致脊柱-骨盆矢状面序列发生对应变化?(2)单侧PAO和双侧PAOs的情况是否不同?(3)这在脊柱柔韧和脊柱僵硬的情况下是否有区别?(4)是否因术前骨盆倾斜而有差异?

方法:前瞻性收集2019年1月1日至2022年1月11日由同一位外科医生完成PAO的55例患者的术前和术后不短于1年的 (15±8个月，最短11个月，最长65个月)EOS髋-踝站立位和坐位x线片，测量骨盆入射角、骨盆倾斜角、骶骨倾斜角、腰椎前凸角、外侧CE角、L1-骨盆角和耻骨联合对骶髂指数（PS-SI）。采用配对样本t检验(正态分布数据)或Wilcoxon符号秩检验(非正态分布数据)评估术前与术后是否有任何变化。然后根据患者是否患有单侧或双侧发育不良以及单侧或双侧手术进行分组，这些亚组的分析方法与整个队列相同。根据腰椎活动度情况(定义为从坐到站的腰椎前凸角变化小于或大于1 SD)再分为两个亚组，亚组的分析方法与整个队列相同。最后根据术前站立位骨盆倾斜度分为站立位骨盆倾斜度< 10°和站立位骨盆倾斜度> 20°两个亚组，并与整个队列进行相同的分析。

结果:所有患者的站立位外侧CE角中位数(IQR)增加了17°，从中位数21°(10°)增加到中位数38°(8°[95%可信区间(CI) 16°~ 20°;p < 0.05];P < 0.001)。坐位外侧CE角增加了17°，从中位数18°(8°)增加到中位数35°(8°[95% CI 14°~ 19°];P < 0.001)。站立位骨盆入射角从50°±11°增加到52°±12°(平均差值2°[95% CI 1°~ 3°];P = 0.004)，但其他测量参数无变化。单侧发育不良患者接受单侧PAO后，任何脊柱-骨盆参数均无变化，但双侧发育不良患者接受双侧PAOs后，骨盆入射角从57°(14°)增加到60°(16°)(95% CI 1°~ 5°;p = 0.02)，耻骨联合-骶髂指数从84 mm (24 mm)降至77 mm (23 mm) (95% CI -7°至-2°;P = 0.007)。术前腰椎柔韧性好的患者未表现出任何矢状位脊柱骨盆参数的变化，但术前腰椎柔韧性差的患者术后出现了一些变化。站立骨盆倾斜小于10°的患者，骨盆入射角中位数(IQR)从43°(9°)增加到45°(12°[95% CI 0.3°~ 4°];P = 0.03)，但术后未发生其他矢状位脊柱骨盆参数的改变。术前骨盆倾斜超过20°的患者矢状位脊柱骨盆参数未发生任何改变。

结论:PAO增加骨盆入射角，可能与髋关节中心前移有关。除双侧PAO术后，其余脊柱骨盆参数无变化。此外，术前脊柱僵硬的患者，表现为站立和坐姿之间腰椎前凸的变化微小，可能会出现脊柱骨盆参数的变价，包括PAO后脊柱活动度的增加。这可能是因为增加髋臼覆盖后代偿性脊柱“夹板”效应减少，但需要进一步研究。

Does Periacetabular Osteotomy Change Sagittal Spinopelvic Alignment？

Background: There are few data on the impact of periacetabular osteotomy (PAO) on sagittal spinopelvic alignment. Prior studies have attempted to delineate the relationship by performing measurements on AP radiographs and using mathematical models to determine changes in postoperative pelvic tilt. This information is clinically significant to a surgeon when evaluating acetabular/pelvic position intraoperatively and understanding spinopelvic alignment changes postoperatively; therefore, radiographic changes from PAO should be described in more detail.

Questions/purposes: In this study, we asked: (1) Does the performance of PAO result in consistent changes in spinopelvic alignment, as measured on EOS radiographs? (2) Does this differ for unilateral versus bilateral PAOs? (3) Does this differ in the setting of a mobile spine versus an immobile spine? (4) Does this differ based on preoperative pelvic tilt?

Methods: Mean preoperative and at least 1-year postoperative (15 ± 8 months from surgery, minimum 11 months, maximum 65 months) EOS hip-to-ankle standing and sitting radiographs for 55 patients in a prospectively collected registry who underwent PAO with a single surgeon from January 1, 2019, to January 11, 2022, were measured for pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, lateral center-edge angle, L1 pelvic angle, and pubic symphysis to the sacroiliac index. Normality was assessed and paired sample t-tests (normally distributed data) or Wilcoxon signed rank tests (not normally distributed data) were utilized to assess if any measurements changed from preoperative to postoperative. Patients were then divided based on whether they had unilateral or bilateral dysplasia and unilateral or bilateral surgery, and these subgroups were analyzed the same way as the entire cohort. Two more subgroups were then formed based on lumbar mobility, defined as a change in sitting-to-standing lumbar lordosis less or greater than 1 SD from the population mean preoperatively, and the subgroups were analyzed the same way as the entire cohort. Finally, two additional subgroups were formed, preoperative standing pelvic tilt less than 10° and more than 20°, and analyzed the same as the entire cohort.

Results: For the entire cohort, the median (IQR) standing lateral-center edge angle increased 17°, from a median of 21° (10°) to a median of 38° (8° [95% confidence interval (CI) 16° to 20°; p < 0.001). The median sitting lateral center-edge angle increased 17°, from a median of 18° (8°) to a median of 35° (8° [95% CI 14° to 19°]; p < 0.001). Standing pelvic incidence increased from 50° ± 11° to 52° ± 12° (mean difference 2° [95% CI 1° to 3°]; p = 0.004), but there were no changes for other measured parameters. There were no changes in any of the spinopelvic parameters for patients with unilateral dysplasia receiving a unilateral PAO, but patients with bilateral dysplasia who underwent bilateral PAOs demonstrated an increase in pelvic incidence from 57° (14°) to 60° (16°) (95% CI 1° to 5°; p = 0.02) and a decrease in pubic symphysis to sacroiliac index from 84 mm (24 mm) to 77 mm (23 mm) (95% CI -7° to -2°; p = 0.007). Patients with mobile lumbar spines preoperatively did not exhibit any changes in sagittal spinopelvic alignment, but patients with immobile lumbar spines preoperatively experienced several changes after surgery. Patients with less than 10° of standing pelvic tilt demonstrated a median (IQR) 2° increase in pelvic incidence from median 43° (9°) to 45° (12° [95% CI 0.3° to 4°]; p = 0.03), but they did not experience any other changes in sagittal spinopelvic alignment parameters postoperatively. Patients with preoperative pelvic tilt more than 20° did not experience any change in sagittal spinopelvic parameters.

Conclusion: PAO increases pelvic incidence, potentially because of anterior translation of the hip center. There were no changes in other spinopelvic parameters postoperatively except after bilateral PAO. Additionally, patients lacking spine mobility preoperatively, indicated by a minimal change in lumbar lordosis between standing and sitting positions, may experience several changes in spinopelvic alignment, including increased mobility of their spine after PAO. This may be because of decreased compensatory spine splinting after increasing acetabular coverage, but further research including patient-reported outcomes is warranted.

文献出处：Cirrincione P, Cao N, Trotzky Z, Nichols E, Sink E. Does Periacetabular Osteotomy Change Sagittal Spinopelvic Alignment? Clin Orthop Relat Res. 2024 Apr 2. doi: 10.1097/CORR.0000000000003031. Epub ahead of print. PMID: 38564796.

文献3

保髋手术后患者报告结局的演变轨迹：一项国家登记库研究

译者 李勇

目的：了解保髋手术后患者报告结局（PROs）的纵向演变轨迹至关重要。本研究旨在利用英国国家保髋登记系统的数据，分析患者术后长达2年的PROs演变轨迹，并检验潜在混杂因素对此的影响。

方法：本研究数据来源于英国非关节置换髋关节登记处（UK Non-Arthroplasty Hip Registry）。纳入标准为：接受了髋关节镜手术（Hip Arthroscopy）或髋臼周围截骨术（PAO）的患者，并具有术前的国际髋关节结局量表（iHOT-12）评分，且在术后6个月、1年或2年至少有两个时间点的随访测量数据。研究团队分析了iHOT-12评分的演变轨迹，并采用潜（隐）增长曲线模型（Latent Growth Curve Modelling）来识别这些轨迹的预测因素。

结果：研究共纳入9845名患者。其中，7081名患者接受了髋关节镜手术，1327名患者接受了髋臼周围截骨术。髋关节镜组： iHOT-12评分从基线（术前）到术后6个月有显著改善；但在术后6个月至1年间无明显变化；在1年至2年间评分出现下降。髋臼周围截骨术组： iHOT-12评分从基线到术后6个月有显著改善；但在术后6个月至1年、以及1年至2年间均无明显变化。潜增长曲线模型分析显示，体重指数（BMI）和性别对术前iHOT-12评分有显著影响，而年龄和性别则显著影响术后的恢复斜率（即恢复速度）。

结论：接受保髋手术的患者，其iHOT-12评分在术后6个月时即获得显著改善，且改善幅度超过了最小临床重要差异（MCID）。这种改善效果在术后2年时趋于稳定（进入平台期）。在髋关节镜术后1年至2年间，评分虽然略有下降，但该下降幅度仍处于临床有意义的范围之内（即未达到MCID）。BMI、年龄和性别均会影响评分的演变轨迹，这凸显了在术前帮助患者建立合理期望的重要性。

The trajectory of patient‐reported outcomes after hip preservation surgery: A National Registry Study

Purpose

Understanding the trajectory of postoperative patient‐reported outcomes after hip preservation surgery is essential. This study aims to analyse patient‐reported outcome trajectories up to 2 years post‐surgery using the UK's national hip preservation registry and to examine the influence of potential confounders.

Methods

Patients who underwent hip arthroscopy or periacetabular osteotomy with preoperative International Hip Outcome Tool‐12 (iHOT‐12) scores and at least two follow‐up measurements at 6 months, 1 year, or 2 years were included from the UK Non‐Arthroplasty Hip Registry. iHOT‐12 score trajectories were analysed, and Latent Growth Curve Modelling was used to identify predictors of these trajectories.

Results

Overall 9845 patients were included in this study. 7081 patients underwent a hip arthroscopy, and 1327 patients underwent a periacetabular osteotomy. For hip arthroscopy, there were significant improvements in the iHOT‐12 scores from baseline to 6 months, but no significant change from 6 months to 1 year. However, there was a decrease in the minimal clinically important difference from 1 to 2 year. For periacetabular osteotomy, there were significant improvements in the iHOT‐12 scores from baseline to 6 months, but no significant change from 6 months to 1 year, and from 1 to 2 years. Latent Growth Curve Modelling showed that body mass index (BMI) and sex had a significant impact on pre‐operative iHOT‐12 scores, while age and sex significantly influenced the recovery slope.

Conclusions

Patients who underwent hip preservation surgery exhibited significant improvement in iHOT‐12 scores, surpassing the minimal clinically important difference at 6 months postoperatively. This improvement plateaued by 2 years, with a slight decline in scores between 1 and 2 years following hip arthroscopy, though the decrease remained within the clinically meaningful range. BMI, age and sex influenced score trajectories, highlighting the importance of setting patient expectations pre‐operatively.

文献出处；Yoshitani J, Ekhtiari S, Malviya A, Khanduja V. The trajectory of patient-reported outcomes after hip preservation surgery: A National Registry Study. Knee Surg Sports Traumatol Arthrosc. 2025 Nov;33(11):4002-4011. doi: 10.1002/ksa.12771. Epub 2025 Aug 19. PMID: 40827496; PMCID: PMC12582234.

文献4

欧洲国家发育性髋关节发育不良筛查与治疗指南概述及质量评估

译者 贾海港

背景/目的：发育性髋关节发育不良（DDH）是最常见的儿童骨科疾病之一，需及时诊断和治疗以预防长期致残。本综述旨在识别、总结并评估当前欧洲各国关于 DDH 筛查和治疗的国家指南质量。

方法 ：通过联系来自 46个欧洲国家的国家骨科学会，并从近期的系统综述中获取指南来识别相关指南。两名研究人员独立提取数据，并采用 AGREE II 量表评估指南质量。采用 Cohen's κ系数评估评分者间一致性。

结果 ：共识别出九份欧洲国家 DDH 指南，其中四份发表在同行评审的科学期刊上。所有指南均建议将临床检查和影像学检查纳入 DDH 筛查方案，但筛查方法和时机存在显著差异。四份指南包含治疗建议。治疗方式（外展治疗 vs. 积极监测）及长期随访时长存在显著差异。指南质量评分范围为 16%至 92%（Cohen's κ=0.62），其中两份指南被评为"良好质量"（≥70%）

结论 ：欧洲各国的 DDH 指南数量稀少，质量和内容差异较大。亟需开展一项协调一致的欧洲倡议，敦促各国使用经过验证的工具制定循证的 DDH 指南，并将这些指南发表在同行评议期刊上，从而促进髋关节发育不良患儿的平等诊疗。

关键词： 髋关节发育不良；诊断；指南；新生儿筛查；治疗学。

An Overview and Quality Assessment of European National Guidelines for Screening and Treatment of Developmental Dysplasia of the Hip

Background/Objectives: Developmental dysplasia of the hip (DDH) is one of the most common pediatric orthopedic disorders and warrants timely diagnosis and treatment to prevent long-term disability. This review identified, summarized, and assessed the quality of current European national guidelines for DDH screening and treatment.

Methods: Guidelines were identified by contacting the national orthopedic societies from 46 European countries and retrieving the guidelines from a recent systematic review. Two researchers independently extracted data and assessed guideline quality using the AGREE II checklist. Interrater agreement was assessed using Cohen's κ.

Results: Nine European national DDH guidelines were identified, of which four were published in peer-reviewed scientific journals. All guidelines advised clinical examination and imaging as part of the DDH screening program, though screening approach and timing varied considerably. Four guidelines included treatment recommendations. The type of treatment (abduction treatment vs. active monitoring) and duration of long-term follow-up showed great variation. Guideline quality ranged from 16 to 92% (Cohen's κ = 0.62), with two out of nine guidelines rated "good quality" (>70%).

Conclusions: European national DDH guidelines appear scarce and of varying quality and content. A coordinated European initiative is warranted to urge countries to develop evidence-based DDH guidelines using validated tools and to publish these guidelines in peer-reviewed journals, thereby advancing equal diagnosis and treatment for children with DDH.

Keywords: developmental dysplasia of the hip; diagnosis; guideline; neonatal screening; therapeutics.

文献出处：Mulder FECM, van Kouswijk HW, Witlox MA, Mathijssen NMC, de Witte PB. An Overview and Quality Assessment of European National Guidelines for Screening and Treatment of Developmental Dysplasia of the Hip. Children (Basel). 2025 Sep 3;12(9):1177. doi: 10.3390/children12091177. PMID: 41007042; PMCID: PMC12468116.

文献5

髋臼周围截骨术治疗伴有严重股骨头非球形畸形的髋关节发育不良临床研究

译者 陶可

背景：伴有股骨近端畸形的髋关节发育不良会导致青年人出现髋关节功能障碍和退行性髋骨关节炎。针对这些复杂的复合畸形，最佳的手术矫正方法仍存在争议。

方法：我们回顾性分析了20例患者的24个髋关节，这些患者均接受了伯尔尼髋臼周围截骨术，其中13个髋关节同时进行了股骨近端外翻截骨术，用于治疗伴有股骨近端结构异常的髋关节发育不良。患者手术时的平均年龄为22.7岁，平均临床随访时间为4.5年。采用Harris髋关节评分和患者对手术的总体满意度来评估髋关节功能和临床结果。X线片用于评估畸形矫正情况、截骨愈合情况以及退行性髋骨关节炎的进展情况。

结果：平均Harris髋关节评分由术前的68.8分提高到最近一次随访时的91.3分（p<0.0001）。16例患者（19个髋关节）临床疗效优良，1例患者（1个髋关节）疗效良好，2例患者（2个髋关节）疗效一般，1例患者（2个髋关节）疗效差。24个髋关节中有22个临床症状得到改善。Wiberg外侧中心边缘角平均改善27.6度（p<0.0001），Lequesne和de Seze前中心边缘角平均改善33.1度（p<0.0001），髋臼顶倾斜度平均改善16.5度（p<0.0001）。髋关节中心平均向内侧移位6.3 mm（p=0.0003）。20个髋关节的Tönnis骨关节炎分级保持不变，3个髋关节的分级升高1级，1个髋关节的分级升高2级。共发生3例主要技术并发症。在最近一次随访时，所有髋关节均无需行全髋关节置换术。

结论：髋关节发育不良合并股骨近端畸形构成了一个复杂的重建难题。髋关节的活动范围和影像学评估是选择手术患者的主要因素。对于部分患者，在必要时，可采用髋臼周围截骨术联合同期股骨手术，以全面矫正畸形并改善髋关节功能。

图1-A：图1-A、1-B、1-C、1-D一名18岁女性患者，患有严重的髋关节发育不良和股骨近端内翻畸形，主诉右髋关节疼痛和跛行。术前髋关节屈曲角度为105°。图1-A该患者既往有Legg-Calvé-Perthes病史，并曾接受过导致内翻畸形的股骨近端截骨术。她股骨头呈椭圆形、股骨颈短和相对较高的股骨大转子。髋关节发育不良明显。

图1-B：该患者接受了髋臼周围截骨术，并展示了术中髋臼的矫正情况。

图1-C：髋臼周围截骨术后，术中内收位X线片显示关节面吻合良好。随后行股骨近端外翻截骨术、大转子前移术及股骨头颈交界处骨软骨成形术。

图1-D：术后24个月，X线片显示截骨愈合良好，畸形已矫正。患者髋关节无疼痛，临床疗效极佳。

Periacetabular osteotomy for the treatment of acetabular dysplasia associated with major aspherical femoral head deformities

Background: Acetabular dysplasia associated with deformity of the proximal part of the femur can result in hip dysfunction and degenerative arthritis in young adults. The optimal method of surgical correction for these challenging combined deformities remains controversial.

Methods: We retrospectively analyzed twenty-four hips in twenty patients who underwent a Bernese periacetabular osteotomy, which was done with a proximal femoral valgus-producing osteotomy in thirteen hips, for the treatment of acetabular dysplasia associated with proximal femoral structural abnormalities. The average age of the patients at the time of surgery was 22.7 years, and the average duration of clinical follow-up was 4.5 years. The Harris hip score and overall patient satisfaction with surgery were used to assess hip function and clinical results. Plain radiographs were used to assess the correction of the deformity, healing of the osteotomy, and progression of degenerative arthritis.

Results: The mean Harris hip score increased from 68.8 points preoperatively to 91.3 points at the time of the most recent follow-up (p<0.0001). Sixteen patients (nineteen hips) had an excellent clinical result, and one patient (one hip) had a good result. Two patients (two hips) had a fair result, and one patient (two hips) had a poor result. Twenty-two of the twenty-four hips improved clinically. There was an average improvement of 27.6 degrees in the lateral center-edge angle of Wiberg (p<0.0001), an average improvement of 33.1 degrees in the anterior center-edge angle of Lequesne and de Seze (p<0.0001), and an average improvement of 16.5 degrees in the acetabular roof obliquity (p<0.0001). The hip center was translated medially an average of 6.3 mm (p=0.0003). The Tönnis osteoarthritis grade was unchanged in twenty hips, progressed one grade in three hips, and progressed two grades in one hip. There were three major technical complications. At the time of the most recent follow-up, none of the hips had required total hip arthroplasty.

Conclusions: The combination of acetabular dysplasia and proximal femoral deformities presents a complex reconstructive problem. The range of motion and radiographic assessment of the hip are major factors in the selection of patients for surgery. In selected patients, the periacetabular osteotomy combined with concurrent femoral procedures, when indicated, can provide comprehensive deformity correction and improved hip function.

文献出处：John C Clohisy, Ryan M Nunley, Madelyn C Curry, Perry L Schoenecker. Periacetabular osteotomy for the treatment of acetabular dysplasia associated with major aspherical femoral head deformities. J Bone Joint Surg Am. 2007 Jul;89(7):1417-23. doi: 10.2106/JBJS.F.00493.

文献6

股骨头坏死中软骨下骨折始于骨吸收区：一项显微计算机断层扫描研究

译者 邱兴

目的： 为成功实现股骨头坏死（ONFH）的关节保留手术，理解塌陷机制至关重要。本研究旨在通过显微CT成像观察整个股骨头，重点分析软骨下骨折与骨吸收区之间的三维关系，探讨ONFH中软骨下骨折的起始过程。

方法： 选取37例患者共40个股骨头标本（根据日本调查委员会标准均为3A或3B期ONFH，均在全髋关节置换术中获取），采用层厚0.146毫米的显微CT进行扫描。根据显微CT测量的塌陷程度（以3毫米为界），将样本分为早期塌陷期和晚期塌陷期。

结果: 通过对整个股骨头多径向平面图像的分析，发现两个重要现象：首先，在全部18个早期塌陷期股骨头标本中，初始骨折裂纹均贯穿前上部分离的骨吸收区；其次，在22个晚期塌陷期标本中有19个观察到硬化边界的坏死骨骨折，以及沿硬化边界坏死侧出现纤维性、肉芽样低密度组织。当骨吸收始于支持带和圆韧带附着点周围并引发软骨下骨折后，股骨头前上部区域的骨吸收扩展可能导致骨折蔓延并引发大面积塌陷。

结论: 三维显微CT显示股骨头坏死中的软骨下骨折始于修复区周围的骨吸收。

关键词: 股骨头坏死；显微CT；软骨下骨折；骨吸收；塌陷

图1 基于三维显微CT的全股骨头分析：重点显示骨坏死中的骨吸收区与软骨下骨折。

图2 a 早期塌陷阶段各径向平面内初始软骨下骨折与骨吸收的发生率分布。图中实线表示各径向平面的软骨下骨折发生率，大点线代表股骨头外侧三分之一区域的骨吸收发生率，小点线显示中间三分之一区域，虚线标示内侧三分之一区域。b 早期塌陷阶段各径向平面内与软骨下骨折相连的骨吸收发生率分布。实线标示各径向平面的软骨下骨折发生率，大点线表示股骨头外侧三分之一区域内与软骨下骨折相连的骨吸收发生率，小点线对应中间三分之一区域，虚线显示内侧三分之一区域。

图3 a 在早期塌陷阶段，所有股骨头的软骨下骨折裂纹均穿行于两个不同的骨吸收区之间；b 部分股骨头外侧三分之一的骨吸收区已延伸至皮质外；c 在晚期塌陷阶段，大面积塌陷似乎由坏死骨的粉碎性骨折导致，沿硬化边界可见纤维性、肉芽样低密度组织；d 晚期塌陷阶段，骨折裂纹从骨吸收区出发，在靠近垂直走向的硬化边界处的坏死骨内延伸。

Subchondral fracture begins from the bone resorption area in osteonecrosis of the femoral head: a micro-computerised tomography study

Purpose: For successful joint preservation in osteonecrosis of the femoral head (ONFH), it is important to understand the mechanism of collapse. The purpose of this study was to investigate the initiation of subchondral fracture in ONFH by using micro-CT imaging of the whole femoral head, focusing on the three-dimensional relationship between the subchondral fracture and the bone resorption area.

Methods: A total of 40 femoral heads from 37 patients retrieved during total hip arthroplasty for stage 3A or 3B ONFH by Japanese Investigation Committee criteria were scanned using micro-CT with a 0.146-mm thickness cuts. We divided the cohort into early and late collapsed stages according to a threshold of 3 mm of collapse as measured by micro-CT.

Results: According to the analysis on multiple radial plane views in the whole femoral head, there were two interesting findings. First, the initial fracture cracks ran between separated bone resorption areas at the anterosuperior portions of all 18 femoral heads in the early collapsed stage. Second, fractures of the necrotic bone at the sclerotic boundary and a fibrous, granulation-like, low-density tissue along the necrotic side of the sclerotic boundary were seen in 19 of the 22 in the late collapsed stage. After bone resorption around the retinaculum and teres insertion initiates the subchondral fracture, bone resorption expanding at the anterosuperior portion of the femoral head may result in the spread of fracture and the potential for massive collapse.

Conclusions: Three-dimensional micro-CT showed bone resorption around the reparative zone initiates the subchondral fracture in ONFH.

Keywords: Bone resorption; Collapse; Micro-CT; Osteonecrosis of the femoral head; Subchondral fracture.

文献出处：Hidetoshi,Hamada,Masaki,et al. Subchondral fracture begins from the bone resorption area in osteonecrosis of the femoral head: a micro-computerised tomography study[J].International Orthopaedics, 2018.

来源：304关节学术

作者：304关节团队

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