髋膝关节文献精译荟萃（第371期）

1、髌骨电烧去神经化对于未置换髌骨的全膝关节置换术有益吗

2、相比于BMI，切口部位脂肪厚度是后路全髋关节置换术后切口相关并发症的更佳预测指标

3、万古霉素在初次全膝关节置换术中的临床效果

4、采用增强模式的 Mako 机器人辅助全髋关节置换术中下肢长度及股骨柄前倾角测量的准确性

5、儿童感染髋严重后遗症的分类与外科处理（1981Hunka分类法）

6、基于超声图像识别髋关节发育不良的深度学习算法

7、运动员腹股沟疼痛：一种新型诊断方法

8、基于二次骨化中心发育的正常髋臼三维形态变化量化研究

9、健康儿童人群中发育性髋关节发育不良（DDH）筛查的风险因素评估及十年经验

10、髋臼周围截骨术后的中长期结果及临床预后预测因素

11、骨关节炎对股骨头软骨下骨小梁区域解剖变异的影响

12、非典型性与不可归类性髋关节脱位伴关节囊及盂唇嵌顿

第一部分：关节置换及保膝相关文献

文献1

髌骨电烧去神经化对于未置换髌骨的全膝关节置换术有益吗：随机对照试验的荟萃分析

译者 张轶超

为了研究未髌骨表面置换的初次全膝关节置换术（TKA）后髌骨去神经化（PD）和未去神经化（NPD）的影响，本研究遵循Cochrane协议的建议，于2023年11月使用PubMed、Embase、Web of Science、Cochrane和Scopus进行了系统的电子检索。仅纳入随机对照研究（RCT）。此外，通过人工检索方式从综述文章的参考文献列表中确定潜在的符合条件的研究。两名研究人员独立进行了文献回顾、数据提取和偏倚风险评估。结果分析包括膝前痛（AKP）的发生率、视觉模拟评分（VAS）、活动范围（ROM）、美国膝关节学会评分（KSS）、牛津膝关节评分（OKS）、髌骨评分（PS）、并发症和再手术情况。Meta分析采用RevMan 5.3软件。为了提高研究的可信度，采用TSA v0.9软件对主要和次要效果的总体情况进行功效分析。纳入了12项研究，涉及1745名患者（1587个膝关节），其中852例做了PD， 893例为NPD。结果显示PD组与NPD组相比，AKP发生率有显著降低。PD和NPD在KSS、OKS和PS方面的差异具有统计学意义。然而，每个结果的95%置信区间上限低于最小临床主要差异（MCID）。两组的VAS和ROM评分无显著差异。此外，PD与并发症或再手术的发生率增加无关。在12个月或更长时间内，PD被证明是一种有益的干预措施，可以在不增加并发症或再手术的情况下降低TKA后的AKP。对于KSS、OKS和PS，通过PD获得的最小优势可能没有临床意义。

Does Patellar Denervation with Electrocautery Benefits for Total Knee Arthroplasty without Patellar Resurfacing: A Meta-analysis of Randomized Controlled Trails

To investigate the effects of patellar denervation (PD) and non-patellar denervation (NPD) after primary total knee arthroplasty (TKA) without patellar resurfacing, this study conducted systematic electronic searches in November 2023 using PubMed, Embase, Web of Science, Cochrane, and Scopus, adhering to Cochrane Collaboration recommendations. Only randomized controlled trials (RCTs) were included. Additionally, a manual search was performed to identify potentially eligible studies from the reference lists of review articles. Two researchers independently conducted literature reviews, data extraction, and risk of bias assessments. The outcome analysis encompassed the incidence of anterior knee pain (AKP), visual analogue scale (VAS), range of motion (ROM), American Knee Society Score (KSS), Oxford Knee Score (OKS), patellar score (PS), complications, and reoperations. Meta-analysis was executed using RevMan 5.3 software. To enhance the credibility of the study, TSA v0.9 software was utilized to perform power analysis on the overall efficacy of primary and secondary outcomes. Twelve studies involving 1745 patients (1587 knees) were included, with 852 undergoing PD and 893 undergoing NPD. Results indicated a superior reduction in AKP incidence in the PD group compared to the NPD group. Statistically significant differences were observed between PD and NPD in KSS, OKS, and PS. However, the upper limit of the 95% confidence interval for each outcome fell below the minimal clinically important difference (MCID). No significant differences were found in VAS and ROM between PD and NPD. Additionally, PD was not associated with an increased incidence of complications or reoperations. Within 12 months and beyond, PD was proven to be a beneficial intervention in reducing AKP following TKA without patellar resurfacing, achieved without an increase in complications or reoperations. Regarding KSS, OKS, and PS, the minimal advantage achievable through PD may not be clinically significant.

文献出处：Zhou X, Jiang Y, Chen D, Chen T, Tian Z. Does Patellar Denervation with Electrocautery Benefits for Total Knee Arthroplasty without Patellar Resurfacing: A Meta-analysis of Randomized Controlled Trails. Orthop Surg. 2024 Aug;16(8):1832-1848.

文献2

相比于BMI，切口部位脂肪厚度是后路全髋关节置换术后切口相关并发症的更佳预测指标

译者 张蔷

背景：体重指数（BMI）被广泛用作评估全髋关节置换（THA）术后并发症风险的重要参考指标。然而，BMI并无法显示患者的脂肪分布情况。既往文献中，有关切口部位脂肪厚度（SSFT）对THA围术期并发症风险预测效果的相关文章稀少。本篇文章的目的是比较BMI和SSFT对THA术后早期并发症的预测效果。

方法：我们选择了某地区医疗中心2022年5月至2024年5月共167例连续的机器人辅助下后入路THA手术病例进行回顾性研究。所有病例均有CT扫描结果。在CT横断位平扫中，选择股骨臀肌粗隆层面自皮肤至髂胫束的水平距离作为SSFT结果。我们对所有病例信息进行了回顾，重点包括围术期变量、早期（术后90天内）术后并发症、再手术和翻修情况。最后，我们对收集到的数据进行了T检验、二元回归分析和受试者工作特征曲线分析。

结果：平均BMI 33.1（范围，18.9-44.3），平均SSFT 52.4mm（范围，8-99）。术后90天内，我们共发现15例（9%）并发症，均为伤口延迟愈合或感染相关；其中7例（4%）进行了再手术。其中4例（2.4%）进行了保留假体的清创手术（DAIR），另外3例（1.8%）进行了清创再缝合手术。单变量分析显示：SSFT与并发症（P < 0.01）、再手术（P < 0.01）和DAIR（P < 0.01）均存在相关性， 而BMI只与并发症（P = 0.02）存在相关性，与再手术（P=0.05）或DAIR（P = 0.27）均不存在相关性。双元回归分析显示：SSFT是并发症（P = 0.03，概率比 1.04）和再手术（P = 0.03，概率比 1.04）的明确预测因素，而BMI（两项P > 0.05）并不是。发生并发症和再手术的SSFT阈值分别为51.5mm（曲线下面积0.73）和64.5mm（曲线下面积0.81）。

结论：与BMI相比，SSFT对THA术后切口相关并发症的预测力更强，且在预测术后早期并发症方面，SSFT是更可靠的指标。

Surgical Site Fat Thickness Is More Predictive of Postoperative Wound Complications than Body Mass Index Following Posterior Approach Total Hip Arthroplasty

Background: Body mass index (BMI) is widely utilized to counsel patients on complication risk following total hip arthroplasty (THA). However, BMI is unable to account for fat distribution. The existing literature is sparse regarding the effect of surgical site fat thickness (SSFT) on perioperative risk in THA. The purpose of the study was to compare BMI and SSFT with acute postoperative complications following THA.

Methods: A retrospective review of 167 consecutive, posterior approach, robotic-arm-assisted THAs between May 2022 and May 2024 at a tertiary academic institution was performed. Computed tomography scans were available for all cases. On the axial computed tomography, SSFT from the iliotibial band to skin at the level of the vastus ridge was measured in mm. A chart review was performed for perioperative variables and acute (within 90 days postoperatively) surgical complications, reoperations, and revisions. T-tests, bivariate regression, and receiver operating characteristic curve analyses were performed.

Results: Mean BMI was 33.1 (range, 18.9 to 44.3), and mean SSFT was 52.4 mm (range, 8 to 99). Within 90 days, there were 15 (9%) complications, all of which were wound- or infection-related; seven (4.2%) were managed with reoperation. Of these, four (2.4%) underwent debridement, antibiotics, and implant retention (DAIR), and three (1.8%) had superficial incision and drainage. With univariate analysis, SSFT was associated with complications (P < 0.01), reoperations (P < 0.01), and DAIR (P = 0.03). Body mass index (BMI) was associated with complications (P = 0.02), but was not associated with reoperations (P = 0.05) or DAIR (P = 0.27). With bivariate regression, SSFT was predictive of complications (P = 0.03, odds ratio 1.04) and reoperations (P = 0.04, odds ratio 1.05), while BMI was not (P > 0.05 for both). Threshold values for complications and reoperations were SSFT of 51.5 mm area under the curve, 0.73) and 64.5 mm (area under the curve, 0.81), respectively.

Conclusions: Compared to BMI, SSFT was more predictive of postoperative wound complications following THA and may be a more reliable measure to counsel patients on early postoperative complication risk.

文献3

万古霉素在初次全膝关节置换术中的临床效果

译者 丁云鹏

背景：关节假体周围感染（PJI）仍然是全膝关节置换术（TKA）后令人担忧的并发症。本研究报告了我们的队列PJI发病率、不良反应和并发症的最新结果，并增加了我们在2021年报道的先前研究的临床随访。

方法：回顾性分析2016年5月至2023年5月期间接受静脉（IV）或骨内（IO）万古霉素治疗的1,923例膝关节，随访时间至少为90天（平均913±611天）。IV组564例，IO组1359例。静脉注射组在切口前按体重给药万古霉素，静脉注射组止血带充气后在胫骨近端给药500 mg万古霉素。所有患者围手术期均接受基于体重剂量的静脉注射头孢唑林。2018年国际共识会议标准用于诊断PJI。急性肾损伤（AKI）定义为肌酐升高0.3 mg/dL。

结果：在随访90天（0.5 vs 1.6%, P = 0.018）、1年（0.7 vs 1.8%, P = 0.048）和2年（0.9 vs 2.4%, P = 0.032）时，IO组PJI发生率明显低于IV组。此外，在随访30天（2.3 vs 4.3%, P = 0.023）和90天（2.5 vs 5.4%, P = 0.003）时，IO组需要口服抗生素的非手术伤口并发症发生率较低。IO组AKI发生率较低（1.6 vs 3.2%, P = 0.078），但差异无统计学意义。在深静脉血栓、肺栓塞或手术伤口并发症的发生率方面没有差异。

结论：在初次TKA后90天、1年和2年的随访中，骨内万古霉素比静脉万古霉素表现出更好的临床效果，PJI的发生率降低。在90天的随访中，IO万古霉素的其他益处是减少了非手术性伤口并发症，并降低了AKI的发生率，但没有统计学意义。

Superior Clinical Results With Intraosseous Vancomycin in Primary Total Knee Arthroplasty

Background: Periprosthetic joint infection (PJI) remains a feared complication after total knee arthroplasty (TKA). This study reports updated outcomes of the incidence of PJI, adverse reactions, and complications of our cohort with increased clinical follow-up of our previous study reported in 2021.

Methods: A retrospective review of 1,923 knees that received either intravenous (IV) or intraosseous (IO) vancomycin during primary TKA between May 2016 and May 2023 with a minimum 90-day follow-up (mean 913 ± 611 days). There were 564 cases in the IV group and 1,359 in the IO group. The IV group received a weight-based dose of vancomycin before incision, and the IO group received 500 mg of vancomycin in the proximal tibia after tourniquet inflation. All patients received a weight-based dose of IV cefazolin perioperatively. The 2018 International Consensus Meeting criteria were used to diagnose PJI. Acute kidney injury (AKI) was defined as a creatinine increase of 0.3 mg/dL.

Results: The IO group demonstrated a significantly lower incidence of PJI compared to the IV group at 90-day (0.5 versus 1.6%, P = 0.018), 1-year (0.7 versus 1.8%, P = 0.048), and 2-year (0.9 versus 2.4%, P = 0.032) follow-up. Additionally, there was a lower incidence of nonoperative wound complications requiring oral antibiotics in the IO group at 30-day (2.3 versus 4.3%, P = 0.023) and at 90-day (2.5 versus 5.4%, P = 0.003) follow-up. There was a lower incidence of AKI in the IO group (1.6 versus 3.2%, P = 0.078), but this did not reach statistical significance. There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, or operative wound complications.

Conclusions: Intraosseous vancomycin demonstrated superior clinical outcomes over IV vancomycin with a reduced incidence of PJI at 90-day, 1- and 2-year follow-up after primary TKA. Additional benefits of IO vancomycin were a reduction in nonoperative wound complications through 90-day follow-up and a nonstatistically significant reduction in the incidence of AKI.

文献出处Kwan J Park , Austin E Wininger , Thomas C Sullivan，Superior Clinical Results With Intraosseous Vancomycin in Primary Total Knee Arthroplasty.J Arthroplasty. 2025Oct;40(10):2650-2654. doi: 10.1016/j.arth.2025.04.074. Epub 2025 May 5.

文献4

采用增强模式的 Mako 机器人辅助全髋关节置换术中下肢长度及股骨柄前倾角测量的准确性

译者 沈松坡

目的

本研究评估了在采用增强模式的 Mako 机器人系统进行全髋关节置换术（total hip arthroplasty，THA）过程中，术中获得的下肢长度及股骨前倾角测量结果的准确性。

方法

本研究回顾性分析了 55 个髋关节病例，其中包括 4 名男性和 51 名女性，均经前外侧入路使用 Mako 系统行初次全髋关节置换术。比较了 Mako 增强模式术中显示的下肢长度及股骨前倾角测量值与术后基于 CT 的测量结果。通过计算绝对误差及其分布情况，以评估术中测量的准确性。

结果

术后下肢长度不等的平均绝对误差为 2.3 ± 1.8 mm，股骨柄前倾角的平均绝对误差为 2.9 ± 2.2°。在 55 个髋关节中，46 例（83.6%）的下肢长度误差在 3 mm 以内，51 例（92.7%）在 5 mm 以内。对于股骨柄前倾角，48 例（87.3%）在 3° 以内，全部 55 例（100%）在 5° 以内。由于股骨阵列松动或固定螺钉穿入髓腔，10.7% 的病例未能完成 Mako 增强模式的测量流程。

结论

Mako 增强模式在术中下肢长度及股骨前倾角测量方面表现出临床可接受的准确性，有助于在机器人辅助全髋关节置换术中实现更精确的股骨柄植入。

关键词：髋关节 · 全髋关节置换术 · 机器人 · Mako · 增强模式

图1 采用Mako系统的增强模式实施全髋关节置换术过程中使用的骨盆与股骨定位架

图2 采用MAKO系统的增强模式进行股骨近端注册

图3 采用MAKO系统的增强模式测量股骨柄的前倾角

图 4　Mako 增强模式下的股骨阵列。

（a）采用增强模式的 Mako 系统所使用的股骨阵列；

（b）术中 X 线影像，显示用于固定股骨阵列的螺钉；

（c）螺钉穿入股骨髓腔。

Accuracy of intraoperative leg length and stem version measurements in robotic‑assisted total hip arthroplasty using the Mako system with enhanced mode

Purpose This study evaluated the accuracy of intraoperative leg length and femoral anteversion measurements obtained during total hip arthroplasty (THA) using the Mako robotic system with enhanced mode.

Methods A total of 55 hips in four men and 51 women who underwent primary THA with the Mako system via an anterolateral approach were retrospectively evaluated. Intraoperative measurements of leg length and femoral anteversion displayed by the Mako enhanced mode were compared with postoperative CT-based measurements. Absolute errors and their distributions were calculated to assess the accuracy of intraoperative assessments.

Results The mean absolute error was 2.3 ± 1.8 mm for postoperative leg length discrepancy and 2.9 ± 2.2° for stem anteversion. Of the 55 hips, 46 (83.6%) showed leg length errors within 3 mm and 51 (92.7%) within 5 mm. For stem anteversion, 48 hips (87.3%) were within 3° and all 55 hips (100%) were within 5°. Mako enhanced mode could not be completed in 10.7% of cases because of femoral array loosening or screw penetration into the medullary canal.

Conclusion Mako enhanced mode demonstrated clinically acceptable accuracy for intraoperative measurement of leg length and femoral anteversion, contributing to precise femoral stem implantation in robotic-assisted THA.

第二部分：保髋相关文献

文献1

儿童感染髋严重后遗症的分类与外科处理（1981Hunka分类法）

译者 罗殿中

婴幼儿和儿童早期感染性髋关节炎结局是灾难性的，可导致严重骨关节后遗症。文献中较好讨论了感染急性期采用抗生素和早期手术引流的处理方案；但很少讨论其残余解剖畸形，也没有清晰的分类方法和治疗建议。Hallel和Salvati报告了24例髋关节感染治疗结果。其中10例股骨头和股骨颈严重破坏，6例采用转子成形手术；上述病例中仅有3例髋关节获得稳定。Weissman和Stetson等各报告一例采用髋关节融合治疗的患者。Rigault等宣称在4例患者中采用转子成形术，其中2例在随访时获得满意效果。有关这方面的信息相对匮乏，我们对蒙特利尔儿童医院（MCH）3例、和蒙特利尔Shriner儿童残障医院（MSH）7例股骨近端严重破坏进行回顾性研究，提出了一项儿童感染性髋关节炎分类系统、及相应的建议治疗方案。

结果：2例III型最终转为V型；2例IVA型，3例IVB型；5例为V型（其中2例为III型转归）。I型和II型不在本文讨论之列。III型处理非常困难，骨移植效果不佳，骨移植仅限于股骨头增大的类型（图5）。IV型预后尚可，残余大转子高位和下肢不等长；可在适当的时机行大转子下移和下肢均衡手术；IVB型必要时可采用髋关节稳定手术。V型虽然X线片表现最为严重，如果早期型大转子成形+股骨近端内翻手术，疗效尚满意。

图1. 儿童感染性髋关节炎后遗症分类。I型，股骨头轻微改变或无变化；IIA型，股骨头畸形但骺板不受累及；IIB型，股骨头畸形且骺板早闭；III型，股骨颈假关节；IVA型，股骨干骺端完全破坏，但残余股骨颈稳定；IVB型，股骨干骺端完全破坏，但残余股骨颈不稳定稳定；V型，股骨头颈完全破坏直达转子间线，髋关节脱位。

图2. V型感染髋后遗症，股骨头和股骨颈消失，髋关节脱位。

图3. 图2患儿行大转子成形术后。

图4. III型感染髋后遗症，股骨颈假关节形成，股骨头坏死、变小。

图5. III型感染髋后遗症，股骨颈假关节，股骨头增大在位。

Classification and surgical management of the severe sequelae of septic hips in children

The treatment of the acute state of septic arthritis of the hip in children has been clearly outlined in the current literature. The treatment of residual anatomic deformity is less well understood; no classification or comprehensive treatment program has been documented. The following classification of the sequelae of septic hips in children is based on the presence or absence of a capital femoral epiphysis and hip stability. This classification defines the case material and outlines the anatomic problem requiring solution. Of ten patients with severe destruction of the femoral head followed for an average period of 11.2 years, there were eight satisfactory and two unsatisfactory results. Both unsatisfactory results were Type III hips with pseudarthrosis of the neck. Both had an average of five surgical procedures, compared with 2.2 procedures for patients with satisfactory results. The complications were leg-length discrepancy, hip instability, and scoliosis.

文献出处：Hunka L, Said SE, MacKenzie DA, Rogala EJ, Cruess RL. Classification and surgical management of the severe sequelae of septic hips in children. Clin Orthop Relat Res. 1982 Nov-Dec;(171):30-6. PMID: 7140082.

文献2

基于超声图像识别髋关节发育不良的深度学习算法：中国的一项回顾性、前瞻性、多中心研究

译者 任宁涛

背景：髋关节超声是诊断疑似婴儿髋关节发育不良（DDH）的一线工具，但其局限性包括重复性差和诊断错误率高。因此本研究旨在利用多中心髋关节超声数据，开发并验证一种名为HipSonoNeuNet模型（HSNN）的深度卷积神经网络算法。

方法：这项多中心横断面研究纳入22家中国医院（2022年9月至2025年1月）的数据，纳入了3082名参与者。共收集髋部超声图像7286张（动态1429张，静态5857张），分为3个数据集。这项研究分三个阶段进行。第一阶段使用2431名参与者（数据集1）训练模型。第二阶段比较了500名参与者中不同经验的放射科医生和模型之间的诊断表现（数据集2）。第三阶段对151名参与者（数据集3）前瞻性地验证了模型的普遍性。

结果：在第一阶段，HSNN在内部测试数据集上的AUC为0.99 (95% CI: 0.99-1.00)，灵敏度为1.00 (95% CI: 0.99-1.00)，特异性为0.91 (95% CI: 0.88-1.00)， F1评分为0.90 （95% CI: 0.87-1.00）。在II期，HSNN的准确率为0.94 (95% CI: 0.88-1.00)， AUC为0.99 (95% CI: 0.99-1.00)，灵敏度为1.00 (95% CI: 0.99-1.00)，特异性为0.94 (95% CI: 0.87-1.00)， F1评分为0.58 (95% CI: 0.50-0.66)，与专家（κ = 0.77）高度一致。人工智能辅助提高了所有7名初级放射科医生的诊断表现（准确率从0.90提高到0.93，AUC从0.80提高到0.95，灵敏度从0.69提高到0.97），并缩短了检查时间，增强了观察者之间的一致性。在第三阶段，模型保持了稳健的性能（精度= 0.92,AUC = 0.99，灵敏度= 1.00，与专家的κ = 0.76）。

图1 研究设计概述。(A)所建立的HSNN框架包含两个步骤，一是关键帧（标准平面）检测，二是关键帧分类；(B) HSNN系统开发和验证的示意图概述。

Deep learning algorithms for identifying developmental retrospective prospective multicenter study in ChinaDeep learning algorithms for identifying developmental retrospective prospective multicenter study in China

Background: Hip ultrasound is the first-line tool to identify developmental dysplasia of the hip (DDH) among suspected infants, yet it has limitations including poor reproducibility and high diagnostic error rates. This study aims to develop and validate a deep convolutional neural network algorithm, named HipSonoNeuNet model (HSNN), using multicenter hip ultrasound data.

Methods: This multicenter cross-sectional study combined data from 22 Chinese hospitals (September 2022-January 2025), enrolling 3082 participants. A total of 7286 hip ultrasound images (1429 dynamic, 5857 static) were collected and were divided into three datasets. The study was conducted in three phases. Phase I trained the models using 2431 participants (Dataset 1). Phase II compared diagnostic performance between radiologists of varied experience and the model across 500 participants (Dataset 2). Phase III prospectively validated the model's generalizability with 151 participants (Dataset 3).

Findings: In Phase I, the HSNN yielded AUC of 0.99 (95% CI: 0.99-1.00), sensitivity of 1.00 (95% CI: 0.99-1.00), specificity of 0.91 (95% CI: 0.88-1.00), F1 score of 0.90 (95% CI: 0.87-1.00) on internal test dataset. In Phase II, the HSNN achieved an accuracy of 0.94 (95% CI: 0.88-1.00), AUC of 0.99 (95% CI: 0.99-1.00), sensitivity of 1.00 (95% CI: 0.99-1.00), specificity of 0.94 (95% CI: 0.87-1.00), F1 score of 0.58 (95% CI: 0.50-0.66), and strong agreement with expert (κ = 0.77). AI assistance improved all 7 junior radiologists' diagnostic performance (accuracy from 0.90 to 0.93, AUC from 0.80 to 0.95, sensitivity from 0.69 to 0.97) and reduced examination time with enhanced interobserver agreement. In Phase III, the model maintained robust performance (accuracy = 0.92, AUC = 0.99, sensitivity = 1.00, κ with experts = 0.76).

文献出处：Xu N, Han T, Huang B, Fan W, Chen X, Zhu M, Miao L, Huang Y, Zhu Z, Tong L, Chen L, Liu J, Lin S, Nie L, Liu C, Gao J, Zhan X, Lin L, Meng M, Xu S, Wang Y, Peng H, Hu X, Cao Z, Zhang Z, Kong D, Feng T, Ni D, Yang X, Zhou L. Deep learning algorithms for identifying developmental dysplasia of the hip based on sonographic images: a retrospective, prospective, multicenter study in China. EClinicalMedicine. 2025 Oct 9;89:103552. doi: 10.1016/j.eclinm.2025.103552. PMID: 41140452; PMCID: PMC12547208.

文献3

运动员腹股沟疼痛：一种新型诊断方法

译者 李勇

对于运动表现活跃的运动员来说，腹股沟疼痛的诊断和治疗极具挑战性。鉴别诊断包括关节内病因、关节外病因以及非肌肉骨骼病因。对这一群体的腹股沟疼痛进行详细的临床和影像学评估至关重要，因为这能确定潜在的病理机制。诊断性髋关节阻滞是区分关节内与关节外病因的有价值工具。髋关节镜检查有助于识别一些难以捉摸的关节内疾病，这些疾病曾经因未被诊断而未得到治疗，导致许多运动员的职业生涯过早结束。本文旨在探讨当前对腹股沟疼痛（尤其是年轻个体）评估的思考，并建立一个简单的临床和诊断方案来应对这一棘手问题。

腹股沟疼痛的解剖学与分类 (Anatomy & Classification)：解剖结构： 涉及腹部与腿部交界处，包括腹直肌下部、腹股沟区、耻骨联合、大腿内收肌上部等。病因分类： 主要分为关节内病因（髋关节球窝内的病变）和关节外病因（球窝外的病变）。专家估计60%的关节内损伤最初被误诊为关节外损伤。非骨骼肌肉病因： 需排除妇科、泌尿科、肿瘤等引起的牵涉痛。

诊断方法 (Approach to Diagnosis)：病史与体检： 是缩窄诊断范围的第一步。例如，髋关节活动时的弹响可能提示盂唇撕裂（关节内）；烧灼样疼痛可能提示神经卡压。 鉴别诊断 (Differential Diagnosis)：关节内病因： 股骨髋臼撞击综合征 (FAI)、软骨盂唇损伤、圆韧带损伤、游离体等。关节外病因： 肌肉拉伤/撕裂、应力性骨折、耻骨骨炎、运动疝、弹响综合征、神经卡压等。

影像学检查 (Imaging Studies)：X光片： 基础检查，用于观察骨骼定义和排列（如FAI的“凸轮”畸形）。超声： 廉价且快速，适合动态评估软组织及排除细微疝气。 MRI/MRA： 诊断软组织、软骨损伤的金标准，尤其是MRA（磁共振关节造影）对盂唇病理评估极佳。CT/神经传导研究： CT用于骨骼重建规划，神经传导研究用于诊断神经卡压。

关键诊断工具与治疗 (Key Diagnostic Tools & Treatment)：诊断性髋关节阻滞 (Diagnostic Hip Block)： 在透视引导下进行关节内注射（皮质类固醇和局麻药）。阳性反应（疼痛缓解）是判断关节内病变的可靠指标（90%可靠性）；若注射无效，应评估隐匿的关节外病因。髋关节镜 (Hip Arthroscopy)： 既是诊断工具也是治疗手段。对于难以确诊的关节内病因极其有效，可处理盂唇撕裂、撞击等问题。

临床流程图 (Clinical Algorithm)：首先进行腹股沟疼痛的临床检查和影像学检查。 若确诊则治疗；若诊断不确定，进行诊断性髋关节阻滞。若疼痛缓解（提示关节内病因），建议进行髋关节镜检查。若疼痛持续（提示关节外病因），则进一步调查关节外原因。髋关节镜无法治疗或不适用的情况，可考虑截骨术、表面置换或全髋置换等。

Groin pain in athletes: a novel diagnostic approach

Abstract：Groin pain in a performing athlete can be very challenging to diagnose and treat. The differential diagnosis includes intra-articular causes, extra-articular causes and non-musculoskeletal causes. A detailed clinical and radiological assessment of groin pain in this group is critical and can identify the underlying pathology. Diagnostic hip block is a valuable tool to differentiate intra-articular causes from extra-articular causes. Hip arthroscopy can help in identifying some of the elusive intra-articular conditions, which were once undiagnosed and therefore, left untreated, resulting in premature ending of competitive careers. This article attempts to explore current thinking on evaluation of groin pain, particularly in young individuals, and to establish a simple protocol for a clinical and diagnostic approach to this difficult problem.

文献出处：Shetty VD, Shetty NS, Shetty AP. Groin pain in athletes: a novel diagnostic approach. SICOT J. 2015 Jul 7;1:16. doi: 10.1051/sicotj/2015017. PMID: 27163072; PMCID: PMC4849255.

文献4

基于二次骨化中心发育的正常髋臼三维形态变化量化研究

译者 张利强

背景‌：髋臼发育由Y形软骨（TRC）和耻骨、坐骨、髂骨的二次骨化中心（SOCs）驱动，其出现和融合存在年龄与性别差异。本研究量化了SOCs对青少年髋臼覆盖、扭转、倾斜及表面积的影响。

方法‌：对540个无髋关节病变的正常髋关节（男性128例，女性142例，年龄8-19岁）进行CT扫描，生成三维重建。使用已发表算法提取髋臼参数（包括八分位覆盖角、扭转、倾斜及表面积），并通过近端股骨成熟指数（PFMI）评估骨骼成熟度。采用广义线性混合模型分析3个SOCs对髋臼形态的贡献。

结果‌：PFMI与年龄显著相关（rs=0.91，p<0.001）。髂骨骨化与上覆盖增加显著相关（p<0.001），坐骨骨化与后覆盖增加相关（p<0.001）。上覆盖与外侧倾斜强相关（rs=0.837），后覆盖与前扭转强相关（rs=0.788）。女性髋臼前扭转（17.7°±6.4° vs 12.2°±6.4°）和外侧倾斜（38.5°±4.7° vs 36.6°±5.7°）更大，男性髋臼表面积更大（31.9±6.4 vs 28.8±4.2 cm²，p<0.001）。耻骨骨化与前覆盖无显著关联（男性p=0.38，女性p=0.065），前覆盖与年龄无相关性（p=0.115）。

结论‌：髂骨和坐骨骨化分别与青少年髋臼上覆盖和后覆盖增加相关，而耻骨骨化与前覆盖无关。SOCs的出现和闭合时间与髋臼形态的关键发育变化一致，强调了其在髋关节稳定性中的作用。

证据等级‌：III级（预后性研究）。

A 冠状截面演示三维覆盖角计算。B 髋臼分为5个区域：后（红色）、上-后（暗红色）、上（蓝色）、上-前（浅蓝色）和前（青色）。每个区域的覆盖角为沿髋臼边缘45°弧度内的平均角度。

CT图像显示髋臼3个继发性骨化中心（soc）的外观和闭合：耻骨（前）、髂骨（上）和坐骨（后）。使用标准化的3D靶向系统显示每个中心的轴位、冠状面和矢状面，以评估多个解剖视图的骨化情况。

Quantifying Changes in 3D Acetabular Morphology in Normal Hips Based on the Development of Secondary Ossification Centers

Background: Acetabular development in pediatric hips is driven by growth from the triradiate cartilage (TRC) and secondary ossification centers (SOCs) of the os pubis, os ischium, and os ilium. These SOCs appear and fuse at different ages, with sex-specific differences affecting their morphology. This study quantifies the impact of SOCs on acetabular coverage, version, tilt, and surface area during adolescence.

Methods: Three-dimensional (3D) surface reconstructions of 540 normal hips (in 128 male and 142 female patients) aged 8 to 19 years with no hip pathology were generated from computed tomography (CT) scans. Acetabular parameters, including coverage angles in predefined octants, version, tilt, and surface area, were extracted with use of a previously published algorithm. The Proximal Femur Maturity Index (PFMI) was used to assess skeletal maturity. Contributions to acetabular morphology from the 3 SOCs were analyzed using generalized linear mixed models. Significance was defined as p < 0.05.

Results: PFMI grades strongly correlated with chronological age (rs = 0.91; p < 0.001). Os ilium ossification was significantly associated with increased superior coverage (p < 0.001), and os ischium ossification was associated with increased posterior coverage (p < 0.001). Superior coverage demonstrated a strong correlation with lateral tilt (rs = 0.837; p < 0.001), and posterior coverage was strongly correlated with anteversion (rs = 0.788; p < 0.001). Female patients exhibited greater acetabular anteversion (17.7 ° ± 6.4 ° versus 12.2 ° ± 6.4 °; p < 0.001) and lateral tilt (38.5 ° ± 4.7 ° versus 36.6 ° ± 5.7 °; p < 0.001), whereas male patients demonstrated larger acetabular surface area (31.9 ± 6.4 versus 28.8 ± 4.2 cm 2 ; p < 0.001). We did not find a significant association between os pubis ossification and increased anterior coverage in male (p = 0.38) or female (p = 0.065) patients, nor did we find a correlation between anterior coverage and age (p = 0.115).

Conclusions: Os ilium and os ischium ossification were associated with increased superior and posterior acetabular coverage, respectively, during adolescence. In contrast, os pubis ossification was not associated with changes in anterior coverage. The timing of SOC appearance and closure aligns with key developmental changes in acetabular morphology, reinforcing the role of SOCs in determining hip stability.

Level of Evidence: Prognostic Level III.

文献出处：Grewal RS, Keil LG, Bomar JD, Ryan J, Beasley BVL, Farnsworth CL, Schmitz MR, Upasani VV. Quantifying Changes in 3D Acetabular Morphology in Normal Hips Based on the Development of Secondary Ossification Centers. J Bone Joint Surg Am. 2025 Nov 5;107(21):2365-2370. doi: 10.2106/JBJS.25.00428. Epub 2025 Sep 12. PMID: 40939009.

文献5

健康儿童人群中发育性髋关节发育不良（DDH）筛查的风险因素评估及十年经验

译者 贾海港

目的： 基于风险的超声筛查是检测髋关节发育不良（DDH）的常用方法。然而，由于数据不足以给出明确的建议，不同国家的风险因素也各不相同。本研究旨在评估髋关节发育不良（DDH）的风险因素。

方法： 本回顾性病例对照研究调查了 2004 年至 2014 年间在土耳其某儿童保健中心接受随访的所有儿童的健康记录，以确定其是否患有发育性髋关节发育不良（DDH）。在 9758 名儿童中，57 名儿童被发现存在超声检查异常（根据 Graf 分级），这些儿童构成病例组。对照组选取了 228 名与病例组儿童出生月份相匹配的健康儿童。比较了两组的危险因素。

结果： 共对 9758 名儿童的 19516 个髋关节进行了发育性髋关节发育不良（DDH）的超声检查。其中 57 名儿童的 97 个髋关节超声检查结果异常。两组比较发现，臀位、多胎妊娠和斜颈是 DDH 的危险因素。病例组中女性患儿的比例也显著高于男性。髋关节外展受限、Ortolani 征阳性和 Barlow 征阳性是病例组的重要临床表现。

结论： 根据我们的研究结果，臀位、女性、斜颈和多胎妊娠是该疾病的危险因素。具有这些危险因素的婴儿应仔细检查是否患有发育性髋关节发育不良（DDH）。

Risk Factor Assessment and a Ten-Year Experience of DDH Screening in a Well-Child Population

Aim: Risk based screening for developmental dysplasia of the hip (DDH) with ultrasound is common. However, risk factors vary from one country to the other since data are insufficient to give clear recommendations. We aimed to evaluate the risk factors for developmental dysplasia of the hip (DDH).

Methods: In this retrospective case-control study, the health records of all children, who were followed up between 2004 and 2014 at a well-child unit, were investigated for the diagnosis of DDH in Turkey. Of 9758 children, 57 children were found to have abnormal ultrasonographic findings (according to Graf classification) and these constituted the case group. As the control group, healthy 228 children who matched the case children in birth months were selected. Two groups were compared for the risk factors.

Results: A total of 19516 hips of 9758 children were examined for DDH. 97 hips of 57 children were found to have abnormal ultrasonographic findings. When the two groups were compared, breech presentation, multiple pregnancy, and torticollis were identified as risk factors. The female sex was also found to have a significantly high prevalence among the children in the case group. Limited hip abduction, positive Ortolani, and Barlow signs were important clinical findings in the case group.

Conclusion: According to our findings, breech presentation, female sex, torticollis, and multiple pregnancy were found to be the risk factors of this disorder. Infants with these risk factors should be investigated carefully for DDH.

文献出处：Kural B, Devecioğlu Karapınar E, Yılmazbaş P, Eren T, Gökçay G. Risk Factor Assessment and a Ten-Year Experience of DDH Screening in a Well-Child Population. Biomed Res Int. 2019 Aug 4;2019:7213681. doi: 10.1155/2019/7213681. PMID: 31467908; PMCID: PMC6699317

文献6

髋臼周围截骨术后的中长期结果及临床预后预测因素

译者 陶可

背景：伯尔尼髋臼周围截骨术是一种常用的保髋（非关节置换）的选择，用于治疗有症状的年轻患者发育性髋关节发育不良。预测哪些髋关节能进行保髋手术，哪些髋关节在髋臼周围截骨术后需要髋关节置换，是一项重大挑战。本研究评估了髋臼周围截骨术后的中期至长期结果，以展示不同程度异常（骨赘）增生和骨关节炎患者的临床结果。基于这些结果，进行了失败概率分析，以预测进行髋关节保髋手术的可能性，并改善手术决策。

方法：在1991年5月至1998年9月期间，单一外科医生接受髋臼周围截骨术治疗的189个髋关节（共157例患者）中，有31例被排除诊断为发育性髋关节发育不良，23例未能随访。其余135个髋关节（共109名患者）均在平均9年内进行了回顾性复查。髋关节的评估采用了西安大略大学和麦克马斯特大学骨关节炎指数的疼痛亚量表，术后评估，以及术前和术后1年及5年以上拍摄的X线片。截骨失败被定义为疼痛评分>或=10，即需要全髋关节置换术。

结果：102个髋关节（76%）平均保存了9年，西安大略大学和麦克马斯特大学的平均疼痛评分为2.4分（满分20分）。33例髋关节（24%）符合失败标准：17例在截骨术后平均6.1年接受全髋关节置换术，16例术后疼痛评分为>或=10。以全髋关节置换术为终点的Kaplan-Meier分析显示，5年存活率为96%（95%置信区间，93%至99%），10年存活率为84%（95%置信区间，77%至90%）。20个髋关节出现并发症。15个髋关节（11%）因软骨和/或盂唇病变接受了后续关节镜手术，平均发生在截骨术后的6.8年。识别出两个独立的失败预测因子（定义为全髋关节置换术或高疼痛评分）：（1）年龄超过35岁，（2）术前关节吻合关系差或一般。无失败预测因素的髋关节失败率为14%，只有一个预测因素（年龄超过35岁或关节吻合关系差或一般）为36%，同时具有两种预测因素者为95%。

结论：伯尔尼髋骨周围截骨术对于治疗疼痛性髋关节发育不良可能有效，但多达15%的病例可能出现并发症。理想的病例是年龄在35岁以下且髋关节吻合关系良好或极佳的患者。

Intermediate to long- term results following the Bernese periacetabular osteotomy and predictors of clinical outcome

Background: The Bernese periacetabular osteotomy is a commonly used non-arthroplasty option to treat developmental hip dysplasia in symptomatic younger patients. Predicting which hips will remain preserved and which hips will go on to require arthroplasty following periacetabular osteotomy is a major challenge. In the present study, we assessed the intermediate to long-term results following periacetabular osteotomy to demonstrate the clinical outcomes for patients with varying amounts of dysplasia and arthritis. From these results, a probability-of-failure analysis was conducted to predict the likelihood of hip preservation and to improve surgical decision-making.

Methods: Of the 189 hips (in 157 patients) that were treated with periacetabular osteotomy by a single surgeon from May 1991 to September 1998, thirty-one had diagnoses other than developmental hip dysplasia and twenty-three were lost to follow-up. The remaining 135 hips (in 109 patients) were retrospectively reviewed at an average of nine years. Hips were evaluated with use of the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index postoperatively as well as with radiographs that were made preoperatively and at one and more than five years postoperatively. Osteotomy failure was defined as a pain score of ‡10 or the need for total hip arthroplasty.

Results: One hundred and two hips (76%) remained preserved at an average of nine years, with an average Western Ontario and McMaster Universities pain score of 2.4 of 20. Thirty-three hips (24%) met the failure criteria: seventeen underwent arthroplasty at an average of 6.1 years after the osteotomy, and sixteen had a postoperative pain score of 10. Kaplan-Meier analysis with arthroplasty as the end point revealed a survival rate of 96% (95% confidence interval, 93% to 99%) at five years and 84% (95% confidence interval, 77% to 90%) at ten years. Complications occurred in twenty hips. Fifteen hips (11%) were treated with a subsequent arthroscopy because of chondral and/or labral lesions at an average of 6.8 years after the osteotomy. Two independent predictors of failure (defined as arthroplasty or a high pain score) were identified: (1) an age of more than thirty-five years and (2) poor or fair preoperative joint congruency. The probability of failure requiring arthroplasty was 14% for hips with no predictors of failure, 36% for those with one predictor (either an age of more than thirty-five years or poor or fair joint congruency), and 95% for those with both predictors.

Conclusions: The Bernese periacetabular osteotomy can be effective for the treatment of painful hip dysplasia, but complications may be expected in as many as 15% of cases. The ideal candidate is the patient who is less than thirty-five years of age and who has good or excellent hip joint congruency.

文献出处：Matheney Travis, YJ Kim, Zurakowski David, Matero Catherine, Millis Michael. Intermediate to long- term results following the Bernese periacetabular osteotomy and predictors of clinical outcome. J Bone Joint Surg Am, 2009; 91:2113-2123.

文献7

骨关节炎对股骨头软骨下骨小梁区域解剖变异的影响

译者 邱兴

背景： 软骨下骨小梁位于关节软骨深层，其中股骨颈上部区域承担髋关节日间承荷的70%以上。这导致股骨头内软骨下骨小梁存在显著的局部解剖差异。本研究旨在探讨骨关节炎是否影响这些局部形态特征。

方法： 研究收集了60例髋关节置换术中获取的股骨头样本，通过骨穿透测量法在8个预设角度以1毫米/秒的穿透速率进行分析。其中28例供体因骨关节炎接受手术，其余为髋部骨折的创伤患者。为将测量结果与非侵入性数据关联，所有样本在实验前均接受微计算机断层扫描（μCT）检查。分析垂直于穿刺路径的横截面积，并将其与记录的骨穿透能量偏差进行比较。

结果： 实验显示骨小梁存在显著的局部形态偏差。骨关节炎样本中的偏差更为明显，且整体需要更高的骨穿透能量。研究发现，骨的方向性强度与其横截面特征存在显著相关性。尽管“性别”对骨穿透能量的影响具有统计学意义，但在将骨穿透能量与二维骨小梁密度关联的回归模型中，性别未被列为自变量，因其并未提高调整后R²值。

结论： 本研究通过对比骨关节炎与健康样本，进一步揭示了骨关节炎患者股骨头承载能力的变化。结果表明，股骨头区域的软骨下骨小梁因骨关节炎而发生更明显的骨重塑和脱矿质过程，这一变化体现在更高的骨穿透测量值中。

关键词： 松质骨特征；股骨头；骨关节炎；骨穿透测量。

图1. 骨穿透测量针及其施力方向示意图

图2. 股骨头软骨下骨横截面积（于股骨头表面以下7 mm处测量，垂直于内上区域方向）

图3. 穿透测试典型测量曲线

The effect of osteoarthritis on the regional anatomical variation of subchondral trabecular bone in the femoral head

Background: The subchondral trabecular bone is located deep inside the articular cartilage, with the subcapital region carrying up to 70% of the diurnal loads occurring in the hip joint. This leads to severe regional anatomical variations of subchondral trabecular bone in the femoral head and the purpose of this study was to examine whether osteoarthritis affects these topographic characteristics.

Methods: 60 femoral heads were harvested during hip replacement and studied by osteopenetration at 8 pre-defined angles, at a penetration rate of 1mm/s. Twenty-eight of the donors underwent surgery due to osteoarthritis, whereas the remaining were trauma patients with hip fractures. To correlate these measurements to non-invasive data, all specimens were scanned by micro Computed Tomography (μCT) prior to experimentation. A cross-sectional area, perpendicular to the needle penetration pathway, was analyzed and the deviations compared to the recorded osteopenetration energy.

Findings: The experiments revealed significant topographical deviations in the trabeculae. These were more pronounced in the osteoarthritic samples which also required overall higher osteopenetration energy. A notable dependency of the directional bone strength to its cross-sectional characteristics was observed. Although the effect of "gender" on osteopenetration energy was proven to be significant, gender was not considered an independent variable in a regression model correlating osteopenetration energy to 2D trabecular bone density as this did not improve the value of the adjusted R(2).

Interpretation: The investigation provided refined insight into femoral head load-bearing capacity of patients suffering from osteoarthritis, as a comparison of osteoarthritic to healthy samples illustrated that subchondral trabecular bone in the femoral head region is subjected to increased remodeling and demineralization, reflected in higher osteopenetration values.

Keywords: Cancellous bone characteristics; Femoral head; Osteoarthritis; Osteopenetration.

文献出处：Tsouknidas, A., K. Anagnostidis, S. Panagiotidou, and N. Michailidis. "The effect of osteoarthritis on the regional anatomical variation of subchondral trabecular bone in the femoral head." Clinical Biomechanics 30, no. 5 (2015): 418-423.

文献8

非典型性与不可归类性髋关节脱位伴关节囊及盂唇嵌顿：病例报告与文献回顾

译者 徐子茵

引言与重要性： 除前脱位、后脱位或中心性脱位外，髋关节脱位的其他类型鲜有报道。我们报告一例无法归类的非典型髋关节脱位，伴有关节囊和盂唇的嵌顿。本文旨在描述一种伴有软组织嵌顿的罕见类型髋关节脱位。

病例报告： 患者男，18岁，无特殊病史，因道路交通事故导致右侧髋关节发生不寻常的移位。首次复位后，复查X线片显示关节间隙持续增宽，强烈提示存在软组织嵌顿。计算机断层扫描证实前侧区域有软组织嵌顿于股骨头与髋臼之间。伤后两周，采用Hueter入路进行手术，术中发现前侧关节囊及盂唇嵌顿，予以松解并复位。术后2年随访，患者主诉疼痛，Postel Merle d'Aubigné (PMA)评分为17分。我们观察到转子周围有钙化，但股骨头未见坏死迹象。

临床讨论： 髋关节脱位主要类型为后脱位和前脱位。不属于这些类型的脱位形式少有文献综述。后者通常需手术治疗，以清除嵌顿物（如软组织或骨块）。然而，手术入路的选择取决于脱位类型。

结论： 非典型髋关节脱位必须谨慎复位，因其存在较高的软组织嵌顿风险。复位后X线片上显示关节间隙增宽应引起对关节囊或盂唇嵌顿的怀疑，并需采取手术策略。

关键词： 非典型髋关节脱位；病例报告；Hueter入路；关节囊和盂唇嵌顿

Atypical and unclassifiable hip dislocation with capsule and labrum incarceration: a case report and review of the literature

Introduction and importance: Hip dislocations excluding the anterior, posterior or central variety have rarely been published. We report an atypical and unclassifiable dislocation of the hip joint with incarceration of the capsule and labrum. The aim of the presentation was to describe an uncommon type of hip dislocation with entrapment of the soft tissue.

Case presentation: 18-year-old patient, with no specific pathological history, was involved in a road traffic accident causing an unusual right hip joint displacement. After the first reduction, the control X-rays showed persistent enlargement of the joint line, strongly suggesting soft-tissue impingement. Computed tomography confirmed soft tissue entrapment in the anterior area between the head and the acetabulum. An Hueter approach carried out two weeks after the injury, revealed incarceration of the capsule and anterior labrum; which was released and repositioned. At 2-year follow-up, the patient complained of the pain and the Postel Merle d'Aubigné (PMA) score was 17. We observed the peritrochanteric calcifications but without signs of osteonecrosis femoral head.

Clinical discussion: Posterior and anterior hip dislocations are the main types. Forms excluding these types have rarely been reviewed. The last ones are usually surgical treatments, which help remove the obstacle, such as soft tissue or a bone fragment. However, the choice of approach depends on the displacement.

Conclusion: Atypical dislocation of the hip must be carefully reduced, due to the high risk of soft-tissue incarceration. An enlarged joint line on a control X-rays should lead to suspicion of a capsule or labrum interposition and a surgical strategy is required.

Keywords: Atypical hip dislocation; Case report; Hueter approach; Incarceration of the capsule and labrum.

文献出处：Zengui FZP, Ellah MR, Bouhelo-Pam KBP, Bilongo-Bouyou ASW, Mvili NSNG, Monka M. Atypical and unclassifiable hip dislocation with capsule and labrum incarceration: a case report and review of the literature. Int J Surg Case Rep.

来源：304关节学术

作者：304关节团队

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