髋膝关节文献精译荟萃（第376期）

本期目录：

1、二期关节置换翻修术再植入假体术中α -防御素阳性与1年感染无关

2、手术体位是否影响全髋关节置换术中神经血管损伤的风险

3、全膝关节置换术中应用负载抗氧化剂的高交联聚乙烯垫片可以降低翻修风险

4、调整机械力线：手术技巧——要点与窍门

5、机器人辅助全膝关节置换术中的骨赘骨性平衡

6、Perthes病患者大转子阻滞术术后的影像学结果

7、计算机辅助髋臼周围截骨术治疗髋关节发育不良患者

8、手术年龄与髋臼周围截骨术后早期患者自述结局无相关性

9、软骨下骨折始于股骨头坏死中的骨吸收区域

第一部分：关节置换及保膝相关文献

文献1

二期关节翻修术再植入假体术中α -防御素阳性与1年感染无关

译者 张轶超

背景：诊断假体周围关节感染（PJI）是一项挑战，它依赖于多种可能不一致的临床和实验室标准。滑膜α -防御素-1 （AD-1）检测已被证明与肌肉骨骼感染学会（MSIS）诊断PJI的标准准确相关，然而，在二期再植入新假体前接受抗生素间隔器的患者中，其与残留PJI的关系尚未得到阐明。采用基于delphi的共识来定义PJI的成功根除，为测试AD-1在这种情况下的效用提供了机会。

问题/目的：(1)，作为德尔菲持续性PJI标准的替代，在使用间隔器治疗PJI的两期翻修术期间通过AD-1测试是否可以确定感染是否得到控制或根除？(2)与MSIS标准相比，AD-1测试的准确性如何？

方法：回顾性分析2014年5月至2016年7月期间接受两期翻关节置换修术患者的多中心数据。我们纳入了先前确诊的PJI并接受了水泥间隔器的患者，进行第二阶段治疗，具有MSIS评分数据和滑液AD-1测试，并且至少随访1年。我们无法确定所有研究单位有多少患者进行了测试，但不符合所有标准就排除在研究之外；我们能够确定有69例患者（43膝，26髋）符合所有标准。在此期间，使用AD-1的适应征因外科医生而异；然而，在此期间，如果外科医生要求将AD-1作为第一阶段手术中测试的一部分，则通常会在第二阶段再植入手术之前重复该测试。为了评估AD-1对1年时持续性PJI测试的有效性，使用持久性PJI的德尔菲标准作为金标准计算以下数据：敏感性，特异性，阳性和阴性预测值，准确性和 95%置信区间（CIs）曲线下面积（AUC）。采用AD-1和MSIS标准计算持续性PJI的德尔菲标准的一致性指数（c-index）及其与受试者工作特征（ROC）曲线的Wald 95% CI。采用DeLong非参数方法比较AD-1和MSIS的C指数。

结果：AD-1试验在检测1年感染根除方面敏感性较差（7%;95% CI, 0.2-34），总体准确性较差（73%;95% CI, 60-83; AUC = 0.5; 95% CI, 0.3-0.6）。AD-1标准与Delphi标准诊断持续性PJI的C指数为0.519 (95% CI, 0.44-0.60)， MSIS标准与Delphi标准诊断持续性PJI的C指数为0.518 (95% CI, 0.49-0.54)，表明这些模型的诊断能力较弱。MSIS标准和AD-1之间的对比估计值在-0.001之间，没有差异（95% CI%, -0.09至0.09;p = 0.99）。

结论：我们发现滑膜液AD-1测试阳性与PJI两期关节置换翻修术后1年持续感染的存在相关性较差。因此，我们不建议在使用水泥间隔器的患者中常规使用AD-1，直到或除非未来的研究证明该测试比我们发现的结果更有效。

Positive Alpha-defensin at Reimplantation of a Two-stage Revision Arthroplasty Is Not Associated with Infection at 1 Year

Background：Diagnosing periprosthetic joint infection (PJI) represents a challenge that relies on multiple clinical and laboratory criteria that may not be consistently present. The synovial alpha-defensin-1 (AD-1) test has been shown to correlate accurately with the Musculoskeletal Infection Society (MSIS) criteria for the diagnosis of PJI, however, its association with persistent PJI has not been elucidated in the setting of patients receiving antibiotic spacers during second-stage reimplantation. Applying a Delphi-based consensus to define successful eradication of PJI offers an opportunity to test the utility of AD-1 in this setting.

Questions/purposes：(1) Can the AD-1 test determine whether infection has been controlled using the Delphi criteria for persistent PJI as a surrogate for infection eradication during two-stage revision for PJI treatment with a spacer? (2) How does the performance of the AD-1 test compare with the MSIS criteria?

Methods：This was a multicenter analysis of retrospectively collected data on patients who underwent a twostage revision arthroplasty between May 2014 and July 2016. We included patients who had a previously con-firmed PJI and received a cement spacer, underwent the second stage, had MSIS criteria data and a synovial fluid AD-1 test, and had a minimum followup of 1 year. We were unable to determine for all study sites how many patients had the test but did not meet all the criteria and so could not be studied; however, we were able to identify 69 patients (43 knees, 26 hips) who met all criteria. During the period in question, indications for use of AD-1 varied by surgeon; however, during that time, in general if a surgeon ordered it as part of the initial workup, the test would have been repeated before the second-stage reimplantation procedure. To assess the validity of AD-1 against persistence of PJI criteria at 1 year, the following were calculated using the Delphi criteria for persistent PJI as the gold standard: sensitivity, specificity, positive and negative predictive values, accuracy, and area under the curve (AUC) with 95% confidence intervals (CIs). Concordance index (c-index) and its Wald 95% CI with receiver operating characteristic (ROC) curve were calculated in relation to Delphi criteria for persistent PJI using AD-1 and then MSIS criteria. The two c-indices of AD-1 and MSIS were compared using the DeLong nonparametric approach.

Results：The AD-1 test showed poor sensitivity (7%; 95% CI, 0.2–34), and poor overall accuracy (73%; 95% CI, 60–83; AUC = 0.5; 95% CI, 0.3–0.6) in detecting infection eradication at 1 year. The c-index for AD-1 versus Delphi criteria for persistent PJI was 0.519 (95% CI, 0.44–0.60), and the c-index for MSIS criteria versus Delphi criteria for persistent PJI was 0.518 (95% CI, 0.49–0.54), suggesting the weak diagnostic abilities of these models. The contrast estimate between MSIS criteria and AD-1 were not different from one another at -0.001 (95% CI%, -0.09 to 0.09; p = 0.99).

Conclusions：We found that a positive synovial fluid AD-1 test correlated poorly with the presence of persistent infection 1 year after two-stage revision arthroplasty for PJI. For this reason, we recommend against the routine use of AD-1 in patients with cement spacers, until or unless future studies demonstrate that the test is more effective than we found it to be.

文献出处：Samuel LT, Sultan AA, Kheir M, Villa J, Patel P, Parvizi J, Higuera CA. Positive Alpha-defensin at Reimplantation of a Two-stage Revision Arthroplasty Is Not Associated with Infection at 1 Year. Clin Orthop Relat Res. 2019 Jul;477(7):1615-1621. doi: 10.1097/CORR.0000000000000620. PMID: 30811358; PMCID: PMC6999964.

文献2

手术体位是否影响全髋关节置换术中神经血管损伤的风险？一项磁共振成像研究

译者 马云青

神经血管损伤是全髋关节置换术（THA）中一种严重的并发症。然而，不同体位下髋关节周围神经血管的位置差异尚未得到研究。作者利用磁共振成像（MRI）探讨了仰卧位和侧卧位髋关节置换时髋部神经血管位置的差异。研究假设为髋部神经血管的位置受手术体位差异的影响。这是一项单中心前瞻性研究，招募了2018年1月至2019年3月期间的15名健康志愿者。每位受试者的双侧髋关节均在仰卧位和侧卧位下使用3.0-T MRI进行扫描。在髋关节中心水平的T1加权轴位图像上，将髋臼前缘和后缘定义为手术中放置牵开器的常见参考点。作者测量了髋臼前缘与股神经（dFN）、股动脉（dFA）和股静脉（dFV）之间的距离，以及髋臼后缘与坐骨神经（dSN）之间的距离。主要结局指标是两种体位下的这些距离。

结果显示仰卧位和侧卧位下的dFN、dFA和dFV（毫米，均值±标准差）分别为：25.8 ± 5.6 和 32.4 ± 6.4（p < 0.0001）、25.7 ± 4.5 和 32.2 ± 5.0（p < 0.0001）、26.5 ± 4.8 和 32.3 ± 5.1（p < 0.0001）。与仰卧位相比，这些结构大部分在侧卧位时向前内侧方向移动。仰卧位和侧卧位之间的dSN没有显著差异（23.7 ± 4.9 和 24.5 ± 6.5，p = 0.46）。结果显示，与侧卧位相比，仰卧位进行THA可能伴随更高的股神经血管损风险。研究结果有助于降低THA术中股神经血管损伤的风险。

Does surgical body position influence the risk for neurovascular injury in total hip arthroplasty? A magnetic resonance imaging study

Background:Neurovascular injury is a critical complication in total hip arthroplasty (THA). However, neurovascular geographic variations around the hip joint in different body positions have not been examined. This study investigated the differences in hip neurovascular geography in the supine and lateral positions using magnetic resonance imaging (MRI).

Hypothesis:The neurovascular geography of the hip is influenced by differences in surgical body position.

Patients and methods:This was a single-center prospective study of 15 healthy volunteers enrolled between January 2018 and March 2019. Each subject's bilateral hips were scanned with a 3-T MRI scanner in both the supine and lateral positions. In T1-weighted axial images at the level of the hip center, the anterior and posterior acetabular edges were defined as reference points at which retractors are commonly placed during surgery. We measured the distance between the anterior acetabular edge and the femoral nerve (dFN), femoral artery (dFA), and femoral vein (dFV), as well as that between the posterior acetabular edge and the sciatic nerve (dSN). The primary outcome measures were the distances in both the supine and lateral positions.

Results:dFN, dFA, and dFV in the supine and lateral positions (mm, mean±standard deviation) were 25.8±5.6 and 32.4±6.4 (p<0.0001), 25.7±4.5 and 32.2±5.0 (p<0.0001), and 26.5±4.8 and 32.3±5.1 (p<0.0001), respectively. Most of these elements moved anteromedially in the lateral position compared to the supine position. There was no significant difference in dSN between the supine and lateral positions (23.7±4.9 and 24.5±6.5 (p=0.46).

Discussion:THA in the supine position may be accompanied by a higher risk of femoral neurovascular injury than that in the lateral position. The application of our findings could reduce the risk of femoral neurovascular injury during THA.

文献出处：Takada R, Jinno T, Miyatake K, Hirao M, Yoshii T, Kawabata S, Okawa A. Does surgical body position influence the risk for neurovascular injury in total hip arthroplasty? A magnetic resonance imaging study. Orthop Traumatol Surg Res. 2021 Dec;107(8):102817. doi: 10.1016/j.otsr.2021.102817. Epub 2021 Jan 20. PMID: 33484902.

文献3

全膝关节置换术中应用负载抗氧化剂的高交联聚乙烯垫片可以降低翻修风险

译者 张蔷

背景：尽管载有抗氧化剂的高交联聚乙烯（HXLPE）垫片在全膝关节置换（TKA）手术中的应用比例逐年增加，文献中却鲜有证据证实其优于普通HXLPE垫片的临床获益。本研究旨在比较应用负载和不负载抗氧化剂HXLPE垫片的TKA翻修风险。

方法：本队列研究选取了来自凯撒永恒医疗集团关节置换登记库的数据。病例选择了2001年至2023年间所有因骨关节炎而施行固定平台初次TKA手术并置换髌骨的病例。研究组为应用负载和未负载抗氧化剂HXLPE垫片的TKA病例。首要研究指标为全因翻修风险；次要研究指标为感染翻修风险以及磨损、松动等非感染翻修风险。我们应用多变量Cox风险比例回归分析法评估调整协变量后的翻修风险。

结果：最终入组92923例TKA病例：其中48846例应用了负载抗氧化剂的HXLPE垫片，另外44077例应用了未负载抗氧化剂的HXLPE垫片。平均年龄67.7岁，平均BMI为31.2kg/m2。女性（64.3%）、白种人（64.8%）和ASA分级为1-2（65.2%）占多数。经粗略计算，术后13年翻修风险：负载抗氧化剂组为3.4%而未负载抗氧化剂组为4.2%。在校正混杂因素后，我们发现负载抗氧化剂组的翻修风险显著低于未负载抗氧化剂组（概率比[HR], 0.86 [95%置信区间(CI), 0.79 - 0.95]）。当调查具体翻修原因时，我们发现负载抗氧化剂组的非感染翻修（HR, 0.86 [95%CI, 0.76 - 0.97]）和磨损翻修（HR, 0.41 [95%CI, 0.21 - 0.81]）的风险更低。

结论：我们发现应用了负载抗氧化剂HXLPE垫片的TKA病例术后的全因翻修风险和磨损翻修风险更低。

Antioxidant-Loaded Highly Cross-Linked Polyethylene May Reduce Revision Risk in Total Knee Arthroplasty

A U.S.-Based Cohort Study

Background: Although the use of highly cross-linked polyethylene (HXLPE) with antioxidants in total knee arthroplasty (TKA) has increased over time, evidence of any benefit in survivorship over HXLPE without antioxidants is lacking. We sought to compare the TKA revision risk for HXLPE with and without antioxidants.

Methods: Data from the Kaiser Permanente health-care system’s total joint replacement registry were used for a cohort study. Adult patients who underwent primary fixed-bearing TKA with patellar resurfacing for osteoarthritis from 2001 to 2023 were included. The study groups were cases of TKA performed with HXLPE with and without antioxidants. The primary outcome was all-cause revision; revisions for septic reasons, any aseptic reasons, wear, and loosening were secondary outcomes. Multivariable Cox proportional-hazards regression was used to evaluate the revision risk by treatment group with an adjustment for covariates.

Results: The final study sample included 92,923 TKA cases: 48,846 performed with HXLPE implants with antioxidants and 44,077 performed with HXLPE implants without antioxidants. The mean patient age was 67.7 years, and the mean patient body mass index was 31.2 kg/m2. Most patients were female (64.3%) and White (64.8%) and had an American Society of Anesthesiologists classification of 1 to 2 (65.2%). The 13-year crude revision incidence was 3.4% for the antioxidant group and 4.2% for the group without antioxidants. After we adjusted for confounders, we observed a lower revision risk for the antioxidant group compared with the group without antioxidants (hazard ratio [HR], 0.86 [95% confidence interval (CI), 0.79 to 0.95]). When we investigated revisions for specific reasons, we observed a lower risk for aseptic revision (HR, 0.86 [95% CI, 0.76 to 0.97]) and for wear (HR, 0.41 [95% CI, 0.21 to 0.81]) in the antioxidant group.

Conclusions: We observed a lower risk of all-cause revision and a lower risk of revision specifically for wear in TKA cases performed with HXLPE with antioxidants added.

文献出处：Prentice HA, Chan PH, Chang RN, Fasig BH, Kelly MP, Hinman AD, Kurtz SM, Paxton EW. Antioxidant-Loaded Highly Cross-Linked Polyethylene May Reduce Revision Risk in Total Knee Arthroplasty: A U.S.-Based Cohort Study. J Bone Joint Surg Am. 2026 Jan 21;108(2):142-149. doi: 10.2106/JBJS.25.00490. Epub 2025 Nov 26. PMID: 41296832.

文献4

调整机械力线：手术技巧——要点与窍门

译者 丁云鹏

引言：机械对线（MA）是一种旨在实现下肢力线中立位的标准化手术方案。使假体对线更接近患者解剖结构的方案可能获得更佳临床疗效。本文介绍的调整机械对线（aMA）手术技术是一种改良的"间隙优先"技术，该技术通过考量膝关节天然韧带张力，从而尽可能避免实施韧带松解。

适应证：aMA技术适用于内翻≤20°的原发性和继发性膝内翻骨关节炎。

手术技术：该术式通过股骨骨性矫正而非韧带松解来实现韧带张力平衡。术中标记经股骨上髁轴线（TEA）和滑车沟线以控制基于韧带张力的股骨旋转。通过清除骨赘确保韧带张力可靠。谨慎牵拉定量韧带张力器，读取间隙宽度及内外侧韧带张力数值。为矫正伸直间隙不对称性，采用特殊股骨截骨模块（而非典型的内侧软组织松解）进行代偿。随后评估屈曲间隙——此时股骨横向旋转需遵循软组织张力。张力器将调节出具有平衡韧带张力的矩形屈曲间隙。完成最终间隙平衡后，结束股骨准备步骤并安装试模。通过反复屈伸活动确定胫骨假体旋转定位。

讨论与结论：本技术将测量截骨技术与个体化韧带张力相结合。在冠状面上，股骨对线与中立位的最大偏差为2.5°。为避免并发症，建议如本技术所述通过调整股骨假体实现基于患者解剖的假体对线。测量截骨技术存在屈曲不稳风险，而间隙平衡技术可在精确胫骨近端截骨前提下实现对称韧带张力。股骨假体旋转对位时需综合考虑屈曲间隙稳定性与髌骨轨迹。需开展大样本长期研究来验证本术式良好的短期疗效。

Adjusted mechanical alignment: operative technique-Tips and tricks

Introduction: Mechanical alignment (MA) is a standardized procedure that aims to achieve a neutrally aligned leg axis. An alignment of the prosthesis closer to the patient's anatomy can be an approach for better clinical outcomes. The surgical technique of adjusted mechanical alignment (aMA) presented here is a modified extension-gap-first technique that takes into account the natural ligamentous tension of the knee joint so that ligamentous releases can be avoided as far as possible.

Indication: The aMA technique can be used for primary and secondary varus gonarthrosis of up to 20° of varus.

Surgical technique: The aim of the operation is to achieve a balanced ligament tension through a femoral osseous correction rather than ligament releases. TEA and the sulcus line are marked to control the ligament-based femoral rotation. The osteophytes are removed to ensure a reliable ligament tension. A quantitative ligament tensioner is stretched with great care, and gap width as well as medial and lateral ligament tension are read off. In order to correct an extension gap asymmetry, instead of the typical medial soft tissue release, the asymmetry is compensated by a special femoral cutting block. Now, the flexion gap is assessed, whereby the transverse femoral rotation follows the soft tissue tension. The tensioner adjusts a rectangular flexion gap with balanced ligament tension. After a final balancing of the gaps, the femoral preparation is completed and the trial components are inserted. Here, the rotation of the tibial component is set by repeated flexion-extension cycles.

Discussion and conclusion: The technique presented combines a measured-resection technique with individual ligament tension. The maximum deviation of the femoral alignment in the coronal plane from the neutral alignment is 2.5°. In order to avoid problems, it is recommended, as with the described technique, to achieve a component alignment based on the patient anatomy by adjusting the femoral component. The measured-resection technique carries the risk of flexion instability. With the gap-balancing technique symmetrical ligament tension can be achieved, assuming precise proximal tibial cuts. When aligning the femoral component rotation, flexion gap stability and patella tracking should be considered. Long-term studies of high case numbers are necessary to evaluate the good short-term results of the presented surgical technique.

文献出处：Hagen Hommel , Spiros Tsamassiotis , Roman Falk,Adjusted mechanical alignment: operative technique-Tips and tricks.Orthopade. 2020 Jul;49(7):562-569. doi: 10.1007/s00132-020-03929-1.

文献5

机器人辅助全膝关节置换术中的骨赘骨性平衡：一种手术技术及软组织松弛度的预测算法

译者 沈松坡

引言：在全膝关节置换术（TKA）过程中切除骨赘会导致软组织张力降低，从而可能引起关节松弛。因此，在进行间隙平衡时，术者往往希望在尚未进行任何骨切除、也未切除骨赘之前，预测骨赘切除对屈曲间隙和伸直间隙的影响。然而，后方骨赘相对难以接近，因为只有在完成股骨后方骨切除之后才能将其切除。由后方骨赘切除所产生的松弛无法通过调整骨切除来纠正，因为骨切除此时已经完成。作者开发了一种用于机器人辅助全膝关节置换术的预测算法，该算法可预判骨赘切除的影响，从而在任何骨切除之前即对骨性切除方案进行调整。

材料与方法：在术前CT扫描的矢状位平面上测量股骨后方骨赘的横截面积。作者的骨赘校正方法是基于后方骨赘的大小和形态，对胫骨切除进行调整，因为作者认为骨赘切除所产生的松弛会同时影响伸直和屈曲间隙。随后，根据骨赘的大小及其位置（后内侧或后外侧）来确定骨切除的具体量及部位。

结果：通过上述技术，作者发现骨赘切除所产生的松弛程度与软组织所跨越骨赘的尺寸呈直接相关。

结论：通过基于CT扫描成像确定的、初始状态下不可直接接近的后方骨赘的大小和形态，作者建立了一种预测性的骨性平衡算法，该算法可与术者偏好的骨性平衡技术相结合。该预测算法能够在骨赘切除之前预判其所引起的松弛，并可用于调整骨切除参数和/或假体参数（例如胫骨垫片的厚度），以适应增加的松弛度，从而实现骨量保留及畸形矫正。

Osteophyte Bony Balancing in Robotic Total Knee Arthroplasty:

A Surgical Technique and Predictive Algorithm for Soft Tissue Laxity

Introduction: The removal of osteophytes during total knee arthroplasty (TKA) results in reduced soft tissue tension, which may result in joint laxity. Thus, for gap balancing, a surgeon may try to predict the effect of osteophyte removal on the resulting flexion and extension gap before any bone cuts are made and before those osteophytes are removed. Posterior osteophytes, however, are relatively inaccessible, since their removal can be done only after posterior bone cuts are made on the femur. Any laxity created by posterior osteophyte removal cannot be corrected by adjusting bone cuts because they have already been made. The authors have developed a predictive algorithm for use in robotic TKA which anticipates the effect of osteophyte removal, allowing adjustment in bony resection before any bone cuts are made.

Materials and Methods: The cross-sectional area of the posterior femoral osteophytes is measured on the sagittal plane of the preoperative CAT scan. The authors method of osteophyte correction is to make changes to the tibial cut based on the size and shape of the posterior osteophytes, as they believe the laxity created by osteophyte removal affect both extension and flexion. The amount and specific location of bony resection is then determined based on the size and location (posteromedial vs posterolateral) of the osteophytes.

Results: Through the described technique, the authors have found that the amount of laxity created by osteophyte removal correlates directly to the dimension of the osteophyte over which the soft tissue extends.

Conclusion: The size and shape of initially inaccessible posterior osteophytes, determined using CAT scan-based imaging, was used to create a predictive bony balancing algorithm, designed to be incorporated with the surgeon’s preferred bony balancing technique. Our predictive algorithm anticipates the laxity created by osteophyte removal prior to their removal and can be used to alter bone resection parameters and/or implant parameters (e.g., thickness of a tibial liner) to accommodate the increased laxity, allowing for the conservation of bone and correction of deformity.

第二部分：保髋相关文献

文献1

Perthes病患者大转子阻滞术术后的影像学结果

译者 任宁涛

目的:Legg-Calvé-Perthes病常导致大转子高位，对髋关节的生物力学产生负面影响。本研究的目的是评估大转子的生长性和大转子阻滞术的放射学效果。

方法:回顾性分析46名单侧Legg-Calvé-Perthes患儿的临床资料，其中男33例，平均年龄(8±1.3)岁，行股骨大转子骨骺固定及局部骨骺融合术。通过术前和术后的骨盆x线片(平均随访3.5年)，确定大转子高度、关节大转子距离和关节中心大转子距离，并与未受影响侧进行比较。建立大转子高度、关节大转子距离和关节中心大转子距离随时间的生理发育参考值。

结果:以大转子高度衡量，大转子阻滞术使大转子生长降低29%，但仅在<8岁组有统计学意义(p = 0.02)。回归分析显示，大转子生长抑制率为0.92 mm/年。在随访期间，患侧和健侧关节大转子距离和关节中心大转子距离趋同:患侧髋关节大转子距离增加(术前:11.2±7 mm，发育成熟:18.5±10 mm;P < 0.01)，而健侧无变化(术前:19.3±5 mm，发育成熟:18±6 mm;P = 0.69)。患侧髋中心转子距离保持不变(术前:(-7.9)±7 mm，发育成熟(-7.8)±9 mm;P = 0.13)。在健侧，关节中心大转子距离变为负值(术前:0.9±6mm，发育成熟:(-6.5)±5mm;P < 0.001)。以关节大转子距离和中心大转子距离测量，31.8%的患者获得最佳结果。

结论:大转子阻滞术对抑制大转子的生长有积极的影响，从而对髋关节的解剖有积极的影响。进一步的研究必须证明这些积极的影响是否也会导致生物力学和功能上的好处。

图1 大转子高度（TH）：大转子尖和大转子最底部两个平行线之间的距离，两个平行线垂直于股骨干轴线。关节大转子距离（ATD）：大转子尖和股骨头最顶部两个平行线之间的距离，两个平行线垂直于股骨干轴线。关节中心大转子距离(CTD)：大转子尖和股骨头中心两个之间的距离，垂直于股骨干轴线。

图2 男，11岁，因LCPD行Salter截骨治疗，后行大转子阻滞术。

Radiographic outcome after greater trochanteric epiphysiodesis in patients with Perthes disease

Purpose: Legg-Calvé-Perthes disease often leads to greater trochanteric overgrowth, which negatively affects the biomechanics of the hip joint. This study aimed to evaluate the physiologic growth of the greater trochanter and the effectiveness of greater trochanteric epiphysiodesis radiographically.

Methods: Retrospectively, 46 children (33 male, average age at greater trochanteric epiphysiodesis 8 ± 1.3 years) with unilateral Legg-Calvé-Perthes disease undergoing greater trochanteric epiphysiodesis with screws and curettage of the epiphysis were included. On radiographs of the pelvis pre- and postoperatively (mean follow-up 3.5 years), trochanteric height, articulotrochanteric distance, and center-trochanter distance were determined and compared to the unaffected side. Reference values for the physiological development of trochanteric height, articulotrochanteric distance, and center-trochanter distance over time were established.

Results: Greater trochanteric epiphysiodesis reduced trochanteric growth by 29% measured by trochanteric height, but only statistically significant in the group "<8 years" (p = 0.02). Regression analysis revealed inhibition of trochanteric growth of 0.92 mm/year. Both articulotrochanteric distance and center-trochanter distance of the affected and unaffected side converged during the follow-up period: articulotrochanteric distance of the affected hip increased (preop: 11.2 ± 7 mm, maturity: 18.5 ± 10 mm; p < 0.01) compared to no change on the unaffected side (preop: 19.3 ± 5 mm, maturity: 18 ± 6 mm; p = 0.69). Center-trochanter distance of the affected hip stayed unchanged (preop: (-7.9) ± 7 mm, maturity: (-7.8) ± 9 mm; p = 0.13). On the unaffected side, center-trochanter distance became negative (preop: 0.9 ± 6 mm, maturity: (-6.5) ± 5 mm; p < 0.001). Measured by articulotrochanteric distance and center-trochanter distance, 31.8% achieved an optimal result.

Conclusion: Greater trochanteric epiphysiodesis has a positive effect on greater trochanter growth and therefore on hip anatomy. Further studies must show whether these positive effects also result in biomechanical and functional benefits.

文献出处：Osterholt AC, Bittersohl B, Westhoff B. Radiographic outcome after greater trochanteric epiphysiodesis in patients with Perthes disease. J Child Orthop. 2024 Feb 4;18(2):153-161. doi: 10.1177/18632521241228700. PMID: 38567042; PMCID: PMC10984151.

文献2

计算机辅助髋臼周围截骨术治疗髋关节发育不良患者

译者 李勇

摘要：髋臼旋转截骨术（RAO）是治疗髋臼发育不良患者的一种成熟手术方式，已有报道显示其具有优异的长期疗效。然而，RAO 技术要求高，该手术的精准实施需要丰富的手术经验。计算机导航在 RAO 中的作用包括：能够进行三维（3D）术前规划；即使在视野不佳的情况下也能安全实施截骨；减少术中透视带来的辐射暴露；以及实时显示骨凿尖端位置。最后一点在教学上也很有用，因为它能让术者以外的工作人员也能跟进手术进程。在我们的研究结果中，比较了 23 例接受导航辅助 RAO 的髋关节与 23 例未接受导航辅助手术的髋关节，并未观察到放射学评估方面有显著差异。然而，导航组未发生围手术期并发症，而非导航组观察到一例暂时性股神经麻痹。利用 3D 术前规划和基于 CT 的导航系统提供的术中辅助，可以实施更精确、更安全的 RAO 手术。

图1.应用计算机软件进行髋臼旋转截骨术前规划。(A)术前规划截骨线时，规划髋臼球形截骨，使球体的中心靠近股骨头中心（或髋关节中心）。(B)计划向外侧旋转，直至臼顶倾斜角度变为0°，纠正前向覆盖。

Computer-Assisted Rotational Acetabular Osteotomy for Patients with Acetabular Dysplasia

Abstract:Rotational acetabular osteotomy (RAO) is a well-established surgical procedure for patients with acetabular dysplasia, and excellent long-term results have been reported. However, RAO is technically demanding and precise execution of this procedure requires experience with this surgery. The usefulness of computer navigation in RAO includes its ability to perform three-dimensional (3D) preoperative planning, enable safe osteotomy even with a poor visual field, reduce exposure to radiation from intraoperative fluoroscopy, and display the tip position of the chisel in real time, which is educationally useful as it allows staff other than the operator to follow the progress of the surgery. In our results comparing 23 hips that underwent RAO with navigation and 23 hips operated on without navigation, no significant difference in radiological assessment was observed. However, no perioperative complications were observed in the navigation group whereas one case of transient femoral nerve palsy was observed in non-navigation group. A more accurate and safer RAO can be performed using 3D preoperative planning and intraoperative assistance with a computed tomography-based navigation system.

文献出处：Inaba Y, Kobayashi N, Ike H, Kubota S, Saito T. Computer-Assisted Rotational Acetabular Osteotomy for Patients with Acetabular Dysplasia. Clin Orthop Surg. 2016 Mar;8(1):99-105. doi: 10.4055/cios.2016.8.1.99. Epub 2016 Feb 13. PMID: 26929806; PMCID: PMC4761609.

文献3

手术年龄与髋臼周围截骨术后早期患者自述结局无相关性

译者 陶可

背景：髋臼周围截骨术(PAO)治疗症状性髋关节发育不良的临床疗效已得到充分证实。然而，关于年龄与临床结局的相关性，目前尚无定论。髋关节功能障碍和骨关节炎结局评分 - 全球版 (HOOSglobal)是近期验证的PAO术后患者自述结局指标。本研究旨在评估PAO术后早期随访时HOOSglobal评分和西安大略大学和麦克马斯特大学骨关节炎指数(WOMAC)评分与手术年龄的关系。

方法：本研究纳入391例接受PAO手术且随访时间至少2年（平均4.71年）的患者，这是一项前瞻性多中心队列研究。患者按年龄分为4个组：<20岁（N = 131）、20-29岁（N = 102）、30-39岁（N = 65）和≥40岁（N = 34）。采用4×2重复测量方差分析（年龄组×时间）比较各年龄组术前和术后的HOOSglobal评分和WOMAC评分。采用多元线性回归分析确定术后HOOSglobal评分的预测因子。

结果：所有年龄组的HOOSglobal评分和WOMAC评分均有所升高；然而，与<20岁（P< .002）、20-29岁（P = .01）和30-39岁（P = .02）组相比，≥40岁组的术前至术后HOOSglobal评分和WOMAC评分的升高幅度具有统计学意义。术前HOOSglobal评分越高，术后HOOSglobal评分也越高（P < .001），但年龄（P = .65）、性别（P = .80）、体重指数（P = .50）和Tönnis分级（P = .07）并非1年预后的独立预测因子。

结论：不同年龄段患者术后早期自述结局无差异，表明在有症状的髋关节发育不良的情况下，PAO手术的成功与患者年龄无关。因此，在评估PAO手术候选者时，仅以年龄作为选择标准可能并不合适。

Age at the Time of Surgery Is Not Predictive of Early Patient-Reported Outcomes After Periacetabular Osteotomy

Background: The clinical success of periacetabular osteotomy (PAO) for the treatment of symptomatic acetabular dysplasia is well-documented. Conflicting evidence exists regarding the correlation of age with clinical outcomes. Hip disability and Osteoarthritis Outcome Score - global (HOOSglobal) is a recently validated patient-reported outcome measure following PAO. The purpose of this study is to asses HOOSglobal and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at early follow-up based on age at the time of PAO.

Methods: A prospective multicenter cohort of 391 patients undergoing PAO with minimum 2-year follow-up (average 4.71 years) were identified. Patients were categorized into 4 age groups: <20 years (N = 131), 20-29 (N = 102), 30-39 (N = 65), and ≥40 (N = 34). A 4 × 2 repeated measures analysis of variance (Age Group × Time) was used to compare preoperative and postoperative HOOSglobal and WOMAC scores between age groups. A multiple linear regression was used to identify predictors of postoperative HOOSglobal scores.

Results: HOOSglobal and WOMAC scores increased across all age groups; however, a statistically greater increase in preoperative to postoperative HOOSglobal and WOMAC scores was found in those ≥40 years compared to those <20 (P< .002), 20-29 (P = .01), and 30-39 years (P = .02). Higher preoperative HOOSglobal scores were predictive of greater postoperative HOOSglobal scores (P < .001) but age (P = .65), gender (P = .80), body mass index (P = .50), and Tönnis Classification (P = .07) were not independent predictors of 1-year outcomes.

Conclusion: The absence of differences in early postoperative patient-reported outcomes across multiple age ranges emphasizes that PAO in the setting of symptomatic acetabular dysplasia can be successful regardless of patient age alone. Therefore, age alone might not be an appropriate selection criterion when evaluating surgical candidates for PAO.

文献出处：Brian T Muffly, Anthony J Zacharias, Kate N Jochimsen, Stephen T Duncan, Cale A Jacobs; ANCHOR Study Group; John C Clohisy. Age at the Time of Surgery Is Not Predictive of Early Patient-Reported Outcomes After Periacetabular Osteotomy. Multicenter Study, J Arthroplasty. 2021 Oct;36(10):3388-3391. doi: 10.1016/j.arth.2021.05.029. Epub 2021 May 25.

文献4

软骨下骨折始于股骨头坏死中的骨吸收区域：一项显微CT断层扫描研究

译者 邱兴

目的： 为成功实施股骨头坏死（ONFH）的保髋治疗，理解其塌陷机制至关重要。本研究旨在通过对完整股骨头进行显微CT成像，探讨ONFH中软骨下骨折的起始点，着重分析软骨下骨折与骨吸收区域之间的三维关系。
方法： 根据日本骨坏死研究会标准，我们选取了37名患者（共40个股骨头）在因3A或3B期ONFH行人工全髋关节置换术时获得的样本，使用层厚为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与晚期塌陷期。
结果： 通过对完整股骨头多个径向平面图像的分析，我们得到了两项重要发现。首先，在所有18个早期塌陷期的股骨头中，初始骨折裂隙均走行于股骨头前上部分离的骨吸收区域之间。其次，在22个晚期塌陷期样本中的19个里，观察到坏死骨在硬化边界处发生断裂，并在硬化边界的坏死骨侧可见纤维性、肉芽样低密度组织。继发于支持带及圆韧带附着处周围的骨吸收引发软骨下骨折后，骨吸收区域在股骨头前上部的扩大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，修复区周围的骨吸收是引发ONFH软骨下骨折的起始点。
关键词： 骨吸收；塌陷；显微CT；股骨头坏死；软骨下骨折。

图1 获取经过股骨头中心点、股骨颈中心点（较大标记点）及股骨距中心点（较小标记点）的冠状面。在该冠状面上，建立一条包含股骨头中心点与股骨头凹中心点（X标记点）的内外侧轴。以此内外侧轴为基准，通过旋转该冠状面，重建出多个径向平面视图。

图2 针对股骨头坏死的骨吸收区域与软骨下骨折进行的全股骨头三维显微CT分析。

图3 a 早期塌陷阶段各径向平面上初始软骨下骨折与骨吸收的发生率。实线代表各径向平面的软骨下骨折发生率；大虚线代表股骨头外侧三分之一的骨吸收发生率；小虚线代表中间三分之一的发生率；虚线代表内侧三分之一的发生率。b 早期塌陷阶段各径向平面上初始软骨下骨折及与骨折相连的骨吸收的发生率。实线代表各径向平面的软骨下骨折发生率；大虚线代表股骨头外侧三分之一区域内与软骨下骨折相连的骨吸收的发生率；小虚线代表中间三分之一的相应发生率，虚线代表内侧三分之一的相应发生率。

图4 a 在早期塌陷阶段，所有股骨头的软骨下骨折裂隙均走行于两个不同的骨吸收区域之间。b 在一些股骨头中，外侧三分之一的骨吸收区域延伸至骨皮质外。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 在晚期塌陷阶段，当硬化边界呈垂直走向时，骨折裂隙从一骨吸收区域开始，在邻近硬化边界的坏死骨内延伸。

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：Hamada, H. , Takao, M. , Sakai, T. , & Sugano, N. . (2018). Subchondral fracture begins from the bone resorption area in osteonecrosis of the femoral head: a micro-computerised tomography study. International Orthopaedics.

来源：304关节学术

作者：304关节团队

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