髋膝关节文献精译荟萃（第381期)

本期目录：

1、全膝关节置换术中髌骨轨迹的机器人评估

2、既往髋臼周围截骨术对发育性髋关节发育不良患者全髋关节置换术疗效的影响

3、膝关节置换术前低认知功能和躯体心理症状与术后谵妄高风险相关

4、机器人辅助全膝关节置换术（TKA）与患者满意度增加无关

5、儿童和青少年股骨颈骨折后股骨头坏死:危险因素分析

6、青少年群体髋臼周围截骨术后坐骨-耻骨结合部骨折

7、股神经和坐骨神经在髋臼周围不同位置的CT研究

8、基于德尔菲法的股骨头坏死塌陷预后模型

第一部分：关节置换及保膝相关文献

文献1

全膝关节置换术中髌骨轨迹的机器人评估

译者 张轶超

目的：机器人作为一种工具已被开发用于改进全膝关节置换术（TKA）的计划、准确性和效果。本研究的目的是描述和阐明一种使用无图像机器人平台评估TKA中髌骨股骨关节（PFJ）的新技术。

方法：由一名外科医生采用上述技术连续做了30例R-TKA。开发了一种在术中，在植入假体前和植入假体后动态评估PFJ的技术。然后收集了9个病例的全套数据并进行了回顾性分析。本文介绍了术中在植入假体前、后收集的一系列动态PFJ轨迹。此外，通过对90度活动范围内的PFJ过度填充和填充不足进行了全面评估。最后，确定并测量了PFJ安装假体前后的旋转中心。

结果：所描述的技术是根据使用上述的机器人平台完成的一系列30 R-TKA而定义的。对9个案例进行了分析，以确定使用机器人平台可以测量哪些数据。通过术中实时数据可以对假体植入前后膝关节0 - 90屈曲运动范围内的PFJ轨迹进行视觉评估。在术中还对0 -90 度屈曲活动范围内PFJ的过度填充和不足进行了评估。术后可以进行更详细的研究，包括确定植入假体前后髌骨旋转中心（COR）。确定了髌骨平面的定义。此外，测量了膝关节完全伸展到极度屈曲过程中髌骨内外侧移位的情况。

结论：TKA术中对PFJ的评估是很困难的。机器人工具已经开发出来，以提高TKA手术中的测量方法和准确性。这些工具可以以新的方式来评估PFJ，这可能会导致TKA技术的进一步改进。

Robotic assessment of patella tracking in total knee arthroplasty

Objectives: Robotic tools have been developed to improve planning, accuracy and outcomes in total knee arthroplasty (TKA). The purpose of this study was to describe and illustrate a novel technique for assessing the patellofemoral (PFJ) in TKA using an imageless robotic platform.

Methods: A consecutive series of 30 R-TKA was undertaken by a single surgeon utilising the described technique. A technique to dynamically assess the PFJ intra-operatively, pre- and post-implantation was developed. A full set of data from 9 cases was then collected and reviewed for analysis. A series of dynamic PFJ tracks collected intra-operatively pre- and post-implantation are presented. Furthermore, a full assessment of PFJ over and under-stuffing through a 90arc of flexion is illustrated. Finally, a pre- and post-centre of rotation for the PFJ was defined and measured.

Results: The described technique was defined over a series of 30 R-TKA using the described robotic platform. Nine cases were analysed to determine what data could be measured using the robotic platform. Intra-operative real time data allowed a visual assessment of PFJ tracking through a range of motion of 0 –90 flexion pre- and postimplantation. PFJ over and under-stuffing was also assessed intra-operatively through a range of motion of 0 –90flexion. Post-operative analysis allowed a more detailed study to be performed, including defining a pre- and postimplantation centre of rotation (COR) for the patella. Defining the COR allowed the definition of a patella plane. Furthermore, patella mediolateral shift in full extension, and end flexion could be measured.

Conclusion: Intra-operative assessment of the PFJ in TKA is challenging. Robotic tools have been developed to improve measurement, accuracy of delivery and outcomes in TKA. These tools can be adapted in novel ways to assess the PFJ, which may lead to further refinements in TKA techniques.

文献出处：Shatrov J, Khasian M, Lording T, Monk AP, Parker D, Lustig S. Robotic assessment of patella tracking in total knee arthroplasty. J ISAKOS. 2024 Oct;9(5):100287. doi: 10.1016/j.jisako.2024.06.006. Epub 2024 Jun 21. PMID: 38909904.

文献2

既往髋臼周围截骨术对发育性髋关节发育不良患者全髋关节置换术疗效的影响

译者 马云青

研究背景：本研究旨在阐述临床医师在为因髋关节发育不良继发骨关节炎的患者行全髋关节置换术（THA）时可能面临的治疗难点。本研究对比了伴有/不伴有既往髋臼周围截骨术（PAO）史、因发育性髋关节发育不良（DDH）继发骨关节炎而行全髋关节置换术的患者的临床结果。

研究方法：患者分为两组。A组为青少年期曾行髋臼周围截骨术、后续在本骨科中心接受全髋关节置换术的患者（共29髋）；B组为患有发育性髋关节发育不良、仅行全髋关节置换术而无既往髋臼周围截骨术史的青少年患者（共24髋）。观测指标包括：术中失血量、髋臼假体尺寸、假体位置、髋臼覆盖情况、髋臼杯倾斜角与前倾角、手术时长、临床评分、住院时长及异位骨化发生情况。

研究结果：改良哈里斯髋关节评分（mHHS）存在显著统计学差异（A组：89分 vs B组：91分；P=0.03）。以术前与术后第3天血红蛋白浓度差值评估失血量，A组差值较B组高0.85 mg/dL（A组：4.4 mg/dL vs B组：3.55 mg/dL；P=0.004）；同时A组术后第3天红细胞压积显著更低（A组：27% vs B组：29.5%；P=0.02）。影像学测量显示两组Brooker分级差异具有统计学意义（P=0.005）。A组13例患者全髋关节置换术后出现Ⅰ级及以上异位骨化，B组仅2例患者出现Ⅰ～Ⅱ级异位骨化。此外，既往行PAO的患者术后旋转中心下移距离显著更大（79 mm，73–83 mm vs 74.5 mm，69–77 mm；P=0.004）。

研究结论：与无既往截骨术史的患者相比，既往行髋臼周围截骨术的患者在接受全髋关节置换术后，改良哈里斯髋关节评分更低，围手术期失血量更多，异位骨化发生风险及旋转中心下移程度均更高。

文献出处：Moses MJ, Novikov D, Luthringer T, Poultsides L, Vigdorchik JM. Clinical Outcomes of Total Hip Arthroplasty in Patients with Prior Periacetabular Osteotomy. Bull Hosp Jt Dis (2013). 2022 Dec;80(4):216-220. PMID: 36403948.

文献3

全膝关节置换术前低认知功能和躯体心理症状与术后谵妄高风险相关

译者 张蔷

背景：谵妄（POD）是接受全膝关节置换（TKA）的高龄患者术后一项严重的并发症，它可能导致住院时间延长，病死率增加和医疗开销增加等问题。尽管认知障碍是一项已知的导致术后谵妄的危险因素，TKA患者术前的综合认知和心理评估依然被显著低估。本研究的目标是评估TKA患者术前认知功能和心理状态评估与术后谵妄的关系。

方法：本前瞻性队列研究选择了1-2家地区性医疗中心所有60岁及以上接受初次TKA手术的574名患者。我们选择评估术前认知功能的工具包括简易精神状态检查（MMSE）、建立阿尔茨海默病登记联盟（CERAD）、主观记忆抱怨问卷（SMCQ）和首尔痴呆知情人报告问卷（SIRQD）。用于心理评估的工具包括匹兹堡睡眠质量指数（PSQI）、患者健康问卷-15项 （PHQ-15）和医院焦虑抑郁量表（HADS）。我们在术后1-5天应用4A试验（4AT）和混淆评估法（CAM）评价患者的POD情况。最后，我们应用多因素逻辑回归分析法来确认术后谵妄的独立危险因素。

结果：共有24例（4.2%）病例出现了术后谵妄。多元分析显示术后谵妄与低MMSE评分（p < 0.001）、高PHQ-15评分（p = 0.014）、高PSQI评分（p = 0.014）、高Charlson合并症指数（p = 0.010）、术前应用镇静剂（p = 0.044）和抗抑郁药（p = 0.027）以及患者所在病房的平均噪音水平（p = 0.002）呈强相关性。在受试者工作特征曲线分析中，我们得出预测术后谵妄的MMSE最佳阈值为≤25分，敏感度为74.5%而特异度为78.3%（曲线下面积，0.834；p = 0.001）。多因素逻辑回归分析显示低MMSE评分（概率比[OR], 0.771; p = 0.002）和高PHQ-15评分（OR, 1.187; p = 0.028）是术后谵妄的独立预测指标。

结论：本研究全面的评估了TKA手术患者术前认知功能和心理状态。我们发现亚临床认知障碍和躯体症状也与术后谵妄相关，突显出对高风险患者施行术前评估鉴别的重要性。

Low Cognitive Function and Somatic Psychological Symptoms Are Correlated with Greater Risk of Delirium After Total Knee Arthroplasty

Background: Postoperative delirium (POD) is a clinically important complication in elderly patients undergoing total knee arthroplasty (TKA) that is associated with prolonged hospitalization, increased morbidity, and higher health-care costs. Although cognitive impairment is a known risk factor for POD, the role of comprehensive cognitive and psychological evaluation remains underexplored in patients undergoing TKA. This study aimed to evaluate the correlation of preoperative cognitive and psychological factors with POD after TKA.

Methods: This prospective cohort study included 574 patients who were ≥60 years of age and underwent primary TKA at 1 of 2 major tertiary care hospitals. We assessed preoperative cognitive function using the Mini-Mental State Examination (MMSE), the full Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) battery, the Subjective Memory Complaints Questionnaire (SMCQ), and the Seoul Informant Report Questionnaire for Dementia (SIRQD). Psychological assessments were conducted with the Pittsburgh Sleep Quality Index (PSQI), the Patient Health Questionnaire-15 (PHQ-15), and the Hospital Anxiety and Depression Scale (HADS). POD was evaluated daily from postoperative days 1 to 5 using the 4 A’s Test (4AT) and the Confusion Assessment Method (CAM). A multivariable logistic regression analysis was performed to identify independent risk factors for POD.

Results: POD occurred in 24 (4.2%) of 574 patients. Univariate analysis revealed that POD was significantly correlated with lower MMSE (p < 0.001), higher PHQ-15 (p = 0.014), higher PSQI (p = 0.014), and higher Charlson Comorbidity Index (p = 0.010) scores; preoperative use of sedatives (p = 0.044) and antidepressants (p = 0.027); and lower mean noise levels in the patient’s hospital room (p = 0.002). In the receiver operating characteristic curve analysis, the optimal cutoff value for predicting POD was an MMSE score of ≤25, with a sensitivity of 74.5% and a specificity of 78.3% (area under the curve, 0.834; p = 0.001). Multivariable logistic regression analysis identified lower MMSE scores (odds ratio [OR], 0.771; p = 0.002) and higher PHQ-15 scores (OR, 1.187; p = 0.028) as significant independent predictors of POD.

Conclusions: This study comprehensively evaluated preoperative cognitive function and psychological symptoms in patients undergoing TKA. Even subclinical cognitive and somatic symptoms were linked to POD, emphasizing the need for preoperative identification of high-risk patients.

文献4

机器人辅助全膝关节置换术（TKA）与患者满意度增加无关

译者 沈松坡

目的 全膝关节置换术（TKA）是一种常见的骨科手术，但术后约20%的病例仍存在不满意。机器人全膝关节置换术（rTKA）有望提高精准性，但与传统全膝关节置换术（cTKA）相比，其对患者满意度的影响仍存在争议。本系统评价旨在评估rTKA术后患者满意度，并比较其与cTKA的结局。

方法 检索并审阅以下数据库中的文献：PubMed、Scopus、Web of Science和Cochrane Online Library，使用的关键词包括“Knee replacement”“Total knee arthroplasty”“Robotic”和“Patient satisfaction”。提取的数据包括患者满意度测量、Knee Society Score、Oxford Knee Score、Forgotten Joint Score、SF-36、HSS和KOOS。采用R软件进行统计分析，包括比值比及95%置信区间。采用Cochrane的Q检验评估异质性。

结果 本系统评价纳入17篇文章，共涉及1148例患者（rTKA组571例，cTKA组577例），评估了rTKA后的患者满意度。比例分析显示，rTKA满意率为95%，而cTKA为91%。比较rTKA与cTKA的Meta分析发现，患者满意度方面无统计学显著差异。此外，还评估了多种患者报告结局指标（PROMs），结果显示在不同研究及不同随访时间点上结论不一。

结论 本研究结果发现，在短期至中期随访中，rTKA与传统方法相比，在患者满意度结局方面无差异。本研究并未断言机器人辅助手术方式具有优越性，这提示在膝关节置换术中，应审慎考虑影响结局的多种因素。

文献出处：Hoveidaei AH, Esmaeili S, Ghaseminejad-Raeini A, Pirahesh K, Fallahi MS, Sandiford NA, Citak M. Robotic assisted Total Knee Arthroplasty (TKA) is not associated with increased patient satisfaction: a systematic review and meta-analysis. Int Orthop. 2024 Jul;48(7):1771-1784. doi: 10.1007/s00264-024-06206-4. Epub 2024 May 6. PMID: 38705892.

第二部分：保髋相关文献

文献1

儿童和青少年股骨颈骨折后股骨头坏死:危险因素分析

译者 任宁涛

背景:儿童和青少年股骨颈骨折最严重的并发症是股骨头坏死。虽然许多因素都涉及到股骨头坏死的发生和发展，但没有确定具体的因果关系。本研究的主要目的是确定儿童和青少年股骨颈骨折后股骨头坏死的发生率，并确定其发生的危险因素。

方法:本回顾性研究确定了2000年至2011年在一个一级儿童创伤中心治疗的70例年龄在1.3 - 18.1岁的股骨颈骨折患者，随访至临床和影像学愈合。通过病历和影像学检查记录人口统计学信息、受伤细节、手术治疗类型、合并损伤、受伤至治疗时间和术后复位。主要统计结局是存在股骨头坏死的，股骨头坏死是通过复查现有影像学确定。多变量logistic回归分析检验了年龄、治疗时间、固定类型、损伤机制、术后复位和关节囊减压是否是发生股骨头坏死的可能危险因素。

结果:70例患者中有20例(29%)发生股骨头坏死，诊断股骨头坏死的中位时间为7.8个月。股骨头坏死的多因素预测因素包括骨折移位(P=0.01)和骨折位置(P=0.02)。患者年龄、固定类型、损伤机制、关节囊减压、术后复位和复位效果不能预测股骨颈骨折后股骨头坏死的发生情况。最后，治疗时间也被发现是股骨头坏死的积极预测因素(P=0.004)，伤后24小时内治疗的患者更有可能发生股骨头坏死，但这一发现可能是由于混淆，因为损伤的严重程度与治疗时间密切相关。

结论:无论采用何种治疗方法，股骨颈骨折后股骨头坏死的发生率仍然很高。识别预测股骨头坏死发展的因素可以帮助外科医生就这种并发症的风险向患者和家属提供适当的咨询。

Osteonecrosis After Femoral Neck Fractures in Children and Adolescents Analysis of Risk Factors

Background: The most serious complication of femoral neck fractures in children and adolescents is osteonecrosis. Although a number of factors have been implicated in the development of osteonecrosis, no specific cause-and-effect relationship has been determined. The primary purpose of this study was to determine the prevalence of osteonecrosis in children and adolescents after femoral neck fractures and to identify risk factors for its development.

Methods: This retrospective review identified 70 patients between the ages of 1.3 and 18.1 years who were treated for a femoral neck fracture between 2000 and 2011 at a single level I pediatric trauma center and followed until clinical and radiographic union. Demographic information, injury event details, type of surgical treatment, associated injuries, time from injury to treatment, and postoperative alignment were recorded from chart and radiographic review. The primary outcome was the presence of osteonecrosis, which was determined by review of available imaging. Multivariable logistic regression analysis tested age, time to treatment, type of fixation, mechanism of injury, postoperative alignment, and capsular decompression as possible risk factors for the development of osteonecrosis.

Results: Osteonecrosis occurred in 20 (29%) of the 70 patients. The median time to diagnosis of osteonecrosis was 7.8 months. Multivariable predictors of osteonecrosis included fracture displacement (P=0.01) and fracture location (P=0.02). Patient age, type of fixation, mechanism of injury, capsular decompression, postoperative alignment, and performance of reduction were not predictive of osteonecrosis after femoral neck fracture. Finally, time to treatment also was found to be a positive predictor of osteonecrosis (P=0.004), with osteonecrosis more likely in patients treated in less than 24 hours, but this finding is likely due to confounding because injury severity was closely linked to time to treatment.

Conclusions: Regardless of the treatment, the prevalence of osteonecrosis after femoral neck fractures remains high. Recognizing factors that are predictive of the development of osteonecrosis can help surgeons counsel patients and families appropriately about the risk of this complication.

文献出处：Spence D, DiMauro JP, Miller PE, Glotzbecker MP, Hedequist DJ, Shore BJ. Osteonecrosis After Femoral Neck Fractures in Children and Adolescents: Analysis of Risk Factors. J Pediatr Orthop. 2016 Mar;36(2):111-6. doi: 10.1097/BPO.0000000000000424. PMID: 25730381.

文献2

青少年群体髋臼周围截骨术后坐骨-耻骨结合部骨折

译者 李勇

引言： Ganz 髋臼周围截骨术（PAO）是一种广泛接受的髋关节发育不良手术干预方式。在青少年人群中，该手术适用于骨骼已成熟且伴有髋臼发育不良相关症状的患者。PAO 术后半骨盆应力重新分布可能导致坐骨-耻骨结合部（IPJ）发生骨折。

方法： 本研究为一项经伦理委员会批准的回顾性分析，纳入 1999 年至 2012 年在一家医疗机构接受 PAO 治疗髋臼发育不良的青少年患者。进行影像学测量，包括外侧中心边缘角、Sharp 髋臼指数和负重区髋臼指数。这些指标在术前、术后 6 周和术后 1 年通过站立位骨盆前后位 X 线片进行测量。同时分析术后改良 Harris 髋关节评分（mHHS）。排除手术时年龄超过 21 岁及随访不足 2 年的患者。

结果： 共纳入 166 例患者（187 例手术髋），平均年龄为 15.6 ± 2.5 岁。12 例患者（6.4%）出现 IPJ 应力性骨折。其中 7 例在术后初次影像学检查中发现，5 例在术后 6 周复查后发现。7 例（58.3%）应力性骨折伴有上后支骨不连。6 例（50%）在术后 2 年内愈合，其余 6 例（50%）发展为骨不连。与无应力性骨折的患者相比，两组在术前、术后 6 周及末次随访时的中心边缘角（P = 0.94、0.29、0.27）、Sharp 髋臼指数（P = 0.95、0.38、0.16）及负重区髋臼指数（P = 0.37、0.21、0.54）方面均无显著差异。术后平均改良 Harris 髋关节评分亦无显著差异（P = 0.63）。易感因素分析显示，患有腓骨肌萎缩症（CMT）的患者更易发生 IPJ 骨折（P = 0.001）。发生 IPJ 骨折的患者年龄更大（17.1 岁 vs. 15.5 岁，P = 0.05）。不同性别之间无显著差异（P = 0.22）。

讨论与结论： 青少年人群 PAO 术后 IPJ 骨折的发生率为 6.4%，部分骨折发生在手术过程中。这些骨折还与上后支截骨处骨不连及腓骨肌萎缩症基础诊断相关。此类骨折在临床上无显著影响，在本研究系列中，发现后均未需进一步干预。

Fracture at the Ischio-Pubic Junction After Periacetabular Osteotomy in the Adolescent Population

Introduction: The Ganz periacetabular osteotomy (PAO) is a well-accepted surgical intervention for hip dysplasia. In the adolescent population it is performed in patients who are skeletally mature with symptoms related to acetabular dysplasia. Redistribution of stresses through the hemipelvis after PAO can lead to a fracture at the ischio-pubic junction (IPJ).

Methods: This is an IRB-approved, retrospective analysis of adolescent patients treated with a PAO for acetabular dysplasia from 1999 to 2012 at a single institution. Radiographic measurements were performed to include the lateral center-edge angle, Sharp acetabular index, and acetabular index of the weight-bearing zone. These were measured preoperatively and at 6-weeks and 1 year postoperatively from a standing anterior posterior pelvis radiograph. Postoperative modified Harris hip scores (mHHS) were also analyzed. Patients over the age of 21 at time of surgery and those with <2 years of follow-up were excluded.

Results: One hundred sixty-six patients (187 operated hips) at an average age of 15.6 ± 2.5 were included. Twelve (6.4%) stress fractures at the IPJ were identified in 12 patients. Seven were identified on the initial postoperative films, whereas 5 were identified after the 6-week visit. Seven (58.3%) stress fractures had an associated superior posterior ramus nonunion. Six (50%) healed by 2 years after surgery; the remaining 6 (50%) went on to non-union. Compared with those without a stress fracture, there was no significant difference in preoperative, 6 weeks postoperative, and final center-edge angle (P = 0.94, 0.29, 0.27), Sharp acetabular index (P = 0.95, 0.38, 0.16), or AIBWZ (P = 0.37, 0.21, 0.54). There was no difference in postoperative mean modified Harris hip scores (P = 0.63). Analysis of predisposing factors demonstrated that patients with Charcot-Marie-Tooth (CMT) disease were more likely to develop an IPJ fracture (P = 0.001). Patients with an IPJ fracture were older (17.1 vs. 15.5, P = 0.05). There was no difference based on patient sex (P = 0.22).

Discussion and Conclusions: The incidence of fracture at the IPJ after PAO in the adolescent population is 6.4% with some occurring at the time of surgery. These fractures are also associated with a nonunion at the superior posterior ramus cut and an underlying diagnosis of Charcot-Marie-Tooth. These fractures are not clinically significant and in this series did not merit further intervention when identified.

文献出处： Swann M, Sucato DJ, Romero J, Podeszwa DA. Fracture at the Ischio-Pubic Junction After Periacetabular Osteotomy in the Adolescent Population. J Pediatr Orthop. 2017 Mar;37(2):127-132. doi: 10.1097/BPO.0000000000000742. PMID: 27137904.

文献3

股神经和坐骨神经在髋臼周围不同位置的CT研究

译者 陶可

背景：股神经和坐骨神经在髋臼周围截骨术的各个阶段都可能受到损伤。改变髋关节位置可能是预防神经损伤最有效的方法。本研究旨在探讨健康成年人骨盆计算机扫描图像中，不同髋关节位置下神经与各骨性标志点之间的距离。

材料与方法：纳入15名健康成年男性（30个髋关节）（年龄30±6岁）。使用量角器测量髋关节在三个不同位置（中立位“N”、屈曲（30-45°）+外展（30-45°）+外旋（20°）“F”（体位）和中立位+外展（30-45°）+外旋（20°）（Nabext））（体位）进行扫描，扫描位置分别为：髋臼眉弓“1”、股骨头中央“2”和Y型软骨下缘“3”。

结果：在髋臼眉弓水平，与屈曲位或中立位+外展+外旋位相比，中立位时股神经与髋臼前缘的距离最远（p < 0.001）。对于坐骨神经，在股骨头中央水平2，髋关节屈曲时坐骨神经与髋臼前缘的距离大于中立位（p = 0.001）。在Y型软骨下缘水平3，与中立位（N 或 Nabex 位）相比，髋关节屈曲导致坐骨神经与髋臼前缘的距离减小（p = 0.001）。

结论：在耻骨截骨术中，股神经在髋关节屈曲或外展加外旋时更靠近髋臼前壁。在坐骨截骨术中，坐骨神经在髋关节屈曲时更靠近坐骨，而在髋臼向后截骨术中则远离骨骼。

图1. a中立位/仰卧位计算机断层扫描图像。b外展（30-45°）+外旋（20°）位计算机断层扫描图像。c外展（30-45°）+外旋（20°）+外展（30-45°）位计算机断层扫描图像。

图2. 骨盆X线片测量平面示意图。

图3. 股神经和坐骨神经在1、2水平的测量示意图。

图4. 坐骨神经在3水平的测量示意图。

A CT study of the femoral and sciatic nerve periacetabular moving in different hip positions

Background: Femoral and sciatic nerves could be damaged during various stages of the periacetabular osteotomy. Changing the position of the hip could be the most effective way of preventing nerve injuries. The purpose of the present study was to investigate the distances of the nerves to various bony landmarks with different hip positions in computerized pelvic scanograms of healthy adults.

Materials and methods: Fifteen healthy male adults (30 hips) (age 30 ± 6) were included. Scans were performed at three different hip positions measured by goniometer (neutral "N," flexion (30-45°) + abduction (30-45°) + external rotation (20°) "F" and neutral+ abduction (30-45°) + external rotation (20°) (Nabext) at three different levels (sourcil "1," the middle of the femoral head "2," and lower border of triradiate cartilage "3."

Results: At the sourcil level, the femoral nerve was found to be the furthest distance from the anterior acetabulum in the neutral position compared to flexion or neutral plus abduction, external rotation (p < 0.001). For the sciatic nerve, at level 2, hip flexion resulted in a greater distance than in the neutral position (p = 0.001). For level 3, hip flexion caused a decrease in the distance of the sciatic nerve to the acetabulum compared to both neutral positions (N or Nabex) (p = 0.001).

Conclusions: During a pubic cut of the osteotomy, the femoral nerve moves closer to the anterior acetabulum wall with hip flexion or abduction plus external rotation. During an ischial cut, the sciatic nerve gets closer to the ischium with hip flexion while it moves away from the bone during retroacetabular cut. Level-III Study.

文献出处：Yagmur Isin, Onur Hapa, Yavuz Selim Kara, Ali Ihsan Kilic, Ali Balcı. A CT study of the femoral and sciatic nerve periacetabular moving in different hip positions. J Orthop Surg Res. 2020 Sep 11;15(1):404. doi: 10.1186/s13018-020-01937-7.

文献4

基于德尔菲法的股骨头坏死塌陷预后模型：一种多因素分析方法

译者 邱兴

股骨头坏死（ONFH） 是一种呈进行性发展且可导致功能严重受损的疾病，其特征为血供不足引发的骨组织坏死。尽管诊断影像学与治疗策略不断取得进展，预测股骨头塌陷风险仍然是临床上面临的一项重大挑战。本研究旨在通过整合临床、影像学及实验室数据，构建一个稳健的预后模型，从而弥补这一不足，以提升早期诊断水平并指导治疗决策。

方法
本研究采用定性系统评价，并结合德尔菲法，从临床资料、影像学表现及实验室指标中筛选关键预后因素。研究纳入2014年1月至2021年12月期间接受治疗的股骨头坏死患者。通过单因素与多因素Cox回归分析，构建了预测股骨头塌陷风险的列线图。模型效能通过一致性指数（C-index）、校准曲线及决策曲线分析（DCA）进行评价。

结果
研究共纳入297例患者（454髋）。确定的关键预后因素包括：存在疼痛（p < 0.001，RR = 0.185，95%置信区间：0.11–0.31）、JIC分型（C1型：p < 0.001，RR = 0.096，95%置信区间：0.054–0.171；C2型：p < 0.001，RR = 0.323，95%置信区间：0.215–0.487）、坏死面积（3 < MNAI < 6：p < 0.001，RR = 0.107，95%置信区间：0.061–0.190；MNAI ≥ 6：p < 0.001，RR = 0.466，95%置信区间：0.314–0.692）、承重减轻状态（p < 0.001，RR = 0.466，95%置信区间：0.323–0.672）、前外侧柱保留（p < 0.001，RR = 0.223，95%置信区间：0.223–0.473）以及CT显示软骨下骨折（p < 0.001，RR = 0.32，95%置信区间：0.217–0.472）。所构建的列线图显示出较高的一致性指数（0.88），表明其具有卓越的预测准确性。校准曲线显示预测结果与实际观测结果具有良好的一致性，决策曲线分析则验证了该模型的临床实用性。

结论
本研究构建的预后模型为预测股骨头坏死患者股骨头塌陷风险提供了可靠的工具。该模型有助于早期识别高危患者，进而指导个体化治疗策略的制定，以改善患者预后，并减少侵入性手术干预的需求。

A delphi-based model for prognosis of femoral head collapse in osteonecrosis: a multi-factorial approach

Background: Osteonecrosis of the femoral head (ONFH) is a progressive and debilitating condition characterized by the death of bone tissue due to inadequate blood supply. Despite advances in diagnostic imaging and treatment strategies, predicting the risk of femoral head collapse remains a significant clinical challenge. This study seeks to address this gap by developing a robust prognostic model that integrates clinical, imaging, and laboratory data to improve early diagnosis and guide therapeutic decision-making.

Methods: We conducted a qualitative systematic review and employed the Delphi method to select key prognostic factors from clinical data, imaging findings, and laboratory indicators. The study included ONFH patients treated from January 2014 to December 2021. We used univariate and multivariate Cox regression analyses to develop a nomogram for predicting the risk of femoral head collapse. The model's performance was evaluated using the concordance index (C-index), calibration plots, and decision curve analysis (DCA).

Results: The study included 297 patients (454 hips) with ONFH. Key prognostic factors identified included pain presence (p < 0.001, RR = 0.185, 95% CI: 0.11-0.31), JIC classification (C1: p < 0.001, RR = 0.096, 95% CI: 0.054-0.171; C2: p < 0.001, RR = 0.323, 95% CI: 0.215-0.487), necrotic area (3 < MNAI < 6: p < 0.001, RR = 0.107, 95% CI: 0.061-0.190; MNAI ≥ 6: p < 0.001, RR = 0.466, 95% CI: 0.314-0.692), weight-bearing reduction (p < 0.001, RR = 0.466, 95% CI: 0.323-0.672), preservation of the anterolateral pillar (p < 0.001, RR = 0.223, 95% CI: 0.223-0.473), and subchondral bone fracture on CT (p < 0.001, RR = 0.32, 95% CI: 0.217-0.472). The nomogram demonstrated a high C-index of 0.88, indicating excellent predictive accuracy. Calibration plots showed good agreement between predicted and observed outcomes, and DCA confirmed the model's clinical utility.

Conclusions: The prognostic model developed in this study provides a reliable tool for predicting femoral head collapse in ONFH patients. It allows for early identification of high-risk patients, guiding personalized treatment strategies to improve patient outcomes and reduce the need for invasive surgical procedures.

文献出处：Yang TJ, Sun SY, Zhang L, Zhang XP, He HJ. A delphi-based model for prognosis of femoral head collapse in osteonecrosis: a multi-factorial approach. Journal of Orthopaedic Surgery & Research. 2024;19(1).

来源：304关节学术

作者：304关节团队

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