髋膝关节文献精译荟萃（第388期)

本期目录：

1、机械臂辅助的功能对线与机械对线全膝关节置换术比较

2、全膝关节置换术中留置尿管增加尿路感染风险

3、急性膝关节置换术后假体周围感染48小时内施行清创，抗生素和假体保留（DAIR）的时机并不提高手术成功率

4、机器人辅助韧带引导单髁膝关节置换术治疗内侧间室骨关节炎

5、盂唇内翻是DDH患儿Pavlik挽具治疗失败的预测因素

6、基于计算机断层扫描导航的髋臼周围截骨术：术前规划与准确性评价

7、髋关节发育不良的生物力学

8、儿童发育性髋关节发育不良治疗中多种截骨术的有限元分析

9、一种基于直接髋关节磁共振关节造影的深度学习方法，用于髋关节软骨和盂唇的自动三维分割

第一部分：关节置换及保膝相关文献

文献1

机械臂辅助的功能对线与机械对线全膝关节置换术比较

译者 张轶超

背景：全膝关节置换术（TKA）采用机械对线（MA）的目的是使所有患者达到中立的下肢力线，而功能对线（FA）的目的是通过截骨和微调假体位置来恢复原始的、患者特异性的解剖和膝关节运动学。本研究的目的是通过比较MA TKA与FA TKA的患者满意度、功能结果、假体生存率、并发症和成本效益来确定TKA的最佳对线技术。机器人技术将用于在所有研究患者中以高精度执行假体定位和肢体对线的计划。

方法和分析：这项前瞻性双盲随机对照试验将纳入100例接受机械臂辅助初次全膝关节置换术的症状性膝骨关节炎患者。在知情同意后，使用在线随机数生成器将患者按1:1的比例随机分配到MA TKA（对照组）或FA TKA（研究组）。盲法观察者将在术后2年定期回访患者，记录与术后康复、临床进展、功能结果、假体定位和肢体对线的准确性、步态、假体稳定性、成本效益和并发症相关的预定好的研究结果。一项优势研究设计将用于评估FA TKA是否比MA TKA有更好的效果。主要和次要目标是量化和推断两组之间治疗效果的差异。将进行意向治疗和每个方案的人群分析。对数据的分析将采用以下统计方法：描述性统计、独立t检验、配对t检验、方差分析、Fisher精确检验、卡方检验和图形显示。获得了英国伦敦-萨里研究伦理委员会的伦理批准。这项研究是由英国伦敦大学学院赞助的。

讨论：这是第一项描述使用机器人技术实现FA TKA的研究，也是目前唯一一项比较机器人MA TKA和机器人FA TKA的临床试验。本研究的结果将使人们更好地理解TKA的最佳对线技术，以实现高水平的患者满意度，改善功能效果，增加假体存活率，提高成本效益，减少并发症。

A prospective double-blinded randomised control trial comparing robotic arm-assisted functionally aligned total knee arthroplasty versus robotic arm-assisted mechanically aligned total knee arthroplasty

Background: Total knee arthroplasty (TKA) with mechanical alignment (MA) aims to achieve neutral limb alignment in all patients, whereas TKA with functional alignment (FA) aims to restore native, patient-specific anatomy and knee kinematics by manipulating bone resections and fine-tuning implant positioning. The objective of this study is to determine the optimal alignment technique in TKA by comparing patient satisfaction, functional outcomes, implant survivorship, complications, and cost-effectiveness in MA TKA versus FA TKA. Robotic technology will be used to execute the planned implant positioning and limb alignment with high-levels of accuracy in all study patients.

Methods and analysis: This prospective double-blinded randomised control trial will include 100 patients with symptomatic knee osteoarthritis undergoing primary robotic arm-assisted TKA. Following informed consent, patients will be randomised to MA TKA (the control group) or FA TKA (the investigation group) at a ratio of 1:1 using an online random number generator. Blinded observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to postoperative rehabilitation, clinical progress, functional outcomes, accuracy of implant positioning and limb alignment, gait, implant stability, cost-effectiveness, and complications. A superiority study design will be used to evaluate whether FA TKA provides superior outcomes compared to MA TKA. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Surrey Research Ethics Committee, UK. The study is sponsored by University College London, UK.

Discussion: This is the first study to describe the use of robotic technology to achieve FA TKA, and the only existing clinical trial comparing robotic MA TKA versus robotic FA TKA. The findings of this study will enable an improved understanding of the optimal alignment technique in TKA for achieving high-levels of patient satisfaction, improving functional outcomes, increasing implant survivorship, improving cost-effectiveness, and reducing complications.

文献出处：Kayani B, Konan S, Tahmassebi J, Oussedik S, Moriarty PD, Haddad FS. A prospective double-blinded randomised control trial comparing robotic arm-assisted functionally aligned total knee arthroplasty versus robotic arm-assisted mechanically aligned total knee arthroplasty. Trials. 2020 Feb 18;21(1):194. doi: 10.1186/s13063-020-4123-8. PMID: 32070406; PMCID: PMC7027302.

文献2

全膝关节置换术中留置尿管增加尿路感染风险：荟萃分析

译者 马云青

背景: 本研究旨在探讨初次全膝关节置换术（TKA）患者是否均需常规留置导尿管。

研究方法：系统检索PubMed、荷兰医学文摘数据库、考克兰图书馆、科学网及中国知网，筛选相关随机对照试验（RCT）。纳入研究均对比初次全膝关节置换术中留置导尿管与不留置导尿管两种方案。主要观察指标为尿潴留、尿路感染；次要观察指标为住院时长、手术时长及首次排尿时间。

研究结果：分析共纳入6项随机对照试验，总计1334例患者。两组患者在尿潴留发生率（P=0.52）、住院时长（P=0.38）及手术时长（P=0.55）方面差异无统计学意义。但留置导尿管组患者的尿路感染风险更高，且首次排尿时间显著延长，组间差异均具有统计学意义（P=0.009、P=0.004）。

结论：现有证据表明，初次全膝关节置换术患者不留置导尿管，可降低尿路感染发生率、缩短首次排尿时间，且不会增加尿潴留风险。

Indwelling catheter increases the risk of urinary tract infection in total knee arthroplasty: A meta-analysis of randomized controlled trials

Background:The purpose of this meta-analysis was to assess whether a urinary catheter is necessary for all patients in primary total knee arthroplasty (TKA).

Methods:PubMed, EMBASE, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure were systematically searched for randomized controlled trials (RCTs). All RCTs were compared with receive either an indwelling urinary catheter or no urinary catheter in TKA. Primary outcomes were urinary retention and urinary tract infection. Secondary outcomes were the length of stay, duration of the surgery, and the first urination time.

Results:A total of 6 RCTs involving 1334 patients were included in the meta-analysis. No significant difference between the 2 groups was found in urinary retention (P = .52), length of stay (P = .38), duration of the surgery (P = .55). However, patients with an indwelling catheter were associated with a higher risk of urinary tract infections and longer time for the first urination than patients without indwelling catheters (P = .009 and P = .004).

Conclusion:The available evidence indicates that patients without using the indwelling catheters could reduce urinary tract infections and the time for the first urination, without increase in the incidence of urinary retention in primary TKA.

文献出处：Shuai M, Li Y. Indwelling catheter increases the risk of urinary tract infection in total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2021 Apr 16;100(15):e25490. doi: 10.1097/MD.0000000000025490. PMID: 33847659; PMCID: PMC8052073.

文献3

急性膝关节置换术后假体周围感染48小时内施行清创，抗生素和假体保留（DAIR）的时机并不提高手术成功率

译者 张蔷

背景：清创，抗生素和假体保留（DAIR）是一种治疗全膝关节置换术（TKA）后急性假体周围感染（PJI）的常见一线治疗方法。然而，施行DAIR的最佳时机目前并未达成共识。本研究的目的是评估从出现症状或确诊PJI到手术干预的时间是否会影响治疗结果。

方法：本回顾性队列研究共入组了某地区医疗中心2016年至2022年间共166例TKA术后急性PJI并施行DAIR的手术病例。患者根据从第一次就医和正式确诊PJI到DAIR的时间分为3组：<24小时, 24小时至48小时和>48小时。首要指标为DAIR失效，定义为PJI再手术。次要指标包括90天内再入院、长期抗生素压制、不良事件和死亡。最终数据应用方差分析、卡方分析和多元回归分析等方法来处理。

结果：有40.4%的病例最终出现DAIR失效，且失效与首发症状（P=0.97）或确诊（P=0.84）到干预时间无关。相似的，首发症状或确诊到干预的时间与再入院、抗生素压制或不良事件均无关。值得注意的是，90天病死率在24小时内施行DAIR手术组（12.1%, P=0.001）的患者中反而更高，提示我们应更加重视高风险患者的鉴别。多元回归分析显示年龄、糖尿病和术前贫血与更差的结果相关。CRP升高并非手术失效和并发症的预测因素。

结论：TKA术后急性PJI发生后早期DAIR的时间窗并不会显著增加失效和并发症率，提示我们应采取紧急干预而非突发性干预。条件适宜的情况下，我们可以考虑适当推迟DAIR以做好术前准备，但本研究统计学效力有限，并无法形成确定性的结论，未来我们需要更大的样本量来明确结论。

Timing of Debridement, Antibiotics, and Implant Retention Within 48 Hours for Acute Knee Periprosthetic Joint Infection May Not Improve Success Rate

Background:Debridement, antibiotics, and implant retention (DAIR) is a common first-line treatment for acute periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). However, the optimal timing for DAIR remains undefined. This study aimed to evaluate whether the time from initial presentation or diagnosis to surgical intervention impacts treatment outcomes.

Methods:A retrospective cohort study was conducted on 166 patients who underwent DAIR for acute PJI after TKA between 2016 and 2022 within a regional academic health system. Patients were stratified by time to DAIR from both the first health care contact and formal PJI diagnosis: < 24, 24 to 48, and > 48 hours. The primary outcome was DAIR failure, defined as reoperation for PJI. The secondary outcomes included 90-day readmission, chronic antibiotic suppression, adverse events, and mortality. Outcomes were assessed with analysis of variance tests or chi-squares and multivariate logistic regressions.

Results:A DAIR failure occurred in 40.4% of cases, with no significant differences by timing from first contact (P = 0.97) or diagnosis (P = 0.84). Similarly, time to debridement was not associated with differences in readmission, chronic suppression, or adverse events. Notably, 90-day mortality was higher in patients who underwent DAIR within 24 hours of diagnosis (12.1%, P = 0.001), potentially reflecting clinical triage of higher-risk patients. Multivariable analysis analyses found that age, diabetes mellitus, and low preoperative hemoglobin were independently associated with worse outcomes. Elevated C-reactive protein was not predictive of failure or complications.

Conclusions:Timing of DAIR for acute TKA PJI within early windows did not significantly affect failure or complication rates, suggesting that urgent rather than emergent intervention is appropriate. Brief delays to allow clinical optimization may be safely considered, although power may have been limited to form definitive conclusions. Larger and more robust studies are needed.

文献出处：Shannon MF, Wong VR, Frear AJ, Bilodeau RE, Drummond EF, Plate JF, Klatt BA, Urish KL. Timing of Debridement, Antibiotics, and Implant Retention Within 48 Hours for Acute Knee Periprosthetic Joint Infection May Not Improve Success Rate. J Arthroplasty. 2026 Jun;41(6):1842-1850.e2. doi: 10.1016/j.arth.2025.09.055. Epub 2025 Nov 3. PMID: 41075944.

文献4

机器人辅助韧带引导单髁膝关节置换术治疗内侧间室骨关节炎：当前概念

译者 沈松坡

尽管单髁膝关节置换术（UKA）相较于全膝关节置换术（TKA）具有理论优势，但由于对耐久性以及登记系统报告翻修率的担忧，UKA 历来应用不足。机器人辅助、韧带引导的内侧 UKA，旨在恢复内侧副韧带（MCL）等长性和估计的关节炎前对线，已成为一种旨在提高技术可重复性和假体生存率的技术。

当代多中心研究显示，在短期、中期和长期随访中均可获得持久结局，包括平均 2.5 年时 98.8% 的生存率、5.7 年时 97.0% 的生存率，以及 10 年时 91.7% 的生存率，患者满意度始终超过 90%。

在一项将机器人辅助内侧 UKA 与 TKA 进行比较的匹配比较研究中，UKA 在 2 年时与较少的僵硬相关干预相关（0 例 vs. 6 例麻醉下手法松解，p = 0.03）、再手术负担更低、恢复更快，并且由遗忘关节评分（FJS）衡量的关节感知更优（90.5 vs. 79.5，p < 0.001）。

在 5 年随访时，机器人辅助 UKA 在所有患者报告结局指标方面均保持优于 TKA，包括关节感知（FJS：87 vs. 59，p < 0.001）、功能（膝关节协会评分［KSS］：88 vs. 75，p < 0.001）和满意度（37.2 vs. 32.5，p < 0.0001），无组件翻修生存率为 100%，而 TKA 为 98%。

当代证据进一步显示，失败的传统 UKA 转换为 TKA 可获得与初次 TKA 相当的结局，从而保留未来重建选择。现存局限性包括缺乏将机器人辅助 UKA 与 TKA 直接比较的长期随机对照试验数据、需要完善患者选择标准，以及重返运动数据有限。

机器人辅助韧带引导内侧 UKA 代表了在适当选择患者中一种持久且可重复的治疗策略。

Robotic-assisted ligament-guided unicompartmental knee arthroplasty for medial compartment osteoarthritis: current concepts

Despite theoretical advantages over total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA) has historically been underutilized due to concerns regarding durability and registry-reported revision rates. Robotic-assisted, ligament-guided medial UKA, designed to restore medial collateral ligament (MCL) isometry and estimated pre-arthritic alignment, has emerged as a technique intended to improve technical reproducibility and survivorship. Contemporary multicenter investigations demonstrate durable outcomes across short-, mid-, and long-term follow-up, including survivorship of 98.8% at a mean of 2.5 years, 97.0% at 5.7 years, and 91.7% at 10 years, with patient satisfaction consistently exceeding 90%. In a matched comparative study comparing robotic-assisted medial UKA to TKA, UKA was associated with fewer stiffness-related interventions at two years (0 vs. 6 manipulations under anesthesia, p=0.03), lower reoperation burden, faster recovery, and superior joint awareness measured by the Forgotten Joint Score (FJS) (90.5 vs. 79.5, p<0.001). At five-year follow-up, robotic-assisted UKA maintained superior outcomes compared with TKA across all patient-reported measures, including joint awareness (FJS: 87 vs. 59, p<0.001), function (Knee Society Score (KSS): 88 vs. 75, p<0.001), and satisfaction (37.2 vs. 32.5, p<0.0001), with 100% survivorship free from component revision compared with 98% for TKA. Contemporary evidence further demonstrates that conversion of failed conventional UKA to TKA yields outcomes comparable to primary TKA, preserving future reconstructive options. Remaining limitations include the absence of long-term randomized controlled trial data directly comparing robotic-assisted UKA with TKA, the need for refined patient selection criteria, and limited return-to-sport data. Robotic-assisted ligament-guided medial UKA represents a durable and reproducible treatment strategy in appropriately selected patients. LEVEL OF EVIDENCE: Level V.

Keywords: ligament-guided alignment; medial compartment osteoarthritis; robotic-assisted surgery; survivorship; total knee arthroplasty; unicompartmental knee arthroplasty.

第二部分：保髋相关文献

文献1

盂唇内翻是DDH患儿Pavlik挽具治疗失败的预测因素

译者 任宁涛

介绍

据报道，Pavlik挽具治疗髋关节发育不良(DDH)的失败率高达55%。本研究的目的是探讨髋臼盂唇内翻对Pavlik挽具治疗DDH疗效的影响。

方法

回顾性分析2004 - 2016年某三级儿科医院DDH患儿，纳入采用Pavlik挽具进行治疗并随访时间不短于12个月的DDH患儿。统计纳入患儿的人口学信息、治疗和随访结果，比较盂唇内翻和无盂唇内翻患儿的预后。

结果

共纳入156名患儿，229例髋关节发育不良。开始治疗的平均年龄为1.9±1.4个月，平均随访时间为37.7±23.0个月。46%(73/156)的患儿诊断为双侧DDH。总共有37%(75/229)髋关节Pavlik挽具治疗失败。进一步治疗中，91%(68/75)的髋关节为硬性外展支具，5%(4/75)的髋关节为闭合复位，4%(3/75)的髋关节为切开复位。10%(22/229)的患儿存在髋关节盂唇内翻。内翻盂唇组Pavlik挽具治疗失败的发生率为91%(20/22)，而对照组为27% (55/207)(P<0.001)。盂唇内翻组86%(15/22)需要闭合或切开复位，对照组3% (7/207)(P<0.001)。盂唇内翻组的缺血性坏死发生率为18%(4/22)，对照组为0.4% (1/207)(P<0.001)。

结论

在接受Pavlik挽具治疗的DDH患儿中，髋臼盂唇内翻的存在是治疗失败的有力预测因素。与没有内翻盂唇的髋关节相比，有内翻盂唇的髋关节需要闭合或切开复位和发生缺血性坏死的风险也明显更高。

图1 生后1周女性患儿，髋关节超声检查可见双侧DDH，B图箭头处可见左髋内翻盂唇，采用Pavlik挽具治疗6周，右髋治疗效果良好，左髋因盂唇内翻接受了进一步的硬性支具的治疗，最终采用闭合复位石膏外固定治疗。

An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia

Introduction: The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH.

Methods: A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum.

Results: A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P<0.001). Closed or open reduction was required in 86% (15/22) of the inverted labrum group compared with 3% (7/207) of hips in the control group (P<0.001). The incidence of avascular necrosis was 18% (4/22) in hips with an inverted labrum compared with 0.4% (1/207) in the control group (P<0.001).

Conclusions: In children with DDH undergoing index treatment in a Pavlik harness, the presence of an inverted acetabular labrum is strongly predictive of treatment failure. Dysplastic hips with an inverted labrum also have a significantly higher risk of requiring closed or open reduction and developing avascular necrosis compared with those without an inverted labrum.

文献出处Lin AJ, Siddiqui AA, Lai LM, Goldstein RY. An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia. J Pediatr Orthop. 2021 Sep 1;41(8):479-482. doi: 10.1097/BPO.0000000000001916. PMID: 34267151.

文献2

基于计算机断层扫描导航的髋臼周围截骨术：术前规划与准确性评价

译者 李勇

目的
自2011年以来，我们一直采用基于计算机断层扫描（CT）的导航技术进行旋转髋臼截骨术（RAO），以安全、精准地治疗发育性髋关节发育不良。为改进已发表技术中的准确性，我们研发了一种使用四个标志点的新方法。本研究介绍了一种按照术前计划实现骨块再定向的新技术，并对其准确性进行了评价。

方法
本研究共纳入40例接受CT导航下RAO的髋关节。其中20例在术中通过导航触碰旋转骨块的外侧部并与术前计划进行比对以确认再定向；其余20例采用新标志点法。为评估各组旋转骨块的位置精度，术后对髋臼周围进行径向重建CT扫描并进行三维评估。采用髋臼扇区角（ASA）来评价髋臼骨块重新定位的准确性。

结果 新标志点法组在11:30至13:30区域的ΔASA绝对值（代表术前计划与实际术后位置之间的误差）显著小于旧方法组（）。术后1年时的Harris髋关节评分在旧法组与新标志点法组之间无显著差异。

结论
新标志点法显著减少了髋臼上外侧区域的再定向误差，记录到的误差更少，且外侧髋臼覆盖矫正不足的病例更少。四个参考标志点的方法有助于按照计划更精确地实现髋臼再定向，误差更小。该标志点法准确性提高对临床结局的影响将在未来的工作中进一步研究。

图 髋臼扇区角（ASA）的定义：髋臼覆盖指数。

ASA定义为在每个径向重建图像上，从髋臼缘至股骨头中心的连线与X轴之间的夹角。该图示为术后CT与规划模型叠加后的3:00位ASA。红线表示规划模型。X轴与规划中股骨头中心至髋臼缘连线（虚线）之间的夹角为规划的ASA。X轴与股骨头中心至实际术后髋臼缘连线（绿线）之间的夹角为术后ASA。a 显示3:00位ASA，b 显示12:00位ASA。规划的ASA与术后ASA之间的差值记为ΔASA，即髋臼骨块再定向的准确性指标。若ΔASA为正值，表示术后髋臼覆盖超过术前规划；反之，若ΔASA为负值，则表示与术前规划相比存在矫正不足。

Periacetabular osteotomy using computed tomography-based navigation: preoperative planning and accuracy evaluation

Purpose
Since 2011, we have used computed tomography (CT)-based navigation to perform safe and accurate rotational acetabular osteotomy (RAO) for treating developmental dysplasia of the hip. We developed a new method with four fiducial points to improve the accuracy of a published technique. In this study, we introduced a new method to achieve reorientation in accordance with planning and evaluated its accuracy.

Methods
This study included 40 joints, which underwent RAO used CT-based navigation. In 20 joints, reorientation was confirmed by touching the lateral aspect of the rotated fragment with navigation and checking whether it matched the preoperative plan. A new fiducial point method was adopted for the remaining 20 joints. To assess the accuracy of the position of the rotated fragment in each group, postoperative radial reformatted CT images were obtained around the acetabulum and three-dimensional evaluation was performed. The accuracy of acetabular fragment repositioning was evaluated using the acetabular sector angle (ASA).

Results The absolute value of ΔASA, which represents the error between preoperative planning and the actual postoperative position, was significantly smaller in the new fiducial method group than the previous method group in the area from 11:30 to 13:30 (). The Harris Hip Score at 1 year after surgery did not differ significantly between the previous and new fiducial point methods.

Conclusion
The new fiducial point method significantly reduced reorientation error in the superior-lateral area of the acetabulum: significantly fewer errors and fewer cases of under-correction of lateral acetabular coverage were recorded. The four-reference fiducial method facilitates reorientation of the acetabulum as planned, with fewer errors. The effect of the improved accuracy of the fiducial point method on clinical outcomes will be investigated in the future work.

文献出处：Inaba, Y., Tezuka, T., Oba, M. et al. Periacetabular osteotomy using computed tomography-based navigation: preoperative planning and accuracy evaluation. Int J CARS 19, 1833–1842 (2024). https://doi.org/10.1007/s11548-024-03210-2

文献3

髋关节发育不良的生物力学

译者 陶可

行走时，两侧髋关节交替承载除去支撑下肢之外的全身体重。该体重形成作用力K作用于髋关节，力臂为h'；髋关节外展肌产生作用力M与之形成力矩平衡，其力臂为h。髋关节关节面传递K与M的合力R，合力R会使髋关节产生压应力。

正常髋关节中，合力R作用于髋关节承重面中心，关节面应力分布均匀，髋臼顶部出现窄带状软骨下骨质硬化，正是这一力学状态的影像学表现。正常股骨颈同时承受弯曲应力与剪切应力：股骨颈内侧骨小梁束承受压应力，外侧骨小梁束承受拉应力，两组骨小梁相互交叉。

髋关节发育不良与肌力失衡会引发相似的力学改变：外展肌力臂h缩短，且外展肌作用力M的方向趋于垂直。力臂h缩短后，为平衡作用力K的力矩，外展肌所需施加力M会相应增大；而作用力M方向改变，又会使合力R向髋臼边缘偏移。最终表现为合力R数值增大、作用面积减小、应力分布不均。

髋臼发育过浅引发的股骨头半脱位，同样会导致合力R作用面积缩小、应力分布紊乱。髋关节压应力分布异常会造成髋臼边缘出现三角状骨质硬化，这也是髋关节半脱位型骨关节炎的早期征象。

髋外翻畸形下，股骨颈可单纯承受压应力，该力学特点也体现在股骨颈的松质骨结构中。髋内翻则呈现截然相反的力学变化：外展肌力臂h延长，外展肌作用力M趋于水平。这会使合力R减小，并向髋臼内侧偏移、作用面积增大，关节整体压应力随之降低。若髋臼内侧软骨发育不足，压应力会再次分布不均，应力集中于髋臼内侧并形成致密三角状骨质硬化，进而发展为髋臼内陷型骨关节炎。

相较于正常髋关节，髋内翻患者的股骨颈弯曲负荷显著增加，影像学可见股骨头内交叉走行的骨小梁更为粗大且呈直角相交：内侧骨小梁束仍承受压应力，外侧骨小梁束承受拉应力。

Biomechanics of hip dysplasia

When walking, each hip alternately carries the body mass minus the supporting leg. This mass exerts a force K acting on the hip with a lever arm h'; it is counter-balanced by a force M exerted by the abductor muscles, which acts on the hip with a lever arm h. The hip joint transmits the resultant R of forces K and M. Force R evokes compressive stresses in the joint. In a normal hip, force R is exerted at the center of the force transmitting surface of the joint, and the stresses are evenly distributed over this surface. This is reflected by the narrow ribbon of subchondral sclerosis in the roof of the socket. The normal femoral neck is stressed in bending with shear. It has a medial bundle of cancellous trabeculae, stressed in compression, intersecting with a lateral bundle, stressed in tension. Dysplasia and an imbalance of the muscles may have similar mechanical consequences: a shortening of the lever arm h and a more vertical orientation of force M. Shortening of h results in an increase of the force M necessary to counterbalance the moment of force K; the change in direction of force M displaces the resultant R towards the edge of the socket. The result is an increased resultant force R which becomes unevenly distributed over a smaller surface. Subluxation of the femoral head due to a shallow socket will also result in an uneven distribution of force R on a smaller surface. The abnormal distribution of compressive stresses is reflected by the development of a triangular sclerosis at the edge of the socket. This is the beginning of subluxating osteoarthritis of the hip. In a coxa valga the femoral neck may be stressed in a pure compression. This appears in the structure of the cancellous bone of the neck. Coxa vara has opposite consequences: lengthening of the lever arm h of the abductor muscles and a more horizontal orientation of force M. This results in a decrease of the resultant force R, which is displaced medially over a larger surface, resulting into smaller compressive stresses in the joint. If the acetabular cartilage of the socket does not develop further medially, the distribution of compressive stresses may become uneven with a maximum medially, where a dense triangular sclerosis develops. This is the beginning of protrusive osteoarthritis of the hip. In coxa vara, the femoral neck is stressed in bending more than in a normal hip, which is reflected by more marked cancellous trabeculae which intersect at right angles in the femoral head. The medial bundle is stressed in compression, the lateral bundle in tension.

文献出处：P Maquet. Biomechanics of hip dysplasia.Acta Orthop Belg. 1999 Sep;65(3):302-14.

文献4

儿童发育性髋关节发育不良治疗中多种截骨术的有限元分析

译者 邱兴

晚期发现的发育性髋关节发育不良畸形通常需要复杂的手术治疗和精细的术前规划。截骨术的选择取决于患者的年龄及髋关节的具体结构畸形。基于一名12岁患者的数据，我们在解剖学髋关节模型上模拟了针对此类病例常推荐的截骨术。我们精确构建了多种截骨术的几何模型，包括Dega、Pemberton、Tönnis、Ganz、Chiari骨盆截骨术及Pauwels股骨截骨术。采用Autodesk Inventor对髋关节及矫正性截骨术进行有限元分析。在比较一期截骨术时，我们发现Dega和Ganz骨盆截骨术，尤其是联合Pauwels股骨截骨术时，取得了最理想的效果。这些联合术式改善了股骨头覆盖，并降低了关节内压力。此外，我们还计算了Dega和Pauwels截骨术后的股骨头与髋臼容积比。所获得的令人鼓舞的结果支持将有限元分析应用于骨盆和股骨虚拟截骨术中，作为治疗发育性髋关节发育不良的术前规划工具。

图 1：一期手术的整体装配图——(a) Pauwels 截骨复位术，(b) Pemberton–Pauwels 联合截骨术，(c) Dega–Pauwels 联合截骨术，(d) Tönnis–Pauwels 联合截骨术，(e) Ganz–Pauwels 联合截骨术，(f) Chiari–Pauwels 联合截骨术。

图 2. 六边形网格的分布情况：
(a) 左侧脱位髋关节，股骨经 Pauwels 截骨复位后的一期手术；(b) Pemberton–Pauwels 联合截骨术；(c) Dega–Pauwels 联合截骨术；(d) Tönnis–Pauwels 联合截骨术；(e) Ganz–Pauwels 联合截骨术；(f) Chiari–Pauwels 联合截骨术。

图 3. 髋臼内的接触压力分布：(a) 正常髋关节(b) 发育不良髋关节(c) 切开复位(d) 复位 + Pemberton 截骨 + Pauwels 截骨(e) 复位 + Dega 截骨 + Pauwels 截骨(f) 复位 + Tönnis 截骨 + Pauwels 截骨(g) 复位 + Ganz 截骨 + Pauwels 截骨(h) 复位 + Chiari 截骨 + Pauwels 截骨。

图4. 股骨头内的接触压力分布：(a) 正常，(b) 发育不良，(c) 切开复位，(d) 复位 + Pemberton 截骨 + Pauwels 截骨，(e) 复位 + Dega 截骨 + Pauwels 截骨，(f) 复位 + Tönnis 截骨 + Pauwels 截骨，(g) 复位 + Ganz 截骨 + Pauwels 截骨，(h) 复位 + Chiari 截骨 + Pauwels 截骨。

Finite Element Analysis of Various Osteotomies Used in the Treatment of Developmental Hip Dysplasia in Children

Late-discovered developmental hip dysplasia deformities often necessitate complex surgical treatments and meticulous preoperative planning. The selection of osteotomies is contingent upon the patient’s age and the specific structural deformity of the hip. In our anatomical hip model, derived from the data of a 12-year-old patient, we performed virtual osteotomies that are commonly recommended for such cases. We precisely constructed geometric models for various osteotomies, including the Dega, Pemberton, Tönnis, Ganz, Chiari pelvic, and Pauwels femoral osteotomies. We employed Autodesk Inventor for the finite element analysis of the hip joint and the corrective osteotomies. In comparing one-stage osteotomies, we noted that the Dega and Ganz pelvic osteotomies, especially when combined with the Pauwels femoral osteotomy, yielded the most favorable outcomes. These combinations led to enhanced femoral head coverage and reduced intra-articular pressure. Furthermore, we calculated the femoral head-to-acetabulum volume ratio for both the Dega and Pauwels osteotomies. The encouraging results we obtained advocate for the integration of finite element analysis in virtual osteotomies of the pelvis and femur as a preoperative tool in the management of developmental hip dysplasia.

文献出处：Incze-Bartha, Z., Incze-Bartha, S., Simon-Szabó, Z., Feier, A. M., Vunvulea, V., Nechifor-Boila, A. I., ... & Denes, L. (2024). Finite element analysis of various osteotomies used in the treatment of developmental hip dysplasia in children. Journal of Personalized Medicine, 14(2), 189.

文献5

一种基于直接髋关节磁共振关节造影的深度学习方法，用于髋关节软骨和盂唇的自动三维分割

译者 徐子茵

本研究旨在利用卷积神经网络（convolutional neural networks，CNNs）基于三维MRI实现髋关节软骨和盂唇的自动分割。在这项单中心回顾性研究中，研究者采用具有 U-Net 架构的CNN，建立了一种基于MRI的髋关节软骨和盂唇全自动分割模型。研究纳入2020年1月至2021年10月期间100例有症状患者的直接髋关节磁共振关节造影资料。该机构的常规扫描方案包括一种三维T1 mapping序列，并将其用于髋关节软骨和盂唇的手工分割。其中80髋用于模型训练，其余20髋用于测试。

模型性能通过包括Dice相似系数（Dice similarity coefficient，DSC）在内的6项评价指标进行评估。此外，研究还采用来自另一机构、包含40例患者的外部数据集进行模型测试，该数据集使用三维T2加权序列。人工分割的评估者间一致性被作为自动分割性能的参考标准。

研究共纳入100例患者，平均年龄为30±10岁，女性占64%。在内部测试集中，软骨的平均DSC为0.92±0.02，95%置信区间为0.92–0.93；盂唇的平均DSC为0.83±0.04，95%置信区间为0.81–0.85。该结果与人工分割的评估者间一致性相当，人工分割中软骨DSC为0.93±0.04，95%置信区间为0.92–0.95；盂唇DSC为0.82±0.05，95%置信区间为0.80–0.85；两者比较差异无统计学意义，p值分别为0.232和0.297。

在外部数据集测试中，软骨和盂唇的DSC分别为0.89±0.02，95%置信区间为0.88–0.90；以及0.71±0.04，95%置信区间为0.69–0.73。研究表明，该深度学习方法能够从三维MRI序列中准确分割髋关节软骨和盂唇，并有望在临床实践中用于快速、准确地构建三维MRI模型。

A deep learning approach for automatic 3D segmentation of hip cartilage and labrum from direct hip MR arthrography

The objective was to use convolutional neural networks (CNNs) for automatic segmentation of hip cartilage and labrum based on 3D MRI. In this retrospective single-center study, CNNs with a U-Net architecture were used to develop a fully automated segmentation model for hip cartilage and labrum from MRI. Direct hip MR arthrographies (01/2020-10/2021) were selected from 100 symptomatic patients. Institutional routine protocol included a 3D T1 mapping sequence, which was used for manual segmentation of hip cartilage and labrum. 80 hips were used for training and the remaining 20 for testing. Model performance was assessed with six evaluation metrics including Dice similarity coefficient (DSC). In addition, model performance was tested on an external dataset (40 patients) with a 3D T2-weighted sequence from a different institution. Inter-rater agreement of manual segmentation served as benchmark for automatic segmentation performance. 100 patients were included (mean age 30±10 years, 64% female patients). Mean DSC for cartilage was 0.92±0.02 (95% confidence interval [CI] 0.92–0.93) and 0.83±0.04 (0.81–0.85) for labrum and comparable (p=0.232 and 0.297, respectively) to inter-rater agreement of manual segmentation: DSC cartilage 0.93±0.04 (0.92–0.95); DSC labrum 0.82±0.05 (0.80–0.85). When tested on the external dataset, the DSC was 0.89±0.02 (0.88–0.90) and 0.71±0.04 (0.69–0.73) for cartilage and labrum, respectively. The presented deep learning approach accurately segments hip cartilage and labrum from 3D MRI sequences and can potentially be used in clinical practice to provide rapid and accurate 3D MRI models.

文献出处：Meier MK, Helfenstein RA, Boschung A, et al. A deep learning approach for automatic 3D segmentation of hip cartilage and labrum from direct hip MR arthrography. Sci Rep. 2025;15(1):4662. Published 2025 Feb 7. doi:10.1038/s41598-025-86727-z

来源：304关节学术

作者：304关节团队

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