髋膝关节文献精译荟萃（第389期)

本期目录：

1、一期与两期双侧全膝关节置换术：系统回顾和荟萃分析

2、应用非交联维生素E聚乙烯垫片的固定平台全膝关节置换手术疗效研究

3、运动学对线机器人全膝关节置换术的患者报告结局：单中心、单术者经验

4、髋关节发育不良患儿的父母无症状发育不良的风险评估

5、基于病理标本的5T MRI T2‑mapping序列对股骨头软骨损伤的临床评估

6、改良 Dunn 手术治疗中重度股骨头骨骺滑脱的长期疗效

7、美国与日本非创伤性股骨头坏死保头手术治疗策略的差异：文献综述

8、患者特异性功能性骨盆倾斜是否影响髋关节发育不良中的关节接触压力

第一部分：关节置换及保膝相关文献

文献1

一期与两期双侧全膝关节置换术：系统回顾和荟萃分析

译者 张轶超

背景：双侧全膝关节置换术（B-TKA）越来越多地被用于治疗晚期双侧膝骨关节炎（OA）。本研究的目的是量化和比较一期和二期B-TKA的临床结果、围手术期参数、并发症、翻修率和死亡率。

方法：根据《系统评价和Meta分析首选报告项目指南》，于2024年2月对PubMed、Cochrane和web of Science三个数据库进行文献检索。纳入标准如下：比较研究，英文文献，无时间限制的比较一期和两期B-TKA治疗双侧膝骨关节炎。每篇文章的质量采用Cochrane非随机干预研究的偏倚风险评估工具进行评估。

结果：在检索到的2130篇文章中，包括69项研究（366722例患者）。一期BTKA显示较低的TKA手术相关并发症(P=0.043),深部的感染(P < 0.001)和伤口并发症(P=0.033),以及较短的手术时间(P=0.028)和住院时间(P < 0.001),以及更明显改善的西安大略和麦克马斯特大学骨关节炎指数评分(P=0.013)和牛津膝评分(P=0.004),但是存在更高的术后1个月(P < 0.001),三个月(P < 0.001)和1年(P=0.001)的死亡率,更高的神经系统并发症（P < 0.013）和胃肠道并发症（P < 0.001）、深静脉血栓形成（P < 0.016）和肺栓塞（P < 0.001）的发生率较高。26项研究的偏倚风险为“低”，36项研究为“中等”，6项研究为“严重”，1项研究为“非常严重”。

结论：与两期B-TKA相比，一期B-TKA与更高的死亡率和血栓栓塞风险相关，但TKA相关并发症和感染并发症较低。一期B-TKA也减少了住院时间和总手术时间，但与两期B-TKA相比，临床结果只有轻度改善，同时显示出更高的神经和胃肠道并发症风险。这些结果为患者和外科医生评估最合适的手术方式提供了重要的信息，从而有助于优化B-TKA患者的管理。

One-Stage Versus Two-Stage Bilateral Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background: Bilateral total knee arthroplasty (B-TKA) represents an increasingly used option to address advanced bilateral knee osteoarthritis (OA). The aim of this study was to quantify and compare one-stage and two-stage B-TKA results in terms of clinical outcomes, perioperative parameters, complications, revisions, and mortality rates.

Methods: The literature search was conducted using three databases (PubMed, Cochrane, andWeb of Science) in February 2024 according to the guidelines for Preferred Reporting Items for Systematic Reviews and MetaAnalysis. The inclusion criteria were as follows: comparative studies, English language, with no time filter on the comparison of one-stage and two-stage B-TKA for bilateral knee osteoarthritis treatment. The quality of each article was assessed using the Cochrane risk of bias in nonrandomized studies of interventions tool.

Results: Among the 2,130 articles retrieved, 69 studies (366,722 patients) were included. One-stage BTKA showed lower rates of TKA-related complications (P ¼ 0.043), deep infections (P < 0.001), and wound complications (P ¼ 0.033), as well as lower operative time (P ¼ 0.028), shorter length of hospital stay (P < 0.001), and higher improvements of Western Ontario and McMaster Universities Osteoarthritis Index score (P ¼ 0.013) and Oxford Knee Score (P ¼ 0.004), but higher mortality rates at the 1-month (P < 0.001), 3-month (P < 0.001), and 1-year (P ¼ 0.001) follow-ups, as well as higher rates of neurological (P ¼ 0.013) and gastrointestinal (P < 0.001) complications, deep vein thrombosis (P ¼ 0.016), and pulmonary embolism (P < 0.001). The risk of bias was “low” in 26 studies, “moderate” in 36 studies, “serious” in six studies, and “critical” in one study.

Conclusions: One-stage B-TKA was associated with a higher mortality rate and thromboembolic risk while presenting lower TKA-related and infective complications compared to two-stage B-TKA. Onestage B-TKA also reduced hospital stay and total surgical time but provided only marginal improvement in clinical outcomes compared to two-stage B-TKA while showing a higher risk of neurologic and gastrointestinal complications. These results offer important information for both patients and surgeons in evaluating the most appropriate surgical approach, thereby contributing to optimize the management of patients undergoing B-TKA.

文献出处：Bensa A, Delcogliano M, Moraca G, Bianco Prevot L, Fattini Fellini G, Filardo G. One-Stage Versus Two-Stage Bilateral Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty. 2025 Sep;40(9):2467-2477. doi: 10.1016/j.arth.2025.03.026. Epub 2025 Mar 14. PMID: 40090502.

文献2

应用非交联维生素E聚乙烯垫片的固定平台全膝关节置换手术疗效研究

一项与传统聚乙烯垫片对比的平均9年随访回顾性研究

译者 张蔷

背景：超高分子量聚乙烯垫片被广泛应用于全膝关节置换手术（TKA）中，而聚乙烯磨损是影响假体寿命的重要因素。聚乙烯中加入维生素E（VEPE）主要是为了增强抗氧化特性。本研究的主要目的是比较非交联VEPE垫片与传统超高分子量垫片（CPE）在TKA术后的长期表现。

方法：我们入组了1994年4月至2016年7月间共488名患者（661膝）。患者被分为VEPE组（169膝）和CPE组（492膝）。临床疗效包括假体生存率、再手术率、活动度和患者自评量表。

图1：研究中所使用的生物型TKA假体：A. CR型 ； B. PS型。

结果：在平均9.0年（VEPE，0.1年-20.4年）和9.9年（CPE，0.1年-27.5年）的随访后，我们得出术后10年、15年和20年的Kaplan-Meier生存率，VEPE组分别为97%、93%和93%，而CPE组为97%、92%和85%。VEPE组和CPE组的再手术率分别为3.0%和5.5%，未见组间显著性差异（P=0.22）。与磨损相关的翻修发生于CPE组，而VEPE组并未出现。两组间的活动度及患者自评量表均无显著性差异。

图2：A为传统超高分子量垫片在术后13年因进展性膝关节疼痛而行翻修手术，回收分析显示垫片前内侧显著聚乙烯磨损；B为维生素E垫片术后7.3年因持续膝关节疼痛而接受翻修手术，回收分析显示轻度聚乙烯磨损。

结论：与传统垫片相比，TKA手术中应用非交联维生素E垫片在术后大约10年随访时表现出与之相当的临床疗效。

Clinical Outcomes of Fixed-Bearing Total Knee Arthroplasty Using Non–Cross-Linked Vitamin E–Enriched Polyethylene

A Retrospective Comparison with Conventional Polyethylene at Mean Nine-Year Follow-Up

Background: Ultra-high molecular weight polyethylene has long been widely used for inserts in total knee arthroplasty (TKA), and polyethylene wear is a factor affecting implant longevity. Vitamin E—enriched polyethylene (VEPE) was developed to enhance oxidative stability. This study compared the long-term clinical performance of non—cross-linked VEPE with that of conventional ultra-high molecular weight polyethylene (CPE) in TKA.

Methods: We conducted a retrospective cohort study involving 488 patients (661 knees) who underwent primary TKA between April 1994 and July 2016. Patients were divided into the VEPE (169 knees) and CPE (492 knees) groups. Clinical outcomes, including implant survival, reoperation rates, range of motion, and patient-reported outcome measures, were assessed.

Results: At a mean follow-up of 9.0 (range, 0.1 to 20.4) and 9.9 (range, 0.1 to 27.5) years for the VEPE and CPE groups, the Kaplan—Meier survival rates at 10, 15, and 20 years were 97, 93, and 93%, respectively, for the VEPE group and 97, 92, and 85%, respectively, for the CPE group. Reoperation rates were 3.0 and 5.5% in the VEPE and CPE groups, respectively, showing no statistically significant difference (P = 0.22). The one wear-related revision occurred in the CPE group and none in the VEPE group. There were no significant differences observed between groups in range of motion or patient-reported outcome measures.

Conclusions: Non—cross-linked VEPE demonstrated clinical outcomes comparable to those of CPE in TKA at a mean follow-up of approximately 10 years.

文献3

运动学对线机器人全膝关节置换术的患者报告结局：单中心、单术者经验

译者 沈松坡

运动学对线（kinematic alignment，KA）旨在恢复患者自身膝关节的原有解剖结构，而机器人辅助手术（robotic-assisted surgery，RAS）可提高全膝关节置换术（total knee arthroplasty，TKA）的手术精确性。目前，关于机器人辅助 KA-TKA 后以患者为中心结局的证据仍然有限。本研究评估术后疼痛、功能恢复和患者满意度。

本研究为回顾性研究，纳入单一三级转诊医院中接受机器人辅助运动学对线全膝关节置换术、且至少随访 12 个月的 94 例患者。收集患者人口学资料和手术相关数据。通过患者在日常活动中的疼痛和满意度评估术后情况，并采用 Forgotten Joint Score-12（FJS-12，遗忘关节评分 12 项）评价患者对关节的感知程度。

本队列包括女性 79 例、男性 15 例，平均年龄 63.9 岁。平均手术时间为 120.8 分钟，平均住院时间为 2.56 天。术后并发症较少，11 例患者出现疼痛，3 例出现水肿。多数患者在静息、日常活动和休闲活动中的疼痛缓解方面满意度较高。爬楼梯、长时间站立或运动等高要求活动中，少数患者仍出现疼痛。患者在多种活动中的关节感知度很低，平均 FJS-12 评分为 86.5。

机器人辅助运动学对线全膝关节置换术与较高患者满意度、有效疼痛控制和良好功能恢复相关，并且并发症和翻修率较低。这些发现支持机器人辅助运动学对线全膝关节置换术的精确性和临床可靠性。未来仍需开展前瞻性、比较性和长期随访研究，以验证其长期结局，并进一步优化以患者为中心的治疗。

关键词：运动学对线；机器人辅助手术；全膝关节置换术；患者报告结局；术后疼痛

图 1 术前站立位正侧位片及全长下肢力线片，显示双膝重度骨关节炎。

图 2 术前站立位正侧位片及全长下肢力线片，显示双膝重度骨关节炎。

图 3 术前站立位正侧位片及全长下肢力线片，显示双膝重度骨关节炎。

图 4 术后正侧位片及站立位全长下肢力线片，显示运动学对线技术效果。

图 5 术后正侧位片及站立位全长下肢力线片，显示运动学对线技术效果。

Patient-reported outcomes of kinematically aligned robotic total knee replacement: a single center, single surgeon experience

Kinematic alignment (KA) aims to restore patients’ native knee anatomy, while robotic-assisted surgery (RAS) enhances surgical precision in total knee arthroplasty (TKA). Limited evidence exists regarding patient-centered outcomes following robotic-assisted KA-TKA. This study evaluates postoperative pain, functional recovery, and patient satisfaction. A retrospective study was conducted on 94 patients undergoing kinematically aligned total knee arthroplasty with robotic assistance at a single tertiary referral hospital with a minimum follow-up of 12 months. Demographic and operative data were collected. Postoperative pain and satisfaction were assessed across daily activities, and joint awareness was evaluated using the Forgotten Joint Score-12. The cohort included 79 females and 15 males with a mean age of 63.9 years. Mean operative time was 120.8 min, and mean hospital stay was 2.56 days. Postoperative complications were infrequent, with 11 patients experiencing pain and three had edema. Most patients reported high satisfaction regarding pain relief during rest, daily, and leisure activities. Pain during demanding tasks such as stair climbing, prolonged standing, or exercise occurred in a minority. Patients exhibited very low joint awareness during multiple activities, with a mean Forgotten Joint Score-12 score of 86.5. Robotic-assisted kinematically aligned total knee arthroplasty is associated with high patient satisfaction, effective pain control, and favorable functional recovery, with low complication and revision rates. These findings support the precision and clinical reliability of robotic-assisted kinematically aligned total knee arthroplasty. Prospective, comparative studies with extended follow-up are warranted to validate long-term outcomes and further optimize patient-centered care.

第二部分：保髋相关文献

文献1

髋关节发育不良患儿的父母无症状发育不良的风险评估

译者 张振东

目的：DDH的原因有多种，包括韧带松弛、宫内原因、产前和产后的位置、遗传原因、种族差异和环境因素等。既往较多研究对遗传因素进行报道，已经证明有DDH成员的家庭，其他成员患有DDH的风险是其他家庭的五倍。因此患有DDH的儿童，其父母也属于高危发病群体。本研究的目的是探讨作为发育性髋关节发育不良儿童的父母是否为无症状髋关节发育不良的危险因素。

方法：经超声筛查诊断为DDH的儿童，通过检查他们无症状父母的骨盆正位X线片来评估其是否亦存在髋关节发育不良。共纳入研究组43人86髋，对照组49人98髋。通过分析骨盆正位片Wiberg角、臼顶倾斜角、髋臼深度/宽度指数、股骨头覆盖率( femoral head coverage ratio，FHCR)和股骨颈干角。

结果：研究组平均髋臼深度/宽度指数为44.3%，对照组为53.5%。研究组的平均FHCR为80%，对照组为82%。两组髋臼深度/宽度指数(p < 0.05)、FHCR (p < 0.05)差异均有统计学意义。另外，研究组21例及对照组2例参与者髋臼深度/宽度指数明显异常；而FHCR异常者在研究组有22人，在对照组有13人。两组髋臼深度/宽度指数或FHCR异常者所占比例均有统计学差异。

结论：父母患有DDH是儿童髋关节发育不良的一个明确的危险因素。此外，作为DDH儿童的父母，患有无症状髋关节发育不良的风险要高于普通人群，这些父母应该行x线检查。

Assessing the risk of asymptomatic dysplasia in parents of children with developmental hip dysplasia

Objective: The aim of this study was to investigate whether being the parents of children with developmental hip dysplasia (DDH) is a risk factor for asymptomatic dysplasia.

Methods: Asymptomatic parents of children who were diagnosed with DDH were assessed for presence of dysplasia by examining their anteroposterior pelvis radiographs at the neutral position. Eighty-six hips of 43 participants were included in the study group and 98 hips of 49 participants were included in the control group. Presence of hip dysplasia over the anteroposterior pelvis radiographs was analyzed for Wiberg's angle, acetabular index of the weight-bearing zone (the Tönnis angle), acetabular depth/width index, femoral head coverage ratio (FHCR) and femoral neck/shaft angle.

Results: The mean acetabular depth/width ratio was 44.3% in the study group and 53.5% in the control group. And, the mean FHCR was 80% in the study group and 82% in the control group. There was a statistically significant difference between the two groups in terms of mean acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05). In addition, 21 participants in the study group and 2 in the control group had a pathological acetabular depth/width ratio. And, the number of participants with a pathological FHCR was 22 in the study group and 13 in the control group. A statistically significant difference was found between the two groups regarding the number of pathological measurements of acetabular depth/width ratio (p < 0.05) and FHCR (p < 0.05).

Conclusion: Having a parent with DDH is a definitive risk factor for the development of hip dysplasia in childhood. In addition, being a parent of a child with DDH is a risk factor for asymptomatic dysplasia. These parents should be screened by roentgenogram.

文献出处：Ayanoglu T, Ataoglu MB, Tokgöz N, Ersöz E, Atalar H, Turanlı S. Assessing the risk of asymptomatic dysplasia in parents of children with developmental hip dysplasia. Acta Orthop Traumatol Turc. 2019 Sep;53(5):346-350. doi: 10.1016/j.aott.2019.07.002. Epub 2019 Aug 7.

文献2

基于病理标本的5T MRI T2‑mapping序列对股骨头软骨损伤的临床评估

译者 李勇

背景 传统的影像学检查手段（如X线和常规MRI）对软骨损伤早期微观变化的敏感性不足，难以评估早期退行性改变。探索更灵敏的影像学技术以精确量化软骨损伤，已成为目前骨关节炎研究的重要方向。本研究旨在通过5T MRI T2‑mapping序列量化股骨头软骨感兴趣区的信号强度，并与Mankin病理评分进行相关性分析，从而评估股骨头软骨损伤的程度。

方法 纳入2023年1月至2023年12月期间诊断为髋关节骨关节炎、股骨头缺血性坏死或先天性髋关节发育不良，并接受全髋关节置换术且留取病理标本的患者。在矢状位5T MRI图像上，确定髋臼中心，将股骨头软骨分为8个区域（A1‑A8），每个区域再等分为3个亚区，共得到24个感兴趣区。测量每个感兴趣区的信号强度值。病理分析方面，沿髋臼中心将股骨头标本矢状位切开，脱钙后行番红O‑固绿染色。采用Mankin评分系统评估软骨损伤程度，以Mankin评分为金标准，建立5T MRI T2‑mapping序列评估股骨头软骨损伤的诊断标准，并通过受试者工作特征曲线进行验证。

结果 共分析15例符合纳入标准的患者，涵盖360个感兴趣区。根据Mankin评分，感兴趣区分为轻度损伤（245个区域）、中度损伤（104个区域）和重度损伤（11个区域）。T2‑mapping值与Mankin评分之间存在统计学显著相关性，不同Mankin分级间的T2‑mapping值差异具有统计学意义。ROC曲线分析显示T2‑mapping值的阈值如下：轻度损伤≤43.6，中度损伤＞43.6且≤75.6，重度损伤＞75.6。

Clinical evaluation of femoral head cartilage damage using 5-Tesla MRI T2‑mapping sequence—based on pathological specimens

Background Traditional imaging modalities like X-rays and conventional MRI lack sensitivity to detect early microscopic changes in cartilage damage, making them insufficient for evaluating early degenerative changes. Exploring more sensitive imaging techniques to precisely quantify cartilage damage has become a key focus in current OA research. This study aimed to evaluate the degree of femoral head cartilage damage by quantifying the signal intensity of cartilage regions of interest (ROI) using the 5T MRI T2‑mapping sequence and correlating it with Mankin pathological scores for cartilage damage.

Methods Patients diagnosed with hip osteoarthritis, avascular necrosis of the femoral head, or congenital hip dysplasia, who underwent total hip arthroplasty with pathological specimen collection, were enrolled between January 2023 and December 2023. On sagittal 5T MRI images, the acetabular center was identified, and the femoral head cartilage was divided into eight regions (A1–A8). Each region was further subdivided into three equal parts, resulting in a total of 24 ROIs. The signal intensity values for each ROI were measured. For pathological analysis, femoral head specimens were sagittally sectioned through the acetabular center, decalcified, and stained with Safranin O‑Fast Green. Cartilage damage was assessed using the Mankin scoring system. The Mankin score served as the gold standard for cartilage damage, and a diagnostic standard for evaluating femoral head cartilage damage using the 5T MRI T2‑mapping sequence was established. Receiver Operating Characteristic Curve (ROC) curve analysis was performed for validation.

Results A total of 15 patients meeting the inclusion criteria were analyzed, encompassing 360 ROI regions. Based on Mankin scoring, the ROIs were classified into mild damage (245 regions), moderate damage (104 regions), and severe damage (11 regions). There was a statistically significant correlation between T2‑mapping values and Mankin scores. Significant differences in T2‑mapping values were observed among the different Mankin grades. ROC curve analysis showed the following thresholds for T2‑mapping values: ≤43.6 for mild damage, >43.6 and ≤75.6 for moderate damage, and >75.6 for severe damage.

文献出处：Zhang Y, Wu G, Jiang C, Qiao Y, Zhou G, Yan Z. Clinical evaluation of femoral head cartilage damage using 5-Tesla MRI T2-mapping sequence-based on pathological specimens. BMC Musculoskelet Disord. 2026 Jan 30;27(1):190. doi: 10.1186/s12891-026-09525-2. PMID: 41612279; PMCID: PMC12958666.

文献3

改良 Dunn 手术治疗中重度股骨头骨骺滑脱的长期疗效：一项随访 7 年的前瞻性病例系列研究

译者 贾海港

引言：股骨头骨骺滑脱（SCFE）是青少年中最常见的髋关节疾病，若治疗不当，可能导致股骨髋臼撞击症、早期骨关节炎以及长期功能障碍。虽然原位钉固定仍是轻度滑脱的标准治疗方法，但对于中重度病例，该方法无法纠正畸形，可能增加发生退行性改变的风险。 改良Dunn术（MDP）的开发旨在通过髋关节外科脱位手术恢复股骨近端解剖结构，同时保留股骨头血供。本研究旨在评估改良Dunn术（MDP）对中度（14 例）和重度（10 例）股骨头骨骺滑脱（SCFE）患者的长期影像学及功能预后，并评估缺血性骨坏死（AVN）、骨关节炎及其他并发症的发生率。

方法：2015 年 8 月至 2019 年 1 月期间，在一家三级医疗机构开展了一项前瞻性病例系列研究。共有 24 例患有中重度股骨头骨骺滑脱（SCFE）且骨骺未闭的患髋接受了经髋关节外科脱位的改良 Dunn 手术（MDP）治疗。轻度及单纯急性滑脱患者被排除在外。MDP 被作为首选术式，在临床评估后，对重度滑脱及选定的中度滑脱患者早期实施。患者接受了临床和影像学随访，平均随访时间为 84 ± 2.6 个月（范围：80-88 个月）。功能结果采用 Harris 髋关节评分（HHS）以及 Merle d’Aubigné和 Postel 评分进行评估。记录了影像学结果和并发症，包括股骨头缺血性坏死（AVN）和继发性关节炎。根据术中情况，使用 Schanz 螺钉、空心螺钉或克氏针进行固定。

结果：术前平均滑脱角（48.3° ± 7.2°）在术后得到显著改善（11.4° ± 3.1°，p < 0.001）。HHS评分从术前平均70.4 ± 5.8提高至末次随访时的92.9 ± 4.2（p < 0.001）。Merle d’Aubigné和Postel评分从术前的13.8 ± 1.6提高至末次随访时的17.5 ± 0.9（p < 0.001）。24例患髋中有4例（16.7%）发生了AVN。24例中有2例（8.3%）发生了关节炎（均为退行性骨关节炎；无化脓性关节炎或软骨溶解），结合AVN，共有6例（25%）出现了严重并发症。未发生术后不稳或伤口感染病例。大多数患者的功能评分显示出持续改善。

结论：对于中重度股骨头骨骺滑脱（SCFE），MDP 术式可带来良好的长期解剖矫正和功能恢复。然而，鉴于发生骨坏死和关节炎的风险（特别是在不稳定或重症病例中），必须谨慎筛选患者并确保手术技术的精准性。长期随访对于发现晚期并发症和评估手术效果的持久性至关重要。

图 1a、b 为术前 X 线片（正位和侧位），显示一名 12 岁男孩的右侧股骨头骨骺滑脱症。c、d 为术后 X 线片（正位和侧位）。术后 1 年随访：采用两枚 4mm 空心全螺纹螺钉进行 MDP 固定。e–g 术后 X 线片（正位和侧位）。最后一次随访（7 年）时，照片显示功能恢复良好，双侧髋关节屈曲范围相同。

图 2 a、b 为术前 X 线片（正位和侧位），显示一名 10 岁男孩左侧股骨头骨骺滑脱症（SCFE）。c、d 为术后 X 线片（正位和侧位），显示采用 MDP 手术和三枚 Schanz 螺钉（3 mm）固定后 1 年的随访情况。e-g 为最后一次随访（7 年）时的术后 X 线片（正位和侧位）及照片，显示左髋关节活动范围和功能均良好。

图 3 a、b 术前 X 光片（正位和侧位）显示一名 11 岁女孩确诊为 SCFE。c、d 为术后 X 线片（正位）以及侧位）在最后一次随访（7 年）时，以及经三点固定后Schanz 螺钉（3 毫米）

Long-term outcomes of the modified Dunn procedure in moderate and severe slipped capital femoral epiphysis: a prospective case series with 7-year follow-up

Introduction Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents and may lead to femoroacetabular impingement, early osteoarthritis, and long-term functional disability if inadequately treated.

While in situ pinning remains the standard treatment for mild slips, it fails to correct the deformity in moderate and severe cases, potentially predisposing to degenerative changes. The modified Dunn procedure (MDP) was developed to restore proximal femoral anatomy through surgical hip dislocation while preserving vascular supply. The aim of the study is to evaluate the long-term radiological and functional outcomes of the MDP in patients

with moderate (14 cases) and severe (10 cases) SCFE, and to assess the incidence of avascular necrosis (AVN), osteoarthritis, and other complications.

Methods A prospective case series was conducted between August 2015 and January 2019 at a single tertiary institution. A total of 24 hips with moderate-to-severe SCFE and open physis were treated using the MDP via surgical hip dislocation. Mild and acute-only slips were excluded. MDP was used as a primary procedure, performed early in severe slips and in selected moderate slips after clinical assessment. Patients were followed clinically and radiologically for a mean duration of 84 ± 2.6 months (range 80–88 months). Functional outcomes were assessed using the Harris Hip Score (HHS) and Merle d’Aubigné and Postel score. Radiographic outcomes and complications, including AVN and secondary arthritis, were documented. Fixation was performed using Schanz screws, cannulated screws, or K-wires according to intraoperative findings.

Results The mean preoperative slip angle (48.3° ± 7.2°) significantly improved postoperatively (11.4° ± 3.1°, p< 0.001). HHS improved from a preoperative mean of 70.4 ± 5.8 to 92.9 ± 4.2 at final follow-up (p< 0.001). The Merle d’Aubigné and Postel score improved from 13.8 ± 1.6 preoperatively to 17.5 ± 0.9 at final follow-up (p< 0.001). AVN developed in 4 out of 24 hips (16.7%). Arthritis developed in 2 out of 24 hips (8.3%, degenerative OA; no septic arthritis or chondrolysis), representing a total of 6 out of 24 hips (25%) with significant complications when combined with AVN. No cases of postoperative instability or wound infection occurred. Functional scores showed sustained improvement in the majority of patients.

Conclusions MDP offers favorable long-term anatomical correction and functional recovery in moderate-to-severe SCFE. However, the risk of AVN and arthritis, particularly in unstable or severe cases, warrants careful patient selection

文献出处：Fahmy, M., Abdelazeem, A.H. & Shawky, M.A. Long-term outcomes of the modified Dunn procedure in moderate and severe slipped capital femoral epiphysis: a prospective case series with 7-year follow-up. J Orthop Traumatol 27, 5 (2026). https://doi.org/10.1186/s10195-026-00899-6

文献4

美国与日本非创伤性股骨头坏死保头手术治疗策略的差异：文献综述

译者 陶可

对于非创伤性股骨头坏死（ONFH）患者，西方国家主要采用髓芯减压术（CD）和植骨术（BG），而日本则以截骨术为主。目前，人们对美国和日本在ONFH保头手术方面的显著差异认识不足。本文旨在探讨两国ONFH治疗策略的背景和差异。我们基于2014年发表的一篇美国论文和2013年发表的一篇日本国家级文献，比较了1997-2001年、2002-2006年和2007-2011年三个时期（美国数据为2007-2008年）两国的手术趋势。我们比较了两份报告中相同条件下非创伤性股骨头坏死（ONFH）的手术细节。

1997-2001年期间，美国ONFH的手术率如下：全髋关节置换术（THA）86%；髓芯减压术（CD）10%；截骨术0.4%。在日本，THA为61%，截骨术为38%，CD为0%。在最近的2007-2011年期间（美国为2007-2008年），美国的THA率为91%，CD为6%，截骨术为0.1%，而日本的相应数据分别为73%、0%和26%。过渡期（2002-2006年）的数据介于新旧数据之间。美国和日本在ONFH的保头手术应用方面存在显著差异。在美国，一线保头手术是髓芯减压术（CD），而在日本则是截骨术。这两种手术在对方国家都很少进行。从2000年到2010年左右，两国全髋关节置换术（THA）的比例均有所上升，而保头手术（美国的股骨头髓芯减压术和日本的截骨术）的比例则有所下降。保头手术比例的下降可能主要归因于技术进步，提高了全髋关节置换术的长期疗效。此外，年轻的股骨头坏死（ONFH）患者也不愿接受截骨术等需要长期住院的保髋手术。

Difference in Therapeutic Strategies for Joint-Preserving Surgery for Non-Traumatic Osteonecrosis of the Femoral Head between the United States and Japan: A Review of the Literature

For patients with non-traumatic osteonecrosis of the femoral head (ONFH), core decompression (CD) and bone grafts (BG) are mainly performed in the West, while osteotomy is found to be predominant in Japan. It is not well recognized how the surgical procedures for joint preservation in patients with ONFH are completely different between the United States and Japan. This paper identifies the contexts and the differences in treatment strategies for ONFH between the two countries. We compared the surgical trends of the two countries over three periods, 1997-2001, 2002-2006, and 2007-2011 (the US data for the third period was 2007-2008), based on a 2014 US paper and a 2013 national publication in Japan. We compared the details of surgery for non-traumatic ONFH under the same conditions in the two reports. For the period 1997-2001, the rates of surgeries for ONFH in the US were as follows: total hip arthroplasty (THA), 86%; CD, 10%; and osteotomy, 0.4%. In Japan, THA was 61%, osteotomy 38%, and CD 0%. For the recent period, 2007-2011 (US 2007-2008), the rate of THA was 91%, CD 6%, and osteotomy 0.1%, in the US, compared to a THA rate of 73%, CD 0%, and osteotomy 26% in Japan. The results for the interim period (2002-2006) were between the old and new data. The use of joint-preserving surgery for ONFH differs greatly between the US and Japan. The first-line joint-preserving surgery was CD in the US and osteotomy in Japan. Each procedure was rarely done in the other country. From about 2000 to 2010, the percentage of THA increased in both countries. The proportion of joint-preserving surgery (CD in the US and osteotomy in Japan) declined. The decrease in joint-preserving procedures may be largely attributed to improved long-term outcomes of THA due to technological advances. There is also a reluctance for young ONFH patients to undergo joint-preserving procedures, such as osteotomy, that require long-term hospitalization.

文献出处：Yutaka Kuroda, Yaichiro Okuzu, Toshiyuki Kawai, Koji Goto, Shuichi Matsuda. Difference in Therapeutic Strategies for Joint-Preserving Surgery for Non-Traumatic Osteonecrosis of the Femoral Head between the United States and Japan: A Review of the Literature. Review Orthop Surg. 2021 May;13(3):742-748. doi: 10.1111/os.12979. Epub 2021 Apr 5.

文献5

患者特异性功能性骨盆倾斜是否影响髋关节发育不良中的关节接触压力？一项有限元分析研究

译者 邱兴

背景：尽管生理性骨盆倾斜的个体差异和姿势变化会影响髋关节发育不良患者的髋臼方向和覆盖范围，但其对髋关节力学环境的影响尚未完全明确。考虑生理性骨盆倾斜的个体化有限元分析可能为发育不良髋关节的接触力学提供有价值的见解，从而有助于进一步理解该患者人群的发病机制并改进治疗方案。

问题/目的：我们采用有限元分析方法，探讨以下问题：与无发育不良的患者相比，髋关节发育不良患者在以下方面是否存在差异：(1) 生理性骨盆倾斜；(2) 骨盆位置与关节接触压力；(3) 与关节接触压力相关的形态学因素。

方法：2016年至2019年间，82例患者因髋关节发育不良接受了骨盆截骨术。纳入70例髋关节发育不良患者（仰卧位骨盆正位X光片上外侧中心边缘角 ≥ 0° 且 < 20°）。排除患有晚期骨关节炎、股骨头畸形、既往髋部或仰卧位手术史或影像质量不佳的患者。最终有32例患者（32髋）符合条件进入本有限元分析研究。对照组纳入了33例无髋关节疾病史的女性志愿者。排除存在明确或临界髋关节发育不良（外侧中心边缘角 < 25°）或影像质量不佳的个体。最终16例个体（16髋）作为对照。两位经专科认证的骨科医生使用骨盆X光片和CT图像测量了矢状面骨盆倾斜（骨盆前平面与垂直轴之间的夹角：即骨盆前平面角）、髋臼前倾角及髋臼覆盖范围。使用Kappa值和组内相关系数评估观察者内及观察者间信度，结果均为良好或优秀。我们利用骨盆CT图像建立了个体化有限元模型，并进行了非线性接触分析，以计算在单腿站立姿势下，针对三种骨盆位置（标准化位：骨盆前平面；仰卧位；站立位）的髋臼软骨上的关节接触压力。采用t检验或Wilcoxon秩和检验比较发育不良组与非发育不良组的生理性骨盆倾斜。采用配对t检验或Wilcoxon符号秩检验（并采用Bonferroni校正）比较三种骨盆位置之间的关节接触压力。我们还分析了关节接触压力与形态学参数及骨盆倾斜之间的相关性。

结果：在仰卧位和站立位中，骨盆前平面角在不同个体间差异很大。站立位时，髋关节发育不良患者的骨盆前平面角大于对照组（3°±6°比-2°±8°；均数差5° [95% CI 1°至9°]；p=0.02）；但在仰卧位时两组间无差异（8°±5°比5°±7°；均数差3° [95% CI 0°至7°]；p=0.06）。髋关节发育不良患者从仰卧位转为站立位时，平均骨盆向后倾斜6°±5°。发育不良髋关节的最大接触压力中位数（范围）高于对照组（站立位：7.3兆帕 [4.1至14] 比 3.5兆帕 [2.2至4.4]；中位数差3.8兆帕；p<0.001）。在髋关节发育不良患者中，站立位骨盆位置的最大接触压力中位数大于仰卧位（7.3兆帕 [4.1至14] 比 5.8兆帕 [3.5至12]；中位数差1.5兆帕；p<0.001）。尽管标准化骨盆位置的最大关节接触压力中位数与站立位相比无差异（7.4兆帕 [4.3至15] 比 7.3兆帕 [4.1至14]；中位数差-0.1兆帕；p>0.99），但最大接触压力的个体差异范围从-3.3兆帕到2.9兆帕不等，这反映了站立位时骨盆前平面角的广泛变异（均值为3°±6°，范围为-11°至14°）。在髋关节发育不良患者中，站立位的最大关节接触压力与站立位骨盆前平面角呈负相关（r = -0.46；p = 0.008）。

结论：我们的发现表明，生理性骨盆倾斜的个体差异和姿势变化会影响髋关节的关节接触压力。未来关于髋关节发育不良发病机制及关节保留手术的研究，不仅应考虑仰卧位或标准骨盆位置，还需要纳入站立位下患者特异性骨盆倾斜对髋关节生物力学环境的影响。

临床相关性：我们建议在诊断髋关节发育不良和规划髋关节保留手术时，评估矢状面骨盆倾斜的姿势变化，因为仰卧位或标准骨盆位置的评估可能会忽视负重位下髋关节接触力学的改变。需要进一步研究以阐明患者特异性功能性骨盆倾斜对发育不良髋关节退变过程、髋臼再定向操作以及关节保留手术临床效果的影响。

图 1 A-B（A）这些图像展示了使用X光片和CT图像匹配矢状面骨盆倾斜的方法。在骨盆正位X光片上，计算双侧骶髂关节与耻骨联合之间的骨盆孔垂直直径（V）除以骨盆孔最大水平直径（H）所得的比值。在由CT图像生成的数字重建X光片上，将骨盆在矢状面上旋转，直至其骨盆孔的比值与骨盆正位X光片上的比值相匹配。
（B）图示为标准、仰卧和站立三种骨盆位置。我们将标准骨盆位置定义为CT扫描仪坐标系与骨盆前平面坐标系重合时的位置。仰卧位和站立位的矢状面骨盆倾斜量化为骨盆前平面与Z轴形成的夹角（即骨盆前平面角）。

图 2 此图展示了髋关节发育不良组（外侧中心边缘角为16°）和对照组（外侧中心边缘角为31°）中代表性患者的右侧髋关节髋臼软骨上关节接触压力的分布情况。从颜色分布可以看出，发育不良髋关节的关节接触压力高于对照髋关节。

Does Patient-specific Functional Pelvic Tilt Affect Joint Contact Pressure in Hip Dysplasia? A Finite-element Analysis Study

Background: Although individual and postural variations in the physiologic pelvic tilt affect the acetabular orientation and coverage in patients with hip dysplasia, their effect on the mechanical environment in the hip has not been fully understood. Individual-specific, finite-element analyses that account for physiologic pelvic tilt may provide valuable insight into the contact mechanics of dysplastic hips, which can lead to further understanding of the pathogenesis and improved treatment of this patient population.

Question/purpose: We used finite-element analysis to ask whether there are differences between patients with hip dysplasia and patients without dysplasia in terms of (1) physiologic pelvic tilt, (2) the pelvic position and joint contact pressure, and (3) the morphologic factors associated with joint contact pressure.

Methods: Between 2016 and 2019, 82 patients underwent pelvic osteotomy to treat hip dysplasia. Seventy patients with hip dysplasia (lateral center-edge angle ≥ 0° and < 20° on supine AP pelvic radiographs) were included. Patients with advanced osteoarthritis, femoral head deformity, prior hip or supine surgery, or poor-quality imaging were excluded. Thirty-two patients (32 hips) were eligible to this finite-element analysis study. For control groups, we reviewed 33 female volunteers without a history of hip disease. Individuals with frank or borderline hip dysplasia (lateral center-edge angle < 25°) or poor-quality imaging were excluded. Sixteen individuals (16 hips) were eligible as controls. Two board-certified orthopaedic surgeons measured sagittal pelvic tilt (the angle between the anterior pelvic plane and vertical axis: anterior pelvic plane [APP] angle) and acetabular version and coverage using pelvic radiographs and CT images. Intra- and interobserver reliabilities, evaluated using the kappa value and intraclass correlation coefficient, were good or excellent. We developed individual-specific, finite-element models using pelvic CT images, and performed nonlinear contact analysis to calculate the joint contact pressure on the acetabular cartilage during the single-leg stance with respect to three pelvic positions: standardized (anterior pelvic plane), supine, and standing. We compared physiologic pelvic tilt between patients with and without dysplasia using a t-test or the Wilcoxon rank sum test. A paired t-test or the Wilcoxon signed rank test with a Bonferroni correction was used to compare joint contact pressure between the three pelvic positions. We correlated joint contact pressure with morphologic parameters and pelvic tilt using the Pearson or the Spearman correlation coefficients.

Results: The APP angle in the supine and standing positions varied widely among individuals. It was greater in patients with hip dysplasia than in patients in the control group when in the standing position (3° ± 6° versus -2° ± 8°; mean difference 5° [95% CI 1° to 9°]; p = 0.02) but did not differ between the two groups when supine (8° ± 5° versus 5° ± 7°; mean difference 3° [95% CI 0° to 7°]; p = 0.06). The mean pelvic tilt was 6° ± 5° posteriorly when shifting from the supine to the standing position in patients with hip dysplasia. The median (range) maximum contact pressure was higher in dysplastic hips than in control individuals (in standing position; 7.3 megapascals [MPa] [4.1 to 14] versus 3.5 MPa [2.2 to 4.4]; difference of medians 3.8 MPa; p < 0.001). The median maximum contact pressure in the standing pelvic position was greater than that in the supine position in patients with hip dysplasia (7.3 MPa [4.1to 14] versus 5.8 MPa [3.5 to 12]; difference of medians 1.5 MPa; p < 0.001). Although the median maximum joint contact pressure in the standardized pelvic position did not differ from that in the standing position (7.4 MPa [4.3 to 15] versus 7.3 MPa [4.1 to 14]; difference of medians -0.1 MPa; p > 0.99), the difference in the maximum contact pressure varied from -3.3 MPa to 2.9 MPa, reflecting the wide range of APP angles (mean 3° ± 6° [-11° to 14°]) when standing. The maximum joint contact pressure in the standing position was negatively correlated with the standing APP angle (r = -0.46; p = 0.008) in patients with hip dysplasia.

Conclusion: Based on our findings that individual and postural variations in the physiologic pelvic tilt affect joint contact pressure in the hip, future studies on the pathogenesis of hip dysplasia and joint preservation surgery should not only include the supine or standard pelvic position, but also they need to incorporate the effect of the patient-specific pelvic tilt in the standing position on the biomechanical environment of the hip.

Clinical relevance: We recommend assessing postural change in sagittal pelvic tilt when diagnosing hip dysplasia and planning preservation hip surgery because assessment in a supine or standard pelvic position may overlook alterations in the hip's contact mechanics in the weightbearing positions. Further studies are needed to elucidate the effect of patient-specific functional pelvic tilt on the degeneration process of dysplastic hips, the acetabular reorientation maneuver, and the clinical result of joint preservation surgery.

文献出处：Kitamura, K., Fujii, M., Ikemura, S., Hamai, S., Motomura, G., & Nakashima, Y. (2021). Does patient-specific functional pelvic tilt affect joint contact pressure in hip dysplasia? A finite-element analysis study. Clinical Orthopaedics and Related Research®, 479(8), 1712-1724.

来源：304关节学术

作者：304关节团队

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