髖膝關節文獻精譯薈萃（第376期）

本期目錄：

1、二期關節置換翻修術再植入假體術中α -防御素陽性與1年感染無關

2、手術體位是否影響全髖關節置換術中神經血管損傷的風險

3、全膝關節置換術中應用負載抗氧化劑的高交聯聚乙烯墊片可以降低翻修風險

4、調整機械力線：手術技巧——要點與竅門

5、機器人輔助全膝關節置換術中的骨贅骨性平衡

6、Perthes病患者大轉子阻滯術術后的影像學結果

7、計算機輔助髖臼周圍截骨術治療髖關節發育不良患者

8、手術年齡與髖臼周圍截骨術后早期患者自述結局無相關性

9、軟骨下骨折始于股骨頭壞死中的骨吸收區域

第一部分：關節置換及保膝相關文獻

文獻1

二期關節翻修術再植入假體術中α -防御素陽性與1年感染無關

譯者 張軼超

背景：診斷假體周圍關節感染（PJI）是一項挑戰，它依賴于多種可能不一致的臨床和實驗室標準。滑膜α -防御素-1 （AD-1）檢測已被證明與肌肉骨骼感染學會（MSIS）診斷PJI的標準準確相關，然而，在二期再植入新假體前接受抗生素間隔器的患者中，其與殘留PJI的關系尚未得到闡明。采用基于delphi的共識來定義PJI的成功根除，為測試AD-1在這種情況下的效用提供了機會。

問題/目的：(1)，作為德爾菲持續性PJI標準的替代，在使用間隔器治療PJI的兩期翻修術期間通過AD-1測試是否可以確定感染是否得到控制或根除？(2)與MSIS標準相比，AD-1測試的準確性如何？

方法：回顧性分析2014年5月至2016年7月期間接受兩期翻關節置換修術患者的多中心數據。我們納入了先前確診的PJI并接受了水泥間隔器的患者，進行第二階段治療，具有MSIS評分數據和滑液AD-1測試，并且至少隨訪1年。我們無法確定所有研究單位有多少患者進行了測試，但不符合所有標準就排除在研究之外；我們能夠確定有69例患者（43膝，26髖）符合所有標準。在此期間，使用AD-1的適應征因外科醫生而異；然而，在此期間，如果外科醫生要求將AD-1作為第一階段手術中測試的一部分，則通常會在第二階段再植入手術之前重復該測試。為了評估AD-1對1年時持續性PJI測試的有效性，使用持久性PJI的德爾菲標準作為金標準計算以下數據：敏感性，特異性，陽性和陰性預測值，準確性和 95%置信區間（CIs）曲線下面積（AUC）。采用AD-1和MSIS標準計算持續性PJI的德爾菲標準的一致性指數（c-index）及其與受試者工作特征（ROC）曲線的Wald 95% CI。采用DeLong非參數方法比較AD-1和MSIS的C指數。

結果：AD-1試驗在檢測1年感染根除方面敏感性較差（7%;95% CI, 0.2-34），總體準確性較差（73%;95% CI, 60-83; AUC = 0.5; 95% CI, 0.3-0.6）。AD-1標準與Delphi標準診斷持續性PJI的C指數為0.519 (95% CI, 0.44-0.60)， MSIS標準與Delphi標準診斷持續性PJI的C指數為0.518 (95% CI, 0.49-0.54)，表明這些模型的診斷能力較弱。MSIS標準和AD-1之間的對比估計值在-0.001之間，沒有差異（95% CI%, -0.09至0.09;p = 0.99）。

結論：我們發現滑膜液AD-1測試陽性與PJI兩期關節置換翻修術后1年持續感染的存在相關性較差。因此，我們不建議在使用水泥間隔器的患者中常規使用AD-1，直到或除非未來的研究證明該測試比我們發現的結果更有效。

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.

文獻出處：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.

文獻2

手術體位是否影響全髖關節置換術中神經血管損傷的風險？一項磁共振成像研究

譯者 馬云青

神經血管損傷是全髖關節置換術（THA）中一種嚴重的并發癥。然而，不同體位下髖關節周圍神經血管的位置差異尚未得到研究。作者利用磁共振成像（MRI）探討了仰臥位和側臥位髖關節置換時髖部神經血管位置的差異。研究假設為髖部神經血管的位置受手術體位差異的影響。這是一項單中心前瞻性研究，招募了2018年1月至2019年3月期間的15名健康志愿者。每位受試者的雙側髖關節均在仰臥位和側臥位下使用3.0-T MRI進行掃描。在髖關節中心水平的T1加權軸位圖像上，將髖臼前緣和后緣定義為手術中放置牽開器的常見參考點。作者測量了髖臼前緣與股神經（dFN）、股動脈（dFA）和股靜脈（dFV）之間的距離，以及髖臼后緣與坐骨神經（dSN）之間的距離。主要結局指標是兩種體位下的這些距離。

結果顯示仰臥位和側臥位下的dFN、dFA和dFV（毫米，均值±標準差）分別為：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）。與仰臥位相比，這些結構大部分在側臥位時向前內側方向移動。仰臥位和側臥位之間的dSN沒有顯著差異（23.7 ± 4.9 和 24.5 ± 6.5，p = 0.46）。結果顯示，與側臥位相比，仰臥位進行THA可能伴隨更高的股神經血管損風險。研究結果有助于降低THA術中股神經血管損傷的風險。

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.

文獻出處：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.

文獻3

全膝關節置換術中應用負載抗氧化劑的高交聯聚乙烯墊片可以降低翻修風險

譯者 張薔

背景：盡管載有抗氧化劑的高交聯聚乙烯（HXLPE）墊片在全膝關節置換（TKA）手術中的應用比例逐年增加，文獻中卻鮮有證據證實其優于普通HXLPE墊片的臨床獲益。本研究旨在比較應用負載和不負載抗氧化劑HXLPE墊片的TKA翻修風險。

方法：本隊列研究選取了來自凱撒永恒醫療集團關節置換登記庫的數據。病例選擇了2001年至2023年間所有因骨關節炎而施行固定平臺初次TKA手術并置換髕骨的病例。研究組為應用負載和未負載抗氧化劑HXLPE墊片的TKA病例。首要研究指標為全因翻修風險；次要研究指標為感染翻修風險以及磨損、松動等非感染翻修風險。我們應用多變量Cox風險比例回歸分析法評估調整協變量后的翻修風險。

結果：最終入組92923例TKA病例：其中48846例應用了負載抗氧化劑的HXLPE墊片，另外44077例應用了未負載抗氧化劑的HXLPE墊片。平均年齡67.7歲，平均BMI為31.2kg/m2。女性（64.3%）、白種人（64.8%）和ASA分級為1-2（65.2%）占多數。經粗略計算，術后13年翻修風險：負載抗氧化劑組為3.4%而未負載抗氧化劑組為4.2%。在校正混雜因素后，我們發現負載抗氧化劑組的翻修風險顯著低于未負載抗氧化劑組（概率比[HR], 0.86 [95%置信區間(CI), 0.79 - 0.95]）。當調查具體翻修原因時，我們發現負載抗氧化劑組的非感染翻修（HR, 0.86 [95%CI, 0.76 - 0.97]）和磨損翻修（HR, 0.41 [95%CI, 0.21 - 0.81]）的風險更低。

結論：我們發現應用了負載抗氧化劑HXLPE墊片的TKA病例術后的全因翻修風險和磨損翻修風險更低。

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.

文獻出處：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.

文獻4

調整機械力線：手術技巧——要點與竅門

譯者 丁云鵬

引言：機械對線（MA）是一種旨在實現下肢力線中立位的標準化手術方案。使假體對線更接近患者解剖結構的方案可能獲得更佳臨床療效。本文介紹的調整機械對線（aMA）手術技術是一種改良的"間隙優先"技術，該技術通過考量膝關節天然韌帶張力，從而盡可能避免實施韌帶松解。

適應證：aMA技術適用于內翻≤20°的原發性和繼發性膝內翻骨關節炎。

手術技術：該術式通過股骨骨性矯正而非韌帶松解來實現韌帶張力平衡。術中標記經股骨上髁軸線（TEA）和滑車溝線以控制基于韌帶張力的股骨旋轉。通過清除骨贅確保韌帶張力可靠。謹慎牽拉定量韌帶張力器，讀取間隙寬度及內外側韌帶張力數值。為矯正伸直間隙不對稱性，采用特殊股骨截骨模塊（而非典型的內側軟組織松解）進行代償。隨后評估屈曲間隙——此時股骨橫向旋轉需遵循軟組織張力。張力器將調節出具有平衡韌帶張力的矩形屈曲間隙。完成最終間隙平衡后，結束股骨準備步驟并安裝試模。通過反復屈伸活動確定脛骨假體旋轉定位。

討論與結論：本技術將測量截骨技術與個體化韌帶張力相結合。在冠狀面上，股骨對線與中立位的最大偏差為2.5°。為避免并發癥，建議如本技術所述通過調整股骨假體實現基于患者解剖的假體對線。測量截骨技術存在屈曲不穩風險，而間隙平衡技術可在精確脛骨近端截骨前提下實現對稱韌帶張力。股骨假體旋轉對位時需綜合考慮屈曲間隙穩定性與髕骨軌跡。需開展大樣本長期研究來驗證本術式良好的短期療效。

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.

文獻出處：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.

文獻5

機器人輔助全膝關節置換術中的骨贅骨性平衡：一種手術技術及軟組織松弛度的預測算法

譯者 沈松坡

引言：在全膝關節置換術（TKA）過程中切除骨贅會導致軟組織張力降低，從而可能引起關節松弛。因此，在進行間隙平衡時，術者往往希望在尚未進行任何骨切除、也未切除骨贅之前，預測骨贅切除對屈曲間隙和伸直間隙的影響。然而，后方骨贅相對難以接近，因為只有在完成股骨后方骨切除之后才能將其切除。由后方骨贅切除所產生的松弛無法通過調整骨切除來糾正，因為骨切除此時已經完成。作者開發了一種用于機器人輔助全膝關節置換術的預測算法，該算法可預判骨贅切除的影響，從而在任何骨切除之前即對骨性切除方案進行調整。

材料與方法：在術前CT掃描的矢狀位平面上測量股骨后方骨贅的橫截面積。作者的骨贅校正方法是基于后方骨贅的大小和形態，對脛骨切除進行調整，因為作者認為骨贅切除所產生的松弛會同時影響伸直和屈曲間隙。隨后，根據骨贅的大小及其位置（后內側或后外側）來確定骨切除的具體量及部位。

結果：通過上述技術，作者發現骨贅切除所產生的松弛程度與軟組織所跨越骨贅的尺寸呈直接相關。

結論：通過基于CT掃描成像確定的、初始狀態下不可直接接近的后方骨贅的大小和形態，作者建立了一種預測性的骨性平衡算法，該算法可與術者偏好的骨性平衡技術相結合。該預測算法能夠在骨贅切除之前預判其所引起的松弛，并可用于調整骨切除參數和/或假體參數（例如脛骨墊片的厚度），以適應增加的松弛度，從而實現骨量保留及畸形矯正。

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：保髖相關文獻

文獻1

Perthes病患者大轉子阻滯術術后的影像學結果

譯者 任寧濤

目的:Legg-Calvé-Perthes病常導致大轉子高位，對髖關節的生物力學產生負面影響。本研究的目的是評估大轉子的生長性和大轉子阻滯術的放射學效果。

方法:回顧性分析46名單側Legg-Calvé-Perthes患兒的臨床資料，其中男33例，平均年齡(8±1.3)歲，行股骨大轉子骨骺固定及局部骨骺融合術。通過術前和術后的骨盆x線片(平均隨訪3.5年)，確定大轉子高度、關節大轉子距離和關節中心大轉子距離，并與未受影響側進行比較。建立大轉子高度、關節大轉子距離和關節中心大轉子距離隨時間的生理發育參考值。

結果:以大轉子高度衡量，大轉子阻滯術使大轉子生長降低29%，但僅在<8歲組有統計學意義(p = 0.02)。回歸分析顯示，大轉子生長抑制率為0.92 mm/年。在隨訪期間，患側和健側關節大轉子距離和關節中心大轉子距離趨同:患側髖關節大轉子距離增加(術前:11.2±7 mm，發育成熟:18.5±10 mm;P < 0.01)，而健側無變化(術前:19.3±5 mm，發育成熟:18±6 mm;P = 0.69)。患側髖中心轉子距離保持不變(術前:(-7.9)±7 mm，發育成熟(-7.8)±9 mm;P = 0.13)。在健側，關節中心大轉子距離變為負值(術前:0.9±6mm，發育成熟:(-6.5)±5mm;P < 0.001)。以關節大轉子距離和中心大轉子距離測量，31.8%的患者獲得最佳結果。

結論:大轉子阻滯術對抑制大轉子的生長有積極的影響，從而對髖關節的解剖有積極的影響。進一步的研究必須證明這些積極的影響是否也會導致生物力學和功能上的好處。

圖1 大轉子高度（TH）：大轉子尖和大轉子最底部兩個平行線之間的距離，兩個平行線垂直于股骨干軸線。關節大轉子距離（ATD）：大轉子尖和股骨頭最頂部兩個平行線之間的距離，兩個平行線垂直于股骨干軸線。關節中心大轉子距離(CTD)：大轉子尖和股骨頭中心兩個之間的距離，垂直于股骨干軸線。

圖2 男，11歲，因LCPD行Salter截骨治療，后行大轉子阻滯術。

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.

文獻出處：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.

文獻2

計算機輔助髖臼周圍截骨術治療髖關節發育不良患者

譯者 李勇

摘要：髖臼旋轉截骨術（RAO）是治療髖臼發育不良患者的一種成熟手術方式，已有報道顯示其具有優異的長期療效。然而，RAO 技術要求高，該手術的精準實施需要豐富的手術經驗。計算機導航在 RAO 中的作用包括：能夠進行三維（3D）術前規劃；即使在視野不佳的情況下也能安全實施截骨；減少術中透視帶來的輻射暴露；以及實時顯示骨鑿尖端位置。最后一點在教學上也很有用，因為它能讓術者以外的工作人員也能跟進手術進程。在我們的研究結果中，比較了 23 例接受導航輔助 RAO 的髖關節與 23 例未接受導航輔助手術的髖關節，并未觀察到放射學評估方面有顯著差異。然而，導航組未發生圍手術期并發癥，而非導航組觀察到一例暫時性股神經麻痹。利用 3D 術前規劃和基于 CT 的導航系統提供的術中輔助，可以實施更精確、更安全的 RAO 手術。

圖1.應用計算機軟件進行髖臼旋轉截骨術前規劃。(A)術前規劃截骨線時，規劃髖臼球形截骨，使球體的中心靠近股骨頭中心（或髖關節中心）。(B)計劃向外側旋轉，直至臼頂傾斜角度變為0°，糾正前向覆蓋。

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.

文獻出處：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.

文獻3

手術年齡與髖臼周圍截骨術后早期患者自述結局無相關性

譯者 陶可

背景：髖臼周圍截骨術(PAO)治療癥狀性髖關節發育不良的臨床療效已得到充分證實。然而，關于年齡與臨床結局的相關性，目前尚無定論。髖關節功能障礙和骨關節炎結局評分 - 全球版 (HOOSglobal)是近期驗證的PAO術后患者自述結局指標。本研究旨在評估PAO術后早期隨訪時HOOSglobal評分和西安大略大學和麥克馬斯特大學骨關節炎指數(WOMAC)評分與手術年齡的關系。

方法：本研究納入391例接受PAO手術且隨訪時間至少2年（平均4.71年）的患者，這是一項前瞻性多中心隊列研究。患者按年齡分為4個組：<20歲（N = 131）、20-29歲（N = 102）、30-39歲（N = 65）和≥40歲（N = 34）。采用4×2重復測量方差分析（年齡組×時間）比較各年齡組術前和術后的HOOSglobal評分和WOMAC評分。采用多元線性回歸分析確定術后HOOSglobal評分的預測因子。

結果：所有年齡組的HOOSglobal評分和WOMAC評分均有所升高；然而，與<20歲（P< .002）、20-29歲（P = .01）和30-39歲（P = .02）組相比，≥40歲組的術前至術后HOOSglobal評分和WOMAC評分的升高幅度具有統計學意義。術前HOOSglobal評分越高，術后HOOSglobal評分也越高（P < .001），但年齡（P = .65）、性別（P = .80）、體重指數（P = .50）和T?nnis分級（P = .07）并非1年預后的獨立預測因子。

結論：不同年齡段患者術后早期自述結局無差異，表明在有癥狀的髖關節發育不良的情況下，PAO手術的成功與患者年齡無關。因此，在評估PAO手術候選者時，僅以年齡作為選擇標準可能并不合適。

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 T?nnis 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.

文獻出處：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.

文獻4

軟骨下骨折始于股骨頭壞死中的骨吸收區域：一項顯微CT斷層掃描研究

譯者 邱興

目的： 為成功實施股骨頭壞死（ONFH）的保髖治療，理解其塌陷機制至關重要。本研究旨在通過對完整股骨頭進行顯微CT成像，探討ONFH中軟骨下骨折的起始點，著重分析軟骨下骨折與骨吸收區域之間的三維關系。
方法： 根據日本骨壞死研究會標準，我們選取了37名患者（共40個股骨頭）在因3A或3B期ONFH行人工全髖關節置換術時獲得的樣本，使用層厚為0.146毫米的顯微CT進行掃描。根據顯微CT測量的塌陷程度，以3毫米為界，將樣本分為早期塌陷期與晚期塌陷期。
結果： 通過對完整股骨頭多個徑向平面圖像的分析，我們得到了兩項重要發現。首先，在所有18個早期塌陷期的股骨頭中，初始骨折裂隙均走行于股骨頭前上部分離的骨吸收區域之間。其次，在22個晚期塌陷期樣本中的19個里，觀察到壞死骨在硬化邊界處發生斷裂，并在硬化邊界的壞死骨側可見纖維性、肉芽樣低密度組織。繼發于支持帶及圓韌帶附著處周圍的骨吸收引發軟骨下骨折后，骨吸收區域在股骨頭前上部的擴大可能導致骨折蔓延并引發大面積塌陷。
結論： 三維顯微CT顯示，修復區周圍的骨吸收是引發ONFH軟骨下骨折的起始點。
關鍵詞： 骨吸收；塌陷；顯微CT；股骨頭壞死；軟骨下骨折。

圖1 獲取經過股骨頭中心點、股骨頸中心點（較大標記點）及股骨距中心點（較小標記點）的冠狀面。在該冠狀面上，建立一條包含股骨頭中心點與股骨頭凹中心點（X標記點）的內外側軸。以此內外側軸為基準，通過旋轉該冠狀面，重建出多個徑向平面視圖。

圖2 針對股骨頭壞死的骨吸收區域與軟骨下骨折進行的全股骨頭三維顯微CT分析。

圖3 a 早期塌陷階段各徑向平面上初始軟骨下骨折與骨吸收的發生率。實線代表各徑向平面的軟骨下骨折發生率；大虛線代表股骨頭外側三分之一的骨吸收發生率；小虛線代表中間三分之一的發生率；虛線代表內側三分之一的發生率。b 早期塌陷階段各徑向平面上初始軟骨下骨折及與骨折相連的骨吸收的發生率。實線代表各徑向平面的軟骨下骨折發生率；大虛線代表股骨頭外側三分之一區域內與軟骨下骨折相連的骨吸收的發生率；小虛線代表中間三分之一的相應發生率，虛線代表內側三分之一的相應發生率。

圖4 a 在早期塌陷階段，所有股骨頭的軟骨下骨折裂隙均走行于兩個不同的骨吸收區域之間。b 在一些股骨頭中，外側三分之一的骨吸收區域延伸至骨皮質外。c 在晚期塌陷階段，大面積塌陷似乎由壞死骨的粉碎性骨折導致。沿硬化邊界可見纖維性、肉芽樣低密度組織。d 在晚期塌陷階段，當硬化邊界呈垂直走向時，骨折裂隙從一骨吸收區域開始，在鄰近硬化邊界的壞死骨內延伸。

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.

文獻出處：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.

來源：304關節學術

作者：304關節團隊

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