髖膝關節文獻精譯薈萃（第378期）

本期目錄：

1、冷凍切片和MSIS標準在假體周圍感染兩期翻修術二期再植入術時檢測可靠嗎？

2、局部使用萬古霉素粉對初次全膝關節置換術中髕骨軟骨退化以及二次髕骨表面置換術的轉化率無影響

3、關節置換術后應用氯吡格雷作常規抗凝-與阿司匹林相比，輸血風險增加但靜脈血栓栓塞風險近似

4、膝關節單純髕股關節炎的髕股關節置換術與全膝關節置換術比較

5、異體結構骨植骨在髖臼周圍截骨術治療嚴重髖關節發育不良的應用

6、髖關節發育不良并發股骨骨骺外側生長障礙的髖臼發育情況

7、術中計算機輔助技術進行髖臼周圍截骨術

8、避免髖臼周圍截骨術的并發癥

9、有癥狀的塌陷前股骨頭壞死伴骨髓水腫的MRI表現

第一部分：關節置換及保膝相關文獻

文獻1

冷凍切片和MSIS標準在假體周圍感染兩期翻修術二期再植入術時檢測可靠嗎？

譯者 張軼超

背景：盡管其實用性有限，冷凍切片組織學依然被廣泛用于假體周圍感染兩期翻修術二期的術前檢測。然而，目前沒有明確的方法在再植術前來評估感染是否得到了控制。由于二期翻修失敗可能會產生嚴重后果，因此明確可能失敗的病例并在必要時推遲再植入新假體是很重要的。因此，通過一個可靠的測試來提供有關感染是否得到了控制和后續失敗風險的信息是非常有必要的。

問題/目的：(1)在二期再植入手術中，與作為金標準的肌肉骨骼感染學會（MSIS）標準相比，冷凍切片的診斷準確性如何？(2) MSIS標準和冷凍切片預測再植失敗的診斷準確性參數是什么？(3)再植入新假體時呈陽性的MSIS標準或冷凍切片是否預示著后續失敗的風險會增加？

方法：選取2013年診斷為假體周圍感染（PJI）而行兩期翻修的全髖關節置換術或全膝關節置換術的97名患者作為研究對象。其中11例的MSIS標準評定不完整，7例缺乏1年隨訪，剩下79例（38膝和41髖）可用于分析。再植入術時，將冷凍切片結果與作為檢測感染金標準的改良MSIS標準進行比較。隨后，再植入假體的成功或失敗的定義是：(1)感染控制，其特征是傷口愈合無竇道、滲出或疼痛；(2)再植入術后無因為感染而導致的后續手術干預；(3)未發生PJI相關死亡；計算改良MSIS標準和冷凍切片預測治療失敗的診斷參數。

結果：在二期再植手術時，冷凍切片可用于判定感染，其特異性為94%(95%可信區間[CI]， 89% - 99%)；然而，排除感染的效用較小，因為敏感性僅為50% （CI, 13%-88%）。MSIS標準和冷凍切片在判定再植失敗方面都具有很高的特異性（MSIS標準特異性：96% [CI， 91%-100%]；冷凍切片：95% [CI， 88%-100%]），但篩查能力有限（MSIS敏感性：26% [CI， 9%-44%]；冷凍切片：22% [CI， 9%-29%]）。再植時MSIS標準陽性是術后失敗的危險因素（風險比[HR]， 5.22 [1.64-16.62], p = 0.005），而冷凍切片陽性則不是（風險比[HR]， 1.16 [0.15-8.86], p = 0.883）。

結論：我們的研究結果建議在第二階段再植入術時可以采用冷凍切片和MSIS。冷凍切片和改良的MSIS標準雖然都具有高特異性，但對感染控制失敗的篩查能力有限。應在兩期翻修術的第二階段進行MSIS標準評估，因為在感染陽性的關節中進行再植入新假體會顯著增加后續失敗的風險。

Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty?

Background：Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary.

Questions/purposes：(1) At second-stage reimplantation surgery, what is the diagnostic accuracy of frozen sections as compared with the Musculoskeletal Infection Society (MSIS) as the gold standard? (2) What are the diagnostic accuracy parameters for the MSIS criteria and frozen sections in predicting failure of reimplantation? (3) Do positive MSIS criteria or frozen section at the time of reimplantation increase the risk of subsequent failure?

Methods：A total of 97 patients undergoing the second stage of revision total hip arthroplasty or total knee arthroplasty in 2013 for a diagnosis of periprosthetic joint infection (PJI) were considered eligible for the study. Of these, 11 had incomplete MSIS criteria and seven lacked 1- year followup, leaving 79 patients (38 knees and 41 hips) available for analysis. At the time of reimplantation, frozen section results were compared with modified MSIS criteria as the gold standard in detecting infection. Subsequently, success or failure of reimplantation was defined by (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality; and diagnostic parameters in predicting treatment failure were calculated for both the modified MSIS criteria and frozen sections.

Results：At the time of second-stage reimplantation surgery, frozen section is useful in ruling in infection, where the specificity is 94% (95% confidence interval [CI], 89%– 99%); however, there is less utility in ruling out infection, because sensitivity is only 50% (CI, 13%–88%). Both the MSIS criteria and frozen sections have high specificity for ruling in failure of reimplantation (MSIS criteria specificity: 96% [CI, 91%–100%]; frozen section: 95% [CI, 88%–100%]), but screening capabilities are limited (MSIS sensitivity: 26% [CI, 9%–44%]; frozen section: 22% [CI, 9%–29%]). Positive MSIS criteria at the time of reimplantation were a risk factor for subsequent failure (hazard ratio [HR], 5.22 [1.64–16.62], p = 0.005), whereas positive frozen section was not (HR, 1.16 [0.15–8.86], p = 0.883).

Conclusions：On the basis of our results, both frozen section and MSIS are recommended at the time of the second stage of revision arthroplasty. Both frozen section and modified MSIS criteria had limited screening capabilities to identify failure, although both demonstrated high specificity. MSIS criteria should be evaluated at the second stage of revision arthroplasty because performing reimplantation in a joint that is positive for infection significantly increases the risk for subsequent failure.

文獻出處：George J, Kwiecien G, Klika AK, Ramanathan D, Bauer TW, Barsoum WK, Higuera CA. Are Frozen Sections and MSIS Criteria Reliable at the Time of Reimplantation of Two-stage Revision Arthroplasty? Clin Orthop Relat Res. 2016 Jul;474(7):1619-26. doi: 10.1007/s11999-015-4673-3. PMID: 26689583; PMCID: PMC4887348.

文獻2

局部使用萬古霉素粉對初次全膝關節置換術中髕骨軟骨退化以及二次髕骨表面置換術的轉化率無影響

譯者 馬云青

簡介：萬古霉素粉（VP）是一種抗生素，最初用于兒童脊柱外科手術，以預防手術部位感染（SSI）。最近，其應用范圍已擴展到全髖關節和膝關節置換術（THA、TKA）以及前交叉韌帶重建術（ACLR）。萬古霉素的軟骨毒性是當前研究熱點。此研究的目的是證明以下假設：在TKA 中局部應用VP不會導致髕骨軟骨變性。 我們傳播的觀點是，二次髕骨表面置換的概率不受其使用的影響。

材料與方法：在 2014 年至 2021 年間，單中心的回顧性隊列研究共納入了4292個關節。所有患者均接受了TKA 治療，且未進行原發性髕骨表面置換術。在醫院程序發生變化后，一組在術中接受了局部萬古霉素治療。另一組在手術期間未接受局部萬古霉素。其余圍手術期手術在調查期間保持不變。兩組二次髕骨表面置換率均未對適應癥進行區分。第二組患者由在TKA后12 個月來接受隨訪，共包含210個關節。術前、出院前和隨訪檢查時均進行了回顧性X線評估。對髕骨軸位X線進行了髕骨追蹤（髕骨外側傾斜、髕骨位移）和髕骨變性（斯珀納分類、髕股關節間隙）分析。

結果：二次髕骨表面置換術的概率無顯著差異（VPG 4.24%，nVPG 4.97%）。 兩組之間的髕骨追蹤和髕骨變性沒有顯著差異。

結論：VP 局部應用不會影響二次髕骨表面置換術的概率。此外，也不會導致髕骨軟骨在TKA后的退化。

Topical vancomycin powder does not affect patella cartilage degeneration in primary total knee arthroplasty and conversion rate for secondary patella resurfacing

Introduction:Vancomycin powder (VP) is an antibiotic first introduced in pediatric spinal surgery to prevent surgical site infections (SSI). Recently its topical application was expanded to total hip and knee arthroplasty (THA, TKA) and anterior cruciate ligament reconstruction (ACLR). Toxicity to cartilage is the subject of current research. The aim of this study was to prove the hypothesis that topical application of VP in TKA does not result in a degeneration of patella cartilage. We propagate that the conversion rate for secondary patella resurfacing is not influenced by its use.

Materials and methods:Between 2014 and 2021, 4292 joints were included in this monocentric retrospective cohort study. All patients underwent TKA without primary patella resurfacing. After a change of the procedure in the hospital, one group (VPG) was administered VP intraoperatively. The other group (nVPG) received no VP during surgery (nVPG). The remaining perioperative procedure was constant over the investigation period. Conversion rates for secondary patella resurfacing for both groups were determined without making distinctions in the indication. A second cohort was composed of patients presenting for follow-up examination 12 months after TKA and included 210 joints. Retrospective radiographic evaluations were performed preoperatively, before discharge and at follow-up examination. Patella axial radiographs were analyzed for patella tracking (lateral patellar tilt, patellar displacement) and patella degeneration (Sperner classification, patellofemoral joint space).

Results:There was no significant difference in the conversion rate for secondary patella resurfacing (4.24% VPG, 4.97% nVPG). Patella tracking and patella degeneration did not differ significantly between both groups.

Conclusions:The topical application of VP does not influence the conversion rate for secondary patella resurfacing. Moreover, it does not result in a degeneration of patella cartilage in TK.

文獻出處：Jacob B, Wassilew G, von Eisenhart-Rothe R, Brodt S, Matziolis G. Topical vancomycin powder does not affect patella cartilage degeneration in primary total knee arthroplasty and conversion rate for secondary patella resurfacing. Arch Orthop Trauma Surg. 2023 Aug;143(8):5249-5254. doi: 10.1007/s00402-022-04721-w. Epub 2022 Dec 20. PMID: 36538161; PMCID: PMC10374468.

文獻3

關節置換術后應用氯吡格雷作常規抗凝-與阿司匹林相比，輸血風險增加但靜脈血栓栓塞風險近似

譯者 張薔

背景：關節置換（TJA）術前長期應用氯吡格雷進行動脈粥樣硬化性血栓預防的病人通常在初次全膝關節置換（TKA）和全髖關節置換（THA）術后繼續將其作為靜脈血栓栓塞（VTE）預防的常規藥物。我們在本研究中試圖比較并評價TJA術后應用氯吡格雷VS.阿司匹林作為VTE常規抗凝藥物的病例術后90天內出血和血栓栓塞的風險。

方法：我們應用某涵蓋全美25%住院患者的醫保數據庫資料并從中挑選出了2016年至2021年間所有施行初次擇期TKA或THA手術的成年患者。所有在術后應用氯吡格雷作為單藥VTE預防的病例，在年齡、性別、手術類型、圍術期氨甲環酸用法和氯吡格雷應用指證近似的基礎上，按照傾向性評分匹配法大約1:7的比例選擇了術后應用阿司匹林作為單藥VET預防的病例。首要研究指標包括術后90天內出血和血栓栓塞性并發癥的風險。

結果：總共挑選出21273例應用阿司匹林的病例和3078例應用氯吡格雷的病例。匹配后，兩組間的患者一般資料、合并癥、氨甲環酸應用率和醫院信息并無顯著性差異。與阿司匹林組相比，應用氯吡格雷的病例在考慮潛在混淆變量后，術后緊急輸血（矯正后概率比 [aOR]: 1.69; 95%置信區間[CI]: 1.30 - 2.21; p < 0.001）和急性貧血（aOR: 1.13; 95%CI: 1.03 - 1.26; p = 0.015）的風險更高。但兩組間在深靜脈血栓栓塞、肺栓塞、中風、急性心肌梗死、血腫或大出血風險無顯著性差異。

結論：與應用阿司匹林相比，關節置換術后應用單藥氯吡格雷作為術后常規VTE抗凝的患者術后出血性并發癥風險更高而血栓栓塞性并發癥風險近似。這些發現提醒我們：對心血管事件高風險的患者來說，我們應謹慎選擇恢復應用氯吡格雷作為術后抗凝藥物的時機，以平衡抗血小板反應導致出血性并發癥的風險。

Postoperative Clopidogrel Thromboprophylaxis in?TJA Increased Risk of Transfusion but Similar Venous Thromboembolic Risk Compared with Aspirin

Background: Patients undergoing total joint arthroplasty (TJA) who are on long-term use of clopidogrel for atherothrombotic prophylaxis often continue this drug as venous thromboembolism (VTE) chemoprophylaxis following primary total knee (TKA) and total hip arthroplasty (THA). We sought to assess the 90-day bleeding and thromboembolic risk profiles of patients receiving clopidogrel monotherapy for postoperative VTE chemoprophylaxis compared with those receiving aspirin following TJA.

Methods: Utilizing a national, all-payer health-care database that captures approximately 25% of all inpatient procedures in the U.S., we identified all adult patients who underwent primary elective TKA or THA between 2016 and 2021. Patients who received clopidogrel monotherapy for postoperative VTE chemoprophylaxis were propensity-score matched in an approximately 1:7 ratio to patients who received aspirin monotherapy on the basis of age, sex, procedure type, perioperative tranexamic acid administration, and known indications for clopidogrel administration. Primary outcomes included the 90-day risks of bleeding and thromboembolic complications.

Results: A total of 21,273 patients who received aspirin were matched to 3,078 patients who received clopidogrel. After matching, there were no significant differences between the 2 cohorts with respect to patient demographics, comorbidities, rates of tranexamic acid administration, and hospital characteristics. After accounting for potential confounding variables, patients who received clopidogrel were at an increased risk for postoperative blood transfusion (adjusted odds ratio [aOR]: 1.69; 95% confidence interval [CI]: 1.30 to 2.21; p < 0.001) and acute anemia (aOR: 1.13; 95% CI: 1.03 to 1.26; p = 0.015) relative to patients receiving aspirin. No significant differences between the cohorts in the risk of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, hematoma, or hemorrhage were found.

Conclusions: Patients who received clopidogrel monotherapy for postoperative VTE chemoprophylaxis had an increased risk of postoperative bleeding complications but a similar risk of thromboembolic complications following TJA compared with patients who received aspirin. These findings suggest that the decision to resume clopidogrel for postoperative thromboprophylaxis should balance the potent antiplatelet activity with the risk of bleeding complications in high-risk cardiovascular patients.

文獻出處：Telang SS, Telang S, Palmer RC, Stronach BM, Stambough JB, Lieberman JR, Heckmann ND. Postoperative Clopidogrel Thromboprophylaxis in TJA: Increased Risk of Transfusion but Similar Venous Thromboembolic Risk Compared with Aspirin. J Bone Joint Surg Am. 2025 Dec 29. doi: 10.2106/JBJS.25.00930. Epub ahead of print. PMID: 41460931.

文獻4

單純髕股關節炎的髕股關節置換術與全膝關節置換術比較：來自一項采用 GRADE 評估的系統綜述的循證推薦

譯者 沈松坡

引言：孤立性髕股骨關節骨關節炎（PFOA）仍然是一個治療難題，其中髕股關節置換術（PFA）和全膝關節置換術（TKA）代表終末期疾病的主要手術選擇。本系統綜述應用 GRADE 框架來評估 PFA 與 TKA 的比較結局，從而提供循證推薦。

材料與方法：采用 PRISMA 方法對 PubMed、Cochrane Library 與 Google Scholar 進行了系統檢索（2010–2025）。納入報告孤立性 PFOA 患者 PFA vs TKA 的 RCT、比較性隊列研究與注冊登記分析。主要結局為經驗證的患者報告結局指標（PROMs）以及 2、5 和 10 年的假體生存率。次要結局為并發癥、患者滿意度、重返運動以及成本效果。偏倚風險采用 RoB 2 與 ROBINS-I 評估，證據確定性使用 GRADE 評定。

結果：共納入 10 項研究（4 項 RCT、6 項隊列研究；約 10,000 例 PFA 來自注冊登記）。中等確定性證據顯示：與 TKA 相比，PFA 可帶來更優的早期 PROMs 以及短期成本效果。兩組 PROMs 在中長期隨訪時趨于一致。長期數據以中等確定性顯示 PFA 的翻修風險持續更高：基于注冊登記的 10 年生存率為 PFA 85% vs TKA 95%，且 PFA 在 10 年后仍繼續惡化。并發癥發生率在兩組相似或 PFA 更低，尤其在全身性內科事件方面。患者滿意度與重返運動在短期更偏向 PFA，但在中期與 TKA 相當。

結論：在嚴格篩選的孤立性 PFOA 患者中，現代 onlay 型 PFA 可實現更快恢復、更優的早期功能以及短期成本效果，且有中等確定性證據支持。但這些優勢會被較 TKA 更高的長期翻修風險所抵消，提示需要將這種權衡告知患者。對于合并脛股關節病變或不穩定的患者，TKA 仍是參考標準，且有高確定性證據支持，并能在更異質的患者群體中提供持久、可預測的長期結局。

證據等級：II 級：系統性 GRADE（Grading of Recommendations, Assessment, Development and Evaluation）綜述，納入 RCT 與觀察性研究。

關鍵詞：孤立性髕股骨關節骨關節炎;髕股關節置換術;全膝關節置換術;全膝關節置換（total knee replacement）;假體生存率;患者報告結局指標（PROMs）

Patellofemoral vs. total knee arthroplasty for isolated patellofemoral osteoarthritis: evidence-based recommendations from a systematic review with GRADE assessment

Introduction: Isolated patellofemoral osteoarthritis (PFOA) remains a therapeutic challenge, with patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) representing the main surgical options for end-stage disease. This systematic review applies the GRADE framework to evaluate comparative outcomes of PFA and TKA, providing evidence-based recommendations.

Materials and methods: A PRISMA systematic search of Pubmed, Cochrane Library, and Google Scholar was conducted (2010–2025). RCTs, comparative cohort studies, and registry analyses reporting on PFA versus TKA for isolated PFOA were included. Primary outcomes were validated PROMs and implant survival at 2, 5, and 10 years. Secondary outcomes were complications, patient satisfaction, return to sport, and cost-effectiveness. Risk of bias was assessed with RoB 2 and ROBINS-I, and certainty of evidence using GRADE.

Results: Ten studies were included (4 RCTs, 6 cohort studies; approximately 10,000 PFAs comprising registries). Moderate-certainty evidence indicated that PFA provides superior early PROMs, and short-term cost-effectiveness compared with TKA. PROMs converged between groups at mid- to long-term follow-up. Long-term data demonstrated a consistently higher revision risk for PFA with moderate certainty, with registry-based 10-year survival of 85% for PFA vs. 95% for TKA, continuing to worsen for PFA after 10 years. Complication rates were similar or lower after PFA, particularly for systemic medical events. Patient satisfaction and return to sport favored PFA short term but became comparable to TKA at mid-term.

Conclusion: In carefully selected patients with isolated PFOA, modern onlay PFA yields faster recovery, superior early function, and short-term cost-effectiveness, supported by moderate-certainty evidence. These advantages are offset by a higher long-term revision risk compared with TKA, highlighting the need to inform patients of this trade-off. TKA remains the reference standard for patients with tibiofemoral disease or instability, supported by high-certainty evidence, and offers durable, predictable long-term outcomes in more heterogeneous patient populations.

Level of evidence, II: Systematic GRADE (Grading of Recommendations, Assessment, Development and Evaluation) review of RCTs and observational studies.

Keywords: Implant survival; Isolated patellofemoral osteoarthritis; Patellofemoral arthroplasty; Patient-reported outcome measures.; Total knee arthroplasty; Total knee replacement.

第二部分：保髖相關文獻

文獻1

異體結構骨植骨在髖臼周圍截骨術治療嚴重髖關節發育不良的應用

譯者 張振東

本研究擬明確髖臼弧形旋轉截骨術聯合使用結構性同種異體骨植骨治療嚴重髖關節發育不良的中期效果。研究回顧了1998年至2019年期間接受髖臼弧形旋轉截骨與結構性骨植骨治療的嚴重DDH患者，嚴重DDH定義是Severin 分級為IVb或V級（即外側中心-邊緣角（LCEA）< 0°）。通過病歷回顧提取了人口統計學數據、與截骨術相關的并發癥以及改良髖關節Harris評分（mHHS）。髖關節發育不良的影像學參數通過術前和術后的X光片進行測量。采用Kaplan-Meier生存分析估算截骨失敗（進展至T?nnis 3級骨關節炎或轉為全髖關節置換術）的累積概率，并采用多變量Cox比例危險模型確定了失敗的預測因素。

本研究共納入 64 例患者（76 髖）。隨訪時間的中位數為 10 年（四分位數間距為 5 至 14 年）。中位 mHHS 從術前的 67（IQR 56 至 80）提高到最近隨訪時的 96（IQR 85 至 97）（p < 0.001）。術后影像學參數均有所改善（p < 0.001），42% 到 95% 的髖關節的影像學參數在正常范圍內。10年的存活率為95%，15年的存活率為80%。術前T?nnis 2級是TOA失敗的獨立風險因素。

本研究表明，對于沒有晚期骨關節炎的青少年和年輕成年人，TOA 和結構性骨異體移植是矯正嚴重發育不良髖臼的可行手術方案，而且中期療效良好。

Clinical results of periacetabular osteotomy with structural bone allograft for the treatment of severe hip dysplasia

Aims:To clarify the mid-term results of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, combined with structural allograft bone grafting for severe hip dysplasia.

Methods:We reviewed patients with severe hip dysplasia, defined as Severin IVb or V (lateral centre-edge angle (LCEA) < 0°), who underwent TOA with a structural bone allograft between 1998 and 2019. A medical chart review was conducted to extract demographic data, complications related to the osteotomy, and modified Harris Hip Score (mHHS). Radiological parameters of hip dysplasia were measured on pre- and postoperative radiographs. The cumulative probability of TOA failure (progression to T?nnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method, and a multivariate Cox proportional hazard model was used to identify predictors for failure.

Results:A total of 64 patients (76 hips) were included in this study. The median follow-up period was ten years (interquartile range (IQR) five to 14). The median mHHS improved from 67 (IQR 56 to 80) preoperatively to 96 (IQR 85 to 97) at the latest follow-up (p < 0.001). The radiological parameters improved postoperatively (p < 0.001), with the resulting parameters falling within the normal range in 42% to 95% of hips. The survival rate was 95% at ten years and 80% at 15 years. Preoperative T?nnis grade 2 was an independent risk factor for TOA failure.

Conclusion:Our findings suggest that TOA with structural bone allografting is a viable surgical option for correcting severely dysplastic acetabulum in adolescents and young adults without advanced osteoarthritis, with favourable mid-term outcomes.

文獻出處：Fujii M, Kawano S, Ueno M, Sonohata M, Kitajima M, Tanaka S, Mawatari D, Mawatari M. Clinical results of periacetabular osteotomy with structural bone allograft for the treatment of severe hip dysplasia. Bone Joint J. 2023 Jul 1;105-B(7):743-750. doi: 10.1302/0301-620X.105B7.BJJ-2023-0056.R1. PMID: 37399069.

文獻2

髖關節發育不良并發股骨骨骺外側生長障礙的髖臼發育情況

譯者 任寧濤

背景:股骨頭骨骺外側生長障礙是髖關節發育不良治療過程中最常見的骨骺生長障礙類型。雖然這種類型的骨骺生長障礙被認為可導致髖臼發育不良，但這種生長障礙模式對髖關節發育不良影響的自然史尚不清楚。為了探討這一問題，我們對48名DDH患者治療后發生股骨頭骨骺外側生長障礙的58例髖臼發育情況進行了回顧性研究。

方法:58例髖關節中，36例行閉合復位，22例行切開復位。復位時患者平均年齡為22個月(范圍，3 ~ 97個月)，最近一次隨訪評估時為21歲(范圍，10 ~ 55歲)。隨訪時Severin I級(優)或II級(良)為臨床效果滿意， Severin III級(可)或IV級(差)的被認為是臨床效果不滿意。在連續的影像學上觀察股骨頭的特定變化，在后期隨訪期間，測量髖關節的各種影像學參數，包括股骨骨骺的側傾程度，并在四個時間節點(復位前、復位后兩年、6至8歲和最終隨訪時)對劃分為滿意和不滿意的髖關節進行比較。

結果:平均10歲(4 ~ 14歲)首次出現股骨頭骨骺外側生長發育障礙。在骨骺、骨骺或干骺端中沒有一致的早期變化模式與骨骺外翻傾斜的后期發展有關。末次隨訪時34例髖(59%)滿意，24例髖不滿意。不滿意的髖關節平均在7歲時表現為髖臼發育不良。隨著時間的推移，骨骺板的傾斜逐漸變得更水平甚至倒置; 然而，連續測量的傾斜度并不是Severin分類的顯著預測因子。

結論：股骨頭骨骺外側生長障礙并不一定與髖臼發育不良有關，因為當發育不良確實發生時，通常在確定骨骺生長障礙之前就很明顯了。重要的是監測復位后髖臼的發育，而不是尋找骨骺生長發育的影像學變化，這在幼兒中很難發現。

圖1 25個月大小患兒，右髖高脫位，行內收肌松解閉合復位

圖2 該患者9歲時，股骨近端骨骺外側傾斜，股骨頸上外側可見向外延續的“骨板”。股骨頭部略扁平，髖臼發育不良。

圖3 該患者11歲時，股骨頭嚴重外翻畸形，伴有殘余髖臼發育不良，淚滴形態異常，右髖關節半脫位。

Acetabular development in developmental dysplasia of the hip complicated by lateral growth disturbance of the capital femoral epiphysis

Background: Lateral growth disturbance of the capital femoral epiphysis is the most common type of physeal arrest complicating the treatment of developmental hip dysplasia. Although this type of physeal damage has been assumed to result in poor acetabular development, the natural history of dysplastic hips affected by this pattern of growth disturbance is still unclear. To investigate this issue, we evaluated acetabular development in a retrospective study of fifty-eight hips in forty-eight patients who had lateral physeal arrest after management of developmental hip dysplasia.

Methods: Of the fifty-eight hips, thirty-six were reduced closed and twenty-two were reduced open. The average age of the patients was twenty-two months (range, three to ninety-seven months) at the time of the reduction and twenty-one years (range, ten to fifty-five years) at the time of the latest follow-up evaluation. Hips rated as Severin class I (an excellent result) or II (a good result) were defined as having a satisfactory result, and those rated as Severin class III (a fair result) or IV (a poor result) were considered to have an unsatisfactory result. Specific femoral head changes were sought in the complete radiographic files on all hips. Various radiographic parameters of hip integrity, including the degree of lateral tilt of the capital femoral epiphysis, were measured over time, and comparisons were made between hips classified as satisfactory and those classified as unsatisfactory at four time-points: before the reduction, at two years after the reduction, at six to eight years of age, and at the time of the final follow-up.

Results: Lateral growth disturbance of the capital femoral epiphysis was first evident by an average of ten years of age (range, four to fourteen years of age). There was no consistent early pattern of changes in the epiphysis, physis, or metaphysis related to later development of valgus tilt of the epiphysis. Thirty-four hips (59 percent) were rated as satisfactory and twenty-four were rated as unsatisfactory at the latest follow-up evaluation. Hips classified as unsatisfactory exhibited poor acetabular development by an average age of seven years. The inclination of the epiphyseal plate became progressively more horizontal or even reversed over time; however, serial measurements of inclination were not significant predictors of Severin classification.

Conclusions: Lateral growth disturbance of the capital femoral epiphysis is not necessarily associated with poor acetabular development, as when dysplasia does occur it is generally evident prior to the identification of the physeal arrest. It is important to monitor acetabular development after reduction rather than search for radiographic changes of physeal arrest, which are difficult to detect in young children.

文獻出處：Kim HW, Morcuende JA, Dolan LA, Weinstein SL. Acetabular development in developmental dysplasia of the hip complicated by lateral growth disturbance of the capital femoral epiphysis. J Bone Joint Surg Am. 2000 Dec;82(12):1692-700. doi: 10.2106/00004623-200012000-00002. PMID: 11130642.

文獻3

術中計算機輔助技術進行髖臼周圍截骨術：一項系統綜述

譯者 李勇

術中計算機輔助技術在髖臼周圍截骨術（PAO）中的作用，以及這些技術的圍手術期和術后結果，目前仍缺乏明確的定義。本系統綜述旨在評估術中計算機輔助技術在PAO中的應用技術及臨床結果。檢索了三個數據庫（PubMed、CINAHL/EBSCOHost和Cochrane），以獲取報告計算機輔助技術用于PAO的臨床研究。排除標準包括：小規模病例系列（患者數<10）、非英文文獻以及未提供計算機輔助技術描述的研究。數據提取內容包括所使用的計算機輔助技術、手術技術、人口學特征、影像學結果、圍手術期結果、患者報告結局（PROs）、并發癥及二次手術情況。九項研究符合納入標準，共涉及208名患者，平均年齡范圍為26至38歲。其中七項研究采用了術中導航，一項研究使用了患者特異性導板，另一項研究同時使用了這兩種技術。三項研究報告稱，與常規PAO相比，計算機輔助PAO的術中輻射暴露顯著減少（P < 0.01）。計算機輔助組與常規組在手術時間和估計失血量方面通常觀察到相似的結果（P > 0.05）。接受計算機輔助PAO的患者術后平均外側中心邊緣角范圍為27.8°至37.4°，其中六項研究報告稱該值與常規PAO相比無顯著差異（P > 0.05）。在所有報告了接受計算機輔助PAO患者術前和術后PROs值的六項研究中，均觀察到PROs得到改善。用于PAO的計算機輔助技術包括對游離髖臼碎片和手術器械的導航追蹤，以及患者特異性截骨導板和旋轉模板。與常規技術相比，計算機輔助PAO可減少術中輻射暴露，且手術時長相似，但由于手術技術和手術設置的異質性，這些結果應謹慎解讀。

Periacetabular osteotomy with intraoperative computer-assisted modalities: a systematic review

The role of intraoperative computer-assisted modalities for periacetabular osteotomy (PAO), as well as the perioperative and post-operative outcomes for these techniques, remains poorly defined. The purpose of this systematic review was to evaluate the techniques and outcomes of intraoperative computer-assisted modalities for PAO. Three databases (PubMed, CINAHL/EBSCOHost and Cochrane) were searched for clinical studies reporting on computer-assisted modalities for PAO. Exclusion criteria included small case series (<10 patients), non-English language and studies that did not provide a description of the computer-assisted technique. Data extraction included computer-assisted modalities utilized, surgical techniques, demographics, radiographic findings, perioperative outcomes, patient-reported outcomes (PROs), complications and subsequent surgeries. Nine studies met the inclusion criteria, consisting of 208 patients with average ages ranging from 26 to 38 years. Intraoperative navigation was utilized in seven studies, patient-specific guides in one study and both modalities in one study. Three studies reported significantly less intraoperative radiation exposure (P < 0.01) in computer-assisted versus conventional PAOs. Similar surgical times and estimated blood loss (P > 0.05) were commonly observed between the computer-assisted and conventional groups. The average post-operative lateral center edge angles in patients undergoing computer-assisted PAOs ranged from 27.8° to 37.4°, with six studies reporting similar values (P > 0.05) compared to conventional PAOs. Improved PROs were observed in all six studies that reported preoperative and post-operative values of patients undergoing computer-assisted PAOs. Computer-assisted modalities for PAO include navigated tracking of the free acetabular fragment and surgical instruments, as well as patient-specific cutting guides and rotating templates. Compared to conventional techniques, decreased intraoperative radiation exposure and similar operative lengths were observed with computer-assisted PAOs, although these results should be interpreted with caution due to heterogeneous operative techniques and surgical settings.

文獻出處：Curley AJ, Bruning RE, Padmanabhan S, Jimenez AE, Laude F, Domb BG. Periacetabular osteotomy with intraoperative computer-assisted modalities: a systematic review. J Hip Preserv Surg. 2023 Apr 20;10(2):104-118. doi: 10.1093/jhps/hnad005. PMID: 37900886; PMCID: PMC10604052.

文獻4

避免髖臼周圍截骨術的并發癥

譯者 陶可

髖臼周圍截骨術最常見的并發癥包括（按發生頻率遞減順序排列）：淺表傷口并發癥、異位骨化、股外側皮神經感覺異常、截骨部位延遲愈合或不愈合、深部血腫以及后柱、坐骨或恥骨的術后骨折。

為降低髖臼周圍截骨術并發癥發生率，術前措施包括：選擇合適的患者、在學習曲線期間接受手術指導以及優化可控風險因素。

為降低并發癥發生率，術中措施包括：精細處理軟組織、適當擺放下肢位置、在截骨時保護神經血管結構、術中透視以評估截骨碎片位置并觀察截骨與髖關節的關系，以及考慮采用血液保護策略以減少出血量和輸血需求。

術后措施包括：術后保護性負重直至X線片顯示截骨愈合，以及預防深靜脈血栓形成和異位骨化。

圖1 顯示了坐骨截骨術中，骨鑿在髖臼下溝內的正確起始位置和角度。圖1A為骨盆模型的前后位圖像，圖1B為50°側位透視圖像；術中，我們使用透視確認該起始點的前后位圖像（圖1C）和50°側位透視圖像（圖1D），以避免醫源性髖臼穿透。外科醫生應確認從坐骨內側到外側的截骨已完成，以便于截骨塊調整移動。

圖2 50°假側位透視可為外科醫生提供后柱截骨起始點的標志，并輔助外科醫生將骨鑿指向髖臼和坐骨大切跡之間的遠端。骨盆模型（圖2A）和術中采用50°假側位透視（圖2B）顯示了后柱截骨的正確骨鑿位置。

Avoiding Complications in Periacetabular Osteotomy

The most common complications that have been described in association with periacetabular osteotomy include, in decreasing order of cumulative frequency, superficial wound complications, heterotopic ossification, lateral femoral cutaneous nerve dysesthesias, delayed union or nonunion of the osteotomy site, deep hematoma, and postoperative fracture of the posterior column, ischium, or pubis.

Preoperative measures to reduce complication rates for periacetabular osteotomy include appropriate patient selection, surgical mentoring during the learning curve, and optimization of modifiable risk factors.

Intraoperative measures to reduce complication rates include meticulous soft-tissue handling, appropriate lower-limb positioning and protection of neurovascular structures when performing osteotomy cuts, intraoperative fluoroscopy to evaluate osteotomy fragment positioning and to visualize osteotomies in relation to the hip joint, and consideration of using blood conservation strategies to reduce blood loss and need for transfusion.

Postoperative measures include protected weight-bearing in the postoperative period until evidence of osteotomy healing is seen on radiographs and prophylaxis for deep venous thrombosis and heterotopic ossification.

文獻出處：Ishaan Swarup, Benjamin F Ricciardi, Ernest L Sink. Avoiding Complications in Periacetabular Osteotomy. JBJS Rev. 2015 Nov 24;3(11):e4. doi: 10.2106/JBJS.RVW.O.00023.

文獻5

有癥狀的塌陷前股骨頭壞死伴骨髓水腫的MRI表現：軟骨下骨折的組織病理學證實

譯者 邱興

目的：在塌陷前股骨頭壞死的磁共振成像中出現的骨髓水腫被認為是隱匿性軟骨下骨折的征象；然而，據我們所知，尚無組織病理學研究證實這一點。本研究旨在通過組織病理學方法，驗證在MRI上表現為骨髓水腫的癥狀性塌陷前股骨頭壞死中，外側壞死邊界處是否存在軟骨下骨折。

材料與方法：在2019年1月至2024年6月于我院行全髖關節置換術切除的149例連續壞死股骨頭中，納入13例術前X線片未見明顯塌陷但MRI顯示骨髓水腫的股骨頭。對每個股骨頭的連續冠狀切片蘇木精-伊紅染色標本進行檢查，以確認軟骨下骨折的存在。使用顯微計算機斷層掃描圖像測量軟骨下骨折周圍的骨微結構。

結果：在所有股骨頭中，組織病理學均證實修復區與壞死區外側交界處存在軟骨下骨折。顯微CT顯示，鄰近軟骨下骨折的修復區骨體積分數、骨小梁厚度和骨礦物質密度均顯著高于鄰近軟骨下骨折的壞死區。

結論：在塌陷前股骨頭壞死中，當MRI上出現骨髓水腫時，必然存在軟骨下骨折。當MRI觀察到骨髓水腫時，即使X線片上股骨頭塌陷不明顯，也應意識到軟骨下骨折已經發生。

關鍵詞：骨髓水腫；股骨頭壞死；軟骨下骨折。

圖1 軟骨下骨折鄰近的修復區與壞死區骨微結構評估。在這兩個區域中，選取3毫米體素作為感興趣區。外側的紅色立方體對應鄰近軟骨下骨折的修復區；內側的黃色立方體對應鄰近軟骨下骨折的壞死區。

圖2 一例55歲男性患者術前1天股骨頭X線平片。正側位X線片未見明顯塌陷，但可見修復區硬化改變（白色箭頭），提示JIC 2期。JIC：日本健康福利部調查研究委員會。

圖3 術前MRI：患者，55歲，術前1個月股骨頭影像。T1加權像可見低信號帶（白色箭頭），伴彌漫性低信號區（白色三角），對應骨髓水腫。脂肪抑制T2加權像可見高信號區（白色三角），亦對應骨髓水腫。MRI，磁共振成像

圖4 該55歲男性患者股骨頭組織病理學檢查。a 全股骨頭蘇木精-伊紅染色切片（×20，標尺=5 mm）。股骨頭頂端可見一條清晰穿過壞死區的骨小梁骨折線（黑色三角）。b 黑方框區域放大圖像（×40，標尺=1 mm）。外側修復區與壞死區之間的軟骨下骨板可見不連續（黑色箭頭）。

圖5 一名75歲男性患者的組織病理學檢查。a 全股骨頭蘇木精-伊紅染色切片（×20，標尺=5 mm）。股骨頭內未見明顯骨小梁骨折線。b 圖a黑方框區域顯微圖像（×40，標尺=1 mm）。外側修復區與壞死區之間的軟骨下骨板可見不連續（黑色箭頭）。

Histopathologic confirmation of subchondral fracture in symptomatic pre-collapse osteonecrosis of the femoral head with bone marrow edema on magnetic resonance imaging

Objective: The presence of bone marrow edema on magnetic resonance imaging (MRI) in pre-collapse osteonecrosis of the femoral head is suggested to be a sign of occult subchondral fracture; however, to our knowledge, there are no histopathological studies verifying this. This study aimed to histopathologically verify the presence of subchondral fracture at the lateral necrotic boundary in symptomatic pre-collapse osteonecrosis of the femoral head with bone marrow edema on MRI.

Materials and methods: Of 149 consecutive necrotic femoral heads resected during total hip arthroplasty at our hospital from January 2019 to June 2024, we included 13 femoral heads that did not show apparent collapse on preoperative radiographs and exhibited bone marrow edema on MRI. Continuous coronal-slice hematoxylin and eosin-stained specimens of each femoral head were examined for the presence of subchondral fracture. Bone microarchitectures around subchondral fractures were measured using micro-computed tomography (CT) images.

Results: In all femoral heads, subchondral fractures were histopathologically confirmed at the lateral junction between the reparative and the necrotic zone. On micro-CT, bone volume fraction, trabecular thickness, and bone mineral density of the reparative zone adjacent to the subchondral fracture were all significantly higher than those of the necrotic zone adjacent to the subchondral fracture.

Conclusion: Subchondral fracture invariably existed when bone marrow edema was present on MRI during pre-collapse osteonecrosis of the femoral head. When bone marrow edema is observed on MRI, it should be known that subchondral fracture has already occurred, even if femoral head collapse is unclear on radiographs.

Keywords: Bone marrow edema; Osteonecrosis of the femoral head; Subchondral fracture.

文獻出處：Ayabe, Y., Motomura, G., Yamaguchi, R., Utsunomiya, T., Sakamoto, K., & Nakashima, Y. (2025). Histopathologic confirmation of subchondral fracture in symptomatic pre-collapse osteonecrosis of the femoral head with bone marrow edema on magnetic resonance imaging. Skeletal Radiology, 54(6), 1275-1281.

來源：304關節學術

作者：304關節團隊

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