本期目录：
1、全膝关节置换术中不同骨水泥技术间的比较
2、髋关节置换术后慢跑的相关研究
3、影像推导的个性化手术器械对全膝关节置换术后翻修率的影响：一项来自澳洲关节登记中心共83823例关节置换的病例研究
4、SARS后股骨头坏死患者接受联合治疗的12年随访
5、使用核磁评估股骨转子上和转子下股骨扭转：与股髋撞击和髋关节发育不良的关系
6、土耳其无症状髋关节撞击症的患病率：横断面研究
7、Chiari骨盆内移截骨手术入路的比较
8、髋臼后壁骨化的放射学研究：对儿童和青少年髋关节疾病诊断的意义
9、通过改良Dunn手术治疗严重股骨头骨骺滑脱的患者长期随访发现股骨头缺血坏死率低、预后良好和骨关节炎少
第一部分：关节置换及保膝相关文献
文献1
全膝关节置换术中不同骨水泥技术间的比较
译者：张轶超
目的：在全膝关节置换手术（TKA）中胫骨假体无菌性松动是导致翻修的一个重要原因。胫骨假体稳定的初始固定是减少假体微动而使得使用时间尽量长的重要因素。文献中描述了不同的胫骨侧骨水泥技术，但目前还存在争议。没有任何指南指出哪种技术更好。
方法：本研究比较了3种常用的骨水泥技术（背托涂抹，全涂抹，骨水泥枪）与只用手指按压的方法（成对的人类胫骨标本，分为四组，n=24）。每个样本都通过CT三维重建来分析骨水泥渗透到骨内的情况并通过力学测试来检测界面间的力量。
结果：骨密度（BMD）高的骨水泥渗透程度差（R2=0.18,p=0.023），但界面间的力量更大(R2=0.56,p<0.001)。各组中不同骨水泥技术对于骨水泥的渗透程度(p≥0.069)或界面间力量(p=0.180)没有明显的影响。
结论：使用冲洗设备和各种干燥方法对胫骨面进行处理看上去好像不那么重要，但正是这些对于增强假体的固定起了很大作用。本文强调了全膝关节置换术中如截骨面准备和表面冲洗等基本原则的重要性。
分组：组1 只将骨水泥涂于假体背托的背面（背托涂抹）；组2 将骨水泥涂在假体背托背面和立柱上（全涂抹）；组3 将骨水泥枪口抵在胫骨截骨面上加压涂抹骨水泥到胫骨表面（骨水泥枪）。
不同方法骨水泥分布的3D模型。从做到右为对照组，背托涂抹组，全涂抹组，骨水泥枪组
Comparison of different cement application techniques for tibial component fixation in TKA
PURPOSE: Aseptic loosening of the tibial component remains a major cause for revision surgery in total knee arthroplasty (TKA). A stable initial fixation of the tibial implant has been suggested to reduce micromotion of the implant and could be decisive regarding its long-term performance. Different techniques for applying cement to the tibial surface have been described in the literature, with controversial results. No guidelines in favour of any particular approach are available.
METHODS: In this study, we compared three commonly used cementing techniques (layered application, stem cementation, cement gun) with surface-only fingerpacking cementation following pulsed lavage (paired human tibiae, four groups, n = 24). Specimens underwent computed tomography scanning for three-dimensional analysis of cement penetration and mechanical testing for assessing interface strength.
RESULTS: Bone cement penetration decreased with increasing bone mineral density (BMD) (R (2) = 0.18, p = 0.023), while interface strength increased with BMD (R (2) = 0.56, p < 0.001). No significant effect of cementation techniques on cement penetration (p ≥ 0.069) or interface strength (p = 0.180) was found in any group.
CONCLUSION: Adequate surface preparation using pulsed lavage and copious drying of the tibial surface appears to be of overruling importance, thus limiting the effect of any particular technique applied to improve implant fixation. This study emphasises the fundamental importance of surface preparation and pulsed lavage in TKA.
文献出处：Schlegel UJ, Bishop NE, Püschel K, Morlock MM, Nagel K. Comparison of different cement application techniques for tibial component fixation in TKA. Int Orthop. 2015 Jan;39(1):47-54.
文献2
髋关节置换术后慢跑的相关研究
译者：马云青
背景：慢跑被认为是一项高强度运动，全髋关节置换术（THA）后的进行慢跑运动的相关研究还没有详细的报道。
目的：探讨术后的慢跑参与率、慢跑参数及慢跑对种植体稳定性和假体磨损的影响。
方法：本研究包括了608名患者（85名男性，523名女性）共804髋的髋关节，这些患者于2005年至2011年间接受了THA，随访时间超过1年。患者平均年龄62岁（26-98岁），平均随访时间4.8年（2.3-7.8岁）。81例患者行髋关节表面置换术（HRA），527例患者行常规THA。在常规的术后随访中，患者接受了关于术前和术后慢跑的问卷调查。对于参与慢跑的患者记录慢跑的频率、距离、持续时间和速度。术后未慢跑的患者被要求提供不慢跑的原因。用专门的软件评估植入物迁移和聚乙烯磨损的放射学征象，并对金属对金属关节的患者进行血清钴和铬离子浓度的研究。
结果：术前慢跑的患者有33例（5.4%），术后慢跑的有23例（3.8%）。在23名术后慢跑患者中，13名患者接受常规THA，10名患者进行HRA。术后，仍然慢跑患者平均每周训练4次（1-7次），平均每次训练距离为3.6公里（0.5-15公里），平均每次训练时间为29分钟（5-90分钟），平均速度为7.7公里/小时（3-18公里/小时）。没有患者抱怨疼痛或显示血清钴和铬离子的浓度大于7 ppb。平均随访5年，髋关节未见松动、假体移位或过度磨损。术后有74名对慢跑感兴趣但未参与慢跑的患者。没有实施慢跑的原因包括焦虑（45名患者；61%）；不可能的原因包括疼痛、运动范围缩小和肌肉无力（18名患者；24%）；以及腰部或膝关节疼痛（11名患者；15%）。多变量分析显示男性和术前慢跑史与术后慢跑有显著关系。
结论：有3.8%的THA患者参加了术后慢跑。术后短期随访未发现慢跑对假体存活率有任何负面影响。
Jogging after total hip arthroplasty
BACKGROUND: Jogging has been classified as a high-impact sport, and jogging after total hip arthroplasty (THA) has not been well documented.
PURPOSE: To investigate the participation rate for postoperative jogging as well as jogging parameters and the influence of jogging on implant stability and bearing wear.
METHODS: Included in this study were 804 hips in 608 patients (85 men, 523 women) who underwent THA between 2005 and 2011 with follow-up longer than 1 year. The mean patient age was 62 years (range, 26-98 years), and mean follow-up duration was 4.8 years (range, 2.3-7.8 years). Hip resurfacing arthroplasty (HRA) was performed in 81 patients and conventional THA in 527 patients. During routine postsurgical visits, patients were given a questionnaire concerning preoperative and postoperative jogging routines. For joggers, frequency, distance, duration, and velocity of jogging were recorded. Patients who did not jog postoperatively were asked to provide reasons for not jogging. Radiographs concerning implant migration and polyethylene wear were evaluated with specialized software, and serum cobalt and chromium ion concentrations were investigated for patients with metal-on-metal articulation.
RESULTS: A total of 33 patients (5.4%) performed jogging preoperatively, and 23 patients (3.8%) performed jogging postoperatively. Of the 23 who jogged postoperatively, conventional THA was performed in 13 patients and HRA in 10 patients. Postoperatively, joggers trained a mean of 4 times (range, 1-7 times) per week, covering a mean distance of 3.6 km (range, 0.5-15 km) in a mean time of 29 minutes (range, 5-90 minutes) per session and at a mean speed of 7.7 km/h (range, 3-18 km/h). No patient complained of pain or showed serum cobalt and chromium ion elevation greater than 7 ppb. No hip showed loosening, abnormal component migration, or excessive wear at a mean 5-year follow-up. There were 74 postoperative non-joggers with an interest in jogging. The reasons given for avoiding jogging included anxiety (45 patients; 61%); impossible because of several reasons, including pain, decreased range of motion, and muscle weakness (18 patients; 24%); and lumbar or knee pain (11 patients; 15%). Multivariate analysis revealed that male sex and a history of preoperative jogging demonstrated significant relationships with postoperative jogging.
CONCLUSION: A total of 3.8% of THA patients participated in postoperative jogging. Short-term postoperative follow-up did not identify any negative influence of jogging on implant survival.
文献出处：Abe H, Sakai T, Nishii T, Takao M, Nakamura N, Sugano N. Jogging after total hip arthroplasty. Am J Sports Med. 2014 Jan;42(1):131-7.
文献3
影像推导的个性化手术器械对全膝关节置换术后
翻修率的影响：一项来自澳洲关节登记中心
共83823例关节置换的病例研究
译者：张蔷
背景：计算机导航和影像推导的个性化手术器械是关节外科领域的新科技，可以改善疗效，甚至降低初次全膝关节置换未来的翻修率。影像推导的个性化手术器械是指人工制造的患者专用的手术截骨器械。关于其对疗效的改善有多大，既往文献中给出了不同的结果。因此本篇文章的首要目标是为了比较应用影像推导的个性化手术器械（IDI）全膝关节置换、计算机导航全膝关节置换和传统方法全膝关节置换（“其他”方法）手术后的翻修率，次要目标是为了明确不同亚组的IDI全膝关节置换术后疗效是否存在差异。
方法：三组数据采集自澳洲骨科协会国家关节置换登记中心（AOANJRR）：IDI，计算机导航和“其他”方法。研究区间选自中心登记的首例IDI全膝置换（2010年4月）日期到2016年12月31日。研究限于由膝关节骨关节炎而施行的初次全膝关节置换手术，需置换髌骨并使用高交联聚乙烯衬垫。亚组分析包括年龄、性别、植入方法、IDI厂家、假体设计和假体类型对于翻修率的影响。用Kaplan-Meier曲线计算假体生存率。应用匹配了年龄和性别的风险比比较翻修率。
结果：IDI组包含了5486例初次全膝关节置换手术病例。5年时三组的累及翻修率并无显著性差异：IDI组3.3%(95%置信区间[CI], 2.4% to 4.6%)，计算机导航组2.4% (95% CI, 2.2% to 2.7%)，“其他”方法组2.5%(95% CI, 2.3% to 2.7%)。亚组分析显示：与计算机导航相比，应用PS假体的IDI组3月后的翻修率明显更高(HR, 1.45 [95% CI, 1.02 to 2.04]; p =0.036)，≤65岁的IDI组同样翻修率高(HR,1.52 [95% CI, 1.10 to 2.09]; p = 0.010)。IDI组的髌骨翻修更多。
K-M曲线
结论：与传统置换方法相比，影像推导的个性化手术器械全膝关节置换手术的早-中期翻修率并无显著性差异。然而应用PS假体，年龄≤65岁以及髌骨翻修等因素会使IDI组翻修率升高，因此应谨慎选择此种方法，同时需要更多的研究来论证其可靠性。
Impactof Image-Derived Instrumentation on Total Knee Arthroplasty Revision Rates： AnAnalysis of 83,823 Procedures from the Australian Orthopedic AssociationNational
Background: Computer navigation and image-derived instrumentation (IDI) aretechnology-based methods developed to improve outcomes and potentially reducerevision total knee arthroplasty (TKA). IDI refers to the use of manufactured,patient-specific surgical jigs. Conflicting reports exist on IDI-associated improvements in outcomes. The primary aim of the current study was to comparethe rates of revision among TKA cases in which components were initiallyimplanted with use of IDI, computer navigation, or neither of these methods(“other” TKA). The secondary aim was to determine whether the outcomes of IDIdiffered for specific subgroups.
Methods:Data were obtained from the Australian Orthopedic Association National JointReplacement Registry (AOANJRR) for the 3 TKA groups: IDI, computer-navigated,and other TKA. The study period was from the first IDI procedure recorded bythe AOANJRR (April 2010) to December 31, 2016. The analysis was restricted toprimary TKA cases undertaken for osteoarthritis and involving patellarresurfacing and the use of a cross-linked polyethylene insert. Sub-analyseswere performed to evaluate the effects of age, sex, implantation method, IDImanufacturer, prosthetic design, and prosthesis type on the rates of revision.Kaplan-Meier estimates of survivorship described the time to first revision.Hazard ratios (HRs, Cox proportional hazards models) with adjustment for ageand sex were used to compare revision rates.
Results: IDI was used in 5,486 primary TKA procedures. There was no significant difference among the groups in the cumulative percent revision (CPR) at 5years: 3.3% (95% confidence interval [CI], 2.4% to 4.6%) for IDI, 2.4% (95% CI,2.2% to 2.7%) for the computer-navigated group, and 2.5% (95% CI, 2.3% to 2.7%)for other TKA. Posterior-stabilized TKA with use of the IDI method had asignificantly higher rate of revision at > 3months (HR, 1.45 [95% CI, 1.02 to2.04]; p =0.036), as did IDI TKA in the ≤65-year-old patient cohort(HR, 1.52 [95% CI, 1.10 to 2.09]; p = 0.010), compared with computer-navigatedTKA. Patellar revision was significantly more likely in the IDI group.
Conclusions: IDI TKA demonstrated no overall difference in early to mid-term revision ratescompared with standard implantation methods. However, elevated rates ofrevision were seen with posterior-stabilized TKA, in patients ≤65years of age, and for patellar revision, meaning that this method should beused with some caution and requires further study.
文献出处：McAuliffe MJ, Beer BR, Hatch JJ, Crawford RW, Cuthbert AR, Donnelly WJ. Impact of Image-Derived Instrumentation on Total Knee Arthroplasty Revision Rates: An Analysis of 83,823 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am. 2019 Apr 3;101(7):580-588. doi: 10.2106/JBJS.18.00326.
第二部分：保髋相关文献
文献1
SARS后股骨头坏死患者接受联合治疗的12年随访
译者：罗殿中
目的：评估阿仑膦酸盐、体外冲击和高压氧联合治疗SARS后股骨头坏死患者的远期疗效。
方法：回顾性研究包括2003年11月至2015年11月在天津医科大学总医院骨科收治的37例SARS后股骨头坏死患者（66髋），其中男性6例（11髋）和女性31例（55髋），年龄19至47岁（平均29.9岁）。比较治疗前和治疗后1、3、6、9、12年的疼痛VAS评分、Harris评分和股骨头坏死ARCO分期。应用题配对t检验评估治疗前后VAS和Harris评分的统计分析。用卡方检验分析所有分期的差异。
结果：通过12年的随访，我们观察到患者VAS评分显着改善（治疗前为6.81，治疗后12年为3.94），Harris评分也有显著提高（治疗前为74.54，治疗后为12年为80.14）（所有p <0.05）。不同ARCO分期患者治疗的有效率存在统计学差异（p <0.05）。不同ARCO分期患者接受联合治疗的预后不同，预后最好的是ARCO第I期。
结论：联合治疗可能延缓SARS后股骨头坏死的病情进展。
37名患者治疗前及治疗后不同时期VAS评分及Harris评分的比较
MRI显示47岁男性双侧股骨头坏死患者治疗前后股骨头坏死区范围的变化。A 治疗前；B 治疗后1年；C 治疗后3年；D 治疗后9=6年；E 治疗后9年；F 治疗后12年
A 12-year follow-up study of combined treatment of post-severe acute respiratory syndrome patients with femoral head necrosis
OBJECTIVE: To investigate the long-term efficacy of a combination treatment of alendronate, extracorporeal shock and hyperbaric oxygen for osteonecrosis of the femoral head (ONFH) of post-severe acute respiratory syndrome (SARS) patients.
PATIENTS AND METHODS: The retrospective study was performed including a total of 37 post-SARS ONFH patients (66 hip joints) in the Department of Orthopedics of the General Hospital of Tianjin Medical University between November 2003 and November 2015, consisting of 6 males (11 hip joints) and 31 females (55 hip joints), with age between 19 and 47 years (average 29.9 years). Visual analog scale (VAS) score, Harris score and Association Research Circulation Osseous (ARCO) stage of imaging examination were compared among those before treatment, and at 1, 3, 6, 9 and 12 years after treatment. Paired t-test was used for statistical analysis of VAS and Harris score before and after treatment. Difference of effective rate on all stages was analyzed with Chi-square test.
RESULTS: With 12-year follow-up, significant improvements on VAS (6.81 of pre-treatment vs 3.94 of 12-year post-treatment) and Harris score (74.54 of pre-treatment vs 80.14 of 12-year post-treatment) were observed (all p<0.05). Effective rate showed statistical significance among three stages of ARCO (p<0.05). The combined treatment showed different efficacies on different ARCO stages; the best was on ARCO Phase I.
CONCLUSION: The combined treatment may delay or discontinue the development of ONFH in post-SARS patients.
文献出处：Liu T, Ma J, Su B, Wang H, Wang Q, Ma X. A 12-year follow-up study of combined treatment of post-severe acute respiratory syndrome patients with femoral head necrosis. Ther Clin Risk Manag. 2017 Oct 19;13:1449-1454.
文献2
使用核磁评估股骨转子上和转子下股骨扭转：
与股髋撞击和髋关节发育不良的关系
译者：程徽
目的：我们研究的目的是评估一种新的方法，用于分别测量股骨转子上和转子下扭转角。在健康志愿者中建立股骨转子上和转子下部分的扭转角的参考值，并比较髋关节发育不良患者、股髋撞击（ FAI）患者的股骨转子上和转子下扭转角度与健康志愿者的异同。
材料和方法：在MRI上对380名患者和61名健康志愿者的股骨扭转角进行评估。为了选择测量方法，两位阅片者分别对100名患者使用三种方法即Kim法，简化Kim法和质心法）进行测量。选择三种方法中具有最高阅片者间一致性的技术来对所有患者和志愿者进行测量。按照专业的髋关节外科医生诊断将患者进行疾病分层，并与健康志愿者的参考值进行比较。统计分析包括独立t检验，Mann-Whitney U检验和组内相关系数（ICC）。
结果：使用质心法测量股骨转子上和转子下扭转，阅片者间一致性在3种方法种最高， ICC为0.979。志愿者的转子上和转子下扭转值分别为31.5°±7.4°和-18.3°±9.9°。与志愿者相比，髋关节发育不良患者的股骨转子上和转子下扭转值均明显较大分别为37.5°±10.3°（p = 0.001）和-9.6°±11.7°（p <0.001）；而钳夹型FAI患者，只有股骨转子上扭转值显著较大为37.8°±8.0°（p = 0.002）。
结论：在髋关节不同疾病之间，股骨扭转的股骨转子上和转子下部位分布存在显著差异：髋关节发育不良的患者主要表现为股骨转子下扭转，而钳形FAI患者只有股骨转子上扭转明显增大。所以，需要对股骨转子上和转子下扭转角度分别进行测量，并进行更详细的分析，才能提出个性化的治疗计划。
MRI Assessment of Supra- and InfratrochantericFemoral Torsion: Association With Femoroacetabular Impingement and HipDysplasia
OBJECTIVE: The objective of our study was toevaluate a novel measurement technique for assessing the supra- andinfratrochanteric components of femoral torsion, establish reference values inhealthy volunteers, and compare supra- and infratrochanteric torsion angles inpatients with hip dysplasia and patients with femoroacetabular impingement (FAI)with those in healthy volunteers.
MATERIALS AND METHODS: Femoral torsion wasassessed in 380 patients and 61 healthy volunteers on MRI. For assessing supra-and infratrochanteric torsion, three measurement techniques (i.e., Kim,simplified Kim, and centroid methods) were evaluated by two readers on 100patients. The technique with the highest interreader reliability was selectedto perform measurements on all patients and volunteers. Supra- andinfratrochanteric torsion angles of patients were stratified by hip disorders,which were diagnosed by specialized hip surgeons, and were compared withreference values of healthy volunteers. Statistical analysis included theindependent t test, Mann-Whitney U test, and intraclass correlation coefficient(ICC).
RESULTS: The centroid method showed thehighest interreader reliability for measuring supra-and infratrochanterictorsion with an ICC of 0.979. The supra- and infratrochanteric torsion valuesof the volunteers were 31.5° ± 7.4° (mean ± SD) and -18.3° ± 9.9°,respectively. In comparison with the volunteers, patients with hip dysplasiahad significantly higher supraand infratrochanteric torsion values of 37.5° ±10.3° (p = 0.001) and -9.6° ± 11.7° (p < 0.001) and patients withpincer-type FAI had significantly higher supratrochanteric torsion values of37.8° ± 8.0° (p = 0.002).
CONCLUSION: The supra- and infratrochantericcomponents of femoral torsion differ substantially between hip disorders:Patients with hip dysplasia have predominantly increased infratrochanterictorsion, whereas patients with pincer-type FAI have increased supratrochanterictorsion. Quantification of separate supra- and infratrochanteric torsion anglesallows a more detailed analysis of hip disorders and may influence treatment planning.
文献出处：Fritz B, Bensler S, Leunig M, ZinggPO, Pfirrmann CWA, Sutter R. MRI Assessment of Supra- and InfratrochantericFemoral Torsion: Association With Femoroacetabular Impingement and HipDysplasia. AJR Am J Roentgenol. 2018 Jul;211(1):155-161.
文献3
土耳其无症状髋关节撞击症的患病率：
横断面研究
译者：肖凯
目的：髋关节撞击症（FAI）是年轻患者髋部疼痛的常见原因。本研究的目的是通过影像学检查明确土耳其人群中无症状FAI的患病率。
方法：回顾性分析了2015年9月至2016年9月期间急诊就诊的患者，年龄18-65岁。进行初步筛选后，得到1076名无症状患者（2152髋），所有患者均有骨盆前后位和蛙式位X线片。在患者X线片上完成α角、外侧中心边缘角（LCEA）、Tönnis角（TA）和颈干角。我们将α角超过55°的定义为Cam型FAI。TA小于0°或LCEA超过39°的定义为Pincer型FAI。 LCEA小于25°或TA值超过10°被认为是髋关节发育不良。
结果：1076名患者（602名女性，474名男性）的平均年龄为42.1±15.6岁。评估显示，15.9％的患者存在Cam畸形，10.6％的患者为Pincer型FAI，3.1％的患者为混合型FAI，9.3％的患者为髋关节发育不良。在土耳其人群中，无症状FAI男性（46％）患病率显著高于女性（17%）。
结论：尽管FAI被认为是导致髋关节骨关节炎的常见病因，但在无症状人群中并不罕见。我们的研究表明，土耳其无症状成人的影像学诊断FAI比例为29.6％。
病人筛选及诊断流程图
总人口、男性及女性人群中正常、Cam畸形、Pincer畸形、混合型FAI及发育不良的比例
Prevalence of asymptomatic femoroacetabular impingement in Turkey; cross sectional study
OBJECTIVES: Femoroacetabular impingement (FAI) is one of the causes of hip pain in young-adult patients. The purpose of our study is to determine the prevalence of radiological FAI findings in asymptomatic population in Turkey.
METHODS: Trauma patients aged 18-65 years who applied to the emergency service between September 2015 and September 2016 were retrospectively evaluated for this study. After a preliminary study and power analysis, 2152 hips of the 1076 previously asymptomatic patients were evaluated radiologically with pelvis antero-posterior and frog-leg radiographs. On radiographs of these patients; alpha angle, lateral central edge angle (LCEA), Tönnis angle (TA) and collodiaphyseal angle were measured. Alpha angle values higher than 55° were noted as cam type FAI. TA values lower than 0° or LCEA values higher than 39° were noted as pincer type FAI. LCEA values lower than 25° or TA values higher than 10° were noted as acetabular dysplasia.
RESULTS:Mean age of 1076 patients (602 female, 474 male) was 42.1 ± 15.6 years. The assessment showed that 15.9% of the patients had cam type, 10.6% had pincer type, 3.1% had combined type FAI and 9.3% had findings of acetabular dysplasia. The prevalence of asymptomatic FAI is significantly more in males (46%) in comparison to females (17%) in Turkey.
CONCLUSION: Even though FAI is considered to be a pathology associated with hip osteoarthritis; it is very common in asymptomatic population. In this respect, our study showed that prevalence of radiological FAI findings in asymptomatic adult population was 29.6% in Turkey.
文献出处：Polat G, Şahin K, Arzu U, Kendirci AŞ, Aşık M. Prevalence of asymptomatic femoroacetabular impingement in Turkey; cross sectional study. Acta Orthop Traumatol Turc. 2018 Jan;52(1):49-53.
文献4
Chiari骨盆内移截骨手术入路的比较
译者：任宁涛
我们对Chiari骨盆内移截骨治疗髋关节发育不良进行了中长期结果的研究，其中包括129名患者135例髋关节，平均手术年龄为24岁，平均随访时间为16.2年。最初的31例髋关节采用了前方髂股入路，未进行大转子截骨，此后79例髋关节采用了后外侧经大转子入路，确保最佳截骨平面和大转子下移，剩余25例髋关节采用Ollier外侧U形入路。103例（77%）髋关节术后临床效果优或良，与采用了前方髂股入路的31例髋关节相比，行经大转子入路的104例髋关节临床效果优越，且截骨平面更加合适，术后Trendelenburg步态出现少。因此我们推荐采用经大转子入路，以获得合适的截骨平面和有效的大转子下移程度。
图1女，12岁，髋关节半脱位，股骨头畸形。生后14个月是曾因发育性髋关节脱位行切开复位，3岁时进行股骨截骨术。影像学资料显示a）术前退行性改变伴软骨下髋臼硬化，大转子高位；b）Chiari骨盆内移截骨术后5年，大转子经后外侧入路下移，关节间隙未见减小；c）术后24年，关节间隙缩小，但临床效果良好，髋关节无疼痛，无Trendelenburg步态。
图2 女，30岁，髋关节发育不良，股骨头畸形。生后28个月时因发育性髋关节脱位行牵引治疗，影像学资料显示a）术前股骨头和髋臼对合关系差，大转子高位，b）Chiari骨盆内移截骨大转子下移，术后2周，股骨头覆盖良好，c）术后15年，关节间隙缩小，但临床效果良好，髋关节无疼痛，无Trendelenburg步态。
Comparison ofthe surgical approaches for a Chiari pelvic osteotomy
We present the mid- to long-term results of the Chiari pelvic osteotomy fordysplastic hips. We followed 135 hips in 129 patients, with a mean age at thetime of surgery of 24 years, for a mean of 16.2 years. We used the anterioriliofemoral approach without trochanteric osteotomy inthe initial 31 hips. Thereafter, we used transtrochanteric approaches in anattempt to ensure that the osteotomy wasat the most appropriate level, and to advance the high-riding greatertrochanter distally. The next 79 hips therefore underwent a posterolateralapproach and the most recent 25 hips an Ollier lateral U approach. The clinicalresult was excellent or good in 103 hips (77%). The outcome in 104 hips inwhich we used a transtrochanteric approach was superior, the osteotomy level was more appropriate and aTrendelenburg gait less common than in 31 hips in which we used an anteriorapproach. We therefore recommend the use of a transtrochanteric approach inorder to ensure that the osteotomy is atan appropriate level and in order to achieve effective distal advancement ofthe high-riding greater trochanter.
文献出处：Ito H, Matsuno T, Minami A. Comparison ofthe surgical approaches for a Chiari pelvic osteotomy. J Bone Joint Surg Br. 2003Mar;85(2):204-8.
文献5
髋臼后壁骨化的放射学研究：
对儿童和青少年髋关节疾病诊断的意义
译者：张利强
背景：髋臼形态的细微变化与几种病理性髋关节疾病有关。虽然认为髋臼形成于髂骨、坐骨和耻骨交界处的Y形软骨，但髋臼后壁的骨化和发育模式尚不清楚。用于评估青少年髋部的标准X线片和计算机断层扫描不能对发育中的髋臼的非骨化部分进行完全评估。本研究的目的是确定目前未知的髋臼后壁骨化模式和发育情况，并确定使用计算机断层扫描和X线照片进行常规检查何时合适。
方法：放射科医生对180例4～15岁患者的磁共振成像检查进行评估，观察髋臼后壁和Y行软骨的骨化情况。并与可用的X线片行相关性分析。
结果：在整个发育过程中髋臼后壁骨化滞后于前壁。平均来说，髋臼后壁在8岁时开始骨化。12岁时，髋臼后壁与骨盆骨化融合之前，在髋臼后壁出现一个离散的钙化边缘（后缘征）。这都发生在所有受试者的Y形软骨闭合之前。男性患者平均比女性患者晚1～1.5年发生髋臼后壁骨化融合。
结论：髋臼后壁的骨化是在Y形软骨闭合前以可预测的方式完成的。
临床相关性：在Y形软骨闭合（通常女孩12岁和男孩14岁）之前，应使用磁共振成像而不是X线片和计算机断层扫描来评估患有髋关节疼痛的儿童，或利用磁共振横断面成像来测量和描述髋臼形态。这项研究发现沿着髋臼后壁边缘有一个二级骨化中心，在Y形软骨融合前就已经骨化。这种二次边缘骨化中心不应与病理情况相混淆，如盂唇撕脱或髋臼后壁损伤。
图A到D 在髋臼后壁水平的冠状MRI图像旁为髋臼的线条图，显示了每个发育阶段的变化。 在每个线条图中，蓝色代表软骨，米色代表骨化骨。5岁男性患者的MRI显示髋臼后壁完全为软骨（第一阶段）（箭头）（图A），9岁男性患者MRI显示髋臼后壁出现不规则的骨化（箭头）和石子样的骨化小岛（第二阶段）（三角箭头）（图B）。12岁的女性患者MRI可见髋臼后壁边缘骨化（第三阶段）（箭头）（图C）。 16岁男性患者的MRI显示完全骨化的髋臼后壁并与后柱融合，箭头显示后壁最外侧面的皮质骨（第四阶段）（图 D）。
图A到D为X线和MRI扫描显示后缘骨化中心。一名14岁男性患者的前后位骨盆X线片（图A）显示双侧髋臼清晰的二次后缘骨化中心，双侧MRI表现（B），冠状位MRI（C和D）。图B中的白线指的是图C和D相应的冠状切片在髋臼后壁的解剖水平。特别是后侧壁与后内侧柱的关系。星号为MRI中显示的后柱。上图X线显示Y形软骨接近闭合，但在MRI仍可见保持开放（B）。
图A到F图片显示：创伤。一个在车祸中发生髋关节后脱位的11岁男性患者的影像和术中照片。 图A闭孔斜位（Judet）片显示看似小的后壁碎片（白色箭头）。Y形软骨双侧开放（黑色箭头）。图B通过髋臼后壁水平的CT扫描显示看似对称的后壁（白色箭头）。矢状位（C）和冠状位（D）MRI软骨像显示75％后壁受累（黑色箭头），表现为垂直位移。图 E和F示通过Kocher-Langenbeck入路术中照片显示4*3cm的软骨后壁骨折（图E）。 图F示可以在后壁深处看到股骨头（星号）。
A Radiographic Study of the Ossification of the Posterior Wall of the Acetabulum: Implications for the Diagnosis of Pediatric and Adolescent Hip Disorders
Background: Subtle variations in acetabular morphology have beenimplicated in several pathologic hip conditions. Although it is understood thatthe acetabulum forms at the junction of the ilium, ischium, and pubis at thetriradiate cartilage, the ossification and development pattern of the posteriorwall of the acetabulum is unknown. Standard radiographs and computedtomographic scans used in evaluation of the adolescent hip do not allow acomplete assessment of the non-ossified portions of the developing acetabulum. Thepurpose of this study was to define the currently unknown ossification patternand development of the posterior wall of the acetabulum and to determine whenconventional imaging, with use of computed tomography and radiographs, isappropriate.
Methods: One hundred and eighty magnetic resonance imagingexaminations in patients who were four to fifteen years old were evaluated by amusculoskeletal radiologist for ossification patterns of the posterior wall ofthe acetabulum and triradiate cartilage. Correlations were made with availableradiographs.
Results: Posterior acetabular wall ossification lags behind anterior wallossification throughout development. On average, the posterior wall of theacetabulum began to ossify at the chronological age of eight years, followed bya discrete rim of posterior calcification (posterior rim sign) at the patientage of twelve years, just prior to the fusion of the posterior acetabular wallelements to the pelvis. This preceded the closure of the triradiate cartilage inall subjects. On average, male patients had fusion of the posterior wall of theacetabulum one to 1.5 years after female patients.
Conclusions: The ossification of the posterior wall of the acetabulum is completedin a predictable manner prior to closure of the triradiate cartilage.
Clinical Relevance: Prior to closure of the triradiate cartilage(typically at theage of twelve years in girls and fourteen years in boys), magnetic resonanceimaging, rather than radiographs and computed tomography, should be used toevaluate a child with hip pain or to measure and characterize acetabularmorphology when cross-sectional imaging is indicated. This study characterizesa secondary ossification center along the edge of the posterior wall of theacetabulum that becomes ossified just prior to fusion. This secondary rimossification center should not be confused with pathologic conditions such aslabral avulsion or posterior acetabular wall injury.
文献出处：Peter D. Fabricant, Brandon P. Hirsch, et al. A radiographicstudy of the ossification of the posterior wall of the acetabulum: implicationsfor the diagnosis of pediatric and adolescent hip disorders. J Bone Joint SurgAm 2013;95(3):230-6
文献6
通过改良Dunn手术治疗严重股骨头骨骺滑脱的
患者长期随访发现股骨头缺血坏死率低、
预后良好和骨关节炎少
译者：陶可（北京大学人民医院骨关节科）
目的：改良Dunn手术有可能恢复严重股骨头骨骺滑脱（SCFE）的髋部解剖结构，但存在股骨头缺血坏死（AVN）的风险。在本文中，我们报告了接受改良Dunn手术治疗严重SCFE的患者的临床和、放射学结果、AVN率和并发症以及长期随访的累积（股骨头）生存率。
患者和方法：我们对1999年至2016年间接受改良Dunn手术治疗严重SCFE（滑移角> 60°）的46例患者46髋关节进行了回顾性分析。在9年随访中，40髋可用于临床和放射学检查。术前平均年龄为13岁，14髋（30％）出现不稳定滑脱。平均术前滑移角为64°。计算了Kaplan-Meier的生存率。
结果：在最近的随访中，Merle d'Aubigné和Postel的平均得分为17分（14至18），平均改良Harris髋关节评分为94分（66至100），平均髋关节残疾和骨关节炎结果评分为91分（67比100）。术后滑移角为7°（1°至16°）。一个髋（2％）有骨关节炎（OA）的进展。两个髋部股骨头（5％）出现AVN，需要进一步手术。由于螺钉断裂或导线更换，其他三个臀部（7％）进行了植入物翻修术。十年随访时累积生存率为86％。
结论：改良Dunn手术治疗严重SCFE时的AVN发生率低、OA进展风险低、长期随访时功能评分高。滑移畸形明显得到纠正，但二次撞击畸形可能在某些髋部发生，可能需要进一步手术治疗。
放射学照片显示a）和b）一名15岁男性患者，患有严重但稳定的股骨头骨骺滑脱，c）和d）接受改良Dunn手术。无论是在e）和f）两个月的随访，还是在g）和h）两年的随访中，他都出现了髋关节疼痛。i）和j）在8年的随访中，Merled'Aubigné和Postel评分为17分，无股骨头缺血性坏死，且无髋骨关节炎进展。
X线照片显示一名11岁男性患者，患有严重但急性的股骨头骨骺滑脱，a）术前和b）经过改良Dunn手术后。c）术后4个月出现骨骺无症状性坏死，d）5个月时行股骨转子间内翻截骨术。e）由于股骨头半月半脱位，他接受了三次截骨术作为抢救手术，f）15个月和g）17个月所示。h）在5年的随访中，患者出现半脱位的迹象。
a）一名17岁男性患者，患有严重且不稳定的股骨头骨骺滑脱，b）接受改良Dunn手术。c）在5个月的随访中，出现了螺钉断裂，d）进行了断钉取出翻修术，e）在13年的随访中，Merled'Aubigné和Postel评分18分，无股骨头缺血性坏死，无骨关节炎进展。
Patients with severe slipped capital femoral epiphysis treated by the modified Dunn procedure have low rates of avascular necrosis, good outcomes, and little osteoarthritis at long-term follow-up
AIMS: Themodified Dunn procedure has the potential to restore the anatomy in hips withsevere slipped capital femoral epiphyses (SCFE). However, there is arisk of developing avascular necrosis of the femoral head (AVN). Inthis paper, we report on clinical outcome, radiological outcome, AVN rate andcomplications, and the cumulative survivorship at long-term follow-up inpatients undergoing the modified Dunn procedure for severe SCFE.
PATIENTSAND METHODS: We performed a retrospective analysis involving 46 hipsin 46 patients treated with a modified Dunn procedure for severe SCFE (slipangle > 60°) between 1999 and 2016. At nine-year-follow-up, 40 hips wereavailable for clinical and radiological examination. Mean preoperative age was13 years, and 14 hips (30%) presented with unstable slips. Mean preoperativeslip angle was 64°. Kaplan-Meier survivorship was calculated.
RESULTS:At thelatest follow-up, the mean Merle d'Aubigné and Postel score was 17 points (14to 18), mean modified Harris Hip Score was 94 points (66 to 100), and mean HipDisability and Osteoarthritis Outcome Score was 91 points (67 to 100).Postoperative slip angle was 7° (1° to 16°). One hip (2%) had progression ofosteoarthritis (OA). Two hips (5%) developed AVN of the femoral headand required further surgery. Three other hips (7%) underwent implant revisiondue to screw breakage or change of wires. Cumulative survivorship was 86% atten-year follow-up.
CONCLUSION:Themodified Dunn procedure for severe SCFE resulted in a low rate of AVN, low riskof progression to OA, and high functional scores at long-term follow-up. Theslip deformities were mainly corrected but secondary impingement deformitiescan develop in some hips and may require further surgical treatment.
文献出处： Lerch TD, Vuilleumier S, SchmaranzerF, Ziebarth K, Steppacher SD, Tannast M, Siebenrock KA. Patients with severe slipped capital femoral epiphysistreated by the modified Dunn procedure have low rates of avascular necrosis,good outcomes, and little osteoarthritis at long-term follow-up. Bone Joint J.2019 Apr;101-B(4):403-414. doi: 10.1302/0301-620X.101B4.BJJ-2018-1303.R1.
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