本期目录：
1、增加术前睡眠可以减轻关节置换术后疼痛和止痛药用量：一个可行性研究
2、初次全关节置换术中万古霉素创面给药后血清和创面药物浓度的变化
3、累及骶骨的腰椎融合手术会增加初次全髋关节置换术后脱位的风险
4、股骨远端去旋转截骨外固定术治疗脑瘫患者股骨前倾角异常
5、与传统CT相比低辐射CT可将保髋手术患者的放射暴露减少90%
6、轻度髋关节发育不良患者接受髋臼周围截骨术后并发症及短期预后情况
7、Chiari骨盆内移截骨治疗伴发盂唇撕裂的发育异常性骨关节炎：10年以上随访结果
8、髋臼周围截骨术改善了外侧中心边缘角为18°到25°之间的患者的疼痛和功能，但这些髋关节真的是临界发育不良吗？
9、股骨头骨骺延长可能有助于股骨头骨骺滑脱的骨骺稳定性
第一部分：关节置换及保膝相关文献
文献1
增加术前睡眠可以减轻关节置换术后疼痛和
止痛药用量：一个可行性研究
译者：张轶超
研究目的：明确在睡眠不足的患者中延长其术前睡眠时间是否可以减轻其全膝或全髋术后的疼痛及减少止痛药的用量。
方法：18名每晚睡眠时间低于人群平均睡眠时间（≤7小时）的睡眠不足患者被纳入研究。将他们随机分为一周内每晚延长睡眠时间2小时组（EXT）和保持原有睡眠时间习惯组（HAB）。通过腕带式体动记录仪来监测病人的情况。记录术后每天阿片类药物的使用剂量（换算成相当于多少毫克的吗啡）和每天的疼痛等级（每天询问3-4次，采用0-10分计分，0分为无痛，10分为在其印象中最疼的程度），观察记录在院的3到4天的情况。
结果：两组在既往的夜间睡眠时间没有明显的差异 [EXT组6.0（±0.78）小时，HAB组6.5（±0.50）小时]。经过一周的睡眠干预，有3名患者延长睡眠时间失败。那些成功延长睡眠时间的患者（n=7）相对于HAB组患者睡眠时间延长了1个多小时（8.0比6.9小时，p<0.05）。术后3-4天的观察发现，EXT组比HAB组明显的平均疼痛评分降低（4.4比5.6，p<0.04），每日阿片类止痛药的吗啡当量用量更少（20.3比38.6 mg，p<0.02）。
结论：在本研究中我们发现术前延长睡眠不足患者的睡眠时间可以减轻关节置换患者术后的疼痛程度和减少阿片类止痛药的用量。
Increasing presurgery sleep reduces postsurgery pain and analgesic use following jointreplacement: a feasibility study
STUDY OBJECTIVES: To determine whether presurgery sleep extension in short-sleeping volunteers scheduled for total knee/hip replacement surgery would reduce postsurgery pain and analgesic use.
METHODS: Eighteen short sleepers, defined by sleep times below the national mean (ie, ≤7 h) nightly, were randomized to one week of a 2-h nightly extension of their time in bed (EXT) or maintenance of their habitual time in bed (HAB) prior to knee or hip replacement surgery. Compliance was monitored by wrist actigraphy. Outcomes were the postsurgery daily dose of opiates (converted to morphine milligram equivalents) and the daily pain ratings (acquired 3-4 times across the day) on a 0-10 rating scale (0 = no pain to 10 = worst pain experienced) over the three to four day inpatient recovery.
RESULTS: On a diary before the presurgery time in bed (TIB) manipulation, there were no significant differences in reported nightly sleeptimes between those randomized to the EXT group [6.0 (±0.78) h] and the HAB group [6.5 (±0.50) h]. During the one-week presurgery TIB manipulation, three participants failed to extend their TIB. Among those extending TIB (n = 7), compared to the HAB group, the EXT group spent significantly more nightly TIB (8.0 vs. 6.9 h, p < 0.05), which resulted in 1 h of more sleep (6.8 vs. 5.8 h, p < 0.04). On the three- to four-day postsurgery inpatient recovery, the EXT group reported significantly less average daily pain (4.4 vs. 5.6, p < 0.04) and less daily morphine milligram equivalent intake (20.3 vs. 38.6 mg, p < 0.02) than those by the HAB group.
CONCLUSIONS: In this feasibility study, we found that a presurgery extended TIB and associated increase in sleep time in short-sleeping patients scheduled for undergoing joint replacement results in reduced postsurgery pain ratings and opiate use.
文献出处：Roehrs TA, Roth T. Increasing presurgery sleep reduces postsurgery pain and analgesic use following jointreplacement: a feasibility study. Sleep Med. 2017 May;33:109-113. doi: 10.1016/j.sleep.2017.01.012. Epub 2017 Feb 6.
文献2
初次全关节置换术中万古霉素创面给药后
血清和创面药物浓度的变化
译者：马云青
背景：人工关节假体周围感染是全关节置换术(TJA)后再住院的最常见原因。伤口内应用万古霉素粉剂(VP)降低了脊柱外科手术中的感染率，但是在原发性TJA中没有关于术中局部应用VP的数据。
方法：34例TJA患者术中给予2g VP，观察VP的药代动力学。术后24小时多时间点测定血清和伤口药物浓度。
结果：所有血药浓度均为亚治疗水平(<15μg/mL)，伤口缝合12h后达到血药浓度高峰(4.7μg/mL,SD,3.2)。术后3h创面组织药物浓度为922μg/mL(SD,523)，24h为207μg/mL(SD,317)。VP在TJA创面的半衰期为7.2小时(95%cl, 7.0~9.3)。
结论：VP在TJA伤口内产生较高治疗水平的药物浓度，同时产生较低的全身血药浓度。VP可作为预防关节假体周围感染的一种安全的辅助手段。
Serum and Wound Vancomycin Levels After Intrawound Administration in Primary Total Joint Arthroplasty
BACKGROUND: Periprosthetic joint infection is the most common cause of readmissions after total joint arthroplasty (TJA). Intrawound vancomycin powder (VP) has reduced infection rates in spine surgery; however, there are no data regarding VP in primary TJA.
METHODS: Thirty-four TJA patients received 2 g of VP intraoperatively to investigate VP's pharmacokinetics. Serum and wound concentrations were measured at multiple intervals over 24 hours after closure.
RESULTS: All serum concentrations were subtherapeutic (<15μg/mL) and peaked 12 hours after closure (4.7μg/mL; standard deviation [SD], 3.2). Wound concentrations were 922 μg/mL (SD, 523) 3 hours after closure and 207 μg/mL (SD, 317) at 24 hours. VP had a half-life of 7.2 hours (95% confidence interval, 7.0-9.3) in TJA wounds.
CONCLUSIONS: VP produced highly therapeutic intrawound concentrations while yielding low systemic levels in TJA. VP may serve as a safe adjunct in the prevention of periprosthetic joint infection.
文献出处：Johnson JD, Nessler JM, Horazdovsky RD, Vang S, Thomas AJ, Marston SB. Serum and Wound Vancomycin Levels After Intrawound Administration in Primary Total Joint Arthroplasty. J Arthroplasty. 2017 Mar;32(3):924-928.
文献3
累及骶骨的腰椎融合手术会增加
初次全髋关节置换术后脱位的风险
译者：张蔷
目的：髋关节与脊柱的共发病变可以改变初次全髋关节置换术后脊柱-骨盆的生物运动学特性。本篇文章主要研究脊柱融合术后的骨盆变化如何增加全髋关节置换术后的脱位风险。
方法：1998至2015年，我们共入组了84名（97髋）脊柱融合术后行初次全髋置换手术的患者。根据脊柱融合节段的长度和是否累及腰骶部，我们将患者分为三组。平均年龄71岁（40-87岁），54人为女性（56%）。平均体重指数（BMI）为30kg/m2（19-45）。平均随访时间为6年（2-17）。同时根据1：2的配平比例，我们选择了另外一组初次全髋关节置换而无脊柱融合病史的患者作为对照组。我们对风险比进行了计算（HR）。
单节段融合组/多节段融合组/累及腰骶部的多节段融合组
结果：在1年随访时，融合组的脱位率为5.2%，对照组为1.7%，但并未达到统计学差异(HR 1.9; p = 0.33)。与对照组相比，接受过未累及腰骶部的脊柱融合手术组的脱位率并无显著性差异。但当脊柱融合手术包含腰骶部，脱位率则显著升高(HR 4.5; p = 0.03)，且累及节段越长，脱位率越高。患者基本情况与全髋置换手术情况（入路和股骨头直径等）对脱位率并无显著影响。不同长度的脊柱融合会产生不同的骨盆前倾角度，单节段融合组22°，多节段融合组27°，腰骶椎组32°（p < 0.01）。融合组的10年假体生存率为93%，而对照组为95%（HR 1.2; p = 0.8）。
结论：包含腰骶部的脊柱融合手术会增加后续全髋关节置换术后半年内的脱位风险。相比于对照组和其他脊柱融合组，累及腰骶部的多节段脊柱融合手术会显著增加术后脱位风险。因此，当遇到此类高风险患者时，术者应从假体安放和选择高稳定性假体等方面综合考量。
Lumbar fusion involving the sacrum increases dislocation risk in primary total hip arthroplasty
Aims: Concurrent hip and spine pathologies can alter the biomechanics of spinopelvic mobility in primary total hip arthroplasty (THA). This study examines how differences in pelvic orientation of patients with spine fusions can increase the risk of dislocation risk after THA.
Patients and Methods: We identified 84 patients (97 THAs) between 1998 and 2015 who had undergone spinal fusion prior to primary THA. Patients were stratified into three groups depending on the length of lumbar fusion and whether or not the sacrum was involved. Mean age was 71 years (40 to 87) and 54 patients (56%) were female. The mean body mass index (BMI) was 30 kg/m2 (19 to 45). Mean follow-up was six years (2 to 17). Patients were 1:2 matched to patients with primary THAs without spine fusion. Hazard ratios (HR) were calculated.
Results: Dislocation in the fusion group was 5.2% at one year versus 1.7% in controls but this did not reach statistical significance (HR 1.9; p = 0.33). Compared with controls, there was no significant difference in rate of dislocation in patients without a sacral fusion. When the sacrum was involved, the rate of dislocation was significantly higher than in controls (HR 4.5; p = 0.03), with a trend to more dislocations in longer lumbosacral fusions. Patient demographics and surgical characteristics of THA (i.e. surgical approach and femoral head diameter) did not significantly impact risk of dislocation (p > 0.05). Significant radiological differences were measured in mean anterior pelvic tilt between the one-level lumbar fusion group (22°), the multiple-level fusion group (27°), and the sacral fusion group (32°; p < 0.01). Ten-year survival was 93% in the fusion group and 95% in controls (HR 1.2; p = 0.8).
Conclusion: Lumbosacral spinal fusions prior to THA increase the risk of dislocation within the first six months. Fusions involving the sacrum with multiple levels of lumbar involvement notably increased the risk of postoperative dislocation compared with a control group and other lumbar fusions. Surgeons should take care with component positioning and may consider higher stability implants in this high-risk cohort.
文献出处：C. G. Salib, N. Reina, K. I. Perry, M. J. Taunton, D. J. Berry, M. P. Abdel. Lumbar fusion involving the sacrum increases dislocation risk in primary total hip arthroplasty.
Cite this article: Bone Joint J 2019;101-B:198–206.
第二部分：保髋相关文献
文献1
股骨远端去旋转截骨外固定术
治疗脑瘫患者股骨前倾角异常
译者：罗殿中
脑瘫患者常发生股骨扭转畸形。这些骨性畸形会进一步削弱已经不完善的行走能力。我们通常进行股骨截骨术以维持和改善患者行走能力。应用股骨髁钢板对股骨截骨端进行固定已获得成功，但患者通常不能立即进行术后完全负重。因此，为了能够术后早期进行康复训练，避免因不活动引起的骨量丢失，我们需要寻找让患者术后即可完全负重的方法。应用自攻式Schanz螺钉结合跨越膝关节的单侧外固定架，可在松质骨中进行将强的锚固，可满足我们术后负重的需求。对27例门诊脑瘫患者进行了回顾性研究，平均年龄为17.5岁（范围9-22岁）; 11例合并双侧严重下肢内旋患者于2008年9月至2012年4月间行股骨髁上截骨术。术后所有患者均可全负重。本研究的目的是描述该手术技术，报道其治疗结果，评估骨愈合所需时间，以及报道跨越膝关节的单臂外固定架固定股骨远端去旋转截骨术相关的并发症。共研究了27名患者[平均体重48.8 kg（范围29.8-75 kg）]。术前髋关节平均内旋69°，外旋平均17°。所有患者术后进行至少1年的临床和放射学评估。平均内旋活动度由69°显着下降至32°（P = 0.00034）。外旋由术前17°显著增加到术后45°（P = 0.0011）。股骨前倾角由术前平均55°显着下降至术后平均17°（P = 0.030）。除了一名患者外，所有患者均获得了稳固骨愈合。一名16岁女性患者由于物理治疗延迟导致膝关节屈曲挛缩30°。一名13岁女性患者接受双侧截骨术，在移除外固定物2周后因为直接创伤发生右股骨无移位骨折，进而接受石膏固定治疗。另一名17岁的男性患者由于两枚Schanz针的松动而发生截端骨不愈合，在通过动态加压钢板翻修术后实现了骨愈合。除4例浅表针道感染外，未发现其他并发症。在脑瘫患者中，通过跨越膝关节的单臂外固定架固定的股骨远端去旋转截骨术是一种可靠的手术方法。大多数患者可以在术后早期完全负重。但是，应尽早解除膝关节的固定以恢复膝关节的最大活动度。
17岁男性脑瘫患者，双下肢内旋
于截骨线远近端打入Schanz钉后进行股骨截骨
调整旋转角度后，打入其余Schanz钉，并连接外固定架，术后患者下肢内旋状况改善
Distal femoral derotational osteotomy with external fixation for correction of excessive femoralanteversion in patients with cerebral palsy
Patients with cerebral palsy (CP) disorder often develop rotational hip deformity. Increasing deformities impair already diminished walking abilities; femoral osteotomies are often performed to maintain and improve walking abilities. Fixation of osteotomies with condylar plates has been used successfully, but does not often enable immediate postoperative full weight-bearing. To avoid considerable postoperative rehabilitation deficit and additional bone loss because of inactivity, a postoperative treatment with full weight-bearing, is therefore, desirable. Self-tapping Schanz screws with a unilateral external fixator crossing the knee joint providing stronger anchoring in osteopenic bone might fulfill these demands. A retrospective study was carried out on 27 ambulatory CP patients, mean age 17.5 years (range 9-22 years); 11 patients with bilateral severe intoeing deformities underwent a supracondylar femoral osteotomy between September 2008 and April 2012. All patients were allowed to bear their full weight postoperatively. The aim of this study was to describe the technique, the results of this technique, to evaluate the time required for bone healing, and the type of complications associated with a distal derotational femoralosteotomy fixed with a uniaxial external fixator crossing the knee joint. A total of 27 patients were studied [mean weight 48.8 kg (range 29.8-75 kg)]. The mean preoperative rotation included internal rotation of 69° and external rotation of 17°. All patients were evaluated clinically and radiographically for a minimum of 1 year after surgery. There was a significant decrease in the mean medial rotation from 69° to 32° (P=0.00034). The lateral rotation increased significantly from preoperative 17° to postoperative 45° (P=0.0011). The femoral anteversiondecreased significantly from a mean of 55° preoperatively to a mean 17° postoperatively (P=0.030). All patients, except one, achieved solid fusion uneventfully. One patient was a 16-year-old female who had sustained a knee flexion contracture of 30° because of a delay in the physiotherapy program. One 13-year-old female patient with a bilateral osteotomy had a nondisplaced fracture in her right femur after a direct trauma 2 weeks after removal of an external fixator, and was treated by a cast. Another 17-year-old male patient developed a nonunion because of loosening of two pins and achieved solid union after revision by dynamic compression plate plating. Besides four cases with superficial pin-tract infection, no other complications were documented. Minimally invasive supracondylar femoral derotational osteotomyfixed with a unilateral external fixators crossing the knee joint is a reliable procedure in CP patients. Most patients can be treated with early postoperative full weight-bearing. However, removal of the knee joint crossing fixator should be performed as early as possible to achieve a full range of motion.
文献出处：Skiak E, Karakasli A, Basci O, Satoglu IS, Ertem F, Havitcioglu H. Distal femoral derotational osteotomy with external fixation for correction of excessive femoralanteversion in patients with cerebral palsy. J Pediatr Orthop B. 2015 Sep;24(5):425-32. doi: 10.1097/BPB.0000000000000168.
文献2
与传统CT相比低辐射CT可将保髋手术
患者的放射暴露减少90%
译者：程徽
目的：比较低辐射髋关节CT扫描方案与传统髋关节CT扫描方案之间的辐射剂量。
方法：本研究为回顾性比较队列研究。观察对象为2016年至2017年期间在我院接受保髋手术（包括关节镜检查，髋关节外科脱位或髋臼周围截骨术）的患者。排除标准为：体重指数（BMI）大于35，有既往手术史，无放射剂量报告。低辐射组只纳入在我院采用100kV（峰值），100毫安-秒（mAs），小视窗CT扫描的患者。传统CT组包括我院和外院行传统髋关节CT的患者。总辐射量，每扫描1毫米厚度的辐射量，患者的年龄和患者的BMI通过单变量分析进行比较。对总辐射量与BMI的相关性进行评估。
图1 传统CT（A，B）和低辐射CT（C,D）三维重建和二维重建
结果：该研究中低辐射组纳入41名连续患者，传统CT组纳入18名连续患者。与传统CT相比，低辐射CT可将放射暴露减少90％（总辐射量0.97±0.28 mSv vs 9.68±6.67 mSv; P <0.0001）。年龄（28±11岁vs 26±10岁，P=0.42），性别（83％女性患者vs 76％女性患者，P=0.74）和BMI（24±3 vs 24±3，P =0.75）这三个指标在两组之间没有差异。低辐射CT组中总辐射量与BMI存在弱相关（R2 = 0.14，斜率= 0.03，P = 0.02）；而传统CT组，总辐射量与BMI不存在相关性（R2 = 0.13，P =0.14）。
结论：对于保髋患者，低辐射CT方案比传统CT放射暴露低90％。
译者的话：大部分的髋关节患者都存在三维空间中的复杂畸形，必须使用CT来判断畸形的情况。髋关节CT的辐射量是普通X线片的上百倍，如果能通过改良CT检查的方案而大幅降低患者的放射暴露量，对患者们来讲无疑又是一件大好事。
Low-Dose Computed Tomography Reduces Radiation Exposure by 90% Compared With Traditional Computed Tomography Among Patients Undergoing Hip-Preservation Surgery
PURPOSE: To compare the delivered radiation dose between a low-dose hip computed tomography (CT) scan protocol and traditional hip CT scan protocols (i.e., 'traditional CT').
METHODS: This was a retrospective comparative cohort study. Patients who underwent hip-preservation surgery (including arthroscopy, surgical hip dislocation, or periacetabular osteotomy procedures) at our institution between 2016 and 2017 were identified. Patients were excluded if they had a body mass index (BMI) greater than 35, they underwent previous surgery, or a radiation dose report was absent. The low-dose group included patients who underwent hip CT at our institution using a standardized protocol of 100 kV (peak), 100 milliampere-seconds (mAs), and a limited scanning field. The traditional CT group included patients who had hip CT scans performed at outside institutions. The total effective dose (Ehip), effective dose per millimeter of body length scanned, patients' age, and patients' BMI were compared by univariate analysis. The correlation of Ehip to BMI was assessed.
RESULTS: The study included 41 consecutive patients in the low-dose group and 18 consecutive patients in the traditional CT group. Low-dose CT resulted in a 90% reduction in radiation exposure compared with traditional CT (Ehip, 0.97 ± 0.28 mSv vs 9.68 ± 6.67 mSv; P < .0001). Age (28 ± 11 years vs 26 ± 10 years, P = .42), sex (83% female patients vs 76% female patients, P = .74), and BMI (24 ± 3 vs 24 ± 3, P = .75) were not different between the 2 groups. Ehip had a poor but significant correlation to BMI in the low-dose CT group (R2 = 0.14, slope = 0.03, P = .02) and did not correlate to BMI in the traditional CT group (R2 = 0.13, P = .14).
CONCLUSIONS: A low-dose hip CT protocol for the purpose of hip-preservation surgical planning resulted in a 90% reduction in radiation exposure compared with traditional CT.
文献出处：Su AW, Hillen TJ, Eutsler EP, Bedi A, Ross JR, Larson CM, Clohisy JC, Nepple JJ. Low-Dose Computed Tomography Reduces Radiation Exposure by 90% Compared With Traditional Computed Tomography Among Patients Undergoing Hip-Preservation Surgery. Arthroscopy. 2019 Apr 12. pii: S0749-8063(18)31067-3. doi: 10.1016/j.arthro.2018.11.013.
文献3
轻度髋关节发育不良患者接受
髋臼周围截骨术后并发症及短期预后情况
译者：肖凯
介绍：本研究的目的是明确轻度髋关节发育不良患者接受髋臼周围截骨术后并发症发生率及短期功能预后。
方法：研究患者前瞻性选自单中心就诊的接受髋臼周围截骨术治疗的患者，其中外侧CE角在18-25°的定义为轻度髋关节发育不良患者，共27例。对照组患者未接受髋臼周围截骨术治疗的严重髋关节发育不良患者，外侧CE角≤17°，共50例。收集患者的人口统计学数据、影像学发现、并发症，同时收集患者术后6个月、1年、2年功能预后评分（6-30个月，平均15个月）。
结果：轻度髋关节发育不良组与对照组患者的人工统计学参数无明显差异。两组患者术后畸形纠正情况及并发症发生率无差异。两组患者术后功能预后评分（改良Harris评分、髋关节预后评分中的日常生活评分、髋关节预后评分中的运动评分、国际髋关节预后评分）改善程度相仿。末次随访时轻度髋关节发育不良组患者评分改善达到最小统计值的超过90%。
讨论：有症状的轻度髋关节发育不良患者接受髋臼周围截骨术后并发症发生率及功能预后与更严重发育不良患者相仿。
Complications and short-term patient outcomes of periacetabular osteotomy for symptomatic mild hip dysplasia
INTRODUCTION: The purpose of our study is to identify complications and early functional outcome scores in patients treated with periacetabular osteotomy (PAO) for mild acetabular dysplasia.
METHODS: The study population consisted of patients from a single centre prospective hip registry undergoing PAO with mild acetabular dysplasia (LCEA ≥18° and ≤25°; n = 27 patients; Mild Dysplasia group). A comparison group of patients undergoing PAO with more severe acetabular dysplasia (lateral centre-edge angle [LCEA] ≤17°; n = 50 patients; Severe Dysplasia group) were included as a comparison cohort. Demographics, radiographic findings, complications, and functional outcome scores were recorded at 6 months, 1 year, and 2 years postoperatively (mean 15 months [range 6-30]).
RESULTS: Demographic characteristics were similar in patients with mild dysplasia undergoing PAO compared with more severe dysplasia. Achievement of radiological correction and complication rates were not different between the 2 groups. Functional outcome scores showed similar improvements in modified Harris Hip Score (mHHS), hip outcome score (HOS) activities of daily living (ADL), HOS Sport, and the international Hip Outcome Tool-33 (iHOT-33) at all time points between the 2 groups with over 90% of patients in the mild dysplasia group achieving a minimum important change (MIC) in functional outcome scores at final follow-up.
DISCUSSION: Patients with symptomatic mild acetabular dysplasia undergoing PAO have similar complication rates and functional outcomes as a cohort of patients with more severe dysplasia.
文献出处：Ricciardi BF, Fields KG, Wentzel C, Nawabi DH, Kelly BT, Sink EL. Complications and short-term patient outcomes of periacetabular osteotomy for symptomatic mild hip dysplasia. Hip Int. 2017 Feb 21;27(1):42-48. doi: 10.5301/hipint.5000420. Epub 2016 Oct 24.
文献4
Chiari骨盆内移截骨治疗伴发盂唇撕裂的
发育异常性骨关节炎：10年以上随访结果
译者：任宁涛
背景：虽然盂唇损伤是影响Chiari骨盆内移截骨术治疗效果的诸多因素之一，但之前很少有文献描述同时行Chiari骨盆内移截骨术与盂唇切除术的长期疗效。本研究旨在评估Chiari骨盆内移截骨术治疗髋关节发育异常伴盂唇撕裂的长期临床和放射学效果，分为两组盂唇切除组（ ）和盂唇未切除组（-）。
方法：选择1983年-1996年34个同时伴有盂唇撕裂的发育不良髋关节，均有同一个术者进行Chiari骨盆内移截骨术，其中23个髋关节行盂唇切除，11个髋关节未行盂唇切除，其中3名行盂唇切除患者在术后5年内失访。剩余31名患者平均年龄为35.5岁（16-54岁），临床和影像学监测平均为16.0年（范围：10-23.3年）。
结果：术后所有患者的疼痛消失，在末次随访时，有8名患者出现临床效果变差，11个髋关节出现骨关节炎（OA）的进展，效果不佳的患者内有1个患者进行了翻修手术。在盂唇切除组（ ），20个髋关节中有10个出现OA的进展，6名患者的临床疗效变差。在未行盂唇切除组（-），11个髋关节中有1个出现OA的进展，2名患者的临床疗效变差。两组的放射学结果有显著差异。
结论：Chiari骨盆内移截骨伴盂唇切除是一种可接受的缓解盂唇损伤引起疼痛的治疗方式，但术后10年或10年以上的效果有变坏的趋势。
图1 两种盂唇撕裂类型。A 盂唇撕裂，有裂口（n=15）， B 盂唇从起点撕脱（n=16
图2 术前、术后5年、术后10年及末次随访时JOA评分情况，盂唇切除（ ）组（黑点）和盂唇未切除（-）组（白点）
图3盂唇切除（ ）组（黑线）和盂唇未切除（-）组（虚线）Kaplan–Meier生存曲线。A 终点为临床效果差（JOA评分<75分），Logrank检验未发现显著性差异。B 终点为影像学效果差（OA进展到晚期或终末期），两组Logrank检验存在明显差异（P=0.0358）
图4 70岁，女性患者盂唇退变显微图像。可见许多软骨细胞样细胞和甲苯胺蓝染色粘多糖，AS：关节面，A 比例尺为1mm， B 比例尺为50μm（甲苯胺蓝染色）
Treatment of dysplastic osteoarthritis with labral tear by Chiari pelvic osteotomy: outcomes after more than 10 years follow-up.
INTRODUCTION: The presence of a damaged labrum is one of many factors influencing the outcomes of Chiari pelvic osteotomy. However, there are few previous papers describing the long-term outcomes of Chiari pelvic osteotomy with labrectomy. The purpose of this study was to evaluate the long-term clinical and radiological outcomes of Chiari pelvic osteotomy for dysplastic hips with labral tears. We compared outcomes between labrectomy ( ) and labrectomy (-) groups.
PATIENTS AND METHODS: Chiari pelvic osteotomies were performed by one surgeon on 34 dysplastic hips with labral tears between 1983 and 1996, in which labrectomy was performed on 23 hips but not on 11 hips. Three patients undergoing labrectomy were lost to follow-up evaluation within 5 years after surgery. The average age of the remaining 31 patients was 35.5 years (range, 16-54 years). The clinical and radiographic surveillance averaged 16.0 years (range, 10-23.3 years).
RESULTS: In all patients, pain disappeared after the operation. At the end of the study, 8 of the 31 patients displayed clinical deterioration. Progression of osteoarthritis (OA) was observed in 11 hips. Patients with poor results have not opted for revision surgery except for one patient. In the labrectomy ( ) group, 10 of the 20 hips showed progression of OA and the clinical outcomes of 6 patients deteriorated. In the labrectomy (-) group, 1 of the 11 hips showed progression of OA and 2 patients deteriorated clinically. Radiological outcomes differed significantly between the two groups.
CONCLUSION: Labrectomy accompanying & nbsp; Chiari pelvic osteotomy & nbsp; is an acceptable procedure for relieving pain caused by the damaged labrum, but the outcomes have a tendency to deteriorate after 10 or more years postoperatively.
文献出处：Nakano S, Nishisyo T, Hamada D, Kosaka H, Yukata K, Oba K, Kawasaki Y, Miyoshi H, Egawa H, Kinoshita I, Yasui N. Treatment of dysplastic osteoarthritis with labral tear by Chiari pelvic osteotomy: outcomes after more than 10 years follow-up. Arch Orthop Trauma Surg. 2008 Jan;128(1):103-9. Epub 2007 Oct 18.
文献5
髋臼周围截骨术改善了外侧中心边缘角为
18°到25°之间的患者的疼痛和功能，
但这些髋关节真的是临界发育不良吗？
译者：张利强
背景：轻度或临界髋臼发育不良的治疗方法存在争议，手术选择包括关节镜下关节囊撕裂缝合或折叠缝合术和髋臼周围截骨术（PAO）。使用这些方法可以改善疼痛和功能的程度可能与髋臼形态和发育不良的严重程度有关，但据我们所知，对于外侧中心边缘角（LCEA）18°至25°间接受PAO的患者髋臼形态的详细放射学评估还没有。
问题/目的：（1）LCEA为18°至25°接受PAO的患者是否有发育不良的其他影像学特征提示髋臼与股骨头覆盖异常？（2）在至少2年的随访中通过观察有无翻修手术、THA或严重疼痛（改良的Harris髋关节评分[mHHS]<70）来评价手术失败率是多少和由改良的Dindo-Clavien严重度量表定义的并发症发生比例是多少？（3）根据UCLA活动评分、mHHS、髋关节残疾和骨关节炎结果评分（HOOS）和SF-12心理和生理评分评价，在手术后至少2年随访中患者报告结果是什么？
方法：2010年1月至2014年12月，我院共对91例髋关节疼痛患者及LCEA18°至25°患者进行了保髋手术。91例患者中36例（40%）接受髋关节镜检查，56例（60%）接受PAO治疗。一般来说，当症状主要与股骨颈前方撞击（即坐位和髋关节弯曲活动时加剧疼痛）有关时，考虑进行髋关节镜检查，体格检查显示前撞击试验阳性，不稳定体征为阴性（前撞击恐惧试验阴性）。当症状显示为不稳定（即站立活动时疼痛，坐位时外展肌疲劳加重）时，考虑行PAO，临床检查显示前撞击恐惧试验阳性。共纳入49名患者（49髋），6名患者接受了双侧手术，研究中仅包括第一次手术侧髋关节。其中一名患者被排除在外，因为PAO是为了解决儿童时期因手术切除股骨近端肿瘤导致的发育不良，该肿瘤与多发性骨骺发育不良有关。49名中有女性46名（94%），平均年龄26.5岁（±8岁），平均体重指数为24kg/m2（±4.5）。术前影像学分析包括LCEA、Tonnis角、前中心边缘角、髋臼前后壁指数和股骨骨骺髋臼顶角指数（FEAR）。49例患者中的39例（80%）进行了至少2年的随访（平均2.2年；范围2-4年），并纳入PAO术后生存率、并发症和功能结果分析。Kaplan-Meier模型被用来计算生存率，定义为术后至少2年内无翻修手术、THA或严重疼痛（mHHS<70）。根据改良的Dindo-Clavien严重程度对并发症进行分级。术前和术后至少2年收集患者报告结果，包括UCLA活动评分、mHHS、HOOS和SF-12心理和生理评分。
结果：49髋中46例（94%）至少有一个其他的发育不良影像学特征提示髋臼股骨头覆盖异常。除LCEA为18°至25°外，73%的髋部（49例中的36例）有两个或更多的髋部发育不良的影像学特征。49例患者中39例（80%）的PAO生存率至少为2年（95%可信区间，80%-90%）。39例患者中有3例（8%）出现并发症。在平均2.2年随访中髋关节活动水平全部有所改善（术前UCLA评分7±2，术后UCLA评分6±2；P=0.02）。术后髋关节症状和功能全部改善，表现为较高的平均mHHS（86±13比64±19；p<0.001）和平均HOOS（386±128比261±117；p<0.001）评分。通过侧重生理的SF-12评分评估的生活质量和整体健康状况全部有所改善（47 ±11比39±12；p<0.001）。然而，根据现有的数据，侧重精神领域的SF-12评分没有改善（52±8比51±11；p=0.881）。
结论：LCEA为18°至25°的髋关节常有发育不良的其他影像学表现，提示髋臼股骨头覆盖异常。仅考虑到LCEA，这些髋关节可能被不当地标记为“临界”或“轻度”发育不良。根据本研究中发育不良的影像学特征，建议对这些髋部进行更全面的影像分析，以确定髋臼对股骨头覆盖异常情况，并制定相应的治疗计划。LCEA为18°至25°的患者在PAO后髋部疼痛和功能都改善，并发症最少，短期随访时持续疼痛或再次手术的比例较低。建议今后的研究调查关注症状性和功能性改善的益处是否能长期持续。
图1A-F显示了用于评估髋臼形态和髋臼股骨头覆盖率的射线照相测量。（A）LCEA是一条连接两侧股骨头中心的线（白色虚线）相垂直的线（黑线）与一条将股骨头中心连接到髋臼眉弓最外侧点（黑色圆圈）的线（白线）之间形成的角；（B）Tonnis角是一条通过髋臼眉弓最外侧点和最内侧点之间（黑色圆圈）之间的连线和一条通过髋臼眉弓最内侧点且与股骨头中心连线相平行的一条线（白线）形成的夹角。（C）通过股骨颈中心点（黑色圆圈）确定股骨颈轴线，股骨头直径（白色箭头=距离D）通过股骨颈轴线，黄色点表示股骨颈轴线穿过髋臼前壁的点（黄色虚线）。髋臼前壁指数通过距离（a）除以股骨头直径（D）计算；（D）通过股骨颈中心点（黑色圆圈）确定股骨颈轴线，股骨头直径（白色箭头=距离D）通过股骨颈轴线，红色点表示股骨颈轴线穿过髋臼后壁的点（黄色虚线）。髋臼后壁指数通过距离（p）除以股骨头直径（D）计算；（E）FEAR指数是由股骨头骨骺线（黑线）与连接髋臼眉弓最内侧和最外侧点的线（白线）之间形成的角度；（F）ACEA通过65度斜位片测量，通过画一条穿过股骨头中心的垂直线（黑线）和一条连接股骨头中心和髋臼眉弓最前点（黑点）的线（白线）形成的角
Periacetabular Osteotomy Improves Pain and Function in Patients With Lateral Center-edge Angle Between 18° and 25°, but Are These Hips Really Borderline Dysplastic?
Background : The treatment of mild or borderline acetabular dysplasia is controversial with surgical options including both arthroscopic labral repair with capsular closure or plication and periacetabular osteotomy (PAO). The degree to which improvements in pain and function might be achieved using these approaches may be a function of acetabular morphology and the severity of the dysplasia, but detailed radiographic assessments of acetabular morphology in patients with a lateral center-edge angle (LCEA) of 18° to 25° who have undergone PAO have not, to our knowledge, been performed.
Questions/purposes: (1) Do patients with an LCEA of 18° to 25° undergoing PAO have other radiographic features of dysplasia suggestive of abnormal femoral head coverage by the acetabulum? (2) What is the survivorship free from revision surgery, THA, or severe pain (modified Harris hip score [mHHS] < 70) and proportion of complications as defined by the modified Dindo-Clavien severity scale at minimum 2-year followup? (3) What are the functional patient-reported outcome measures in this cohort at minimum 2 years after surgery as assessed by the UCLA Activity Score, the mHHS, the Hip disability and Osteoarthritis Outcome Score (HOOS), and the SF-12 mental and physical domain scores?
Methods: Between January 2010 and December 2014, a total of 91 patients with hip pain and LCEA of 18° to 25° underwent a hip preservation surgical procedure at our institution. Thirty-six (40%) of the 91 patients underwent hip arthroscopy, and 56 hips (60%) were treated by PAO. In general, patients were considered for hip arthroscopy when symptoms were predominantly associated with femoroacetabular impingement (that is, pain aggravated by sitting and hip flexion activities) and physical examination showed a positive anterior impingement test with negative signs of instability (negative anterior apprehension test). In general, patients were considered for PAO when symptoms suggested instability (that is, pain with upright activities, abductor fatigue now aggravated by sitting) and clinical examinations demonstrated a positive anterior apprehension test. Bilateral surgery was performed in six patients and only the first hip was included in the study. One patient was excluded because PAO was performed to address dysplasia caused by surgical excision of a proximal femoral tumor associated with multiple epiphyseal dysplasia during childhood yielding a total of 49 patients (49 hips). There were 46 of 49 females (94%), the mean age was 26.5 years (±8), and the mean body mass index was 24 kg/m2 (± 4.5). Radiographic analysis of preoperative films included the LCEA, To ̈nnis acetabular roof angle, the anterior center-edge angle, the anterior and posterior wall indices, and the Femoral Epiphyseal Acetabular Roof index. Thirty-nine of the 49 patients (80%) were followed for a minimum 2-year followup (mean, 2.2 years; range, 2-4 years) and were included in the analysis of survivorship after PAO, complications, and functional outcomes. Kaplan-Meier modeling was used to calculate survivorship defined as free from revision surgery, THA, or severe pain (mHHS<70) at minimum 2 years after surgery. Complications were graded according to the modified Dindo-Clavien severity. Patient-reported outcomes were collected preoperatively and at minimum 2 years after surgery and included the UCLA Activity Score, the mHHS, the HOOS, and the SF-12 mental and physical domain scores.
Results: Forty-six of 49 hips (94%) had at least one other radiographic feature of dysplasia suggestive of abnormal femoral head coverage by the acetabulum. Seventy-three percent of the hips (36 of 49) had two or more radiographic features of hip dysplasia aside from a LCEA of 18° to 25°. The survivorship of PAO at minimum 2 years for the 39 of 49 (80%) patients available was 94% (95% confidence interval, 80%-90%). Three of 39 patients (8%) developed a complication. At a mean of 2.2 years of followup, there was improvement in level of activity (preoperative UCLA score 7±2 versus postoperative UCLA score 6±2; p = 0.02). Hip symptoms and function improved postoperatively, as reflected by a higher mean mHHS (86±13 versus 64±19; p < 0.001) and mean HOOS (386±128 versus 261±117; p < 0.001). Quality of life and overall health assessed by the physical domain of the SF-12 improved (47±11 versus 39±12; p < 0.001). However, with the numbers available, no improvement was observed for the mental domain of the SF-12 (52±8 versus 51±11; p = 0.881).
Conclusions: Hips with LCEA of 18° to 25° frequently have other radiographic features of dysplasia suggestive of abnormal femoral head coverage by the acetabulum. These hips may be inappropriately labeled as “borderline” or “mild” dysplasia on consideration of LCEA alone. A more comprehensive imaging analysis in these hips by the radiographic features of dysplasia included in this study is recommended to identify hips with abnormal coverage of the femoral head by the acetabulum and to plan treatment accordingly. Patients with LCEA of 18° to 25° showed improvement in hip pain and function after PAO with minimal complications and low proportions of persistent pain or reoperations at short-term followup. Future studies are recommended to investigate whether the benefits of symptomatic and functional improvement are sustained long term.
文献出处：Michael P. McClincy, James D. Wylie MD, et al. Periacetabular Osteotomy Improves Pain and Function in Patients With Lateral Center-edge Angle Between 18° and 25°, but Are These Hips Really Borderline Dysplastic? Clin Orthop Relat Res 2019;477(5):1145-1153
文献6
股骨头骨骺延长可能有助于
股骨头骨骺滑脱的骨骺稳定性
译者：陶可（北京大学人民医院骨关节科）
背景：肥胖和髋关节周围骨密度增加的因素与股骨头骨骺滑脱（SCFE）的风险增加有关。最近的证据表明，上方骨骺延长可能有助于生理稳定性并防止SCFE发生。本研究的目的是采用年龄和性别匹配的队列研究以探索骨骺延长与SCFE之间的关系。
方法：我们选取了两个独立的队列进行比较：89名患有单侧SCFE的患者和89名没有髋关节疾病或畸形证据的健康志愿者。我们利用髋关节的前后位和侧位X线片来测量Southwick角和骨骺延长率（EER），EER被定义为股骨头骨骺延长至股骨颈下端的长度相对于股骨头直径的比率。然后，我们在两组和亚组分析之间比较这些基于滑脱稳定性以及受试者是否进展为对侧滑动的测量值。
结果：与对照相比，SCFE队列显示出上方骨骺伸长率增加（表层EER 0.71对比0.68，P = 0.002）。从对照组（0.71±0.07）到稳定滑脱（0.69±0.06）再到不稳定滑脱（0.65±0.04）的上方EER有显着下降趋势，各组间存在总体差异（P = 0.001）。44名（41%）单侧稳定滑脱和至少6个月随访的受试者中的18名继续发展成对侧肢体SCFE。发生对侧滑脱的受试者较年轻（11.6±1.2岁对比12.7±1.4岁，P = 0.008）；然而，上方或前方骨骺延长没有差异（分别为P = 0.75和0.23）。Southwick角与上方或前方EER之间无显著的线性相关（r = 0.13和0.17，两者均P> 0.05）。
结论：增加股骨头骺骨骺延长可有助于SCFE的骨骺稳定性。我们提出，这种骨骺延长反映了一种适应性反应，以限制骨骺压力并降低进展为SCFE的风险。
图1. A-C，骨骺向上延伸至股骨颈的上方[以骨骺延长率（EER）测量]可有助于骨骺稳定性并防止因股骨头骨骺滑脱而发生的干骺端的相对位移
图2. A和B，通过首先在股骨头上覆盖最佳拟合圆以确定直径（D）来测量骨骺延长率（EER）。在上部（S）或前部（A）平面中的骨骺延长被测量为骨骺沿平行于股骨颈轴线的下骺延伸的长度。然后分别基于前后（AP）或蛙式位X线片测量EER为：上方EER = S / D或前方EER = A / D
图3. 通过首先测量受影响的（A0）和未受影响的（A）肢体的股骨头-股骨干角度来确定Southwick角（θ）。股骨头-股骨干角度定义为沿着股骨干轴线的直线与连接骨骺顶点的直线的垂线之间形成的夹角。然后测量Southwick角（θ）作为受影响侧和未受影响侧之间的股骨头-股骨干角度的差异（y = A' - A）
图4. A和B，Southwick角与上方或前方骨骺伸长率之间没有显着的线性相关性（分别为P = 0.26和0.14）
图5. 上方骨骺延伸（黑色虚线）可以反映身体抵抗剪切力的适应性反应，以防止股骨头骨骺滑脱的进展
Capital Femoral Epiphyseal Extension May Confer Physeal Stability in Slipped Capital Femoral Epiphysis
BACKGROUND: Factors including obesity and morphologic parameters around the hip that increase physeal stress are associated with an increased risk of slipped capital femoral epiphysis (SCFE). Recent evidence suggests that superior epiphyseal extension may confer stability to the physis and help protect against SCFE. The purpose of this study is to investigate the relationship between epiphyseal extension and SCFE using an age-matched and sex-matched cohort study.
METHODS: We generated 2 separate cohorts for comparison: 89 patients with unilateral SCFE and 89 healthy subjects with no evidence of hip disease or deformity. We utilized the anterior-posterior and lateral films of the hip to measure the Southwick angle and the epiphyseal extension ratio (EER), defined as the ratio of extension of the capital femoral epiphysis down the femoral neck relative to the diameter of the femoral head. We then compared these measurements between cohorts and in subgroup analysis based on slip stability and whether subjects progressed to a contralateral slip.
RESULTS: The SCFE cohort demonstrated a decreased superior epiphyseal extension ratio compared with control (superior EER 0.71 vs. 0.68, P=0.002). There was also a significant downward trend in superior EER from the control subjects (0.71±0.07) to the stable slips (0.69±0.06) to the unstable slips (0.65±0.04) with an overall difference between the groups (P=0.001). Eighteen of 44 (41%) subjects with unilateral stable slips and at least 6 months of follow-up went on to develop SCFE of the contralateral limb. The subjects who developed contralateral slips were younger (11.6±1.2 vs. 12.7±1.4 y, P=0.008); however, there was no difference in superior or anterior epiphyseal extension (P=0.75 and 0.23, respectively). There was no significant linear correlation between Southwick angle and superior or anterior EER (r=0.13 and 0.17, respectively, P>0.05 for both).
CONCLUSIONS: Increasing capital femoral epiphyseal extension may confer physeal stability in the setting of SCFE. We propose that this epiphyseal extension reflects an adaptive response to limit physeal stress and reduce the risk for progression to SCFE.
文献出处：Morris WZ, Napora JK, Conry KT, Liu RW. Capital Femoral Epiphyseal Extension May Confer Physeal Stability in Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2019 Mar;39(3):119-124. doi: 10.1097/BPO.0000000000000881.
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