本期目录：
1、全膝关节置换术后麻醉下推拿的危险因素、效果和时机
2、下肢关节置换术前是否需要治疗抑郁症？
3、及以下年龄初次全髋关节置换病例的10年生存随访
4、股骨转子间后旋截骨治疗股骨头坏死：平均11年随访
5、股骨转子间截骨治疗非创伤性股骨头坏死的长期随访
6、髋关节疾病患者关节周围软组织的差异
7、髋关节发育不良继发髋外翻的治疗
第一部分：关节置换相关文献
文献1
全膝关节置换术后麻醉下推拿的危险因素、效果和时机
译者：张轶超
背景：全膝关节置换术（TKA））后膝关节僵直的病人在麻醉下进行推拿松解（MUA））的效果不理想，但是目前我们还不清楚MUA的危险因素和时机选择。
方法：回顾了在一个医疗中心完成的初次全膝关节置换术。比较了术后做过MUA和没做过的病例的一些临床变量。利用那些存在差异的变量来选择条件相匹配的未行MUA病例作为对照组来进行比较。MUA组被分为早期组（≤6周）和晚期组（＞6周）两个亚组。比较多个时间点的屈曲度值。
结果：一共1729名TKA病人；有62名实行了MUA。做了MUA的病人更加年轻(55.2岁对65.3岁,P<.001)，有较高的近期(21.0%对7.3%,P<.001)和以往(59.7%对40.4%, P=0.002)吸烟率，更多的病人之前做过关节镜手术；在没有做MUA的病例中匹配选择这些变量相似的做为对照组。两组间术前的屈曲度没有明显差异，早期MUA组(106.7°)中最终的屈曲度与对照组(115.6°)相似，而晚期MUA组则存在差异(101.3°, P=0.001)。
结论：TKA术后做过MUA的病人趋于更加年轻，近期有吸烟史及既往曾有膝关节手术史。术后即使活动受限严重，只要在6周内进行MUA，最终效果与不需要实行MUA病人的效果相近。
Risk Factors, Outcomes, and Timing of Manipulation Under Anesthesia After Total Knee Arthroplasty
BACKGROUND: Knee stiffness requiring manipulation under anesthesia (MUA) is an undesirable outcome following total knee arthroplasty(TKA), but risk factors for, and optimal timing of, MUA remain unclear.
METHODS: Primary TKAs performed at a single center were retrospectively reviewed. Clinical variables were compared between patients who underwent MUA and those who did not; variables that differed were utilized to identify an appropriately matched control group of non-MUA patients. The MUA group was divided into early (MUA ≤6 weeks from index) and late (>6 weeks) subgroups. Flexion values at multiple time points were compared.
RESULTS: In total, 1729 TKA patients were reviewed; MUA was performed in 62 patients. Patients undergoing MUA were younger (55.2 vs 65.3 years, P < .001) and had higher rates of current smoking (21.0% vs 7.3%, P < .001) and prior procedure (59.7% vs 40.4%, P = .002), most commonly arthroscopy; a control group of patients not requiring MUA, matched on the basis of these variables, was identified. While no difference in pre-TKA flexion existed across groups, final flexion in the early MUA group (106.7°) was equivalent to that of controls (115.6°), while final flexion in the late MUA group was not (101.3°, P = .001).
CONCLUSION: TKA patients undergoing MUAs were younger, more likely to be current smokers, and more likely to have undergone prior knee surgery. Even in patients with severe initial postoperative limitations in range of motion, MUA within 6 weeks may allow for final outcomes that are equivalent to those experienced by similar patients not requiring manipulation.
文献出处：Newman ET, Herschmiller TA, Attarian DE, Vail TP, Bolognesi MP, Wellman SS. Risk Factors, Outcomes, and Timing of Manipulation Under Anesthesia After Total Knee Arthroplasty. J Arthroplasty. 2018 Jan;33(1):245-249.
文献2
下肢关节置换术前是否需要治疗抑郁症？
译者：马云青
背景：为确保手术疗效，患者的术前优化教育在关节置换术前变得越来越重要。有人认为抑郁症是关节置换围手术期的危险因素，应在术前加以纠正。手术前的心理干预措施是否能改善预后疗效仍有待确定。我们的认为，使用术前抑郁量表预测术后的疗效可能受到关节炎引起的疼痛和关节功能异常的影响。为了确定抑郁是否是术前应纠正的一个可改变的危险因素，我们提出了以下问题：(1)关节置换术前患者抑郁的发生率是多少？(2)术后抑郁症状是否有所改善？(3)术前抑郁是否与预后疗效有关？
方法：择期关节置换手术的患者完成患者健康问卷(PHQ-9)，评估患者术前及术后1年抑郁症的发生率和严重程度。
结果：282例患者中65例PHQ-9>10分，表现为中等程度抑郁，57例(88%)术后改善为<10分(P=0.0012)。PHQ-9>20分者10例，表现为重度抑郁，9例(90%)术后改善为<10分(P=0.10)。术前PHQ-9评分>10分的65例患者中，术后髋关节功能障碍和骨关节炎评分中位数为92.3，膝关节损伤和骨关节炎评分中位数为84.6。非抑郁患者术后髋关节功能障碍和骨关节炎评分中位数为96.2，膝关节损伤和骨关节炎评分中位数为84.6分(P=0.9041)。
结论：通过关节置换术减轻疼痛和改善功能，抑郁症状可以得到明显改善。与非抑郁患者相比，术前有抑郁症状的患者有相似的术后功能评分。因此，不应通过关节置换术前优化程序包括的抑郁量表测试值来推迟或拒绝抑郁患者的手术安排。
Should Depression Be Treated Before Lower Extremity Arthroplasty?
Background: Patient optimization is becoming increasingly important before arthroplasty to ensure outcomes. It has been suggested that depression is a modifiable risk factor that should be corrected preoperatively. It remains to be determined whether psychological intervention before surgery will improve outcomes. We theorized that the use of preoperative depression scales to predict postoperative outcomes may be influenced by the pain and functional disability of arthritis. To determine whether depression is a modifiable risk factor that should be corrected preoperatively we asked the following questions: (1) What is the prevalence of depression in arthroplasty patients preoperatively? (2) Do depressive symptoms improve after surgery? (3) Is preoperative depression associated with outcome?
Methods: Patients scheduled for surgery completed a patient health questionnaire (PHQ-9) to assess the presence and severity of depression pre-operatively and one year post-operatively.
Results: Sixty-five of the 282 patients had a PHQ-9 score >10 indicating moderate depression and 57 (88%) improved to <10 postoperatively (P ¼ .0012). Ten patients had a PHQ-9 score >20 indicating severe depression and 9 (90%) improved to <10 postoperatively (P ¼ .10). Of the 65 patients who had a PHQ-9 score >10 preoperatively, the median postoperative Hip Disability and Osteoarthritis Outcome Score (N ¼ 40) was 92.3, while the median postoperative Knee Injury and Osteoarthritis Outcome Score (N ¼ 25) was 84.6. The median postoperative Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score in nondepressed patients were 96.2 and 84.6, respectively (P ¼ .9041).
Conclusion: By diminishing pain and improving function through arthroplasty, depression symptoms improve significantly. Patients with depressive symptoms preoperatively had similar postoperative outcome scores compared to non-depressed patients. Patients should not be denied surgical intervention through optimization programs that include a depression scale threshold.
文献出处：Fehring TK, Odum SM, Curtin BM, Mason JB, Fehring KA, Springer BD. Should Depression Be Treated Before Lower Extremity Arthroplasty? J Arthroplasty. 2018 Jun 4. pii: S0883-5403(18)30521-7.
文献3
30岁及以下年龄初次全髋关节置换病例的10年生存随访
译者：张蔷
目标：这篇回顾性队列研究比较了30岁及以下年龄（年轻）患者和60岁及以上（老年）患者初次全髋关节置换术后的再翻修率、假体生存率、翻修适应证、并发症和患者自评疗效。
方法：我们回顾了医院数据库里2000年至2015年间所有初次全髋置换病例，共有145例年轻病例和1359例老年病例，平均随访5.3年（1~18年）。应用广义估计方程比较患者基本参数和翻修率，应用Kaplan-Meier曲线计算生存率并应用Cox回归分析计算风险率。
结果：年轻患者组总体翻修率为11%（16/145），老年患者组总体翻修率为3.83%（52/1359）（概率比(OR)2.58, 95%置信区间(CI) 1.43至4.63）。在匹配了组间ASA评分、性别和既往手术史后，年轻患者组匹配后翻修率依然更高（匹配后风险比(HR)2.48, 95% CI 1.34至4.58）。年轻患者组10年生存率为82%（95% CI, 71 to 89），老年患者组10年生存率为96%（95% CI,94 to 97）（p < 0.001）。由金对金摩擦界面引起并发症而导致的翻修方面，年轻患者组明显更高（p < 0.001）。末次随访时，与老年患者组相比，年轻患者组的关节功能更佳（p= 0.002），精神健康水平更低（p = 0.001），疼痛情况类似（p = 0.670）。
结论：年轻患者组的总体翻修率更高。这也可能是由于组内的金对金界面比例较高引起的。年轻患者应用非金对金摩擦界面的生存率较高，并发症情况也与老年患者组近似。
Ten-year survivorship of primary total hip arthroplasty in patients 30 years of age or younger
Aims: For this retrospective cohort study, patients aged ≤ 30 years (very young) who underwent total hip arthroplasty (THA) were compared with patients aged ≥ 60 years (elderly) to evaluate the rate of revision arthroplasty, implant survival, the indications for revision, the complications, and the patient-reported outcomes.
Patients and Methods: We retrospectively reviewed all patients who underwent primary THA between January 2000 and May 2015 from our institutional database. A total of 145 very young and 1359 elderly patients were reviewed. The mean follow-up was 5.3 years (1 to 18). Logistic generalized estimating equations were used to compare characteristics and the revision rate. Survival was evaluated using Kaplan–Meier curves and hazard rates were created using Cox regression.
Results: The overall revision rate was 11% (16/145) in the very young and 3.83% (52/1359) in the elderly groups (odds ratio (OR) 2.58, 95% confidence interval (CI) 1.43 to 4.63). After adjusting for the American Society of Anesthesiologists (ASA) score, gender, and a history of previous surgery in a time-to-event model, the risk of revision remained greater in the very young (adjusted hazard ratio (HR) 2.48, 95% CI 1.34 to 4.58). Survival at ten years was 82% (95% CI, 71 to 89) in the very young and 96% (95% CI, 94 to 97) in the elderly group (p < 0.001). The very young had a higher rate of revision for complications related to metal-on-metal (MoM) bearing surfaces (p < 0.001). At last follow-up, the very young group had higher levels of physical function (p = 0.002), lower levels of mental health (p = 0.001), and similar levels of pain (p = 0.670) compared with their elderly counterparts.
Conclusion: The overall revision rate was greater in very young THA patients. This was largely explained by the use of MoM bearings. Young patients with non-MoM bearings had high survivorship with similar complication profiles to patients aged≥60 years.
文献出处：C. A. Makarewich, M. B. Anderson, J. M. Gililland, C. E. Pelt, C. L. Peters. Ten-year survivorship of primary total hip arthroplasty in patients 30 years of age or younger. Bone Joint J 2018; 100-B: 867–74.
第二部分：保髋相关文献
文献1
股骨转子间后旋截骨治疗股骨头坏死：平均11年随访
译者：罗殿中
背景：既往研究认为术后股骨头负重区完整比值（旋转后股骨头负重区外侧完好部分的宽度/负重区宽度，图1）为股骨转子间旋转截骨术治疗股骨头坏死的预后因素之一，Miyanishi等人报道称当该比值大于34%时，股骨头发生塌陷进展的可能性小。然而有些病例，虽然没有发生股骨头塌陷，该比值也位于34%以上，但却发生关节间隙进行性狭窄。目前尚无相关报道分析与术后关节间隙狭窄相关的因素。因此本研究从影像学角度，分析股骨转子间后旋截骨术治疗股骨头坏死，术后发生股骨头塌陷及关节间隙狭窄的预后影响因素。
图1 股骨头负重区完整比值（Intact ratio）示意图
方法：研究纳入47例（51髋）患者，平均年龄为34岁（范围12-54岁），包括男性29例、女性18例。平均随访时间为11年（范围：5-20年）。根据影像学结果，将患者分为以下2组：I，股骨头塌陷和/或关节间隙狭窄；II，无股骨头塌陷或关节间隙狭窄。通过单因素分析及多因素分析明确预后影响因素。
结果：截止末次随访，I组6髋、II组45髋。术后股骨头负重区完整比值及术前股骨头坏死分期均与术后股骨头塌陷或关节间隙狭窄相关（单因素分析分别为：P﹤0.0001,P = 0.006；多因素分析分别为P = 0.0014, P = 0.0039）。术后股骨头负重区完整比值的临界值为36.8%，即当该比值为36.8%以上时，术后发生股骨头塌陷及关节间隙狭窄的可能性小。（图2-4）
图2 女性，41岁。a 术前，股骨头坏死3A期、C1型；b 股骨转子间后旋90度，术后股骨头负重区完整比值为45.7%；c 术后10年，坏死区范围缩小
图3 男性，27岁。a 术前，股骨头坏死3A期； b 术前核磁，股骨头坏死分型为C2；c 股骨转子间后旋70度，术后股骨头负重区完整比值为27.4%；d 术后13年，股骨头无塌陷，但关节间隙狭窄、关节边缘骨赘出现，为骨关节炎表现
图4 K-M生存分析图：纵轴表示生存率，横轴表示随访时间，终点事件为股骨头塌陷进展和/或关节间隙进行性狭窄。Intact ratio：股骨头负重区完整比值
结论：该研究指出术后股骨头负重区完整比值为股骨转子间后旋截骨治疗股骨头坏死的主要预后因素之一，旋转后改值应至少为36.8%。这也为该手术的术前设计及手术适应证选择提供临床指导。
Radiological outcome analyses of transtrochanteric posterior rotational osteotomy for osteonecrosis of the femoral head at a mean follow-up of 11 years
Background: This study investigated the radiological factors that correlated with progression of collapse and joint space narrowing after transtrochanteric posterior rotational osteotomy (PRO) for osteonecrosis of the femoral head.
Methods: This study reviewed 51 hips in 47 patients with a mean follow-up of 11 years (5-20). The subjects included 29 males and 18 females with a mean age of 34 years (12-54) at the time of surgery. The 51 hips were divided into two groups based on the radiological outcome (group I: evidence of progression of collapse and/or joint space narrowing, group II: no evidence of either progression of collapse or joint space narrowing). Both clinical and radiological factors were analyzed by both univariate and multivariable analyses.
Results: Six hips were categorized as group I and 45 hips were categorized as group II. The postoperative intact ratio and preoperative stage were significantly correlated with the radiological outcome in both univariate (P < 0.0001, P = 0.006) and multivariate (P = 0.0014, P = 0.0039) analysis. The cutoff point for the postoperative intact ratio (the minimum ratio required to prevent both progression of collapse and joint space narrowing) was 36.8 %.
Conclusions: The results of this study indicate that the postoperative intact ratio is one of the main influences on progression of collapse and/or joint space narrowing after PRO, and should be at least 36.8 %. An increased awareness of this critical ratio would be useful for planning the optimal use of this procedure.
文献出处：Zhao, Garida & Yamamoto, Takuaki & Motomura, Goro & Iwasaki, Kenyu & Yamaguchi, Ryosuke & Ikemura, Satoshi & Iwamoto, Yukihide. (2013). Radiological outcome analyses of transtrochanteric posterior rotational osteotomy for osteonecrosis of the femoral head at a mean follow-up of 11 years. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. 18. 10.1007/s00776-012-0347-0.
文献2
股骨转子间截骨治疗非创伤性股骨头坏死的长期随访
译者：程徽
目的：对于患有非创伤性股骨头坏死（ONFH）的年轻患者可以通过股骨转子间旋转截骨术（TRO）保护髋关节。我们的目的是在此过程15年后调查长期结果和失败的风险因素。
患者与方法：这项研究包括95名通过TRO治疗ONFN的患者（111髋），平均年龄40岁（21至64）。平均随访时间为18.2年（3至26）。以全髋关节置换术（THA）、影像可见的股骨头的二次塌陷和骨关节为终点事件，进行Kaplan-Meier生存分析。行多变量分析以评估每种结果的风险因素。
结果：以THA为终点事件分析髋关节的15年生存率是59％（95％可信区间（CI）为49至67），以影像学可见的塌陷和骨关节炎分析髋关节的15年生存率是30％（95％CI为22至39），转行THA的危险因素，坏死型为C2型的ONFH（病变横向延伸至髋臼边缘）和年龄> 40岁，风险比（HR）分别为3.9和2.5。出现影像可见的股骨头的二次塌陷和骨关节的危险因素为，大于3a级的 ONFH和年龄> 40岁，风险比分别是2.0和1.9。
结论：TRO治疗ONFH后的15年效果不佳，因为术后5年骨关节炎发生率较高。
Long-term outcomes of transtrochanteric rotational osteotomy for non-traumatic osteonecrosis of the femoral head
AIMS: Transtrochanteric rotational osteotomy (TRO) is performed for young patients with non-traumatic osteonecrosis of the femoral head (ONFH) to preserve the hip. We aimed to investigate the long-term outcomes and the risk factors for failure 15 years after this procedure.
PATIENTS AND METHODS: This study included 95 patients (111 hips) with a mean age of 40 years (21 to 64) who underwent TRO for ONFH. The mean follow-up was 18.2 years (3 to 26). Kaplan-Meier survivorship analyses were performed with conversion to total hip arthroplasty (THA) and radiological failure due to secondary collapse of the femoral head or osteoarthritic changes as the endpoint. Multivariate analyses were performed to assess risk factors for each outcome.
RESULTS: Survival rates at 15 years with conversion to THA and radiological failure as the endpoint were 59% (95% confidence interval (CI) 49 to 67) and 30% (95% CI 22 to 39), respectively. Necrotic type C2 ONFH (lesions extending laterally to the acetabular edge) (hazards ratio (HR) 3.9) and age > 40 years (HR 2.5) were risk factors for conversion to THA. Stage > 3a ONFH (HR 2.0) and age > 40 years (HR 1.9) were risk factors for radiological failure.
CONCLUSION: The 15 year outcomes after TRO for ONFH are unfavorable because osteoarthritic changes occur after five years post-operatively. Cite this article: Bone Joint J 2017;99-B:175-83.
文献出处：Morita D, Hasegawa Y, Okura T, Osawa Y, Ishiguro N. Long-term outcomes of transtrochanteric rotational osteotomy for non-traumatic osteonecrosis of the femoral head. Bone Joint J. 2017 Feb;99-B(2):175-183.
文献3
髋关节疾病患者关节周围软组织的差异
译者：肖凯
背景：临床上，了解不同髋关节疾病患者关节周围软组织差异情况，将会进一步指导手术治疗与非手术治疗。很少有研究将软组织因素作为潜在的病因，在术前与其它关节病变进行鉴别诊断。
目的：明确不同髋关节疾病患者髋关节造影MRI上软组织结构是否存在差异。
方法：我们将57例患者分为3组：DDH组17例（女性11例，男性6例，平均年龄35.1岁，19.6-53.6岁），单纯盂唇损伤组20例（女性17例，男性3例，平均年龄38.4岁，15.2-62.1岁），Cam型髋关节撞击症组20例（女性11例，男性9例，平均年龄38.8岁，18.9-51.2岁）。所有患者术前均进行髋关节造影MRI检查。测量指标包括：盂唇宽度，关节囊厚度，腰大肌、骨直肌、臀肌大小，所有测量均用标准化数值，便于统计分析。
髋关节造影MRI上关节囊厚度及盂唇宽度测量方法
髋关节轴位MRI上髂腰肌、骨直肌及臀肌的大小测量。图1图2交叉十字分别代表肌肉的最长轴与最短轴，图3的白线代表肌肉的最短轴
结果：DDH组（标准化值，NV：0.30）髋臼上方盂唇的宽度显著大于FAI组（NV:0.25, P < 0.05）。此外，DDH组（NV:0.24）在髋臼12点方向关节囊的厚度显著大于单纯盂唇损伤组（NV: 0.15, P < 0.05）及FAI组（NV: 0.16, P < 0.05）。另外，DDH组（NV: 0.18）在髋臼3点方向的关节囊厚度也显著大于单纯盂唇损伤组（NV: 0.13, P < 0.05）。DDH组（NV: 1.39）骨直肌横向直径大于FAI组（NV: 1.14, P < 0.05）。
结论：相比其它髋关节疾病患者，DDH患者骨直肌更发达、关节囊更厚、盂唇更宽。
Soft Tissue Structures Differ in Patients With Prearthritic Hip Disease
BACKGROUND: Clinically, understanding how the soft tissue envelope adapts to various forms of hip dysfunction could enhance both surgical and nonsurgical management. Very few studies have looked at soft tissue structures as preoperative discriminators between varying underlying etiologies of hip conditions.
PURPOSE: To demonstrate that the magnetic resonance arthrography assessment of soft tissue structures of the hip will preoperatively differ in patients with different underlying hip joint diseases.
METHODS: Fifty-seven patients who underwent preoperative magnetic resonance arthrography and corrective hip surgery were retrospectively identified yielding 3 groups: 17 with developmental dysplasia of the hip (DDH) (11 F, 6 M; mean age 35.1 years, range 19.6-53.6); 20 with isolated labral tears (LTs) (17 F, 3 M; mean age 38.4 years, range 15.2-62.1), and 20 with cam-type femoroacetabular impingement (FAI) (11 F, 9 M; mean age 38.8 years, range 18.9-51.2). Measurements of the hip labral length, capsule thickness, and psoas, rectus femoris, and gluteal muscle dimensions were performed, with normalization of the values for statistical analysis.
RESULTS: The superior labral length was significantly greater in the DDH group [normalized value (NV): 0.30] compared with the FAI group (NV: 0.25, P < 0.05). In addition, the superior (12 o'clock) capsular thickness (NV: 0.24) was significantly greater compared with the LT group (NV: 0.15, P < 0.05) and the FAI group (NV: 0.16, P < 0.05). The DDH group also had a significantly greater anterior (3 o'clock) capsular thickness (NV: 0.18) compared with the LT group (NV: 0.13, P < 0.05). The transverse dimension of the rectus femoris was larger in the DDH group (NV: 1.39) compared with the FAI group (NV: 1.14, P < 0.05).
CONCLUSION: An enlarged rectus femoris and thicker hip capsule as well as an enlarged labrum are characteristic findings in hip dysplasia.
文献出处：Le Bouthillier A, Rakhra KS, Belzile EL, et al. Soft Tissue Structures Differ in Patients With Prearthritic Hip Disease. J Orthop Trauma. 2018 Feb;32 Suppl 1:S30-S34.
文献4
髋关节发育不良继发髋外翻的治疗
译者：张振东
股骨头骨骺生长发育障碍是儿童髋关节发育不良患者复位治疗后的并发症之一。若股骨头外侧骨骺生长发育迟缓，可导致髋外翻畸形，多发生于复位治疗后4-6年，并可能再次出现髋关节发育不良或坐骨-股骨撞击征。一般认为股骨近端内翻截骨术是治疗髋外翻畸形的有效方法，然而手术较大、术后恢复期长且存在骨不连、内固定失败、继发骨折以及股骨头坏死的潜在风险。骨骺导向生长手术（Guided growth）具有创伤小、恢复快的优点，在纠正下肢畸形方面应用越来越多。动物实验已证实股骨头骨骺内侧阻滞可造成髋内翻畸形，亦有一系列选择性骨骺阻滞治疗脑瘫后遗症或髋关节发育不良患儿髋外翻畸形的相关报道。本研究旨在明确：1）术后股骨形态改变情况；2）髋臼侧形态改变与否；3）内固定螺钉是否会损伤股骨头骨骺？
研究纳入了2011年至2014年共10例髋外翻畸形的患儿（既往均曾因髋关节发育不良行切开或闭合复位术，手术年龄平均为1.7岁）。接受骨骺导向生长手术时平均年龄9.1岁（范围：7-11.5岁），术后随访平均3.3年（范围：2.5-4.5年）。术前及随访时测量指标包括：髋关节中心边缘角（center edgeangle）、颈干角（neck-shaft angle，NSA）、头干角（head-shaft angle，HSA）、骨骺倾斜角（physis tilt angle，PTA）以及关节面-大转子间距（articulotrochanteric distance，ATD）（图1）。
图1 各指标测量图示：颈干角（neck-shaft angle，NSA）、头干角（head-shaft angle，HSA）、骨骺倾斜角（physis tilt angle，PTA）、关节面-大转子间距（articulotrochanteric distance，ATD）以及髋臼指数（acetabular index，AI）
结果显示，术后首先出现的改变为关节面-大转子间距的减小，随后于术后1.5年时出现骨骺倾斜角逐渐增加。术后2年，CE角由术前平均18.3度改善至平均24.8度。术后1.5至2年内，其中4例螺钉取出后出现PTA及HSA反弹，分别由平均25.3度降至21.5度、由平均149.9度增加至169.4度。这说明骨骺阻滞为机械拉力阻滞，而非损伤骨骺所致。
图2 男，10岁，既往右髋切开复位、骨盆Salter截骨手术史。a 术前X线示右侧髋外翻伴髋关节发育不良（ATD: 33.6 mm, PTA: − 6°, HSA: 175°, CEA: 18.8°）；b 术后2年（ATD: 30.8 mm,PTA: 13.9°, HSA: 158°, CEA:24.4°）
图3 女，7岁，既往1.2岁时右髋闭合复位、4岁时Pemberton截骨术。a 骨盆X线片示右侧髋外翻伴髋关节发育不良（ATD: 29.6 mm, PTA: 5.6°, HSA: 168°, CEA: 13.6°）；b 一枚经骨骺螺钉固定内侧骨骺；c 术后1.5年（ATD: 25 mm,PTA: 22°, HSA: 153°, CEA: 15.7°）；d 术后3年，内固定取出后（ATD:29 mm, PTA: 9.6°, HSA: 167°,CEA: 28.8°），可见髋关节发育不良明显改善，但部分指标反弹
Guided growth for caput valgum in developmental dysplasia of the hip
This study reported guided growth for caput valgum deformity and subsequent hip development. Ten children with unilateral hip dysplasia had guided growth by one eccentric transphyseal screw at age 9.1 years with minimum 2 years of follow-up. The first change was decreasing articulotrochanteric distance and then increasing physis tilt angle and head-shaft angle by 1.5 years. The center edge angle that was significantly less than the normal side (18.3 vs. 24.8°) preoperatively became comparable between both the hips 2 years later. Rebounding of physis inclination after screw back out suggested mechanical tethering, rather than permanent physis closure, resulted in morphologic changes in the femur.
文献出处：Peng SH , Lee WC , Kao HK , Yang WE , Chang CH. Guided growth for caput valgum in developmental dysplasia of the hip. J Pediatr Orthop B 2018 Jun.
张洪主任好大夫网站zhanghongmd.haodf.com
张洪主任门诊时间：周三上午
关节外科护士站：01066867304 转848810（请在14:00-18:00拨入）
膝关节置换:张轶超 13261817537
髋关节置换:马云青 13811705624
保髋疗法:罗殿中 18911358880
联系客服
