本期目录：
1、髌骨友好型假体的膝关节置换术后再次进行髌骨置换的预测
2、关节镜下稳定膝关节外侧半月板部分切除术后最少20年的临床疗效和影像学随访
3、THA翻修术中使用髋臼撑开技术治疗慢性骨盆中断的影像学研究：来自两家医院平均5年的随访
4、髓芯减压联合植入脱钙骨基质治疗非创伤性股骨头坏死
5、残余髋关节发育不良：是否有还有造盖术的一席之地？
6、盂唇重建的临床及影像学预后
第一部分：关节置换相关文献
文献1
髌骨友好型假体的膝关节置换术后再次进行髌骨置换的预测
译者：张轶超
目的：全膝关节置换术（TKA）中髌骨是否需要置换一直存在很大争议。这个回顾性个案对照研究的目的是确定全膝置换术后需要再次行髌骨置换（SPR）的预测因素，为医生术前确定是否需要进行髌骨置换提供一个参考标准。我们假定只要选择合适的TKA假体，假体位置安装良好以及保持一个正常的髌骨形状就会使得髌骨再置换的风险变小。但是这可能只是一个猜想，如超重这样的自身因素也可能会影响髌骨再置换的发生率。
方法：入选合适的病人，按照年龄、性别按1：2进行匹配，共有29例实验组（TKA/SPR）和58例对照组（TKA）入选，筛查他们的临床和流行病学数据以及术后影像学数据。通过采用Pearson相关对照研究和逻辑回归模型分析来确定TKA术后SPR的可能预测因素。
结果：通过二元回归分析把88.5%的病例分成实验组和对照组。显示髌骨倾斜角，髌骨高度和厚度以及Delta角是TKA术后需要行SPR的一个明显的预测因素。髌骨宽度增加1mm则会增加SPR的风险，而厚度增加1mm将会降低SPR的风险。髌骨倾斜度增加1°则会增加SPR的风险。Delta角增加1°将会降低SPR的风险。
结论：简单方便的影像学测量可以作为预测SPR风险的方法。术前是否需要做髌骨置换的指证目前还是一个具有很大争议的问题，通过这个研究所得到的合理指证，如髌骨倾斜度、宽度和厚度是可以给医生在术前评估SPR风险提供很好的帮助。而TKA手术技术，胫骨假体位置对于降低SPR风险也是非常重要的。
膝关节屈曲30°位（髌骨切线位）时的髌骨倾斜角
膝关节屈曲30°位（髌骨切线位）时的髌骨宽度和厚度
Predictors for secondary patellar resurfacing after primary total knee arthroplasty using a B patella-friendly ^ total knee arthroplasty system
Purpose: Patellar resurfacing (PR) in total knee arthroplasty (TKA) is still one of the major controversies in orthopaedic surgery today. The aim of the present retrospective case-control study was to identify predictors for secondary patellar resurfacing (SPR) after initial TKA to create a rationale for surgeons to decide which patients to resurface primarily. It was hypothesized that proper TKA implantation and component positioning as well as a maintained physiological patellar geometry will lead to a reduced risk of SPR. Overmore, it was hypothesized that intrinsic factors like overweight might also have an influence on the need for SPR.
Methods: After identification of suitable patients and age/sex matching in a 1:2 fashion, 29 cases (TKA/SPR) and 58 controls (TKA) were included and screened for available clinical and epidemiological data as well as for radiographic data after primary TKA. Pearson ’ s correlation analysis as well as logistic regression modeling was performed to identify possible predictors for SPR following TKA.
Results: Binary logistic regression was able to correctly classify 88.5% of patients into case or control groups. It indicated that patella tilt, patella height, and thickness as well as the delta angle were significant predictors of a need for SPR following primary TKA. An increase in patellar width by 1 mm will increase the risk of SPR, while an increase in patellar thickness by 1 mm will reduce it. An increase in patellar tilt by 1° will also increase the risk of SPR. Finally, an increase in delta angle by 1° will again reduce the risk of SPR.
Conclusions: Easy and accessible radiographic measurements have been identified as possible predictors of SPR following primary TKA. Although indication for primary PR may still remain a controversial topic, a rationale has been proposed in this study to support surgeons in objectively estimating an individual patient ’ s risk for SPR prior to primary TKA measuring the patella tilt, width, and thickness. Overmore, regarding surgical aspects of TKA, tibial component positioning has also been shown to be of importance to reduce the risk of SPR.
文献出处：Philip P. Roessler, Randa Moussa, Cornelius Jacobs,et al. Predictors for secondary patellar resurfacing after primary total knee arthroplasty using a B patella-friendly ^ total knee arthroplasty system. International Orthopaedics.
文献2
关节镜下稳定膝关节外侧半月板部分切除术后最少20年的临床疗效和影像学随访
译者：马云青
摘要：研究目的，通过回顾性多中心分析评价外侧半月板切除术后的长期疗效，并确定这些患者是否存在最有可能发展为骨关节炎(OA)的风险因素。
方法：对89例膝关节稳定的患者行关节镜下的外侧半月板部分切除术，术后平均随访22±3年。分析相关因素，包括年龄、性别、体重指数(BMI)、活动量、下肢力线、半月板病变类型、半月板切除程度及早期软骨损伤等。由一名独立的检查者对所有患者进行检查随访，使用主观的(KOOS和IKDC评分)和客观的临床和放射资料(IKDC评分)。以对侧膝关节为参考，计算OA的患病率和发病率。
结果：患者手术时平均年龄为35±13岁。病变的主要部位为外侧半月板的中段(79%)。在最近一次随访中，48%的患者有积极的生活方式，多达48%的患者在术后22年仍有中等强度的体力活动(而在术前这一比例为71%)。在同一时期，KOOS评分从82%上升到69%。患膝OA的患病率为56%，手术侧与健康侧的膝关节患病率差异为44%。在术侧膝关节患有OA而对侧膝关节正常的患者中，OA的发生率为53%。手术时年龄大于38岁、肥胖(BMI>30)、外翻畸形、软骨及半月板退行性病变等因素对继发OA具有预测作用。
结论：长期而言，对膝关节稳定无软骨损伤的青年患者行关节镜下半月板部分切除是可以取得良好的疗效的。如果患者年龄超过40岁，手术时具有高BMI、膝关节外翻畸形和软骨病变更有可能发展为有症状的OA。本研究为外侧半月板撕裂的外科治疗提供了一定的指导原则。
Clinical and radiographic results of arthroscopic partial lateral meniscectomies in stable knees with a minimum follow up of 20 years
Abstract：Purpose The purpose of this retrospective multicentric study was to evaluate the long-term effects of lateral meniscectomy and to identify those patients who are at the most risk of developing osteoarthritis (OA).
Methods: Eighty-nine arthroscopic partial lateral meniscectomies in stable knees with a mean follow-up of 22 ± 3 years were included. The following influencing factors were analyzed: age, sex, body mass index (BMI), physical activity, alignment, the types of meniscal lesions, the extent of meniscal resections and the initially associated cartilage lesions. An independent examiner reviewed all patients, using subjective (KOOS and IKDC scores) and objective clinical and radiological evaluations (IKDC score). The contralateral knee was used as a reference to calculate the prevalence and the incidence of OA.
Results: The mean age at the time of surgery was 35 ± 13 years. The main location of the lesions was the mid-section of the lateral meniscus (79 % of the cases). At the latest follow-up, 48 % of the patients had an active lifestyle with as many as 48 % of the patients enjoying moderate to intense physical activity 22 years after the procedure (vs. 71 % before surgery). The KOOS score evolved from 82 to 69 % during the same period. The prevalence of OA was 56 % in the affected knee and the difference of prevalence between the operated and healthy knees was 44 %. In those patients presenting with an OA of the operated knee and a normal contralateral knee, the incidence of OA was 53 %. Predictors of OA were an age superior to 38 years at the time of surgery, obesity (BMI >30), and valgus malalignment as well as the presence of cartilage and degenerative meniscal lesions at the time of surgery.
Conclusion: In the long term, arthroscopic partial lateral meniscectomy in stable knees without initial cartilage lesions might yield good to excellent results in young patients. Patients are at higher risk to develop symptomatic OA if they are over 40, having a high BMI, valgus malalignment and cartilage lesions at the time of surgery. This study provides precise guidelines for the surgical treatment of lateral meniscus tears.
文献出处：Hulet C, Menetrey J, Beaufils P, et al. Clinical and radiographic results of arthroscopic partial lateral meniscectomies in stable knees with a minimum follow up of 20 years. Knee Surg Sports Traumatol Arthrosc. 2015 Jan;23(1):225-31.
文献3
THA翻修术中使用髋臼撑开技术治疗慢性骨盆中断的影像学研究：来自两家医院平均5年的随访
译者：张蔷
目的：本篇研究的目的是研究使用髋臼撑开技术治疗髋翻修手术中的慢性骨盆中断在假体稳定植入、获得生物学固定以及骨-假体愈合方面的效果。
方法：共入组2006年至2013年间32名因慢性骨盆中断在髋翻修手术中使用髋臼撑开技术治疗的病例，全部接受了平均62个月的影像学随访（25-160个月）。这其中28人为女性患者（87.5%）。翻修时的平局年龄为67岁（44-86岁）。所有患者均为来自两家医院使用完全相同的手术技术治疗的连续病例。
术中撑开骨盆时使用的撑开器
PaproskyⅢB型骨缺损伴有骨盆中断
使用髋臼撑开技术的翻修术后影像
结果：这32人中，1人因无菌性松动需要翻修，2人有影像学松动征象但没有翻修，3人出现髋臼假体移位但仍然稳定。影像学上分析，本组中22人（69%）最终骨盆中断愈合。如果以无菌性松动作为终末点，Kaplan-Meier曲线生存率为83.3%。在那名患者7.4年随访因无菌性松动再次翻修时，共有7名随访时间超过7年的患者存在失败的风险。
Kaplan-Meier曲线
结论：髋臼撑开技术显现出令人鼓舞的效果，骨盆中断愈合率超过2/3。它能诱导骨-假体界面的生物学固定，并可根据术中骨缺损的大小个性化选择植入的假体。
Two-centre radiological survivorship of acetabular distraction technique for treatment of chronic pelvic discontinuity：MEAN FIVE-YEAR FOLLOW-UP
Aims：The aim of this study was to examine the results of the acetabular distraction technique in achieving implantation of a stable construct, obtaining biological fixation, and producing healing of chronic pelvic discontinuity at revision total hip arthroplasty.
Patients and Methods：We identified 32 patients treated between 2006 and 2013 who underwent acetabular revision for a chronic pelvic discontinuity using acetabular distraction, and who were radiographically evaluated at a mean of 62 months (25 to 160). Of these patients, 28 (87.5%) were female. The mean age at the time of revision was 67 years (44 to 86). The patients represented a continuous series drawn from two institutions that adhered to an identical operative technique.
Results：Of the 32 patients, one patient required a revision for aseptic loosening, two patients had evidence of radiographic loosening but were not revised, and three patients had migration of the acetabular component into a more stable configuration. Radiographically, 22 (69%) of the cohort demonstrated healing of the discontinuity. The Kaplan–Meier construct survivorship was 83.3% when using revision for aseptic acetabular loosening as an endpoint. At the time when one patient failed due to aseptic loosening (at 7.4 years), there were a total of seven patients with a follow-up of seven years or longer who were at risk of failure.
Conclusion: The acetabular distraction technique demonstrates encouraging radiographic outcomes, with healing of the discontinuity in over two-thirds of our series. This surgical technique permits biological fixation and intraoperative customization of the construct to be implanted based on the pattern of the bone loss identified following component removal.
文献出处：N. P. Sheth, C. M. Melnic, N. Brown, S. M. Sporer, W. G. Paprosky. Two-centre radiological survivorship of acetabular distraction technique for treatment of chronic pelvic discontinuity：MEAN FIVE-YEAR FOLLOW-UP. Bone Joint J 2018; 100-B: 909–14.
第二部分：保髋相关文献
文献1
髓芯减压联合植入脱钙骨基质治疗非创伤性股骨头坏死
译者：罗殿中
介绍：髓芯减压是治疗早期非创伤性股骨头坏死的标准方法。然而，对于是否有必要在髓芯减压同时进行骨移植、应用生长因子或细胞仍然存在争议。本研究对接受髓芯减压联合脱钙骨基质植入治疗的患者进行评估，明确长期随访过程中接受髋关节置换的比例。
材料及方法：14名非创伤性股骨头坏死患者（18髋），Ficat分期为I-IIB期，均接受髓芯减压联合脱钙骨基质治植入术。术前及术后12-24个月进行X线片及MRI检查。应用Merle d'Aubigné评分评估临床预后，其中平均随访时间９年。
结果：18髋中的14髋（77%）在术后2年时获得了好或非常好的临床效果。Merle d'Aubigné评分在术后12个月（p = 0.0001）及24个月（p = 0.0002）时明显提高。但是MRI容积分析显示坏死骨容积由3.16 ± 0.54升高至3.88 ± 0.62 cm3（p = 0.04）。在术后的9年中，18髋中的13髋（72%）需要接受人工关节置换术治疗。只有7髋（39%）报道临床效果持续改善，并且患者表示愿意接受同样的手术。没有接受人工关节置换的5髋术后9年对临床效果仍然满意。
A 36岁Ficat II期股骨头坏死患者术前、术后52周及术后104周髋关节X线片，随访过程中未发现坏死区进展。B 同一患者MRI显示坏死区范围无变化
以人工关节置换为终点的生存曲线
结论：对于早期股骨头坏死患者，髓芯减压联合脱钙骨基质植入术可以临时、有限地缓解髋关节疼痛，与单纯髓芯减压效果相似。然而长期随访效果并不令人满意，需要进行人工关节置换的比例较高。因此，这种治疗方式并不能避免术后再接受人工关节置换的可能。
Core decompression combined with implantation of a demineralised bone matrix for non-traumatic osteonecrosis of the femoral head
INTRODUCTION: Core decompression is the standard surgical procedure in the treatment of early stage non-traumatic osteonecrosis of the femoral head (ONFH). However, there is still a debate whether decompression in combination with supplementary augmentation by bone grafts, growth factors, or cell implementation is superior to conventional decompression alone. This study evaluated patients after core decompression combined with an augmentation by a demineralised bone matrix, and particularly aimed to report long-term conversion rates to total hip replacement (THR).
MATERIALS AND METHODS: 14 patients with 18 hips suffering from ONFH (Ficat stage I-IIB) underwent this surgical procedure. All patients underwent radiographic and MRI investigations at baseline and at follow-up periods of 12 and 24 months. The clinical follow-up was done using the Merle d'Aubigné-score for an average period of 9 years after surgery.
RESULTS: 14 of the 18 subjects (77 %) achieved at least a good clinical result after 2 years. The Merle d'Aubigné-score improved significantly after 12 (p = 0.0001) and 24 months (p = 0.0002). However, the MRI volumetric analysis showed an increased necrotic bone volume from 3.16 ± 0.54 to 3.88 ± 0.62 cm(3) (p = 0.04). Within 9 years, 13 out of 18 cases (72 %) required further surgery by THR. Only 7 out of 18 subjects (39 %) reported an ongoing postoperative clinical benefit, and would retrospectively redo the same surgical approach again. The five patients that did not require THR were still satisfied after 9 years.
CONCLUSIONS: In patients with early- stage femoral head osteonecrosis core decompression combined with the implantation of a demineralised bone matrix leads to a limited, temporary pain relief as seen in core decompression alone. However, long-term results were not encouraging with a high rate of conversion to arthroplasty. Therefore, core decompression with implantation of a demineralised bone matrix may be not appropriate to avoid THR in the long term.
文献出处：Helbig L, Simank HG, Kroeber M, Schmidmaier G, Grützner PA, Guehring T. Core decompression combined with implantation of a demineralised bone matrix for non-traumatic osteonecrosis of the femoral head. Arch Orthop Trauma Surg. 2012 Aug;132(8):1095-103.
文献2
残余髋关节发育不良：是否有还有造盖术的一席之地？
译者：程徽
目的：在现代髋臼截骨术发明后，越来越少的医生使用造盖术。本研究的目的是评估改良Spitzy造盖术的短期和长期结果，并将结果与髋臼周围截骨术（PAO）进行比较。
方法：总共有44名患有髋关节发育不良和残余发育不良的患者（55髋）进行了改良Spitzy造盖术。手术时的平均年龄为13.2岁（8-22岁）。手术指征是中心边缘角度<20°，有或没有髋部疼痛。使用无痛期的持续时间和转换为全髋关节置换术（THA）作为终点的生存分析来评估结果。
结果：46％的髋部出现术前髋部疼痛，在手术≥12岁的患者中更为常见（p <0.001）。术后一年，93％的髋部无痛。随访10年以上的髋关节疼痛分析显示术后平均无痛无效期为20.0年（0-49年）。总共有44髋（80％）在平均患者年龄为50.5（37-63）岁时接受了THA。造盖术的平均存活率（从手术到THA的时间）为39.3（21-55）年。
结论：Spitzy造盖术对髋部疼痛具有良好的短期和长期影响，72％的髋部存活30年（无THA）。这些结果与PAO的结果相当，并且表明在年龄较大的儿童和年轻人中仍然存在一席之地。
译者的评价：虽然本文中作者认为Spitzy造盖术的临床结果与PAO相当，但是我们要注意PAO手术30年随访研究中的患者的平均手术年龄是29 (13–56)岁，而本文中患者的平均手术年龄是13.2（8-22）岁。我们知道患者越年轻，治疗效果越好， “Spitzy造盖术的临床结果与PAO相当”这个结论还是有待商榷。
Residual hip dysplasia: is there a place for hip shelf operation?
Purpose: After modern acetabular osteotomies were introduced, hip shelf operations have become much less commonly used. The aims of this study were to assess the short-term and long-term outcome of a modified Spitzy shelf procedure and to compare the results with those of periacetabular osteotomy (PAO).
Methods: In all, 44 patients (55 hips) with developmental dysplasia of the hip and residual dysplasia had a modified Spitzy shelf operation. Mean age at surgery was 13.2 years (8 to 22). Indication for surgery was a centre-edge angle < 20° with or without hip pain. Outcome was evaluated using duration of painless period and survival analysis with conversion to total hip arthroplasty (THA) as endpoints.
Results: Preoperative hip pain was present in 46% of the hips and was more common in patients ≥ 12 years at surgery (p < 0.001). One year postoperatively, 93% of the hips were painless. Analysis of pain in hips with more than ten years follow-up showed a mean postoperative painless period of 20.0 years (0 to 49). In all, 44 hips (80%) had undergone THA at a mean patient age of 50.5 years (37 to 63). Mean survival of the shelf procedure (time from operation to THA) was 39.3 years (21 to 55).
Conclusions: The Spitzy operation had good short and long-term effects on hip pain and a 30-year survival (no THA) of 72% of the hips. These results compare favourably with those of PAO and indicate that there is still a place for the shelf procedure in older children and young adults.
文献出处：T. Terjesen. Special symposium issue: Developmental dysplasia and dislocation of the hip. Journal of Children's Orthopaedics, Vol. 12, No. 4.
文献3
盂唇重建的临床及影像学预后
译者：肖凯
髋关节撞击症的治疗包括去除潜在的骨性畸形，在可能的情况下应进行修复盂唇的治疗。对于髋关节盂唇缺失或者损伤程度超出修复范围的患者，我们可以通过盂唇重建来恢复其对股骨头的密封吸附作用。自2008-2011年，共有84例髋关节接受外科脱位入路FAI治疗，这其中的13髋（11名患者）由于盂唇损伤严重或盂唇缺损而进行了盂唇重建术（应用股骨头圆韧带进行盂唇重建）。术后进行了平均38个月（19-56个月）的随访。我们对患者术前及末次随访时的影像学资料及临床数据进行分析。临床数据包括牛津髋关节评分、总体满意度、休息及负重时的疼痛VAS评分（0-100）。比较盂唇重建组与盂唇修复组的临床预后差异。盂唇重建组患者牛津髋关节评分由术前平均29分（标准差8）提高至术后44分（标准差4分）（P≤0.001）。整体的满意度由44（标准差35）显著提高至87（标准差15）（P=0.002）。休息状体下的疼痛VAS评分由45分（标准差35）降低至5分（标准差7）（P=0.0004）。负重状态的疼痛VAS评分由59分（标准差26）降至16分（标准差19）（P=0.0007）。盂唇重建组与盂唇修复组之间的临床预后数据无明显差异。通过股骨头圆韧带重建髋臼盂唇可以获得良好的临床预后。技术上优于开放盂唇重建术的手术可能会获得更好的临床效果。
盂唇重建术中照片。A 两箭头之间部分为盂唇切除后的髋臼缘；B 通过3枚锚钉将韧带固定在盂唇缺损部位
A术前髋关节正位，LCE角39°；B 术后髋关节正位，LCE角纠正至31°；C 术前左髋关节穿卓位，alpha角62°； D alpha角纠正至44°
术后髋关节造影核磁显示两枚锚钉之间的重建盂唇，重建盂唇与髋臼愈合良好，无盂唇撕裂及液体信号充盈
Clinical and radiographical results of labral reconstruction
Treatment of femoroacetabular impingement (FAI) includes correction of underlying bony deformities. Labrum preservation is recommended whenever possible. In hips, where the labrum is missing or damaged beyond preservation, labral reconstruction is an option to restore labral seal. Between 2008 and 2011, 84 hips underwent treatment for FAI by means of a surgical hip dislocation. In 13 of these hips (11 patients), the severely damaged or missing labrum was reconstructed with ligamentum capitis femoris. Pre- and postoperative radiographic and clinical data were analysed with a mean follow-up of 38 months (range: 19-65 months). Clinical outcome was determined with Oxford hip score (OHS) and overall satisfaction, rest and load pain with a visual analogue scale (VAS; 0-100). Clinical outcome was compared with a control group where labral refixation was performed. Mean OHS improved significantly (P ≤ 0.001) from 29 (SD 8) to 44 (SD 4). Overall satisfaction with the hip increased significantly (P = 0.002) from 44 (SD 35) to 87 (SD 15). Mean VAS for rest pain decreased significantly (P = 0.0004) from 45 (SD 35) to 5 (SD 7) as well as for load pain (P = 0.0007) from 59 (SD 26) to 16 (SD 19). There were no significant differences between the two groups. Reconstruction of the acetabular labrum with ligamentum capitis femoris yields good clinical results. Technical superiority of open labral reconstruction may explain the unexpected, excellent outcome.
文献出处：Camenzind RS, Steurer-Dober I, Beck M. Clinical and radiographical results of labral reconstruction. J Hip Preserv Surg. 2015 Nov 4;2(4):401-9.
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