本期目录：
1、单髁置换术中关节线保留的重要性：有限元分析
2、医生能否通过后外侧入路降低初次髋关节置换术后脱位的风险？
3、全膝关节置换术中应用动力对线技术诱导的步态优于机械对线
4、骶髂疼痛：骶髂关节区疼痛的结构原因
5、股骨内外旋转对髌股关节内软骨应力的影响
6、髋关节发育不良超声检查
7、利用有限元预测正常髋关节的软骨接触应力
8、CT三维重建研究显示与健康髋关节相比，股骨头骨骺滑脱具有较小的骨骺结节和较大的外周覆盖
第一部分：关节置换及保膝相关文献
文献1
单髁置换术中关节线保留的重要性：
有限元分析
译者：张轶超
对于部分膝关节的骨关节炎，单髁置换术（UKA）是一种有效的缓解疼痛和恢复关节功能的外科治疗技术。但是，在UKA中关节线的重要性，尤其是生物力学方面的影响还不曾被研究。本研究以数字化形式针对关节线的变化对于加载在聚乙烯（PE）垫片上、关节软骨上及对侧半月板上的接触应力进行有限元（FE）分析。在FE模型中关节线被设置为从内侧胫骨平台边缘到解剖轴的垂线。在ISO步态负重情况下，关节线的变化从-6到 6mm每间隔2mm为一组，共分析了7组模型并进行了相互比较。观察到作用在PE垫片上、残留的关节软骨上及对侧半月板上的接触应力在参考线（0mm）, ±2mm和±4mm高度时没有明显差别，但在到±6mm变化时就出现明显差异了。在 6mm高度时，加载在PE上的接触应力高于加载在关节软骨上的应力，而在-6mm时则刚好相反。本研究证明了在UKA中保留正常的关节线的重要性。
Importance of joint line preservation in unicompartmental knee arthroplasty: Finite element analysis
Unicompartmental knee arthroplasty (UKA) is an effective surgical technique for pain relief and functional restoration in patients with localized osteoarthritis of the knee joint. However, the role of the joint line in UKA, especially its biomechanical effect, has not been previously investigated. This study numerically evaluates the effects of the joint line on the contact stresses in polyethylene (PE) inserts, articular cartilage, and lateral meniscus using the finite element (FE) analysis. The FE model for joint line was modeled as the orthogonal projection line from the medial tibial plateau to the anatomical axis. The joint line was varied from -6 to 6 mm in 2 mm intervals, and the seven FE models were analyzed and compared under ISO gait loading conditions. The contact stresses in the PE insert, articular cartilage, and lateral meniscus matched those of the reference joint line (0 mm) in the ±2 and ±4 mm joint line cases but significantly differed from the reference in the ±6 mm joint line cases. On the 6 mm joint line, the contact stress was greater on the PE insert than on the articular cartilage, whereas the reverse occurred on the -6 mm joint line. This study confirms the post-operative significance of joint line preservation in UKA implantation surgery. © 2016 Orthopaedic Research Society.
文献出处：Kwon OR, Kang KT, Son J, Suh DS, Baek C, Koh YG. Importance of joint line preservation in unicompartmental knee arthroplasty: Finite element analysis. J Orthop Res. 2017 Feb;35(2):347-352. doi: 10.1002/jor.23279. Epub 2016 May 12.
文献2
医生能否通过后外侧入路降低初次髋关节置换
术后脱位的风险？
译者：马云青
背景：髋关节脱位是THA术后最常见的并发症之一。潜在的风险包括患者相关和手术相关因素。我们进行了一项回顾性队列研究，以确定后外侧入路接受THA的患者术后脱位的危险因素。
方法：对2010~2015年间连续1326个连续的初次全髋关节置换病例。患者资料包括入院记录，X线平片用于评价髋臼杯位置、偏心距和肢体长度的变化。用多元Logistic回归法确定脱位的危险因素。术后随访由丹麦国家患者登记处协调完成。
结果：年龄和ASA评分在THA脱位病例中明显高于非脱位的患者。髋臼杯前倾角在脱位患者中小于非脱位患者。脱位的独立危险因素包括高龄、BMI<25和>30、肢体短缩>5mm。
结论：外科医生手术时应注意避免下肢短缩>5mm，以减少初次THA术后脱位的风险。虽然脱位患者的前倾减少，但并没有绝对通用的髋臼安全区定义。髋关节的稳定性是多因素决定的，最佳的髋臼杯位置可能因人而异。
Can Surgeons Reduce the Risk for Dislocation After Primary Total Hip Arthroplasty Performed Using the Posterolateral Approach?
BACKGROUND: Hip dislocation is one of the most common postoperative complications after total hip arthroplasty (THA). Potential contributors include patient- and surgical-related factors. We performed a retrospective cohort study to identify risk factors for postoperative dislocation in patients receiving THA via the posterolateral approach.
METHODS: We assessed 1326 consecutive primary THAs performed between 2010 and 2015. Patient information was documented, and plain radiographic films were used to evaluate cup positioning, hip offset, and hip length change. A multiple logistic regression was used to identify risk factors for dislocation. Follow-up was coordinated by the Danish National Patient Registry.
RESULTS: Age and American Society of Anesthesiologists scores were higher in dislocating THA compared with those in the nondislocating THA. Cup anteversion was less in dislocating THA compared with that in nondislocating THA. Independent risk factors for cup dislocation were increased age, body mass index <25 and >30 kg/m2, and leg shortening of >5 mm.
CONCLUSION: Surgeons should aim for a shortening of leg length <5 mm to reduce the risk of postoperative dislocation in primary THA. Although anteversion was reduced for dislocating THA, there is likely no universal safe zone for cup positioning. Hip stability is multifactorial, and optimal cup positioning may vary from patient to patient.
文献出处：Seagrave KG, Troelsen A, Madsen BG, Husted H, Kallemose T, Gromov K. Can Surgeons Reduce the Risk for Dislocation After Primary Total Hip Arthroplasty Performed Using the Posterolateral Approach? J Arthroplasty. 2017 Oct;32(10):3141-3146. doi: 10.1016/j.arth.2017.04.047. Epub 2017 May 4.
文献3
全膝关节置换术中应用动力对线技术诱导的
步态优于机械对线
译者：张蔷
目的：全膝关节置换术中应用动力对线是为了重建患者膝关节解剖及韧带张力，并恢复膝关节动力学特性。本篇文章的目的是比较动力对线全膝关节置换术与机械对线全膝关节置换术后步态中的动力学参数（膝关节屈曲-伸直，内收-外展，胫骨内旋-外旋和步速），并将之与健康对照相比较。试验前设想是应用动力对线技术的全膝关节置换术后步态比机械对线的步态更接近健康对照。
方法：本研究为回顾性的病例对照研究。入组18例动力对线全膝关节置换术病例，经性别、年龄、术者和假体类型匹配后，再入组18例机械对线全膝关节置换术病例。应用一台光电膝关节分析仪（Knee KG），我们对所有动力对线TKA组、机械对线TKA组和健康对照组的病人进行了术后膝关节三维动力学分析。另外，我们还比较了影像学结果和临床评分。
结果：动力对线组参数与健康对照组相比，在矢状面活动度、最大屈曲角度、内收-外展曲线或胫骨外旋角度方面，没有显著性差异。相反的，机械对线组的动力学参数有几项明显弱于健康对照组：矢状面活动度更小（49.1° vs. 54.0°, p = 0.020），最大屈曲角度更小（52.3° vs. 57.5°, p = 0.002），内收角度更大（2.0–7.5° vs. − 2.8–3.0°, p < 0.05），胫骨外旋角度更大（平均大2.3 ± 0.7°, p < 0.001）。与机械对线组相比，动力对线组的术后KOOS评分显著更高（74.2 vs. 60.7, p = 0.034）。
结论：与机械对线TKA相比，应用动力对线技术的全膝关节置换术后膝关节动力学参数与健康的膝关节更加接近。一点可能的原因是动力对线技术可以更好的恢复患者膝关节解剖和韧带张力。而术后步态参数更接近健康步态能够提升术后疗效，并增加患者满意度。
Kinematic alignment in total knee arthroplasty better reproduces normal gait than mechanical alignment
Purpose: Kinematic alignment technique for TKA aims to restore the individual knee anatomy and ligament tension, to restore native knee kinematics. The aim of this study was to compare parameters of kinematics during gait (knee flexion–extension, adduction–abduction, internal–external tibial rotation and walking speed) of TKA patients operated by either kinematic alignment or mechanical alignment technique with a group of healthy controls. The hypothesis was that the kinematic parameters of kinematically aligned TKAs would more closely resemble that of healthy controls than mechanically aligned TKAs.
Methods: This was a retrospective case–control study. Eighteen kinematically aligned TKAs were matched by gender, age, operating surgeon and prosthesis to 18 mechanically aligned TKAs. Post-operative 3D knee kinematics analysis, performed with an optoelectronic knee assessment device (Knee KG®), was compared between mechanical alignment TKA patients, kinematic alignment TKA patients and healthy controls. Radiographic measures and clinical scores were also compared between the two TKA groups.
Results: The kinematic alignment group showed no significant knee kinematic differences compared to healthy knees in sagittal plane range of motion, maximum flexion, abduction–adduction curves or knee external tibial rotation. Conversely, the mechanical alignment group displayed several significant knee kinematic differences to the healthy group: less sagittal plane range of motion (49.1° vs. 54.0°, p = 0.020), decreased maximum flexion (52.3° vs. 57.5°, p = 0.002), increased adduction angle (2.0–7.5° vs. − 2.8–3.0°, p < 0.05), and increased external tibial rotation (by a mean of 2.3 ± 0.7°, p < 0.001). The post-operative KOOS score was significantly higher in the kinematic alignment group compared to the mechanical alignment group (74.2 vs. 60.7, p = 0.034).
Conclusions: The knee kinematics of patients with kinematically aligned TKAs more closely resembled that of normal healthy controls than that of patients with mechanically aligned TKAs. This may be the result of a better restoration of the individual’s knee anatomy and ligament tension. A return to normal gait parameters post-TKA will lead to improved clinical outcomes and greater patient satisfaction.
文献出处：Blakeney W, Clément J, Desmeules F, Hagemeister N, Rivière C, Vendittoli PA. Kinematic alignment in total knee arthroplasty better reproduces normal gait than mechanical alignment. Knee Surg Sports Traumatol Arthrosc. 2019 May;27(5):1410-1417. doi: 10.1007/s00167-018-5174-1. Epub 2018 Oct 1.
第二部分：保髋相关文献
文献1
骶髂疼痛：骶髂关节区疼痛的结构原因
译者：罗殿中
背景：目前报道的原发性骶髂关节（SIj）疼痛的发病率在15%-30%之间。SIj区疼痛的鉴别诊断包括腰椎、SIj和髋关节的疼痛。SIj功能障碍的病因目前还存在争议，并且疼痛是否来源于这个关节也受到质疑。
目的：回顾性分析腰椎、SIj和髋关节病变在主诉SIj疼痛（占疼痛原因的50%以上）患者的相对发病率。
研究设计：这是一项回顾性病例队列研究。
方法：纳入标准：主诉SIj疼痛（占疼痛原因的50%以上）。共从一个脊柱外科诊所共收集到124个病人的调查表。所有患者均由同样的2名医生进行评估，并对所有病例进行临床检查、诊断试验、最终诊断、治疗和临床随访。
结果：确诊后发现112例（90%）有腰椎痛，5例（4%）有髋关节痛，4例（3%）有原发性骶髂关节痛，3例（3%）初诊时疼痛来源不明。通过透视引导的诊断注射证实SIj疼痛产生原因。在相应的治疗后，11名（9%）患者因持续/复发性SIj区疼痛再次就诊，平均间隔时间为2.4年，进一步调查显示，6名患者证实了疼痛来源于腰椎，3名患者证实了疼痛来源于SIj，2名患者的疼痛来源不明。
结论：主诉SIj疼痛（占疼痛原因的50%以上）的原因很少发生在骶髂关节，只占疼痛发生原因的3%-6%，通常是由腰椎疼痛引起（88%-90%）。临床医生在问诊腰痛的患者时，应该量化疼痛区域（占疼痛原因的百分比)，以区分潜在的疼痛源。推荐的相关区域包括下背部、SIj区域、臀部/腿部、腹股沟/前大腿。
持续性SI区疼痛患者的诊断算法（平均随访2.4y，n=11）。*骶髂关节注射阳性的患者被认为疼痛来自骶髂关节本身。DDD表示退行性椎间盘疾病；FAI，股骨髋臼撞击；HNP，髓核突出；IDR，孤立性腰椎椎间盘吸收综合征；PLIF，经后路椎间融合术；SI，骶髂关节；SNRB，选择性神经根阻滞；TLIF，腰椎间孔椎间融合术
Sacroiliac Pain：Structural Causes of Pain Referring to the SI Joint Region
Background: The currently reported incidence of primary sacroiliac joint (SIj) pathology ranges from 15% to 30%. The differential diagnosis of SIj region pain includes pain generated from the lumbar spine, the SIj, and the hip joint. The origins of SIj dysfunctions are controversial and pain generation from this joint has been questioned.
Purpose: Retrospectively analyze the relative incidence of lumbar spine, SIj, and hip joint etiologies in patients complaining of ≥ 50% SIj region pain.
Study Design: This is a retrospective cohort case series.
Methods: Inclusion criteria: chief complaint SIj pain ( ≥ 50% of overall complaint). In total, 124 patients charts were reviewed from a single spine surgeon’s clinic. All patients were evaluated by the same 2 practitioners and all cases were reviewed for clinical examination findings, diagnostic tests performed, final diagnosis, treatment, and clinical follow-up.
Results: After complete diagnostic workup, 112 (90%) had lumbar spine pain, 5 (4%) had hip pain, 4 (3%) had primary SIj pain, and 3 (3%) had an undetermined source of pain upon initial diagnosis. SIj pain generation was confirmed via fluoroscopy-guided diagnostic injections. Following designated treatment, 11 (9%) patients returned to clinic at an average of 2.4 years complaining of continued/recurrent SIj region pain. Further investigation revealed 6 patients had confirmed pain generation from the lumbar spine, 3 patients had confirmed pain generation from the SIj, and 2 patients had undetermined sources of pain.
Conclusions: The SIj is a rare pain generator (3%–6%) in patients complaining of ≥ 50% SIj region pain and is a common site of referral pain from the lumbar spine (88%–90%). Clinicians ought to quantify areas of pain (via percent of overall complaint) when interviewing their patients complaining of low back pain to distinguish potential pain generators. Recommended breakdown of areas of interest include axial low back, SIj region, buttock/leg, groin/anterior thigh.
文献出处：Dephillipo N N , Corenman D S , Strauch E L , et al. Sacroiliac Pain[J]. Clinical Spine Surgery, 2018.
文献2
股骨内外旋转对髌股关节内软骨应力的影响
译者：肖凯
股骨的内旋及外旋会明显影响到髌股关节，包括髌股关节的方向、关节的接触面积、关节压力和软骨应力分布。本研究的目的是确定股骨内旋及外旋活动对髌股关节软骨应力的影响。我们采集了16位志愿者（8位男性和8位女性）的膝关节磁共振图像（MR）并构建了髌股关节的有限元模型。受试者在负重位下蹲（膝关节屈曲60度）情况下在开放式MR扫描仪内和步态分析实验室中进行检查。使用肌电图描记设备评估每个受试者的股四头肌肌肉力，并将数据输入到有限元分析中。在胫股关节处于中立位及股骨以5度为间隔分别内旋及外旋至15度位，分别模拟髌股关节软骨的静态压力和八个方向的剪切应力。与股骨内旋相比，软骨应力对股骨的外旋转更敏感，受试者之间差异较大。75%的受试者在股骨15度外旋下，髌骨关节的剪切应力峰值增加了10％以上。与股骨软骨相比，髌骨软骨的剪切应力更高，而且髌骨软骨应力对股骨旋转的敏感程度比股骨软骨更高。不同个体之间软骨应力反应的较大变化反映了伸肌机制的复杂，在考虑通过改变股骨内外旋转来减轻软骨应力的治疗策略时具有临床意义。
The influence of femoral internal and external rotation on cartilage stresses within the patellofemoral joint
Internal and external rotation of the femur plays an important role in defining the orientation of the patellofemoral joint, influencing contact areas, pressures, and cartilage stress distributions. The purpose of this study was to determine the influence of femoral internal and external rotation on stresses in the patellofemoral cartilage. We constructed finite element models of the patellofemoral joint using magnetic resonance (MR) images from 16 volunteers (8 male and 8 female). Subjects performed an upright weight-bearing squat with the knee at 60 degrees of flexion inside an open-MR scanner and in a gait laboratory. Quadriceps muscle forces were estimated for each subject using an electromyographic-driven model and input to a finite element analysis. Hydrostatic and octahedral shear stresses within the cartilage were modeled with the tibiofemoral joint in a 'neutral' position and also with the femur rotated internally or externally by 5 degrees increments to /-15 degrees . Cartilage stresses were more sensitive to external rotation of the femur, compared with internal rotation, with large variation across subjects. Peak patellar shear stresses increased more than 10% with 15 degrees of external rotation in 75% of the subjects. Shear stresses were higher in the patellar cartilage compared to the femoral cartilage and patellar cartilage stresses were more sensitive to femoral rotation compared with femoral cartilage stress. Large variation in the cartilage stress response between individuals reflects the complex nature of the extensor mechanism and has clinical relevance when considering treatment strategies designed to reduce cartilage stresses by altering femoral internal and external rotation.
文献出处：Besier TF, Gold GE, Delp SL, Fredericson M, Beaupré GS. The influence of femoral internal and external rotation on cartilage stresses within the patellofemoral joint. J Orthop Res. 2008 Dec;26(12):1627-35.
文献3
髋关节发育不良超声检查
译者：任宁涛
早期诊断发育性髋关节发育不良（DDH）对制定合适的治疗方案、减少并发症的发生具有重要意义。DDH的危险因素包括遗传、发育、机械和生理因素。早期可通过Ortolani和Barlow手法检查进行诊断，由于婴儿髋关节软骨成分在影像上显影欠佳，平片摄影术即使在应用几个典型的标志点、线和测量时，对DDH的诊断也是有限的。20世纪80年代早期，超声被用于评估髋关节软骨结构，其中Graf的超声检查方法强调形态学，而动态检查使用物理手法来诱发髋关节松弛或脱位。Pavlik支具是治疗婴幼儿DDH的主要方法，佩戴Pavlik支具时超声检查有助于监测病情的发展，对Pavlik支具治疗不佳或无效的病例可采用闭合复位或切开复位。尽管在欧洲非选择性筛查已被更广泛地应用，但大多数北美作者认为新生儿超声筛查并不具有成本效益。
图1 髋关节超声截面图
图2 髋关节超声对应的解剖关系，1：骨性边缘 2：软骨性边缘 3：盂唇 4：关节囊 5：滑膜
图3 α角和β角示意图
图4 超声检查对应的解剖结构，FH：股骨头，T：Y形软骨，IL：髂骨，IS：坐骨，G1：臀小肌，G2：臀中肌，G3：臀大肌。
图5 标准层面显示正常、半脱位和脱位。正常的髋关节在一个非常圆的髋臼内，成角锐利，半脱位时髋臼变的陡峭，股骨头部分外移，关节囊拉伸，盂唇部分反转，脱位时髋臼畸形，变浅，股骨头外移明显，盂唇反转到髋臼内，影响股骨头复位
图6 高脱位，可见盂唇反转到髋臼内，股骨头骨骺外移使关节囊牵拉增厚，臀肌受到牵拉
表1 髋关节超声筛查方案
Sonography of Hip Dysplasia
Early diagnosis of developmental dysplasia of the hip (DDH) is important to institute appropriate treatment and reduce the incidence of long-term complications. Risk factors for DDH include genetic, developmental, mechanical, and physiologic factors. Physical examination using Ortolani and Barlow maneuvers is standard for early detection. Plain film radiography is limited for the diagnosis of DDH even when applying several classic landmarks, lines, and measurements, due to the lack of visualization of the cartilaginous components of the infant's hip. Ultrasound arose as a tool for evaluation of the cartilaginous structures of the hip in the early 1980s. Graf's method of examination by ultrasound stresses morphology, whereas dynamic examination uses physical maneuvers to elicit laxity of the hip. The Pavlik harness is the mainstay of treatment of DDH in the young infant, and ultrasound examination in the harness is useful to monitor progress. Closed or open surgical reduction is reserved for unresponsive or advanced cases. Universal ultrasound screening of newborns is not deemed cost effective by most North American authors, although in Europe non-selective screening has been more widely used.
文献出处：Smergel E, Losik SB, Rosenberg HK. Sonography of Hip Dysplasia. Ultrasound Q. 2004 Dec;20(4):201-16.
文献4
利用有限元预测正常髋关节的软骨接触应力
译者：张利强
我们的目标是获得一组正常志愿者在行走、上下楼梯时的软骨接触应力，并评估受试者之间和不同负荷情况下接触应力和面积的变化。选择10名外侧中心边缘角和髋臼指数正常且无髋关节疼痛或疾病史的志愿者。在一侧髋关节行CT检查。用体积图像数据分割骨和软骨表面，并使用的可行的方案构建和分析对应髋关节的有限元模型。测定7种行走时相的髋臼接触应力和接触面积。最大应力为步行时的7.52±2.11mpa（233%bw）和下楼时的8.66±3.01mpa（261%bw）。所有活动的平均接触面积占髋臼软骨表面的34%。接触应力的分布高度不均匀，同一行走时相的受试者之间的差异性大于单个受试者之间的差异性。尽管随着载荷方向的改变接触模式也随之改变，但接触应力的大小和面积在不同的行走时相之间是一致的。股骨和髋臼软骨之间相对较小的不匹配对接触应力有很大影响。这些影响往往持续在所有模拟活动中。这些结果显示了健康髋关节在日常生活中软骨接触应力的多样性和变化趋势，为今后比较正常髋关节和病理髋关节提供了依据。
图1.有限元模型创建和模拟加载场景。（a）通过股骨近端中心的CT扫描，关节腔内注入造影剂以区分髋臼和股骨头软骨。分割线显示髋臼轮廓和股骨形态。（b）骨（灰白色）和软骨（蓝色）的三维重建。（c）髋臼模型的侧视图分别显示了代表骨和软骨的三角形和六面体单元（d–j）。模拟活动期间股骨和骨盆的方向
图2.步行、上楼梯和下楼梯时，每个受试者髋臼软骨上的接触应力。左侧是髋臼前方前方。受试者（列）之间的应力变化大于加载方式（行）之间的应力变化。
一个受试者接触应力的CT图像和模型图像，说明接触应力对骨骼形状的影响。位于髋臼顶部（箭头，上图）的小洞在建模之前（箭头，中图）和加载期间（箭头，下图）都有显示。图片显示在相应的接触位置有一个相对较低的接触应力区域。
Finite Element Prediction of Cartilage Contact Stresses in Normal Human Hips
Our objectives were to determine cartilage contact stress during walking, stair climbing, and descending stairs in a well-defined group of normal volunteers and to assess variations in contact stress and area among subjects and across loading scenarios. Ten volunteers without history of hip pain or disease with normal lateral center-edge angle and acetabular index were selected. Computed tomography imaging with contrast was performed on one hip. Bone and cartilage surfaces were segmented from volumetric image data, and subject-specific finite element models were constructed and analyzed using a validated protocol. Acetabular contact stress and area were determined for seven activities. Peak stress ranged from 7.52±2.11 MPa for heel-strike during walking (233% BW) to 8.66±3.01 MPa for heel-strike during descending stairs (261% BW). Average contact area across all activities was 34% of the surface area of the acetabular cartilage. The distribution of contact stress was highly non-uniform, and more variability occurred among subjects for a given activity than among activities for a single subject. The magnitude and area of contact stress were consistent between activities, although inter-activity shifts in contact pattern were found as the direction of loading changed. Relatively small incongruencies between the femoral and acetabular cartilage had a large effect on the contact stresses. These effects tended to persist across all simulated activities. These results demonstrate the diversity and trends in cartilage contact stress in healthy hips during activities of daily living and provide a basis for future comparisons between normal and pathologic hips.
文献出处：Michael D Harris, Andrew E Anderson, et al. Finite element prediction of cartilage contact stresses in normal human hips.J Orthop Res IF(2018):3.043 2012;30(7):1133-9 doi:10.1002/jor.22040
文献5
CT三维重建研究显示与健康髋关节相比，
股骨头骨骺滑脱具有较小的骨骺结节
和较大的外周覆盖
译者：陶可（北京大学人民医院骨关节科）
背景：股骨头骨骺的内表面对于生长板的稳定性很重要。然而，与股骨头骨骺滑脱（SCFE）的发病机制有关的骨骺形态异常仍知之甚少。这项研究比较了SCFE和正常髋关节髋骨的三维解剖学和髋臼周围的覆盖。
方法：我们利用计算机断层扫描（CT）成像技术对51例SCFE患者和80例因腹部疼痛而接受CT的无髋关节症状的受试者进行扫描，创建了股骨头骨骺的三维模型。测量骨骺结节以及周围的覆盖的高度、宽度和长度，并通过骨骺直径进行标准化，并以百分比表示。在调整了年龄和性别之后，我们使用方差分析比较了SCFE和对照组正常髋关节之间的测量结果。
结果：与正常髋关节相比，轻度SCFE髋关节的平均骨骺结节高度（0.9％±0.9％相比对照组的4.4％±0.4％；p = 0.006）和长度（32.3％±1.8％相比对照组的43.7％±0.8％；p<0.001）。与正常髋关节相比，中度髋关节（0.6％±0.9％；p = 0.004）和重度SCFE（0.3％±0.8％；p <0.001）的臀关节平均骨骺结节高度也较小。SCFE亚组之间的骨骺结节高度和长度的测量结果未见明显差异。总体上，与正常髋关节相比，轻度（16.3％±1.0％；p <0.001）、中度（16.4％±1.1％；p <0.001）和重度SCFE（18.9％±0.9％；p <0.001）的髋关节平均外周覆盖面积在所有区域进行单独评估均较大（10.6％±0.5％）。
结论：与健康髋关节相比，SCFE髋关节的骨骺结节较小、外周覆盖较大。较小的骨骺结节可能是易感的形态因素，也可能是继滑脱后的整体剪切应力增加的结果。周围生长的增加可能是对不稳定性的适应性反应，因为其他稳定剂（即骨骺结节和前骨膜）因滑脱进展而受到损害。还需要更多的研究以确定我们形态学发现的生物力学基础。
图1-A至1-D. 对股骨近端进行3-D分割和重建的过程。股骨头骨骺和股骨近端的其余部分被分割为2个独立的部分。图1-A在轴位图上进行了分割，然后根据需要进行了修改。图1-B在冠状位的分割。图1-C在矢状位的分割。然后，图1-D分段独立地将每个部位重建后的3-D模型。
图2-A，2-B和2-C. 显示了股骨骨骺的3-D模型。图2-A使用最合适的球体建立骨骺中心（黑色圆圈）。图2-B建立骨骺的上参考点（白色箭头所示的白色圆圈）作为股骨颈中平面与骨骺上的最上点的交点。图2-C定义在上点（白色圆圈）以骨骺局部坐标系作为参考。
图3-A至3-D. 显示了骨骺结节和骨骺覆盖的多平面测量。图3-A骨骺结节的高度和宽度的测量。图3-B骨骺结节高度和长度的测量。图3-C骨骺上下覆盖的测量。图3-D测量骨骺的前后覆盖。
图4. 正常髋关节和轻度、中度和重度SCFE髋关节的股骨头骨骺的典型3-D模型。骨骺结节用黑色箭头指示。
Smaller Epiphyseal Tubercle and Larger Peripheral Cupping in Slipped Capital Femoral Epiphysis Compared with Healthy Hips: A 3-Dimensional Computed Tomography Study
BACKGROUND: The inner surface of the capital femoral epiphysis is important for growth plate stability. However, abnormalities of epiphyseal morphology associated with the pathogenesis of slipped capital femoral epiphysis (SCFE) remain poorly understood. This study compares the 3-dimensional anatomy of the epiphyseal tubercle and peripheral cupping in hips with SCFE and normal hips.
METHODS: We created 3-dimensional models of the capital femoral epiphysis with use of computed tomography (CT) imaging from 51 patients with SCFE and 80 subjects without hip symptoms who underwent CT because of abdominal pain. The height, width, and length of the epiphyseal tubercle and the peripheral cupping were measured and normalized by the epiphyseal diameter and presented as a percentage. We used analysis of variance for the comparison of the measurements between SCFE and control hips after adjusting for age and sex.
RESULTS: Compared with normal hips, hips with mild SCFE had smaller mean epiphyseal tubercle height (0.9% ± 0.9% compared with 4.4% ± 0.4%; p = 0.006) and length (32.3% ± 1.8% compared with 43.7% ± 0.8%; p < 0.001). The mean epiphyseal tubercle height was also smaller in hips with moderate (0.6% ± 0.9%; p = 0.004) and severe SCFE (0.3% ± 0.8%; p < 0.001) compared with normal hips. No differences were observed for measurements of epiphyseal tubercle height and length between SCFE subgroups. The mean peripheral cupping was larger in hips with mild (16.3% ± 1.0%; p < 0.001), moderate (16.4% ± 1.1%; p < 0.001), and severe SCFE (18.9% ± 0.9%; p < 0.001) overall and when assessed individually in all regions compared with normal hips (10.6% ± 0.5%).
CONCLUSIONS: Hips with SCFE have a smaller epiphyseal tubercle and larger peripheral cupping compared with healthy hips. A smaller epiphyseal tubercle may be a predisposing morphologic factor or a consequence of the increased shearing stress across the physis secondary to the slip. Increased peripheral growth may be an adaptive response to instability as other stabilizers (i.e., epiphyseal tubercle and anterior periosteum) become compromised with slip progression. Future studies are necessary to determine the biomechanical basis of our morphologic findings.
文献出处：Novais EN, Maranho DA, Vairagade A, Kim YJ, Kiapour A. Smaller Epiphyseal Tubercle and Larger Peripheral Cupping in Slipped Capital Femoral Epiphysis Compared with Healthy Hips: A 3-Dimensional Computed Tomography Study. J Bone Joint Surg Am. 2019 Oct 9. doi: 10.2106/JBJS.19.00291.
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