本期目录：
第一部分：关节置换及保膝相关文献
文献1
弓形股骨预示着全膝置换翻修术后力线不良
译者：张轶超
在全膝置换（TKA）翻修术中，如果股骨干弓形较大，可能会导致下肢力线不良。本研究评估了277名接受TKA翻修术患者的冠状面曲度和髋膝角（HKA）。股骨弓平均内翻1.52° ± 0.18°(−10.1° 到 8.4°)。胫骨弓平均外翻1.25° ± 0.13°(−5.9°到 10°)。HKA术前平均内翻3.08° ± 0.35°，术后内翻0.86° ± 0.25°。观测者间和观测者内具有高的可信度。股骨弓超过4°与术后HKA力线不良显著相关(r = 0.402,P= 0.008)。39.7%的患者下肢HKA成角比中立机械轴高3°或更多，这些大多发生在股骨弓较大的患者中，呈显著相关性(0.94° ± 0.31°,P= 0.003)。在TKA翻修术中，股骨干的明显的弓形会对术后下肢力线产生明显的影响。
股骨和胫骨冠状站立位X片的测量方法。（A）股骨弓内翻-5.2°。（B）胫骨弓外翻 4.8°
同一肢体术前和术后的HKA角度测量。（A）术前站立位片显示HKA内翻-11.3°。（B）翻修术后显示矫正到-2.8°。
Femoral Bow Predicts Postoperative Malalignment in Revision Total Knee Arthroplasty
Diaphyseal bowing may compromise axial alignment in revision total knee arthroplasty (TKA). 277 patients undergoing revision TKA were evaluated for coronal bowing and hip-knee-ankle (HKA) axis. The mean femoral bow was 1.52 degrees /- 0.18 degrees varus ( - 10.1 degrees to 8.4 degrees). The mean tibial bow was 1.25 degrees /- 0.13 degrees valgus ( - 5.9 degrees to 10 degrees). HKA axis averaged 3.08 degrees /- 0.35 degrees varus preoperatively compared to 0.86 degrees /- 0.25 degrees varus postoperatively. Inter-rater and intra-rater reliability was high. Femoral bow greater than 4 degrees significantly correlated with postoperative HKA axis malalignment (r = 0.402, P = 0.008). 39.7% of patients deviated 3 degrees or greater from a neutral mechanical axis with a significant difference in femoral bow (0.94 degrees /- 0.31 degrees, P = 0.003). Diaphyseal bowing clearly has an important effect on postoperative limb alignment in revision TKA. (C) 2014 Elsevier Inc. All rights reserved.
文献出处：Sebastian A S , Wilke B K , Taunton M J , et al. Femoral Bow Predicts Postoperative Malalignment in Revision Total Knee Arthroplasty[J]. The Journal of Arthroplasty, 2014, 29(8):1605-1609.
文献2
一种减少后入路髋关节置换术后脱位的
肌/关节囊软组织(SMS)修复技术：
临床影像学研究
译者：马云青
背景：评价一种新的改良髋关节后入路软组织修复方法，以及其对全髋关节置换术后稳定性和功能的影响。
材料与方法：采用回顾性对比研究，比较采用传统后路手术的233髋(A组)和改良后入路的567髋(B组)的术后功能和脱位率。在该技术中，将2-3根斜拉缝合线缝合外旋肌，然后将跨过关节囊表面的关节囊肌，并与临近的臀小肌连接到梨状肌肌腱，短旋肌和部分股方肌一起形成一个肌关节囊袖。在植入假体后，将袖状软组织的上半部分(关节囊、梨状肌肌腱)缝合在大转子顶端的下部，肌关节囊袖的下部分与股骨粗隆外侧缝合。采用随机表，选择B组50例患者于术后1周和12周进行MRI检查，评价修复效果。
结果：随访3.9年，平均Harris髋关节评分A组为83.2分，B组为88.7分，B组仅1例脱位，脱位率为0.176%，A组为12例脱位，脱位率5.15%。MRI显示完整修复47例(94%)，B组纤维连续性2例(6%)。
结论：中期结果表明，该技术提高了关节稳定性，改善了术后功能。但是，需要更多的前瞻性和随机对照研究，并进行长期随访，以确认其在预防髋关节脱位方面的作用。
分离软关节囊肌肉组织袖
分两部分缝合软组织袖
缝合后效果
缝合后MRI显示完整的后关节囊
关节囊不完整可见关节液溢出
A novel single myocapsular sleeve (SMS) repair technique to reduce dislocation in posterior approach to the hip: A clinico-radiographic study
Background: To assess a new modification of posterior approach to the hip and its effect on stability and functional outcome in total hip arthroplasty.
Material & methods: A comparative retrospective study was done to assess the functional outcome and rate of dislocation among 233 hips (Group A) operated by conventional posterior approach and 567 hips (Group B) by our novel modified posterior approach. In this technique, 2-3 stay sutures are applied in external rotators, then a single conjoint-myocapsular sleeve is raised linearly over the capsule with adherent fibers of gluteus minimus to piriformis tendon, short rotators and part of quadratus for exposure of femoral head. After inserting the definite prosthesis, upper part of sleeve (capsule, piriformis tendon) is sutured at the lower part of tip of greater trochanter & lower part with lateral trochanteric bone. Fifty patients, using randomised tables, in group B underwent MRI to evaluate the efficacy of the repair at 1 and 12 weeks postoperatively.
Results: Average Harris hip score at minimum 3.9 year follow up was 83.2 in Group A & 88.7 in Group B. Group B had only one dislocation (0.176%) while Group A had 12 dislocations (5.15%). MRI showed intact repair in 47 patients (94%); fibrous continuity in 2 patients (6%) in group B patients.
Conclusion: Intermediate results shows that this technique provides enhanced stability and improved functional outcome. But more prospective and randomised controlled studies with long term followup are required to confirm its role in prevention of hip dislocations.
文献出处：Yadav CS, Mittal S, Singh S, Gamanagatti S, Anand S, Kumar A. A novel single myocapsular sleeve (SMS) repair technique to reduce dislocation in posterior approach to the hip: A clinico-radiographic study. J Clin Orthop Trauma. 2019 Oct;10(Suppl 1):S247-S251. doi: 10.1016/j.jcot.2019.03.014. Epub 2019 Mar 22.
文献3
全髋关节置换术中股骨偏心距及
外展力臂的作用
译者：张蔷
背景：为了获得运动机能良好的置换后髋关节（THA），很重要的一点是重建股骨偏心距以及相应的外展力臂。本篇文章的目的是评估经直接前入路微创全髋关节置换手术中增加外展力臂超过自身正常力臂后的效应。
方法：我们入组了148单侧全髋关节置换手术病例，并在平片上比较了术侧髋关节外展力臂与对侧髋关节外展力臂。患者根据力臂维持和力臂增加分为两组，评价指标包括髋关节骨关节炎评分（HOOS评分）、Harris髋关节评分和UCLA运动评分。
外展力臂定义为：髋关节旋转中心至髋关节外展肌发力方向的距离
结果：维持原有力臂组的患者临床评分并不优于力臂增加组的患者，而全髋关节置换术后1年内两组的临床评分在任意随访时间点均无显著性差异。
结论：本研究结果提示增加外展力臂并不会对THA术后临床效果产生大的影响，而为了避免缩小力臂带来的潜在负面效果，术者应尽量保持原有力臂或少量增加。
The role of femoral offset and abductor lever arm in total hip arthroplasty
Background: In order to create a well-functioning total hip arthroplasty (THA), it is important to restore femoral off-set and thus the abductor lever arm. The aim of this study was to investigate the clinical effect of increasing the abductor lever arm to and beyond the anatomical native lever arm in minimally invasive total hip arthroplasty performed through a direct anterior approach.
Materials and methods: We compared the lever arm of the operated hip to the lever arm of the contralateral native hip on radiographs in 148 patients following THA. The patients were divided in two groups based on whether they kept their anatomical lever arm or had an increased lever arm. The clinical outcome was assessed using hip osteoarthritis outcome score (HOOS), Harris hip score and UCLA activity score.
Results: Patients who kept their anatomical lever arm did not experience a significantly better clinical outcome than the patients with an increased abductor lever arm. We found no significant difference in clinical scores at any of the follow-ups during the first year after THA.
Conclusion: The results of this study suggest that an increase in the abductor lever arm does not have major effects on the clinical outcome after THA. To avoid the potential negative effects of decreasing the lever arm, the surgeon should aim for an equal or slightly increased lever arm.
文献出处：Bjørdal F, Bjørgul K. The role of femoral offset and abductor lever arm in total hip arthroplasty. J Orthop Traumatol. 2015 Dec;16(4):325-30. doi: 10.1007/s10195-015-0358-7. Epub 2015 Jun 12.
第二部分：保髋相关文献
文献1
成年患者髋部原发性化脓性关节炎
手术治疗2年后死亡率和感染复发率较高：
一项观察性研究
译者：罗殿中
成人髋关节原发性化脓性关节炎很少见，但可能造成髋关节毁灭性破坏。其最佳手术治疗方法和临床预后尚不清楚。在这项回顾性队列研究中，我们调查了髋关节化脓性关节炎患者手术后的死亡率和再感染率。我们回顾了2005年10月至2016年12月接受治疗的髋关节原发性化脓性关节炎的患者。共纳入51名成年患者，其中38例发现髋关节发生破坏性改变。术后结果的欠佳的定义是手术后2年内死亡或复发感染。手术后1年内有7例（13.7％）发生死亡，两年内5例（9.8％）髋关节复发感染。因此，在该研究队列中有22％（n = 11）患者判定为预后欠佳。在38例髋关节破坏性患者中，有7例（18.4％）在术后1年内死亡，而4例（10.5％）在2年内髋关节复发感染。合并除髋关节外的感染灶和肝硬化被认为是预后不良的危险因素。医生在治疗成人原发性髋关节化脓性关节炎时，需要知道手术治疗的失败率较高。此外，在与这些患者及其家属讨论外科治疗时，应告知其较高的死亡率。
A 51岁男性患者，左髋关节原发性化脓性关节炎，关节破坏明显；B 关节清创、抗生素骨水泥占位器治疗后；C 后期进行了人工髋关节置换术
High 2-year mortality and recurrent infection rates after surgical treatment for primary septic arthritis of the hip in adult patients: An observational study
Primary septic arthritis of the hip is rare and potentially devastating in adults. Its optimal surgical treatment and clinical outcomes remain unclear.In this retrospective cohort study, we investigated mortality and reinfection rates after surgery of patients with septic hip arthritis. We reviewed patients treated for primary septic hip joints from October 2005 to December 2016. A total of 51 adult patients were identified, and 38 among them had destructive hip joints. A poor postoperative outcome was defined as mortality or recurrent infection within 2 years of surgery.After surgery, 7 (13.7%) patients died within 1 year and 5 (9.8%) patients developed a recurrent hip infection within 2 years. Therefore, poor outcomes occurred in 22% (n = 11) of the study cohort. Among the 38 patients with a destructive hip joint, 7 (18.4%) died within 1 year after surgery and 4 (10.5%) developed a recurrent hip infection within 2 years of surgery. Correlative infections other than infected hip joint and liver cirrhosis were identified as risk factors for poor outcomes.In conclusion, clinical physicians treating adult primary septic hip joints should be cognizant of the high failure rate of surgical treatment. In addition, the high mortality rate should be considered during the discussion of surgical treatment with these patients and their families.
文献出处：Kao FC, Hsu YC, Liu PH, Tu YK, Jou IM. High 2-year mortality and recurrent infection rates after surgical treatment for primary septic arthritis of the hip in adult patients: An observational study. Medicine (Baltimore). 2019 Aug;98(32):e16765. doi: 10.1097/MD.0000000000016765.
文献2
CT导航辅助下股骨近端截骨术的误差
译者：程徽
目的：本研究的目的是了解在基于计算机断层扫描(CT)导航系统辅助下进行股骨近端截骨术时候，截骨与术前计划的误差。
方法：4例患者(4髋)采用了转子间旋转截骨术(TRO)， 3例患者(4髋)采用了CT导航辅助下的内翻截骨术(CVO)。术前和术后进行容积登记以评估误差。
结果：对于TRO，内外翻方向的平均截骨角度误差为1.1∘(范围0°−3.1°)和前后倾方向角度误差为1.8°(范围0°−4.3°)向后弯曲的方向。而股骨头侧为正，截骨的平均位置误差为- 0.4 mm(范围为- 1.4 - 0 mm)。股骨头颈骨块的旋转运动误差是2.5°(范围0°−10°)。在CVO中，以股骨头侧为正的截骨平均位置误差，小转子部位为- 0.2 mm(范围为- 2.0至1.7 mm)，大转子部位为- 0.8 mm(范围为0-3.2 mm)。骨头碎片内翻误差为2.3°(范围0°−5°)。
结论：在股骨近端截骨术使用基于CT的导航进行截骨，角度误差在5°以内，位置误差在4mm以内。股骨头颈部的旋转运动误差在10°以内。在术前计划时应考虑这些误差范围。为了提高手术的准确性，有必要开发一种计算机辅助设备来跟踪截骨块。
Error range in proximal femoral osteotomy using computer tomography-based navigation
Purpose: The purpose of this preliminary study was to determine the error range compared with preoperative plans in proximal femoral osteotomy conducted using a computed tomography (CT)-based navigation system.
Methods: Four patients (four hips) underwent transtrochanteric rotational osteotomy (TRO), and three patients (four hips) underwent curved varus osteotomy (CVO) using CT-based navigation. Volume registration of pre- and postoperative CT was performed for error assessment.
Results: In TRO, the mean osteotomy angle error was 1.1∘ (range 0∘−3.1∘ ) in the valgus direction and 1.8∘ (range 0∘−4.3∘ ) in the retroversion direction. The mean osteotomy position error, with the femoral head side as positive, was −0.4 mm (range −1.4 to 0 mm). The bone fragment rotational movement error was 2.5∘ (range 0∘−10∘ ). In CVO, the mean osteotomy position error, with the femoral head side as positive, was −0.2 mm (range −2.0 to 1.7 mm) at the level of the lesser trochanter and 0.8 mm (range 0–3.2 mm) at the level of the greater trochanter. Bone fragment varus accuracy was 2.3∘ (range 0∘−5∘ ).
Conclusions: In proximal femoral osteotomy using CT-based navigation, the angle error of osteotomy was within 5∘ and the positional error was within 4 mm. The rotational movement error of the proximal fragment was within 10∘ . These margins of error should be considered in preoperative planning. To improve surgical accuracy, it would be necessary to develop a computer-assisted device which can track the osteotomized fragment.
文献出处：Takao M, Sakai T, Hamada H, Sugano N. Error range in proximal femoral osteotomy using computer tomography-based navigation. Int J Comput Assist Radiol Surg. 2017 Dec;12(12):2087-2096. doi: 10.1007/s11548-017-1577-6. Epub 2017 Apr 1.
文献3
髋关节不稳：髋关节发育不良
和其他影响因素的综述
译者：肖凯
背景：髋关节不稳定通常与新生儿和儿童的髋关节发育不良（DDH）有关。但是，许多因素可能与儿童、青少年和成人的髋关节不稳定有关。
目的：本文通过对所有年龄段患者髋关节不稳的文献进行简明扼要回顾分析，进而帮助医疗保健人员正确诊断和治疗可能导致髋关节不稳定的各种疾病。
方法：我们对涉及了髋关节发育不良和其他髋关节不稳定诊断和外科治疗的文献进行了回顾分析。
结论：多个关节内和关节外因素可能导致髋关节不稳定，包括髋臼骨性覆盖、股骨扭转角、股骨髋臼撞击和软组织松弛。体格检查和进一步的影像学检查分析对于准确诊断导致患者髋关节不稳定至关重要。包括活动习惯调整和物理治疗的保守治疗可用于关节内病变导致关节不问的一线治疗。对于持续出现髋关节疼痛或不稳定的患者，应进行髋关节镜手术或开放手术治疗，以处理潜在的关节病变。
a 右髋关节严重发育不良，股骨头向外上方移位，Shenton’s线中断；b 右髋临界发育不良，髋关节前覆盖降低，外侧CE角尚可，蓝色区域为髋臼前覆盖；c 右髋关节严重发育不良，外侧覆盖及厚覆盖不足，红色区域为髋臼后覆盖，股骨头中心位于后覆盖外
a CT三维重建显示股骨颈前倾角增大，导致股骨头前方功能性覆盖不足；b 右髋关节发育不良合并颈干角显著增大；c、d、e、f 微创髓内截骨进行股骨去旋转截骨术及预后
a 髋臼周围截骨术髋臼旋转方向，术后可恢复髋关节正常应力方向；b 伯明翰多边形骨盆截骨示意图，通过多边形的锁定机制增加术后稳定性，患者可以术后即刻全负重，减少肌肉萎缩；c、d、e 右髋关节临界发育不良，外侧覆盖及后覆盖相对不足，髋臼周围截骨术后，髋关节覆盖改善
Hip instability: a review of hip dysplasia and other contributing factors
BACKGROUND: Hip instability has classically been associated with developmental dysplasia of the hip (DDH) in newborns and children. However, numerous factors may contribute to hip instability in children, adolescents, and adults.
PURPOSE: This review aims to concisely present the literature on hip instability in patients of all ages in order to guide health care professionals in the appropriate diagnosis and treatment of the various disorders which may contribute to an unstable hip.
METHODS: We reviewed the literature on the diagnosis and surgical management of hip dysplasia and other causes of hip instability.
CONCLUSIONS: Multiple intra- and extra-articular variables may contribute to hip instability, including acetabular bony coverage, femoral torsion, femoroacetabular impingement, and soft tissue laxity. Physical examination and advanced imaging studies are essential to accurately diagnose the pathology contributing to a patient's unstable hip. Conservative management, including activity modification and physical therapy, may be used as a first-line treatment in patients with intra-articular hip pathology. Patients who continue to experience symptoms of pain or instability should proceed with arthroscopic or open surgical treatment aimed at correcting the underlying pathology.
文献出处：Kraeutler MJ, Garabekyan T, Pascual-Garrido C, Mei-Dan O. Hip instability: a review of hip dysplasia and other contributing factors. Muscles Ligaments Tendons J. 2016 Dec 21;6(3):343-353. doi: 10.11138/mltj/2016.6.3.343. eCollection 2016 Jul-Sep.
文献4
Chiari骨盆内移截骨治疗髋关节发育不良
伴头臼匹配差的临床效果：长期随访
译者：任宁涛
关于Chiari骨盆内移截骨治疗髋关节发育不良伴OA（前期至晚期）的中长期随访（平均20.3年，10-32.5年）结果的研究，纳入163名日本患者（173髋），平均手术年龄为20岁（9-54岁），其中124个髋关节（72%）治疗效果满意，Harris评分≥ 80。治疗效果满意的124个髋关节包括134个早期OA髋关节中的105个髋关节（78%）和39个晚期OA髋关节中的19个髋关节（49%）。共15个髋关节（9%）接受THR，截骨术与THR的平均间隔为16.4年。THR为终点事件，30年的髋关节生存率85.9%（95%CI 82.3-89.5），其中OA前期或早期的患者髋关节生存率为91.8%，OA晚期的患者髋关节生存率为43.6%（p<0.001）。对于髋关节发育不良伴头臼匹配差的患者而言更愿意选择保髋而不是THR。
图1 Chiari骨盆内移截骨不同年龄患者分布
图2 30岁，男性，左侧髋关节早期OA（a），Chiari骨盆内移截骨术后3周（b），术后21年，髋臼塑形好，关节间隙存在，Harris评分89
图3 Kaplan-Meier生存曲线，前期或早期OA，晚期OA行Chiari骨盆内移截骨治疗，THR为终点事件
表1 Chiari骨盆内移截骨术后保髋率的研究
The Chiari pelvic osteotomy for patients with dysplastic hips and poor joint congruency: long-term follow-up
We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001). We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.
文献出处：Ito H, Tanino H, Yamanaka Y, Nakamura T, Minami A, Matsuno T. The Chiari pelvic osteotomy for patients with dysplastic hips and poor joint congruency: long-term follow-up. J Bone Joint Surg Br. 2011 Jun;93(6):726-31. doi: 10.1302/0301-620X.93B6.26178.
文献5
临界到轻度发育不良的髋关节与骨关节炎
之间有关联吗？CT骨吸收测定分析
译者：张利强
背景：对临界到轻度发育不良的髋关节的治疗仍有争议。对骨关节炎（OA）的病因有更全面的了解，并阐明临界到轻度发育不良的髋关节与OA发病机制之间的任何可能联系是极其重要的。
问题/目的：（1）髋臼软骨下骨密度的分布是否随发育不良的严重程度而增加？（2）临界到轻度发育不良的髋关节与OA的发病机制有联系吗？
方法：对接受偏心髋臼旋转截骨术（ERAO）的发育性髋关节发育不良患者的双侧髋关节进行评估，并将其纳入发育不良组，对对侧髋关节行股骨粗隆间弧形内翻截骨术（CVO）的单侧特发性股骨头坏死（ONFH）患者的髋关节进行评估，并将其纳对照组。在2013年1月至2016年8月期间，我们医院对46名患者进行了ERAO，对32名患者进行了CVO。所有患者均行双侧髋关节CT检查。研究包括55髋，按发育不良严重程度分类：（1）临界-轻度，19髋（15°<外侧中心边缘角[LCEA]<25°）；（2）中度，20髋（5°<LCEA<15°）；（3）重度，16髋（LCEA<5°）；（4）对照组，15髋。排除37个发育不良髋关节（年龄<15岁或>50岁，既往行同侧髋关节手术，半脱位，非球形股骨头，凸轮畸形，X线示骨关节炎）和17个对照髋关节（年龄<15岁或>50岁，双侧ONFH，LCEA<25°或≥35°，凸轮畸形，X线示骨关节炎）。CT骨吸收仪（OAM）通过评估软骨下骨密度来预测关节的生理生物力学状态。我们用CT-OAM评估了髋臼软骨下骨密度的分布，将应力分布图分为六个部分：前内侧、前外侧、中央内侧、中央外侧、后内侧和后外侧。我们计算了高密度区域的百分比，定义为每个区域的Hounsfield单位值上升30%，并比较四组间随机截距模型估计的最小二乘均值差。
结果：在所有区域，临界-轻度组与对照组之间的高密度区百分比无差异（如前外侧16.2±5.6[95%CI，13.4～18.9]与15.5±5.7[95%CI，12.4～18.5，p=0.984]；中央外侧39.1±5.7[95%CI，36.4～41.8]与39.5±4.7[95%CI，36.6～42.5，p=0.995]；后外侧，10.9±5.2[95%可信区间，8.0~13.8]与15.1±6.8[95%可信区间，11.7~18.5，p=0.389]）。在前外侧区，临界-轻度组的高密度区百分比小于中度组（16.2±5.6[95%CI，13.4-18.9]对28.2±5.1[95%CI，25.5-30.9]，p<0.001）和重度组（16.2±5.6[95%CI，13.4-18.9]对22.2±6.8[95%CI，19.2-25.2，p=0.026）。
结论：与重度髋关节发育不良不同，临界-轻度髋关节发育不良的累积应力分布不集中在髋臼外侧。
临床相关性：根据应力分布模式，我们的结果可能提示OA的发病机制与临界-轻度髋关节发育不良之间没有关联。进一步的研究需要评估临界-轻度髋关节发育不良和髋关节不稳定之间的关系。
（A）图像显示了我们如何建立AP（前-后）测量范围。（B）图像显示了我们如何确定负重面的宽度。（C）图显示使用CT-OAM方法描述并用九级色度显示的髋臼表面映射图像。*线为髂前上棘至耻骨结节的线；† 线为股骨头前缘切线与其后距离5mm的平行线；‡线为股骨头后缘切线与其前距离5mm平行线；‖髋臼软骨下骨外侧缘；§髋臼软骨下骨内侧缘与卵圆窝交界
（A）图显示了用于定量分析的髋臼的骨密度片段。‖髋臼软骨下骨外侧缘，§髋臼软骨下骨内侧缘与卵圆窝交界。（B）图像显示髋臼的最大骨密度数据。Ant-med=前内侧区；Ant-lat=前外侧区；Cent-med=中央内侧区；Cent-lat=中央外侧区；Post-med=后内侧区；Post-lat=后外侧区。
(A)图显示不同程度的髋关节发育不良和对照组的骨盆前后位平片；(B)图显示通过CT-OAM分析描述的髋臼表面的骨密度分布图
Is There an Association Between Borderline-to-mild Dysplasia and Hip Osteoarthritis? Analysis of CT Osteoabsorptiometry
Background: The definitive treatment of borderline-to-mild dysplasia remains controversial. A more comprehensive understanding of the etiology of osteoarthritis (OA) and clarification of any possible association between borderline-to-mild dysplasia and the pathogenesis of OA are essential.
Questions/purposes: (1) Does the distribution of acetabular subchondral bone density increase according to dysplasia severity? (2) Is there an association between borderline-to-mild dysplasia and OA pathogenesis?
Methods: We evaluated bilateral hips of patients with developmental dysplasia of the hip who underwent eccentric rotational acetabular osteotomy (ERAO) for inclusion in the dysplasia group and contralateral hips of patients with unilateral idiopathic osteonecrosis of the femoral head (ONFH) who underwent curved intertrochanteric varus osteotomy (CVO) for the control group. ERAO was performed in 46 patients and CVO was performed in 32 patients between January 2013 and August 2016 at our institution. All patients underwent bilateral hip CT. The study included 55 hips categorized according to dysplasia severity: (1) borderline-mild, 19 hips (15° ≤ lateral center- edge angle [LCEA] < 25°); (2) moderate, 20 hips (5° ≤ LCEA < 15°); (3) severe, 16 hips (LCEA < 5°); and (4) control, 15 hips. Thirty-seven dysplastic hips (age < 15 or > 50 years old, prior hip surgery, subluxation, aspherical femoral head, cam deformity, and radiographic OA) and 17 control hips (age < 15 or > 50 years old, bilateral ONFH, LCEA < 25° or ≥ 35°, cam deformity, and radiographic OA) were excluded. CT-osteoabsorptiometry (OAM) predicts physiologic biomechanical conditions in joints by evaluating subchondral bone density. We evaluated the distribution of subchondral bone densities in the acetabulum with CT-OAM, dividing the stress distribution map into six segments: anteromedial, anterolateral, centromedial, centrolateral, posteromedial, and posterolateral. We calculated the percentage of high-density area, which was defined as the upper 30% of Hounsfield units values in each region and compared least square means difference estimated by the random intercept model among the four groups.
Results: In all regions, the percentage of high-density area did not differ between the borderline-mild group and the control (eg, anterolateral, 16.2 ± 5.6 [95% CI, 13.4 to 18.9] versus 15.5 ± 5.7 [95% CI, 12.4 to 18.5, p = 0.984]; centrolateral, 39.1 ± 5.7 [95% CI, 36.4 to 41.8] versus 39.5 ± 4.7 [95% CI, 36.6 to 42.5, p = 0.995]; posterolateral, 10.9 ± 5.2 [95% CI, 8.0 to 13.8] versus 15.1 ± 6.8 [95% CI, 11.7 to 18.5, p = 0.389]). In the anterolateral region, a smaller percentage of high-density area was observed in the borderline-mild group than in both the moderate group (16.2 ± 5.6 [95% CI, 13.4-18.9] versus 28.2±5.1 [95% CI, 25.5-30.9], p < 0.001) and the severe group (16.2 ± 5.6 [95% CI, 13.4-18.9] versus 22.2 ± 6.8 [95% CI, 19.2-25.2, p = 0.026).
Conclusions: Our results suggest that the cumulative hip stress distribution in borderline-to-mild dysplasia was not concentrated on the lateral side of the acetabulum, unlike severe dysplasia.
Clinical Relevance: Based on the stress distribution pattern, our results may suggest that there is no association between borderline-to-mild dysplasia and the pathogenesis of OA. Further studies are needed to evaluate the association between borderline-to-mild dysplasia and instability of the hip.
文献出处：Irie T , Takahashi D , Asano T , et al. Is There an Association Between Borderline-to-mild Dysplasia and Hip Osteoarthritis? Analysis of CT Osteoabsorptiometry[J]. Clinical Orthopaedics and Related Research, 2018:1.
文献6
髋关节撞击综合征（FAI）：
外科医生想知道的知识
译者：陶可（北京大学人民医院骨关节科）
髋关节撞击综合征（FAI）被越来越多地认为是年轻活跃患者早期髋关节病变的危险因素。诊断取决于临床检查和适当的影像学检查，这些检查应能够发现异常情况，有时还可以观察到细微的髋关节形态变化。没有潜在的骨骼异常，很少发生唇裂和软骨损伤。即使在对FAI形态学的标准影像学诊断没有明确定义的共识下，治疗FAI的手术方法在世界范围内也已显着增加。髋部异常包括髋臼侧和股骨头颈侧的形状、大小和空间方向相关的多种异常。没有足够的影像学研究可能难以确证。本文介绍了骨外科医生需要了解的放射科知识，以计划最合理的方案来治疗由机械异常引起的髋关节疼痛。
图1 （a）垂直于股骨颈轴的磁共振径向平面标出了两个径向平面的位置。（b）2点钟位置的径向平面显示出凸轮变形，α角为70度。（c）在4点钟位置的径向平面，我们可以描绘出由于颈部撞击髋臼缘而导致的骨质凸出反应（箭头），α角为50度。（d）同一患者的术中关节镜图像，显示头颈部交界处的骨并置。a，前方；s，上方。
图2 股骨头的术中图片，显示了股骨头后上方（12点至10点）的凸轮畸形（黄色箭头）与股骨头支持血管区域（虚线）重叠。两个小箭头指向支持血管滑膜褶皱的前边界。Fh，股骨头；Fn，股骨颈；p，近端；R，支持血管的延伸。
图3 （a）显示出一条贯穿股骨头的支持血管（箭头）的径向磁共振图像。（b）在后上象限中，在轴位相可见的同一血管（箭头），垂直于股骨颈。
图4 根据Nötzli等人的定义，α角（α）是在股骨头中心的两条线的交点：一条线与股骨颈中心轴重合，而另一条线在该点与股骨头不再是球形时的外周相交线。正常值被认为小于50度。该图示出了70度的病理α角。
图5 Ω角定义为凸轮变形的径向延伸。它包含了所有α角均在正常值以上的径向平面。在图中，红色结构代表支持动脉。a，前方；s，上方。
图6 （a）两条穿越股骨头中心的线形成了横向中心边缘（LCE）角，一条线垂直于骨盆的横向平面，另一条线穿过髋臼外侧缘。正常值25度到40度。根据Wiberg的说法，大于40度定义为髋臼过度覆盖，小于25度的发育不良。（b）髋臼指数（AI）角由骨盆横断面中的一条线和一条连接髋臼顶硬化带内侧端和髋臼顶外侧缘的线形成。正常值从0到10度不等。根据Tönnis的规定，大于10度的值表明髋臼发育不良。负值是髋臼过度覆盖和髋臼突出的典型表现。（c）髋臼前壁和后壁的投影图。为了计算髋臼壁指数，绘制了与股骨头轮廓最合适的圆。确定股骨头的半径（r），并测量沿股骨颈轴线从圆圈的内侧边缘到前壁（aw）和后壁（pw）的距离。前壁指数（awi）和后壁指数（pwi）分别计算为aw/r和pw/r。根据Siebenrock等人的研究，正常髋关节的数值约为awi= 0.41（0.30–0.51）和pwi= 0.91（0.81–1.14）。
图7 一名20岁女性的骨盆后位X线片显示髋臼逆行的经典征象。前壁线与后壁线（虚线）交叉形成八字形或交叉符号（co）；后壁位于股骨头旋转中心的内侧，从而产生后壁征象（pw）；坐骨脊伸入骨盆，形成坐骨脊征(is)。垂直虚线（isl）代表髂坐线。
图8 一名22岁男性患者的骨盆X线片显示右髋关节髋臼后倾。（a）在手术之前，我们可以识别交叉标志，后壁标志和坐骨脊标志。（b）髋臼周围截骨手术后，交叉征象和后壁征象消失了。
图9 一名27岁女性患者的骨盆X线照片显示髋臼过度覆盖。（a）手术前我们可以确定外侧中心边缘角（LCE）增大，AI角为负，髋臼窝的位置高于正常位置（1）以及前壁（aw）和后壁（pw）指数增加。（b）髋臼周围截骨术联合髋关节外科脱位，髋臼缘修剪和股骨颈相对延长后，髋臼覆盖角（LCE）减小，髋臼窝的外侧界限相对内移。后壁仍位于旋转中心外侧，因为月状面尺寸相对较小阻碍对后壁进行过多的边缘修整。
图10 （a）一名25岁男性MRI径向平面1点钟位置显示股骨头颈cam型畸形，软骨严重脱离软骨下骨和软骨盂唇撕裂。以下是同一病例的术中情况，其中软骨表现为严重的纤维形成并完全脱离了盂唇结合的软骨下骨。（b）一名40岁的女性在夹钳撞击时的2点MRI径向平面。影像学检查显示发育不良的盂唇，较小的相邻软骨信号改变而无软骨盂唇分离。下面，同一病例的术中表现为发育不良的盂唇和较不严重的软骨损伤。C，软骨；FH，股骨头；L，盂唇。
Femoroacetabular Impingement: What the Surgeon Wants to Know
Femoroacetabular impingement (FAI) is increasingly recognized as a risk factor for early hip degeneration in young active patients. The diagnosis depends on clinical examination and proper imaging that should be able to identify abnormal and sometimes subtle morphological changes. Labral tears and cartilage lesions rarely occur without underlying bone abnormalities. Surgical approaches to treat FAI are increasing significantly worldwide, even without a clearly defined consensus of what should be accepted as the standard imaging diagnosis for FAI morphology.Hip abnormalities encompass many variations related to the shape, size, and spatial orientation of both sides of the joint and can be difficult to characterize if adequate imaging is not available.This article presents a comprehensive review about the information orthopaedic surgeons need to know from radiologists to plan the most rational approach to a painful hip resulting from a mechanical abnormality.
文献出处：Paulo Rego, Paul E Beaulé, Olufemi R Ayeni, Marc Tey, Oliver Marin-Peña, Pedro Dantas, Geoffrey Wilkin, George Grammatopoulos, Inês Mafra, Kevin Smit, Adrian Z Kurz. Femoroacetabular Impingement: What the Surgeon Wants to Know. Semin Musculoskelet Radiol, 2019, 23(3), 257-275.
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