本期目录：
2、两例先天性无痛无汗症导致的夏柯关节病患者接受人工全髋关节置换术的临床预后
3、应用大直径球头和现代聚乙烯内衬行单纯股骨头和内衬更换在全髋关节翻修术中的疗效
4、自内侧单间室单髁置换翻修为全膝关节置换的翻修风险：基于丹麦膝关节登记中心中期结果，并与初次膝和膝翻修相比较
5、伯尔尼髋臼周围截骨术治疗髋臼发育不良，哪些因素影响术中透视辐射量？
6、髂前下棘撕脱骨折导致的畸形引发年轻运动员关节外撞击：病例报道
7、脑瘫患者髋关节重建术成功恢复头臼匹配的远期疗效
8、髋臼发育不良患者髋臼周围截骨术后患者特异性的软骨盂唇接触力学
9、基于年龄、性别和牛津骨年龄的髋关节发育中的股骨头骨骺延长的标准值
第一部分：关节置换及保膝相关文献
文献1
机器人辅助下单髁置换术的系统性回顾：
应该关注假体设计及类型
译者：张轶超
目的：机器人辅助下的单髁置换术（UKA）可以精准的安放假体，可能会提高生存率及功能效果。本文的目的是给大家提供近期关于机器人辅助UKA的情况并依据假体位置，活动范围（ROM），功能和生存率及假体和机器人的类型来观察其效果。
材料和方法：2018年10月根据系统回顾优先报告项目和Meta分析报表的要求搜索Pubmed和Medline。搜索词包括“robotic”，“knee”和“surgery”。入选标准是任何讲述机器人UKA并报告观察了假体位置，ROM，功能和临床生存率，尸体上操作或干骨上操作的文献。
结果：从数据库及参考列表中选择出528篇文章。经全文筛选，有38篇符合入选标准。其中，有20篇描述了假体的位置，18篇涉及了功能效果，16片涉及了生存率，6片描述了ROM。32篇(84%)中使用的是Mako机器人(Stryker, Mahwah, New Jersey)，3篇(8%)有的是Bluebelt Navio机器人(Blue Belt Technologies, Plymouth, Minnesota)，2篇(5%)用SculptorRGA (Stanmore Implants, Borehamwood United Kingdom)，1篇(3%)用的Acrobot(The Acrobot Co. Ltd., London, United Kingdom)。大多使用Restoris MCK (史赛克)假体。9篇(24%)没有说明用的什么假体。术后6年时的累积生存率为96%。但是，在术后6年时，全嵌入胫骨假体（全聚乙烯平台）的生存率为89%，分体式胫骨假体（带金属背托的）的生存率为97% (优势比 3.66, 95% 置信区间 20.7到 6.46, p < 0.001)。
结论：在机器人辅助UKA的文献中，一谈到影响生存率的问题就很少有描述假体选择的。机器人辅助UKA比人工安放假体的位置更精确并且重复性更好，位置更精确可能会有更好的功能效果，但是否会改善中期到长期的生存率尚需进一步观察。
A systematic review of robotic-assisted unicompartmental knee arthroplasty: prosthesis design and type should be reported
AIMS: Robotic-assisted unicompartmental knee arthroplasty (UKA) promises accurate implant placement with the potential of improved survival and functional outcomes. The aim of this study was to present the current evidence for robotic-assisted UKA and describe the outcome in terms of implant positioning, range of movement (ROM), function and survival, and the types of robot and implants that are currently used.
MATERIALS AND METHODS: A search of PubMed and Medline was performed in October 2018 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Search terms included 'robotic', 'knee', and 'surgery'. The criteria for inclusion was any study describing the use of robotic UKA and reporting implant positioning, ROM, function, and survival for clinical, cadaveric, or dry bone studies.
RESULTS: A total of 528 articles were initially identified from the databases and reference lists. Following full text screening, 38 studies that satisfied the inclusion criteria were included. In all, 20 studies reported on implant positioning, 18 on functional outcomes, 16 on survivorship, and six on ROM. The Mako (Stryker, Mahwah, New Jersey) robot was used in 32 studies (84%), the BlueBelt Navio (Blue Belt Technologies, Plymouth, Minnesota) in three (8%), the Sculptor RGA (Stanmore Implants, Borehamwood United Kingdom) in two (5%), and the Acrobot (The Acrobot Co. Ltd., London, United Kingdom) in one study (3%). The most commonly used implant was the Restoris MCK (Stryker). Nine studies (24%) did not report the implant that was used. The pooled survivorship at six years follow-up was 96%. However, when assessing survival according to implant design, survivorship of an inlay (all-polyethylene) tibial implant was 89%, whereas that of an onlay (metal-backed) implant was 97% at six years (odds ratio 3.66, 95% confidence interval 20.7 to 6.46, p < 0.001).
CONCLUSION: There is little description of the choice of implant when reporting robotic-assisted UKA, which is essential when assessing survivorship, in the literature. Implant positioning with robotic-assisted UKA is more accurate and more reproducible than that performed manually and may offer better functional outcomes, but whether this translates into improved implant survival in the mid- to longer-term remains to be seen.
文献出处：Robinson PG, Clement ND, Hamilton D, Blyth MJG, Haddad FS, Patton JT. A systematic review of robotic-assisted unicompartmental knee arthroplasty: prosthesis design and type should be reported. Bone Joint J. 2019 Jul;101-B(7):838-847. doi: 10.1302/0301-620X.101B7.BJJ-2018-1317.R1.
文献2
两例先天性无痛无汗症导致的夏柯关节病患者
接受人工全髋关节置换术的临床预后
译者：罗殿中
传统经验认为夏柯关节病是人工全髋关节置换术（THA）的绝对禁忌症。但是一些近期的文献报道通过提升假体安置的稳定性可以获得满意的短期及中期预后。本研究报道了两例先天性无痛无汗症导致的夏柯关节病患者接受THA后的中期及长期临床预后。两名患者术后6个月内均经历了多次髋关节后脱位。然而，经过持续应用无弹性髋外展支具，一名患者最终可以拄手杖行走，另一名患者可以拄单拐行走。尽管一名患者术后5年再次出现关节脱位，但术后5年及9年的髋关节X线片均未发现假体松动的迹象。我们认为，通过细致的术前计划及应用适当的假体，THA可用于治疗先天性无痛无汗症导致的夏柯关节病。
一名夏柯关节病患者术前片可见右髋关节明显的夏柯关节病改变
术后即刻（左）及术后9年的X线片，无假体松动迹象
Clinical Results of Total Hip Arthroplasty in Two Patients with Charcot Hip Joints due to Congenital Insensivity to Pain with Anhydrosis
Traditionally, Charcot arthropathy has been considered an absolute contraindication for total hip arthroplasty (THA). However, some recent reports have shown that good short- to mid-term results can be achieved by improving the durability of the implant. This paper reports the mid- to long-term results of THA in two patients with Charcot hip joints caused by congenital insensivity to pain with anhydrosis. Both patients suffered multiple posterior dislocations in the six months immediately following surgery. However, with the continuous use of a hard abduction brace, one patient was eventually able to walk with a lofstrand cane and the other with the use of one crutch. Although one patient experienced a dislocation five years after surgery, X-rays taken after nine years and five years, respectively, revealed no clinical signs of implant loosening. We conclude that, with careful planning and appropriate precautions, THA may be a viable treatment option for Charcot hip joints caused by congenital insensivity to pain with anhydrosis.
文献出处：Inoue D, Kabata T, Kajino Y, Taga T, Yamamoto T, Takagi T, Ohmori T, Tsuchiya H. Clinical Results of Total Hip Arthroplasty in Two Patients with Charcot Hip Joints due to Congenital Insensivity to Pain with Anhydrosis. Case Rep Orthop. 2018 Jan 31;2018:1743068. doi: 10.1155/2018/1743068. eCollection 2018.
文献3
应用大直径球头和现代聚乙烯内衬行单纯股骨头
和内衬更换在全髋关节翻修术中的疗效
译者：马云青
背景：既往关于髋关节翻修术中单纯股骨头和内衬更换的报告发现术后关节不稳定的发生率很高。大多数的研究报告中应用的是小于或等于28mm的股骨头。本研究的目的是确定使用现代的手术技术和较大直径球头是否能改善单纯更换股骨头和内衬的翻修术后的关节不稳定发生率。
方法：我们研究了132例患者中的138个髋关节，患者因为聚乙烯磨损/骨溶解（57%）、急性感染（27%）、金属溶解（13%）或其他（2%）原因接受的股骨头和内衬更换翻修术。所有患者均接受32mm（23%）、36mm（62%）或40（15%）mm直径股骨头的翻修。所有翻修均更换交联聚乙烯。104例（75%）髋关节使用了带高边和/或高偏心距的内衬。平均随访时间为3.5（1.0-9.1）年。P<.05为有显著性统计学差异。
结果：术后5年以翻修为终点的假体生存率为94.6%，非感染率为98.2%。11例（8%）髋关节出现并发症，7例（5%）髋关节需要再次翻修。初次翻修后4例（3%）髋关节发生脱位，5例（4%）髋关节发生感染，1例（1%）髋关节翻修是由不愈合导致的。无手术因素显著影响结局。
结论：我们的研究表明，使用大直径股骨头和现代聚乙烯内衬单纯翻修股骨头和内衬比以前的研究报告有更好的关节稳定性。翻修后最常见的并发症是感染。我们没有发现特殊类型的患者、手术因素或假体因素降低了不稳定性或其他并发症风险。
Outcomes of Isolated Head and Liner Exchange Using Large Femoral Heads and Modern Liners in Revision Total Hip Arthroplasty
BACKGROUND: Previous reports on the outcomes of isolated head and liner exchange in revision total hip arthroplasty have found high rates of instability after these surgeries. Most reports have studied constructs using ≤28 mm femoral heads. The purpose of this study was to determine if modern techniques with the use of larger head sizes can improve the rate of instability after head and liner exchange.
METHODS: We identified 138 hips in 132 patients who underwent isolated head and liner exchange for polyethylene wear/osteolysis (57%), acute infection (27%), metallosis (13%), or other (2%). All patients underwent revision with either 32 (23%), 36 (62%), or 40 (15%) mm diameter heads. Cross-linked polyethylene was used in all revisions. Lipped and/or offset liners were used in 104 (75%) hips. Average follow-up was 3.5 (1.0-9.1) years. Statistical analyses were performed with significance set at P < .05.
RESULTS: Revision-free survivorship for any cause was 94.6% and for aseptic causes was 98.2% at 5 years. 11 (8%) hips experienced a complication with 7 (5%) hips requiring additional revision surgery. After revision, 4 (3%) hips experienced dislocation, 5 (4%) hips experienced infection, and 1 (1%) hip was revised for trunnionosis. No demographic or surgical factors significantly affected outcomes.
CONCLUSION: Our study shows that isolated head and liner exchange using large femoral heads and modern liners provides for better stability than previous reports. The most common complication was infection. We did not identify specific patient, surgical, or implant factors that reduced the risk of instability or other complication.
文献出处：Sutter EG, Akram F, Miller A, Paprosky WG, Berger RA, Gerlinger TL. Outcomes of Isolated Head and Liner Exchange Using Large Femoral Heads and Modern Liners in Revision Total Hip Arthroplasty. J Arthroplasty. 2019 Nov 20. pii: S0883-5403(19)31087-3. doi: 10.1016/j.arth.2019.11.015.
文献4
自内侧单间室单髁置换翻修为全膝关节置换的翻修风险：
基于丹麦膝关节登记中心中期结果，
并与初次膝和膝翻修相比较
译者：张蔷
背景：内侧单间室膝关节置换手术（UKAs）临床效果良好，但假体生存率逊于全膝关节置换（TKAs）。当单髁失败时转为全膝是个可行的方法，但这种方法存在争议。本篇文章的目的是分析转自单髁的全膝置换手术假体生存率并与初次全膝和膝翻修的生存率相比较。
方法：基于1997年至2017年间丹麦膝关节置换登记系统，共1012例转自单髁的全膝关节置换手术，对照组为73819例初次全膝置换和2572例膝翻修病例。首要评估指标为翻修风险，次要指标为评估假体类型、转为全膝的指证和手术量对假体生存率的影响，最后，文章还比较了翻修的指证。
结果：单髁转全膝的病例大多数为移动平台（85%），与初次全膝（70±9岁，35% Charnley A型）和膝翻修（70±10岁，42% Charnley A型）的病例相比，单髁转全膝的患者更为年轻（66±10岁），Charnley A型比例更高（55%）（全部p < 0.001）。单髁转全膝的假体生存率与膝翻修（p = 0.42）可比，而显著低于初次全膝（p < 0.001）。而且这一结果不受组间差异影响，校正后的风险比为与膝翻修比较0.94（95%置信区间：0.74-1.19）、与初次全膝比较3.00（95%CI：2.47-3.66）。单髁转全膝的假体生存率不受假体类型（p ‡ 0.47）、翻修情况（p ‡ 0.06）和翻修指证（p ‡ 0.27）影响。单髁转为全膝病例的常见翻修指证包括不稳定（26%）和不明原因疼痛（13%）（p < 0.001）。
结论：单髁转全膝病例的未来翻修风险是初次全膝的三倍。假体生存率与膝翻修相似，但更容易出现不稳定和不明原因的疼痛。
Revision Risk for Total Knee Arthroplasty Converted from Medial Unicompartmental Knee Arthroplasty: Comparison with Primary and Revision Arthroplasties, Based on Mid-Term Results from the Danish Knee Arthroplasty Registry
Background: Medial unicompartmental knee arthroplasties (UKAs) have good clinical outcomes but implant survival is inferior to that of total knee arthroplasties (TKAs). Conversion to a TKA is a reliable option when UKA fails. However, there is controversy regarding these conversions. The aim of this study was to analyze the survival of TKAs converted from UKAs when compared with both primary and revision TKAs.
Methods: On the basis of registrations in the Danish Knee Arthroplasty Registry from 1997 to 2017, 1,012 TKAs converted from UKAs were compared with 73,819 primary TKAs and 2,572 revision TKAs. The primary outcome was the risk of revision. Secondarily, the study analyzed the influence of different implants, the indication for the UKA conversion, and surgical volume on the survival of TKA converted from UKA. Third, the study compared the indications for revision.
Results: The converted UKAs were mainly mobile-bearing (85%) and, at the time of conversion, the patients were younger (mean [standard deviation], 66 ± 10 years) and more were Charnley class A (55%) compared with patients with primary TKA (70 ± 9 years and 35% class A) or revision TKA (70 ± 10 years and 42% class A) (all p < 0.001). The survival of TKAs converted from UKAs was comparable with that of revision TKAs (p = 0.42) and significantly inferior to the survival of primary TKAs (p < 0.001). This relationship was unaffected by differences between the groups, with an adjusted hazard ratio of 0.94 (95% confidence interval [CI]: 0.74 to 1.19) compared with revision TKAs and 3.00 (95% CI: 2.47 to 3.66) compared with primary TKAs. The survival of TKA converted from UKA was unaffected by differences in the conversion
implants (all p ‡ 0.47), experience with revision surgery (all p ‡ 0.06), and the indications for the UKA-to-TKA conversion (all p ‡ 0.27). Instability (26%) and unexplained pain (13%) were more frequent indications for revisions of TKA converted from UKA (p < 0.001).
Conclusions: TKA converted from medial UKA has a 3-fold higher risk of revision when compared with primary TKA. The implant survival resembled that of revision TKA but with a higher prevalence of unexplained pain and instability.
文献出处：El-Galaly A, Kappel A, Nielsen PT, Jensen SL. Revision Risk for Total Knee Arthroplasty Converted from Medial Unicompartmental Knee Arthroplasty: Comparison with Primary and Revision Arthroplasties, Based on Mid-Term Results from the Danish Knee Arthroplasty Registry. J Bone Joint Surg Am. 2019 Nov 20;101(22):1999-2006. doi: 10.2106/JBJS.18.01468.
第二部分：保髋相关文献
文献1
伯尔尼髋臼周围截骨术治疗髋臼发育不良，
哪些因素影响术中透视辐射量？
译者：程徽
目的：髋臼周围截骨术(PAO)是治疗成年髋臼发育不良的首选手术方法。虽然我们已经证明了在PAO术中，病人因素和手术方式与透视时间与辐射量相关，究竟都有哪些因素可以影响PAO术中辐射量目前尚知之甚少。
方法：本研究回顾性分析了378例2012年1月至2017年8月间，进行PAO的378例患者。患者平均年龄21.7岁，其中326例(86%)为女性。共有85例患者在PAO手术的同时进行了关节镜手术，60例患者同时进行髋关节内开放手术。我们以分钟为单位记录透视时间，以mGy·m2为单位记录总辐射量 (辐射强度和面积的乘积DAP)。使用多变量一般线性模型确定影响透视时间和总辐射量的独立预测因子。
结果：每台手术中，平均透视时间为1.21分钟，辐射总量平均为0.71 mGy·m2。男性患者(P = 0.001)、主刀医生(P < 0.001)和是否同时行进行关节镜手术(P < 0.001)是增加透视时间的多变量预测因素。高体重指数(BMI) (P= 0.001)、主刀医生(P < 0.001)和是否同时行进行关节镜手术(P < 0.001) 是增加总辐射量的多变量预测因素。
结论：行PAO手术的同时进行关节镜手术，增加透视时间和总辐射量。其他影响总透视时间的因素包括男性和主刀医生，影响总辐射量的因素是主刀医生和BMI。本研究结果加深了我们对在PAO手术对患者辐射量的认识。
译者点评：PAO术中同时行髋关节镜，其实是同时进行了两台手术，手术时间和辐射量增大无可厚非。总体来看一次手术的辐射量对患者的影响几乎可以忽略，也是对于常年手术的医生，应该加以重视。
What factors affect fluoroscopy use during Bernese periacetabular osteotomy for acetabular dysplasia?
Periacetabular osteotomy (PAO) is the treatment of choice for acetabular dysplasia in the skeletally mature. Little is known about factors affecting fluoroscopy use in PAO. Therefore, we strived to determine patient and surgery factors are associated with the amount of fluoroscopy time and radiation dose during PAO. We performed a retrospective review of 378 patients who underwent PAO between January 2012 and August 2017.The mean age was 21.7yearsand 326 (86%) were females. A total of 85 patients underwent concomitant arthroscopy and 60 underwent open arthrotomy. We recorded fluoroscopy time in minutes and radiation dose area product (DAP) in mGy·m2. Multivariate general linear modeling identified independent predictors of fluoroscopy time and radiation dose. Mean fluoroscopy time was 1.21minutesand mean fluoroscopy DAP was 0.71 mGy·m2. Multivariate predictors of increased fluoroscopy time were male gender (P=0.001), surgeon (P<0.001) and whether an arthroscopy was performed(P<0.001). Multivariate predictors of increased fluoroscopy DAP were increased body mass index (BMI) (P=0.001), surgeon (P<0.001) and whether an arthroscopy was performed(P<0.001). Patients undergoing hip arthroscopy concomitant to PAO are at higher risk of longer fluoroscopy time and higher radiation dose. Other factors affecting fluoroscopy time included male gender and surgeon, while radiation dose was further affected by surgeon and BMI. Our findings can facilitate discussion about the risk of radiation exposure during PAO.
文献出处：Wylie JD, McClincy MP, StielerEK, Millis M3, Kim YJ, Peters C4, Novais EN. What factors affect fluoroscopy use during Bernese periacetabular osteotomy for acetabular dysplasia? J HipPreserv Surg. 2019 Sep 17;6(3):259-264. doi: 10.1093/jhps/hnz035. eCollection2019 Aug.
文献2
髂前下棘撕脱骨折导致的畸形引发年轻运动员
关节外撞击：病例报道
译者：肖凯
髂前下棘（AIIS）既往外伤后畸形导致的髋关节外撞击可导致年轻运动员腹股沟区疼痛，但这种情况并不常见。目前，这种情况最常见的治疗方式是关节镜下骨成形术。然而，髋关节镜尚未广泛普及，且需要较高的技术要求。我们回顾分析了2例AIIS外伤后畸形愈合导致的关节外撞击年轻运动员，均接受开放骨切除手术。与运动医学相关多学科医生需要知道AIIS创伤可以导致后期出现关节外撞击，开放手术进行骨切除与关节镜手术均可用于其治疗。
13岁男性橄榄球运动员，在橄榄球运动时受伤，右髋关节疼痛3个月。a 右髋蛙式位显示股骨形态正常，箭头处为向股骨颈突出的不规则钙化；b 3D CT显示AIIS处有大范围骨化；c 轴位MRI显示大量骨软骨块自AIIS凸向髋关节（白箭头），髋臼盂唇完整无撕裂（红箭头）；d 术中最终照片显示股直肌直头连同一骨块被固定到了起始位置；e 术后2年蛙式位显示AIIS撞击灶未复发，股骨颈偏心距正常。
16岁男性足球及棒球运动员，右髋关节疼痛6个月，既往骑自行车时被车撞倒，有髋关节着地。a 骨盆正位片显示AIIS附近异常钙化；b 假斜位显示骨组织向髋关节前方凸出；c 蛙式位显示AIIS凸出（红箭头）与股骨cam型撞击灶（白箭头）；d 开放骨切除术后2年；e 术后2年蛙式位股骨头颈交界区正常。
Anterior Inferior Iliac Spine Deformity as a Cause for Extra-articular Hip Impingement in Young Athletes After an Avulsion Fracture: A Case Report
Extra-articular hip impingement from prior traumatic injury to the anterior inferior iliac spine (AIIS) is an uncommon cause of groin pain in young athletes. Currently, the most common treatment for this injury is arthroscopic decompression. However, hip arthroscopy is not universally available and requires advanced skills. We report 2 cases of the development of extra-articular hip impingement from unusual bony exostoses off the AIIS after traumatic injury in 2 young athletes who underwent open surgical resection. The multidisciplinary sports medicine team should be aware of the development of extra-articular impingement from traumatic injury to the AIIS and that open surgical resection is a viable alternative to arthroscopic decompression.
文献出处：Novais EN, Riederer MF, Provance AJ. Anterior Inferior Iliac Spine Deformity as a Cause for Extra-articular Hip Impingement in Young Athletes After an Avulsion Fracture: A Case Report. Sports Health. 2018 May/Jun;10(3):272-276. doi: 10.1177/1941738117744547. Epub 2017 Dec 6.
文献3
脑瘫患者髋关节重建术成功恢复头臼匹配的远期疗效
译者：任宁涛
目的：脑瘫（CP）患者常常可出现神经源性髋关节脱位，如果股骨头和髋臼非同心圆对位，但无脱位，则髋关节在相对小的手术下可恢复复位，如股骨头半脱位或脱位，则需要进行重建手术。但是何时股骨头病变的需要一个挽救性治疗，或髋关节重建手术是否成功地恢复了CP患者的关节匹配，目前尚无定论，因此本研究旨在研究髋关节重建术后股骨头的可塑性。
方法：研究对象为CP和髋关节高脱位（Tönnis IV）患者，总共有68名，其中23名为双侧高脱位，91个髋关节进行了复查重建手术，术前、术后及长期随访时均进行标准化放射学检查。
结果：疼痛是选择复杂髋关节重建最常见的原因（49例，72%），术后疼痛明显改善。术后45个髋关节出现非球形不匹配，术后平均7.7年得以改善，59个髋关节关节匹配度好。只有15%的病人在最后的随访时感到疼痛，而且疼痛强度很低。
结论：早期保守治疗有助于髋关节脱位的治疗，也应及早进行手术重建。持续随访是必要的，Reimers指数有助于监测髋关节的外移情况。在髋关节疼痛和股骨头畸形的情况下，我们的长期研究表明，髋关节重建手术作为多节段手术的一部分，可以改善CP和Tönnis IV型髋关节脱位患者的疼痛和功能，即使术后出现髋关节匹配性差，但这种不匹配在术后数年可改善。如有可能，应在股骨头形变之前进行重建，髋关节高的可塑性提示即使股骨头变形，也可以采用髋关节重建术。
图1 球形匹配和球形不匹配
图2 非球形匹配和非球形不匹配
图3 91例髋关节术后外移指数
图4 术后及随访时匹配情况
图5 8岁，脑瘫患者，手术前GMFCS分级为V，术前和术后（FDO和Salter截骨）片子（右），术后1年取内固定，对侧手术。第一次手术术后7.5年随访片子可见关节匹配好。
Hip reconstruction surgery is successful in restoring joint congruity in patients with cerebral palsy: long-term outcome
PURPOSE: Neurogenic hip dislocation is frequently observed in patients with cerebral palsy (CP). If the hip is not centred but not dislocated, the hip joint can be recentered with minor operative effort. Reconstructive procedures are indicated if the femoral head is subluxated or dislocated. There are no data as to when destruction of the femoral head requires a salvage procedure or whether hip reconstruction surgeryis successful in restoring joint congruity in patients with CP. Our aim was to investigate femoral head plasticity after hip reconstruction surgeryin a long-term outcome study.
METHODS: We studied a large cohort of patients with CP and high hip dislocation (Tönnis grade IV) before surgery. Sixty-eight patients were assessed, of whom 23 presented with bilateral high hip dislocation, and 91 complex hip reconstructions were conducted. Standardised radiographic examination was performed before and directly after surgery and at the long-term follow-up examination.
RESULTS: Pain was the most frequent reason for complex hip-joint reconstruction (49 patients, 72%). An impressive improvement in pain was demonstrated postoperatively. Forty-five hip joints presented aspheric incongruity postoperatively, which improved on average 7.7 years after surgery and 59 hip joints showed congruency. Only 15% of patients experienced pain at the time of final follow-up, and that was of low intensity.
CONCLUSIONS: Early conservative treatment for hip dislocation is helpful, and operative reconstruction should also be scheduled early. Continued surveillance is necessary, and Reimers index is useful for monitoring the development of hip centering. In case of hip pain and femoral head deformity, our long-term study indicates that hip reconstruction surgery as a part of multilevel surgery improves pain and function in patients with CP and Tönnis IV hip dislocation, even if the hip joint is incongruent after operation. This incongruity improves over the long-term. If possible, a reconstruction procedure should be performed before the femoral head becomes deformed. High plasticity of the hip joint suggest that even if the femoral head is deformed, hip reconstruction can be recommended.
文献出处：Braatz F, Eidemüller A, Klotz MC, Beckmann NA, Wolf SI, Dreher T. Hip reconstruction surgery is successful in restoring joint congruity in patients with cerebral palsy: long-term outcome. Int Orthop. 2014 Nov;38(11):2237-43. doi: 10.1007/s00264-014-2379-x. Epub 2014 Jun 27.
文献4
髋臼发育不良患者髋臼周围截骨术后患者
特异性的软骨盂唇接触力学
译者：张利强
目的：采用一种有效的、患着特异性的有限元（FE）建模方法，对髋臼周围截骨术（PAO）前后的软骨和盂唇力学进行评估，以了解该手术对改善发育不良髋关节力学的能力。
设计：这项病例对照前瞻性研究共招募了5例髋臼发育不良患者。利用PAO前后的CT关节造影扫描生成模型，包括骨、软骨和盂唇的解剖结构。对软骨和盂唇的接触应力和接触面积进行整体和区域性的量化。分析了以髋关节总负荷的百分比描述的由盂唇支撑的负荷。
结果：术后软骨接触面积百分率在髋臼的整体、中部、上部均有所增加。髋臼接触应力峰值在整体、外侧、前方和上方均降低。平均接触应力在整体、外侧、前后方均降低。只有上盂唇平均接触应力和盂唇总体峰值应力下降。盂唇支持的负荷变化不明显。
结论：PAO能有效地调节软骨接触面积，降低软骨接触应力，从而减少对发育不良髋关节外侧髋臼内常见的导致局灶性软骨损伤、软骨下囊肿和软骨剥脱的有害负荷。然而，发育不良的髋关节中过度突出、肥大的盂唇仍与股骨头接触，股骨头仍承载PAO术后由盂唇传递的力。PAO术后持续盂唇负重的临床后果尚不清楚。然而，在PAO术后，如果不能减少由盂唇承受的负荷，可能导致髋关节OA。
单个患者的有限元模型表示。在（a）术前和（b）术后状态下，对患者特异的股骨和骨盆进行三维重建。股骨半透明以突出股骨前外侧覆盖（箭头所示）。（c） 具有代表性的术后模型，显示骨、股骨软骨和盂唇。（d） 骨（黄色）髋臼软骨（蓝色）和盂唇（红色）的矢状网格离散视图。
用于分析髋臼软骨和盂唇的区域。（a） 分析髋臼软骨的外侧和内侧区。（b） 然后进行三区分析，将髋臼软骨（蓝色）和盂唇（红色）分成前区、上区和后区。
每个患者术前（a）和术后（b）在步态中期的接触应力。总的来说，术后接触分布较好，应力居中。然而，对于一个病人（PT 4），在髋臼内侧部分观察到更高的应力，延伸到髋臼窝。色彩显示为8 MPa表示接触应力升高。然而，接触应力峰值往往超过8 MPa。
所有5例患者术前（顶排）和术后（底排）在所有活动中的平均接触应力。所有患者术后接触面均向内侧移位。术后前外侧局部负荷减轻。注：所有五个受试者的接触应力都被映射到一个网格上进行可视化。盂唇没有显示。
Patient-specific chondrolabral contact mechanics in patients with acetabular dysplasia following treatment with peri-acetabular osteotomy
Objective: Using a validated, patient-specific finite element (FE) modeling protocol, we evaluated cartilage and labrum (i.e., chondrolabral) mechanics before and after peri-acetabular osteotomy (PAO) to provide insight into the ability of this procedure to improve mechanics in dysplastic hips.
Design: Five patients with acetabular dysplasia were recruited in this case-controlled, prospective study. Models, which included anatomy for bone, cartilage, and labrum, were generated from computed tomography (CT) arthrography scans acquired before and after PAO. Cartilage and labrum contact stress and contact area were quantified overall and regionally. Load supported by the labrum, expressed as a percentage of the total hip force, was analyzed.
Results: Percent cartilage contact area increased post-operatively overall, medially, and superiorly. Peak acetabular contact stress decreased overall, laterally, anteriorly, and superiorly. Average contact stress decreased overall, laterally, anteriorly, and posteriorly. Only average contact stress on the superior labrum and peak labrum stress overall decreased. Load supported by the labrum did not change significantly.
Conclusions: PAO was efficacious at medializing cartilage contact and reducing cartilage contact stresses, and therefore may minimize deleterious loading to focal cartilage lesions, subchondral cysts, and cartilage delaminations often observed in the lateral acetabulum of dysplastic hips. However, the excessively prominent, hypertrophied labrum of dysplastic hips remains in contact with the femoral head, which continues to load the labrum following PAO. The clinical ramifications of continued labral loading following PAO are not known. However, it is plausible that failure to reduce the load experienced by the labrum could result in end-stage hip OA following PAO.
文献出处：Abraham C L , Knight S J , Peters C L , et al. Patient-specific Chondrolabral Contact Mechanics in Patients with Acetabular Dysplasia Following Treatment with Peri-acetabular Osteotomy[J]. Osteoarthritis and Cartilage, 2016, 25(5):676.
文献5
基于年龄、性别和牛津骨年龄的髋关节发育中的
股骨头骨骺延长的标准值
译者：陶可（北京大学人民医院骨关节科）
背景：最近证据表明，持续增加的股骨头骨骺延长可能是大多数凸轮形态的适应性反应，而股骨头骨骺滑脱（SCFE）与其缺乏有关。然而，目前尚缺乏关于现代青少年正常发育的髋关节股骨头骨骺增长的准确数据。本研究的目的是为正常青少年人群建立前方和上方股骨头骨骺增长的标准值。
方法：回顾性分析了就诊时接受骨盆X线检查的年龄在8至17岁之间的210名儿科受试者（420髋）。收集了人口统计学基本数据。排除所有患髋关节病理的受试者。测量骨骺延长率（EER），定义为股骨颈以下的股骨骨骺相对于股骨头直径的延长率。分别在前后位和蛙式位侧方测量双髋上方EER。骨骼成熟度根据股骨近端的牛津骨龄（OBA）进行分级。
结果：上方EER从8岁时的0.63±0.05增加到17岁时的0.80±0.05。相似地，前方EER从8岁时的0.56±0.06增加到17岁时的0.74±0.05。上方和前方EER随着年龄增加在男性（分别为r = 0.80和0.75）和女性（r = 0.67和0.65）通过骨骺线闭合以线性方式变化。当按股骨头OBA分期对受试者进行标准化时，在OBA分期6、7或8时，女性和男性均无统计学差异。
结论：上方和前方EER增加贯穿于整个青春期发育直至骨骺线闭合之前。在控制骨骼成熟度时，性别之间没有显著差异。这些标准数据可能有助于指导今后SCFE和凸轮畸形的治疗与研究。
图1. 患者队列的股骨第4（A），5（B），6（C），7（D）和8（E）期的牛津骨龄（OBA）。OBA分期的特征如下：4，生长板软骨减少和股骨头的骨骺和干骺端之间的关节表面变光滑，在大转子的骨骺上内侧角出现结节，以及早期小转子的生长软骨板的骨性浸润；5，股骨头骨骺的下内侧角处“喙”状骨充填介于股骨颈和大转子结节之间，以及小转子的生长板软骨的整体骨化；6，股骨颈以外的骨骺增宽，大转子的生长板软骨完全骨化；7，股骨生长板软骨骨早期浸润；8，股骨头生长板软骨的完全骨化。
图2. 骨骺延长率（EER）的测量方法是：首先在股骨头上覆盖一个最合适的圆圈，以确定其直径（D）。前方（A）或上方（S）平面的骨骺延长量的测量方法是与股骨颈轴线平行的骨骺向下沿着干骺端延伸一条线段的长度。然后分别基于蛙式侧位或前后位将EER测量为EER = A / D或EER = S / D。Ant示前方；Sup示上方。
图3. 男性和女性在骨闭合的整个阶段的上方和前方骨骺延长率（EER）随年龄呈线性增长。
Normative Values for Capital Femoral Epiphyseal Extension of the Developing Hip Based on Age, Sex, and Oxford Bone Age
BACKGROUND: Recent evidence suggests that increasing capital femoral epiphyseal extension may be an adaptive response that underlies the development of most cam morphology, whereas slipped capital femoral epiphysis is associated with its deficiency. However, there is an absence of rigorous data on the normal development of epiphyseal extension in the hip joint in modern adolescents. The aim of this study was to establish normative values for anterior and superior epiphyseal extension in a normal adolescent control population.
METHODS: A total of 210 pediatric subjects (420 hips) between the ages of 8 and 17 years old at the time of presentation who received pelvic radiographs were retrospectively reviewed. Basic demographic data were collected. All subjects with underlying hip pathology were excluded. Epiphyseal extension ratio (EER) was measured, defined as the ratio of extension of the capital femoral epiphysis down the femoral neck relative to the diameter of the femoral head. Superior EER was measured on the anterioposterior view and anterior EER on the frog-leg lateral view bilaterally. Skeletal maturity was graded based on Oxford bone age (OBA) at the proximal femur.
RESULTS: The superior EER increased from 0.63±0.05 at age 8 to 0.80±0.05 at age 17. The anterior EER similarly increased from 0.56±0.06 at age 8 to 0.74±0.05 at age 17. The superior and anterior EERs increased with age in a linear fashion for males (r=0.80 and 0.75, respectively) and females (r=0.67 and 0.65) through physeal closure. When subjects were standardized by the OBA stage of the femoral head, females and males showed no statistical difference at OBA stages 6, 7 or 8.
CONCLUSIONS: Superior and anterior EER increased throughout adolescent development until physeal closure. When controlling for skeletal maturity, there were no significant differences between sexes. This normative data may help guide future management and research of slipped capital femoral epiphysis and cam morphology.
文献出处：Marshall DC, Morris WZ, Liu RW. Normative Values for Capital Femoral Epiphyseal Extension of the Developing Hip Based on Age, Sex, and Oxford Bone Age. J Pediatr Orthop. 2019 Dec 9. doi: 10.1097/BPO.0000000000001476.
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