本期目录：
1、全膝关节置换术后高体力活动水平在前12年内不会增加翻修手术的风险
2、全膝关节置换（选择性髌骨置换）术后膝前痛和功能障碍的发生率
3、全膝关节置换术矫正严重外翻骨关节炎与术后踝关节症状增加相关
4、行业资助对全关节置换术新兴技术的临床结果没有影响
5、膝骨关节炎合并肥胖、肌萎缩性肥胖和肌萎缩的风险
6、髋臼发育不良和髋臼后倾患者股骨髋臼联合前倾与性别相关且不同
7、盂唇内翻引发髋关节快速破坏性骨关节炎
8、Graf超声评估多胎妊娠儿童髋关节发育不良的危险因素
9、髋臼盂唇较大与髋关节发育不良、关节不匹配及临床症状有关
10、发育性髋脱位手术复位后股骨头的重塑
11、髋臼后倾患者中髋臼周围截骨术(PAO)比髋臼边缘修整术提供更高的髋关节存活率
12、日常生活活动中的髋、膝和踝关节运动学
第一部分：关节置换及保膝相关文献
文献1
全膝关节置换术后高体力活动水平在前12年内不会增加翻修手术的风险:一项meta分析和GRADE的系统综述
译者 张轶超
背景:全膝关节置换术(TKA)后高体力活动(HPA)水平可能与磨损增加和随后出现的假体无菌性松动有关，对TKA假体的生存率产生负面影响。本系统综述研究了TKA患者中期(3 ~ 10年)和长期(>10年)随访时活动水平与翻修手术风险之间的相关性。
方法: 检索截至2021年10月12日的PubMed、Embase数据库。纳入了比较TKA患者低体力活动(LPA)和HPA水平与翻修风险的相关文献。在数据提取和方法学质量评估后，进行meta分析。使用GRADE框架评估证据质量。PROSPERO注册号:CRD42020194284。
结果: 5项队列研究和1项病例对照研究符合纳入标准，共纳入4263例患者的4811例TKA手术，平均随访4-12年。5项研究方法学质量中等，1项质量较低。荟萃分析显示，HPA水平与全因翻修手术风险增加(风险比(RR) 0.62, 95%可信区间(CI) 0.24 -1.63，确定性水平极低)或无菌性松动翻修手术风险增加(RR 1.33, 95% CI 0.34- 5.24，确定性水平中等)之间没有相关性。只有一项关于生存率的研究报告了HPA组生存率有提高(优势比为2.4，95% CI为1.2- 4.7，确定性水平低)。
结论:在TKA术后的前12年中，HPA水平的患者与LPA水平的患者相比，似乎没有增加翻修手术的风险。
A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE
Background: High physical activity (HPA) levels after total knee arthroplasty (TKA) might be related to increased wear and subsequent aseptic loosening, negatively affecting TKA survival. This systematic review studied the association between activity levels and risk of revision surgery at medium (3–10 years) and long term (>10 years) follow up in patients with TKA.
Methods: Databases (PubMed, Embase) were searched up to 12 October 2021. Studies comparing low physical activity (LPA) and HPA levels in TKA patients and related risk of revision surgery were eligible for inclusion. After data extraction and evaluation of methodological quality, a meta-analysis was performed. Quality of evidence was assessed using the GRADE framework. PROSPERO registration: CRD42020194284.
Results: Five cohort studies and one case–control study met the inclusion criteria, involving 4811 TKA procedures in 4263 patients (mean follow up 4–12 years). Five studies were of moderate methodological quality and one of low quality. Meta-analysis demonstrated no association between HPA level and an increased risk of all-cause revision surgery (risk ratio (RR) 0.62, 95 % confidence interval (CI) 0.24–1.63, level of certainty: very low) or revision surgery due to aseptic loosening (RR 1.33, 95 % CI 0.34–5.24, level of certainty: moderate). Only one study reported on survivorship, with an improved survivorship for the HPA group (odds ratio of 2.4, 95 % CI 1.2–4.7, level of certainty: low).
Conclusion: During the first 12 postoperative years after TKA, there seems to be no increased risk for revision surgery for patients with a HPA level compared with patients with an LPA level.
文献出处：Kornuijt A, Kuijer PPFM, van Drumpt RA, Siebelt M, Lenssen AF, van der Weegen W. A high physical activity level after total knee arthroplasty does not increase the risk of revision surgery during the first twelve years: A systematic review with meta-analysis and GRADE. Knee. 2022 Dec;39:168-184. doi: 10.1016/j.knee.2022.08.004. Epub 2022 Oct 5. PMID: 36208528.
文献2
全膝关节置换（选择性髌骨置换）术后膝前痛和功能障碍的发生率：一项前瞻性队列研究
译者 张蔷
背景：全膝关节置换（TKA）术中置换髌骨对于膝前痛、爬台阶和其他功能活动的影响并不明确。本研究主要目的是探索髌骨置换对于与膝前痛和功能相关的患者自评评分（PROMs）的影响。
方法：我们入组了5年内共950例TKA病例，收集的数据包括术前及术后1年的关节置换病人膝关节损伤及骨关节炎评分（KOOS,JR.）。髌骨置换的指征包括四级髌股关节（PFJ）改变或试模过程中的机械性症状。950例TKA病例中有393例施行了髌骨置换。我们使用KOOS，JR量表中的项目评估患者爬楼及直立过程中的膝关节疼痛和坐位站起过程中的膝关节功能，并将数据进行多变量回归分析。在配平了手术年龄、性别、基础疼痛及功能等基本资料后，我们为KOOS,JR.量表中的每一项目标题目建立了独立回归模型。
结果：我们并未发现术后一年膝前痛和功能与置换髌骨存在相关性（P = .17, .97）。术前爬楼时存在中重度疼痛的患者术后出现疼痛和功能障碍的可能性更大（概率比 2.3, P =.013），男性患者术后出现膝前痛的概率比女性患者低42%（概率比 0.58, P = .002）。
结论：依据髌股关节退变和机械性症状来选择性进行髌股置换的治疗策略并不会造成患者自评评分的显著性差异。
Incidence of Anterior Knee Pain and Functional Difficulty in a Prospectively Recruited Cohort Following Total Knee Arthroplasty with Selective Patellar Resurfacing
Background: The influence of patellar resurfacing on anterior knee pain, stair climbing, and functional activity outcomes following total knee arthroplasty (TKA) are incompletely understood. This study examined the influence of patellar resurfacing on patient-reported outcome measures (PROMs) relating to anterior knee pain and function.
Methods: The Knee Injury and Osteoarthritis Outcome Score of Joint Replacement (KOOS, JR.) patient PROMs were collected preoperatively and at 12 months follow-up for 950 TKAs performed over 5 years. Indications for patellar resurfacing included Grade IV patello-femoral (PFJ) changes or mechanical PFJ findings during patellar trialing. Patellar resurfacing was performed on 393 (41%) of the 950 TKAs performed. Multivariable binomial logistic regressions were performed, using KOOS, JR. questions assessing pain during stair climbing, standing upright, and function during rising from sitting as surrogates for anterior knee pain. Independent regression models were performed for each of the targeted KOOS, JR. questions, with adjustment for age at surgery, sex, and baseline pain and function.
Results: No association was observed between 12-month postoperative anterior knee pain and function with patellar resurfacing (P = .17, .97). Patients who had moderate or greater preoperative pain on stairs had an increased likelihood of postoperative pain and functional difficulty (odds ratio 2.3, P =.013), while males were 42% less likely to report postoperative anterior knee pain (odds ratio 0.58, P = .002).
Conclusion: Selective patellar resurfacing based on PFJ degeneration and mechanical PFJ symptoms produces similar improvement in PROMs for resurfaced and unresurfaced knees.
文献3
全膝关节置换术矫正严重外翻骨关节炎与术后踝关节症状增加相关
译者 丁云鹏
目的 本研究的目的是评估高度外翻骨关节炎全膝关节置换术（TKA）后踝关节的中期临床结果。
方法 在这项病例对照研究中，纳入了 36 名术前机械胫股角 (mTFA) ≥ 15°、2002 年 12 月至 2012 年 12 月期间接受 TKA 的患者。使用病例匹配创建了 n = 60 名患者的对照组 (mTFA < 15°)。分析放射学[机械胫股角 (mTFA) 和踝关节相对地面方向 (G-AJLO)] 和临床参数 [足功能指数 (FFI)、膝关节协会评分、遗忘关节评分和运动范围 (ROM)] 。平均随访时间为 59 个月 (IQR [56, 62])。
结果 尽管膝关节和踝关节线已矫正至中立方向，但 TKA 矫正 mTFA 的程度与术后 FFI 显着相关（R = 0.95，p < 0.05）。计算出的截止值为 16.5° [AUC 0.912 (0.85–0.975 95% CI)，敏感性 = 0.8，特异性 = 0.895]，高于该值，出现踝关节症状的比值比 (OR) 大幅增加 [OR 34.0 (9.10) –127.02 95% CI)]。距下关节的 ROM 限制与 FFI 具有很强的显着相关性（R = 0.74，p < 0.05），表明距下关节的 ROM 减少与踝关节的恶化结果相关。
结论 在这项研究中，TKA 中较高程度的腿轴矫正与术后踝关节症状的增加相关。当膝关节过度外翻骨关节炎进行全膝关节置换术时，外科医生应该意识到这可能会引发踝关节症状的发作或进展，特别是在距下关节僵硬的情况下。
Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms
Purpose The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis.
methods In this case–control study, n = 36 patients with a preoperative mechanical tibiofemoral angle (mTFA) ≥ 15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA < 15°) of n = 60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]).
Results The degree of correcting the mTFA by TKA significantly correlated with the postoperative FFI (R = 0.95, p < 0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-off value of 16.5° [AUC 0.912 (0.85–0.975 95% CI), sensitivity = 0.8, specificity = 0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10–127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong significant correlation with the FFI (R = 0.74, p < 0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint.
Conclusions In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stiff subtalar joint.
文献出处：Frank Graef, Hagen Hommel, Roman Falk,et, Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms.Knee Surg Sports Traumatol Arthrosc. 2022; 30(2): 527–535.
文献4
行业资助对全关节置换术新兴技术的临床结果没有影响:：文献计量学和利益冲突的系统回顾
译者 沈松坡
背景：新的全关节置换术技术的应用越来越多，包括患者特异性植入物/器械(PSI)、计算机辅助(CA)和机器人辅助(RA)技术。关于提供的价值和对利益冲突(COI)的潜在担忧，存在持续的争论。
方法：遵循PRISMA指南。检索PubMed、MEDLINE和Web of Science数据库，检索全髋关节和全膝关节置换术、单髁膝关节置换术(UKA)、PSI、CA和RA。评估文献计量学数据、财务COI、临床/功能评分和患者报告的结果。
结果：87项研究被评估，其中35项(40.2%)包括至少一名作者报告COI, 13项(14.9%)披露了行业资助。COI和行业资助对结果无显著影响(P = 0.682, P = 0.447)，冲突和资助对证据水平无显著影响(P = 0.508, P = 0.826)。作者披露COI的研究的相对被引率(RCR)和影响因子(IF)显著高于未披露COI的研究(P <0.001, p = 0.032)。亚组分析显示RA和PSI研究更有可能报告COI或行业资助(P = 0.045)。RA (OR = 6.31, 95% CI: 1.61-24.68)和UKA (OR = 9.14, 95% CI: 1.43-58.53)报告有利结果的几率高于PSI。
结论：作者COI(约40%)可能低于先前报道的骨科技术/技术综述。使用RA和PSI的研究更有可能报告COI，而RA和UKA研究比PSI更有可能报告有利的结果。COI的存在和/或行业资助与有利结果的频率或研究证据水平之间没有统计学上显著的关联。
Funding has no efect on clinical outcomes of total joint arthroplasty emerging technologies: a systematic review of bibliometrics and conficts of interest
Background: The use of new total joint arthroplasty technologies, including patient-specifc implants/instrumentation (PSI), computer-assisted (CA), and robotic-assisted (RA) techniques, is increasing. There is an ongoing debate regarding the value provided and potential concerns about conficts of interest (COI).
Methods: PRISMA guidelines were followed. PubMed, MEDLINE, and Web of Science databases were searched for total hip and knee arthroplasties, unicompartmental knee arthroplasties (UKA), PSI, CA, and RA. Bibliometric data, financial COI, clinical/functional scores, and patient-reported outcomes were assessed.
Results: Eighty-seven studies were evaluated, with 35 (40.2%) including at least one author reporting COI, and 13 (14.9%) disclosing industry funding. COI and industry funding had no significant effects on outcomes (P = 0.682, P = 0.447), and there were no significant effects of conflicts or funding on level of evidence (P = 0.508, P = 0.826). Studies in which author(s) disclosed COI had significantly higher relative citation ratio (RCR) and impact factor (IF) than those without (P < 0.001, P = 0.032). Subanalysis demonstrated RA and PSI studies were more likely to report COI or industry funding (P = 0.045). RA (OR = 6.31, 95% CI: 1.61-24.68) and UKA (OR = 9.14, 95% CI: 1.43-58.53) had higher odds of reporting favorable outcomes than PSI.
Conclusions: Author COIs (about 40%) may be lower than previously reported in orthopedic technologies/techniques reviews. Studies utilizing RA and PSI were more likely to report COI, while RA and UKA studies were more likely to report favorable outcomes than PSI. No statistically significant association between the presence of COIs and/or industry funding and the frequency of favorable outcomes or study level of evidence was found.
Level of evidence: Level V Systematic Review.
Keywords: Computer-navigated; Conflict of interest; Funding; Patient-specific implant; Robotic-assisted; Total joint arthroplasty.
文献5
膝骨关节炎合并肥胖、肌萎缩性肥胖和肌萎缩的风险
译者 张峻
目的：通过人体测量定义的肥胖是膝关节骨关节炎（OA）的一个众所周知的风险因素，但关于身体成分（脂肪和肌肉含量）与膝关节骨关节炎风险的相关性的数据相对较少。我们实施此研究以检查基于脂肪和肌肉含量的身体成分类别与膝关节骨关节炎发病风险的纵向关联。
方法：我们纳入了来自多中心骨关节炎研究的参与者，该研究是一个由患有膝OA或处在膝OA风险的个体组成的纵向队列。根据全身双x射线吸收仪的身体成分（即脂肪和肌肉质量），将受试者分为肥胖性非肌萎缩（肥胖）、肌萎缩性肥胖、肌萎缩性非肥胖（肌萎缩性）或非肌萎缩非肥胖（参考类别）。我们使用具有稳健方差估计的二项回归，对潜在的混杂因素进行了调整，研究了基线身体成分类别与60个月时发生放射学OA风险的关系。
结果：在1653名基线时未进行膝关节骨关节炎放射学检查的受试者中，肥胖女性（相对风险[RR]2.29[95%置信区间{95%CI}1.64-3.20]）、肥胖男性（RR1.73[95%CI 1.08-2.78]）和肌肉萎缩性肥胖女性（RR2.09[95%CI 1.17-3.73]）发生膝关节骨折的风险显著增加，但在肌肉减少性肥胖男性中没有（RR 1.74[95%CI 0.68-4.46]）。肌肉减少与膝关节OA的风险无关（女性RR 0.96[95%CI 0.62-1.49]；男性RR 0.66[95%CI0.34-1.30]）。
结论：在这个大型纵向队列中，我们发现基于身体成分的肥胖和少肌性肥胖与膝关节骨关节炎的风险相关，但与肌少症无关。膝关节骨关节炎的减肥策略应侧重于肥胖和肌肉萎缩性肥胖。
Risk of Knee Osteoarthritis With Obesity, Sarcopenic Obesity, and Sarcopenia
Objective: Obesity, defined by anthropometric measures, is a well-known risk factor for knee osteoarthritis (OA), but there is a relative paucity of data regarding the association of body composition (fat and muscle mass) with risk of knee OA. We undertook this study to examine the longitudinal association of body composition categories based on fat and muscle mass with risk of incident knee OA.
Methods: We included participants from the Multicenter Osteoarthritis Study, a longitudinal cohort of individuals with or at risk of knee OA. Based on body composition (i.e., fat and muscle mass) from whole-body dual x-ray absorptiometry, subjects were categorized as obese nonsarcopenic (obese), sarcopenic obese, sarcopenic nonobese (sarcopenic), or nonsarcopenic nonobese (the referent category). We examined the relationship of baseline body composition categories with the risk of incident radiographic OA at 60 months using binomial regression with robust variance estimation, adjusting for potential confounders.
Results: Among 1,653 subjects without radiographic knee OA at baseline, significantly increased risk of incident radiographic knee OA was found among obese women (relative risk [RR] 2.29 [95% confidence interval {95% CI} 1.64-3.20]), obese men (RR 1.73 [95% CI 1.08-2.78]), and sarcopenic obese women (RR 2.09 [95% CI 1.17-3.73]), but not among sarcopenic obese men (RR 1.74 [95% CI 0.68-4.46]). Sarcopenia was not associated with risk of knee OA (for women, RR 0.96 [95% CI 0.62-1.49]; for men, RR 0.66 [95% CI 0.34-1.30]).
Conclusion: In this large longitudinal cohort, we found body composition-based obesity and sarcopenic obesity, but not sarcopenia, to be associated with risk of knee OA. Weight loss strategies for knee OA should focus on obesity and sarcopenic obesity.
文献出处：Misra D, Fielding RA, Felson DT, Niu J, Brown C, Nevitt M, Lewis CE, Torner J, Neogi T; MOST study. Risk of Knee Osteoarthritis With Obesity, Sarcopenic Obesity, and Sarcopenia. Arthritis Rheumatol. 2019 Feb;71(2):232-237. doi: 10.1002/art.40692. Epub 2019 Jan 4. PMID: 30106249; PMCID: PMC6374038.
第二部分：保髋相关文献
文献1
髋臼发育不良和髋臼后倾患者股骨髋臼联合前倾与性别相关且不同
译者 罗殿中
目的：在发育性髋关节发育不良（DDH）患者中，股骨前倾（FV）、髋臼前倾（AV）和联合前倾（CV）的发生率尚不明了。本研究拟调查DDH患者和髋臼后倾（AR）患者中股骨前倾（FV）、股骨前倾和股骨后倾比例、及联合前倾（CV，FV+AV）情况。
患者及方法：该回顾性观察研究经伦理委员会（IRB）通过，包含有症状DDH患者78例90髋，因髋臼后倾（AR）导致髋关节撞击征（FAI）患者65例77髋。对基于CT/MRI测量的股骨前倾角（FV，Murphy法），和中心层面髋臼前倾角（AV）进行比较。计算FV轻度增大（FV>25°）、FV中度增大（FV>35°）、FV极度增大（FV>45°）、FV减小（FV<10°）和CV（McKibbin-index/COTAV-index）数值及分布情况。
结果：与髋臼后倾（AR）患者（16°±11°和28°±13°）相比较，DDH患者股骨前倾（FV）和联合前倾（CV）显著增大（均值±SD分别为25°±11°和47°±18°），P<0.001。相对男性DDH患者（18°±13°）和FAI-AR患者（13°±8°），女性DDH患者（27°±16°）和FAI-AR患者（19°±12°）股骨前倾角显著增大，P<0.001。在DDH患者中，FV轻度增大（FV>25°）占47%，FV中度增大（FV>35°）占23%。
相对于DDH患者中FV减小（FV<10°）的比例（17%），FAI-AR患者中FV减小（FV<10°）的比例明显增多（31%），P<0.001。18%的DDH患者AV>25°，联合FV>25°；12%的FAI-AR患者FV<10°，联合AV<10°。
结论：DDH患者与髋臼后倾（FAI-AR）患者中FV和CV显著不同，且性别相关。在DDH患者中，FV中度增大（FV>35°）占23%，FV减小（FV<10°）占17%，可能影响治疗。这些不同组合凸显出，在开放保髋手术（PAO和PFO）和髋关节镜手术之前，进行个体化评估非常重要。
Combined femoral and acetabular version is sex-related and differs between patients with hip dysplasia and acetabular retroversion
Aims:Frequency of abnormal femoral and acetabular version (AV) and combinations are unclear in patients with developmental dysplasia of the hip (DDH). This study aimed to investigate femoral version (FV), the proportion of increased FV and femoral retroversion, and combined-version (CV, FV+AV) in DDH patients and acetabular-retroversion (AR).
Patients and methods:A retrospective IRB-approved observational study was performed with 78 symptomatic DDH patients (90 hips) and 65 patients with femoroacetabular-impingement (FAI) due to AR (77 hips, diagnosis on AP radiographs). CT/MRI-based measurement of FV (Murphy method) and central AV were compared. Frequency of increased FV(FV > 25°), severely increased FV (FV > 35°) and excessive FV (FV > 45°) and of decreased FV (FV < 10°) and CV (McKibbin-index/COTAV-index) was analysed.
Results:Mean FV and CV was significantly (p < 0.001) increased of DDH patients (mean ± SD of 25 ± 11° and 47 ± 18°) compared to AR (16 ± 11° and 28 ± 13°). Mean FV of female DDH patients (27 ± 16°) and AR (19 ± 12°) was significantly (p < 0.001) increased compared to male DDH patients (18 ± 13°) and AR (13 ± 8°). Frequency of increased FV (>25°) was 47% and of severely increased FV (>35°) was 23% for DDH patients. Proportion of femoral retroversion (FV < 10°) was significantly (p < 0.001) higher in patients AR (31%) compared to DDH patients (17%). 18% of DDH patients had AV > 25° combined with FV > 25°. Of patients with AR, 12% had FV < 10° combined with AV < 10°.
Conclusion:Patients with DDH and AR have remarkable sex-related differences of FV and CV. Frequency of severely increased FV > 35° (23%) is considerable for patients with DDH, but 17% exhibited decreased FV, that could influence management. The different combinations underline the importance of patient-specific evaluation before open hip preservation surgery (periacetabular osteotomy and femoral derotation osteotomy) and hip-arthroscopy.
文献2
盂唇内翻引发髋关节快速破坏性骨关节炎
译者 张振东
髋关节快速破坏性骨关节炎（OA）的病理生理学尚不清楚。本研究记录了髋臼盂唇内翻的病例，其临床放射学特征与初期快速破坏性髋关节OA相似。本研究基于对9例快速破坏性髋关节OA患者的前瞻性数据回顾。术中发现，所有患者的髋臼盂唇前上方部分都已内翻嵌入关节间隙，并伴有许多关节软骨碎片。9例患者中有8例患者的股骨头软骨下不全骨折就发生在内翻盂唇的下方。因此，盂唇内翻可能与快速破坏性髋关节 OA 的关节间隙快速变窄和股骨头软骨下不全骨折有关。
图1 .(A)髋关节疼痛后1个月，左髋关节正位x线片。(B)疼痛出现3个月后，同一髋关节的x线片显示关节间隙狭窄进展迅速。
图2 .(A)图1同一患者术中照片，显示前上方盂唇内翻嵌入关节内（黄色箭头）。星号表示髋臼窝。ANT，前；POST，后。(B)术中照片显示提起内翻的盂唇。
图3 .(A)从红色矩形区域获得的显微照片，显示左股骨头中冠状位的大体外观，与图1是同一患者。一层很薄的关节软骨（黑色长箭头）与一层几乎完整的关节软骨层（黑色短箭头）共存。(B)图3a中黑色矩形内区域的放大照片。薄层关节软骨表面不均匀，有间断的凹形缺损（黑色箭头），但没有髋关节软骨溶解时常见的明显缺损。
图4.(A)对同一患者切除的盂唇进行的显微观察。显微照片中的绿色箭头对应于术中照片中的绿色箭头。(B)图4a中红色矩形区域的放大图像，显示内翻盂唇以及许多关节软骨碎片（星号）。
Inversion of the acetabular labrum triggers rapidly destructive osteoarthritis of the hip: representative case report and proposed etiology
The pathophysiology of rapidly destructive osteoarthritis (OA) of the hip is unknown. This study documented cases of inversion of the acetabular labrum, which has clinicoradiologic features similar to those of initial-stage rapidly destructive hip OA. Our study was based on a prospective review of data for 9 patients with rapidly destructive hip OA. Intraoperative findings showed that the anterosuperior portion of the acetabular labrum had inverted into the articular space, along with many fragments of articular cartilage, in all patients. Subchondral insufficiency fractures of the femoral heads were seen just under the inverted labra in 8 of the 9 patients. Inversion of the acetabular labrum may be involved in rapid joint-space narrowing and subchondral insufficiency fracture in rapidly destructive hip OA.
Keywords: acetabular labrum; inversion; joint-space narrowing; rapidly destructive osteoarthritis of the hip; subchondral insufficiency fracture.
文献出处：Fukui K, Kaneuji A, Fukushima M, Matsumoto T. Inversion of the acetabular labrum triggers rapidly destructive osteoarthritis of the hip: representative case report and proposed etiology. J Arthroplasty. 2014 Dec;29(12):2468-72. doi: 10.1016/j.arth.2014.06.017. Epub 2014 Jun 28. PMID: 25081509.
文献3
Graf超声评估多胎妊娠儿童髋关节发育不良的危险因素
译者 任宁涛
背景:
单胎妊娠婴儿髋关节发育不良(DDH)的危险因素是众所周知的，其中许多因素现在也被用于多胎妊娠。本文的目的是评估经筛选的、广泛认可的单胎妊娠DDH危险因素是否也是多胎妊娠婴儿DDH的危险因素。对DDH家族史、臀位、孕龄、出生体重、性别等危险因素进行分析。
方法:
该研究纳入200名多胎妊娠的新生儿(400个髋关节)。在生后5 d采用Graf法进行超声筛查。
结果:
研究组未发现需要治疗的髋关节发育不良病例，根据Graf超声对髋关节类型和评估的危险因素之间的相关性进行分析，结果显示:有DDH家族史的26名(6.91%)婴儿，1名臀位 (1.22%)婴儿，23名早产儿(8.93%)和平均出生体重为2402 g的28名婴儿报道了IIa型髋关节，但是相关性无统计学意义。21名女婴(10.82%)报告了IIa，两者之间有统计学意义(p < 或 = 0.05)。
结论:
多胎妊娠新生儿髋关节发育的危险因素中，仅胎儿性别对髋关节发育有影响。IIa型髋关节多见于女婴。Graf髋关节类型与DDH家族史、胎儿臀位、妊娠时间小于38周或婴儿出生体重之间无统计学意义的相关性。
Evaluation of risk factors in developmental dysplasia of the hip in children from multiple pregnancies
Background: The risk factors for developmental dysplasia of the hip (DDH) in infants from unifetal pregnancies are commonly known. Many of these factors also apply to multiple pregnancies. The aim of this paper was to evaluate the influence of selected, widely recognized DDH risk factors in unifetal pregnancy on the development of hip joints in infants from multiple pregnancies. The following risk factors were examined: family history of DDH, breech presentation, duration of pregnancy, birth weight and sex.
Material and methods: The study included 200 newborns (400 hip joints) from multiple pregnancies. Ultrasound screening was performed using the Graf method during the first five postnatal days.
Results: No cases of hip joint dysplasia requiring treatment were reported in the study group. The analysis of correlations between hip joint type according to Graf and the evaluated risk factors revealed the following results: type IIa hips were reported in 26 (6.91%) infants with a family history of DDH, one infant (1.22%) who demonstrated a breech presentation, 23 prematurely born infants (8.93%) and 28 infants with a mean birth weight of 2402 g. The correlations were not statistically significant. Type IIa hips were reported in 21 female infants (10.82%), which constituted a statistically significant correlation (p < or = 0.05).
Conclusions: Among the examined risk factors only the sex of the infant turned out to be significant for the development of hip joints in babies from multiple pregnancies. Type IIa hip joints were more common in female infants.No statistically significant correlations were found between Graf hip types and family history of DDH, breech presentation of the fetus, pregnancy duration under 38 weeks or the infant's birth weight.
文献出处：Sionek A, Czubak J, Kornacka M, Grabowski B. Evaluation of risk factors in developmental dysplasia of the hip in children from multiple pregnancies: results of hip ultrasonography using Graf's method. Ortop Traumatol Rehabil. 2008 Mar-Apr;10(2):115-130. English, Polish. PMID: 18449122.
文献4
髋臼盂唇较大与髋关节发育不良、关节不匹配及临床症状有关
译者 李勇
目的:探讨唇部长度与髋臼形态及临床症状的关系。方法:回顾性纳入2015年1月至2018年12月在我院髋关节门诊就诊的患者。我们的样本包括接受以下一种或多种诊断的患者:髋关节唇撕裂、股骨-髋臼撞击(FAI)和髋关节发育不良。排除骨关节炎和/或骨坏死患者。测量双侧唇长度为在中央冠状面tl加权磁共振成像扫描水平交叉参考轴向面(3-9点钟位置)，从髋臼边缘到唇边缘的距离。平片评价髋臼外侧中心边缘角(LCEA)和髋臼顶倾斜角(ARO)。LCEA为25°或更小被定义为髋关节发育不良，而LCEA为30°或更大、LCEA大于40°或髋臼倾角小于0°的阳性交叉信号被定义为钳夹型FAI。α角大于50°或股骨头颈偏移度小于8mm被认为是凸轮FAI。使用日本骨科协会疼痛量表评估双侧髋关节症状的严重程度，其中得分为满分(即满分)的髋关节被定义为无症状，而得分为所有其他分数的髋关节被认为有症状。我们使用简单的线性回归来检验唇部长度与LCEA和ARO的相关性。根据患者髋关节症状状态，使用Mann-Whitney U测试比较下唇长度。结果:本研究纳入102例患者(14例双侧症状，88例单侧症状)。盂唇长度与LCEA (r=-0.612, P＜0.001)和ARO (r= 0.635, P＜0.001)呈显著相关。此外，有症状髋关节患者的盂唇(9.5±3.0 mm)明显大于无症状髋关节患者(7.9±2.1 mm, P = 0.004)。结论:发育不良，形态不匹配，有临床症状的髋关节的髋臼盂唇长度显著增长。
Larger Acetabular Labrum Is Associated With Hip Dysplasia, Joint Incongruence, and Clinical Svmptoms
Purpose: To evaluate the association of labral length with acetabular morphology and clinical symptoms. Method-l s: Patients treated at our hip joint clinic between January 2015 and December 2018 were retrospectively enrolled in the study. Our sample included patients who received a diagnosis of one or more of the following: hip labral tear, femoroacetabular impingement (FAI), and developmental dysplasia of the hip. Patients with osteoarthritis and/or osteonecrosisl were excluded. Bilateral labral length was measured as the distance from the acetabular rim to the edge of the labrum at the level of the central coronal T1-weighted magnetic resonance imaging scan cross-referenced to the axial plane (3- to 9- o'clock position). The lateral center-edge angle (LCEA) and acetabular roof obliquity (ARO) were evaluated with plainl radiographs. An LCEA of 25° or less was defined as developmental dysplasia of the hip, whereas a positive crossover signal in the presence of an LCEA of 30° or greater, an LCEA greater than 40°, or acetabular inclination lower 0° was defined as pincer FAI. An alpha angle greater than 50° or head-neck offset lower 8 mm was considered cam FAI. The severity of hip symptoms was evaluated bilaterally using the Japanese Orthopaedic Association pain scale, on which hips scoring full points (i.e., a perfect score) were defined as asymptomatic whereas hips with all other scores were considered symptomatic. We used simple linear regression to examine the correlations of labral length with the LCEA and ARO. Labral length was also compared according to patient hip symptom status using the Mann-Whitney U test. Results: The studyl included 102 patients (14 with bilateral symptoms and 88 with unilateral symptoms). Labral length was strongly corre-l lated with the LCEA (r=-0.612, P <.001) and ARO (r = 0.635, P <.001). Additionally, patients with symptomatic hips had significantly larger labra (9.5 ±3.0 mm) than those with asymptomatic hips (7.9 ± 2.1 mm, P = .004). Conclusions: Acetabular labral length is significantly greater in dysplastic, irregularly congruent, symptomatic hips.
出处：Kamenaga T, Hashimoto S, Hayashi S, Takayama K, Niikura T, Kuroda R, Matsumoto T. Larger Acetabular Labrum Is Associated With Hip Dysplasia, Joint Incongruence, and Clinical Symptoms. Arthroscopy. 2020 Sep;36(9):2446-2453. doi: 10.1016/j.arthro.2020.05.023. Epub 2020 May 24. PMID: 32461021.
文献5
发育性髋脱位手术复位后股骨头的重塑
译者 张利强
目的：髋关节发育不良很常见，其与股骨头和髋臼发育不良有关。很少有文献描述发育性髋脱位手术复位后股骨头重塑的情况。本研究旨在描述和量化髋关节发育不良患者闭合或切开复位后股骨头球形曲度的变化。
方法：本研究为回顾性队列研究，纳入2009-2022年在一家医院接受闭合或切开复位，并在术后即刻和平均3周行磁共振成像(MRI)检查的典型发育性髋脱位患者。部分患者有3年随访的MRI结果。排除复位时影像学资料不全或进行骨骼手术的患者。我们设计了一种方法，通过比较轴面和冠状面MRI切面上股骨头测量半径的差异来量化股骨头“球形曲度”。然后计算每个平面的半径方差，并求平均值以计算组合方差。方差用于表示“球形曲度”，方差越大，表示半径分布越广，因此球形曲度越差。
结果：本研究共纳入74名患者（69名女性），共96例髋关节。复位时患儿的中位年龄为8.7个月[四分位数间距（IQR）：2.2]。超过一半（58.3%）的髋关节进行了闭合复位，而其余的进行了切开复位（41.7%）。术后即刻、3周和3年的综合方差中位值分别为1.1（IQR：3.93）、0.51（IQR：1.32）和0.31（IQR：0.50），表明随着时间的推移，股骨头球形曲度在改善。
结论：发育性髋脱位股骨头球形曲度在术后即刻以及复位后的头几年都在改善。需要进一步研究以评估重塑机制、理想的复位时机以及股骨头和髋臼重塑之间的关系。
证据级别：IV级——病例系列，治疗研究。
Femoral Head Remodeling After Surgical Reduction of Developmental Hip Dislocations
Objective: Developmental dysplasia of the hip is prevalent and is associated with dysplasia of both the femoral head and acetabulum. There is a paucity of literature describing femoral head remodeling after surgical reduction of developmentally dislocated hips. The purpose of this study was to describe and quantify changes in femoral head sphericity after closed or open reduction for developmental dysplasia of the hip.
Methods: A retrospective cohort study was performed including patients with typical developmental hip dislocations who underwent closed or open reduction from 2009 to 2022 at a single institution and had immediate postoperative and average 3-week follow-up magnetic resonance imaging (MRI) scans. A subset of patients also had 3-year follow-up MRI scans. Patients with insufficient imaging or bony procedures at the time of reduction were excluded. We developed a technique to quantify femoral head “sphericity' by comparing differences in measured radii of the femoral head on axial and coronal plane MRI slices. We then calculated the variance of the radii for each plane and averaged these to calculate a combined variance. The variance was used to represent “sphericity,' with a larger variance indicating a wider distribution of radii and thus a less spherical shape.
Results: A total of 74 patients (69 females) with 96 hips were included in this series. The median age of the child at the time of reduction was 8.7 months [interquartile range (IQR): 2.2]. Over half (58.3%) of the hips had a closed reduction, whereas the remaining were open reduced (41.7%). Immediately postoperatively, at the 3-week time point, and at the 3-year time point the median combined variance was 1.1 (IQR: 3.93), 0.51 (IQR: 1.32), and 0.31 (IQR:0.50), respectively, indicating improved sphericity over time.
Conclusions: Sphericity of the femoral head in developmental hip dislocations improves in both the immediate postoperative period, as well as the first few years after reduction. Further research is needed to evaluate the mechanism of remodeling, the ideal timing of reduction, and the relationship between femoral head and acetabular remodeling.
Level of Evidence: Level IV--case series, therapeutic study.
文献出处：Ellsworth BK, Lee JY, Sankar WN. Femoral Head Remodeling After Surgical Reduction of Developmental Hip Dislocations. J Pediatr Orthop. 2023 Dec 25. doi: 10.1097/BPO.0000000000002597. Epub ahead of print. PMID: 38145396.
文献6
髋臼后倾患者中髋臼周围截骨术(PAO)比髋臼边缘修整术提供更高的髋关节存活率
译者 陶可
背景：髋臼后倾可引起股骨髋臼撞击征，导致髋关节疼痛和骨关节炎。它可以通过前倾髋臼周围截骨术（PAO）或髋臼边缘修整并重新固定盂唇来治疗。越来越多的证据表明髋臼后倾是由骨盆倾斜异常所致，而不是髋臼前壁的局部过度生长。髋臼前壁过度骨性增长所致的髋臼后倾可行PAO治疗。然而，与髋臼边缘修整术相比，尚不清楚这种更大的手术，是否更有利于中期随访中的髋关节存活率和Merle d'Aubigné评分。
问题/目的：我们随访调研了对于有症状的髋臼后倾患者，与通过髋关节外科脱位进行髋臼边缘修整术相比，前倾PAO是否会增加髋关节的存活率。
方法：我们进行了一项回顾性比较研究，评估了两个匹配的有症状的髋臼后倾患者组的中期生存率，这些患者接受前倾PAO或通过髋关节外科脱位进行髋臼边缘修整术。髋臼后倾的定义是同时存在阳性交叉征、后壁征和坐骨棘征。1997年至2012年间，我们中心共有279个髋关节接受了髋臼后倾手术干预（166个髋臼周围截骨术，113个通过髋关节外科脱位进行髋臼边缘修整术）。共有99名患者(60%)被排除在PAO组之外，56名患者(50%)被排除在髋臼边缘修整术组之外，因为他们患有几种已知的病症（例如，PAO组有61例[37%]发育不良或儿科病症）和边缘修整组也有2例[2%]）、配对（10 [6%] / 10 [9%]个髋关节）、记录有缺陷（10 [6%] / 13 [12%]个髋关节）或患者拒绝或失访（18 [11%]/ 31 [27%]个髋关节）。这使得67个髋关节（57名患者）接受了前倾PAO治疗，57个髋关节（52名患者）接受了髋臼边缘修整术。两组在年龄、性别、体重指数、术前活动范围、术前Merle d'Aubigné-Postel评分、髋臼放射学形态（髋臼全覆盖和前髋覆盖除外）、α角、骨关节炎Tönnis分级，以及术前MRI上的盂唇和软骨病变方面，没有显著性差异。在此期间，我们通常从1997年至2003年进行PAO。随着髋关节外科脱位和盂唇修复术的出现，我们通常从2004年至2010年进行髋臼边缘修整术。随着对潜在病理形态学了解的不断增长，大约在2007年至2008年，前倾PAO再次变得更加常见。这项研究需要至少2年的随访。任何时候都包含失败。前倾PAO组的中位随访时间为9.5年（范围，2-17.4年），髋臼边缘修整术组的中位随访时间为6.8年（范围，2.2-10.5年）（p < 0.001）。Kaplan-Meier生存分析使用以下5年和10年终点进行：THA、骨关节炎放射学进展一级（Tönnis等级）和/或Merle d'Aubigné-Postel评分 < 15分。
结果：尽管根据现有数据，两组的5年生存率没有差异（前倾PAO为86% [95% CI, 76%-94%]，而前倾PAO为86% [95% CI, 76%] -96%]进行髋臼边缘修整术），我们发现接受前倾PAO治疗髋臼后倾的髋关节10年生存率增加（79% [95% CI，68%-90%]）与10年髋臼边缘修整术（23% [95% CI，6%-40%]）相比(p < 0.001)。通过髋关节外科脱位进行髋臼边缘修整术组的生存曲线从第6年开始下降。失败的主要原因是Merle d'Aubigné评分下降。
结论：前倾PAO可能是治疗髋臼明显后倾的髋关节更合适的治疗方法。这可能是由于通过边缘修整髋臼后倾，缩小了已经较小的髋关节月状面的结果。然而，边缘修整可能仍然有益于髋臼后倾的髋关节，其中三个体征中只有一两个是阳性的。未来的随机研究应该比较这些治疗方法。
图1 显示了1997年至2012年间接受PAO和髋关节外科脱位(SHD)的患者总数以及纳入本研究的患者人数。
图2 (A)说明了髋臼后倾的定义。我们将髋臼后倾定义为存在以下所有三个体征：髋臼前壁(AW)和后壁(PW)的交叉征（星号）、坐骨棘征阳性（坐骨棘骨盆内突出，箭头）和后壁征阳性（后壁向股骨头中心内侧延伸）。(B)显示了使用前倾PAO并可选同时进行股骨骨软骨成形术的治疗。通常不涉及盂唇。(C)显示了通过髋关节外科脱位而进行髋臼边缘修整和盂唇重新固定的治疗。需要两个转子螺钉来重新固定大转子截骨块。
图3 该图显示了与通过髋关节外科脱位(SHD)进行髋臼边缘修整相比，针对有症状的髋臼后倾的前倾PAO的Kaplan-Meier生存率。终点定义为：转换为THA、骨关节炎的放射学进展以及Merle d’Aubigne´-Postel 评分为15分。尽管5年生存率相当，但与前倾PAO相比，接受髋臼边缘修整的髋关节生存曲线在6年时有所下降(p = 0.0002)。
Periacetabular Osteotomy Provides Higher Survivorship Than Rim Trimming for Acetabular Retroversion.
Background: Acetabular retroversion can cause impaction-type femoroacetabular impingement leading to hip pain and osteoarthritis. It can be treated by anteverting periacetabular osteotomy (PAO) or acetabular rim trimming with refixation of the labrum. There is increasing evidence that acetabular retroversion is a rotational abnormality of the entire hemipelvis and not a focal overgrowth of the anterior acetabular wall, which favors an anteverting PAO. However, it is unknown if this larger procedure would be beneficial in terms of survivorship and Merle d'Aubigné scores in a midterm followup compared with rim trimming.
Questions/purposes: We asked if anteverting PAO results in increased survivorship of the hip compared with rim trimming through a surgical hip dislocation in patients with symptomatic acetabular retroversion.
Methods: We performed a retrospective, comparative study evaluating the midterm survivorship of two matched patient groups with symptomatic acetabular retroversion undergoing either anteverting PAO or acetabular rim trimming through a surgical hip dislocation. Acetabular retroversion was defined by a concomitantly present positive crossover, posterior wall, and ischial spine sign. A total of 279 hips underwent a surgical intervention for acetabular retroversion at our center between 1997 and 2012 (166 periacetabular osteotomies, 113 rim trimmings through surgical hip dislocation). A total of 99 patients (60%) were excluded from the PAO group and 56 patients (50%) from the rim trimming group because they had any of several prespecified conditions (eg, dysplasia or pediatric conditions 61 [37%] for the PAO group and two [2%] for the rim trimming group), matching (10 [6%]/10 [9%] hips), deficient records (10 [6%]/13 [12%] hips), or the patient declined or was lost to followup (18 [11%]/31 [27%] hips). This left 67 hips (57 patients) that underwent anteverting PAO and 57 hips (52 patients) that had acetabular rim trimming. The two groups did not differ in terms of age, sex, body mass index, preoperative ROM, preoperative Merle d'Aubigné-Postel score, radiographic morphology of the acetabulum (except total and anterior acetabular coverage), alpha angle, Tönnis grade of osteoarthritis, and labral and chondral lesions on the preoperative MRI. During the period in question, we generally performed PAO from 1997 to 2003. With the availability of surgical hip dislocation and labral refixation, we generally performed rim trimming from 2004 to 2010. With growing knowledge of the underlying pathomorphology, anteverting PAOs became more common again around 2007 to 2008. A minimum followup of 2 years was required for this study. Failures were included at any time. The median followup for the anteverting PAO group was 9.5 years (range, 2-17.4 years) and 6.8 years (range, 2.2-10.5 years) for the rim trimming group (p < 0.001). Kaplan-Meier survivorship analysis was performed using the following endpoints at 5 and 10 years: THA, radiographic progression of osteoarthritis by one Tönnis grade, and/or Merle d'Aubigné-Postel score < 15 points.
Results: Although the 5-year survivorship of the two groups was not different with the numbers available (86% [95% confidence interval {CI}, 76%-94%] for anteverting PAO versus 86% [95% CI, 76%-96%] for acetabular rim trimming), we found increased survivorship at 10 years in hips undergoing anteverting PAO for acetabular retroversion (79% [95% CI, 68%-90%]) compared with acetabular rim trimming (23% [95% CI, 6%-40%]) at 10 years (p < 0.001). The drop in the survivorship curve for the acetabular rim trimming through surgical hip dislocation group started at Year 6. The main reason for failure was a decreased Merle d'Aubigné score.
Conclusions: Anteverting PAO may be the more appropriate treatment for hips with substantial acetabular retroversion. This may be the result of reduction of an already smaller lunate surface of hips with acetabular retroversion through rim trimming. However, rim trimming may still benefit hips with acetabular retroversion in which only one or two of the three signs are positive. Future randomized studies should compare these treatments.
文献出处：Corinne A Zurmühle, Helen Anwander, Christoph E Albers, Markus S Hanke, Simon D Steppacher, Klaus A Siebenrock, Moritz Tannast. Periacetabular Osteotomy Provides Higher Survivorship Than Rim Trimming for Acetabular Retroversion. Comparative Study, Clin Orthop Relat Res. 2017 Apr;475(4):1138-1150.doi: 10.1007/s11999-016-5177-5.
文献7
日常生活活动中的髋、膝和踝关节运动学：一项横断面研究
译者 王一昕
背景：健康受试者的关节角度数据是康复训练必要的基线信息。
目的：分析患者因活动范围受限而难以进行日常生活活动（ADL）的问题，并根据客观数据提供ADL指导。
方法：使用电磁三维跟踪系统（FASTRAK）测量26名健康成年人在进行22项与穿衣、如厕、洗澡、捡东西和蹲下有关的日常生活活动时，主腿的髋关节、膝关节和踝关节角度。对于每个ADL，26名受试者的最大角度取平均值。还测量了髋关节最大屈曲时的内收/外展和内旋/外旋的平均角度。
结果：髋关节屈曲（蹲下时躯干旋转）的最大平均最大角度为101°，髋关节内收（穿鞋）为17°，膝关节屈曲（跪下时躯干转动）为149°。髋关节最大屈曲时的内收/外展和内/外旋角度分析显示，穿鞋时内收角度最大，蹲下躯干旋转时内旋角度最大。
结论：蹲下和穿裤子等日常活动能力比走路、爬楼梯和站起来表现出更大的关节角度。本研究的结果可为全髋关节置换术和股骨髋臼撞击患者的ADL指导提供重要的客观数据。
关键词：下肢关节；运动范围；康复；自我照料。
Hip, knee, and ankle kinematics during activities of daily living: a cross-sectional study
Background: Joint angle data from healthy subjects are necessary as baseline information.
Objective: To analyze the problems of patients who struggle with activities of daily living (ADL) due to restricted range of motion and to provide ADL guidance based on objective data.
Method: An electromagnetic three-dimensional tracking system (FASTRAK) was used to quantify the hip, knee, and ankle angles of the dominant leg of 26 healthy adults as they performed 22 ADLs related to dressing, using the toilet, bathing, picking up objects, and crouching. For each ADL, the maximum angle was averaged across the 26 subjects. Mean angles of adduction/abduction and internal/external rotation during maximum hip flexion were also measured.
Results: The largest mean maximum angle was 101° for hip flexion (trunk rotation during crouching), 17° for hip adduction (putting on shoes), and 149° for knee flexion (trunk rotation during crouching). Analysis of adduction/abduction and internal/external rotation angles during maximum hip flexion showed the largest angle of adduction when putting on shoes, and the largest angle of internal rotation with trunk rotation during crouching.
Conclusions: ADLs such as crouching and putting on pants showed larger joint angles than walking, climbing stairs, and standing up. Results obtained from this study can provide important objective data for ADL guidance for total hip arthroplasty and femoroacetabular impingement patients.
文献出处：Kashitaro Hyodo, Tadashi Masuda, Junya Aizawa, Tetsuya Jinno, Sadao Morita. Hip, knee, and ankle kinematics during activities of daily living: a cross-sectional study. Braz J Phys Ther. 2017 May-Jun.
保髋门诊：张洪，罗殿中 18911358880，张建立 18810029556，程徽 13810382426：周三上午，周二下午
关节置换门诊：张洪：周三上午；马云青 13811705624：周二上午，周三上午
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