本期目录：
1、在关节假体周围感染的手术治疗过程中应用美兰作为清创范围标记物
2、全膝关节置换术中关闭切口时膝关节的最佳位置：文献综述
3、一体式等弹力髋臼杯可以比分体式压配髋臼杯保留更多髋臼侧和股骨侧骨质：一项前瞻性随机对照试验
4、机械臂辅助全膝关节置换术提高了手术准确性及患者报告的结果: 系统回顾和荟萃分析
5、应用髋臼横韧带确定术中髋臼杯外展角
6、股骨头坏死细针多孔道髓芯减压术疗效观察：基于核磁影像和等效球回顾性队列分析
7、髋臼覆盖测量值的差异：重识前覆盖和外侧覆盖
8、幼儿髋关节发育不良患者的髋臼前倾角和股骨颈前倾角
9、关于治疗脑瘫髋外翻生长调控螺钉位置的研究
10、髋臼旋转截骨术对发育性髋关节发育不良患者髋关节内机械应力的影响：病人特异的有限元分析
11、使用体积来确定股骨头坏死病灶大小的精确且可靠的方法
第一部分：关节置换及保膝相关文献
文献1
在关节假体周围感染的手术治疗过程中
应用美兰作为清创范围标记物
译者：张轶超
背景：近期没有好的在假体周围感染（PJI）外科手术中区分出感染组织的方法。本研究的目的是（1）评估美兰作为蓝色标记物在PJI清创手术过程中找到病灶范围的应用及（2）评估其在术中对于切除感染组织和保留未感染组织的有效性。
方法：本前瞻性研究包含16例全膝关节置换术后因PJI行两期膝翻修手术的第一次手术病例，这些病例均符合骨骼肌肉感染协会对于PJI的诊断标准。清创前将稀释的美兰（0.1%）注入到膝关节内，去掉多余的美兰，清除着色的组织。清创过程中从股骨侧、胫骨侧和关节囊上分别取着色组织和未着色组织做为病理标本。取出的标本分别做中性粒细胞计数、半定量培养及定量聚合酶链反应（PCR）测定。手术成功率被作为次要效果被评估。
结果：病例的平均年龄为64.0 ± 6.0岁，平均随访24.4 ± 3.5 月。半定量培养结果显示美兰着色组织中培养出细菌的比例高于未着色组织（P=0.001)。PCR测定葡萄球菌含量结果显示美兰着色组中的生物负载量是未着色组的9倍（P=0.02）。通过组织病理学观察到着色组中每高倍视野下的多核中性粒细胞含量平均为 53 ± 46个，未着色组为4 ± 13个（P=0.0001）。所有病例经过第一次清创后均作了二期假体再置植入手术。在平均2年的随访时，有25%的病例又出现因新的病原体导致的感染。
结论：本结果建议大家可以在做PJI手术时使用美兰作为清除感染组织的可视性指示剂。
图示：示范流程。1、稀释美兰；2、切开关节后注入美兰稀释液；3、清创.从股骨侧、胫骨侧和关节囊上取标本；4、在取下的假体上可见生物被膜。
Methylene Blue-Guided Debridement as an Intraoperative Adjunct for the Surgical Treatment of Periprosthetic Joint Infection
Background: Current methods to identify infected tissue in periprosthetic joint infection (PJI) are inadequate. The purpose of this study was (1) to assess methylene blue-guided surgical debridement as a novel technique in PJI using quantitative microbiology and (2) to evaluate clinical success based on eradication of infection and infection-free survival.
Methods: Sixteen total knee arthroplasty patients meeting Musculoskeletal Infection Society criteria for PJI undergoing the first stage of 2-stage exchange arthroplasty were included in this prospective study. Dilute methylene blue (0.1%) was instilled in the knee before debridement, residual dye was removed, and stained tissue was debrided. Paired tissue samples, stained and unstained, were collected from the femur, tibia, and capsule during debridement. Samples were analyzed by neutrophil count, semiquantitative culture, and quantitative polymerase chain reaction (PCR). Clinical success was a secondary outcome.
Results: The mean age was 64.0 ± 6.0 years, and follow-up was 24.4 ± 3.5 months. More bacteria were found in methylene blue-stained vs unstained tissue-based on semiquantitative culture (P = .001). PCR for staphylococcal species showed 9-fold greater bioburden in methylene blue-stained vs unstained tissue (P = .02). Tissue pathology found 53 ± 46 polymorphonuclear leukocytes per high-power field in methylene blue-stained vs 4 ± 13 in unstained tissue (P = .0001). All subjects cleared their primary infection and underwent reimplantation. At mean 2-year follow-up, 25% of patients failed secondary to new infection with a different organism.
Conclusion: These results suggest a role for methylene blue in providing a visual index of surgical debridement in the treatment of PJI.
文献出处：Shaw JD, Miller S, Plourde A, Shaw DL, Wustrack R, Hansen EN. Methylene Blue-Guided Debridement as an Intraoperative Adjunct for the Surgical Treatment of Periprosthetic Joint Infection. J Arthroplasty. 2017 Dec;32(12):3718-3723. doi: 10.1016/j.arth.2017.07.019. Epub 2017 Jul 21. PMID: 28811108.
文献2
全膝关节置换术中关闭切口时膝关节的
最佳位置：文献综述
译者：马云青
如何提高全膝关节置换术后膝关节活动度(ROM)的研究已经成为外科医生关注的焦点。全膝关节置换术中关闭切口的方式被认为是膝关节置换围手术期的影响术后膝关节活动度的因素之一。因此，本研究旨在探讨膝关节置换术中关闭切口时膝关节的位置对：1.术后关节活动度(ROM)、2.术后并发症、3.膝关节社会评分(KSS)、4.术后疼痛、5.肌力及居家功能恢复的影响。使用PubMed、Ovid和Google Scholar进行文献检索，使用以下搜索关键词的不同组合,包括：“切口关闭”、“膝关节位置”、“切口缝合”和“膝关节置换”。这些检索出的文献均根据关闭切口时膝关节的位置进行了分层，并比较评价了TKA术后的临床结果。根据纳入和排除标准，共有7项研究被采用，包括516名患者(屈曲缝合组259例患者，伸膝缝合组257例患者)。根据文献回顾，与伸直位缝合组比较，屈曲缝合组TKA术后早期膝关节ROM恢复显著提高(4项研究肯定和3项研究中立)，术后早期疼痛评分较好(2项肯定和1项研究中立)，身体恢复较快(2项研究肯定)和更好的肌肉力量恢复，能够早期达到物理治疗目标。在远期ROM 恢复、术后长期疼痛评分、伤口相关并发症(7项研究中立)、KSS膝关节功能评分(5项研究中立)、TKA术后患者满意度等方面，屈曲缝合与伸直位缝合无差异。虽然此综述是仅包含了有限的文献研究，但文献中明确表明，相比于伸直位缝合切口，全膝关节置换术后屈曲位缝合切口能够在术后早期提供更好的关节活动度，达到快速恢复，提高患者满意度，同时并不会产生较高的伤口并发症风险。
Knee Position during Surgical Wound Closure in Total Knee Arthroplasty: A Review
Study areas concerning maximizing knee range of motion (ROM) following total knee arthroplasty (TKA) have come under focus by surgeons. Among the perioperative factors that were identified to affect ROM after TKAs is knee position during surgical wound closure. Therefore, the aim of this study was to review the impact of knee position during TKA wound closure on: (1) postoperative ROM, (2) wound-related complications, (3) Knee Society Score (KSS), (4) postoperative pain, and (5) muscle strength and home functional recovery. A literature search was performed using PubMed, Ovid, and Google Scholar using various combinations of the following search terms: 'wound closure,' 'knee position,' 'surgical closure,' and 'knee arthroplasty.' The studies were evaluated for outcomes after TKA and stratified based on the knee position at surgical closure. After application of inclusion and exclusion criteria, seven studies were analyzed. The total number of patients included was 516 patients (259 patients in the flexion group and 257 patients in the full extension group). Based on the reviewed literature, wound closure in flexion was associated with significant improvement in ROM recovery at earlier follow-ups after TKA (four positive and three neutral studies), better early postoperative pain scores (two positive and one neutral study), and faster physical recovery (two positive studies) (better muscle strength and early achievement of physical therapy milestones) compared with wound closure in extension. No difference was found between wound closure in flexion compared with closure in extension in terms of long-term ROM recovery, long-term postoperative pain scores, wound-related complications (seven neutral studies), knee function measured by KSS (five neutral studies), or patient satisfactions after TKA. Although the current review is limited by the number of studies that are available in the literature, it demonstrates that overall, compared with extension, surgical wound closure in flexion may provide better ROM, faster recovery, comparable patient satisfaction, and no risk of higher wound complications.
文献出处：Faour M, Sodhi N, Khlopas A, Piuzzi NS, Stearns KL, Krebs VE, Higuera CA, Mont MA. Knee Position during Surgical Wound Closure in Total Knee Arthroplasty: A Review. J Knee Surg. 2018 Jan;31(1):6-12. doi: 10.1055/s-0037-1608838. Epub 2017 Nov 22. PMID: 29166680.
文献3
一体式等弹力髋臼杯可以比分体式压配髋臼杯
保留更多髋臼侧和股骨侧骨质：
一项前瞻性随机对照试验
译者：张蔷
背景：对于全髋关节翻修来说，翻修假体稳定植入的前提是有充足的骨量。由于应力遮挡的缘故生物型髋臼杯会导致假体周围骨密度（BMD）相对降低。
方法：本项前瞻性随机对照试验共入组了50位患者。组1（RM组）应用一体式等弹力髋臼杯（RM 压配式 vitamys；Mathys）。组2（IT组）应用分体式钽金属髋臼杯（Allofit-S IT 配聚乙烯内衬；Zimmer）。我们把髋臼周围骨质进一步划分为4个兴趣区，并应用双能X线法分别在术后1周（基线值）和术后4年两个时间点测定兴趣区的骨密度。我们的初步结果是发现了髋臼周围骨密度降低。
左侧为一体式髋臼杯RM杯；右侧为分体式髋臼杯IT杯。
DeLee和Charnley制定的髋臼周围分区法
股骨侧Greun分区法
结果：相较于术后一周，术后4年时的髋臼周围骨密度RM组平均下降了15.1%而IT组平均下降了16.5%。髋臼周围骨质在组间无显著性差异。而RM组（4.9%±10.0%）和IT组（15.9%±14.9%）在极区（2区）的骨量减低存在显著性差异（p=0.005）。应用一体式RM杯所引发的骨量减低显著低于分体式IT杯。
结论：我们统计了术后4年髋臼周围骨密度减低情况。髋臼周围总体骨量减低在组间无显著性差异，但应用一体式髋臼杯组在髋臼周围2区的骨量减低显著更少。两种髋臼杯的优劣比较需要长期的随访结果来佐证。
An Isoelastic Monoblock Cup Retains More Acetabular and Femoral Bone Than a Modular Press-Fit Cup: A Prospective Randomized Controlled Trial
Background: For cup revision after total hip arthroplasty, sufficiently good periacetabular bone stock is a prerequisite for fixation of the revision implant. Cementless cups can lead to a relevant reduction of peri-implant bone mineral density (BMD) through stress-shielding.
Methods: Fifty patients were included in this prospective randomized controlled trial. Group 1 (RM group) received an isoelastic monoblock cup (RM Pressfit vitamys; Mathys). Group 2 (IT group) received a modular titanium cup (Allofit-S IT Alloclassic with a polyethylene liner; Zimmer). Periacetabular BMD was determined and subdivided into 4 regions of interest by dual x-ray absorptiometry at 1 week (baseline) and at 4 years postoperatively. Our primary outcome was reduction in periacetabular BMD.
Results: Periacetabular BMD was reduced by an average of 15.1% in the RM group and 16.5% in the IT group at 4 years postoperatively. No significant difference was found between the 2 groups over the periacetabular structure as a whole. However, the decrease of BMD in the polar region was significantly different in the RM group (4.9% ± 10.0%) compared with the IT group (15.9% ± 14.9%, p = 0.005). Use of the isoelastic RM cup showed significantly less bone loss than the modular IT cup.
Conclusions: Relevant loss of BMD at 4 years after surgery was identified in the periacetabular region in both groups. No differences between the 2 cup systems were found when looking at the overall periacetabular region. As a secondary outcome, less postoperative periacetabular bone loss occurred in the polar region when an isoelastic cup was used. Longer follow-up is required to allow for conclusions to be drawn about the long-term course of the 2 cup systems.
文献出处：Brodt S, Jacob B, Nowack D, Zippelius T, Strube P, Matziolis G. An Isoelastic Monoblock Cup Retains More Acetabular and Femoral Bone Than a Modular Press-Fit Cup: A Prospective Randomized Controlled Trial. J Bone Joint Surg Am. 2021 Feb 18. doi: 10.2106/JBJS.19.00787. Epub ahead of print. PMID: 33617161.
文献4
机械臂辅助全膝关节置换术提高了手术准确性
及患者报告的结果: 系统回顾和荟萃分析
译者：沈松坡
本研究进行了系统回顾和荟萃分析，以比较机械臂辅助全膝关节置换术(RATKA)与徒手TKA (mTKA)的假体定位、对线和平衡技术的准确性、患者报告的结果、并发症和相关的学习曲线。利用PRISMA指南在2020年10月对PubMed、Medline和谷歌学术网站进行了检索。检索词包括“机器人”、“膝关节”和“关节成形术”。纳入标准为已发表的临床研究文章，报告RATKA的学习曲线和比较假体位置精度、对线和平衡技术、功能结果或mTKA并发症。经过全文筛选，初步确定有198篇文章，最终有16篇研究符合纳入标准，报告了rTKA学习曲线(n=5)、假体定位精度(n=6)、对线和平衡技术(n=7)、功能结果(n=7)或并发症(n=5)。两项研究报告了使用CUSUM分析仅通过7到11个案例即可完成操作熟练度拐点的学习曲线，发现在假体定位精度方面没有学习曲线。荟萃分析显示，与mTKA组相比，RATKA组术前设计与术后实际假体位置的差异显著降低，且弥散较窄(股骨冠状位:均值1.31,95%置信区间(CI) 1.08-1.55, p<0.00001;胫骨冠状面:平均值1.56,95% CI 1.32-1.81, p<0.00001)。三项研究中mTKA组和RATKA组之间使用了不同的对线和平衡技术，两项研究对两组使用了相同的方法，两项研究没有说明在他们RATKA组使用的方法。与mTKA相比，RATKA在中短期随访中膝关节学会评分更好(95%CI[−1.23，−0.51]，p=0.004)。在关节纤维化、浅表和深层感染、伤口裂开或总体并发症发生率方面没有差异。RATKA证明了假体定位的准确性和患者报告的结果。RATKA对手术时间的学习曲线为7 ~ 11例。未来关于RATKAs的有指导意义的研究应报道膝关节对线和平衡技术，以便更好地比较哪些技术能使患者的预后最佳。
Robotic‐arm assisted total knee arthroplasty is associated with improved accuracy and patient reported outcomes: a systematic review and meta‐analysis
This systematic review and meta-analysis were conducted to compare the accuracy of component positioning, alignment and balancing techniques employed, patient-reported outcomes, and complications of robotic-arm assisted total knee arthroplasty (RATKA) with manual TKA (mTKA) and the associated learning curve. Searches of PubMed, Medline and Google Scholar were performed in October 2020 using PRISMA guidelines. Search terms included “robotic”, “knee” and “arthroplasty”. The criteria for inclusion were published clinical research articles reporting the learning curve for RATKA and those comparing the component position accuracy, alignment and balancing techniques, functional outcomes, or complications with mTKA. There were 198 articles identified, following full text screening, 16 studies satisfied the inclusion criteria and reported the learning curve of rTKA (n=5), component positioning accuracy (n=6), alignment and balancing techniques (n=7), functional outcomes (n=7), or complications (n=5). Two studies reported the learning curve using CUSUM analysis to establish an inflexion point for proficiency which ranged from 7 to 11 cases and there was no learning curve for component positioning accuracy. The meta-analysis showed a significantly lower difference between planned component position and implanted component position, and the spread was narrower for RATKA compared with the mTKA group (Femur coronal: mean 1.31, 95% confidence interval (CI) 1.08–1.55, p<0.00001; Tibia coronal: mean 1.56, 95% CI 1.32–1.81, p<0.00001). Three stud- ies reported using different alignment and balancing techniques between mTKA and RATKA, two studies used the same for both group and two studies did not state the methods used in their RATKA groups. RATKA resulted in better Knee Society Score compared to mTKA in the short-to-mid-term follow up (95%CI [− 1.23, − 0.51], p=0.004). There was no difference in arthrofibrosis, superficial and deep infection, wound dehiscence, or overall complication rates. RATKA demonstrated improved accuracy of component positioning and patient-reported outcomes. The learning curve of RATKA for operating time was between 7 and 11 cases. Future well-powered studies on RATKAs should report on the knee alignment and balancing techniques utilised to enable better comparisons on which techniques maximise patient outcomes.
文献出处：Zhang J, Ndou WS, Ng N, Gaston P, Simpson PM, Macpherson GJ, Patton JT, Clement ND. Robotic-arm assisted total knee arthroplasty is associated with improved accuracy and patient reported outcomes: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2021 Feb 6. doi: 10.1007/s00167-021-06464-4. Epub ahead of print. PMID: 33547914.
文献5
应用髋臼横韧带确定术中髋臼杯外展角
译者：张峻
背景：全髋关节置换术的成功取决于理想的髋臼杯安放，以确保股骨头和髋臼杯在髋关节的所有位置都能很好地匹配。髋臼杯位置不良与脱位、撞击、微分离、假体松动以及由于边缘负荷致磨损加速有关。本研究探讨了一种在初次全髋关节置换术中应用髋臼横韧带（TAL）确定髋臼杯外展角的新方法。
方法：采用9具尸体16髋进行描述性研究。计算机导航系统测量髋臼假体在3个位置的外展角，分别为髋臼杯下缘：（1）与TAL平齐，（2）距TAL自由缘近5mm，（3）距TAL自由缘远5mm。
结果：中位外展角度（1）为44°，中位外展角度（2）为30°，中位外展角度（3）为64°。3种不同位置的前倾角中位数为19°。
结论：当杯底边缘齐平TAL或距TAL近5mm范围内时，髋臼杯外展角可接受。
The Transverse Acetabular Ligament as an Intraoperative Guide to Cup Abduction
Background: The success of a total hip arthroplasty relies on optimal acetabular cup placement to ensure mating of the femoral head and acetabular cup throughout all positions of the hip joint. Poor cup placement is associated with dislocation, impingement, microseparation, component loosening, and accelerated wear due to rim loading. This study examined a novel method of using the transverse acetabular ligament (TAL) to guide cup inclination during primary total hip arthroplasty.
Methods: A descriptive study using 16 hips from 9 cadavers. A computer navigation system measured inclination and version of the acetabular component in 3 positions with the lower edge of cup: (1) flush with, (2) 5 mm proximal to, and (3) 5 mm distal to free border of the TAL.
Results: The median inclination angles were 44° in position (1), 30° in position (2), and 64° in position (3). The median anteversion angle for all positions was 19°.
Conclusion: Cup inclination was acceptable when the lower edge of the cup was flush or within 5 mm proximal to the TAL.
文献出处：Hiddema WB, van der Merwe JF, van der Merwe W. The Transverse Acetabular Ligament as an Intraoperative Guide to Cup Abduction. J Arthroplasty. 2016 Jul;31(7):1609-13. doi: 10.1016/j.arth.2016.01.019. Epub 2016 Jan 21. PMID: 26897492.
第二部分：保髋相关文献
文献1
股骨头坏死细针多孔道髓芯减压术疗效观察：
基于核磁影像和等效球回顾性队列分析
译者：罗殿中
背景：股骨头坏死（ANFH）在社区中发病率较高，带来一系列健康问题、经济问题和社会压力。髓芯减压是针对早期股骨头坏死应用最为广泛的治疗方法，虽然已经有多篇研究报告了髓芯减压对股骨头坏死治疗的有效性，但这些研究在对股骨头坏死的严重程度、坏死局部分布、手术前后坏死范围的变化等方面仍有不足。本研究基于核磁影像和等效球分析，深入分析细针多孔道髓芯减压术治疗ANFH的临床效果。
方法：自2013年7月至2016年11月，共有24例32髋ANFH经过细针多孔道髓芯减压治疗（克氏针2.5mm3枚+3.0mm2枚，共5孔道），对此进行回顾性队列分析。所有患者于术前、术后6/12/24月分别进行MRI检查、VAS评分、OHS-C评分、HHS评分。
结果：减压术后24个月，10个股骨头被切除/置换，酒精性股骨头坏死（AFNH）、不明原因股骨头坏死（IFNH）、激素引起的股骨头坏死（SIFNH）的生存率分别为100%、87.5%（-2个）、0%（-8个）。MRI和等效球分析发现，前上内象限最易发生股骨头坏死，后上内象限其次。手术后，所有病例总计酒精性股骨头坏死（AFNH）范围由14.5%减小至10.3%；不明原因股骨头坏死（IFNH）坏死范围由16.3%减小至9.2%；但激素导致的股骨头坏死（SIFNH）坏死范围由30.4%增加至33.1%。
结论：经皮细针多孔髓芯减压对酒精性股骨头坏死（AFNH）和不明原因的股骨头坏死（IFNH）可以显著较小坏死范围，但对激素引起的股骨头坏死（SIFNH）疗效欠佳。
Study on the outcome of patients with aseptic femoral head necrosis treated with percutaneous multiple small-diameter drilling core decompression: a retrospective cohort study based on magnetic resonance imaging and equivalent sphere model analysis
Background: Aseptic necrosis of the femoral head (ANFH) has a high incidence in the community and causes substantial problems with health as well as economic and social stress. Core decompression is the most commonly used treatment for early ANFH. Although many studies have reported on the efficacy of femoral head core decompression surgery for ANFH, there are still some shortcomings in assessing the severity of femoral head necrosis, the location distribution, and changes in necrotic lesions before and after surgery. Magnetic resonance imaging (MRI) and equivalent sphere model analysis were used to further clarify the clinical efficacy of percutaneous multiple small-diameter drilling core decompression in patients with ANFH.
Methods: From July 2013 to November 2016, 24 patients (32 cases of the hip joint) with ANFH who underwent percutaneous multiple small-diameter drilling core decompression were selected, and a retrospective analysis was conducted. MRI as well as VAS, OHS-C, and HHS scores were used to evaluate joint function in all patients before and 6, 12, and 24 months after the operation.
Results: Twenty-four months after the operation, 10 hips were amputated. The survival rates of alcoholic femoral head necrosis (AFNH), idiopathic femoral head necrosis (IFHN), and steroid-induced femoral head necrosis (SIFHN) patients at 24 months were 100%, 85.7% (- 2 hips), and 0.0% (- 8 hips), respectively. The MRI and equivalent sphere analysis results revealed that the anterior superior medial quadrant was the area most prone to osteonecrosis, and the posterior superior medial quadrant was the area second most prone to necrosis. After the operation, the average percentage of the AFHN necrosis area in the total volume of the femoral head decreased from 14.5 to 10.3%, and the average percentage of the IFHN necrosis area decreased from 16.3 to 9.2%; however, the average percentage of the necrosis area for SIFHN increased from 30.4 to 33.1%.
Conclusion: Percutaneous multiple small-diameter drilling core decompression significantly reduced the lesion volume for AFHN and IFHN, but the effect on SIFHN was not good.
文献出处：Tan Y, He H, Wan Z, Qin J, Wen Y, Pan Z, Wang H, Chen L. Study on the outcome of patients with aseptic femoral head necrosis treated with percutaneous multiple small-diameter drilling core decompression: a retrospective cohort study based on magnetic resonance imaging and equivalent sphere model analysis. J Orthop Surg Res. 2020 Jul 15;15(1):264. doi: 10.1186/s13018-020-01786-4. PMID: 32669119; PMCID: PMC7362550.
文献2
髋臼覆盖测量值的差异：重识前覆盖和外侧覆盖
译者：程徽
背景：外侧中心边缘角(LCEA)和前中心边缘角(ACEA)是评估股骨头髋臼覆盖情况的常用指标。文献中发现测量角度有两种不同的方法。分别为：测量到骨缘最外侧和眉弓硬化带外侧。这两种方法之间的差异可能影响对髋臼覆盖的估计，并可能最终导致临床误诊和治疗失误。本研究的目的是量化这两种测量方法（骨缘最外侧和眉弓硬化带外侧）的差异，并确定差异对成年患者临界髋关节病变评估的影响程度。
图1 测量LCEA：B，测量到骨缘最外侧；S，测量到眉弓硬化带外侧。
方法：两名观察者分别使用术前前后位片和假斜位片进行测量。Bland-Altman plot和配对t检验用于比较测量方法。
图2 测量ACEA：B，测量到骨缘最外侧；S，测量到眉弓硬化带外侧。
结果：使用两种测量方法（骨缘最外侧和眉弓硬化带外侧）测量LCEA和ACEA测量值有显著差异(P均< 0.001)。骨缘最外侧LCEA比眉弓硬化带外侧LCEA平均大4°(95%的置信区间-2°~10°)。骨缘最外侧ACEA比眉弓硬化带外侧平均大10°(95%置信区间-2°~ 22°)。这种差异可导致对同一髋关节的不同临床分类。
结论：在测量成年患者的LCEA和ACEA时，使用骨缘最外侧法和眉弓硬化带外侧法对髋臼覆盖的定量在统计学和临床意义上看均有显著差异，因此必须明确在每项研究中使用的是哪种方法。
译者的话：在LCE角和ACE角都 原始文献中，并没有指定测量是到骨缘最外侧还是到眉弓硬化带外侧，随着认识不断加深我们才逐渐认识到两者有不同，眉弓硬化带外侧才是真正的髋臼覆盖。所以阅读经典文时也需要用批判的眼光学习，不能教条的照单全收。
Discrepancies in measuring acetabular coverage: revisiting the anterior and lateral center edge angles
The lateral center edge angle (LCEA) and the anterior center edge angle (ACEA) are commonly used to assess acetabular coverage of the femoral head. There are two distinct methods found in the literature to obtain these angles, specifically, measuring to the most lateral bone edge versus the sclerotic lateral sourcil edge. A difference between these two methods may contribute to inconsistent estimates of acetabular coverage, and potentially lead to clinical misdiagnosis and treatment mismanagement.
The objectives of this study were to quantify the difference between bone edge and sourcil edge measurements and to determine how the difference influences the classification of acetabular coverage in adult patients with suspected hip pathomorphology. Two observers completed the measurements independently using preoperative anteroposterior and false profile radiographs. Bland-Altman plots and paired t-tests were used to compare measurement methods.
Bone and sourcil measurements of the LCEA and ACEA were significantly different (both P < 0.001). On average, the bone LCEA was 4° (95% limits of agreement = -2° to 10°) greater than the sourcil LCEA. The bone ACEA was, on average, 10° (95% limit of agreement = -2° to 22°) greater than the sourcil ACEA. The differences often led to different clinical classifications for the same hip.
With a statistically and clinically significant difference in the quantification of acetabular coverage using bone edge versus sourcil edge methods for measuring the LCEA and ACEA in adult patients, it should be mandatory to clearly identify which method was used in each study.
文献出处：Joey A Hanson, Ashley L Kapron, Kathryn M Swenson, Travis G Maak, Christopher L Peters, Stephen K Aoki. Discrepancies in measuring acetabular coverage: revisiting the anterior and lateral center edge angles. J Hip Preserv Surg. 2015 Jun 13;2(3):280-6. doi: 10.1093/jhps/hnv041. eCollection 2015 Oct.
文献3
幼儿髋关节发育不良患者的髋臼前倾角和股骨颈前倾角
译者：肖凯
本研究通过应用计算机断层扫描对27名早期行走的髋关节发育不良的患儿（年龄范围：18-48个月）的髋臼前倾角与股骨颈前倾角之间的关系进行研究。在标准骨盆正位X射线照片中测量中心边缘角和髋臼指数，并使用二维计算机断层扫描测量患儿的髋臼前倾角和股骨颈前倾角。使用Ishida标准通过影像学检查确定髋关节是否有发育不良、半脱位和完全脱位。所有54髋中，有25髋完全脱位，19髋半脱位，10髋正常。三组之间的中心边缘角、髋臼指数和髋臼前倾角有统计学差异。三组间股骨颈前倾角无统计学差异。正常组髋臼前倾角为13.4 +/- 2.8度（平均+/- SD），半脱位组为16.7 +/- 1.9度，完全脱位组为19.8 +/- 2.5度。三组之间在统计学上有显着差异，所有组中髋臼前倾角的范围都很大（9-26度）。在每名患儿的脱位侧髋臼前倾角增加，无髋臼后倾的情况。另一方面，各组之间在股骨颈前倾角没有显着差异。我们得出结论，在治疗幼儿发育性髋关节发育不良患者时，需要通过二维计算机断层扫描来确认髋臼和股骨颈前倾角。
Anteversion of the acetabulum and femoral neck in early walking age patients with developmental dysplasia of the hip
Computed tomography measurements were made to quantify the relationship between the anteversion of the acetabulum and femoral neck in 27 early walking age patients (age range; 18-48 months) with developmental dysplasia of the hip. The centre-edge angle and acetabular index were measured in standard pelvis radiographs, and anteversion of acetabulum and femoral neck were measured by use of two-dimensional computed tomography in 25 complete dislocated, 19 subluxated and 10 unaffected hips (a total of 54 hips). The diagnosis of dysplasia, subluxation and complete dislocation of developmental hip dysplasia were determined radiographically using Ishida's criteria. There were statistically significant differences between the three groups for the centre-edge angle, the acetabular index, and acetabulum anteversion. There was no statistically significant difference between the three groups for femoral neck anteversion. The acetabular anteversion was found to be 13.4+/-2.8 degrees (mean+/-SD) in unaffected hips, 16.7+/-1.9 degrees in subluxated hips and 19.8+/-2.5 degrees in complete dislocated hips. There was statistically significant difference between the three groups, with a wide range of acetabular anteversion values noted in all groups (9-26 degrees ). The acetabular anteversion was increased on the dislocated side in each patient and we found no retroverted acetabulum. On the other hand there was no significant difference between the groups with regards to femoral neck anteversion. We conclude that confirming anteversion of the acetabulum and the femoral neck by two-dimensional computed tomography is needed in treatment planning of early walking age patients with developmental hip dysplasia.
文献出处：Sarban S, Ozturk A, Tabur H, Isikan UE. Anteversion of the acetabulum and femoral neck in early walking age patients with developmental dysplasia of the hip. J Pediatr Orthop B. 2005 Nov;14(6):410-4. doi: 10.1097/01202412-200511000-00003. PMID: 16200015.
文献4
关于治疗脑瘫髋外翻生长调控螺钉位置的研究
译者：任宁涛
目的：生长调控可用于治疗儿童脑瘫（CP）引起的髋外翻，然而关于置钉最佳位置的研究未有报道，本研究旨在研究不同置钉位置对生长调控效果的影响。
方法：采用回顾性研究，纳入2012年7月-2017年9月之间行股骨近端内侧骨骺阻滞的脑瘫患儿，共32名62例髋关节，通过冠状面上螺钉经过内侧骺板的位置分为两组，组1为经过骨骺的内侧1/4（< 25%），组2为经过内侧骨骺的中间1/4（≥ 25%, < 50%），对术前和术后头干角（HSA）、Reimer外移指数（MP）、髋臼指数（AI）以及股骨前倾角（FAVA）进行比较，对术后两年内螺钉失效的发生率进行统计。进行线性和Cox回归分析，以确定与HSA矫正和螺钉失效风险相关的因素。
结果：组1共纳入37例髋关节，组2纳入24例髋关节，其中组1的HAS（p = 0.003）和MP（p = 0.032）矫正较为显著，两组在AI（p = 0.809）和FAVA（p = 0.304）矫正效果相似。与组2相比，组1螺钉失效率高（p = 0.038）。回归分析结果表明，螺钉位置的偏心与HSA的矫正相关，但增加了螺钉失效的风险。
结论：生长调控可有效改善CP患儿髋外翻和股骨前倾角的有效方法，对于年轻患者，我们推荐使用组2 的置钉位置，虽然降低了内翻矫正效果，但可降低螺钉失效的概率。
图1 a 组1置钉位置，b 组2置钉位置
Aims: Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth.
Methods: We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer's migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw.
Results: A total of 37 hips in Group 1 and 24 hips in Group 2 were compared. Group 1 showed a more substantial decrease in the HSA (p = 0.003) and the MP (p = 0.032). Both groups had significant and similar improvements in the AI (p = 0.809) and the FAVA (p = 0.304). Group 1 presented a higher incidence of the physis growing-off the screw (p = 0.038). Results of the regression analysis indicated that the eccentricity of screw position correlated with HSA correction and increases the risk of the physis growing-off the screw.
Conclusion: Guided growth is effective in improving coxa valga and excessive femoral anteversion in CP children. For younger children, despite compromised efficacy of varus correction, we recommend a more centered screw position, at least across the middle quarter of the medial physis, to avoid early revision. Cite this article: Bone Joint J 2020;102-B(9):1242-1247.
文献出处：Po-Jen Hsu, Kuan-Wen Wu, Chia-Che Lee, Sheng-Chieh Lin, Ken N Kuo 2 5, Ting-Ming Wang 2 6 Does screw position matter for guided growth in cerebral palsy hips. Bone Joint J . 2020 Sep;102-B(9):1242-1247.
文献5
髋臼旋转截骨术对发育性髋关节发育不良患者
髋关节内机械应力的影响：病人特异的有限元分析
译者：张利强
在这项研究中，我们使用病人特异的有限元分析来研究髋臼旋转截骨术（RAO）对髋关节的力学影响，并分析各种放射学测量值与髋关节机械应力之间的相关性。
我们对12例（男2例，女10例，平均手术年龄32.0岁；19～46岁）发育性髋关节发育不良（DDH）患者行RAO治疗，共13髋。根据CT数据重建受试者特异的有限元模型。在骨盆正位片上测量RAO术前和术后的中心-边缘角（CE）、髋臼股骨头指数（AHI）、髋臼角和髋臼顶角（ARA）。分析髋关节应力与放射学测量参数之间的关系。
髋臼应力由术前的4.1mpa（2.7～6.5）降至术后的2.8mpa（1.8～3.6）（p<0.01）。髋臼应力与放射学测量值呈中度相关：CE角（R=-0.645，p<0.01）；AHI（R=-0.603，p<0.01）；髋臼角（R=0.484，p=0.02）；ARA（R=0.572，p<0.01）。
DDH患者术后髋臼应力降低。纠正CE角、AHI和ARA被认为是降低髋关节机械应力的重要因素。
髋臼旋转截骨术前后髋臼应力分布的图像。显示承载区的应力集中
Effects of rotational acetabular osteotomy on the mechanical stress within the hip joint in patients with developmental dysplasia of the hip: A subject-specific finite element analysis
In this study we used subject-specific finite element analysis to investigate the mechanical effects of rotational acetabular osteotomy (RAO) on the hip joint and analysed the correlation between various radiological measurements and mechanical stress in the hip joint.
We evaluated 13 hips in 12 patients (two men and ten women, mean age at surgery 32.0 years; 19 to 46) with developmental dysplasia of the hip (DDH) who were treated by RAO. Subject-specific finite element models were constructed from CT data. The centre–edge (CE) angle, acetabular head index (AHI), acetabular angle and acetabular roof angle (ARA) were measured on anteroposterior pelvic radiographs taken before and after RAO. The relationship between equivalent stress in the hip joint and radiological measurements was analysed.
The equivalent stress in the acetabulum decreased from 4.1 MPa (2.7 to 6.5) pre- operatively to 2.8 MPa (1.8 to 3.6) post-operatively (p < 0.01). There was a moderate correlation between equivalent stress in the acetabulum and the radiological measurements: CE angle (R = –0.645, p < 0.01); AHI (R = –0.603, p < 0.01); acetabular angle (R = 0.484, p = 0.02); and ARA (R = 0.572, p < 0.01).
The equivalent stress in the acetabulum of patients with DDH decreased after RAO. Correction of the CE angle, AHI and ARA was considered to be important in reducing the mechanical stress in the hip joint.
文献出处：Ike H, Inaba Y, Kobayashi N, Yukizawa Y, Hirata Y, Tomioka M, Saito T. Effects of rotational acetabular osteotomy on the mechanical stress within the hip joint in patients with developmental dysplasia of the hip: a subject-specific finite element analysis. Bone Joint J. 2015 Apr;97-B(4):492-7. doi: 10.1302/0301-620X.97B4.33736. PMID: 25820887.
文献6
使用体积来确定股骨头坏死病灶大小的
精确且可靠的方法
译者：陶可（北京大学人民医院骨关节科）
背景：使用磁共振成像（MRI）和3D软件确定与股骨头坏死有关的体积测量结果是否比其他先前描述的方法更为精确。
方法：24例患者被纳入该研究。两名肌肉骨骼放射科医生使用Kerboul等人[9]，Koo和Kim [10]和Cherian等人[11]描述的方法，独立地分析了X线片和MRI结果。体积测量值是使用3D成像软件从MRI计算得到。使用类间相关系数（ICC）计算所有4种方法的评定者间可靠性。使用Levene检验比较各种方法之间的方差，以衡量每种方法的精度。
结果：体积测量的ICC值为0.81。Kerboul等人，Koo和Kim以及Cherian等人的方法的ICC值分别为0.94、0.61和0.49。使用Levene绝对偏差对方差均一性的检验表明，各方法之间的方差不相等（P <0.01）。计算出方差和相应的95％置信区间，表明所测量的4种方法中体积测量的方差最小，表明与其他方法相比，体积测量在表征病变大小方面更为精确。
结论：使用3D MRI成像软件评估股骨头坏死的体积测量病变大小比以前描述的方法更为精确，且具有出色的观察者间可靠性。股骨头坏死体积的3D MRI评估可能对临床决策有用。
图1. Kerboul方法是根据在前后位X线片上测得的角度（红线）之和估算骨坏死病变的大小。
图2. Koo和Kim [12]方法，是使用在（A）冠状T1和（B）矢状PD FS MR图像上测量的角度（用红线表示）来估计病变大小。MR，核磁共振；PD FS，质子密度抑制脂肪。
图3. 在同一髋关节上测量的Cherian等人[11]的方法，如图2所示。Cherian方法也是使用角度（用红线表示）来估计在冠状T1和矢状PD上测得的病变大小FS MR图像；然而，测量是在显示最大病变尺寸的（A）冠状和（B）矢状图像上进行的。
图4. 使用Synapse 3D软件在冠状T1图像上进行体积测量。测量每个切片上的病变面积（以A-C表示），并乘以切片的厚度。然后将每个切片的体积相加从而得到病灶总体积。然后，将该体积除以股骨头的总体积，从而计算出坏死过程累及股骨头的百分比（在D-E中显示）。
图5. 使用4种不同的方法测量24例股股骨头的坏死病灶的大小：使用3D软件，Kerboul方法，Koo和Kim方法以及Cherian方法进行体积测量。绘制这些值，除体积测量外，使用各种方法对病变的大小通常会高估，病变大小在股骨头受累的100％左右或以上。
图6. 股骨头坏死病变的大小和位置可能明显不同，角度测量结果可能无法反映这一点。以上是病变的示例（每个髋关节中的A和B），通过角度测量可以认为是等效的，但是大小和位置明显不同，并且可能会导致不同的处理方式。
A Precise and Reliable Method of Determining Lesion Size in Osteonecrosis of the Femoral Head Using Volumes
Background: To ascertain whether volumetric measurements to characterize lesion size in osteonecrosis of the femoral head using magnetic resonance imaging (MRI) and 3D software are more precise than other previously described methods.
Methods: Twenty-four patients were included in the study. Two musculoskeletal radiologists independently analyzed radiographs and MRIs using the methods described by Kerboul et al [9], Koo and Kim [10], and Cherian et al [11]. Volumetric measurements were calculated from the MRIs using 3D imaging software. Inter-rater reliability was calculated for all 4 methods using the interclass correlation coefficient (ICC). Levene's test was used to compare the variance across methods, serving as a measure of precision of each method.
Results: An ICC value of 0.81 was calculated for the volumetric measurements. The ICC values of the Kerboul et al, Koo and Kim, and Cherian et al methods were 0.94, 0.61, and 0.49, respectively. Levene's test for homogeneity of variance using absolute deviations showed the variance was not equal across methods (P < .01). The variance and the corresponding 95% confidence interval were calculated showing that the variance for the volumetric measurements was the smallest among the 4 methods examined, indicating that the volumetric measurements are more precise in characterizing lesion size as compared to the other methods.
Conclusion: Volumetric measurements of lesion size using 3D MRI imaging software to assess osteonecrosis of the femoral head are more precise than previously described methods and have excellent interobserver reliability. A 3D MRI assessment of volume of osteonecrosis in the femoral head may be useful in clinical decision-making.
文献出处：Kevork N Hindoyan, Jay R Lieberman, George R Matcuk Jr, Eric A White. A Precise and Reliable Method of Determining Lesion Size in Osteonecrosis of the Femoral Head Using Volumes. J Arthroplasty. 2020 Jan;35(1):285-290.
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