本期目录：
1、髋关节和膝关节置换术后耐药、非典型和培养阴性的关节假体周围感染的处理
2、术中内侧副韧带撕脱伤对初次全膝关节置换术疗效的影响
3、全膝关节置换术前的营养学实验室检查：临床实践与文献结果的比较
4、膝关节融合术治疗全膝关节置换术后感染的功能结局
5、将运动与临床、功能和结构结果联系起来：来自骨关节炎计划的证据图
6、膝关节软骨下骨不全骨折：当前概念和影像学鉴别诊断的综述
7、股骨颈相对延长联合关节外截骨短期并发症
8、髋关节发育不良的流行病学：日本国家数据库分析
9、应用Graf超声分析臀位与头位分娩新生儿DDH的风险
10、反向髋臼周围截骨术治疗有症状的髋臼前倾
11、髋臼周围截骨术（PAO）：治疗髋臼后倾：系统评价和荟萃分析
12、活跃患者在髋臼周围截骨术中期随访中的活动水平维持的研究
13、早期骨关节炎的物理因子治疗方案
第一部分：关节置换及保膝相关文献
文献1
髋关节和膝关节置换术后耐药、非典型和培养阴性的关节假体周围感染的处理
译者 张轶超
背景:关节假体周围感染(PJI)是关节置换术(TJA)后的严重并发症。它是TJA术后出现问题和翻修的主要原因。因此，PJI是导致医疗成本增加的一个重要因素。由于耐药和非典型病原菌导致PJI的患病率逐渐在增加，大约10-30%的PJI为培养阴性。本综述的目的是总结目前与耐药、非典型病原体和培养阴性PJI相关的PJI的流行病学、诊断和治疗。
方法:回顾关于非典型、耐药和培养阴性PJI的流行病学、诊断和治疗相关的文献。
结果:PJI的临床诊断往往是具有挑战性的，特别是当病原体很难被发现的或按照经验使用抗生素的。分子学诊断研究，如关节液α-防御素，即使在同时使用抗生素或伴随全身性炎症疾病的情况下也可以提供快速，准确的PJI鉴定。一旦确诊PJI，两期翻修术仍然是治疗耐药微生物PJI的金标准，因为冲洗、清创和一期翻修术治疗失败率很高。
结论:真菌和分枝杆菌等罕见致病菌引起的PJIs的最佳治疗方法有待进一步研究。需要廉价、可靠的检测方法来快速检测特定的微生物种类和抗微生物药物的敏感性。还需要进一步研究来确定特定的生物体、针对其的临床应对策略、手术技术和抗菌素治疗方案，以提高保留假体手术的治疗成功率。
Management of Resistant, Atypical and Culture-negative Periprosthetic Joint Infections after Hip and Knee Arthroplasty
Background: Periprosthetic joint infection (PJI) is a devastating complication following lower extremity total joint arthroplasty (TJA). It is a leading cause of morbidity and revision following TJA. As such, PJI is a significant driver of healthcare costs. The prevalence of PJI related to resistant and atypical organisms is increasing, and approximately 10-30% of PJIs are culture-negative. The purpose of this review is to summarize the current epidemiology, diagnostics, and management of PJI associated with resistant and atypical pathogens and of culture-negative PJIs.
Methods: The published literature related to the epidemiology, diagnosis, and management of atypical, drug-resistant, and culture-negative PJI is reviewed.
Results: The clinical diagnosis of PJI is often challenging, particularly when pathogens are fastidious or when antibiotics have been administered empirically. Molecular diagnostic studies, such as synovial α-defensin, may provide rapid, accurate identification of PJI, even in the setting of concurrent antibiotics administration or systemic inflammatory disease. Once PJI is diagnosed, two-stage exchange arthroplasty remains the gold standard for treating PJI with resistant microorganisms, since there is a high rate of treatment failure with irrigation and debridement and with one-stage exchange arthroplasty.
Conclusion: Additional research is needed to define the optimal treatment of PJIs associated with rare pathogens, such as fungi and mycobacteria. There is a need for inexpensive, reliable tests that rapidly detect specific microbial species and antimicrobial susceptibilities. Additional research is also required to define the specific organisms, clinical scenarios, surgical techniques, and antimicrobial regimens that allow for reproducible treatment success with prosthetic retention strategies.
文献出处：McLawhorn AS, Nawabi DH, Ranawat AS. Management of Resistant, Atypical and Culture-negative Periprosthetic Joint Infections after Hip and Knee Arthroplasty. Open Orthop J. 2016 Nov 30;10:615-632. doi: 10.2174/1874325001610010615. PMID: 28503214; PMCID: PMC5408484.
文献2
术中内侧副韧带撕脱伤对初次全膝关节置换术疗效的影响
译者 马云青
背景:本研究的目的是(1)了解在初次全膝关节置换术中应用螺钉和垫圈治疗内侧副韧带(MCL)骨性撕脱伤的临床和影像学结果，(2)预测可能导致MCL撕脱型损伤的术前因素。
方法: 2011年1月至2015年12月，4916例初次全膝关节置换术(TKA)中46例(0.8%)发生术中MCL撕脱伤。排除后，41个膝关节1:2配对与无MCL损伤进行对照，并比较各种临床，影像学和功能参数。分析的临床参数包括年龄、性别、体重指数、术前诊断如骨关节炎或类风湿性关节炎、活动范围、矢状面畸形和维生素D水平。计算冠状面畸形、胫骨近端内翻角、股骨远端外翻角、关节线一致角、胫骨倾斜度、“杯碟（股骨胫骨匹配）”形态、是否存在膝关节半脱位、胫骨内翻和股骨前弓。分析术前和术后膝关节社会评分和膝关节社会功能评分。随访期间发现并发症或翻修(如果有的话)。多变量Logit模型分析用于预测术前MCL撕脱伤的危险因素。
结果: 平均随访58.4±19.3个月，无放射学或体格检查不稳定表现。与术前相比在最终随访中，研究组和对照组的临床评分(膝关节社会评分和膝关节社会功能评分)均有统计学意义上的改善(P<.001)。研究组术前平均冠状面畸形为170.6±6.96，对照组为167.7±4.3(P=0.021)。研究组术前平均胫骨斜率为10.5±4.9，对照组为7.91±4.15(P=.003)。研究组术前膝关节半脱位发生率为48.8%(P<0.001)，“杯碟”形态发生率为68.3%(P<0.001)。术中MCL损伤的病例更多出现在在重度内翻畸形([OR]1.462,95%[CI]1.15-1.86)，膝关节半脱位(OR39.78,95%CI3.78-418.86)和膝关节“杯碟”形态(OR33.11,95%CI5.69-192.66)的患者。
结论:术中采用螺钉和垫圈可以成功地处理初次全膝关节置换术中MCL骨性撕脱伤，无需增加假体限制性。严重的内翻畸形、膝关节半脱位和膝关节“杯碟”形态的存在增加了MCL撕脱伤的风险。
文献3
全膝关节置换术前的营养学实验室检查：临床实践与文献结果的比较
译者 张蔷
背景：全膝关节置换（TKA）术前的营养状态评估成为了最近的讨论热点，有多篇美国骨科医师协会（AAOS）成员发表文章推荐特定的营养学实验室检查。然而，医生在临床约行这些检查的频率并不明确。我们希望通过这项来自大型数据库的研究来了解TKA术前90天内约行这些营养学检查的频率。
方法：我们选择了PearlDiver数据库中，共557670例自2011年至2020年间接受初次TKA手术的患者，所有患者均在术前90天内接受过生化常规或红细胞计数检查。我们主要关注的项目包括前白蛋白，转铁蛋白，维生素D和锌。最终我们通过卡方检验将所检项目与手术年份、患者一般资料以及临床数据相比较。
结果：TKA术前90天内进行营养学实验室检查的频率很低，接受前白蛋白检查的比例为2.2%，转铁蛋白 1.9%，维生素D 10.2%，锌 0.2%。从2011年至2020年，这些项目的开具比例稳步提高：前白蛋白的比例从0.8%升至3.4%，p<0.001；转铁蛋白的比例从0.8%升至2.7%，p<0.001；维生素D的比例从7.6%升至9.4%，p<0.001；只有锌的提升幅度较小，0.1%-0.2%，p<0.001。这些营养学检查项目与患者性别、年龄、肥胖、糖尿病和贫血等仅呈现弱相关性或无相关性。
结论：尽管存在既往文献的报道和近期文章的推荐，医生依然在TKA术前很少开具营养学实验室检查。近十年，营养学检查的开具比例略有提高，但其与性别和肥胖等因素并无相关性。我们只有理解了现在的临床实践现状，才能更精准的选择未来提升的方向。
Nutritional Laboratory Studies Prior to Total Knee Arthroplasty
Practice versus Publication
Background: Recent emphasis has been placed on nutritional status assessment prior to total knee arthroplasty (TKA), including multiple American Academy of Orthopedic Surgeons publications recommending specific laboratory studies; however, the frequency with which surgeons obtain these laboratory studies remains unclear. We sought to assess the incidence of ordering nutritional laboratory studies in the 90 days prior to TKA, utilizing data from a large administrative claims database.
Methods: With use of the PearlDiver database, we identified 557,670 patients undergoing primary TKA from 2011 to 2020 with a metabolic panel or blood cell count claim within 90 days prior to TKA. We then determined the incidence of prealbumin, transferrin, vitamin D, and zinc laboratory tests claimed 90 days prior to TKA. Associations between claims and the year of surgery, patient demographics, and clinical characteristics were assessed by comparing proportions and chi-square testing.
Results: Nutritional laboratory studies were infrequently claimed within 90 days prior to TKA, with studies for prealbumin being performed in 2.2% of patients; transferrin, 1.9%; vitamin D, 10.2%; and zinc, 0.2%. From 2011 to 2020, there was a moderate but steady increase in the proportion of patients with claims for prealbumin (change from 0.8% in 2011 to 3.4% in 2020; p < 0.001), transferrin (0.8% to 2.7%; p < 0.001), and vitamin D (7.6% to 9.4%; p < 0.001) laboratory tests but there was less of a change for zinc (0.1% to 0.2%; p < 0.001). There were weak-to-absent associations of age, gender, obesity, diabetes, and anemia with laboratory claims.
Conclusions: Despite multiple publications and recommendations, nutritional laboratory studies are infrequently ordered prior to TKA. Although there has been a slight increase in the use of nutritional laboratory studies over the past decade, patient factors such as gender and obesity were not associated with this increase. Understanding current practice patterns may help target future areas for improvement.
文献4
膝关节融合术治疗全膝关节置换术后感染的功能结局
译者 沈松坡
介绍：随着全膝关节置换术(TKA)的实施率预计将持续上升，关节假体周围感染(PJIs)和全膝关节翻修术的频率也将持续上升。多次翻修可导致膝关节无法重建。在这种情况下，可以通过关节融合术挽救膝关节。我们评估了身高、BMI和年龄是否会影响因PJI而行翻修TKA后膝关节融合术的患者报告结果测量(PROMs)。
方法：我们对2014年至2022年在专门的骨科感染服务中心接受关节融合术治疗感染TKA的患者进行了回顾性研究。从36项短表调查(SF-36)和膝关节损伤和骨关节炎结局评分(KOOS)问卷中收集患者人口统计数据和PROMs。进行相关分析以确定身高、BMI和年龄之间是否存在与各种PROMs和子分数之间的关联。
结果：纳入44例患者(男19例，女25例)，平均随访48个月。身高(>166 cm)、体重指数(>30)和年龄(>62岁)的增加对三项SF-36成分:健康变化(P = 0.016)、身体功能能力(P = 0.0096)和一般健康成分(P = 0.0075)有统计学上显著的负面影响。
结论:我们的研究结果表明，对于具有良好功能PROMs和活动状态的持续性膝关节PJI患者，膝关节融合术是一种可接受的选择。身高较矮、BMI较低、年龄较年轻的患者总体上表现出更好的结果。膝关节融合术可以作为一种替代选择以避免再感染TKA的患者中进行截肢，并在选定的患者中提供良好的功能结局。
图1 长髓内钉
正位x线平片显示右膝抗生素骨水泥包覆长髓内钉与Palacos骨水泥间隔块(箭头)
图2 短髓内钉
正位x线平片显示左膝短联结钉，植入前向髓腔内注入抗生素浸透硫酸钙骨水泥
Functional Outcomes of Knee Arthrodesis for Infected Total Knee Arthroplasty
Abstract
Introduction: As the occurrence of total knee arthroplasties (TKAs) is forecasted to continue rising, so too will the frequency of prosthetic joint infections (PJIs) and revision TKAs. Multiple revisions can result in an unreconstructible knee. In such instances, the knee may be salvaged through arthrodesis. We evaluated whether height, BMI, and age impacted patient-reported outcome measures (PROMs) in patients who underwent knee arthrodesis after revision TKA due to PJI.
Methods: We conducted a retrospective review of patients undergoing arthrodesis for an infected TKA at a dedicated orthopedic infection service from 2014 to 2022. Patient demographics and PROMs from 36-Item Short Form Survey (SF-36) and Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires were collected. Correlation analysis was performed to determine if any association between height, BMI, and age was present with the various PROMs and sub-scores.
Results: Forty-four patients (19 males, 25 females) were included, with a mean follow-up of 48 months. Increases in height (>166 cm), BMI (>30), and age (>62 years) had a statistically significant negative impact on three SF-36 components: health changes (P = 0.016), physical functioning ability (P = 0.0096), and general health components (P = 0.0075).
Conclusion: Our results suggest that a knee arthrodesis is an acceptable option in patients with a persistent knee PJI with good functional PROMs and ambulatory status. Patients with shorter height, lower BMI, and younger age showed overall better outcomes. Knee arthrodesis can be an alternative option for
amputation in patients with an infected TKA and provide good functional outcomes in selected patients.
Keywords: proms, tka revision, tka, pji, periprosthetic joint infection, knee arthrodesis
文献5
将运动与临床、功能和结构结果联系起来：来自骨关节炎计划的证据图
译者 张峻
在治疗膝骨关节炎的临床实践指南中，一直建议进行体育活动，但执行率很低。系统评价的方法来直观地说明和总结已发表的证据，强调文献中的空白，形成研究问题。本研究的目的是回顾和总结骨关节炎计划（OAI）发表的将体育活动与临床、功能和结构相关的膝骨关节炎结果联系起来的证据。搜索电子数据库为2021年6月之前。包括OAI报告主观（老年人体育活动量表，PASE）或客观（加速度计）体育活动数据的研究。创建散点图来表示每个结果组（临床、功能、结构）和体育活动测量（PASE、加速度计），以通过与体育活动相关的方向效应（积极、相互作用、消极或无影响）来映射证据。共纳入42篇文章。
使用PASE（n=21）、加速度计（n=20）或两者（n=1）对体育活动进行量化。研究报道除了少数例外，体育活动对临床（n=22）和功能（n=20）结果的影响始终是积极的。结构性相关（n=15）结果在很大程度上被报道为体育活动强度或性别的交互作用，或者没有显著影响。出现了一个相互关联的结果网络，临床和功能相关结果通常一起报告，结构相关结果单独报告。这项研究使用OAI驱动的模型概述了目前将体育活动与多种相关的膝骨关节炎结果联系起来的证据。这些证据图可以作为一个框架，指导未来对体育活动对膝骨关节炎影响的研究。
Linking physical activity with clinical, functional, and structural outcomes: an evidence map using the Osteoarthritis Initiative
Physical activity is consistently recommended across clinical practice guidelines for managing knee osteoarthritis, yet prescription rates are low. Evidence mapping uses a systematic approach to visually illustrate and summarize published evidence, highlight gaps in the literature, and formulate research questions. The purpose of this study was to review and summarize evidence published from the Osteoarthritis Initiative (OAI) linking physical activity with clinical, functional, and structural knee osteoarthritis outcomes. Electronic databases were searched until June 2021. Studies from the OAI reporting subjective (Physical Activity Scale for the Elderly, PASE) or objective (accelerometry) physical activity data were included. Scatter plots were created to represent each outcome group (clinical, functional, structural) and physical activity measure (PASE, accelerometry) to map the evidence by the directional effect (positive, interaction, negative, or no effect) associated with physical activity. Forty-two articles were included in this review. Physical activity was quantified using PASE (n = 21), accelerometry (n = 20), or both (n = 1). Studies reported consistently positive physical activity effects on clinical (n = 22) and functional (n = 20) outcomes, with few exceptions. Structural (n = 15) outcomes were largely reported as interaction effects by physical activity intensity or sex, or as no significant effect. A network of interconnected outcomes emerged, with clinical and functional outcomes often reported together, and structural outcomes reported individually. This study provides an overview of current evidence linking physical activity to multiple interrelated knee osteoarthritis outcomes using an OAI-driven model. These evidence maps can be used as a framework to guide future investigations of the effects of physical activity on knee osteoarthritis.
文献出处：Budarick AR, Moyer RF. Linking physical activity with clinical, functional, and structural outcomes: an evidence map using the Osteoarthritis Initiative. Clin Rheumatol. 2022 Apr;41(4):965-975. doi: 10.1007/s10067-021-05995-y. Epub 2021 Nov 21. PMID: 34802082.
文献6
膝关节软骨下骨不全骨折：当前概念和影像学鉴别诊断的综述
译者 肖凯
膝关节软骨下骨不全骨折（SIFK）是老年人膝关节疼痛的常见原因。SIFK是一种应力性骨折，多发生对软骨下骨施加重复和过度的压力时。如果骨折不愈合，病变会发展成骨坏死，并导致骨软骨塌陷，需要进行手术治疗。在没有磁共振成像（MRI）的时代，基于SIFK的这些临床表现，其最初被称为“膝关节自发性骨坏死（SONK）”。SONK现在被归类为SIFK疾病谱系中的一种进展性病变，一些作者认为“SONK”并非是一个确切词语。MRI在SIFK的早期诊断中起到重要作用。MRI上的典型表现为受累及的股骨髁或胫骨髁在T2相低信号线性影像及向周围扩展的骨髓水肿信号。较大范围的的病变和影像学上的骨软骨塌陷与骨关节炎进展的风险增加有关。然而，仅有骨髓水肿信号和骨软骨塌陷并不是SIFK的专有改变，还应考虑其他骨软骨病变，包括缺骨血性坏死、软骨碎裂和骨关节炎。许多患有SIFK的患者也发现有软骨病变和半月板异常，包括半月板后根撕裂，目前认为其与SIFK的发展有关。我们回顾了SIFK的临床和影像学表现，包括其解剖学，回顾了历史术语以及其鉴别诊断。放射科医师应熟悉这些影像特征和临床表现。
Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses
Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. SIFK is a type of stress fracture that occurs when repetitive and excessive stress is applied to the subchondral bone. If the fracture does not heal, the lesion develops into osteonecrosis and results in osteochondral collapse, requiring surgical management. Because of these clinical features, SIFK was initially termed 'spontaneous osteonecrosis of the knee (SONK)' in the pre-MRI era. SONK is now categorized as an advanced SIFK lesion in the spectrum of this disease, and some authors believe the term 'SONK' is a misnomer. MRI plays a significant role in the early diagnosis of SIFK. A subchondral T2 hypointense line of the affected condyle with extended bone marrow edema-like signal intensity are characteristic findings on MRI. The large lesion size and the presence of osteochondral collapse on imaging are associated with an increased risk of osteoarthritis. However, bone marrow edema-like signal intensity and osteochondral collapse alone are not specific to SIFK, and other osteochondral lesions, including avascular necrosis, osteochondral dissecans, and osteoarthritis should be considered. Chondral lesions and meniscal abnormalities, including posterior root tears, are also found in many patients with SIFK, and they are considered to be related to the development of SIFK. We review the clinical and imaging findings, including the anatomy and terminology history of SIFK, as well as its differential diagnoses. Radiologists should be familiar with these imaging features and clinical presentations for appropriate management.
文献出处：Ochi J, Nozaki T, Nimura A, Yamaguchi T, Kitamura N. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. Jpn J Radiol. 2022 May;40(5):443-457. doi: 10.1007/s11604-021-01224-3. Epub 2021 Nov 29. PMID: 34843043; PMCID: PMC9068663.
第二部分：保髋相关文献
文献1
股骨颈相对延长联合关节外截骨短期并发症
译者 罗殿中
目的：股骨颈相对延长术（RNL）是治疗短髋畸形和髋内翻的一项新技术，在不改变股骨头与股骨干关系的情况下，改善髋关节撞击、并提升髋外展肌功能。股骨近端截骨术（PFO）需要改变股骨头与股骨干之间的位置关系。我们拟研究RNL联合PFO的近期并发症。
方法：所有通过髋关节外科脱位（SHD）、股骨颈筋膜瓣松解延长（ERFD）行RNL和PFO的患者纳入本研究。单纯行关节内股骨截骨手术（IAFO）的患髋予以排除。RNL联合PFO，同时又行关节内股骨截骨手术（IAFO）的患者纳入本研究。术中对股骨头钻孔检查股骨头血运情况。术后1周、6周、3月、6月、12月、24月分别对患者临床功能和影像进行随访。
结果：72例患者（31例男性，41例女性，年龄6～52岁）79髋进行了RNL联合PFO手术。22髋追加了其它手术，如股骨头缩小、股骨颈截骨、髋臼截骨手术。记录了6例主要并发症和5例次要并发症。2髋出现不愈合，均为股骨颈基底内翻截骨术。4髋出现股骨头缺血，其中2髋行早期干预避免了股骨头塌陷。1髋出现持续性髋外展肌力减弱，行内固定取出术；3髋均为男孩、因术侧因内翻截骨髋部增宽导致新的症状。1髋出现无症状大转子不愈合。
结论：FNL常规需要筋膜瓣松解延长，将短外旋肌从股骨近端的止点剥离，该技术虽然避免直接损伤股骨头血运，若股骨近端矫正较大，看起来会导致血管牵拉。我们建议在术中和术后检查股骨头血运，并采取必要措施以减轻对筋膜瓣的牵拉。在股骨近端大幅度矫正中，避免过度牵拉筋膜瓣更安全。
图1. RNL联合PFO术后股骨头缺血示例。A.一例严重稳定性股骨头骨骺滑脱，行改良Dunn截骨术后，为进一步改善股骨头内旋，行转子下内旋截骨术。股骨头复位后，活跃的股骨头血运停止。B.术后骨扫描显示，左侧股骨头未见核素摄入。C.该患者在PFO部位减少内旋幅度，股骨头血运立即得到恢复，术后49个月随访，患者恢复良好。
图2. 股骨颈基底内翻截骨不愈合示例。A.术前骨盆前后位片显示，左侧股骨头外翻、股骨头小凹高位、负重时股骨头局部软骨损伤。B.左髋RNL联合股骨颈基底内翻截骨术后即刻片显示，股骨头小凹高位和股骨头覆盖得到改善。C.初次术后9月随访，大转子愈合，股骨颈截骨不愈合，且内固定失效。D.随后行PHP翻修再次固定 骨移植。
文献出处：Short‑Term Complications of Relative Femoral Neck Lengthening
Combined with Extra‑Articular Osteotomies of the Proximal Femur. Indian Journal of Orthopaedics (2023) 57:1112–1117.
文献2
髋关节发育不良的流行病学：日本国家数据库分析
译者 张振东
背景：髋关节发育不良（DDH）是一组影响婴儿髋关节发育的疾病。据报道，DDH相关髋脱位（DDH-髋脱位）的发病率为0.1%-0.3%；然而，日本全国范围内DDH-髋脱位的发病率此前尚未见报道。本研究的主要目的是利用日本全国健康保险索赔和特定健康检查数据库（NDB）报告日本全国的 DDH 髋脱位发病率，并研究其在日本各地的地区差异。
方法：这是一项利用 NDB 进行的回顾性队列研究。研究人员提取了2011年至2013年期间出生、2011年至2018年期间被诊断为DDH脱位相关疾病代码的患者数据。其中，在2011年至2018年期间接受DDH-髋脱位治疗的患者被定义为DDH-髋脱位患者。
结果：在2011年、2012年和2013年的出生人群中，共有2367例被诊断为DDH髋脱位，全国发病率为0.076%。日本各地区的发病率几乎相似。数据分析显示，有 273 例（11.5%）患者在≥1 岁时被确诊。在寒冷月份出生对DDH髋脱位的发病率有显著影响（相对风险[RR] = 1.89，95%置信区间[CI]：1.75-2.06）。女孩发生 DDH 脱位的风险约为男孩的七倍。
结论：这是首个报告日本全国 DDH 脱位发病率的研究，估计发病率为 0.076%。地区差异不大，日本所有地区的发病率大致相同。
Epidemiology of Developmental Dysplasia of the Hip: Analysis of Japanese National Database
Background:Developmental dysplasia of the hip (DDH) is a cluster of hip development disorders that affects infants. The incidence of DDH-related dislocation (DDH-dislocation) is reportedly 0.1-0.3%; however, the nationwide incidence of DDH-dislocation in Japan has not been previously reported. The primary aim of this study was to report the nationwide incidence of DDH-dislocation in Japan using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), and to examine its regional variation across Japan.
Methods:This was a retrospective birth cohort study using the NDB. Data on patients born between 2011 and 2013 and assigned DDH-dislocation-related disease codes during 2011-2018 were extracted. Among these, patients who underwent treatment for DDH-dislocation between 2011 and 2018 were defined as patients with DDH-dislocation.
Results:Across the 2011, 2012, and 2013 birth cohorts, 2,367 patients were diagnosed with DDH-dislocation, yielding the nationwide incidence of 0.076%. Region-specific incidence rates were almost similar across Japan. Secondary analyses revealed that 273 (11.5%) patients were diagnosed at the age of ≥1 year. The effect of birth during the cold months on the incidence of DDH-dislocation was significant (relative risk [RR] = 1.89, 95% confidence interval [CI]: 1.75-2.06). The risk of DDH-dislocation among girls was approximately seven times higher than that among boys.
Conclusion:This is the first study to report the nationwide incidence of DDH-dislocation in Japan, which was estimated at 0.076%. The regional variation was trivial and unlikely to be clinically significant. Thus, the incidence rates were approximately equal across all regions in Japan.
文献出处：Den H, Ito J, Kokaze A. Epidemiology of Developmental Dysplasia of the Hip: Analysis of Japanese National Database. J Epidemiol. 2023 Apr 5;33(4):186-192. doi: 10.2188/jea.JE20210074. Epub 2022 Apr 15. PMID: 34380918; PMCID: PMC9939923.
文献3
应用Graf超声分析臀位与头位分娩新生儿DDH的风险
译者 任宁涛
目的:髋关节发育不良(DDH)是婴幼儿最常见的肌肉骨骼疾病之一。最重要的危险因素包括女性、臀位、左髋关节和家族史。在这项研究中，我们利用Graf方法在不同的时间间隔评估臀位分娩和头位出生的新生儿。'目的是比较头位和臀位分娩新生儿DDH的发生率，并研究臀位分娩新生儿的髋关节是否表现出不同的成熟模式。
材料和方法:我们前瞻性研究了618个髋关节(309个新生儿)。每个髋关节采用Graf法在以下四个时间段进行检查:第1阶段(0-1周)、第2阶段(1-4周)、第3阶段(4-7周)和第4阶段(7-10周)。测量各髋关节的α角和β角，并根据Graf分类法对髋关节进行分类。通过我们在不同阶段的统计分析，我们能够调查臀位和头位分娩的新生儿在成熟模式上的潜在变化。
结果:第1阶段臀位分娩新生儿与头位分娩新生儿(35.6 ~ 8.6%)比较，差异有统计学意义(5%水平)。在接下来的阶段中，这一差异有减小的趋势(第2阶段为13.6-1%，第3阶段为2.5-0%，第4阶段为1.7-0%)。在第1阶段和第4阶段(8.5-0%)中也观察到头位分娩的新生儿有显著差异(5%水平)，但百分比较低。此外，臀位分娩的DDH发生率从1阶段到4阶段差异极大(分别为35.6-11.9%，2.5%和1.7%)。
结论：臀位分娩和头位分娩的新生儿DDH的发病率似乎确实存在差异，尽管这种差异可能没有以前认为的那么显著。大多数最初被认为是病态的臀位分娩的新生儿(第一阶段)实际上是健康的。这在后期(2-4阶段)进行的后续超声检查中得到确认，此时病理病例的发生率降低。这可能归因于这些群体之间潜在的不同成熟模式。
The risk of DDH between breech and cephalic-delivered neonates using Graf ultrasonography
Purpose: Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal disorder in infants. The most significant risk factors include female gender, breech presentation, left hip and family history. In this study, we utilized the Graf method at different time intervals to evaluate both breech-delivered and cephalic-born newborns. The objectives were to compare the incidence of DDH in cephalic and breech-delivered neonates and investigate whether the hip joints of neonates delivered in the breech position exhibit a distinct maturation pattern.
Material and methods: We studied prospectively 618 hip joints (309 newborns). Each hip joint was examined with the Graf method in four time periods as follows: Phase #1 (0-1 weeks), Phase #2 (1-4 weeks), Phase #3 (4-7 weeks), and Phase #4 (7-10 weeks). The α and β angles for each hip joint were measured, and the hips were classified according to Graf classification. With our statistical analysis within the different phases, we were able to investigate potential variations in the maturation patterns between newborns delivered in the breech and cephalic delivery positions.
Results: A significant difference (at the 5% level) was observed in Phase 1 between breech and cephalic-delivered neonates (35.6-8.6%). This difference tended to decrease in next phases (13.6-1% in Phase 2, 2.5-0% in Phase 3 and 1.7-0% in Phase 4). A significant difference (at the 5% level) for cephalic-delivered neonates was also observed between Phase 1 and Phase 4 (8.5-0%), but the percentages were low. Additionally, the breech-delivered had extreme difference in incidence of DDH from Phase 1 to Phase 4 (35.6-11.9%, 2.5%, and 1.7%, respectively).
Conclusion: It appears that there is an actual difference in the incidence of DDH between breech-delivered and cephalic-delivered neonates, although the difference may be less significant than previously considered. The majority of the breech-delivered neonates that were initially considered as pathological (Phase 1) are, in fact, healthy. This is ascertained in subsequent ultrasound examinations conducted in later phases (Phases 2-4), when the incidence of pathological cases decreases. This could be attributed to potential different maturation pattern between these groups.
文献出处：Kolovos S, Sioutis S, Polyzou M, Papakonstantinou ME, Karampikas V, Altsitzioglou P, Serenidis D, Koulalis D, Papagelopoulos PJ, Mavrogenis AF. The risk of DDH between breech and cephalic-delivered neonates using Graf ultrasonography. Eur J Orthop Surg Traumatol. 2023 Nov 10. doi: 10.1007/s00590-023-03770-0. Epub ahead of print. PMID: 37947897.
文献4
反向髋臼周围截骨术治疗有症状的髋臼前倾
译者 张利强
背景
传统上用外侧中心边缘角（LCEA）定义髋臼发育不良，并用髋臼周围截骨术（PAO）治疗。然而，最近描述的Ottawa分类法用三维术语进一步量化了发育不良，Ottawa A型发育不良为单纯髋臼过度前倾或髋臼前覆盖不足。我们试图确定与传统的发育不良患者相比，Ottawa A型发育不良患者在接受PAO时是否可以获得类似的结果。
方法
选择接受PAO治疗Ottawa A型髋关节发育不良患者，并与髋臼外侧覆盖不足的对照组患者进行比较。收集术前和不同随访时间的改良Harris髋关节评分（mHHS）和国际髋关节结果工具-33（iHOT-33），最终平均随访2.3年（范围0.9至6.2）。
结果
将Ottawa A型发育不良的17名患者（21髋）与对照组的69名患者（88髋）进行比较。在末次随访时，两组的mHHS和iHOT-33均有显著改善，P<0.001。两组之间在任意测量结果或实现最小临床重要差异（MCID）或显著临床获益（SCB）的比率方面都没有差异。MCID发生率为82.4%～100%，SCB发生率为47.1%～52.9%。
结论
在接受PAO治疗有症状的髋臼前倾或单纯前覆盖不足的患者中，预期患者报告结果显著改善，MCID实现率高。与传统发育不良接受PAO的患者对比，两者间无显著差异。
术前LCEA为27°，CT显示3点的髋臼前倾角为28°
术后LCEA为40°
Retroverting Periacetabular Osteotomy for Symptomatic Acetabular Anteversion
Abstract
Background
Acetabular dysplasia has traditionally been defined using the lateral center edge angle (LCEA) and treated with periacetabular osteotomy (PAO). However, the recently described Ottawa classification further quantifies dysplasia in three-dimensional terms, categorizing Ottawa A as dysplasia due to isolated, excessive acetabular anteversion or anterior acetabular under-coverage. We sought to determine if patients who have Ottawa A dysplasia can expect similar outcomes when undergoing a PAO compared to a traditional dysplasia cohort.
Methods
Patients who had undergone PAO with Ottawa A hip dysplasia were selected based on outlined radiographic parameters and compared to a control group of patients who had lateral acetabular under-coverage. The modified Harris Hip Score (mHHS) and International Hip Outcome Tool - 33 (iHOT-33) were collected pre-operatively and at various follow-up points for a final follow-up average of 2.3 years (range,0.9 to 6.2).
Results
The seventeen patients (21 hips) who had Ottawa A dysplasia were compared to a control cohort of 69 patients (88 hips). Both groups saw significant improvements in mHHS and iHOT-33 at final follow-up, P<0.001. There were no differences between groups in any of the outcome measures or rates of achieving minimal clinically important difference (MCID) or substantial clinical benefit (SCB). Rates of MCID ranged from 82.4 to 100%, and rates of achieving SCB ranged from 47.I to 52.9%.
Conclusion
In patients undergoing a PAO for symptomatic acetabular anteversion or isolated anterior under-coverage, a significant improvement in patient reported outcomes can be expected with high rates of MCID achievement. This is not significantly different for patients undergoing PAO for more traditional dysplasia parameters,
Keywords: periacetabular osteotomy, acetabular anteversion, hip dysplasia, hip pain
文献出处：Selley RS, Peck JB, Trotzky ZA, Robustelli S, Sink EL. Retroverting Periacetabular Osteotomy for Symptomatic Acetabular Anteversion. J Arthroplasty. 2023 Nov 14:S0883-5403(23)01136-1. doi: 10.1016/j.arth.2023.11.013. Epub ahead of print. PMID: 37972667.
文献5
髋臼周围截骨术（PAO）：治疗髋臼后倾：系统评价和荟萃分析
译者 陶可
简介：髋臼周围截骨术（PAO）用于治疗髋臼后倾的证据仍然有限。本综述旨在回答以下问题：（1）前倾型PAO治疗髋臼后倾的适应证有哪些？(2)髋臼后倾行前倾PAO时何时需要其他伴随手术？(3)前倾型PAO在多大程度上能够矫正髋臼后倾？(4)前倾型PAO用于髋臼后倾时，临床结果如何？(5)在需要进行其他手术之前，用于治疗髋臼后倾的PAO的估计生存期是多少？（6）前倾型PAO术中有哪些并发症及并发症发生率？(7)与治疗髋臼后倾的其他外科手术相比，前倾PAO的结果如何？
材料和方法：系统评价是使用PRISMA指南进行的。该检索是使用PubMed在线医学文献分析和检索系统(MEDLINE)以及护理和联合健康文献累积索引(CINAHL)进行的，从开始到2020年5月1日。使用的关键词是“髋臼周围截骨术”。所有报告髋臼周围截骨术治疗髋臼后倾的结果的研究均被纳入。然后单独检索每项研究的数据。分析了每项研究的研究设计、手术技术、适应证、结果和并发症。
结果：纳入7项涉及225个髋关节的研究。与术后相比，术前阳性交叉征和后壁征的合并比值比(OR)分别为456.31（95% CI：99.57 至 2091.28）和53.45（95% CI：23.05 至 123.93）。术前平均外侧中心边缘角（LCEA）和臼顶倾斜角（AI）在发育不良范围内的研究的汇总加权平均差(WMD)分别为12.61（95% CI：6.54 至 18.68）和-15.0（95% CI：-19.40 至 -11.80），而术前平均LCEA和AI在正常范围内的研究的汇总WMD分别为3.43（95% CI：1.08 至 5.77）和-3.56（95% CI：-5.29 至 -1.83）。髋臼后倾矫正、髋关节发育不良矫正、功能结果和活动范围等其他指标也显着改善，并持续至术后11年。只有7.1%的髋部需要因撞击症状或骨关节炎进展而进行后续手术，所有研究的生存时间平均估计为123.90个月（95% CI：119.94 至 127.86）。低度并发症发生率为31.6%，高度并发症发生率为12.0% [注：根据Dindo-Clavien系统，这些并发症分为低度或高度并发症]。
讨论：前倾PAO适用于有症状的髋臼后倾，一旦实施，可以对髋臼后倾和髋关节发育不良产生良好的畸形矫正，临床结果的积极改善可持续至术后11年，平均估计生存时间超过10年。
图. 髋臼周围截骨术用于治疗髋臼后倾时的生存曲线分析，终点是需要针对髋关节撞击症或髋骨关节炎进展而需要进行后续手术。
Periacetabular osteotomy for acetabular retroversion: A systematic review and meta-analysis
Abstract
Introduction: The evidence for periacetabular osteotomy (PAO) when used in the management of acetabular retroversion remain limited. The review aims to answer the following questions: (1) What are the indications for an anteverting PAO for acetabular retroversion? (2) When are other concomitant procedures required when performing anteverting PAO for acetabular retroversion? (3) To what extent is an anteverting PAO able to correct acetabular retroversion? (4) What are the clinical outcomes for an anteverting PAO when used in acetabular retroversion? (5) What is the estimated survival for anteverting PAO when used in the treatment of acetabular retroversion, before other procedures need to be performed? (6) What are the complications and the complication rates when an anteverting PAO is performed? (7) How do the outcomes of an anteverting PAO compare to other surgical procedures used in the management of acetabular retroversion?
Material and methods: The systematic review was conducted using the PRISMA guidelines. The search was conducted using PubMed Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception through 1 May 2020. The keywords used were 'periacetabular osteotomy'. All studies that reported the outcomes of periacetabular osteotomy for acetabular retroversion were included. Each study's data was then retrieved individually. The study design, surgical technique, indications, outcomes and complications of each study were analysed.
Results: Seven studies with 225 hips were included. The pooled odds ratio (OR) for a positive crossover sign and posterior wall sign preoperatively as compared to postoperatively were 456.31 (95% CI: 99.57 to 2091.28) and 53.45 (95% CI: 23.05 to 123.93) respectively. The pooled weighted mean difference (WMD) for studies with their mean preoperative LCEA and AI in the dysplastic range were 12.61 (95% CI: 6.54 to 18.68) and-15.0 (95% CI: -19.40 to -11.80) respectively, while the pooled WMD for studies with their mean preoperative LCEA and AI in the normal range were 3.43 (95% CI: 1.08 to 5.77) and -3.56 (95% CI: -5.29 to -1.83) respectively. Other indicators for acetabular retroversion correction, hip dysplasia correction, functional outcomes and range of motion were also significantly improved and sustained up till 11 years postoperatively. Only 7.1% of the hips required subsequent surgical procedures for impingement symptoms or progression of osteoarthritis, and the mean estimate for survival time across the studies was 123.90 months (95% CI: 119.94 to 127.86). The complication rates for low-grade complication were 31.6% while the rate for high-grade complications was 12.0%.
(These complications were classified into low-grade or high-grade complications according to the Dindo-Clavien system.
Daniel Dindo, Nicolas Demartines, Pierre-Alain Clavien. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13.)
Discussion: Anteverting PAO is indicated for symptomatic acetabular retroversion, and when performed, leads to good deformity correction for both acetabular retroversion and hip dysplasia, positive improvement in clinical outcomes sustainable till 11 years postoperatively and a mean estimated survival time of more than 10 years.
文献出处：Si Heng Sharon Tan, Joelle Hwee Inn Tan, Andrew Kean Seng Lim, James Hoipo Hui. Periacetabular osteotomy for acetabular retroversion: A systematic review and meta-analysis. Review, Orthop Traumatol Surg Res. 2021 Dec;107(8):103078. doi: 10.1016/j.otsr.2021.103078.
文献6
活跃患者在髋臼周围截骨术中期随访中的活动水平维持的研究
译者 李勇
背景：对于接受髋臼周围截骨术（PAO）的活跃患者来说，术后恢复和维持高水平的活动是优先考虑的。目的：评估接受PAO治疗症状性髋臼发育不良的活跃患者在中期随访期间的活动水平维持情况。研究设计：病例系列；证据水平4级。方法：通过回顾我们的前瞻性长期的机构保髋数据库，在2006年6月至2013年8月间因症状性髋臼发育不良接受PAO的患者。所有术前UCLA评分>7且具有潜在的至少5年随访时间的患者都被纳入研究。功能结果评估指标为UCLA评分、修正Harris髋关节评分（mHHS）和西安大略和麦克马斯特大学骨关节炎指数（WOMAC）。高水平活动的维持被定义为最终随访时的UCLA评分为27,并测量放射学参数。统计学显著性定义为P值<0.05。结果：共纳入66个髋部（58名患者）。平均年龄为25.3岁（范围14-47岁），平均体重指数为23.9 kg/m2（范围19-32 kg/m2），72%为女性。平均随访时间为6.8年（范围5-11年）。有67%的患者维持了UCLA评分为27。患者自报的结果从术前到术后均有所改善，mHHS（88±14 vs 67±17，P<0.001）和WOMAC（89±15 vs 73±20，P<0.001）。最终随访时，外侧中心边缘角、前中心边缘角和髋臼倾斜角均有显著改善（P<0.001）。只有4名患者（7%）报告术后活动受限是由于髋痛引起的。没有患者转换为全髋关节置换术。结论：大多数（67%）的活跃患者在PAO术后中期随访期间恢复到术前或更高的活动水平。
Activity Level Maintenance at Midterm Follow-up Among Active Patients Undergoing Periacetabular Osteotomy
Background: For active patients undergoing periacetabular osteotomy (PAO), returning to and maintaining a high level of activity postoperatively is a priority. Purpose: To evaluate the maintenance of activity levels at midterm follow-up in active patients treated with PAO for symptomatic acetabular dysplasia. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent PAO for symptomatic acetabular dysplasia between June 2006 and August 2013 were identified by a retrospective review of our prospective longitudinal institutional Hip Preservation Database. All patients with a preoperative University of California, Los Angeles (UCLA) score of >7 and a potential minimum 5 years of follow-up were included in the study. Functional outcome measures were the UCLA score, modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The maintenance of high activity levels was defined as a UCLA score of 27 at final follow-up. Radiographic parameters were measured. Statistical significance was defined as a P value <.05. Results: A total of 66 hips (58 patients) were included. The mean age was 25.3 years (range, 14-47 years), the mean body mass index was 23.9 kg/m2 (range, 19-32 kg/m2), and 72% were female. The mean follow-up was 6.8 years (range, 5-11 years). Therel were 67% of patients who maintained a UCLA score of 27. Patient-reported outcomes improved postoperatively from preoperatively for the mHHS (88 ± 14 vs 67 ± 17, respectively; P <.001) and WOMAC (89 ± 15 vs 73 ± 20, respectively; P <.001). The lateral center-edge angle, anterior center-edge angle, and acetabular inclination were significantly improved at final follow-up (P <.001). Only 4 patients (7%) cited postoperative activity limitations as being caused by hip pain. There were no conversions to totall hip arthroplasty. Conclusion: The majority (67%) of active patients returned to preoperative or higher activity levels after PAO at midterm follow-up.
文献出处：Okoroafor, U. C., Pascual-Garrido, C., Schwabe, M. T., Nepple, J. J., Schoenecker, P. L., & Clohisy, J. C. (2019). Activity Level Maintenance at Midterm Follow-up Among Active Patients Undergoing Periacetabular Osteotomy. The American Journal of Sports Medicine, 036354651988142. doi:10.1177/0363546519881421
文献7
早期骨关节炎的物理因子治疗方案
译者 王一昕
治疗早期骨关节炎（EOA）是临床医生面临的挑战。目前在其定义和诊断上没有达成共识，但早期及时的治疗干预可以对功能和生活质量产生重大影响。运动是EOA的核心治疗方法；然而，通常有几种常用的物理因子治疗被应用于这类患者。本文的目的是研究物理因子治疗在EOA治疗中的作用。由8名在物理因子治疗和肌肉骨骼方面具有专业知识的医学专家组成的技术专家小组（TEP）根据PRISMA ScR（系统评价的首选报告项目和范围界定评价的荟萃分析扩展）模型进行了审查。TEP在EOA管理中寻找以下物理因子治疗的证据：“电刺激疗法”、“脉冲电磁场”、“低水平光疗法”、“激光疗法”、“磁场疗法”、“体外冲击波疗法”、“温热诱导疗法”、“冷疗”、“振动疗法”、“全身振动疗法”、“物理治疗”。我们发现了经皮神经电刺激（TENS）、体外冲击波治疗（ESWT）、低强度脉冲超声（LIPUS）、脉冲电磁场刺激（PEMF）和全身振动（WBV）治疗膝关节EOA的临床前和临床数据。我们发现了两项关于TENS和PEMF的临床研究，以及六项临床前研究——三项关于ESWT，一项关于WBV，一项涉及PEMF，一项有关LIPUS。临床前研究证明了物理因子治疗对EOA的几种生物学效应，表明了潜在的疾病改善作用。然而，考虑到EOA患者使用这些干预措施的数据有限，进一步的临床研究中应该更好地研究这些治疗的作用。
Physical Agent Modalities in Early Osteoarthritis: A Scoping Review
Early osteoarthritis (EOA) still represents a challenge for clinicians. Although there is no consensus on its definition and diagnosis, a prompt therapeutic intervention in the early stages can have a significant impact on function and quality of life. Exercise remains a core treatment for EOA; however, several physical modalities are commonly used in this population. The purpose of this paper is to investigate the role of physical agents in the treatment of EOA. A technical expert panel (TEP) of 8 medical specialists with expertise in physical agent modalities and musculoskeletal conditions performed the review following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) model. The TEP searched for evidence of the following physical modalities in the management of EOA: 'Electric Stimulation Therapy', 'Pulsed Electromagnetic field', 'Low-Level Light Therapy', 'Laser Therapy', 'Magnetic Field Therapy', 'Extracorporeal Shockwave Therapy', 'Hyperthermia, Induced', 'Cryotherapy', 'Vibration therapy', 'Whole Body Vibration', 'Physical Therapy Modalities'. We found preclinical and clinical data on transcutaneous electrical nerve stimulation (TENS), extracorporeal shockwave therapy (ESWT), low-intensity pulsed ultrasound (LIPUS), pulsed electromagnetic fields stimulation (PEMF), and whole-body vibration (WBV) for the treatment of knee EOA. We found two clinical studies about TENS and PEMF and six preclinical studies-three about ESWT, one about WBV, one about PEMF, and one about LIPUS. The preclinical studies demonstrated several biological effects on EOA of physical modalities, suggesting potential disease-modifying effects. However, this role should be better investigated in further clinical studies, considering the limited data on the use of these interventions for EOA patients.
文献出处：Giulia Letizia Mauro, Dalila Scaturro, Francesca Gimigliano, Marco Paoletta, Sara Liguori, Giuseppe Toro, Giovanni Iolascon, Antimo Moretti. Physical Agent Modalities in Early Osteoarthritis: A Scoping Review. Medicina (Kaunas). 2021 Oct 26;57(11):1165. PMID: 34833383. DOI: 10.3390/medicina57111165
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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