本期目录：
第一部分：关节置换及保膝相关文献
文献1
采用运动对线方法行TKA后的双足站立踝关节线
比力学对线更接近正常的踝关节线
译者：张轶超
力学对线的全膝关节置换术（MATKA）是要将髋、膝和踝关节的力线对齐。但是，近期的证据显示如果每个病例的下肢机械力线都对齐了可能有部分病例会出现踝关节的问题，包括临床上和影像学上的问题。相反，采用运动对线方法的全膝关节置换术（KATKA）可以最大限度的恢复原有的膝关节面。在本研究中，我们检验了KATKA和MATKA的效果，以确定哪种手术可以恢复踝关节线的夹角，使得在双足站立位时和原有正常的踝关节线更接近。在此我们先假定KATKA比MATKA对恢复踝关节线的效果更好。回顾性的分析了60位健康成人（对照组，n=120膝），行了MATKA患者（n=90膝）和行了KATKA患者（n=90膝）的下肢站立位全长片。测量并分析了髋-膝-踝角，胫骨远端关节面和距骨顶面与地面（分别是G-顶和G-距骨）的夹角及胫骨远端关节面和距骨顶关节面与下肢机械力线之间（分别是M-顶和M-距骨）的夹角。结果显示当双足站立时KATKA患者的踝关节线夹角(G-顶:-0.65±3.03 和 G-距骨:-1.72±4.02)与对照组的没有明显差异。与从对照组中获得的正常关节线数据(G-顶:-0.76±2.69和 G-距骨:-1.30±3.25)比较，行MATKA患者的胫骨远端关节面和距骨顶关节面相对地面成明显的外侧倾斜(G-顶: -2.32±3.30 和G-距骨:-2.97±3.98,p=0.001和p=0.004)。因此，KATKA术后踝关节夹角与地面平行，比MATKA技术术后更接近正常踝关节线。
踝关节夹角的测量。虚线代表地面水平。（A）踝关节线与下肢机械轴和地面水平间的成角（AA，解剖轴；LDTA，胫骨远端外侧角；MA，下肢机械轴；M-顶，胫骨远端关节面与机械轴的夹角。）。（B）G-顶夹角（G-顶，胫骨远端关节线与地面水平的成角）。
Kinematically Aligned TKA Aligns the Ankle Joint Line Closer to Those of the Native Ankle than Mechanically Aligned TKA in Bipedal Stance
Mechanically aligned total knee arthroplasty (MATKA) aims to make alignment of the hip, knee, and ankle straight unexceptionally. However, emerging evidence suggests that unexceptional straightening the mechanical axis of the lower limb may lead to clinical and radiological problems of the ankle joint. By contrast, kinematically aligned total knee arthroplasty (KATKA) strives to restore the articular surface of the prearthritic knee. In this study, we examined results from KATKA and MATKA to determine which surgery restores the ankle joint orientation closer to the native ankle joint in bipedal stance and hypothesized that KATKA, rather than MATKA, would be more effective. Data from long-leg standing radiographs of 60 healthy adults (control group, n = 120 knees), patients who underwent MATKA (n = 90 knees), and patients who underwent KATKA (n = 90 knees) were retrospectively reviewed. The hip-knee-ankle angle, orientation of the tibial plafond and the talar dome relative to the ground (G-plafond and G-talus, respectively), and orientation of the plafond relative to the mechanical axis of the limb (M-plafond and M-talus, respectively) were measured and analyzed for comparison. Results show that bipedal stance alignment in patients who underwent KATKA (G-plafond: -0.65 ± 3.03 and G-talus: -1.72 ± 4.02) were not significantly different to native ankle joint alignment indicated by the control group. Compared with the native ankle joint measured in the control group (G-plafond: -0.76 ± 2.69 and G-talus: -1.30 ± 3.25), the tibial plafond and talar dome significantly tilted laterally relative to the ground in ankle joints after MATKA (G-plafond: -2.32 ± 3.30 and G-talus: -2.97 ± 3.98, p = 0.001 and p = 0.004, respectively). Thus, postoperative ankle joint line orientation after KATKA was horizontal to the floor and closer to that of native ankle joints than those after MATKA. The level of evidence is Level III.
文献出处：Kim JT, Han J, Lim S, Shen QH, Won YY. Kinematically Aligned TKA Aligns the Ankle Joint Line Closer to Those of the Native Ankle than Mechanically Aligned TKA in Bipedal Stance. J Knee Surg. 2019 Oct;32(10):1033-1038. doi: 10.1055/s-0039-1694796. Epub 2019 Aug 21.
文献2
夏科关节病行初次人工全髋关节置换术风险与收益并存
译者：罗殿中
背景：神经性关节病（夏科关节病）较为少见，但其可导致关节严重破坏、骨量丢失、关节功能障碍。THA是治疗髋关节夏科关节病的一种可行方案，但关于THA治疗夏科关节病的文献报道非常少。本研究的目的是为了分型THA治疗夏科关节病的临床疗效，尤其关注假体的生存率、并发症和临床预后。
方法：回顾性分析了从2007-2014年采用初次THA治疗夏科关节病的12位患者。所有的患者均有严重神经病变，并且有明确的影像学确诊证据。患者平均年龄为54岁，其中4名为女性。平均随访时间为5年。
结果：术后2年和5年随访时假体生存率为75%。3例进行了翻修术，其中2例反复关节不稳，1例股骨假体松动。THA术后2年和5年随访时未进行任何再手术的比例均为67%。1例因发生温哥华分型为B1的假体周围骨折而接受骨折内固定术。患者术后总的并发症发生率为58%，包括3例反复脱位，2例假体周围骨折，1例股骨侧假体松动，1例切口延迟愈合。Harris评分由术前平均43分提高至术后平均81分，差异有统计学意义(P < .001)。
结论：我们的研究在已报道的研究中病例术最多，我们发现夏科关节病患者接受THA可一明显改善临床功能，但是早期并发症及翻修的风险较高，其中多术与术后髋关节反复不稳定有关。我们需要采取特殊的措施来预防早期并发症，如应用可以提升或加强固定稳定性的假体组件，以及采用其它可以提高髋关节稳定性的措施。
Primary Total Hip Arthroplasty for Charcot Arthropathy is Associated With High Complications but Improved Clinical Outcomes
BACKGROUND: Neuropathic (Charcot) arthropathy of the hip is rare but can lead to joint destruction, bone loss, and dysfunction. While total hip arthroplasty (THA) may be considered a treatment option, only very limited data in the form of case reports are available on the results of THA. The goal of this study was to analyze the outcomes of primary THA for Charcot arthropathy with emphasis on implant survivorship, complications, and clinical outcomes.
METHODS: Eleven patients undergoing 12 primary THAs for Charcot arthropathy from 2007 to 2014 were retrospectively reviewed. All patients had a severe underlying neuropathy and clear radiographic evidence of Charcot arthropathy. Mean age was 54 years with 4 patients being female. Mean follow-up was 5 years.
RESULTS: Survivorship free of any revision was 75% at both 2 and 5 years. Three THAs (3/12) were revised: 2 for recurrent instability and 1 for femoral component loosening. Survivorship free of any reoperation was 67% at both 2 and 5 years. One additional THA underwent open reduction and internal fixation of a Vancouver B1 periprosthetic fracture. The overall complication rate (including revisions and reoperations) was high at 58% with 3 recurrent dislocations, 2 periprosthetic fractures, 1 femoral component loosening, and 1 delayed wound healing. Harris Hip Scores improved from a mean of 43 preoperatively to 81 postoperatively (P < .001).
CONCLUSION: In this study, the largest to date, we found that patients undergoing primary THA for Charcot arthropathy have a significant improvement in clinical outcomes but that there was a high risk of early complications and revisions, mostly related to recurrent instability. Specific precautions to avoid early complications, namely utilization of components that provide robust fixation and strategies that provide enhanced hip stability, should be considered.
文献出处：Chalmers B P , Tibbo M E , Trousdale R T , et al. Primary Total Hip Arthroplasty for Charcot Arthropathy is Associated With High Complications but Improved Clinical Outcomes. The Journal of Arthroplasty, 2018:S0883540318303413.
文献3
初次全髋关节置换术中真正的股骨前倾角：
基于术后CT的研究
译者：程徽
本研究探讨在非骨水泥全髋关节置换术中，仅在股骨近端股骨颈的切割面上，哪一条参考线更接近于真实股骨前倾角。我们对33例单侧原发性股骨头缺血性坏死进行非骨水泥全髋关节置换术的患者合并进行了术后双侧髋关节CT扫描，以观察股骨柄的位置及其与对侧真正前倾的关系。病变侧中皮层角平均14.1度 /- 6.8度，与对侧真实前倾角差别只有0.1度 /- 1.3度。本研究表明，使用位于前皮质线和后皮质线之间的皮质中线的前倾与真正的股骨前前倾是一致的。然而，需要进一步的研究来证实真正的股骨前倾。
图1 A线前皮质线，B线中皮质线，C线股骨柄前倾角，D线后皮质线，E后髁线。股骨颈前倾角β角比中皮质线α角大3.8°。
True femoral anteversion during primary total hip arthroplasty: use of postoperative computed tomography-based sections
This study investigated a reference line that is closer to the true femoral anteversion on only the cutting surface of the proximal femoral neck during a femoral stem insertion in a cementless total hip arthroplasty. A postoperative computed tomography of both hips from 33 consecutive patients after a unilateral primary cementless total hip arthroplasty with an avascular necrosis of the femoral head was taken to observe the positioning of the stem and its correlation with the true anteversion of the contralateral side. The average of the midcortical angle was 14.1 degrees /- 6.8 degrees on the lesion side and 0.1 degrees /- 1.3 degrees more than the true anteversion on the contralateral side. This study has shown that anteversion using a midcortical line between the anterior cortical line and the posterior cortical line is compatible with the true femoral anteversion. However, further investigation is required to confirm the true femoral anteversion.
文献出处：Suh KT, Kang JH, Roh HL, Moon KP, Kim HJ. True femoral anteversion during primary total hip arthroplasty: use of postoperative computed tomography-based sections. J Arthroplasty. 2006 Jun;21(4):599-605.
文献4
全髋关节置换术患者骨盆轴向旋转的变异性研究
译者：马云青
背景：骨盆轴向旋转影响髋臼假体的功能定位。骨盆轴向旋转1°可改变髋臼功能前倾角1°。因为在常规X线片上很难测量，所以THA患者骨盆旋转的相关研究有限。因此，我们使用脊柱至踝关节的双平面X线来研究患者在THA前后盆腔旋转的变异性。
方法：对156例初次单侧THA患者，采用双平面X线平片系统测量术前、术后6周和1年的站立和坐位骨盆旋转情况。固定骨盆旋转畸形的患者在所有站立或坐位图像上的骨盆旋转的大小和方向相似。我们进一步确定患者的旋转畸形是否与位置无关或者是位置依赖的骨盆旋转。
结果：THA患者骨盆旋转畸形多见，其中在至少一张影像上有旋转畸形>7°者有82例，占53%。固定旋转畸形12例(8%)，单独位置轴旋转畸形6例(4%)，位置依赖轴旋转畸形6例(4%)。
结论：确定患者是否存在固定的骨盆轴向旋转畸形十分重要，就像髋关节在功能像中是前倾还是后倾一样。固定旋转将增加或减少髋臼假体的功能前倾前倾角度。进一步的研究可以更好地描述固定旋转的关联和预测因素，及其对THA患者预后的影响。
Variability of pelvic axial rotation in patients undergoing total hip arthroplasty
BACKGROUND: Pelvic axial rotation affects the functional orientation of an acetabular component. Every 1° of axial rotation changes functional acetabular anteversion by 1°. There is limited information on pelvic rotation in THA patients, since it is difficult to measure on routine radiographs. Therefore, we used spine-to-ankle biplanar radiography to investigate variability in pelvic rotation in patients before and after THA.
METHODS: In 156 patients undergoing primary unilateral THA, we measured preoperative, 6 weeks and 1 year postoperative pelvic rotation in both standing and sitting positions using a biplanar radiography system. Patients with fixed pelvic rotation had a similar magnitude and direction of pelvic rotation in all standing or sitting images. We further identified patients with position-independent or position-dependent fixed pelvic rotation.
RESULTS: Pelvic rotation was common in THA patients, with 82 patients (53% of 156 patients) having at least 1 image with > 7° of rotational deformity. 12 patients (8% of 156 patients) had fixed rotation, 6 patients (4%) had position-independent fixed axial rotation and 6 patients (4%) had position-dependent fixed axial rotation.
CONCLUSIONS: It may be important to recognise whether a THA patient has a fixed pelvic axial rotational deformity, where 1 hip is consistently forward or backward in functional imaging. Fixed rotation will increase or decrease the functional anteversion of an acetabular component depending on THA side. Further research might better characterise associations and predictors of fixed axial rotation and its impact on patient outcomes after THA.
文献出处：Premkumar A, Almeida B, Ranawat CS, Jerabek SA, Esposito CI, Mayman DJ. Variability of pelvic axial rotation in patients undergoing total hip arthroplasty. Hip Int. 2019 Dec 13:1120700019889618. doi: 10.1177/1120700019889618.
文献5
髋臼外展角和股骨偏心距与聚乙烯内衬磨损的关系
译者：张蔷
恢复髋臼外展角和股骨偏心距的情况可能会对全髋关节置换术后聚乙烯内衬的磨损产生影响。我们因此评估了生物型全髋关节置换术中股骨偏心距和髋臼外展角对传统（非高交联）聚乙烯内衬磨损的影响。
我们前瞻性的随访了43例生物型全髋关节置换手术病例，最短随访时间为49个月（平均64个月；范围49-88个月）。我们在平片中测量了股骨偏心距、髋臼外展角和传统聚乙烯内衬磨损。平均（±标准差）线性磨损率为0.14mm/年（±0.01mm/年），平均容积性磨损率为53.1mm3/年（±5.5mm3/年）。髋臼外展角小于45°的病例，平均磨损率为0.12mm/年（±0.01mm/年），而髋臼外展角大于45°的病例，平均磨损率为0.18mm/年（±0.02mm/年）。重建的股骨偏心距与健侧相比在5mm以内的病例，其平均磨损率0.12mm/年，明显低于偏心距与健侧相比超过5mm的病例（0.16mm/年）。
本研究显示：全髋关节置换术中髋臼外展角超过45°或股骨偏心距与健侧差距超过5mm，均会增加传统（非高交联）超高分子量聚乙烯内衬的磨损。
Acetabular Polyethylene Wear and Acetabular Inclination and Femoral Offset
Restoration of femoral offset and acetabular inclination may influence polyethylene (PE) wear in THA. We therefore assessed the effect of femoral offset and acetabular inclination (angle) on acetabular conventional (not highly cross-linked) PE wear in uncemented THA. We prospectively followed 43 uncemented THAs for a minimum of 49 months (mean, 64 months; range, 49–88 months). Radiographs were assessed for femoral offset, acetabular inclination, and conventional PE wear. The mean (± standard deviation) linear wear rate in all THAs was 0.14 mm/year (± 0.01 mm/year) and the mean volumetric wear rate was 53.1 mm3/year (± 5.5 mm3/year). In THAs with an acetabular angle less than 45°, the mean wear was 0.12 mm/year (± 0.01 mm/year) compared with 0.18 mm/year (± 0.02 mm/year) in those with a reconstructed acetabular angle greater than 45°. Reproduction of a reconstructed femoral offset to within 5 mm of the native femoral offset was associated with a reduction in conventional PE wear (0.12 mm/year versus 0.16 mm/year). Careful placement of the acetabular component to ensure an acetabular angle less than 45° in the reconstructed hip allows for reduced conventional PE wear.
文献出处：Little N J , Busch C A , Gallagher J A , et al. Acetabular Polyethylene Wear and Acetabular Inclination and Femoral Offset[J]. Clinical Orthopaedics and Related Research®, 2009, 467(11):2895-2900.
第二部分：保髋相关文献
文献1
术中血液回收设备应用可降低
髋臼周围截骨术患者围手术期异体输血率
译者：肖凯
髋臼周围截骨术（PAO）的手术失血量有较大的变化空间，已发表的系列文章中报道失血量在100至3900ml之间。尽管同种异体输血有较大的风险，但围手术期仍经常使用。术中血液回收设备是一种常见的减少血液丢失工具；但是，目前尚缺乏支持将其用于PAO的证据。本研究目的是评估术中血液回收设备是否会影响PAO的患者围手术期异体输血率。我们回顾了2016年1月1日至2018年4月30日期间由同一名外科医生完成的54名患者（中位年龄24.7岁，四分位间距17.8-29.4岁）中58例连续PAO的临床资料。所有患者术前均未采集自体血，且手后未使用引流。由于技术人员的限制，在此研究期间间歇性地使用了术中血液回收设备。根据是否使用术中血液回收设备，将患者分为术中血液回收组或无术中血液回收组。两组患者年龄、性别、体重指数、发育不良严重程度、区域麻醉技术、氨甲环酸应用情况、手术时间或估计失血量均无显着差异（均P> 0.05）。与非术中血液回收组组相比，术中血液回收组术前血红蛋白较低（中位数为13.4μg/ dl，而中值为14.4μg/ dl，P ＝ 0.006）。与非术中血液回收组组相比，术中血液回收组的同种异体输血率显着降低（2.5％ VS 33.3％，P = 0.003）。多变量模型分析显示，术中血液回收可以降低异体输血率（P = 0.003），并且输血几率降低了80倍（OR值0.01；95％CI，0-0.57）。据我们所知，这是第一项评估术中血液回收设备使用对接受PAO患者同种异体输血率影响的研究。我们的结果表明，术中血液回收是所有接受PAO患者血液管理的重要组成部分。
Intraoperative cell salvage use reduces the rate of perioperative allogenic blood transfusion in patients undergoing periacetabular osteotomy
Blood loss during periacetabular osteotomy (PAO) is variable, with losses ranging from 100 to 3900 ml in published series. Perioperative allogenic blood transfusion is frequently utilized although is associated with significant risk of morbidity. Cell salvage (CS) is a common blood conservation tool; however, evidence supporting its use with PAO is lacking. Our aim was to assess whether CS affects perioperative allogenic blood transfusion rate in patients undergoing PAO. The clinical records of 58 consecutive PAOs in 54 patients (median age 24.7 years, interquartile range 17.8-29.4 years) performed by a single surgeon between 1 January 2016 and 30 April 2018 were reviewed. Autologous blood pre-donation and surgical drains were not used. Due to variable technician availability, CS was intermittently used during the study period. PAOs were allocated into a CS group or no cell salvage group (NCS group), according to whether an intraoperative CS system was used. There was no significant difference in patient age, gender, body mass index, dysplasia severity, regional anesthetic technique, tranexamic acid administration, surgical duration or estimated blood loss (all P > 0.05) between the two groups. The CS group had a lower preoperative hemoglobin compared to the NCS group (median, 13.4 g/dl versus 14.4 g/dl, P = 0.006). The incidence of allogenic blood transfusion was significantly lower in the CS group compared to the NCS group (2.5% versus 33.3% patients transfused, P = 0.003). Multivariate modeling showed CS use to be protective against allogenic blood transfusion (P = 0.003), with an associated 80-fold reduction in the odds of transfusion (odds ratio, 0.01; 95th% CI, 0-0.57). To our knowledge, this is the first study to assess the effect of CS use on allogenic transfusion rate in patients undergoing PAO. Our results demonstrate CS to be a mandatory component of blood conservation for all patients undergoing PAO.
文献出处：van der Merwe M, Lightfoot NJ, Munro JT, Boyle MJ. Intraoperative cell salvage use reduces the rate of perioperative allogenic blood transfusion in patients undergoing periacetabular osteotomy. J Hip Preserv Surg. 2019 Oct 12;6(3):277-283. doi: 10.1093/jhps/hnz039. eCollection 2019 Aug.
文献2
小儿骨科医生行PAO手术术后早期/中期
髋关节存活率和功能结果的研究
译者：任宁涛
背景：PAO是保髋常用手术方法，在不造成新的撞击下实现髋关节的稳定，但是术后能否获得预期效果尚未明确界定，此外，PAO的学习曲线尚未进行研究。
目的：本研究旨在研究（1）同一术者行PAO手术，术后10年的髋关节存活率和功能结果（2）回顾哪些患者、手术和放射学因素可以预测术后效果（3）确定髋臼矫正的学习曲线。
方法：回顾性分析68例有症状的髋关节发育不全患者的临床资料，所有患者随访时间不短于2年，随访终点（n=2）为患者最后一次就诊。在研究期间，同一术者进行了562例骨盆截骨术（包括Salter、Pemberton、Dega和Chiari）和64例髋臼成形术。PAO仅用于治疗发育成熟的髋关节，CE角< 25°，臼顶倾斜，无明显的头臼匹配差和半脱位。其中女性患者偏多（n=49,60个髋关节 88%），手术时平均年龄为25岁（SD 7），16个髋关节曾有治疗史，平均随访时间为8年（2-18年），使用WOMAC进行术后效果的评估（好-坏：0-96），使用电脑软件对术前术后的影像学指标（AI、CE角、匹配情况、Tönnis分级和关节间隙）进行评估。
结果：髋关节10年的存活率为93%（95%CI，82%-100%），其中有4名患者在研究期间进行可髋关节进一步的手术治疗。影响术后髋关节存活率的因素包括关节匹配度（100% VS 78%，95%CI 61%-96%，P=0.03）和髋臼矫正程度（术后AI< 15° [ 100% VS 65%，95%CI 43%-88%，P< 0.001]和术后CE角处于20°- 40°之间[100% VS 71.9%; 52.8-100; p <0.001]）。如术后AI < 15° (7 VS 25, p = 0.005)和CE角处于20°- 40°之间，则可获得较好的WOMAC评分。在进行第20次手术后，更好的髋臼矫正能力提升（30% VS 70%，p=0.008）。
结论：术者经验与PAO术后效果相关，髋臼矫正需谨慎，后期需对术前设计和术中操作以及降低学习曲线进行研究。
表2 人口统计学和临床数据
表3 影像学测量指标
表4 影像学参数测定对临床疗效的影响
What Is the EarlyMid-term Survivorship and Functional Outcome After Bernese Periacetabular Osteotomy in a Pediatric Surgeon Practice
BACKGROUND: The Bernese periacetabular osteotomy (PAO) is a recognized joint-preserving procedure. Achieving joint stability without creating impingement is important, but the orientation target that best balances these sometimes competing goals has not yet been clearly defined. Moreover, the learning curve of this challenging procedure has not been described.
QUESTIONS/PURPOSES: The purposes of this study were (1) to determine the 10-year survivorship and functional outcome after BernesePAO in a single-surgeon series; (2) to review which patient, surgical, and radiographic factors might predict outcome after the procedure; and (3) to define the learning curve for target acetabular correction.
METHODS: The first 68 PAOs performed for symptomatic hip dysplasia were retrospectively evaluated. None have been lost to followup with followup less than 2 years. Endpoints for the lost to followup (n = 2) are at the time of when last seen. During the study period, the same surgeon performed 562 pelvic osteotomies (including Salter, Pemberton, Dega and Chiari) and 64 shelf acetabuloplasties. Bernese PAO was used only for symptomatic dysplasia (center-edge angle < 25° and nonhorizontal acetabular roof) in developmentally mature hips without evidence of major joint incongruence or subluxation. Most patients were female (n = 49 [60 hips, 88%]); mean age at operation was 25 years (SD 7). Sixteen hips had previous hip procedures. The study's mean followup was 8 years (range, 2-18 years). Patient-reported functionaloutcome was obtained using the WOMAC score (best-worst: 0-96). Radiographic parameters of dysplasia (acetabular index [AI], center-edge angle [CEA], congruency, Tönnis grade, and joint space) were evaluated from preoperative and postoperative radiographs using computer software.
RESULTS: The 10-year survival rate was 93% (95% confidence interval [CI], 82%-100%); four patients underwent further surgery to the hip in the study period. The mean WOMAC was 12 (range, 0-54). Factors that influenced survival included joint congruency (100% versus 78%; 95% CI, 61%-96%; p = 0.03) and acetabular orientation correction achieved (AIpostoperative < 15° [100% versus 65%; 95% CI, 43-88; p < 0.001] and CEApostoperative 20° to 40° [100% versus 71.9%; 52.8-100; p < 0.001]). Better WOMAC scores were seen if postoperative AI < 15° (7 versus 25, p = 0.005) and CEA between 20° and 40° (7 versus 23, p = 0.005) were achieved. The chances of obtaining acetabular correction within this range improved after the 20(th) procedure (30% versus 70%, p = 0.008).
CONCLUSIONS: This study reports excellent results after Bernese PAO in the hands of an experienced pediatric hip surgeon. We advocate cautious correction of the acetabular fragment. Future studies should concentrate on how to determine what the optimal target is and how to achieve it intraoperatively, minimizing the learning curve associated with it.
文献出处：Grammatopoulos G, Wales J, Kothari A, Gill HS, Wainwright A, Theologis T. What Is the EarlyMid-term Survivorship and Functional Outcome After Bernese Periacetabular Osteotomy in a Pediatric Surgeon Practice Clin Orthop Relat Res. 2016 May;474(5):1216-23. doi: 10.1007/s11999-015-4386-7.
文献3
髋关节发育不良和不稳定：
关节镜和切开手术的客观评价
译者：张利强
近十年来，包括髋关节发育不良在内的年轻人髋关节疾病的治疗有了长足的发展。髋关节发育不良与髋关节骨关节炎的关系是一致认可的，但仍以基本的影像学参数为基础。我们对髋关节发育不良的复杂性和多样性的认识一直在发展。由于轻度和临界髋臼发育不良的临床表现与其他年轻成人髋关节疾病非常相似，例如股骨髋臼撞击，全面的病史、体格检查，同时放射学评估对正确诊断这些患者非常重要。髋臼周围截骨术是治疗髋臼发育不良最常见的方法，术后20多年随访疗效良好。基于改善长期疗效的理论目标，髋臼周围截骨术同时行关节内唇软骨病理和股骨颈偏心距异常的治疗已越来越普遍。临界发育不良的髋关节仍然是一个有争议的话题，与髋关节微不稳定的其他原因，如结缔组织松弛等有明显的重叠。本文就髋臼发育不良的相关文献和治疗方法进行综述。
髋关节发育不良各种表现。中度髋关节发育不良伴Shenton线断裂。中度髋关节发育不良伴完整的Shenton线。C，轻度髋关节发育不良，股骨形态正常。D、轻度髋关节发育不良伴股骨近端凸轮畸形
轻度髋臼发育不良1例。A，术前X线片显示轻度髋臼发育不良伴股骨头外移。B，术中透视图像显示髋臼覆盖率的改善和髋臼内移。C，术后1年的X线片显示截骨愈合，髋臼覆盖率和解剖结构改善。
右髋关节发育不良前外侧关节内病变的观察。伴有边缘软骨软化症的慢性盂唇脱离（A）；伴有关节软骨和盂唇复合体剥离的唇部肥大（B）；盂唇修复（C）；不稳定关节软骨瓣切除后全层关节软骨丢失（D）；圆韧带部分撕裂（E）；清创术后显示圆韧带（F）。
The Dysplastic and Unstable Hip: A Responsible Balance of Arthroscopic and Open Approaches
The treatment of young adult hip disorders, including hip dysplasia, has evolved significantly in the last decade. The association of hip dysplasia with hip osteoarthritis is well accepted, but remains based on basic radiographic parameters. Our understanding of the complexity and variability of hip dysplasia continues to evolve. As the clinical presentation of mild and borderline acetabular dysplasia is very similar to that of other young adult hip disorders, such as femoroacetabular impingement, a thorough history, physical examination, and radiographic evaluation are important to properly diagnose these patients. Acetabular reorientation via the periacetabular osteotomy has become the most common treatment for acetabular dysplasia with good outcomes reported at over 20 years postoperatively. The treatment of intraarticular labrochondral pathology and femoral head-neck offset abnormalities at the time of periacetabular osteotomy has become more common place with the theoretical goal of improving long- term outcomes. The borderline dysplastic hip remains a controversial topic, with significant overlap with other causes of hip microinstability such as connective tissue laxity. In the current article, we present a relevant review of the literature and a balanced approach to the treatment of acetabular dysplasia.
文献出处：Nepple J J , Clohisy J C . The Dysplastic and Unstable Hip: A Responsible Balance of Arthroscopic and Open Approaches[J]. Sports medicine and arthroscopy review, 2015, 23(4):180-186.
文献4
医源性髋关节不稳是严重的股骨头骨骺滑脱
改良Dunn手术后的毁灭性并发症
译者：陶可（北京大学人民医院骨关节科）
背景：改良的Dunn手术通过髋关节外科脱位方法，有助于股骨头骨骺滑脱（SCFE）的股骨重新对位。此前尚未研究过这种手术后的医源性髋关节不稳。但是，当我们观察到这种严重并发症的几个病例时，我们感到担忧，我们希望对其进行进一步研究。
问题/目的：本研究的目的是评估经过改良Dunn术式治疗SCFE后与医源性髋关节不稳定相关的发生概率、时间和临床表现（包括并发症）。
方法：2007年至2014年间，8个国际机构通过外科脱位方法对406例患者进行了改良的Dunn手术。在所讨论的时期内，这些部位的适应证各不相同，但该方法仅用于少数接受SCFE手术治疗的患者（31％[406/1331]），而大多数患者采用原位固定治疗。通常是针对严重畸形，滑移角大于40°的患者进行改良Dunn术式治疗。在数据库中搜索所有发生术后髋关节不稳的SCFE患者，这些患者定义为术后半髋关节半脱位或受累髋关节脱位。作者详细回顾了那些表现为髋关节不稳定患者的临床记录和手术记录。作者获得了人口统计学信息，从SCFE发生到手术的时间、固定的类型、手术细节以及包括并发症发生率在内的临床过程。对那些不稳定患者的随访平均随访时间为2年（范围1-5年）。根据改良的Dindo-Clavien分类对并发症进行分级、且回顾了放射学资料以测量术前滑移角和确定骨坏死的存在。
结果：改良Dunn术式治疗的患者中，术后有4％发生了髋关节不稳（406个中的17髋）。患者的平均年龄为13岁（9-16岁）。不稳定性表现为术后持续性髋部疼痛，或在术后就诊时通过影像学检查偶然发现，并在改良的Dunn手术后中位出现了3周（范围为1天至2个月）。8例患者接受了翻修手术，以解决术后不稳定的问题。在此短期随访中，17例患者中有14例发生股骨头缺血性坏死，17例患者中有3例进行了THA。
结论：改良Dunn手术治疗严重慢性SCFE后所发生的前外侧髋关节不稳是一种罕见但潜在的破坏性并发症。未来的研究可能会评估术后在外展位施以支具或石膏固定数周，维持前髋关节预防措施的有效性，以预防这种并发症。
图2A–H（A）前后位和（B）侧位X线片显示，一个12岁的男孩因急性髋关节疼痛和跛行而至急诊科就诊。他已经经历了超过1年的右膝和髋关节疼痛。他被诊断出患有中度、慢性、稳定的SCFE。（C）前后位和（D）蛙式位固定后的X线片。（E）在分度手术后4个月进行改良Dunn手术后的前后位X线片。（F）术后2周就诊时的X线片显示高位错。进行切开复位和绑扎支撑6周。改良的Dunn手术2年后（G）前后位和（H）侧位X线片：有放射学证据表明轻度股外侧头缺血性坏死。但是，患者没有髋部疼痛。他的脚后跟步态相对，脚外旋角度约为10°。髋关节屈曲活动度达到100°。两髋对称地具有20°内旋和40°外旋。
Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis
BACKGROUND: The modified Dunn procedure facilitates femoral capital realignment for slipped capital femoral epiphysis (SCFE) through a surgical hip dislocation approach. Iatrogenic postoperative hip instability after this procedure has not been studied previously; however, we were concerned when we observed several instances of this serious complication, and we wished to study it further.
QUESTIONS/PURPOSES: The purpose of this study was to evaluate the frequency, timing, and clinical presentation (including complications) associated with iatrogenic instability after the modified Dunn procedure for SCFE.
METHODS: Between 2007 and 2014, eight international institutions performed the modified Dunn procedure through a surgical dislocation approach in 406 patients. During the period in question, indications varied at those sites, but the procedure was used only in a minority of their patients treated surgically for SCFE (31% [406 of 1331]) with the majority treated with in situ fixation. It generally was performed for patients with severe deformity with a slip angle greater than 40°. Institutional databases were searched for all patients with SCFE who developed postoperative hip instability defined as hip subluxation or dislocation of the involved hip during the postoperative period. We reviewed in detail the clinical notes and operative records of those who presented with instability. We obtained demographic information, time from slip to surgery, type of fixation, operative details, and clinical course including the incidence of complications. Followup on those patients with instability was at a mean of 2 years (range, 1-5 years) after the index procedure. Complications were graded according to the modified Dindo-Clavien classification. Radiographic images were reviewed to measure the preoperative slip angle and the presence of osteonecrosis.
RESULTS: A total of 4% of patients treated with the modified Dunn procedure developed postoperative hip instability (17 of 406). Mean age of the patients was 13 years (range, 9-16 years). Instability presented as persistent hip pain in the postoperative period or was incidentally identified radiographically during the postoperative visit and occurred at a median of 3 weeks (range, 1 day to 2 months) after the modified Dunn procedure. Eight patients underwent revision surgery to address the postoperative instability. Fourteen of 17 patients developed femoral head avascular necrosis and three of 17 patients underwent THA during this short-term followup.
CONCLUSIONS: Anterolateral hip instability after the modified Dunn procedure for severe, chronic SCFE is an uncommon yet potentially devastating complication. Future studies might evaluate the effectiveness of maintaining anterior hip precautions for several weeks postoperatively in an abduction brace or broomstick cast to prevent this complication.
文献出处：Upasani VV, Birke O, Klingele KE, Millis MB; International SCFE Study Group. Iatrogenic Hip Instability Is a Devastating Complication After the Modified Dunn Procedure for Severe Slipped Capital Femoral Epiphysis. Clin Orthop Relat Res. 2017 Apr;475(4):1229-1235. doi: 10.1007/s11999-016-5094-7.
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