髖膝關(guān)節(jié)文獻(xiàn)精譯薈萃（第159期）

文獻(xiàn)1

不能自主活動(dòng)的年青腦癱患者全髖置換報(bào)告

翻譯：羅殿中

背景：不能自主活動(dòng)的青少年和年青成人腦癱患者，由于髖關(guān)節(jié)疼痛或僵硬，造成日常生活受到嚴(yán)重影響。傳統(tǒng)的手術(shù)治療方法，如股骨近端切除術(shù)（PFR）一方面是毀損手術(shù)，另一方面疼痛緩解效果不很滿(mǎn)意。

假設(shè)：本文通過(guò)回顧性研究，假定對(duì)這類(lèi)患者行全髖關(guān)節(jié)置換（THA）較股骨近端切除術(shù)（PFR）在不加重活動(dòng)受限的情況下，疼痛緩解更徹底、更有效。

病人與方法：本組病例采用雙動(dòng)髖關(guān)節(jié)假體、非骨水泥髖臼、骨水泥股骨柄、股骨近端短縮、術(shù)后石膏固定等措施，共33例40髖置換，其中31例患者合并多項(xiàng)功能障礙。主要對(duì)關(guān)節(jié)功能、疼痛、活動(dòng)度三方面進(jìn)行隨訪。

結(jié)果：平均隨訪5年，疼痛幾乎完全緩解。活動(dòng)度改善不明顯，功能無(wú)明顯改善。有2例普通并發(fā)癥、2例感染、10例機(jī)械并發(fā)癥，6例需要再次手術(shù)去除假體。

結(jié)論：在不能自主活動(dòng)的年青腦癱患者中，全髖關(guān)節(jié)置換（THA）在緩解疼痛方面較股骨近端切除手術(shù)（PFR）更為徹底。對(duì)于這類(lèi)能夠承受較長(zhǎng)時(shí)間手術(shù)、能夠植入較小股骨假體的嚴(yán)重腦癱患者，全髖關(guān)節(jié)置換可以作為備選方案。

圖1. 雙動(dòng)髖關(guān)節(jié)假體：骨水泥股骨柄、26mm股骨頭、壓配進(jìn)入聚乙烯雙動(dòng)股骨頭內(nèi)。

圖2. 一位單側(cè)脫位、嚴(yán)重痙攣性疼痛、不能自主活動(dòng)的腦癱患者，手術(shù)后12年隨訪。

圖3. （a）腦癱患者多次手術(shù)髖關(guān)節(jié)嚴(yán)重疼痛，第二次髖關(guān)節(jié)置換后發(fā)生呼吸抑制，住重癥監(jiān)護(hù)，肺部培養(yǎng)出假單胞菌。（b）術(shù)后9年復(fù)查攝片，無(wú)疼痛，可輕松坐起來(lái)。25歲去世。

圖4. 雙動(dòng)頭與股骨柄裝配失效，需要手術(shù)復(fù)位。

圖5. 患者清醒無(wú)肌肉痙攣時(shí)小轉(zhuǎn)子撕脫骨折，非手術(shù)牽引治療后愈合。

圖6. 非骨水泥假體，進(jìn)行性股骨外側(cè)壁吸收、無(wú)癥狀。

Total hip replacement in young non-ambulatory cerebral palsy patients

Introduction: The everyday life of a non-ambulatory adolescent or young adult with cerebral palsy can be severely impaired by a painful or stiff hip. The usual surgical solutions such as proximal femoral resection (PFR) are not entirely satisfactory for pain relief, and are mutilating.

Hypothesis: A retrospective study assessed the impact of total hip replacement (THR) on such impairment, on the hypothesis that it is more effective than PFR in relieving pain, without aggravating disability.

Patients and methods: The surgical technique consisted in implanting a dual-mobility prosthesis with uncemented acetabular component and cemented femur, after upper femoral shaft shortening and short hip-spica cast immobilization. Forty THRs were performed in 33 patients, including 31 with multiple disability. Follow-up assessment focused on change in functional status, pain, and range of motion.

Results: Mean follow-up was 5 years. Pain was more or less entirely resolved. Improvement in range of motion was less striking, and there was no significant change in functional status. There were 2 general, 2 septic and 10 mechanical complications, 6 of which required surgical revision.

Discussion: In non-ambulatory cerebral palsy, THR provided much better alleviation of pain than found with PFR treatment. It should be reserved for patients able to withstand fairly long surgery and with femur size compatible with implantation of a femoral component, however small.

文獻(xiàn)出處：C. Morin, C. Ursu, C. Delecourt, Total hip replacement in young non-ambulatory cerebral palsy patients, Orthopaedics & Traumatology: Surgery & Research, Volume 102, Issue 7, 2016, Pages 845-849,

文獻(xiàn)2

膝關(guān)節(jié)囊的感覺(jué)神經(jīng)分布及對(duì)于關(guān)節(jié)神經(jīng)阻滯和

射頻消融的意義：解剖學(xué)研究

譯者：張軼超

背景：盡管顯現(xiàn)出治療上的效果，但是對(duì)于人類(lèi)膝關(guān)節(jié)囊的關(guān)節(jié)神經(jīng)支配在解剖描述和術(shù)語(yǔ)應(yīng)用上還是存在很多差異。出于治療的目的，本尸體研究是為了確定神經(jīng)的起點(diǎn)、走行、相關(guān)性和定位。

方法：我們解剖了21具尸體的21個(gè)下肢以評(píng)估膝關(guān)節(jié)囊上的關(guān)節(jié)神經(jīng)的解剖分布。我們根據(jù)解剖標(biāo)識(shí)來(lái)找出關(guān)節(jié)神經(jīng)進(jìn)入膝關(guān)節(jié)囊的恒定位置，用克氏針穿過(guò)神經(jīng)釘?shù)狡湎碌墓趋郎献鳛槟繕?biāo)點(diǎn)。進(jìn)行測(cè)量及拍攝前后位和側(cè)位X片。

結(jié)果：支配骨內(nèi)側(cè)肌的神經(jīng)、隱神經(jīng)、閉孔神經(jīng)前支、和坐骨神經(jīng)的一支提供了內(nèi)側(cè)關(guān)節(jié)囊和支持帶的主要神經(jīng)支配。坐骨神經(jīng)和支配股外側(cè)肌的感覺(jué)神經(jīng)提供了膝關(guān)節(jié)上外側(cè)部分的神經(jīng)支配而腓神經(jīng)則提供了外下部的神經(jīng)支配。脛神經(jīng)和閉孔神經(jīng)后支提供后關(guān)節(jié)囊的神經(jīng)支配。根據(jù)我們的研究，有5個(gè)恒定準(zhǔn)確的關(guān)節(jié)神經(jīng)定位標(biāo)識(shí)可以被用于治療時(shí)使用。

結(jié)論：支配膝關(guān)節(jié)囊的感覺(jué)神經(jīng)分布圖可以為準(zhǔn)確、安全的治療提供恒定的5個(gè)關(guān)節(jié)神經(jīng)的位置。本能研究為關(guān)節(jié)神經(jīng)阻滯和射頻消融治療提供了穩(wěn)妥的解剖學(xué)基礎(chǔ)研究。

Distribution of sensory nerves supplying the knee joint capsule and implications for genicular blockade and radiofrequency ablation: an anatomical study

Background: Despite their emerging therapeutic relevance, there are many discrepancies in anatomical description and terminology of the articular nerves supplying the human knee capsule. This cadaveric study aimed to determine their origin, trajectory, relationship and landmarks for therapeutic purpose.

Methods: We dissected 21 lower limbs from 21 cadavers, to investigate the anatomical distribution of all the articular nerves supplying the knee joint capsule. We identified constant genicular nerves according to their anatomical landmarks at their entering point to knee capsule and inserted Kirschner wires through the nerves in underlying bone at those target points. Measurements were taken, and both antero-posterior and lateral radiographs were obtained.

Results: The nerve to vastus medialis, saphenous nerve, anterior branch of obturator nerve and a branch from sciatic nerve provide substantial innervation to the medial knee capsule and retinaculum. The sciatic nerve and the nerve to the vastus lateralis supply sensory innervation to the supero-lateral aspect of the knee joint while the fibular nerve supplies its infero-lateral quadrant. Tibial nerve and posterior branch of obturator nerve supply posterior aspect of knee capsule. According to our findings, five constant genicular nerves with accurate landmarks could be targeted for therapeutic purpose.

Conclusion: The pattern of distribution of sensitive nerves supplying the knee joint capsule allows accurate and safe targeting of five constant genicular nerves for therapeutic purpose. This study provides robust anatomical foundations for genicular nerve blockade and radiofrequency ablation.

文獻(xiàn)出處：Fonkoué L, Behets C, Kouassi JK, Coyette M, Detrembleur C, Thienpont E, Cornu O. Distribution of sensory nerves supplying the knee joint capsule and implications for genicular blockade and radiofrequency ablation: an anatomical study. Surg Radiol Anat. 2019 Dec;41(12):1461-1471. doi: 10.1007/s00276-019-02291-y. Epub 2019 Jul 23. PMID: 31338537.

文獻(xiàn)3

術(shù)前內(nèi)翻角度大于15°全膝關(guān)節(jié)置換術(shù)

髕骨骨折發(fā)生率增加: 病例對(duì)照研究

譯者：馬云青

背景: 處理嚴(yán)重的膝關(guān)節(jié)內(nèi)翻畸形需要軟組織平衡才能植入低限制型膝關(guān)節(jié)假體。髕骨并發(fā)癥在這個(gè)特殊群體中很少被研究。本研究的假設(shè)是嚴(yán)重膝內(nèi)翻(>15 °)會(huì)增加髕骨并發(fā)癥的發(fā)生率。

方法: 采用前瞻性隊(duì)列研究方法，對(duì)1987年開(kāi)始在同一中心的4216例人工膝關(guān)節(jié)置換病例進(jìn)行分析，對(duì)280例術(shù)前膝關(guān)節(jié)內(nèi)翻角度大于15 ° 的患者與673例術(shù)前髖-膝-踝為180 ° ± 2 ° 的全膝關(guān)節(jié)患者進(jìn)行比較。比較兩組術(shù)前和術(shù)后的臨床和影像學(xué)特征，特別注意比較髕骨并發(fā)癥。

結(jié)果: 平均隨訪時(shí)間為40.2個(gè)月(24-239)。術(shù)前正常力線組(髖-膝-踝180 ° ± 2)平均膝關(guān)節(jié)社會(huì)評(píng)分(KSS)明顯較高(62.65 vs 37.47，p = . 001)。最后一次隨訪，兩組術(shù)后 KSS 無(wú)顯著性差異(內(nèi)翻組87.5，正常力線組87.3，p = . 87)。兩組患者滿(mǎn)意率相同(85.3% vs 88.8% ，p = . 49)。而中期隨訪內(nèi)翻組髕骨骨折病例較多(2.9% vs 0.9% ，p = . 005)。內(nèi)翻組和髕骨骨折組患者髕骨高度明顯降低(p < 0.001)。

結(jié)論: 嚴(yán)重內(nèi)翻膝關(guān)節(jié)行TKA術(shù)后的KSS 評(píng)分與力線正常膝關(guān)節(jié)TKA術(shù)后相當(dāng)。內(nèi)翻畸形患者髕骨骨折的風(fēng)險(xiǎn)可能會(huì)導(dǎo)致術(shù)中髕骨置換的患者比例下降，特別是在術(shù)前存在髕骨低位的患者。

Increased Patellar Fracture Rate in Total Knee Arthroplasty With Preoperative Varus Greater Than 15°: A Case-Control Study

Background: Management of severe varus deformity requires soft tissue balancing for implantation of low-constraint knee prosthesis. Patellar complications have been rarely studied in this specific group. Our hypothesis was that severe genu varum (>15°) would increase the rate of patellar complications.

Methods: Using a prospective cohort of 4216 prostheses performed at a single center beginning in 1987, we analyzed 280 prostheses having preoperative varus greater than 15°, compared to 673 total knee arthroplasties (TKAs) with a preoperative hip-knee-ankle angle of 180° ± 2°. Preoperative and postoperative clinical and radiological characteristics were compared between the 2 groups, with particular attention paid to patellar complications.

Results: Average follow-up was 40.2 months (24-239). The mean preoperative Knee Society Score (KSS) was statistically higher in the normal (hip-knee-ankle angle 180° ± 2) axis group (62.65 vs 37.47, P = .001). At the last follow-up, no significant difference was found between the 2 groups in terms of postoperative KSS (87.5 in the varus group vs 87.3 in the normal axis group, P = .87). The rate of satisfied patients was identical between the 2 groups (85.3% vs 88.8%, P = .49). However, at mid-term, there were more patellar fractures in the varus group (2.9% vs 0.9%, P = .005). A significantly lower patellar height in both the varus group and the group of patella fractures (P < .001) was also found.

Conclusion: TKA in severe varus knees produces a KSS equivalent to TKA in knees with a mechanical axis of 0 ± 2. The risk of patellar fracture could initiate a decline in patella resurfacing in patients with major varus deformation, especially in case of a preoperative patella baja.

文獻(xiàn)出處：Mouton J, Gaillard R, Bankhead C, Batailler C, Servien E, Lustig S. Increased Patellar Fracture Rate in Total Knee Arthroplasty With Preoperative Varus Greater Than 15°: A Case-Control Study. J Arthroplasty. 2018 Dec;33(12):3685-3693. doi: 10.1016/j.arth.2018.08.001. Epub 2018 Aug 7. PMID: 30197216.

文獻(xiàn)4

與住院關(guān)節(jié)置換相比，現(xiàn)代的門(mén)診關(guān)節(jié)置換同樣安全：

一項(xiàng)包含了574375例匹配后手術(shù)病例的隊(duì)列研究

譯者：張薔

背景：門(mén)診關(guān)節(jié)置換是解決目前病例增多的方案之一，其需求正在快速增長(zhǎng)。然而我們發(fā)現(xiàn)，最近七年，既往文獻(xiàn)中并沒(méi)有比較門(mén)診關(guān)節(jié)置換與匹配后住院關(guān)節(jié)置換病例的相關(guān)研究。本篇文章的目的就是比較匹配后的門(mén)診或住院關(guān)節(jié)置換病例的術(shù)后30天內(nèi)并發(fā)癥以及再住院率。

方法：我們從國(guó)家外科質(zhì)量改進(jìn)計(jì)劃數(shù)據(jù)庫(kù)中選取了2009年至2018年間所有初次全髖關(guān)節(jié)置換（THA）、初次全膝關(guān)節(jié)置換（TKA）和初次單髁置換（UKA）的病例。我們根據(jù)十項(xiàng)圍手術(shù)期相關(guān)指標(biāo)，按照1:4的比例，匹配了門(mén)診關(guān)節(jié)置換與住院關(guān)節(jié)置換病例。我們使用McNemar試驗(yàn)比較了兩組間的術(shù)后30天內(nèi)并發(fā)癥和再住院率，并應(yīng)用多因素回歸分析明確了并發(fā)癥和再住院的危險(xiǎn)因素。

結(jié)果：在所有入選的574375例病例中，21506例（3.74%）接受了門(mén)診關(guān)節(jié)置換手術(shù)。進(jìn)行匹配的組間比較后，我們發(fā)現(xiàn)門(mén)診關(guān)節(jié)置換的病例術(shù)后并發(fā)癥更少（3.18% VS. 7.45%；p < 0.001）。而當(dāng)門(mén)診TKA、THA和UKA置換病例分別與住院相應(yīng)病例亞組進(jìn)行比較時(shí)，我們發(fā)現(xiàn)所有門(mén)診置換亞組的并發(fā)癥率均低于對(duì)照組，而再住院率并無(wú)顯著性差異。門(mén)診關(guān)節(jié)置換是并發(fā)癥率更低的獨(dú)立影響因素（概率比OR，0.407，95%置信區(qū)間，0.369-0.449；p < 0.001），而并不會(huì)增加再住院率（OR, 1.004 [95%置信區(qū)間, 0.878-1.148]; p = 0.951）。

結(jié)論：與匹配后的住院關(guān)節(jié)置換相比，門(mén)診關(guān)節(jié)置換在本研究中展現(xiàn)出了并發(fā)癥率更低而并不增加30天內(nèi)再住院率的優(yōu)勢(shì)。盡管康復(fù)地點(diǎn)的選擇應(yīng)該在多因素分析后決定，門(mén)診關(guān)節(jié)置換仍不失為住院關(guān)節(jié)置換的一種安全有效的替代治療方法。

Contemporary Outpatient Arthroplasty Is Safe Compared with Inpatient Surgery: A Propensity Score-Matched Analysis of 574,375 Procedures

Background: Outpatient joint arthroplasty is a potential modality for increased case throughput and is rising in demand. However, we are aware of no study that has compared outcomes between risk-matched outpatient and inpatient procedures within the last 7 years. The aims of this study were to compare matched patient cohorts who underwent outpatient or inpatient joint arthroplasty in terms of 30-day adverse events and readmission rates.

Methods: From the National Surgical Quality Improvement Program database, we identified patients who underwent primary total hip arthroplasty (THA), primary total knee arthroplasty (TKA), and primary unicompartmental knee arthroplasty (UKA) from 2009 to 2018. Using 10 perioperative variables, patients who underwent an outpatient procedure were 1:4 propensity score-matched with patients who underwent an inpatient procedure. The rates of 30-day adverse events and readmission were compared using the McNemar test. The risk factors for adverse events and readmissions were identified using multivariate regression.

Results: Of 574,375 patients identified, 21,506 (3.74%) underwent an outpatient procedure. After propensity score matching, an outpatient joint arthroplasty was associated with a lower rate of adverse events (3.18% compared with 7.45%; p < 0.001). When assessed individually, outpatient TKA (3.15% compared with 8.11%; p < 0.001), THA (4.94% compared with 10.05%; p < 0.001), and UKA (1.78% compared with 3.39%; p < 0.001) were all associated with fewer adverse events overall and there was no difference in the rate of 30-day readmission, when compared with inpatient analogs. Outpatient joint arthroplasty was an independent factor for lower adverse events (odds ratio [OR], 0.407 [95% confidence interval (CI), 0.369 to 0.449]; p < 0.001), with no increase in the risk of readmission (OR, 1.004 [95% CI, 0.878 to 1.148]; p = 0.951).

Conclusions: Contemporary outpatient joint arthroplasty demonstrated lower rates of adverse events with no increased rate of 30-day readmission when compared with risk-matched inpatient counterparts. Although multiple factors should guide the decision for the site of care, outpatient arthroplasty may be a safe alternative to inpatient arthroplasty.

文獻(xiàn)出處：Lan RH, Samuel LT, Grits D, Kamath AF. Contemporary Outpatient Arthroplasty Is Safe Compared with Inpatient Surgery: A Propensity Score-Matched Analysis of 574,375 Procedures. J Bone Joint Surg Am. 2021 Apr 7;103(7):593-600. doi: 10.2106/JBJS.20.01307. PMID: 33646984.

文獻(xiàn)5

確定髖臼三維定向的新方法：

基于200例病例的研究結(jié)果

譯者：張峻

背景：由于骨盆和髖臼固有的復(fù)雜三維形態(tài)造成難以準(zhǔn)確地判斷髖臼的定向。本研究目的是尋找一種可靠的和準(zhǔn)確的確定臼三維定向的方法，并且能夠描述沒(méi)有明顯髖關(guān)節(jié)病變的大樣本人群的相關(guān)特征。

方法：從本單位數(shù)據(jù)庫(kù)中選擇接受高分辨率CT掃描的200名患者，這些患者起初接受骨盆掃描的適應(yīng)癥與骨科方面無(wú)關(guān)。生成每個(gè)骨性骨盆的三維模型以提取特定的解剖數(shù)據(jù)集。研究一種新的計(jì)算方法以便明確在自動(dòng)識(shí)別的前骨盆平面內(nèi)參考框架內(nèi)臼三維定向的標(biāo)準(zhǔn)測(cè)量值。在髖臼骨性邊緣自動(dòng)選擇點(diǎn)來(lái)產(chǎn)生描述髖臼定向的最佳擬合平面。

結(jié)果：我們的方法表明良好的觀察者間和觀察者內(nèi)一致性（組內(nèi)相關(guān)系數(shù)>0.999），并獲得了較高的準(zhǔn)確性。觀察到男性和女性在前傾角（平均3.5°；95%置信區(qū)間[CI]，所有角度定義1.9°至5.1°；p<0.0001）和外展角（1.4°；95%CI，解剖角度定義0.6°至2.3°；p<0.002）方面存在顯著差異。解剖測(cè)量的患者內(nèi)部不對(duì)稱(chēng)性顯示雙側(cè)前傾角（最大12.1°）和外展角（最大10.9°）存在差異。

結(jié)論：只有對(duì)整個(gè)髖臼精確地測(cè)量才能發(fā)現(xiàn)髖臼定向在性別之間的差別。雖然觀察到患者間髖臼定向角度變異較大，但大多數(shù)個(gè)體的髖臼的外展角和前傾角相對(duì)對(duì)稱(chēng)。

臨床相關(guān)性：一種高精準(zhǔn)度和可重復(fù)性強(qiáng)的測(cè)量髖臼孔定向的方法會(huì)使醫(yī)生和患者受益，進(jìn)一步細(xì)化正常髖關(guān)節(jié)和異常髖關(guān)節(jié)特征的區(qū)別。深入理解髖臼有助于髖關(guān)節(jié)疾病的診斷，計(jì)劃和手術(shù)的實(shí)施，以及優(yōu)化新假體的設(shè)計(jì)。

A novel approach for determining three-dimensional acetabular orientation: results from two hundred subjects

Background: The inherently complex three-dimensional morphology of both the pelvis and acetabulum create difficulties in accurately determining acetabular orientation. Our objectives were to develop a reliable and accurate methodology for determining three-dimensional acetabular orientation and to utilize it to describe relevant characteristics of a large population of subjects without apparent hip pathology.

Methods: High-resolution computed tomography studies of 200 patients previously receiving pelvic scans for indications not related to orthopaedic conditions were selected from our institution's database. Three-dimensional models of each osseous pelvis were generated to extract specific anatomical data sets. A novel computational method was developed to determine standard measures of three-dimensional acetabular orientation within an automatically identified anterior pelvic plane reference frame. Automatically selected points on the osseous ridge of the acetabulum were used to generate a best-fit plane for describing acetabular orientation.

Results: Our method showed excellent interobserver and intraobserver agreement (an intraclass correlation coefficient [ICC] of >0.999) and achieved high levels of accuracy. A significant difference between males and females in both anteversion (average, 3.5°; 95% confidence interval [CI], 1.9° to 5.1° across all angular definitions; p < 0.0001) and inclination (1.4°; 95% CI, 0.6° to 2.3° for anatomic angular definition; p < 0.002) was observed. Intrapatient asymmetry in anatomic measures showed bilateral differences in anteversion (maximum, 12.1°) and in inclination (maximum, 10.9°).

Conclusions: Significant differences in acetabular orientation between the sexes can be detected only with accurate measurements that account for the entire acetabulum. While a wide range of interpatient acetabular orientations was observed, the majority of subjects had acetabula that were relatively symmetrical in both inclination and anteversion.

Clinical relevance: A highly accurate and reproducible method for determining the orientation of the acetabulum's aperture will benefit both surgeons and patients, by further refining the distinctions between normal and abnormal hip characteristics. Enhanced understanding of the acetabulum could be useful in the diagnostic, planning, and execution stages for surgical procedures of the hip or in advancing the design of new implant systems.

文獻(xiàn)出處：Higgins SW, Spratley EM, Boe RA, Hayes CW, Jiranek WA, Wayne JS. A novel approach for determining three-dimensional acetabular orientation: results from two hundred subjects. J Bone Joint Surg Am. 2014 Nov 5;96(21):1776-84. doi: 10.2106/JBJS.L.01141. PMID: 25378504.

第二部分：保髖相關(guān)文獻(xiàn)

文獻(xiàn)1

髖臼周?chē)毓切g(shù)后遲發(fā)坐骨神經(jīng)損傷報(bào)告一例

譯者：程徽

1984年Ganz教授發(fā)明了伯爾尼髖臼周?chē)毓切g(shù)(PAO)，目前是最常用的青少年和成人髖臼畸形矯形技術(shù)。盡管廣泛應(yīng)用，髖臼周?chē)毓切g(shù)對(duì)手術(shù)技術(shù)要求很高，學(xué)習(xí)曲線較長(zhǎng)，并發(fā)癥發(fā)生率從6%到37%不等。總的來(lái)說(shuō)，坐骨神經(jīng)麻痹在發(fā)生率為15%。在手術(shù)量比較大中心，大神經(jīng)損傷的發(fā)生率為2.1%。

本文描述了由髖臼骨塊旋轉(zhuǎn)角度較大引起的遲發(fā)性坐骨神經(jīng)麻痹。類(lèi)似情況傷及股神經(jīng)已有報(bào)告，但坐骨神經(jīng)損傷的報(bào)告尚無(wú)。

有關(guān)該病例的資料的提交發(fā)表已告知患者及其父母，他們表示理解并同意。

病例報(bào)告

術(shù)前評(píng)估：一名12歲女性患者于2009年出現(xiàn)雙髖疼痛。疼痛集中于腹股溝和大轉(zhuǎn)子區(qū)域，主要出現(xiàn)在長(zhǎng)時(shí)間步行或體力活動(dòng)后。體檢見(jiàn)，患者身高157厘米(處于90百分位)，體重69公斤(處于97百分位)。右髖臀中肌試驗(yàn)陽(yáng)性；雙髖屈曲90度時(shí)內(nèi)旋85度，外旋20度，臨床檢查股骨提示股骨前傾50度角。術(shù)前骨盆前后位線片顯示嚴(yán)重的髖關(guān)節(jié)發(fā)育不良(圖1)。外展位X線片顯示雙股骨頭無(wú)外移，與髖臼匹配好。按本中心的要求并未常規(guī)進(jìn)行磁共振成像(MRI)。

圖1 術(shù)前骨盆前后位片

手術(shù)：計(jì)劃行雙側(cè)截骨手術(shù)，手術(shù)間隔6個(gè)月；癥狀較重的右側(cè)先行手術(shù)。2009年11月，患者行右側(cè)PAO手術(shù)，無(wú)任何并發(fā)癥發(fā)生。她經(jīng)歷了治療過(guò)程平穩(wěn)和臨床恢復(fù)滿(mǎn)意，臀中肌肌力也恢復(fù)正常。

2010年5月，即右髖PAO治療6個(gè)月后，患者接受左髖PAO治療。與第一次手術(shù)一樣，手術(shù)是全透視手術(shù)臺(tái)上進(jìn)行的，患者取仰臥位。采用Ganz等所描述的標(biāo)準(zhǔn)方法。所有的截骨手術(shù)都順利進(jìn)行，髖臼骨塊的旋轉(zhuǎn)過(guò)程也遇到任何困難。

坐骨截骨術(shù)中，背伸外展髖關(guān)節(jié)，屈曲膝關(guān)節(jié)以減輕坐骨神經(jīng)張力，避免損傷坐骨神經(jīng)。由于髖臼復(fù)位后髖臼骨塊內(nèi)旋角度（60°）和股骨前傾角較大，未進(jìn)行前囊切開(kāi)術(shù)和頭頸骨軟骨成形。本中心不常規(guī)使用術(shù)中透視和神經(jīng)監(jiān)測(cè)。用術(shù)中骨盆正位片評(píng)估髖臼矯形情況，影像顯示截骨髖臼對(duì)位對(duì)線良好。與對(duì)側(cè)相同，使用3顆螺釘固定 (圖2-A)。校正結(jié)果與右側(cè)一致。盡管術(shù)后臼頂傾斜角略?xún)A斜，但處于可接受的范圍內(nèi)，且雙側(cè)對(duì)稱(chēng)。術(shù)中判斷不需要進(jìn)行股骨側(cè)截骨術(shù)。術(shù)后3年，截骨完全愈合，臨床效果良好(圖2-B)。

圖2 術(shù)后骨盆前后位片 A左側(cè)術(shù)中 B術(shù)后3年

術(shù)后病情變化：左髖術(shù)后在恢復(fù)室進(jìn)行第一次術(shù)后評(píng)估，3條主要神經(jīng)均反應(yīng)良好，患者否認(rèn)左肢麻木。

術(shù)后第一天開(kāi)始康復(fù)，患肢不負(fù)重點(diǎn)地。在被動(dòng)屈髖時(shí)，出現(xiàn)髖后坐骨神經(jīng)痛和足背內(nèi)側(cè)感覺(jué)部分喪失。踝關(guān)節(jié)背屈和外翻的力量與對(duì)側(cè)相比略有下降。超聲檢查發(fā)現(xiàn)左髖關(guān)節(jié)周?chē)猩倭糠e液。術(shù)后第2天，疼痛加重，從髖關(guān)節(jié)向足踝放射。直腿抬高測(cè)試加劇疼痛。

CT顯示髖臼骨塊向外突出(圖3-A和3-B)，這可能壓迫坐骨神經(jīng)。我們推測(cè)截骨碎片和髖臼骨塊旋轉(zhuǎn)角度較大可能壓迫和刺穿神經(jīng)，因此，有必要進(jìn)行翻修手術(shù)。

圖3 向外突出的髖臼骨塊

遂決定進(jìn)行翻修。我們采用側(cè)臥，后外側(cè)Gibson入路。分離臀大肌牽向后方，可以看到髖關(guān)節(jié)的小外旋轉(zhuǎn)肌。沿坐骨神經(jīng)探查，在股方肌的近端神經(jīng)周?chē)局邪l(fā)現(xiàn)一個(gè)小血腫。神經(jīng)本身連續(xù)性好，沒(méi)有肉眼可見(jiàn)的損傷。髖臼骨塊旋轉(zhuǎn)后，在其后緣可捫及突起。打開(kāi)梨狀肌和上孖肌之間的間隙后，發(fā)現(xiàn)該骨突的皮質(zhì)形成一個(gè)尖刺，壓迫坐骨神經(jīng)(圖4-A)。屈曲髖關(guān)節(jié)時(shí)，神經(jīng)壓迫加重。切除部分高突的骨皮質(zhì)，坐骨神經(jīng)完全減壓，髖屈曲時(shí)也無(wú)壓迫(圖4-B)。 

術(shù)后放射疼痛雖有所改善，但在住院期間并沒(méi)有完全消失。患者持續(xù)感到踝關(guān)節(jié)背屈和外翻無(wú)力，因此使用了踝足矯形器。術(shù)后2個(gè)月，疼痛完全消失。此時(shí)，術(shù)后X線片顯示骨位良好，恥骨支和坐骨已經(jīng)愈合。隨后12個(gè)月的多次復(fù)查中發(fā)現(xiàn)足背屈和外翻力量逐漸改善。術(shù)后1年，在足跟行走時(shí)，可見(jiàn)踝關(guān)節(jié)背屈殘余輕微的無(wú)力。在術(shù)后3年影像學(xué)隨訪中，雙側(cè)截骨愈合；股骨頭在位，Shenton線完整(右側(cè)LCE角36°，左側(cè)30°；臼頂傾斜角右側(cè)2°，左側(cè)0°)。

患者否認(rèn)有任何虛弱或功能限制。然而，神經(jīng)學(xué)檢查發(fā)現(xiàn)，左側(cè)腳趾與對(duì)側(cè)相比背屈輕微力弱。

討論：PAO是治療年輕人有癥狀的髖臼發(fā)育不良的首選保髖手術(shù)。據(jù)報(bào)道，高達(dá)90%的患者治療結(jié)果良好，疼痛得以緩解，患者恢復(fù)日常活動(dòng)。股骨神經(jīng)、坐骨神經(jīng)或股外側(cè)皮神經(jīng)的損傷都可能在手術(shù)中發(fā)生；尚未見(jiàn)閉孔神經(jīng)的損傷的報(bào)道。目前的文獻(xiàn)只報(bào)道了由于過(guò)度的軟組織牽拉和截骨時(shí)直接破壞造成的坐骨神經(jīng)損傷。在所有先前報(bào)道的病例中，患者要么是在手術(shù)后立即出現(xiàn)癥狀，要么是神經(jīng)監(jiān)測(cè)發(fā)現(xiàn)。Matheney等人報(bào)道了1例與我們類(lèi)似的病例，在復(fù)位髖臼的時(shí)候發(fā)生神經(jīng)損傷；然而，該研究只提供了有限的資料。在我們的病例中，神經(jīng)損傷癥狀在術(shù)后第一次活動(dòng)時(shí)，患者坐在床上時(shí)被動(dòng)屈曲髖關(guān)節(jié)就得以發(fā)現(xiàn)。術(shù)后第2天CT診斷為骨碎片直接刺激神經(jīng)。

完整的后柱可以保護(hù)坐骨神經(jīng)。在PAO過(guò)程中，髖臼碎片的內(nèi)旋與前旋導(dǎo)致其后下角部分抬高；然而，這個(gè)移位較小。髖臼骨塊的內(nèi)移可能與髂骨邊緣產(chǎn)生的效果相似，兩者都不能造成坐骨神經(jīng)損傷。當(dāng)髖臼碎片的后上緣有皮質(zhì)骨刺，髖臼矯正后骨突尖向坐骨神經(jīng)附近擺動(dòng)時(shí)，可能傷及神經(jīng)。這種類(lèi)型的骨刺可能由于髖臼上截骨不完全造成，也有可能出現(xiàn)于反髖臼周?chē)毓切g(shù)。

通常，PAO中使用透視評(píng)估截骨的準(zhǔn)確性、髖臼矯形和內(nèi)固定的位置。對(duì)于我們的患者而言，術(shù)中透視只能產(chǎn)生質(zhì)量較差的后前位二維小視野圖像，不能辨識(shí)壓迫坐骨神經(jīng)的骨塊。盡管如此，透視檢查與術(shù)后X光片有良好相關(guān)性，尤其當(dāng)外科醫(yī)生在學(xué)習(xí)曲線中時(shí)，可輔助手術(shù)。

一些中心使用術(shù)中神經(jīng)監(jiān)測(cè)，盡管術(shù)中信號(hào)與神經(jīng)損傷的術(shù)后診斷有關(guān)，但尚未發(fā)現(xiàn)它們有助于預(yù)防此類(lèi)損傷。我們的患者在術(shù)伸髖屈膝，一定程度上降低了神經(jīng)的張力。如果我們的病人也使用神經(jīng)監(jiān)測(cè)，在伸膝時(shí)，我們可以早期發(fā)現(xiàn)問(wèn)題。我們認(rèn)為，避免這類(lèi)并發(fā)癥的最好方法是在復(fù)位時(shí)認(rèn)真觀察髖臼骨塊后上外緣的移動(dòng)。

Delayed-Onset Sciatic Nerve Palsy After Periacetabular Osteotomy: A Case Report

Case: A large surgical correction was required for severe hip dysplasia, which was associated with a delayed-onset sciatic nerve injury in an adolescent patient. A cortical bone spur on the outside of the acetabular fragment produced an indirect injury that became symptomatic during mobilization of the patient.

Conclusion: The risk of direct injury to the sciatic nerve during a periacetabular osteotomy is quite low when the osteotomy is executed in extension with abduction of the hip and flexion of the knee to reduce tension on the sciatic nerve. Reported injuries have been attributed to direct damage from excessive soft-tissue retraction or during osseous ischial, supra-acetabular, and/or retroacetabular osteotomies.

文獻(xiàn)出處：Michael Leunig, Jonathan M Vigdorchik, Aidin Eslam Pour, Silvia Willi-D?hn, Reinhold Ganz. Delayed-Onset Sciatic Nerve Palsy After Periacetabular Osteotomy: A Case Report. Case Reports JBJS Case Connect. Jan-Mar 2017;7(1):e9. doi: 10.2106/JBJS.CC.16.00084.

文獻(xiàn)2

肌效貼是否可以矯正過(guò)度的動(dòng)態(tài)膝外翻？

一項(xiàng)隨機(jī)雙盲對(duì)照試驗(yàn)

譯者：肖凱

背景：髖關(guān)節(jié)周?chē)窠?jīng)肌肉控制能力不足會(huì)導(dǎo)致過(guò)大的動(dòng)態(tài)膝外翻（DKV），這會(huì)影響膝關(guān)節(jié)甚至導(dǎo)致膝蓋受傷，尤其易導(dǎo)致ACL運(yùn)動(dòng)損傷。盡管肌效貼（KT）可以改善功能、穩(wěn)定性和本體感覺(jué)，但有關(guān)其對(duì)運(yùn)動(dòng)員有效性的證據(jù)尚無(wú)定論。我們假設(shè)，肌效貼可以通過(guò)增強(qiáng)對(duì)髖關(guān)節(jié)周?chē)纳窠?jīng)肌肉控制來(lái)降低DKV。

目的/目的：與對(duì)照組相比，確定臀中肌肌效貼是否可以矯正過(guò)度的動(dòng)態(tài)膝外翻，并提高髖關(guān)節(jié)外展肌力量。

方法：本研究招募了40名年齡在18至28歲之間的大學(xué)水平的運(yùn)動(dòng)員，他們都存在動(dòng)態(tài)膝外翻（男性> 8°，女性> 13°）。排除標(biāo)準(zhǔn)包括：在過(guò)去一年中有下腰痛史、外傷史或手術(shù)史。符合入選標(biāo)準(zhǔn)的受試者被隨機(jī)分為肌效貼組和對(duì)照組。在對(duì)他們進(jìn)行肌效貼固定之后的第三天，進(jìn)行跳躍測(cè)試和外展肌力測(cè)試，并記錄數(shù)據(jù)。

結(jié)果：在使用肌效貼即刻，男性[4.0°（95％CI 3.5-4.5）；p <0.001]和女性[4.3°（95％CI 3.5-5.2）；p <0.002] 的DKV顯著降低。但在使用后第三天效果消失。肌效貼組在使用肌效貼即刻及三天內(nèi)的肌力均顯著提高于對(duì)照組。

結(jié)論：應(yīng)用肌效貼后，DKV立刻減少。然而，使用第三天兩組間DKV沒(méi)有顯著差異。在使用肌效貼后，臀中肌力量也顯示出明顯的改善，而且保持到了第三天。

肌效貼使用示意圖

動(dòng)態(tài)膝關(guān)節(jié)外翻測(cè)量示意圖

Does Kinesio taping correct exaggerated dynamic knee valgus? A randomized double blinded sham-controlled trial

Background: Deficiency in hip girdle neuromuscular control can cause exaggerated Dynamic Knee Valgus (DKV) which afflicts the knee joint and lead to knee injuries especially ACL injury in sports. Though Kinesio taping (KT) is known to improve function, stability and proprioception, the evidence is inconclusive on its effectiveness in athletes. We hypothesized that kinesio taping could enhance neuromuscular control of the hip girdle there by causing a reduction in DKV.

Aim/objective: To determine whether KT on Gluteus medius can correct exaggerated dynamic knee valgus and improves hip abductor strength when compared to sham KT.

Method: 40 collegiate level athletes, aged between 18 and 28 years, of both genders with presence of dynamic knee valgus (>8° for men and >13° for women) were recruited in the study. Athletes were excluded if they had history of lower back pain, history of any injury or surgery to the lower extremities during the past year. Subjects who met the inclusion criteria were randomized into kinesio taping (KT) group and sham taping (ST) group. The Drop Jump test and the Donnatelli Drop Leg Test (DDT) were performed before, and on the third day, immediately after the application of KT on them and documented.

Results: There was a significant reduction in DKV among male [4.0° (95% CI 3.5-4.5); p < 0.001] and female [4.3° (95% CI 3.5-5.2); p < 0.002] immediately after application of taping but not on the third day after application of KT. There was a significant rise in DDT immediately and on the third day after application of KT between KT group and SC group.

Conclusion: There was a reduction in DKV immediately after the application of KT. However, there was no significant difference between KT group and SC group on the third day. Meanwhile, gluteus medius strength also showed significant improvement immediately after taping and it was maintained even on the third day.

文獻(xiàn)出處：Rajasekar S, Kumar A, Patel J, Ramprasad M, Samuel AJ. Does Kinesio taping correct exaggerated dynamic knee valgus? A randomized double blinded sham-controlled trial. J Bodyw Mov Ther. 2018 Jul;22(3):727-732. doi: 10.1016/j.jbmt.2017.09.003. Epub 2017 Sep 8. PMID: 30100304.

文獻(xiàn)3

大轉(zhuǎn)子阻滯結(jié)合軟組織松解治療LCPD

譯者：任寧濤

Perthes病碎裂早期的治療目的主要集中在增加股骨頭的覆蓋，無(wú)論是采用支具、外展石膏、髖臼和/或股骨近端截骨，其目的均是最大限度的獲得好的頭臼匹配和關(guān)節(jié)活動(dòng)度，避免出現(xiàn)鉸鏈和FAI的形成。Perthes病可導(dǎo)致股骨頸生長(zhǎng)障礙，我們的治療方法是大轉(zhuǎn)子阻滯加內(nèi)側(cè)軟組織松解，除了可以增加股骨頭覆蓋，還可以解決后期下肢長(zhǎng)度和外展問(wèn)題，并可避免截骨引起來(lái)的醫(yī)源性?xún)?nèi)翻畸形。

本研究采用回顧性研究，選取12名Perthes病患者，其中9名男孩，3名女孩，平均年齡7.3歲（5.3-9.7），均采用非手術(shù)治療。采用八字板進(jìn)行大轉(zhuǎn)子阻滯，同時(shí)行內(nèi)收肌和髂腰肌松解，Petrie石膏固定。對(duì)平均術(shù)后49個(gè)月（14-78）的臨床和影像學(xué)資料進(jìn)行比較。6塊八字板在術(shù)后平均43.7個(gè)月（28-69）時(shí)因?yàn)閮?nèi)固定刺激被取出，其余的未取出，在最終隨訪時(shí)，11名患者疼痛、跛行和Trendelenburg征改善，大多數(shù)患者的髖關(guān)節(jié)活動(dòng)范圍得到改善或維持，外展接近正常，未出現(xiàn)大轉(zhuǎn)子撞擊。頸干角、Shenton's線、骨骺突出指數(shù)、CE角和大轉(zhuǎn)子高度無(wú)明顯變化。1名患者后期行大轉(zhuǎn)子下移，所有患者后期無(wú)行髖臼和股骨近端截骨治療。4名患者出現(xiàn)嚴(yán)重的下肢不等長(zhǎng)，后行對(duì)側(cè)骨骺阻滯治療。術(shù)后雙下肢不等長(zhǎng)無(wú)明顯改變，無(wú)圍手術(shù)期并發(fā)癥出現(xiàn)。

我們采用內(nèi)收肌和髂腰肌肌腱松解和Petrie石膏，大轉(zhuǎn)子阻滯以此來(lái)重新引導(dǎo)股骨近端骨骺軟骨的生長(zhǎng)。采用此方法可避免醫(yī)源性?xún)?nèi)翻和外展肌肌力減弱，此方法目的是保持外展肌力量，避免大轉(zhuǎn)子下移或股骨近端截骨。

圖1 a 該患者觀察6個(gè)月后出現(xiàn)半脫位的趨勢(shì)，Shenton's線不連續(xù)，內(nèi)側(cè)間隙增寬，外側(cè)柱覆蓋不佳；b 造影可見(jiàn)外展25度時(shí)覆蓋改善，但是大轉(zhuǎn)子高位；c 采用大轉(zhuǎn)子阻滯，內(nèi)收肌和髂腰肌肌腱松解和Petrie石膏固定4周；d 9歲時(shí)片子，可見(jiàn)螺釘成角，證明大轉(zhuǎn)子阻滯起效，Shenton's線恢復(fù)，外展肌力量好；e 可能是由于外展肌力量好，髖臼發(fā)育不良有所改善；f 10歲時(shí)，髖關(guān)節(jié)活動(dòng)良好，每年復(fù)查。

Guided growth of the trochanteric apophysis combined with soft tissue release for Legg-Calve-Perthes disease

During the initial fragmentation stage of Perthes disease, the principle focus is to achieve containment of the femoral head within the acetabulum. Whether by bracing, abduction casts, femoral and/or pelvic osteotomy, the goals are to maximize the range of hip motion and to avoid incongruity, hoping to avert subsequent femoro-acetabular impingement or hinge abduction. A more subtle and insidious manifestation of the disease relates to growth disturbance involving the femoral neck. We have chosen to tether the greater trochanteric physis, combined with a medial soft tissue release, as part of our non-osteotomy management strategy for select children with progressive symptomatology and related radiographic changes. In addition to providing containment, we feel that this strategy addresses potential long-range issues pertaining to limb length and abductor mechanics, while avoiding iatrogenic varus deformity caused by osteotomy. This is a retrospective review of 12 patients (nine boys, three girls), average age 7.3 years old (range 5.3-9.7), who underwent non-osteotomy surgery for Perthes disease. An eight-plate was applied to the greater trochanteric apophysis at the time of arthrogram, open adductor and iliopsoas tenotomy, and Petrie cast application. We compared clinical and radiographic findings at the outset to those at an average follow-up of 49 months (range 14-78 months). Six plates were subsequently removed; the others remain in situ. Eleven of twelve patients experienced improvement in pain, and alleviation of limp and Trendelenburg sign at latest follow-up.The majority had improved or maintained range of motion and prevention of trochanteric impingement demonstrated by near normalization of abduction. Neck-shaft angles, Shenton's line, extrusion index, center edge angles and trochanteric height did not change significantly. One patient underwent subsequent trochanteric distalization and no other patients have undergone subsequent femoral or periacetabular osteotomies. Leg length discrepancy worsened in four patients and was treated with contralateral eight-plate distal femoral epiphysiodesis. As a group the mean leg length discrepancy did not change significantly. There were no perioperative complications. six trochanteric plates were subsequently removed after an average of 43.7 months (range 28-69) due to irritation of hardware; the others remain in situ, pending further growth. We employed open adductor and iliopsoas tenotomy and Petrie cast application and guided growth of the greater trochanter as a means of redirecting the growth of the common proximal femoral chondroepiphysis. The accrued benefits of preventing relative trochanteric overgrowth with a flexible tether are the avoidance of iatrogenic varus and weakening of the hip abductors. The goals are to preserve abductor strength and avoid trochanteric transfer or intertrochanteric osteotomy.

文獻(xiàn)出處：Peter M Stevens , Lucas A Anderson, Jeremy M Gililland, Eduardo Novais. Guided growth of the trochanteric apophysis combined with soft tissue release for Legg-Calve-Perthes disease. Strategies Trauma Limb Reconstr . 2014 Apr;9(1):37-43.

文獻(xiàn)4

計(jì)算機(jī)輔助髖臼周?chē)毓切g(shù)與常規(guī)截骨術(shù)

治療髖關(guān)節(jié)發(fā)育不良的療效比較

譯者：張利強(qiáng)

目的：比較計(jì)算機(jī)輔助髖臼周?chē)毓切g(shù)（PAO）與常規(guī)PAO治療髖關(guān)節(jié)發(fā)育不良（DDH）的療效。

方法：91名患者（98髖）納入本研究。在每一個(gè)DDH病例中，采用常規(guī)PAO治療，其截骨的角度和方向由術(shù)中X線檢查確定，采用計(jì)算機(jī)輔助PAO治療，則使用3D導(dǎo)航系統(tǒng)。40髖接受常規(guī)PAO治療，58髖接受計(jì)算機(jī)輔助PAO治療。

結(jié)果：常規(guī)PAO患者的日本骨科協(xié)會(huì)髖關(guān)節(jié)評(píng)分中從術(shù)前的70.0分顯著提高到術(shù)后的90.7分，在計(jì)算機(jī)輔助PAO患者中則從術(shù)前的74.5分顯著提高到術(shù)后的94.2分。所有計(jì)算機(jī)輔助PAO患者術(shù)后AHI和VCA角均在影像學(xué)可接受范圍。部分常規(guī)PAO患者術(shù)后AHI和VCA角度未達(dá)影像學(xué)可接受范圍。平均隨訪5.4年后，我們對(duì)98例行PAO治療髖關(guān)節(jié)中的5例（5.1%）進(jìn)行了全髖關(guān)節(jié)置換術(shù)（THA）。計(jì)算機(jī)輔助PAO治療的58個(gè)髖關(guān)節(jié)（0%）中沒(méi)有一例。

討論：計(jì)算機(jī)輔助PAO可實(shí)現(xiàn)術(shù)中截骨部位的確認(rèn)，并可實(shí)時(shí)確定截骨塊的位置。與常規(guī)PAO相比，計(jì)算機(jī)輔助PAO患者股骨頭的前、外側(cè)覆蓋充分無(wú)需早期轉(zhuǎn)為T(mén)HA。

結(jié)論：計(jì)算機(jī)輔助PAO不僅提高了手術(shù)的準(zhǔn)確性和安全性，而且是股骨頭獲得了足夠的前側(cè)和外側(cè)覆蓋，從而防止DDH的進(jìn)展。

a-c使用規(guī)劃軟件將術(shù)前三維圖像轉(zhuǎn)換為標(biāo)準(zhǔn)模格式。d 將數(shù)據(jù)導(dǎo)入導(dǎo)航軟件和基于CT的髖關(guān)節(jié)導(dǎo)航系統(tǒng)

a-b 49歲女性，右DDH，術(shù)前LCEA 1°，VCA 12°。c-d 利用跟蹤探頭檢測(cè)PAO術(shù)后截骨塊位置，確定前側(cè)及外側(cè)覆蓋是否足夠。e-f 術(shù)后ACEA為38°，VCA為42°。g 術(shù)后5年無(wú)骨關(guān)節(jié)炎

Outcomes of computer-assisted peri-acetabular osteotomy compared with conventional osteotomy in hip dysplasia

Aim of the study: To compare the outcomes after computer-assisted peri-acetabular osteotomy (PAO) and conventional PAO performed for hip dysplasia (DDH).

Methods: Ninety-one patients (98 hips) were enrolled in this study. In each case, DDH was treated with either conventional PAO, in which the angle and direction of the osteotomy was determined by intra-operative X-ray examination, or with computer- assisted PAO, which used the 3D navigation system. Forty hips underwent conventional PAO and 58 hips underwent computer- assisted PAO.

Results: Japanese Orthopaedic Association hip scores improved significantly from 70.0 points pre-operatively to 90.7 points post-operatively in patients with conventional PAO, and from 74.5 points pre-operatively to 94.2 points post-operatively in patients with computer-assisted PAO. In all patients with computer-assisted PAO, the post-operative AHI and VCA angle were within the radiographic target zone. Some patients with conventional PAO had post-operative AHI and VCA angle outside of the target zone. We performed total hip arthroplasty (THA) on five of the 98 PAO hips (5.1%) after an average follow-up period of 5.4 years. None of 58 hips (0%) with computer-assisted PAO was revised.

Discussion: Computer-assisted PAO enabled intra-operative confirmation of osteotomy sites, and the position of the osteotomized bone fragment could be confirmed in real time. Adequate anterior and lateral coverage of the femoral head in patients with computer-assisted PAO resulted in no need for early conversion to THA, in contrast to conventional PAO.

Conclusion: Computer-assisted PAO not only improved accuracy and safety but also achieved sufficient anterior and lateral displacement to prevent the progression of DDH.

文獻(xiàn)出處：Imai H, Kamada T, Miyawaki J, Maruishi A, Mashima N, Miura H. Outcomes of computer-assisted peri-acetabular osteotomy compared with conventional osteotomy in hip dysplasia. Int Orthop. 2020 Jun;44(6):1055-1061. doi: 10.1007/s00264-020-04578-x. Epub 2020 Apr 28. PMID: 32342143; PMCID: PMC7260271.

文獻(xiàn)5

股骨髖臼撞擊征（FAI）的前期手術(shù)是否會(huì)

影響髖關(guān)節(jié)置換術(shù)的結(jié)果？

譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）

背景：開(kāi)放和關(guān)節(jié)鏡下手術(shù)已被報(bào)道用來(lái)解決股骨髖臼撞擊征（FAI）。盡管效果良好，但仍有一部分患者隨后需要進(jìn)行全髖關(guān)節(jié)置換術(shù)（THA）。但是，關(guān)于FAI手術(shù)后THA結(jié)局的研究數(shù)據(jù)很少。該項(xiàng)研究的目的是確定THA的臨床結(jié)局是否受到前期開(kāi)放或關(guān)節(jié)鏡下（手術(shù)治療）FAI的影響。

方法：本項(xiàng)病例匹配的回顧性研究共納入了23例（24髖）患者，這些患者在FAI前期手術(shù)（14例關(guān)節(jié)鏡和10例開(kāi)放）后接受了THA治療，并將他們與24例沒(méi)有（THA）術(shù)前髖關(guān)節(jié)手術(shù)史的匹配對(duì)照（病例）進(jìn)行了比較。對(duì)照患者的年齡、性別、手術(shù)方式、所用植入物以及術(shù)前改良的Harris髖關(guān)節(jié)評(píng)分（mHHS）在兩組之間沒(méi)有差異。主要結(jié)果指標(biāo)是mHHS。兩組之間還比較了手術(shù)時(shí)間、失血量和THA后異位骨化的存在。

結(jié)果：在進(jìn)行33（24-70）個(gè)月的THA平均隨訪后，F(xiàn)AI治療組的平均mHHS 92.9±12.7與對(duì)照組的平均mHHS 95.2±6.6（P = 0.43）之間無(wú)顯著差異。與對(duì)照組相比，髖關(guān)節(jié)外科脫位（SHD；平均109.3±29.8）后，THA的手術(shù)時(shí)間增加了（平均88.0±24.2；P <0.05）。兩組之間的失血量無(wú)顯著差異。與對(duì)照相比，SHD后異位骨化的發(fā)生率顯著更高（P <0.05）。

結(jié)論：THA后的臨床結(jié)局不受前期開(kāi)放或關(guān)節(jié)鏡治療FAI的影響。但是，SHD后（THA的）手術(shù)時(shí)間增加、異位骨化風(fēng)險(xiǎn)增加。

圖1.（A）對(duì)照組和FAI治療組（在THA之前接受了HA或髖關(guān)節(jié)外科脫位治療）之間在THA之后的平均mHHS的箱形圖（P?.4）。（B）THA后平均mHHS的亞分析，比較有HA、髖關(guān)節(jié)外科脫位病史和對(duì)照組患者。兩組之間無(wú)顯著差異（P?.4）。FAI，股骨髖臼撞擊征；HA，髖關(guān)節(jié)鏡；mHHS，改良的Harris髖關(guān)節(jié)評(píng)分；THA，全髖關(guān)節(jié)置換術(shù)。

Does Prior Surgery for Femoroacetabular Impingement Compromise Hip Arthroplasty Outcomes?

Background: Open and arthroscopic approaches have been described to address femoroacetabular impingement (FAI). Despite good outcomes, there is a subset of patients who subsequently require total hip arthroplasty (THA). However, there is a paucity of data on the outcomes of THA after surgery for FAI. The purpose of this study was to determine whether clinical outcomes of THA are affected by prior open or arthroscopic treatment of FAI.

Methods: This case-matched retrospective review included 23 patients (24 hips) that underwent THA after previous surgery for FAI (14 arthroscopic and 10 open) and compared them to 24 matched controls with no history of prior surgery on the operative hip. The controls were matched for age, sex, surgical approach, implants used, and preoperative modified Harris hip score (mHHS) did not differ between groups. The primary outcome measure was the mHHS. Operative time, blood loss, and the presence of heterotopic ossification after THA were also compared between groups.

Results: There was no significant difference in mean mHHS between the FAI treatment group 92.9 ± 12.7 and controls 95.2 ± 6.6 (P = .43) at a mean follow-up after THA of 33 (24-70) months. Increased operative times were noted for THA after surgical hip dislocation (SHD; mean 109.3 ± 29.8) compared to controls (mean 88.0 ± 24.2; P < .05). There was no significant difference in blood loss between groups. The occurrence of heterotopic ossification was significantly higher after SHD compared to controls (P < .05).

Conclusions: Clinical outcomes after THA are not affected by prior open or arthroscopic procedures for FAI. However, increased operative times and an increased risk of heterotopic ossification were noted after SHD.

文獻(xiàn)出處：Luke S Spencer-Gardner, Christopher L Camp, J Ryan Martin, Rafael J Sierra, Robert T Trousdale, Aaron J Krych. Does Prior Surgery for Femoroacetabular Impingement Compromise Hip Arthroplasty Outcomes? J Arthroplasty. 2016 Sep;31(9):1899-903.

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