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本期目录：

1、抗阻运动训练可以改善膝关节置换术患者术后康复效果

2、应用维生素C预防全膝关节置换术后复杂性局部疼痛综合征复发

3、机器人全膝关节置换术的真实世界疗效

4、幼年髋脱位治疗的患者成年后的生活质量

5、儿童创伤性三角软骨损伤的回顾性分析

6、日间骨盆截骨术治疗发育性髋关节发育不良的长期经验

7、髋臼周围截骨术治疗严重髋关节发育不良

8、髋臼周围截骨术后髋关节中心内移的评估：X光平片验证

第一部分：关节置换及保膝相关文献

文献1

抗阻运动训练可以改善膝关节置换术患者术后康复效果

译者 张轶超

膝关节骨关节炎与肌肉力量、肌肉量和身体功能的缺陷有关。尽管采用了包括体能/功能训练这些标准化的康复计划，肌肉相关的缺陷在全膝关节置换术（TKA）后依然会急剧加重，并在手术后持续很长时间。抗阻运动训练（RET）已被证明是一种非常有效的办法，可以改善健康人群和病人与肌肉相关的手术效果。然而，在TKA后的传统康复计划中，RET的使用是非常有限的。在这篇叙述性综述中，我们提供了一种最新的观点，即在TKA后恢复期（长达1年）将RET加入标准康复（SR）中，与单独进行SR相比，是否会导致肌肉相关效果的更大改善。总的来说，研究结果清楚地表明，与SR相比，基于RET的康复可以在更大程度上改善肌肉力量和肌肉量。此外，与SR相比，依赖股四头肌力量和平衡的身体功能测量（例如，爬楼梯，站椅子等）也似乎从基于RET的计划中获益更多，特别是在身体功能水平较低的患者中。但重要的是，为了使RET达到最佳效果，它应该以最大肌力的70%-80%进行训练，每次练习3 - 4组，每周至少3次，持续8周。基于这一叙述性回顾，我们建议将这种高强度的渐进式RET纳入TKA术后康复的标准方案中。

Resistance exercise training to improve post‐operative rehabilitation in knee arthroplasty patients: A narrative review

Knee osteoarthritis is associated with deficits in muscle strength, muscle mass, and physical functioning. These muscle‐related deficits are acutely exacerbated following total knee arthroplasty (TKA) and persist long after surgery, despite the application of standardized rehabilitation programs that include physical/functional training. Resistance exercise training (RET) has been shown to be a highly effective strategy to improve muscle‐related outcomes in healthy as well as clinical populations. However, the use of RET in traditional rehabilitation programs after TKA is limited. In this narrative review, we provide an updated view on whether adding RET to the standard rehabilitation (SR) in the recovery period (up to 1 year) after TKA leads to greater improvements in muscle‐related outcomes when compared to SR alone. Overall, research findings clearly indicate that both muscle strength and muscle mass can be improved to a greater extent with RET‐based rehabilitation compared to SR. Additionally, measures of physical functioning that rely on quadriceps strength and balance (e.g., stair climbing, chair standing, etc.) also appear to benefit more from a RET‐based program compared to SR, especially in patients with low levels of physical functioning. Importantly though, for RET to be optimally effective, it should be performed at 70%–80% of the one‐repetition maximum, with 3–4 sets per exercise, with a minimum of 3 times per week for 8 weeks. Based upon this narrative review, we recommend that such high‐intensity progressive RET should be incorporated into standard programs during rehabilitation after TKA.

文献出处：Monsegue AP, Emans P, van Loon LJC, Verdijk LB. Resistance exercise training to improve post-operative rehabilitation in knee arthroplasty patients: A narrative review. Eur J Sport Sci. 2024 Jul;24(7):938-949. doi: 10.1002/ejsc.12114. Epub 2024 May 12. PMID: 38956794; PMCID: PMC11235919.

文献2

应用维生素C预防全膝关节置换术后复杂性局部疼痛综合征复发

译者 张蔷

背景：有多项研究调查了复杂性局部疼痛综合征（CRPS）的风险以及应用维生素C预防的相关情况。然而，目前缺少相关文献探究全膝关节置换（TKA）术后应用维生素C预防CRPS发作或复发的有效性。

方法：本回顾性单中心观察性队列研究选择2017年1月至2021年12月的病例资料，并应用倾向性评分匹配方法。最初，我们入组了1088例TKA病例，其中49例既往曾有CRPS发作的病史。排除50例不符合入组标准的病例，最终包含467例（45%）接受了维生素C预防治疗（1g Qd * 40天）的病例和571例（55%）未接受维生素C预防治疗的病例。在性别、年龄、BMI、糖尿病及高血压情况、吸烟饮酒情况、止血带应用情况、焦虑与抑郁情况经1:1匹配后，维生素C预防组和未预防组各包含480例病例。共960例中有28例曾有CRPS发作史。

结果：在经过倾向性评分匹配后的病例组中，6.9%（33例）的维生素C预防组病例术后出现CRPS发作，而未预防组的病例为11.0%（53例）（概率比OR=0.59[95%置信区间(CI), 0.37 - 0.9], p = 0.024）。而曾有CRPS发作史会显著增加术后复发的概率（发作史32% VS. 无发作史8%；OR=5.4 [95% CI, 2.57 - 11.4], p < 0.001）。在28例曾有CRPS发作史的病例中，应用维生素C预防治疗会将术后发作概率降至19%（21例中4例），而未应用维生素C预防治疗的病例发作概率为71%（7例中5例）（OR=0.09 [95% CI, 0.01 - 0.64], p = 0.02）。多变量回归分析后，维生素C预防也与TKA术后CRPS低复发率独立相关（OR=0.53 [95% CI, 0.3 - 0.86], p = 0.011）。

结论：应用维生素C预防可以减少TKA术后CRPS发作。此外，本研究还发现维生素C预防可以降低术前曾有CRPS发作史病例TKA术后CRPS复发的概率。

Prophylaxis against Complex Regional Pain Syndrome Recurrence with Vitamin C in Total Knee Arthroplasty-A Propensity Score-Matched Analysis of 960 Cases

Background: Several studies have investigated the risk of complex regional pain syndrome (CRPS) and its prevention with vitamin C. However, evidence regarding the effectiveness of vitamin C for prevention of CRPS development or recurrence after total knee arthroplasty (TKA) is lacking.

Methods: This retrospective single-center observational cohort study, which utilized propensity-score matching (PSM), was conducted from January 2017 to December 2021. It initially included 1,088 TKAs, 49 of which were in patients who had a previous CRPS. After exclusion of 50 TKAs, the study included 467 TKAs (45%) in patients who received vitamin C prophylaxis (1 g daily for 40 days) after surgery and 571 (55%) in patients who did not. After 1:1 matching on the basis of sex, age, body mass index, presence of diabetes mellitus and hypertension, use of tobacco and alcohol, anesthesia modality, tourniquet use, and anxiety and depression, the vitamin C group and the no-vitamin C group comprised 480 patients each. Twenty-eight of these 960 patients had a history of CRPS.

Results: In the PSM population, 6.9% (33) of the 480 patients who received vitamin C prophylaxis after TKA developed CRPS compared with 11.0% (53) of the 480 who did not receive vitamin C (odds ratio [OR] = 0.59 [95% confidence interval (CI), 0.37 to 0.9], p = 0.024). The rate of CRPS was significantly higher in patients with a history of CRPS (32% versus 8% for patients with no previous CRPS; OR = 5.4 [95% CI, 2.57 to 11.4], p < 0.001). In the 28 patients with a history of CRPS, vitamin C prophylaxis reduced the rate of CRPS recurrence after TKA to 19% (4 of 21) compared with 71% (5 of 7) in the patients not treated with vitamin C (OR = 0.09 [95% CI, 0.01 to 0.64], p = 0.02). In multivariable regression of the matched patients, vitamin C was also found to be independently associated with a lower rate of CRPS recurrence after TKA (OR = 0.53 [95% CI, 0.3 to 0.86], p = 0.011).

Conclusions: Vitamin C prophylaxis may be appropriate for preventing CRPS after TKA. Furthermore, the study highlights the beneficial role of vitamin C in reducing the rate of CRPS recurrence in patients with a history of CRPS who are undergoing TKA.

文献3

机器人全膝关节置换术的真实世界疗效：一家非学术中心的五年经验

译者 沈松坡

背景：机器人辅助手术系统已改变了全膝关节置换术（TKA），其宣称可提高精度并改善术中一致性，然而来自非学术中心的真实世界数据仍然有限。

目的：本研究评估了一种半自主、基于CT的机械臂辅助TKA在德国一家三级非教学医院中五年的临床应用情况，重点关注术前规划精度、间隙平衡及术中结果。

方法： 我们回顾性分析了2020年至2025年间接受MAKO辅助TKA的全部患者（n=457），手术均由三名骨科医生采用标准化股内侧肌下入路完成。评估内容包括术前畸形、术中对线、假体尺寸及间隙平衡。当有必要时术中调整手术计划。通过斜率分析比较术前计划与术后实施值，以评估执行一致性。

结果：患者中位年龄为67.0岁（四分位距：60.0–75.0）；84.1%为内翻（7.0°，IQR: 4.0°–10.0°），13.2%为外翻（3.0°，IQR: 1.5°–5.8°），2.7%为中立对线。80.4%存在屈曲挛缩（6.0°，IQR: 3.0°–10.0°），12.7%出现反屈（2.0°，IQR: 1.5°–5.0°）。即使在术中计划调整情况下，规划与执行的一致性仍然较高。各对线参数的斜率值分别为：胫骨旋转1.0、股骨矢状角0.8、胫骨矢状角0.9、冠状后髁角0.9、股骨假体尺寸1.0、胫骨假体尺寸1.0。超过95%的病例中计划值与最终值的偏差≤3.0°。骨切除一致性表现为中等相关性，斜率介于0.8（股骨内侧后切，单位mm）到0.5（胫骨外侧切，单位mm）之间。术中各阶段间隙平衡均改善，内外侧伸屈间隙的变异性下降（均p<0.05）。功能重建显示伸展、屈曲及畸形显著改善（均p<0.001）。

结论： 半自主、基于CT的机械臂辅助TKA在非学术中心得以成功实施，显示出可接受的术中及功能重建结果，支持其在非学术机构中应用的可行性。

关键词：机器人辅助TKA；真实世界数据；术中对线；间隙平衡；非学术医院

Real-World Outcomes of Robotic Total Knee Arthroplasty: Five Years' Experience in a Non-Academic Center

Background: Robotic-assisted systems have transformed total knee arthroplasty (TKA), promising improved accuracy and intraoperative consistency, yet real-world data from non-academic centers remain limited.

Objective: This study evaluates five-year clinical integration of a semi-autonomous, CT-based, robotic-arm-assisted TKA at a tertiary non-teaching hospital in Germany, focusing on planning accuracy, gap balancing, and intraoperative outcomes. Methods: We retrospectively analyzed all patients (n = 457) who underwent MAKO-assisted TKA from 2020 to 2025, performed by three orthopedic surgeons using a standardized subvastus approach. We assessed preoperative deformities, intraoperative alignment, implant sizing, and gap balancing. Surgical plans were adapted intraoperatively when indicated. Pre- vs. post-implantation values were compared using slopes to evaluate execution consistency.

Results: Median patient age was 67.0 years (IQR: 60.0-75.0), with varus in 84.1% (7.0°, IQR: 4.0°-10.0°), valgus in 13.2% (3.0°, IQR: 1.5°-5.8°), and neutral alignment in 2.7%. Flexion contracture occurred in 80.4% (6.0°, IQR: 3.0-10.0%), hyperextension in 12.7% (2.0°, IQR: 1.5°-5.0°). Planning-to-execution consistency was high, even with plan adaptations. Slope values for alignment parameters were: tibial rotation in degrees (slope value: 1.0), femoral sagittal angle in degrees (0.8), tibial sagittal angle in degrees (0.9), coronal posterior condylar angle in degrees (0.9), femoral component size (1.0), tibial component size (1.0). Over 95% of cases showed ≤3.0° deviation between planned and final values. Bone resection concordance showed moderate agreement, with slopes from 0.8 (posterior medial femoral cut in mm) to 0.5 (lateral tibial cut in mm). Gap balancing improved at all stages, with reduced variability in medial/lateral extension and flexion gaps (all p < 0.05). Functional reconstruction showed significant improvements in extension, flexion, and deformities (all p < 0.001).

Conclusions: Semi-autonomous, CT-based, robotic-arm-assisted TKA was successfully implemented in this non-academic setting, demonstrating acceptable intraoperative and functional reconstruction outcomes, supporting the feasibility of robotic-assisted surgery outside academic centers.

Keywords: gap balancing; intraoperative alignment; non-academic hospital; real-world data; robotic-assisted TKA.

第二部分：保髋相关文献

文献1

幼年髋脱位治疗的患者成年后的生活质量

译者 张振东

髋关节发育不良（DDH）如不及时干预可导致髋关节功能过早丧失；然而很少有研究关注DDH儿童时期治疗后的长期结果。

本研究对儿童时期接受过髋关节脱位治疗的患者进行了一项健康相关生活质量调查。研究者向在其机构接受过儿童期髋关节脱位治疗的 287 名DDH 患者发放了调查问卷。调查患者的人口统计学特征、特定疾病病史以及与健康相关的生活质量。将患者的身体功能评分（PCS）、心理功能评分（MCS）和社会认知评分（RCS）与标准值进行了比较。最终纳入68 名患者进行了评估。

结果显示，患者的 PCS、MCS 和 RCS 总平均值与标准值相当。PCS 一直保持到 50 岁，但有 10 名 50 岁以上的患者 PCS 显著下降。此外，接受切开复位术的患者的 PCS 明显低于接受保守复位术的患者。在各年龄组和治疗组中，患者的 MCS 和 RCS 与标准值无差异。 此外，PCS、MCS 和 RCS 在双侧、诊断年龄或是否需要额外手术方面也没有差异。DDH患者的身体生活质量在50岁之前一直保持不变，但之后迅速下降，尤其是那些在童年时期就需要进行切开复位的患者。

Quality of life in adult patients with developmental dysplasia of the hip who were treated for hip dislocation during childhood

Developmental dysplasia of the hip (DDH) can lead to premature loss of hip function if not properly treated; however, few studies have focused on the long-term outcomes of DDH. We conducted a survey of health-related quality of life in adult patients with DDH who were treated for hip dislocation during childhood. We sent a questionnaire to 287 adult patients with DDH who were treated for hip dislocation during childhood in our institutions. We examined patient demographics, disease-specific medical history, and health-related quality of life using the short form-36. Physical component summary (PCS), mental component summary (MCS) and role/social component summary (RCS) were compared between the patients and Japanese standard values. Sixty-eight patients were evaluated after exclusion. The overall mean PCS, MCS and RCS scores of the patients were comparable to the standard values. The PCS was maintained until the age of 50, but it was significantly decreased in 10 patients over 50 years old. In addition, PCS was significantly lower in patients who underwent open reduction than in those who were conservatively reduced. The MCS and RCS of the patients did not differ from the standard values in each age and treatment group. Additionally, the PCS, MCS and RCS did not differ according to bilaterality, age at diagnosis, or requirement for additional surgeries. Physical quality of life was maintained until the age of 50 but rapidly declined thereafter in patients with DDH, especially in those who required open reduction during childhood.

文献出处：Sawamura K, Kitoh H, Matsushita M, Mishima K, Kamiya Y, Imagama S. Quality of life in adult patients with developmental dysplasia of the hip who were treated for hip dislocation during childhood. J Pediatr Orthop B. 2025 Jan 1;34(1):38-43. doi: 10.1097/BPB.0000000000001173. Epub 2024 Feb 26. PMID: 38451811.

文献2

儿童创伤性三角软骨损伤的回顾性分析

译者 任宁涛

背景:总结分析儿童外伤后三角软骨损伤(TCI)的流行病学特点、治疗方法及相应疗效，为早期诊断和改进治疗提供理论依据。

方法:采用Bucholz分型对TCI损伤进行分型，随访时采用Harris髋关节评分及影像学检查评价最终疗效。最后，通过查阅文献中的病例并结合我院的患者进行综合分析。

结果:本院共收治三角软骨损伤15例(18髋)。I型损伤1例，II型损伤9例，IV型损伤2例，V型损伤1例，VI型损伤5例。随访完整的12例患者中，8例在三角软骨内或周围发现骨桥，5例出现早期三角软骨融合，3例髋关节发育不良，4例股骨头半脱位，HHS优8例，良4例。

结论:TCI损伤的早期诊断仍是一个难题。保守治疗通常是首选。髋臼骨折累及三角软骨的整体预后较差。三角软骨骨桥的形成通常预示着过早闭合的可能性，这可能导致创伤后髋臼发育不良和股骨头半脱位的严重并发症。

Retrospective analysis of traumatic triradiate cartilage injury in children

Background: To summarize and analyze the epidemiological characteristics, treatment and corresponding curative effect of triradiate cartilage injury(TCI) in children after trauma, to provide a theoretical basis for early diagnosis and improvement of treatment.

Methods: The TCI was classified according to Bucholz classification, and the final curative effect was evaluated with Harris Hip Score and imaging examination during follow-up. Finally, a comprehensive analysis was made by reviewing the cases in the literature combined with the patients in our hospital.

Results: A total of 15 cases (18 hips) of triradiate cartilage injuries were collected in our hospital. There was 1 hip with type I injury, nine hips with type II injury, two hips with type IV injury, one hip with type V injury and five hips with type VI injury. Among the 12 cases with complete follow-up, the bone bridge was found in or around the triradiate cartilage in 8 cases, early fusion of triradiate cartilage occurred in 5 patients, 3 cases had hip dysplasia, 4 cases had a subluxation of the femoral head, and HHS was excellent in 8 cases and good in 4 cases.

Conclusion: The early diagnosis of TCI is still a difficult problem. Conservative treatment is often the first choice. The overall prognosis of acetabular fractures involving triradiate cartilage is poor. The formation of the bone bridge in triradiate cartilage usually indicates the possibility of premature closure, which may lead to severe complications of post-traumatic acetabular dysplasia and subluxation of the femoral head.

文献出处：Dong Y, Wang J, Qin J, Nan G, Su Y, He B, Cai W, Chen K, Gu K, Liang X, Yan G, Wang Z. Retrospective analysis of traumatic triradiate cartilage injury in children. BMC Musculoskelet Disord. 2021 Aug 10;22(1):674. doi: 10.1186/s12891-021-04565-2. PMID: 34376165; PMCID: PMC8356404.

文献3

日间骨盆截骨术治疗发育性髋关节发育不良的长期经验

译者 李勇

目的 发育性髋关节发育不良（DDH）的发病率为每1000名活产儿6.73例，每年导致大量的骨科转诊。这种高需求推动了在儿科骨科环境中优化服务效率的动力。这里，我们描述了我们在一项创新的日间骨盆截骨术项目中获得的长期经验。我们还描述了在执行日间骨盆截骨术时可能预见的任何潜在并发症。

方法 这是一项非随机前瞻性队列研究，旨在比较2017年1月至2023年11月期间进行的传统住院骨盆截骨术与日间截骨术。所有手术均在一家城市三级国家转诊中心进行，由四名对DDH具有特别专业兴趣的儿科骨科医生执刀。

结果 总共进行了164例Salter和Pemberton截骨术，其中115例符合日间手术标准。根据HSE的“专科成本报告”和“年度报告与财务报表”，接受住院截骨术患者的总出院花费为6619欧元，而每位日间手术患者的花费为2670欧元。对于这110例日间手术，治疗花费总计为293,700欧元；因此，医院通过执行这110例日间手术总共节省了434,390欧元。这相当于每例日间手术节省了3949欧元。

结论 7年期的回顾表明，针对DDH的日间骨盆截骨术仍然是一项安全且具有成本效益的举措，它显著减少了对住院病床资源的需求。

A long-term experience of day-case pelvic osteotomy for developmental dysplasia of the hip

Objective Developmental hip dysplasia has an incidence of 6.73 per 1000 live births and leads to a significant number of orthopaedic referrals annually. This high demand has encouraged the drive to optimize the efficiency of service provision in the paediatric orthopaedic setting. Here we describe our long-term experience with a novel day-case pelvic osteotomy initiative. We also describe any potential complications one can expect when performing day-case pelvic osteotomies.

Methods This was a non-randomized prospective cohort study conducted to compare conventional in-patient pelvic osteotomies with day-case osteotomies performed between January 2017 and November 2023. All surgeries took place at an urban tertiary national referral centre by four paediatric orthopaedic surgeons with a specialist interest in DDH.

Results 164 Salter and Pemberton osteotomies were performed of which 115 met the day-case criteria. Based on the HSE ‘Specialty Costing Report’ and ‘Annual Report and Financial Statements’, the total discharge cost for patients undergoing an in-patient osteotomy was €6619 in contrast to €2670 per day-case patient. For the 110 day-cases, the cost to treat amounted to €293,700; hence, there was a total saving of €434,390 made by the hospital for the 110 day-cases performed. This amounts to €3949 saved for every day-case.

Conclusion Review at 7 years has demonstrated that day-case pelvic osteotomy surgery for DDH remains a safe and cost-effective initiative that significantly reduces the demand on in-patient hospital bed resources.

文献出处：Moore DM, Howells C, Gallagher O, Moore DP, O'Toole P. A long-term experience of day-case pelvic osteotomy for developmental dysplasia of the hip. Ir J Med Sci. 2025 Jun;194(3):963-967. doi: 10.1007/s11845-025-03963-y. Epub 2025 May 9. PMID: 40343576; PMCID: PMC12276099.

文献4

髋臼周围截骨术治疗严重髋关节发育不良

译者 陶可

背景：对于伴有股骨头半脱位或继发性髋臼(病变)的严重髋关节发育不良，最佳治疗方案仍存在争议。本研究旨在分析伯尔尼髋臼周围截骨术治疗青少年及青年重度髋关节发育不良的矫正程度及早期临床疗效。

方法：纳入13例患者共16个髋关节，平均年龄17.6岁（范围13.0～31.8岁），均被诊断为重度髋关节发育不良（根据Severin分型为IV或V组）。其中8个髋关节为半脱位，8个髋关节为继发性髋臼(病变)。术前，所有患者均存在髋关节疼痛，且X线片显示髋关节匹配度良好，符合截骨术指征。所有16个髋关节均行伯尔尼髋臼周围截骨术，其中6个髋关节同时行股骨近端截骨术。术后，对髋关节进行X线检查，以评估畸形矫正情况、截骨部位愈合情况以及骨关节炎进展情况。术后平均4.2年，采用Harris髋关节评分评估临床结果和髋关节功能。

结果：术前和随访X线片对比显示，Wiberg外侧中心边缘角平均改善44.6度（由-20.5度改善至24.1度），Lequesne和de Seze前方中心边缘角平均改善51.0度（由-25.4度改善至25.6度），髋臼顶倾斜度平均改善25.9度（由37.3度改善至11.4度）。髋关节中心平均向内侧移位10 mm（范围0至31 mm）。所有髂骨截骨部位均已愈合。术前平均Harris髋关节评分73.4分提高至末次随访时的91.3分。13例患者中有11例（16个髋关节中的14个）对术后效果满意，14个髋关节的临床效果良好或优异。主要并发症包括1例患者出现髋臼固定失败，需再次手术；另1例患者出现髋臼过度矫正及相关坐骨不愈合。两例患者在末次随访时均获得良好的临床效果。未发生重大神经血管损伤或关节内骨折。

结论：髋臼周围截骨术是治疗青少年及青年严重髋臼发育不良的有效手术方法。本组病例术后平均4.2年的早期临床效果良好；两例主要并发症并未影响良好的临床效果。

图1-A和1-B 病例6，一名16岁男孩，患有严重的髋关节发育不良，前后位（图1-A）和假斜位（图1-B）X线片均显示了这一情况。该患者接受了髋臼周围截骨术联合股骨近端内翻截骨术治疗。

Periacetabular osteotomy for the treatment of severe acetabular dysplasia

Background: The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients.

Methods: Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively.

Results: Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees ) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees ) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees ) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures.

Conclusions: The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

文献出处：John C Clohisy, Susan E Barrett, J Eric Gordon, Eliana D Delgado, Perry L Schoenecker. Periacetabular osteotomy for the treatment of severe acetabular dysplasia. J Bone Joint Surg Am. 2005 Feb;87(2):254-9. doi: 10.2106/JBJS.D.02093.

文献5

髋臼周围截骨术后髋关节中心内移的评估：X光平片验证

译者 邱兴

背景： 髋臼周围截骨术通过增加股骨头的髋臼覆盖并使髋关节中心内移，以恢复正常关节生物力学。既往研究虽已报道PAO所能实现的内移程度，但内移的测量从未通过对不同影像学模式或测量技术的比较得到验证。由于坐骨棘线可能因PAO而发生改变，且在股骨头下1/3水平显示更佳，因此，采用从股骨头下1/3处开始测量的新方法可能更有优势。

研究问题/目的： (1) PAO实现的髋关节中心真实内移量及其变异性是多少？(2) 哪些影像学参数（如外侧中心边缘角和髋臼倾斜角）与实现的内移程度相关？(3) 在X光平片上，于股骨头中心（传统方法）还是股骨头下1/3处（新方法）测量内移，哪个与真实内移相关性更好？(4) 术中透视图像与术后X光片在测量髋关节内移方面是否存在差异？

方法： 我们利用一个既往建立的、在PAO术后接受了低剂量CT检查的患者队列进行了一项回顾性研究。本研究纳入标准包括：因有症状的髋臼发育不良而接受PAO、有术前CT扫描、以及术后随访时间在9个月至5年之间。2009年2月至2018年7月期间接受PAO的333名患者符合这些标准。此外，仅纳入手术时年龄在16至50岁之间的患者。排除标准包括：既往同侧手术史、股骨髋臼撞击征、妊娠、神经肌肉疾病、Perthes样畸形、术前CT不充分以及无法参与研究。最终研究组纳入39名患者的39个髋关节；其中87%为女性患者，13%为男性患者。手术时的中位年龄为27岁（范围16至49岁）。获取了术前和术后入组时的低剂量CT图像；我们还获取了术前和术后X光片以及术中透视图像。在X光平片上评估LCEA和AI。由一名独立的、不知分组情况的评估者通过所有影像学模式评估髋关节内移。在X光平片上，采用了测量髋关节内移的传统方法和新方法。根据可见的骨盆旋转程度，划分出优质和合格X光片亚组进行亚组分析。为回答第一个问题，通过三维CT髋关节重建模型的测量来评估所有髋关节的内移。为回答第二个问题，计算了Pearson相关系数、单因素方差分析和Student t检验，以评估影像学参数（如LCEA和AI）与实现的内移量之间的相关性。为回答第三个问题，进行了统计分析，包括线性回归分析，以使用Pearson相关系数、95%置信区间和估计标准误，来确定两种测量内移的X线方法与CT所示真实内移之间的相关性。为回答第四个问题，计算了Pearson相关系数以确定使用术中透视测量内移是否与X光片上的测量结果不同。

结果： 在本研究中，通过参考标准CT测量评估，PAO实现的髋关节中心真实内移量为4 ± 3毫米；46%的髋关节内移了0至5毫米，36%内移了5至10毫米，5%内移超过10毫米。13%的髋关节发生了外侧移位（内移< 0毫米）。不同LCEA亚组之间的内移量存在微小差异（LCEA ≤ 15°者为6 ± 3毫米，LCEA在15°至20°之间者为4 ± 4毫米，LCEA在20°至25°之间者为2 ± 3毫米）。AI ≥ 15°的髋关节实现的内移量大于AI < 15°的髋关节。与作为参考标准的CT扫描测量结果相比，在X光平片上于股骨头中心测量内移（传统方法）的相关性弱于在股骨头下1/3处测量（新方法）。传统方法在所有X光片或仅在优质X光片中均未显示出相关性，而新方法在所有X光片和仅在优质X光片中评估时，分别呈现出强相关和极强相关。术中透视图像上的髋关节内移测量结果与术后X光片上的测量结果未发现差异。

结论： 通过术前和术后CT测量，本研究显示PAO实现的平均真实内移量为4毫米，但变异性很大。在股骨头中心测量内移的传统方法可能不准确；在股骨头下1/3处测量内移的新方法是评估髋关节中心位置的更优方法。我们建议转而使用这种新方法以获得最佳的临床和研究数据，但要认识到两种基于X光平片的方法似乎都低估了PAO实现的真实内移量。最后，本研究提供证据表明，髋关节中心的位置和内移可以在术中通过透视进行准确评估。

图1、 A-B 采用骨盆前后位X光片测量髋关节位置。(A) 在这张术前X光片中，线1代表从股骨头中心起始的传统测量方法，线2代表从股骨头直径下三分之一处起始并延伸至坐骨棘线的替代测量方法。(B) 在这张术后X光片中，坐骨棘线在股骨头中部水平不可见，但在采用从股骨头直径下三分之一处起始的测量方法时清晰可见且易于测量。

图2 、基于CT扫描的内移测量方法图示：将股骨头中心与一条代表中线的垂直参考线相连进行测量。

图3 、替代性内移测量的起始点定于股骨头内侧缘，具体位置在股骨头垂直径的下三分之一分界点。

图4、A-B 如(A)术前与(B)术后X光片所示，该髋关节经PAO术后实现内移。采用X光平片的替代测量法（自股骨头直径下三分之一处起始进行测量）测得该髋关节内移量为9毫米，而通过参考标准CT测量法测得的内移量为8毫米。

Medialization of the Hip's Center with Periacetabular Osteotomy: Validation of Assessment with Plain Radiographs

Background: Periacetabular osteotomy (PAO) increases acetabular coverage of the femoral head and medializes the hip's center, restoring normal joint biomechanics. Past studies have reported data regarding the degree of medialization achieved by PAO, but measurement of medialization has never been validated through a comparison of imaging modalities or measurement techniques. The ilioischial line appears to be altered by PAO and may be better visualized at the level of the inferior one-third of the femoral head, thus, an alternative method of measuring medialization that begins at the inferior one-third of the femoral head may be beneficial.

Questions/purposes: (1) What is the true amount and variability of medialization of the hip's center that is achieved with PAO? (2) Which radiographic factors (such as lateral center-edge angle [LCEA] and acetabular inclination [AI]) correlate with the degree of medialization achieved? (3) Does measurement of medialization on plain radiographs at the center of the femoral head (traditional method) or inferior one-third of the femoral head (alternative method) better correlate with true medialization? (4) Are intraoperative fluoroscopy images different than postoperative radiographs for measuring hip medialization?

Methods: We performed a retrospective study using a previously established cohort of patients who underwent low-dose CT after PAO. Inclusion criteria for this study included PAO as indicated for symptomatic acetabular dysplasia, preoperative CT scan, and follow-up between 9 months and 5 years. A total of 333 patients who underwent PAO from February 2009 to July 2018 met these criteria. Additionally, only patients who were between 16 and 50 years old at the time of surgery were included. Exclusion criteria included prior ipsilateral surgery, femoroacetabular impingement (FAI), pregnancy, neuromuscular disorder, Perthes-like deformity, inadequate preoperative CT, and inability to participate. Thirty-nine hips in 39 patients were included in the final study group; 87% (34 of 39) were in female patients and 13% (5 of 39 hips) were in male patients. The median (range) age at the time of surgery was 27 years (16 to 49). Low-dose CT images were obtained preoperatively and at the time of enrollment postoperatively; we also obtained preoperative and postoperative radiographs and intraoperative fluoroscopic images. The LCEA and AI were assessed on plain radiographs. Hip medialization was assessed on all imaging modalities by an independent, blinded assessor. On plain radiographs, the traditional and alternative methods of measuring hip medialization were used. Subgroups of good and fair radiographs, which were determined by the amount of pelvic rotation that was visible, were used for subgroup analyses. To answer our first question, medialization of all hips was assessed via measurements made on three-dimensional (3-D) CT hip reconstruction models. For our second question, Pearson correlation coefficients, one-way ANOVA, and the Student t-test were calculated to assess the correlation between radiographic parameters (such as LCEA and AI) and the amount of medialization achieved. For our third question, statistical analyses were performed that included a linear regression analysis to determine the correlation between the two radiographic methods of measuring medialization and the true medialization on CT using Pearson correlation coefficients, as well as 95% confidence intervals and standard error of the estimate. For our fourth question, Pearson correlation coefficients were calculated to determine whether using intraoperative fluoroscopy to make medialization measurements differs from measurements made on radiographs.

Results: The true amount of medialization of the hip center achieved by PAO in our study as assessed by reference-standard CT measurements was 4 ± 3 mm; 46% (18 of 39 hips) were medialized 0 to 5 mm, 36% (14 hips) were medialized 5 to 10 mm, and 5% (2 hips) were medialized greater than 10 mm. Thirteen percent (5 hips) were lateralized (medialized < 0 mm). There were small differences in medialization between LCEA subgroups (6 ± 3 mm for an LCEA of ≤ 15°, 4 ± 4 mm for an LCEA between 15° and 20°, and 2 ± 3 mm for an LCEA of 20° to 25° [p = 0.04]). Hips with AI ≥ 15° (6 ± 3 mm) achieved greater amounts of medialization than did hips with AI of < 15° (2 ± 3 mm; p < 0.001). Measurement of medialization on plain radiographs at the center of the femoral head (traditional method) had a weaker correlation than using the inferior one-third of the femoral head (alternative method) when compared with CT scan measurements, which were used as the reference standard. The traditional method was not correlated across all radiographs or only good radiographs (r = 0.16 [95% CI -0.17 to 0.45]; p = 0.34 and r = 0.26 [95% CI -0.06 to 0.53]; p = 0.30), whereas the alternative method had strong and very strong correlations when assessed across all radiographs and only good radiographs, respectively (r = 0.71 [95% CI 0.51 to 0.84]; p < 0.001 and r = 0.80 [95% CI 0.64 to 0.89]; p < 0.001). Measurements of hip medialization made on intraoperative fluoroscopic images were not found to be different than measurements made on postoperative radiographs (r = 0.85; p < 0.001 across all hips and r = 0.90; p < 0.001 across only good radiographs).

Conclusion: Using measurements made on preoperative and postoperative CT, the current study demonstrates a mean true medialization achieved by PAO of 4 mm but with substantial variability. The traditional method of measuring medialization at the center of the femoral head may not be accurate; the alternate method of measuring medialization at the lower one-third of the femoral head is a superior way of assessing the hip center's location. We suggest transitioning to using this alternative method to obtain the best clinical and research data, with the realization that both methods using plain radiography appear to underestimate the true amount of medialization achieved with PAO. Lastly, this study provides evidence that the hip center's location and medialization can be accurately assessed intraoperatively using fluoroscopy.

文献出处：Fowler, Lucas M., Jeffrey J. Nepple, Clarabelle Devries, Michael D. Harris, and John C. Clohisy. "Medialization of the hip’s center with periacetabular osteotomy: validation of assessment with plain radiographs." Clinical Orthopaedics and Related Research® 479, no. 5 (2021): 1040-1049.

来源：304关节学术

作者：304关节团队

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