本期目录：
1、未置换髌骨的全膝关节置换术中，髌骨周缘去神经化不能减轻膝前痛
2、全髋关节置换术治疗髋臼周围截骨术后患者在中期随访中髋关节功能显著改善且翻修率较低
3、预期难以预料的意外：日间手术中心施行初次关节置换手术术中并发症的发生率和处理
4、全膝关节置换中使用止血带与不使用止血带的中长期术后随访比较
5、机器人辅助全膝关节置换术联合金属垫块增强治疗合并胫骨缺损的严重膝内翻畸形
6、胚胎期和胎儿早期骨盆骨骼的软骨形成
7、不同测量方法评估股骨扭转的差异在股骨过度扭转的髋关节中显著增大
8、髋臼周围截骨术治疗发育性髋关节发育不良：首批44例病例的初步经验和结果
9、股骨头坏死中软骨下骨深部变化的CT与MRI表现用于区分ARCO 2期与3A期
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第一部分：关节置换及保膝相关文献
文献1
未置换髌骨的全膝关节置换术中，髌骨周缘去神经化不能减轻膝前痛：前瞻性比较
译者 张轶超
背景：本研究旨在评估髌骨周缘去神经化在髌骨未行表面置换的全膝关节置换术（TKA）后减轻膝前痛（AKP）和改善临床结果的有效性。
材料和方法：这项前瞻性、非随机、观察性研究纳入了2023年8月至2024年1月期间在我院接受初次TKA的患者。患者分为两组：接受髌骨去神经化的患者（PD组）和未接受髌骨去神经化的患者（NPD组）。主要结果是通过视觉模拟评分（VAS）评测膝前痛（AKP）的减轻情况。次要结果包括Kujala膝关节评分、西安大略和麦克马斯特大学关节炎指数（WOMAC）和活动范围（ROM）。术前及术后3、6个月进行评估。
结果：PD组4例、NPD组5例患者因未能完成随访而被排除在研究之外。最终纳入女性74例，男性16例，平均年龄67.4±4.2岁。两组患者在年龄、性别、手术侧、身高、体重、BMI、髌股关节骨关节炎分级、术前ROM、VAS评分、Kujala评分和WOMAC评分方面无显著差异（所有变量p: 无差异）。VAS、Kujala和WOMAC评分在任何时间点组间均无显著差异（p: n.s）。重复测量方差分析表明，随着时间的推移，这些评分有了显著的改善（两组的p=0.001）。两两比较显示术前至术后第3个月和第6个月以及术后第3个月至第6个月均有显著改善（所有比较p=0.001）。两组在第3个月时膝关节活动度均有所下降，6个月时恢复到术前水平，两组间无显著差异。研究期间无并发症发生。
结论：与未行髌骨置换的TKA未去神经化相比，髌骨周缘去神经化在减轻膝前痛或改善功能效果方面没有额外的益处。
Circumferential patellar denervation does not reduce anterior knee pain in total knee arthroplasty without patellar resurfacing; a prospective comparison
Background：This study aimed to evaluate the effectiveness of circumferential patellar denervation in reducing anterior knee pain (AKP) and improving clinical outcomes after total knee arthroplasty (TKA) without patellar resurfacing.
Materials and methods：This prospective, non-randomized, observational study included patients who underwent primary TKA at our institution between August 2023 and January 2024. Patients were divided into two groups: those who received patellar denervation (PD group) and those who did not (NPD group). The primary outcome was the reduction in anterior knee pain (AKP), measured by the Visual Analog Scale (VAS). Secondary outcomes included the Kujala Knee Score, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and range of motion (ROM). Assessments were conducted preoperatively and at 3 and 6 months postoperatively.
Results：Four patients in the PD group and five in the NPD group were excluded from the study due to failure to complete follow-up. Thus, 74 female and 16 male patients with a mean age of 67.4±4.2 years were included in the final analysis. There were no significant differences between the two groups with respect to age, sex, side of surgery, height, weight, BMI, grade of patellofemoral osteoarthritis, preoperative ROM, VAS score, Kujala score, and WOMAC score (p: n.s. for all variables). No significant differences were found between the groups for VAS, Kujala, and WOMAC scores at any time point (p: n.s.). Significant improvements in these scores over time were indicated by repeated measures ANOVA (p=0.001 for both groups). Pairwise comparisons showed significant improvements from preoperative to postoperative months three and six and from postoperative months three to six (p=0.001 for all comparisons). Both groups experienced decreased knee ROM at third month, which returned to preoperative values at sixth month with no significant differences. No complications were observed during the study.
Conclusions：Circumferential patellar denervation does not provide additional benefit in reducing anterior knee pain or improving functional outcomes compared to the non-denervation approach in TKA without patellar resurfacing.
文献出处：Dogruoz F, Yapar A, Buyukarslan V, Egerci OF, Etli I, Kose O. Circumferential patellar denervation does not reduce anterior knee pain in total knee arthroplasty without patellar resurfacing; a prospective comparison. J Orthop Surg Res. 2024 Oct 15;19(1):653. doi: 10.1186/s13018-024-05161-5. PMID: 39402657; PMCID: PMC11475715.
文献2
全髋关节置换术治疗髋臼周围截骨术后患者在中期随访中髋关节功能显著改善且翻修率较低
译者 马云青
研究背景：伯尔尼髋臼周围截骨术能改善髋臼发育不良患者的症状并延缓退行性改变。然而，其中许多患者最终仍需接受全髋关节置换术。PAO对后续THA结果的影响尚不明确。
作者研究旨在明确：1）临床结果，2）术后并发症，3）既往同侧PAO后接受THA患者的假体生存率。
研究方法：本研究在三家机构进行了回顾性分析，以确定在同侧PAO术后接受THA且至少随访1年的患者。收集了术前和末次随访时的患者报告结局指标。通过查阅医疗记录，记录了手术细节、影像学和临床结果，以及根据改良Dindo-Clavien分级系统判定的主要并发症。使用回归分析t检验比较术前和术后结局评分。采用Kaplan-Meier分析评估假体生存率。
结果：作者共确定112名患者的113例THA。其中103例髋关节获得至少1年随访，平均随访时间为5±4年（范围1至20年）。10例髋关节（9%）失访，剩下103例（91%）可供研究，且随访时间至少1年（平均5年）。从PAO到THA的平均间隔时间为7.7年（范围2-15年）。与术前评分相比，术后平均mHHS评分提高了37分（从50分提高到87分，P < 0.001）。8名患者（7.1%）发生了主要（III-V级）手术并发症。包括2例关节不稳、2例髋臼假体松动，以及各1例假体周围骨折、伤口裂开、假体周围感染、髋臼假体松动和肺炎。失败发生较早，平均为术后3.2年。全因翻修的生存率分析显示，5年和10年生存率均为96%。
结论：在PAO术后接受THA可获得显著的临床改善，中期随访显示生存率令人满意（96%），主要并发症发生率为7.1%。
Total Hip Arthroplasty After Peri-Acetabular Osteotomy Results in Significant Improvement in Hip Function With Low Revision Rates at Mid-Term Follow-Up
Background:Bernese periacetabular osteotomy (PAO) improves symptoms and delays degenerative changes in patients with acetabular dysplasia. Yet, eventual total hip arthroplasty (THA) is needed in many of these patients. The impact of PAO on subsequent THA outcomes is not well defined.
The purpose of this study is to define:1) clinical outcomes, 2) post-operative complications and 3) implant survivorship for patients undergoing THA after prior ipsilateral PAO.
Methods:A retrospective review was conducted at three institutions to identify individuals undergoing THA after ipsilateral PAO surgery with minimum 1 year follow up. Patient reported outcome measures (PROMs) were collected preoperatively and at final follow-up. Surgical details, radiographic and clinical outcomes, and major complications according to the modified Dindo-Clavien classification system were identified through review of the medical record. Regression analysis and student's t-test were used to compare pre- and post-operative outcome scores. Kaplan-Meier analysis was performed to estimate reoperation-free survivorship.
Results:A total of 113 THA in 112 patients were identified with initial review. 103 hips had a minimum of 1-year follow-up and an average follow of 5 ± 4 years (range, 1 to 20). 10 hips (9%) were lost to follow-up leaving 103 (91%) hips available for review with a minimum of 1-year follow-up (mean = 5 years). Mean interval from PAO to THA was 7.7 years (range, 2-15). The average post-operative mHHS improved 37 points (50 to 87, P < 0.001) when compared to pre-operative scores. Eight patients (7.1%) experienced a major grades III-V) surgical complication. These included 2 cases of instability, 2 cases of acetabular loosening, and one case each of periprosthetic fracture, wound dehiscence, periprosthetic infection, acetabular loosening and pneumonia. Failures occurred early at average 3.2 years and survivorship analysis for all-cause revision demonstrated 96% survivorship at both 5 and 10 years.
Conclusion:THA after PAO achieves significant clinical improvement and satisfactory survivorship (96%) at mid-term follow-up, with a major complication rate of 7.1%.Level of Evidence: III.
Keywords: mid-term follow-up; periacetabular osteotomy; survivorship; total hip arthroplasty; young adult.
文献出处：West C, Inclan P, Laboudie P, Labbott J, J Sierra R, T Trousdale R, Beaulé P, Thornton T, Thapa S, Pashos G, Clohisy JC. Total Hip Arthroplasty After Peri-Acetabular Osteotomy Results in Significant Improvement in Hip Function With Low Revision Rates at Mid-Term Follow-Up. Iowa Orthop J. 2024;44(1):73-78. PMID: 38919338; PMCID: PMC11195879.
文献3
预期难以预料的意外：日间手术中心施行初次关节置换手术术中并发症的发生率和处理
译者 张蔷
背景：初次关节置换手术（TJA）在近些年逐渐由中心手术室转为日间手术中心（ASCs）施行。然而，日间手术中心通常手术资源有限，包括手术器械和翻修假体的选择均受到限制。术前难以预料的术中并发症通常需要翻修假体，而这会显著增加手术时间、花费和患者相关风险。既往文献中鲜有资料记载需要特殊假体来处理的初次关节置换术中并发症率。因此，本研究旨在评估初次关节置换术中计划外并发症的发生率、指证和类型，以改善日间手术患者的准备状态、优化日间手术中心资源配置。
方法：我们选择单一医疗中心自2021年1年至2024年10月间初次全髋关节置换（THA）和初次全膝关节置换（TKA）的手术病例来施行回顾性研究。本研究包含了施行初次关节置换手术时术中遇到计划外并发症并应用特殊假体的病例。特殊假体包括Cone锥度补块、环扎钢缆、钢板、组配或一体式翻修柄、内-外翻限制性假体（VVC）和带延长杆的股骨假体。通过病例回顾，我们筛选出了必须使用翻修假体的病例。此外，我们还收集了患者一般信息，如年龄、性别、吸烟情况和Charlson合并症指数等。
结果：在1307例TKA病例中，有5例（0.4%）因为内（n = 3）或外（n = 2）侧副韧带损伤而需要应用内-外翻限制性假体。在1061例THA病例中，有9例（0.9%）需要特殊假体，包括8例术中假体周围骨折而进行钢缆环扎的病例，其中1例应用了组配式股骨柄。另外1例因为股骨过度后倾而应用了一体化股骨柄。
结论：据我们所知，本文是第一篇评估日间手术中心施行的初次关节置换术中并发症率的文章，揭示出较低的术中并发症率（TKA 0.4%，THA 0.9%）。确保备好关键假体可以减少日间关节置换手术延迟情况、降低手术风险，维持最佳的术后疗效。
Expecting the Unexpected Incidence and Management of Intraoperative Complications in Primary Total Joint Arthroplasty at Ambulatory Surgery Centers
Background: Primary total joint arthroplasty (TJA) has increasingly moved to ambulatory surgery centers (ASCs) in recent years. However, ASCs often operate with limited resources, including a constrained selection of orthopaedic instruments and revision implants. Unanticipated intraoperative complications requiring revision components can increase operative time, costs, and patient risks. The incidence of complications requiring specialized components during primary TJA remains largely undocumented. Therefore, this study aimed to evaluate the frequency, indications, and types of unplanned complications during primary TJA to improve surgeon preparedness and resource allocation in ASCs.
Methods: We conducted a retrospective review of primary total hip (THA) and total knee arthroplasty (TKA) cases performed at a single academic-affiliated ASC from January 2021 to October 2024. The study included patients undergoing primary TJA without preoperatively planned use of specialized components. Evaluated components included cones, cerclage cables, plates, modular or monoblock revision stems, varus-valgus constrained (VVC) implants, and stemmed femoral components. The chart review identified cases necessitating revision components. In addition, patient demographics such as age, sex, smoking status, and Charlson Comorbidity Index were collected.
Results: Among 1,307 TKA cases, five patients (0.4%) required varus-valgus constrained implants due to medial (n = 3) or lateral (n = 2) collateral ligament injury. Among 1,061 THA cases, nine patients (0.9%) required specialized implants, including eight patients who received cerclage cables for intraoperative periprosthetic fractures, with one of these patients also requiring a modular femoral stem. Another patient required a monoblock femoral stem alone due to excessive femoral retroversion.
Conclusions: To our knowledge, this study is the first to examine the incidence of intraoperative complications during primary TJA at an ASC, revealing a low incidence rate (0.4% for TKA and 0.9% for THA). Ensuring the availability of essential components can help ASCs minimize surgical delays, mitigate risks, and maintain optimal patient outcomes.
文献出处：Wong BW, Oleisky ER, Chandrashekar AS, Fox JA, Locascio LM, Puczko D, Baker CE, Martin JR. Expecting the Unexpected: Incidence and Management of Intraoperative Complications in Primary Total Joint Arthroplasty at Ambulatory Surgery Centers. J Arthroplasty. 2025 Dec;40(12):3303-3307. doi: 10.1016/j.arth.2025.05.092. Epub 2025 Jun 2. PMID: 40466918.
文献4
全膝关节置换中使用止血带与不使用止血带的中长期术后随访比较
译者 丁云鹏
背景：在全膝关节置换术（TKA）中应用非止血带技术日益普及，但其对膝关节假体使用寿命的影响尚未形成共识。本研究通过探讨止血带使用对骨水泥渗透及假体周围透亮线（RLL）的影响，评估TKA术中止血带应用是否影响假体生存率。
方法：回顾性分析2014年1月1日至2015年6月1日期间收治的符合入选标准的166例患者，根据术中使用止血带情况分为止血带组（80例）与非止血带组（86例）。比较两组术前资料及相关并发症，基于术后影像学数据测量髋-膝-踝角（HKA）、胫骨近端内侧角（MPTA）及截骨面骨水泥渗透深度，并观察假体周围出现透亮线的概率。
结果：共纳入166例患者，平均年龄68.52±4.74岁，平均随访时间105.67±5.98年。两组人口统计学资料无显著差异（P>0.05）。两组各有1例因假体无菌性松动行翻修手术。术前及术后膝关节协会功能评分（HSS）、膝关节活动度、HKA、MPTA在两组间均无显著差异（P>0.05）。在股骨3A区外侧观察区及股骨平均观察区，两组截骨面骨水泥渗透深度存在显著差异（P<0.05）。不同观察区域透亮线发生率两组间略有差异，但翻修率无显著统计学差异（P>0.05）。
结论：长期随访显示，非止血带TKA在假体稳定性、假体生存率、再手术率、膝关节活动度及膝关节功能等多个方面均可达到与使用止血带相当的临床效果。
Comparison of medium- and long-term total knee arthroplasty follow-up with or without tourniquet
Background: Applying non-tourniquet technology in total knee arthroplasty (TKA) is becoming increasingly popular. However, there is no consensus on its effect on the service life of knee prostheses. This study examined the effect of tourniquet use on cement penetration and radiolucent line (RLL) to assess whether the use of tournique in TKA affects prosthesis survival.
Methods: We retrospectively analyzed 166 patients admitted to our hospital between January 1, 2014, and June 1, 2015, who met the inclusion criteria. The patients were divided into the tourniquet (80 cases) and non-tourniquet groups (86 cases) according to whether a tourniquet was used during the operation. We compared the preoperative data and related complications between both groups. Hip-knee-ankle (HKA), medial proximal tibial angle (MPTA) and the penetration depth of bone cement on the osteotomy surface was measured according to postoperative imaging data. Furthermore, the probability of occurrence of radio-clear lines around the prosthesis was observed.
Results: A total of 166 patients were enrolled with a mean age of 68.52 ± 4.74 years and a mean follow-up time of 105.67 ± 5.98 years. No significant demographic differences were observed between the two groups (P > 0.05). Revision surgery was performed for one patient in each group due to aseptic loosening of the prosthesis. The preoperative and postoperative knee association function scores (HSS), knee range of motion, HKA, and MPTA between the two groups did not differ significantly (P > 0.05). In the lateral observation of zone femur 3A and the average observation area of the femur, the penetration depth of the osteotomy surface were significantly different between the two groups (P < 0.05). The incidence of radiolucent lines differed slightly between both groups in different observation areas,but the revision rate did not differ significantly between the two groups (P > 0.05).
Conclusion: In the long term, TKA without tournique use can achieve clinical effects comparable to the use of tourniquet in many aspects, such as prosthesis stability, prosthesis survival rate, reoperations rate, knee range of motion, and knee functionality.
文献出处：Qigang Zhong , Hu Yang , Renfei Qi,Comparison of medium- and long-term total knee arthroplasty follow-up with or without tourniquet.BMC Musculoskelet Disord. 2025 Feb 27;26(1):205. doi: 10.1186/s12891-025-08462-w.
文献5
机器人辅助全膝关节置换术联合金属垫块增强治疗合并胫骨缺损的严重膝内翻畸形
译者 沈松坡
背景
对于合并非包容性胫骨内侧骨缺损的重度膝内翻畸形患者行全膝关节置换术（TKA），由于需要额外的骨切除以去除骨缺损区域、应用金属增强垫块以及调整软组织平衡，技术上仍然对骨科医生构成挑战。机器人技术已被证实可在TKA中实现精确的骨切除和最佳的软组织平衡。本研究旨在报告机器人辅助TKA联合金属增强块治疗严重膝内翻畸形的病例系列。
方法
本研究纳入15例患者，共22膝，术后随访时间均超过12个月。所有患者均在机器人技术辅助下行初次TKA联合金属增强垫块。评估内容包括假体植入位置、软组织平衡及临床疗效。
结果
视觉模拟评分（VAS）及膝关节损伤与骨关节炎结局评分（KOOS）均较术前显著改善。此外，下肢力线及假体在冠状位和矢状位的植入位置在影像学上均表现出较高的准确性。术后内侧膝关节稳定性得以维持，而外侧松弛度明显降低。
结论
在传统TKA中，将骨缺损区域切除至与金属增强块深度完全一致在技术上具有较大难度。然而，借助机器人技术，不仅可完成初始骨切除，还可对残余骨缺损进行评估、调整软组织平衡，并准确完成额外骨切除。因此，机器人技术在合并内侧胫骨骨缺损的严重膝内翻畸形患者行金属垫块增强TKA中具有潜在优势。
关键词（Keywords）：膝骨关节炎；全膝关节置换术；胫骨骨缺损；金属垫块增强；机器人技术
图1术前影像学表现及术前手术规划。
（a）–（c）为一名79岁女性患者的术前影像学资料，分别为正位、侧位及下肢全长正位片。股胫角（FTA）为201°，髋-膝-踝角（HKA）为 -24°。
（d）术前手术规划显示，在完成初次胫骨骨切除后，预测内侧胫骨骨缺损仍将残留。虚线圆圈表示骨缺损区域。图1–3及补充资料1–3所示数据均来源于同一名患者。
图2初次胫骨骨切除。
（a）术前胫骨规划显示，蓝色区域为预测将在初次胫骨骨切除中被切除的区域。
（b）预测的初次胫骨切除后骨面显示内侧胫骨仍残留骨缺损。
肉眼观察结果显示，残余胫骨骨缺损的形态（c）及深度（d）与（a）和（b）所示一致。虚线圆圈表示骨缺损区域。
图3额外胫骨骨切除。
（a）额外5 mm胫骨切除的术前规划显示，蓝色区域为预测将被切除的部分。
（b）实施额外胫骨切除（白色区域），其尺寸与半块金属增强块完全一致。
（c）切除的骨块证实了额外胫骨切除的准确性。
（d）切除后的骨面平整，并与术前规划图像高度一致。虚线圆圈表示额外骨切除区域。
图4术后肉眼及影像学表现。
（a）联合金属增强块的假体与胫骨贴合良好。
影像学评估显示，假体位置及下肢力线均准确恢复（b–d）。
Robotic-Assisted Total Knee Arthroplasty With Metal Block Augmentation for Severe Varus Knee With Tibial Defect
Background: Total knee arthroplasty (TKA) for severe varus knee deformity with an uncontained medial tibial bone defect remains challenging for orthopaedic surgeons because additional bone resection to remove the bone defect area, application of metal augmentation, and adjustment of soft tissue balancing are technically difficult. Robotic technology has been demonstrated to achieve accurate bone resection and optimal soft tissue balancing in TKA. This study aimed to present a case series of the application of robotic-assisted TKA with metal augmentation for severe varus knee.
Methods: Fifteen patients with 22 affected knees and postoperative follow-up of longer than 12 months were included in this study. Primary TKA with metal block augmentation was performed using robotic technology, and the implant positions, soft tissue balancing, and clinical outcomes were evaluated.
Results: The visual analog scale score and knee injury and osteoarthritis outcome score were significantly improved. In addition, the lower extremity alignment and implant positions in the coronal and sagittal planes were radiographically accurate. Moreover, the medial knee stability was maintained, and lateral looseness diminished postoperatively.
Conclusions: To resect the bone defect area perfectly the same as the depth of metal augmentations was technically difficult in conventional TKA. However, besides the primary bone resections, residual bone defect evaluation, soft tissue balancing adjustment, and additional bone resection to remove the bone defect area were performed easily and accurately using robotic technology. Therefore, robotic technology provides potential benefits for TKA with metal block augmentation in severe varus knees with medial tibial bone defects.
Level of evidence: Level IV case series study.
Keywords: Knee osteoarthritis; Metal block augmentation; Robotic technology; Tibial bone defect; Total knee arthroplasty.
文献出处：Oshima Y, Majima T. Robotic-Assisted Total Knee Arthroplasty With Metal Block Augmentation for Severe Varus Knee With Tibial Defect. Arthroplast Today. 2025 Dec 3;36:101915. doi: 10.1016/j.artd.2025.101915. PMID: 41438996; PMCID: PMC12720117.
02
第二部分：保髋相关文献
文献1
胚胎期和胎儿早期骨盆骨骼的软骨形成
译者 任宁涛
骨盆骨骼是通过软骨内骨化形成的。然而，目前尚不清楚正常软骨是如何在骨化发生前形成的。此外，骨盆软骨形成的总体时间和软骨形态尚不清楚。本研究使用相位对比计算机断层扫描和7T磁共振成像，观察了25例人类胎儿(冠-臀长[CRL] = 11.9-75.0 mm)骨盆骨骼的软骨形成。髂骨、坐骨、耻骨的软骨中心在卡内基期(CS) 18首次同时出现，位于髋臼周围，后期呈放射状生长。髂嵴在CS20阶段形成，而髂体中央部分仍呈软骨状。髂骨体在CS22阶段形成一个盘状结构。髂骨的生长速率大于骶骨-尾骨、耻骨和坐骨。在有限的时间内形成连接和关节，骶髂关节在CS21阶段形成。在CS23阶段可观察到耻骨联合关节、骶髂关节连接、髋骨三部分与髋臼Y形连接;在胎儿早期（EF）观察到坐骨和耻骨分支的连接。此外，在不同的样本中，骶骨中心的连接程度也不同。大多数盆腔测量数据显示与CRL高度相关。小骨盆入口的横向径和前后径在不同的样本中存在差异(R2 = 0.11)。耻骨下角也有变化(65 ~ 90°)，与CRL无关(R2 = 0.22)。此外，软骨结构的形成似乎影响骨结构。这项研究为骨盆结构的形态发生提供了有价值的信息。
图1 盆腔环形成。骨盆骨骼软骨形成的三维重建视图。蓝色：股骨; 绿色：耻骨; 浅蓝色：尾骨; 橙色：主动脉和髂总动脉。紫色：髂骨; 红色：骶骨; 黄色：坐骨。括号中的数字为CRL (mm)。刻度条表示1mm。
Cartilage formation in the pelvic skeleton during the embryonic and early-fetal period
The pelvic skeleton is formed via endochondral ossification. However, it is not known how the normal cartilage is formed before ossification occurs. Furthermore, the overall timeline of cartilage formation and the morphology of the cartilage in the pelvis are unclear. In this study, cartilage formation in the pelvic skeletons of 25 human fetuses (crown-rump length [CRL] = 11.9-75.0 mm) was observed using phase-contrast computed tomography and 7T magnetic resonance imaging. The chondrification center of the ilium, ischium, and pubis first appeared simultaneously at Carnegie stage (CS) 18, was located around the acetabulum, and grew radially in the later stage. The iliac crest formed at CS20 while the iliac body's central part remained chondrified. The iliac body formed a discoid at CS22. The growth rate was greater in the ilium than in the sacrum-coccyx, pubis, and ischium. Connection and articulation formed in a limited period, while the sacroiliac joint formed at CS21. The articulation of the pubic symphysis, connection of the articular column in the sacrum, and Y-shape connection of the three parts of the hip bones to the acetabulum were observed at CS23; the connection of the ischium and pubic ramus was observed at the early-fetal stage. Furthermore, the degree of connection at the center of the sacrum varied among samples. Most of the pelvimetry data showed a high correlation with CRL. The transverse and antero-posterior lengths of the pelvic inlet of the lesser pelvis varied among samples (R2 = 0.11). The subpubic angle also varied (65-90°) and was not correlated with CRL (R2 = 0.22). Moreover, cartilaginous structure formation appeared to influence bone structure. This study provides valuable information regarding the morphogenesis of the pelvic structure.
文献出处：Okumura M, Ishikawa A, Aoyama T, Yamada S, Uwabe C, Imai H, Matsuda T, Yoneyama A, Takeda T, Takakuwa T. Cartilage formation in the pelvic skeleton during the embryonic and early-fetal period. PLoS One. 2017 Apr 6;12(4):e0173852. doi: 10.1371/journal.pone.0173852. PMID: 28384153; PMCID: PMC5383024.
文献2
不同测量方法评估股骨扭转的差异在股骨过度扭转的髋关节中显著增大
译者 李勇
背景：准确量化股骨扭转对于诊断扭转畸形、确定手术适应证以及规划矫形量至关重要。然而，截至目前，尚无研究针对股骨过度扭转的髋关节明确评估不同股骨扭转测量方法之间的差异。
研究目的：(1) 五种常用的基于 CT 的股骨扭转测量方法之间有何差异？(2) 在股骨过度扭转的髋关节中，这些测量方法之间的差异是否会随之增大？(3) 这五种扭转测量方法各自的信度和重复性如何？
方法：在 2016 年 3 月至 8 月期间，我院（三级医疗中心）门诊接诊了 86 名（95 侧髋关节）主诉为髋部疼痛且体格检查怀疑为股骨头髋臼撞击综合征（FAI）的新诊患者。其中，56 名患者（62 侧髋关节）接受了包含股骨远端在内的全长盆腔 CT 扫描以测量股骨扭转。我们排除了 7 名（7 侧）既往接受过髋关节手术的患者、2 名（2 侧）Legg-Calvé-Perthes 病（股骨头缺血性坏死）后遗症患者以及 1 名（1 侧）创伤后畸形患者。最终纳入的研究小组包含 46 名患者（52 侧髋关节），平均年龄 28 ± 9 岁（范围 17-51 岁），女性 27 名（59%）。
研究对比了五种常用的评估方法，即：Lee 法、Reikerås 法、Jarrett 法、Tomczak 法和 Murphy 法。这些方法的主要区别在于股骨颈近端轴线的解剖参考层面：Lee 法采用的定义最靠近近端，其次是位于股骨颈基底部的 Reikerås 法、Jarrett 法和 Tomczak 法，而 Murphy 法采用的定义最靠近远端（位于小转子层面）。所有五种方法的股骨头中心定义和远端参考标准均保持一致。
我们使用 Murphy 法作为股骨扭转测量的基准方法，因为据报道该方法最接近真实的股骨解剖扭转。采用该方法测得的平均股骨扭转角为 28° ± 13°。使用多变量方差分析比较五种方法测得的股骨扭转平均值。通过在整个股骨扭转范围内绘制任意两种测量方法之间的差异曲线，以评估在股骨过度扭转的髋关节中差异是否增加。所有测量由两名不知情的骨科住院医师（FS, TDL）在两个不同时间点独立完成，并使用组内相关系数（ICCs）评估观察者内重复性和观察者间信度。
结果：我们发现，随着股骨颈近端轴线定义越趋向远端，测得的股骨扭转值越高：Lee 法（定义最靠近端：11° ± 11°）、Reikerås 法（15° ± 11°）、Jarrett 法（19° ± 11°）、Tomczak 法（25° ± 12°）以及 Murphy 法（定义最靠远端：28° ± 13°）。差异最显著的是 Lee 法与 Murphy 法之间的对比，平均差值达 17° ± 5°（95% 置信区间，16°-19°；p < 0.001）。在 10 组可能的两两比较中，有 6 组显示方法间的差异随股骨扭转角的增大而增大，随其减小而减小。任何方法与 Murphy 法相比，以及 Reikerås 法和 Jarrett 法与 Tomczak 法相比，均观察到中度至强度的线性相关（R 范围为 0.306-0.622；所有 p 值 < 0.05）。例如，根据 Murphy 法测量扭转角为 10° 的髋关节，根据 Reikerås 法测得仅为 1°，差异为 9°；而在过度扭转的髋关节中，这一差异增加到了 20°（例如：Murphy 法测得 60°，则 Reikerås 法测得约为 40°）。所有五种测量方法在观察者内重复性（ICC 0.905-0.973）和观察者间信度（ICC 0.938-0.969）方面均表现优异。
结论：由于股骨扭转角在过度扭转的髋关节中因测量方法不同而存在显著差异，因此在报告股骨扭转数值时，必须注明所采用的具体测量方法，并保持测量方法的一致性。在制定手术决策和规划矫正角度时，必须考虑到这些差异。忽视不同测量方法之间的量化差异，可能会导致误诊及手术规划错误。
图1 示意图展示了用于基于CT测量股骨扭转的五种不同方法。蓝色线条代表基于真实轴位切面的方法（A-D）；绿色线条代表基于轴斜位图像的方法（E）。所有五种方法均以股骨头中心和股骨远端后髁作为标志点。它们的区别在于对近端股骨参考轴的定义，该参考轴的位置从近端（A）向远端（D）逐步移动。
Differences in Femoral Torsion Among Various Measurement Methods Increase in Hips With Excessive Femoral Torsion
Background: Correct quantification of femoral torsion is crucial to diagnose torsional deformities, make an indication for surgical treatment, or plan the amount of correction. However, no clear evaluation of different femoral torsion measurement methods for hips with excessive torsion has been performed to date.
Questions/purposes: (1) How does CT-based measurement of femoral torsion differ among five commonly used measurement methods? (2) Do differences in femoral torsion among measurement methods increase in hips with excessive femoral torsion? (3) What is the reliability and reproducibility of each of the five torsion measurement methods?
Methods: Between March and August 2016, we saw 86 new patients (95 hips) with hip pain and physical findings suggestive for femoroacetabular impingement at our outpatient tertiary clinic. Of those, 56 patients (62 hips) had a pelvic CT scan including the distal femur for measurement of femoral torsion. We excluded seven patients (seven hips) with previous hip surgery, two patients (two hips) with sequelae of Legg-Calvé-Perthes disease, and one patient (one hip) with a posttraumatic deformity. This resulted in 46 patients (52 hips) in the final study group with a mean age of 28 ± 9 years (range, 17-51 years) and 27 female patients (59%). Torsion was compared among five commonly used assessment measures, those of Lee et al., Reikerås et al., Jarrett et al., Tomczak et al., and Murphy et al. They differed regarding the level of the anatomic landmark for the proximal femoral neck axis; the method of Lee had the most proximal definition followed by the methods of Reikerås, Jarrett, and Tomczak at the base of the femoral neck and the method of Murphy with the most distal definition at the level of the lesser trochanter. The definition of the femoral head center and of the distal reference was consistent for all five measurement methods. We used the method described by Murphy et al. as our baseline measurement method for femoral torsion because it reportedly most closely reflects true anatomic femoral torsion. With this method we found a mean femoral torsion of 28 ± 13°. Mean values of femoral torsion were compared among the five methods using multivariate analysis of variance. All differences between two of the measurement methods were plotted over the entire range of femoral torsion to evaluate a possible increase in hips with excessive femoral torsion. All measurements were performed by two blinded orthopaedic residents (FS, TDL) at two different occasions to measure intraobserver reproducibility and interobserver reliability using intraclass correlation coefficients (ICCs).
Results: We found increasing values for femoral torsion using measurement methods with a more distal definition of the proximal femoral neck axis: Lee et al. (most proximal definition: 11° ± 11°), Reikerås et al. (15° ± 11°), Jarrett et al. (19° ± 11°), Tomczak et al. (25° ± 12°), and Murphy et al. (most distal definition: 28° ± 13°). The most pronounced difference was found for the comparison between the methods of Lee et al. and Murphy et al. with a mean difference of 17° ± 5° (95% confidence interval, 16°-19°; p < 0.001). For six of 10 possible pairwise comparisons, the difference between two methods increased with increasing femoral torsion and decreased with decreasing femoral torsion. We observed a fair-to-strong linear correlation (R range, 0.306-0.622; all p values < 0.05) for any method compared with the Murphy method and for the Reikerås and Jarrett methods when compared with the Tomczak method. For example, a hip with 10° of femoral antetorsion according Murphy had a torsion of 1° according to Reikerås, which corresponds to a difference of 9°. This difference increased to 20° in hips with excessive torsion; for example, a hip with 60° of torsion according to Murphy had 40° of torsion according to Reikerås. All five methods for measuring femoral torsion showed excellent agreement for both intraobserver reproducibility (ICC, 0.905-0.973) and interobserver reliability (ICC, 0.938-0.969).
Conclusions: Because the quantification of femoral torsion in hips with excessive femoral torsion differs considerably among measurement methods, it is crucial to state the applied methods when reporting femoral torsion and to be consistent regarding the used measurement method. These differences have to be considered for surgical decision-making and planning the degree of correction. Neglecting the differences among measurement methods to quantify femoral torsion can potentially lead to misdiagnosis and surgical planning errors.
文献出处：Schmaranzer F, Lerch TD, Siebenrock KA, Tannast M, Steppacher SD. Differences in Femoral Torsion Among Various Measurement Methods Increase in Hips With Excessive Femoral Torsion. Clin Orthop Relat Res. 2019 May;477(5):1073-1083. doi: 10.1097/CORR.0000000000000610.
文献3
髋臼周围截骨术治疗发育性髋关节发育不良：首批44例病例的初步经验和结果
译者 陶可
目的：描述伯尔尼髋臼周围截骨术(PAO)治疗发育性髋关节发育不良的手术技巧、适应症和初步结果。
材料与方法：2011年5月至2020年5月，共对44例患者（35例女性，平均年龄30岁，23-38岁）进行了44次髋臼周围截骨术（PAO）。所有患者均被诊断为症状性髋关节发育不良。平均中心边缘角为17°（9-20°），平均髋臼指数为18°（15-20°）。其中22例患者在同一手术阶段通过髋关节镜评估并修复了髋关节内病变。评估了矫正效果、截骨愈合情况以及随访结束时的功能结果。
结果：22例患者存在与髋关节发育不良相关的髋臼唇肥厚和撕裂。10例患者发现髋臼唇旁囊肿。术后平均中心边缘角为32°（27°至35°），髋臼指数为6°（4°至9°）。PAO手术时间为130分钟；若同时进行关节镜手术，则手术时间为148分钟。
结论：PAO手术技术难度较高，但对于髋关节软骨完整且畸形可矫正的患者，其疗效可预测。截骨术前进行髋关节镜检查有助于评估软骨状况，诊断和治疗与该病理相关的髋关节内病变，并判断是否需要矫正软组织缺损。
图1 A.一名21岁右髋关节发育不良症状患者的术前髋关节正位X线片。B.术前影像显示髋臼前后壁交叉征。C.术后影像显示伯尔尼髋臼周围截骨术的骨愈合情况；注意髋臼前后壁交叉征消失。
Ganz Periacetabular Osteotomy for the Treatment of Developmental Dysplasia of the Hip: Initial Experience and Results From the First 44 Cases
Objective: To describe the surgical technique, indications, and initial results of the Bernese periacetabular osteotomy (PAO) for the treatment of developmental dysplasia of the hip. Materials and Methods: Between May 2011 and May 2020, 44 PAOs were performed in 44 patients (35 women) with an average age of 30 years (23-38). All patients had a diagnosis of symptomatic hip dysplasia. The average center-edge angle was 17 (9 to 20) and the average acetabular index was 18 (15 to 20). In 22 cases, the intra-articular findings were evaluated and repaired by arthroscopy in the same surgical stage. The correction obtained, the consolidation of the osteotomy, and the functional outcomes at the end of the follow-up were evaluated. Results: Hypertrophy and rupture of the acetabular labrum associated with hip dysplasia were evidenced in 22 patients. Paralabral cysts were found in 10 patients in the series. The average postoperative center-edge angle was 32o (27o to 35o) and the acetabular index was 6o (4o to 9o). The surgical time for PAO was 130 minutes; in patients where an arthroscopic procedure was added, the time was 148 minutes. Conclusions: PAO is technically demanding, but has predictable outcomes in patients with articular cartilage integrity and correctable deformities. Arthroscopy before osteotomy allows assessing cartilage conditions, diagnosing and treating intra-articular lesions associated with this pathology, and deciding on the need to correct the soft tissue deficit.
文献出处：Zanotti G, Lucero CM, Diaz Dilernia F, Slullitel P, Comba F, Piccaluga F, Buttaro M. Ganz Periacetabular Osteotomy for the Treatment of Developmental Dysplasia of the Hip: Initial Experience and Results From the First 44 Cases. Rev Asoc Argent Ortop Traumatol 2021;86(6):727-736.
文献4
股骨头坏死中软骨下骨深部变化的CT与MRI表现用于区分ARCO 2期与3A期
译者 邱兴
目的： 探讨股骨头坏死中软骨下骨以远深部变化对于区分国际骨循环研究协会分期中ARCO 2期与3A期的诊断价值。
方法： 这项回顾性研究纳入了2017年5月至2022年8月期间的124例股骨头坏死髋关节，包括2期49例和3A期75例，所有病例均接受了CT检查，其中85例同时接受了MRI检查。分析CT上的深部变化以及MRI上的深部变化。评估了这些征象诊断3A期的效能，并进行了多变量分析。
结果： 与2期相比，3A期更频繁地出现骨吸收区、囊性变、骨髓水肿及关节积液。对于诊断3A期，骨吸收区和囊性变显示出较低的敏感性但较高的特异性；而骨髓水肿和关节积液则显示出较高的敏感性但较低的特异性。多变量分析显示，预测3A期的征象按效力高低依次为：骨吸收区、囊性变、关节积液；而骨吸收区合并囊性变的组合具有最佳的预测价值。
结论： 在深部变化中，骨吸收区和囊性变对诊断ARCO 3A期具有高特异性，而骨髓水肿和关节积液则具有高敏感性。骨吸收区合并囊性变的组合对于预测ARCO 3A期具有最佳的诊断价值。
关键点： • 准确区分ARCO 2期与3A期至关重要，但仅依靠软骨下骨折有时难以鉴别，尤其是在股骨头轮廓尚存的早期塌陷后阶段。• 预测3A期的征象效力顺序为：骨吸收区、囊性变、关节积液；骨吸收区合并囊性变的组合预测价值最佳。• 分析软骨下骨以远的深部变化可能有助于更轻松地区分ARCO 2期与3A期。
关键词： 股骨头坏死；磁共振成像；骨坏死；体层摄影术，X线计算机
图1 2019版修订ARCO 3期标准中介绍的软骨下骨折、坏死区内骨折及股骨头变平的CT表现：冠状面重组CT图像显示：(a) 与新月征相关的软骨下骨折（粗箭头，新月征用细箭头标示）；(b) 伴有骨吸收区的软骨下骨折（粗箭头，骨吸收区用细箭头标示）；(c) 连接骨吸收区的坏死区内骨折（粗箭头，骨吸收区用细箭头标示）；(d) 股骨头变平（粗箭头），伴坏死区与硬化反应界面之间的塌陷（细箭头标示）。
图2 软骨下骨深部变化的CT表现，包括骨吸收区与囊性变：骨吸收区与囊性变的定位划分方法如下：(a) 在冠状面重组图像上，通过两条线划分为C1–C3区；(b) 在轴位图像上，通过两条线将股骨头划分为四个象限。这些表现还可根据其与硬化反应界面的位置关系，分为界面内侧或外侧。(c, d) 骨吸收区表现为与硬化反应界面相连的透亮区（d图中细箭头标示界面），且无周围硬化边（c和d图中粗箭头标示）。此病例报告为骨吸收区位于C1及A1–2区，且在硬化反应界面内侧。注意伴随骨吸收区的软骨下骨折（c图中箭头标示），提示为ARCO 3A期。(e, f) 囊性变表现为囊性病灶形成，与硬化反应界面相连（f图中细箭头标示界面），且有周围硬化边（e和f图中粗箭头标示）。此病例报告为囊性变位于C2及A2区，且在硬化反应界面的外侧。注意伴随新月征的软骨下骨折（e图中箭头标示），提示为ARCO 3A期。
图3 软骨下骨深部变化的MRI表现，包括骨髓水肿与关节积液: 冠状位T2加权脂肪抑制图像显示股骨头坏死区（图a-d中的细箭头标示）。(a) 坏死区周围可见T2高信号的肉芽组织，而非骨髓水肿（分级为0级，即无骨髓水肿）。注意关节积液量极少，宽度<5 mm（箭头标示），归类为关节积液“阴性”。(b) 坏死区伴有1级骨髓水肿，局限于股骨头内（粗箭头标示）。注意明确的关节积液伴关节囊隐窝扩张（箭头标示），归类为关节积液“阳性”。(c) 坏死区伴有2级骨髓水肿，延伸至股骨颈（粗箭头标示）。注意明确的关节积液伴关节囊隐窝扩张（箭头标示），归类为关节积液“阳性”。(d) 坏死区伴有3级骨髓水肿，延伸至转子间区域（粗箭头标示）。注意明显的关节积液，宽度≥5 mm（箭头标示），归类为关节积液“阳性”。
图4 维持股骨头球形轮廓的ARCO 3A期病例及其相关的CT与MRI深部变化表现
a–c 一位42岁女性，患有伴新月征的3A期病变：图a、b冠状位重组CT图像显示位于硬化反应界面内侧的骨吸收区，以及伴有新月征的软骨下骨折，提示为ARCO 3A期。图c冠状位T2加权脂肪抑制图像显示高信号的新月征、延伸至股骨颈的骨髓水肿以及扩张的关节囊隐窝。d–f 一位64岁男性，患有伴软骨下及皮质骨折的3A期病变：图d、e冠状位重组CT图像显示位于硬化反应界面外侧的囊性变，以及伴有骨吸收区的软骨下及皮质骨折，提示为ARCO 3A期。图f冠状位T2加权脂肪抑制图像显示延伸至股骨颈的骨髓水肿以及扩张的关节囊隐窝。
CT and MRI findings beyond the subchondral bone in osteonecrosis of the femoral head to distinguish between ARCO stages 2 and 3A
Objectives: To determine the diagnostic values of deep changes beyond the subchondral bone in osteonecrosis of the femoral head (ONFH) to distinguish between Association Research Circulation Osseous (ARCO) stages 2 and 3A.
Methods: This retrospective study included 124 hips with ONFH of stages 2 (n = 49; 23 females; mean age, 50.7 years) and 3A (n = 75; 20 females; mean age, 53.2 years) from May 2017 to August 2022, who underwent CT (n = 124) and MRI (n = 85). Deep changes beyond subchondral bone were analyzed on CT (bone resorption area and cystic change) and on MRI (bone marrow edema [BME] and joint effusion). Diagnostic performance and multivariate analysis were evaluated for detecting stage 3A.
Results: Stage 3A showed more frequent bone resorption area (72.0% vs. 4.1%), cystic change (52.0% vs. 0.0%), BME (93.5% vs. 43.6%), and joint effusion (76.0% vs. 24.5%) than stage 2 (p < 0.001, all). Bone resorption area and cystic change showed low sensitivities (52.0~72.0%) but high specificities (96.0~100.0%), while BME and joint effusion showed high sensitivities (76.0~93.0%) but low specificities (56.0~76.0%) for stage 3A. Predictors were in the order of bone resorption area, cystic change, and joint effusion (odds ratio: 32.952, 26.281, 9.603, respectively), and combined bone resorption area and cystic change had the best predictive value (AUC, 0.900) for stage 3A.
Conclusions: Among deep changes, bone resorption area and cystic changes were highly specific and BME and joint effusion were highly sensitive for stage 3A. Combined bone resorption area and cystic change had the best predictive value for predicting ARCO stage 3A.
Key points: • The exact classification between ARCO stage 2 and 3A is essential but it is sometimes difficult to distinguish between ARCO stage 2 and 3A only by subchondral fracture, especially early post-collapse stage with preservation of femoral head contour. • The predictors of stage 3A were in the order of bone resorption area, cystic change, and joint effusion and combined bone resorption area and cystic change had the best predictive value for predicting stage 3A. • Analysis of deep changes beyond the subchondral bone may make it easier to distinguish between ARCO stage 2 and 3A.
Keywords: Femoral head necrosis; Magnetic resonance imaging; Osteonecrosis; Tomography, X-ray computed.
文献出处：Kim, J., Lee, S. K., Kim, J. Y., & Kim, J. H. (2023). CT and MRI findings beyond the subchondral bone in osteonecrosis of the femoral head to distinguish between ARCO stages 2 and 3A. European Radiology, 33(7), 4789-4800.
来源：304关节学术
作者：304关节团队
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