髖膝關節文獻精譯薈萃（第364期）

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本期目錄：

1、抗阻運動訓練可以改善膝關節置換術患者術后康復效果

2、應用維生素C預防全膝關節置換術后復雜性局部疼痛綜合征復發

3、機器人全膝關節置換術的真實世界療效

4、幼年髖脫位治療的患者成年后的生活質量

5、兒童創傷性三角軟骨損傷的回顧性分析

6、日間骨盆截骨術治療發育性髖關節發育不良的長期經驗

7、髖臼周圍截骨術治療嚴重髖關節發育不良

8、髖臼周圍截骨術后髖關節中心內移的評估：X光平片驗證

第一部分：關節置換及保膝相關文獻

文獻1

抗阻運動訓練可以改善膝關節置換術患者術后康復效果

譯者 張軼超

膝關節骨關節炎與肌肉力量、肌肉量和身體功能的缺陷有關。盡管采用了包括體能/功能訓練這些標準化的康復計劃，肌肉相關的缺陷在全膝關節置換術（TKA）后依然會急劇加重，并在手術后持續很長時間。抗阻運動訓練（RET）已被證明是一種非常有效的辦法，可以改善健康人群和病人與肌肉相關的手術效果。然而，在TKA后的傳統康復計劃中，RET的使用是非常有限的。在這篇敘述性綜述中，我們提供了一種最新的觀點，即在TKA后恢復期（長達1年）將RET加入標準康復（SR）中，與單獨進行SR相比，是否會導致肌肉相關效果的更大改善。總的來說，研究結果清楚地表明，與SR相比，基于RET的康復可以在更大程度上改善肌肉力量和肌肉量。此外，與SR相比，依賴股四頭肌力量和平衡的身體功能測量（例如，爬樓梯，站椅子等）也似乎從基于RET的計劃中獲益更多，特別是在身體功能水平較低的患者中。但重要的是，為了使RET達到最佳效果，它應該以最大肌力的70%-80%進行訓練，每次練習3 - 4組，每周至少3次，持續8周。基于這一敘述性回顧，我們建議將這種高強度的漸進式RET納入TKA術后康復的標準方案中。

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.

文獻出處：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.

文獻2

應用維生素C預防全膝關節置換術后復雜性局部疼痛綜合征復發

譯者 張薔

背景：有多項研究調查了復雜性局部疼痛綜合征（CRPS）的風險以及應用維生素C預防的相關情況。然而，目前缺少相關文獻探究全膝關節置換（TKA）術后應用維生素C預防CRPS發作或復發的有效性。

方法：本回顧性單中心觀察性隊列研究選擇2017年1月至2021年12月的病例資料，并應用傾向性評分匹配方法。最初，我們入組了1088例TKA病例，其中49例既往曾有CRPS發作的病史。排除50例不符合入組標準的病例，最終包含467例（45%）接受了維生素C預防治療（1g Qd * 40天）的病例和571例（55%）未接受維生素C預防治療的病例。在性別、年齡、BMI、糖尿病及高血壓情況、吸煙飲酒情況、止血帶應用情況、焦慮與抑郁情況經1:1匹配后，維生素C預防組和未預防組各包含480例病例。共960例中有28例曾有CRPS發作史。

結果：在經過傾向性評分匹配后的病例組中，6.9%（33例）的維生素C預防組病例術后出現CRPS發作，而未預防組的病例為11.0%（53例）（概率比OR=0.59[95%置信區間(CI), 0.37 - 0.9], p = 0.024）。而曾有CRPS發作史會顯著增加術后復發的概率（發作史32% VS. 無發作史8%；OR=5.4 [95% CI, 2.57 - 11.4], p < 0.001）。在28例曾有CRPS發作史的病例中，應用維生素C預防治療會將術后發作概率降至19%（21例中4例），而未應用維生素C預防治療的病例發作概率為71%（7例中5例）（OR=0.09 [95% CI, 0.01 - 0.64], p = 0.02）。多變量回歸分析后，維生素C預防也與TKA術后CRPS低復發率獨立相關（OR=0.53 [95% CI, 0.3 - 0.86], p = 0.011）。

結論：應用維生素C預防可以減少TKA術后CRPS發作。此外，本研究還發現維生素C預防可以降低術前曾有CRPS發作史病例TKA術后CRPS復發的概率。

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.

文獻3

機器人全膝關節置換術的真實世界療效：一家非學術中心的五年經驗

譯者 沈松坡

背景：機器人輔助手術系統已改變了全膝關節置換術（TKA），其宣稱可提高精度并改善術中一致性，然而來自非學術中心的真實世界數據仍然有限。

目的：本研究評估了一種半自主、基于CT的機械臂輔助TKA在德國一家三級非教學醫院中五年的臨床應用情況，重點關注術前規劃精度、間隙平衡及術中結果。

方法： 我們回顧性分析了2020年至2025年間接受MAKO輔助TKA的全部患者（n=457），手術均由三名骨科醫生采用標準化股內側肌下入路完成。評估內容包括術前畸形、術中對線、假體尺寸及間隙平衡。當有必要時術中調整手術計劃。通過斜率分析比較術前計劃與術后實施值，以評估執行一致性。

結果：患者中位年齡為67.0歲（四分位距：60.0–75.0）；84.1%為內翻（7.0°，IQR: 4.0°–10.0°），13.2%為外翻（3.0°，IQR: 1.5°–5.8°），2.7%為中立對線。80.4%存在屈曲攣縮（6.0°，IQR: 3.0°–10.0°），12.7%出現反屈（2.0°，IQR: 1.5°–5.0°）。即使在術中計劃調整情況下，規劃與執行的一致性仍然較高。各對線參數的斜率值分別為：脛骨旋轉1.0、股骨矢狀角0.8、脛骨矢狀角0.9、冠狀后髁角0.9、股骨假體尺寸1.0、脛骨假體尺寸1.0。超過95%的病例中計劃值與最終值的偏差≤3.0°。骨切除一致性表現為中等相關性，斜率介于0.8（股骨內側后切，單位mm）到0.5（脛骨外側切，單位mm）之間。術中各階段間隙平衡均改善，內外側伸屈間隙的變異性下降（均p<0.05）。功能重建顯示伸展、屈曲及畸形顯著改善（均p<0.001）。

結論： 半自主、基于CT的機械臂輔助TKA在非學術中心得以成功實施，顯示出可接受的術中及功能重建結果，支持其在非學術機構中應用的可行性。

關鍵詞：機器人輔助TKA；真實世界數據；術中對線；間隙平衡；非學術醫院

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：保髖相關文獻

文獻1

幼年髖脫位治療的患者成年后的生活質量

譯者 張振東

髖關節發育不良（DDH）如不及時干預可導致髖關節功能過早喪失；然而很少有研究關注DDH兒童時期治療后的長期結果。

本研究對兒童時期接受過髖關節脫位治療的患者進行了一項健康相關生活質量調查。研究者向在其機構接受過兒童期髖關節脫位治療的 287 名DDH 患者發放了調查問卷。調查患者的人口統計學特征、特定疾病病史以及與健康相關的生活質量。將患者的身體功能評分（PCS）、心理功能評分（MCS）和社會認知評分（RCS）與標準值進行了比較。最終納入68 名患者進行了評估。

結果顯示，患者的 PCS、MCS 和 RCS 總平均值與標準值相當。PCS 一直保持到 50 歲，但有 10 名 50 歲以上的患者 PCS 顯著下降。此外，接受切開復位術的患者的 PCS 明顯低于接受保守復位術的患者。在各年齡組和治療組中，患者的 MCS 和 RCS 與標準值無差異。 此外，PCS、MCS 和 RCS 在雙側、診斷年齡或是否需要額外手術方面也沒有差異。DDH患者的身體生活質量在50歲之前一直保持不變，但之后迅速下降，尤其是那些在童年時期就需要進行切開復位的患者。

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.

文獻出處：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.

文獻2

兒童創傷性三角軟骨損傷的回顧性分析

譯者 任寧濤

背景:總結分析兒童外傷后三角軟骨損傷(TCI)的流行病學特點、治療方法及相應療效，為早期診斷和改進治療提供理論依據。

方法:采用Bucholz分型對TCI損傷進行分型，隨訪時采用Harris髖關節評分及影像學檢查評價最終療效。最后，通過查閱文獻中的病例并結合我院的患者進行綜合分析。

結果:本院共收治三角軟骨損傷15例(18髖)。I型損傷1例，II型損傷9例，IV型損傷2例，V型損傷1例，VI型損傷5例。隨訪完整的12例患者中，8例在三角軟骨內或周圍發現骨橋，5例出現早期三角軟骨融合，3例髖關節發育不良，4例股骨頭半脫位，HHS優8例，良4例。

結論:TCI損傷的早期診斷仍是一個難題。保守治療通常是首選。髖臼骨折累及三角軟骨的整體預后較差。三角軟骨骨橋的形成通常預示著過早閉合的可能性，這可能導致創傷后髖臼發育不良和股骨頭半脫位的嚴重并發癥。

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.

文獻出處：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.

文獻3

日間骨盆截骨術治療發育性髖關節發育不良的長期經驗

譯者 李勇

目的 發育性髖關節發育不良（DDH）的發病率為每1000名活產兒6.73例，每年導致大量的骨科轉診。這種高需求推動了在兒科骨科環境中優化服務效率的動力。這里，我們描述了我們在一項創新的日間骨盆截骨術項目中獲得的長期經驗。我們還描述了在執行日間骨盆截骨術時可能預見的任何潛在并發癥。

方法 這是一項非隨機前瞻性隊列研究，旨在比較2017年1月至2023年11月期間進行的傳統住院骨盆截骨術與日間截骨術。所有手術均在一家城市三級國家轉診中心進行，由四名對DDH具有特別專業興趣的兒科骨科醫生執刀。

結果 總共進行了164例Salter和Pemberton截骨術，其中115例符合日間手術標準。根據HSE的“專科成本報告”和“年度報告與財務報表”，接受住院截骨術患者的總出院花費為6619歐元，而每位日間手術患者的花費為2670歐元。對于這110例日間手術，治療花費總計為293,700歐元；因此，醫院通過執行這110例日間手術總共節省了434,390歐元。這相當于每例日間手術節省了3949歐元。

結論 7年期的回顧表明，針對DDH的日間骨盆截骨術仍然是一項安全且具有成本效益的舉措，它顯著減少了對住院病床資源的需求。

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.

文獻出處：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.

文獻4

髖臼周圍截骨術治療嚴重髖關節發育不良

譯者 陶可

背景：對于伴有股骨頭半脫位或繼發性髖臼(病變)的嚴重髖關節發育不良，最佳治療方案仍存在爭議。本研究旨在分析伯爾尼髖臼周圍截骨術治療青少年及青年重度髖關節發育不良的矯正程度及早期臨床療效。

方法：納入13例患者共16個髖關節，平均年齡17.6歲（范圍13.0～31.8歲），均被診斷為重度髖關節發育不良（根據Severin分型為IV或V組）。其中8個髖關節為半脫位，8個髖關節為繼發性髖臼(病變)。術前，所有患者均存在髖關節疼痛，且X線片顯示髖關節匹配度良好，符合截骨術指征。所有16個髖關節均行伯爾尼髖臼周圍截骨術，其中6個髖關節同時行股骨近端截骨術。術后，對髖關節進行X線檢查，以評估畸形矯正情況、截骨部位愈合情況以及骨關節炎進展情況。術后平均4.2年，采用Harris髖關節評分評估臨床結果和髖關節功能。

結果：術前和隨訪X線片對比顯示，Wiberg外側中心邊緣角平均改善44.6度（由-20.5度改善至24.1度），Lequesne和de Seze前方中心邊緣角平均改善51.0度（由-25.4度改善至25.6度），髖臼頂傾斜度平均改善25.9度（由37.3度改善至11.4度）。髖關節中心平均向內側移位10 mm（范圍0至31 mm）。所有髂骨截骨部位均已愈合。術前平均Harris髖關節評分73.4分提高至末次隨訪時的91.3分。13例患者中有11例（16個髖關節中的14個）對術后效果滿意，14個髖關節的臨床效果良好或優異。主要并發癥包括1例患者出現髖臼固定失敗，需再次手術；另1例患者出現髖臼過度矯正及相關坐骨不愈合。兩例患者在末次隨訪時均獲得良好的臨床效果。未發生重大神經血管損傷或關節內骨折。

結論：髖臼周圍截骨術是治療青少年及青年嚴重髖臼發育不良的有效手術方法。本組病例術后平均4.2年的早期臨床效果良好；兩例主要并發癥并未影響良好的臨床效果。

圖1-A和1-B 病例6，一名16歲男孩，患有嚴重的髖關節發育不良，前后位（圖1-A）和假斜位（圖1-B）X線片均顯示了這一情況。該患者接受了髖臼周圍截骨術聯合股骨近端內翻截骨術治療。

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.

文獻出處：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.

文獻5

髖臼周圍截骨術后髖關節中心內移的評估：X光平片驗證

譯者 邱興

背景： 髖臼周圍截骨術通過增加股骨頭的髖臼覆蓋并使髖關節中心內移，以恢復正常關節生物力學。既往研究雖已報道PAO所能實現的內移程度，但內移的測量從未通過對不同影像學模式或測量技術的比較得到驗證。由于坐骨棘線可能因PAO而發生改變，且在股骨頭下1/3水平顯示更佳，因此，采用從股骨頭下1/3處開始測量的新方法可能更有優勢。

研究問題/目的： (1) PAO實現的髖關節中心真實內移量及其變異性是多少？(2) 哪些影像學參數（如外側中心邊緣角和髖臼傾斜角）與實現的內移程度相關？(3) 在X光平片上，于股骨頭中心（傳統方法）還是股骨頭下1/3處（新方法）測量內移，哪個與真實內移相關性更好？(4) 術中透視圖像與術后X光片在測量髖關節內移方面是否存在差異？

方法： 我們利用一個既往建立的、在PAO術后接受了低劑量CT檢查的患者隊列進行了一項回顧性研究。本研究納入標準包括：因有癥狀的髖臼發育不良而接受PAO、有術前CT掃描、以及術后隨訪時間在9個月至5年之間。2009年2月至2018年7月期間接受PAO的333名患者符合這些標準。此外，僅納入手術時年齡在16至50歲之間的患者。排除標準包括：既往同側手術史、股骨髖臼撞擊征、妊娠、神經肌肉疾病、Perthes樣畸形、術前CT不充分以及無法參與研究。最終研究組納入39名患者的39個髖關節；其中87%為女性患者，13%為男性患者。手術時的中位年齡為27歲（范圍16至49歲）。獲取了術前和術后入組時的低劑量CT圖像；我們還獲取了術前和術后X光片以及術中透視圖像。在X光平片上評估LCEA和AI。由一名獨立的、不知分組情況的評估者通過所有影像學模式評估髖關節內移。在X光平片上，采用了測量髖關節內移的傳統方法和新方法。根據可見的骨盆旋轉程度，劃分出優質和合格X光片亞組進行亞組分析。為回答第一個問題，通過三維CT髖關節重建模型的測量來評估所有髖關節的內移。為回答第二個問題，計算了Pearson相關系數、單因素方差分析和Student t檢驗，以評估影像學參數（如LCEA和AI）與實現的內移量之間的相關性。為回答第三個問題，進行了統計分析，包括線性回歸分析，以使用Pearson相關系數、95%置信區間和估計標準誤，來確定兩種測量內移的X線方法與CT所示真實內移之間的相關性。為回答第四個問題，計算了Pearson相關系數以確定使用術中透視測量內移是否與X光片上的測量結果不同。

結果： 在本研究中，通過參考標準CT測量評估，PAO實現的髖關節中心真實內移量為4 ± 3毫米；46%的髖關節內移了0至5毫米，36%內移了5至10毫米，5%內移超過10毫米。13%的髖關節發生了外側移位（內移< 0毫米）。不同LCEA亞組之間的內移量存在微小差異（LCEA ≤ 15°者為6 ± 3毫米，LCEA在15°至20°之間者為4 ± 4毫米，LCEA在20°至25°之間者為2 ± 3毫米）。AI ≥ 15°的髖關節實現的內移量大于AI < 15°的髖關節。與作為參考標準的CT掃描測量結果相比，在X光平片上于股骨頭中心測量內移（傳統方法）的相關性弱于在股骨頭下1/3處測量（新方法）。傳統方法在所有X光片或僅在優質X光片中均未顯示出相關性，而新方法在所有X光片和僅在優質X光片中評估時，分別呈現出強相關和極強相關。術中透視圖像上的髖關節內移測量結果與術后X光片上的測量結果未發現差異。

結論： 通過術前和術后CT測量，本研究顯示PAO實現的平均真實內移量為4毫米，但變異性很大。在股骨頭中心測量內移的傳統方法可能不準確；在股骨頭下1/3處測量內移的新方法是評估髖關節中心位置的更優方法。我們建議轉而使用這種新方法以獲得最佳的臨床和研究數據，但要認識到兩種基于X光平片的方法似乎都低估了PAO實現的真實內移量。最后，本研究提供證據表明，髖關節中心的位置和內移可以在術中通過透視進行準確評估。

圖1、 A-B 采用骨盆前后位X光片測量髖關節位置。(A) 在這張術前X光片中，線1代表從股骨頭中心起始的傳統測量方法，線2代表從股骨頭直徑下三分之一處起始并延伸至坐骨棘線的替代測量方法。(B) 在這張術后X光片中，坐骨棘線在股骨頭中部水平不可見，但在采用從股骨頭直徑下三分之一處起始的測量方法時清晰可見且易于測量。

圖2 、基于CT掃描的內移測量方法圖示：將股骨頭中心與一條代表中線的垂直參考線相連進行測量。

圖3 、替代性內移測量的起始點定于股骨頭內側緣，具體位置在股骨頭垂直徑的下三分之一分界點。

圖4、A-B 如(A)術前與(B)術后X光片所示，該髖關節經PAO術后實現內移。采用X光平片的替代測量法（自股骨頭直徑下三分之一處起始進行測量）測得該髖關節內移量為9毫米，而通過參考標準CT測量法測得的內移量為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.

文獻出處：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.

來源：304關節學術

作者：304關節團隊

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