髖膝關節文獻精譯薈萃（第365期）

本期目錄：

1、膝骨關節炎患者全膝關節置換術后生活質量的決定因素

2、膝關節置換手術病人的心理測量學特性和可行性評估

3、機器人輔助關節置換手術：歐洲關于外科醫生采用與應用趨勢的觀點

4、髖關節疼痛患者通常存在兩種或以上的撞擊或不穩定畸形

5、髖臼周圍截骨術是否改變脊柱骨盆矢狀面序列

6、保髖手術后患者報告結局的演變軌跡

7、歐洲國家發育性髖關節發育不良篩查與治療指南概述及質量評估

8、髖臼周圍截骨術治療伴有嚴重股骨頭非球形畸形的髖關節發育不良臨床研究

9、股骨頭壞死中軟骨下骨折始于骨吸收區：一項顯微計算機斷層掃描研究

第一部分：關節置換及保膝相關文獻

文獻1

膝骨關節炎患者全膝關節置換術后生活質量的決定因素：一項系統綜述

譯者 張軼超

目的：系統回顧、總結和評價影響膝骨關節炎患者全膝關節置換術后生活質量（QoL）的因素。

方法：通過檢索PubMed、Scopus、Web of Science、CINAHL、EMBASE、ProQuest等6個數據庫，采用合適的檢索詞檢索TKA術后影響生活質量的因素的相關文獻。兩名審稿人獨立對研究進行篩選和納入。如有異議就咨詢第三位審稿人。納入研究的方法學質量采用改良Downs和Black指數檢查表進行評估。本綜述已在PROSPERO注冊（CRD42022352887），并根據PRISMA核對表要求進行報告。

結果：我們共搜索到8517項研究，其中29項被納入。高齡;女性;身體質量指數（BMI）的增加；存在合并癥，如糖尿病；對側膝關節疼痛；術前狀態差；心理和疼痛相關因素，如對疼痛過度敏感；中樞性敏感;運動恐懼癥;焦慮;抑郁癥;慢性疼痛;悲痛;樂觀程度低；和降低的患者滿意度被用來作為確定TKA術后的生活質量評分內容。在這些研究中，高BMI和抑郁是最常見的因素。總體而言，納入研究的方法學質量從高到低不等。

結論：經TKA治療后，患者總體生活質量評分有所提高。然而，有一些生理、行為和心理因素會影響生活質量。確定這些因素可以幫助臨床醫生和衛生專業人員在患者的治療和康復過程中改善TKA患者的預后。

Factors determinant of quality of life after total knee arthroplasty in knee osteoarthritis: A systematic review

Objective: To systematically review, summarize and appraise evidence on the factors determining quality of life (QoL) after total knee arthroplasty (TKA) in individuals with knee osteoarthritis.

Methods: We searched six databases (PubMed, Scopus, Web of Science, CINAHL, EMBASE, and ProQuest) using appropriate search terms to identify the relevant literature published on the factors determining QoL following TKA. Two reviewers independently performed the study screening and study selection. A third reviewer was consulted in case of any disagreement. The methodological quality of the included studies was assessed using the Modified Downs and Black Index checklist. This review was registered in PROSPERO (CRD42022352887) and reported according to the PRISMA checklist.

Results: We identified a total of 8517 studies, 29 of which were included. Advanced age; female sex; increased body mass index (BMI); the presence of comorbidities such as diabetes; contralateral knee pain; poor preoperative status; psychological and pain-related factors such as the presence of pain catastrophizing; central sensitization; kinesiophobia; anxiety; depression; chronic pain; psychological distress; low level of optimism; and reduced patient satisfaction were used to determine post-TKA QoL scores. High BMI and depression were the most common factors evaluated in these studies. Overall, the methodological quality of the included studies varied from high to low.

Conclusion: After TKA, the overall QoL score improved. However, there are a few physical, behavioral, and psychological factors that influence QoL. Identifying these factors could aid clinicians and health professionals in treating and rehabilitating patients by helping them improve patient prognosis after TKA.

文獻出處：Shetty S, Maiya GA, Rao Kg M, Vijayan S, George BM. Factors determinant of quality of life after total knee arthroplasty in knee osteoarthritis: A systematic review. J Bodyw Mov Ther. 2024 Oct;40:1588-1604. doi: 10.1016/j.jbmt.2024.08.013. Epub 2024 Aug 23. PMID: 39593495.

文獻2

應用患者自評結果測量系統-計算機自適應測試工具VS.疾病特異性評價工具對膝關節置換手術病人的心理測量學特性和可行性評估

譯者 張薔

背景：相比于常用的疾病特異性評價工具，通用性極佳的患者自評結果測量系統-計算機自適應測量（PROMIS CATs）工具可以幫助我們更有效的評價膝關節置換手術患者的健康狀態。本研究旨在比較不同的PROMIS-CATs工具（包括疼痛[PROMIS-PI-CAT, v1.1]、功能[PROMIS-PF-CAT, v2.0]、行動能力[PROMIS Mob-CAT, v2.0]、參與社會角色與活動能力[PROMIS-AS-CAT, v2.0]和對社會角色與活動能力的滿意度[PROMIS-SS-CAT, v2.0]）與傳統的膝關節疼痛和骨關節炎評分（KOOS），包括KOOS功能短表（KOOS-PS）和KOOS關節置換（KOOS-JR）以及WOMAC評分在評價膝關節置換手術患者療效方面的心理測量學特性和可行性。

方法：在AZ Alma（Eeklo，比利時）醫院接受單側或雙側初次或翻修全膝關節置換手術的患者（n=193；平均年齡，64.4±10.1歲；56%為女性；平均BMI，29.6±5.2 kg/m2）分別在術前6周、術后6周、術后3個月、術后6個月和術后12個月隨訪時完成了評測。本研究分別評估了評測的準確性（百分標準差[SE%]）、反應性（假定相關性和標準反應均數[SRM]）、地板和天花板效應（最差和最佳所占百分比）和可行性（完成時間以及完成項目數）。

結果：與傳統的KOOS/WOMAC評價系統相比，PROMIS-PI-CAT和PROMIS-PF-CAT顯示出更為優秀的準確性（SE%, 4.6 vs 7.1/9.3和3.6 vs 4.4/4.4），但在術后12個月隨訪時準確性變差（SE %, 6.8 vs 4.8/5.5和3.6 vs 3.0/3.0）。所有的PROMIS CATs評測工具都有很好的反應性（75% - 100% 的設定未拒絕; 術后12個月隨訪時SRMs: PROMIS-PI-CAT = 21.35 vs KOOS 疼痛 = 1.78 和 WOMAC 疼痛 = 21.59; PROMIS-PFCAT = 1.14 vs KOOS-ADL/WOMAC-PF = 1.43/21.44; PROMIS-AS-CAT = 0.93 和 PROMIS-SS-CAT = 0.93）。PROMIS-PF-CAT在術后12個月隨訪時沒有顯現出天花板效應，與KOOS-ADL/WOMAC-PF正相反（17.5%）。與KOOS和WOMAC評分相比，PROMIS CATs評測工具可行性更佳。

結論：PROMIS-CATs評測工具能有效的評價膝關節置換患者的療效，顯示出優秀的心理測量學特性和可行性，支持其在以療效主導的診療過程中發揮更大的作用。

Psychometric Properties and Feasibility of PROMIS Computerized Adaptive Tests Compared with Disease-Specific Measures in Knee Arthroplasty

Background: The efficient assessment of health outcomes in knee arthroplasty may benefit from universally applicable Patient-Reported Outcomes Measurement Information System computerized adaptive tests (PROMIS CATs), rather than disease-specific measures. This study aimed to evaluate and compare some psychometric properties and the feasibility of various PROMIS CATs (Pain Interference [PROMIS-PI-CAT, v1.1], Physical Function [PROMIS-PF-CAT, v2.0], Mobility [PROMIS Mob-CAT, v2.0], Ability to Participate in Social Roles and Activities [PROMIS-AS-CAT, v2.0], and Satisfaction with Social Roles and Activities [PROMIS-SS-CAT, v2.0]), with the Knee Injury and Osteoarthritis Outcome Score (KOOS) scales, including the KOOS Physical Function Short-form [KOOS-PS] and KOOS for Joint Replacement [KOOS-JR], and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scales.

Methods: Patients (n = 193; mean age [and standard deviation], 64.4 ± 10.1 years; 56% female; mean body mass index, 29.6 ± 5.2 kg/m2 ) undergoing unilateral or bilateral primary or revision knee arthroplasty at AZ Alma (Eeklo, Belgium) completed the measures 6 weeks before and 6 weeks and 3, 6, and 12 months after surgery. The study evaluated precision (standard error as a percentage of scale range [SE%]), responsiveness (hypothesized correlations and standardized response mean [SRM]), floor and ceiling effects (percentage with the worst and the best scores), and feasibility (completion time and number of items).

Results: The PROMIS-PI-CAT and PROMIS-PF-CAT showed better precision at baseline compared with corresponding KOOS/WOMAC scales (SE%, 4.6 versus 7.1/9.3 and 3.6 versus 4.4/4.4), but less precision at 12 months of follow-up (SE %, 6.8 versus 4.8/5.5 and 3.6 versus 3.0/3.0). All PROMIS CATs had good responsiveness (75% to 100% of hypotheses not rejected; SRMs at 12 months: PROMIS-PI-CAT = 21.35 versus KOOS Pain = 1.78 and WOMAC Pain = 21.59; PROMIS-PFCAT = 1.14 versus KOOS-ADL/WOMAC-PF = 1.43/21.44; PROMIS-AS-CAT = 0.93 and PROMIS-SS-CAT = 0.93). The PROMIS-PF-CAT did not show ceiling effects at 12 months, unlike the KOOS-ADL/WOMAC-PF (17.5%). PROMIS CATs were more feasible at baseline and follow-ups compared with KOOS and WOMAC scales.

Conclusions: PROMIS-CATs effectively assess health outcomes in knee arthroplasty patients, showing strong psychometric properties and favorable feasibility, supporting their role in value-based health care.

文獻3

機器人輔助關節置換手術：歐洲關于外科醫生采用與應用趨勢的觀點

譯者 沈松坡

背景： 機器人輔助全關節置換術（TJA）提升了手術精度和假體定位的準確性，然而外科醫生對其認知及采用模式仍未被充分理解。本研究聚焦三個關鍵問題：（1）不同地區在機器人技術使用及興趣方面的當前趨勢如何？（2）不同手術類型的機器人使用情況有何差異？外科醫生對各類機器人系統的熟悉程度如何？（3）哪些因素最能影響外科醫生在關節置換手術中選擇或避免使用機器人輔助？

方法： 本研究于2023年10月在歐洲范圍內開展了一項橫斷面匿名調查。符合條件的參與者需具有至少兩年的獨立執業經驗，并且每年完成的關節置換手術量不少于100例。有主要植入物制造商財務關聯的外科醫生被排除在外。網絡問卷收集了人口統計學信息、手術量、2018年至2023年的機器人系統使用情況，以及外科醫生對采用因素和主要機器人平臺熟悉程度的評分。所得數據采用描述性方法進行分析。

結果： 從2019年至2023年，歐洲使用機器人輔助TJA的外科醫生比例從1%上升至14%，而對該技術感興趣的外科醫生比例則從32%上升至50%。機器人技術應用最多的手術類型為部分膝關節置換術（PKA），其次為全膝關節置換術（TKA），再次為全髖關節置換術（THA）。外科醫生認為“手術效率”和“術前計劃執行力”是使用機器人輔助的兩大關鍵驅動因素。

結論： 在過去五年中，歐洲地區對機器人輔助技術的興趣與使用率均顯著增長。外科醫生普遍認為提高手術效率和計劃執行力是采用該技術的主要動因。未來仍需進一步研究，以評估未來十年內該技術的使用模式。

關鍵詞： 髖關節；膝關節；機器人；問卷調查；技術；全關節置換術。

Robotic-Assisted Joint Arthroplasty: European Perspectives on Surgeon Adoption and Utilization Trends

Background: Robotic-assisted total joint arthroplasty (TJA) has improved surgical precision and implant positioning, yet surgeon perceptions and adoption patterns remain incompletely understood. This study addresses three key questions: (1) What are the current trends in robotic technology use and interest across regions? (2) How does utilization vary by procedure type, and how familiar are surgeons with different robotic systems? and (3) Which factors most influence surgeons' decisions to adopt or avoid robotic assistance in arthroplasty?

Methods: A cross-sectional, anonymous survey was conducted in October 2023 among orthopaedic surgeons in Europe. Eligible participants had at least two years of independent practice and an arthroplasty volume of at least 100 cases annually. Surgeons who had financial ties to major implant manufacturers were excluded. The web-based survey collected demographic data, procedure volumes, robotic system usage from 2018 to 2023, and surgeon ratings of adoption factors and familiarity with key robotic platforms. Data were analyzed descriptively.

Results: From 2019 to 2023, the percentage of European surgeons utilizing robotic-assisted TJA rose from 1 to 14%, while the number of surgeons interested in the technology increased from 32 to 50%. The greatest utilization of robotic technology was seen in partial knee arthroplasty (PKA), followed by total knee arthroplasty (TKA), then total hip arthroplasty (THA). Surgeons rated efficiency and plan execution as the two most important factors for utilizing robotics assistance.

Conclusion: Interest and utilization of robotic assistance have grown tremendously over the past five years in Europe. Surgeons view efficiency and plan execution as motivators for using this technology. Further studies are needed to evaluate usage patterns over the next decade.

Keywords: Hip; Knee; Robotics; Survey; Technology; Total joint arthroplasty

第二部分：保髖相關文獻

文獻1

髖關節疼痛患者通常存在兩種或以上的撞擊或不穩定畸形

譯者 張振東

由于股骨和髖臼前傾角、頸干角、α角和外側中心邊緣角等解剖因素造成的撞擊或不穩定可導致髖關節損傷。這些解剖因素之間的關聯以及它們在疼痛的髖關節中發生的頻率尚不清楚，但如果不加以解決，可能會導致保髖手術失敗。

研究擬確定性別對撞擊相關或不穩定相關因素的影響；這些因素之間的關聯；以及撞擊和/或不穩定因素在同一髖關節中發生的頻率。

研究對因任何原因接受髖關節磁共振的 170 髖（145 患者）進行了回顧性分析。 排除了58例嚴重發育不良、Perthes病后遺癥、既往手術史或影像學信息不完整的髖關節，剩下112例髖關節（96患者）納入本研究。在核磁共振上測量了股骨前傾角和α角。骨盆X光片上測量了髖臼前傾角、外側CEA和頸干角。

結果顯示，研究觀察到性別與α角之間存在相關性。其他五個參數之間的相關性較弱或沒有相關性。在 66% 的髖關節中發現了五個參數中的兩個或兩個以上符合撞擊征的指標，在 51% 的髖關節中發現了兩個或兩個以上符合髖關節不穩定的指標。

結論：髖關節疼痛患者通常有多種可能導致軟骨髖臼損傷的解剖因素。要解決由于撞擊和/或不穩定造成的病理性髖關節負荷增加，就必須了解所有的解剖影響因素。由于本研究沒有發現解剖因素之間存在關聯，因此建議對每個疼痛的髖關節進行個體化評估。

Two or more impingement and/or instability deformities are often present in patients with hip pain

Background:Damage to the hip can occur due to impingement or instability caused by anatomic factors such as femoral and acetabular version, neck-shaft angle, alpha angle, and lateral center-edge angle (CEA). The associations between these anatomic factors and how often they occur in a painful hip are unclear but if unaddressed might explain failed hip preservation surgery.

Questions/purposes:We determined (1) the influence of sex on the expression of impingement-related or instability-related factors, (2) the associations among these factors, and (3) how often both impingement and/or instability factors occur in the same hip.

Methods:We retrospectively reviewed a cohort of 170 hips (145 patients) undergoing MR arthrography of the hip for any reason. We excluded 58 hips with high-grade dysplasia, Perthes' sequelae, previous surgery, or incomplete radiographic information, leaving 112 hips (96 patients). We measured femoral version and alpha angles on MR arthrograms. Acetabular anteversion, lateral CEA, and neck-shaft angle were measured on pelvic radiographs.

Results:We observed a correlation between sex and alpha angle. Weak or no correlations were observed between the other five parameters. In 66% of hips, two or more (of five) impingement parameters, and in 51% of hips, two or more (of five) instability parameters were found.

Conclusions:Patients with hip pain frequently have several anatomic factors potentially contributing to chondrolabral damage. To address pathologic hip loading due to impingement and/or instability, all of the anatomic influences should be known. As we found no associations between anatomic factors, we recommend an individualized assessment of each painful hip.

文獻出處：Tibor LM, Liebert G, Sutter R, Impellizzeri FM, Leunig M. Two or more impingement and/or instability deformities are often present in patients with hip pain. Clin Orthop Relat Res. 2013 Dec;471(12):3762-73.

文獻2

髖臼周圍截骨術是否改變脊柱骨盆矢狀面序列

譯者 任寧濤

背景:目前關于髖臼周圍截骨術對脊柱骨盆矢狀面序列影響的數據很少。先前的研究試圖通過在AP 位X線片上進行測量和使用數學模型來確定術后骨盆傾斜的變化來描述兩者之間的關系。這些信息對外科醫生在術中評估髖臼/骨盆位置和了解術后脊柱-骨盆矢狀面序列變化具有臨床意義;因此，應更詳細地描述PAO引起的影像學變化。

問題/目的:在本研究中，我們的問題是:(1) 根據EOS X線片測量，PAO術后是否會導致脊柱-骨盆矢狀面序列發生對應變化?(2)單側PAO和雙側PAOs的情況是否不同?(3)這在脊柱柔韌和脊柱僵硬的情況下是否有區別?(4)是否因術前骨盆傾斜而有差異?

方法:前瞻性收集2019年1月1日至2022年1月11日由同一位外科醫生完成PAO的55例患者的術前和術后不短于1年的 (15±8個月，最短11個月，最長65個月)EOS髖-踝站立位和坐位x線片，測量骨盆入射角、骨盆傾斜角、骶骨傾斜角、腰椎前凸角、外側CE角、L1-骨盆角和恥骨聯合對骶髂指數（PS-SI）。采用配對樣本t檢驗(正態分布數據)或Wilcoxon符號秩檢驗(非正態分布數據)評估術前與術后是否有任何變化。然后根據患者是否患有單側或雙側發育不良以及單側或雙側手術進行分組，這些亞組的分析方法與整個隊列相同。根據腰椎活動度情況(定義為從坐到站的腰椎前凸角變化小于或大于1 SD)再分為兩個亞組，亞組的分析方法與整個隊列相同。最后根據術前站立位骨盆傾斜度分為站立位骨盆傾斜度< 10°和站立位骨盆傾斜度> 20°兩個亞組，并與整個隊列進行相同的分析。

結果:所有患者的站立位外側CE角中位數(IQR)增加了17°，從中位數21°(10°)增加到中位數38°(8°[95%可信區間(CI) 16°~ 20°;p < 0.05];P < 0.001)。坐位外側CE角增加了17°，從中位數18°(8°)增加到中位數35°(8°[95% CI 14°~ 19°];P < 0.001)。站立位骨盆入射角從50°±11°增加到52°±12°(平均差值2°[95% CI 1°~ 3°];P = 0.004)，但其他測量參數無變化。單側發育不良患者接受單側PAO后，任何脊柱-骨盆參數均無變化，但雙側發育不良患者接受雙側PAOs后，骨盆入射角從57°(14°)增加到60°(16°)(95% CI 1°~ 5°;p = 0.02)，恥骨聯合-骶髂指數從84 mm (24 mm)降至77 mm (23 mm) (95% CI -7°至-2°;P = 0.007)。術前腰椎柔韌性好的患者未表現出任何矢狀位脊柱骨盆參數的變化，但術前腰椎柔韌性差的患者術后出現了一些變化。站立骨盆傾斜小于10°的患者，骨盆入射角中位數(IQR)從43°(9°)增加到45°(12°[95% CI 0.3°~ 4°];P = 0.03)，但術后未發生其他矢狀位脊柱骨盆參數的改變。術前骨盆傾斜超過20°的患者矢狀位脊柱骨盆參數未發生任何改變。

結論:PAO增加骨盆入射角，可能與髖關節中心前移有關。除雙側PAO術后，其余脊柱骨盆參數無變化。此外，術前脊柱僵硬的患者，表現為站立和坐姿之間腰椎前凸的變化微小，可能會出現脊柱骨盆參數的變價，包括PAO后脊柱活動度的增加。這可能是因為增加髖臼覆蓋后代償性脊柱“夾板”效應減少，但需要進一步研究。

Does Periacetabular Osteotomy Change Sagittal Spinopelvic Alignment？

Background: There are few data on the impact of periacetabular osteotomy (PAO) on sagittal spinopelvic alignment. Prior studies have attempted to delineate the relationship by performing measurements on AP radiographs and using mathematical models to determine changes in postoperative pelvic tilt. This information is clinically significant to a surgeon when evaluating acetabular/pelvic position intraoperatively and understanding spinopelvic alignment changes postoperatively; therefore, radiographic changes from PAO should be described in more detail.

Questions/purposes: In this study, we asked: (1) Does the performance of PAO result in consistent changes in spinopelvic alignment, as measured on EOS radiographs? (2) Does this differ for unilateral versus bilateral PAOs? (3) Does this differ in the setting of a mobile spine versus an immobile spine? (4) Does this differ based on preoperative pelvic tilt?

Methods: Mean preoperative and at least 1-year postoperative (15 ± 8 months from surgery, minimum 11 months, maximum 65 months) EOS hip-to-ankle standing and sitting radiographs for 55 patients in a prospectively collected registry who underwent PAO with a single surgeon from January 1, 2019, to January 11, 2022, were measured for pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, lateral center-edge angle, L1 pelvic angle, and pubic symphysis to the sacroiliac index. Normality was assessed and paired sample t-tests (normally distributed data) or Wilcoxon signed rank tests (not normally distributed data) were utilized to assess if any measurements changed from preoperative to postoperative. Patients were then divided based on whether they had unilateral or bilateral dysplasia and unilateral or bilateral surgery, and these subgroups were analyzed the same way as the entire cohort. Two more subgroups were then formed based on lumbar mobility, defined as a change in sitting-to-standing lumbar lordosis less or greater than 1 SD from the population mean preoperatively, and the subgroups were analyzed the same way as the entire cohort. Finally, two additional subgroups were formed, preoperative standing pelvic tilt less than 10° and more than 20°, and analyzed the same as the entire cohort.

Results: For the entire cohort, the median (IQR) standing lateral-center edge angle increased 17°, from a median of 21° (10°) to a median of 38° (8° [95% confidence interval (CI) 16° to 20°; p < 0.001). The median sitting lateral center-edge angle increased 17°, from a median of 18° (8°) to a median of 35° (8° [95% CI 14° to 19°]; p < 0.001). Standing pelvic incidence increased from 50° ± 11° to 52° ± 12° (mean difference 2° [95% CI 1° to 3°]; p = 0.004), but there were no changes for other measured parameters. There were no changes in any of the spinopelvic parameters for patients with unilateral dysplasia receiving a unilateral PAO, but patients with bilateral dysplasia who underwent bilateral PAOs demonstrated an increase in pelvic incidence from 57° (14°) to 60° (16°) (95% CI 1° to 5°; p = 0.02) and a decrease in pubic symphysis to sacroiliac index from 84 mm (24 mm) to 77 mm (23 mm) (95% CI -7° to -2°; p = 0.007). Patients with mobile lumbar spines preoperatively did not exhibit any changes in sagittal spinopelvic alignment, but patients with immobile lumbar spines preoperatively experienced several changes after surgery. Patients with less than 10° of standing pelvic tilt demonstrated a median (IQR) 2° increase in pelvic incidence from median 43° (9°) to 45° (12° [95% CI 0.3° to 4°]; p = 0.03), but they did not experience any other changes in sagittal spinopelvic alignment parameters postoperatively. Patients with preoperative pelvic tilt more than 20° did not experience any change in sagittal spinopelvic parameters.

Conclusion: PAO increases pelvic incidence, potentially because of anterior translation of the hip center. There were no changes in other spinopelvic parameters postoperatively except after bilateral PAO. Additionally, patients lacking spine mobility preoperatively, indicated by a minimal change in lumbar lordosis between standing and sitting positions, may experience several changes in spinopelvic alignment, including increased mobility of their spine after PAO. This may be because of decreased compensatory spine splinting after increasing acetabular coverage, but further research including patient-reported outcomes is warranted.

文獻出處：Cirrincione P, Cao N, Trotzky Z, Nichols E, Sink E. Does Periacetabular Osteotomy Change Sagittal Spinopelvic Alignment? Clin Orthop Relat Res. 2024 Apr 2. doi: 10.1097/CORR.0000000000003031. Epub ahead of print. PMID: 38564796.

文獻3

保髖手術后患者報告結局的演變軌跡：一項國家登記庫研究

譯者 李勇

目的：了解保髖手術后患者報告結局（PROs）的縱向演變軌跡至關重要。本研究旨在利用英國國家保髖登記系統的數據，分析患者術后長達2年的PROs演變軌跡，并檢驗潛在混雜因素對此的影響。

方法：本研究數據來源于英國非關節置換髖關節登記處（UK Non-Arthroplasty Hip Registry）。納入標準為：接受了髖關節鏡手術（Hip Arthroscopy）或髖臼周圍截骨術（PAO）的患者，并具有術前的國際髖關節結局量表（iHOT-12）評分，且在術后6個月、1年或2年至少有兩個時間點的隨訪測量數據。研究團隊分析了iHOT-12評分的演變軌跡，并采用潛（隱）增長曲線模型（Latent Growth Curve Modelling）來識別這些軌跡的預測因素。

結果：研究共納入9845名患者。其中，7081名患者接受了髖關節鏡手術，1327名患者接受了髖臼周圍截骨術。髖關節鏡組： iHOT-12評分從基線（術前）到術后6個月有顯著改善；但在術后6個月至1年間無明顯變化；在1年至2年間評分出現下降。髖臼周圍截骨術組： iHOT-12評分從基線到術后6個月有顯著改善；但在術后6個月至1年、以及1年至2年間均無明顯變化。潛增長曲線模型分析顯示，體重指數（BMI）和性別對術前iHOT-12評分有顯著影響，而年齡和性別則顯著影響術后的恢復斜率（即恢復速度）。

結論：接受保髖手術的患者，其iHOT-12評分在術后6個月時即獲得顯著改善，且改善幅度超過了最小臨床重要差異（MCID）。這種改善效果在術后2年時趨于穩定（進入平臺期）。在髖關節鏡術后1年至2年間，評分雖然略有下降，但該下降幅度仍處于臨床有意義的范圍之內（即未達到MCID）。BMI、年齡和性別均會影響評分的演變軌跡，這凸顯了在術前幫助患者建立合理期望的重要性。

The trajectory of patient‐reported outcomes after hip preservation surgery: A National Registry Study

Purpose

Understanding the trajectory of postoperative patient‐reported outcomes after hip preservation surgery is essential. This study aims to analyse patient‐reported outcome trajectories up to 2 years post‐surgery using the UK's national hip preservation registry and to examine the influence of potential confounders.

Methods

Patients who underwent hip arthroscopy or periacetabular osteotomy with preoperative International Hip Outcome Tool‐12 (iHOT‐12) scores and at least two follow‐up measurements at 6 months, 1 year, or 2 years were included from the UK Non‐Arthroplasty Hip Registry. iHOT‐12 score trajectories were analysed, and Latent Growth Curve Modelling was used to identify predictors of these trajectories.

Results

Overall 9845 patients were included in this study. 7081 patients underwent a hip arthroscopy, and 1327 patients underwent a periacetabular osteotomy. For hip arthroscopy, there were significant improvements in the iHOT‐12 scores from baseline to 6 months, but no significant change from 6 months to 1 year. However, there was a decrease in the minimal clinically important difference from 1 to 2 year. For periacetabular osteotomy, there were significant improvements in the iHOT‐12 scores from baseline to 6 months, but no significant change from 6 months to 1 year, and from 1 to 2 years. Latent Growth Curve Modelling showed that body mass index (BMI) and sex had a significant impact on pre‐operative iHOT‐12 scores, while age and sex significantly influenced the recovery slope.

Conclusions

Patients who underwent hip preservation surgery exhibited significant improvement in iHOT‐12 scores, surpassing the minimal clinically important difference at 6 months postoperatively. This improvement plateaued by 2 years, with a slight decline in scores between 1 and 2 years following hip arthroscopy, though the decrease remained within the clinically meaningful range. BMI, age and sex influenced score trajectories, highlighting the importance of setting patient expectations pre‐operatively.

文獻出處；Yoshitani J, Ekhtiari S, Malviya A, Khanduja V. The trajectory of patient-reported outcomes after hip preservation surgery: A National Registry Study. Knee Surg Sports Traumatol Arthrosc. 2025 Nov;33(11):4002-4011. doi: 10.1002/ksa.12771. Epub 2025 Aug 19. PMID: 40827496; PMCID: PMC12582234.

文獻4

歐洲國家發育性髖關節發育不良篩查與治療指南概述及質量評估

譯者 賈海港

背景/目的：發育性髖關節發育不良（DDH）是最常見的兒童骨科疾病之一，需及時診斷和治療以預防長期致殘。本綜述旨在識別、總結并評估當前歐洲各國關于 DDH 篩查和治療的國家指南質量。

方法 ：通過聯系來自 46個歐洲國家的國家骨科學會，并從近期的系統綜述中獲取指南來識別相關指南。兩名研究人員獨立提取數據，并采用 AGREE II 量表評估指南質量。采用 Cohen's κ系數評估評分者間一致性。

結果 ：共識別出九份歐洲國家 DDH 指南，其中四份發表在同行評審的科學期刊上。所有指南均建議將臨床檢查和影像學檢查納入 DDH 篩查方案，但篩查方法和時機存在顯著差異。四份指南包含治療建議。治療方式（外展治療 vs. 積極監測）及長期隨訪時長存在顯著差異。指南質量評分范圍為 16%至 92%（Cohen's κ=0.62），其中兩份指南被評為"良好質量"（≥70%）

結論 ：歐洲各國的 DDH 指南數量稀少，質量和內容差異較大。亟需開展一項協調一致的歐洲倡議，敦促各國使用經過驗證的工具制定循證的 DDH 指南，并將這些指南發表在同行評議期刊上，從而促進髖關節發育不良患兒的平等診療。

關鍵詞： 髖關節發育不良；診斷；指南；新生兒篩查；治療學。

An Overview and Quality Assessment of European National Guidelines for Screening and Treatment of Developmental Dysplasia of the Hip

Background/Objectives: Developmental dysplasia of the hip (DDH) is one of the most common pediatric orthopedic disorders and warrants timely diagnosis and treatment to prevent long-term disability. This review identified, summarized, and assessed the quality of current European national guidelines for DDH screening and treatment.

Methods: Guidelines were identified by contacting the national orthopedic societies from 46 European countries and retrieving the guidelines from a recent systematic review. Two researchers independently extracted data and assessed guideline quality using the AGREE II checklist. Interrater agreement was assessed using Cohen's κ.

Results: Nine European national DDH guidelines were identified, of which four were published in peer-reviewed scientific journals. All guidelines advised clinical examination and imaging as part of the DDH screening program, though screening approach and timing varied considerably. Four guidelines included treatment recommendations. The type of treatment (abduction treatment vs. active monitoring) and duration of long-term follow-up showed great variation. Guideline quality ranged from 16 to 92% (Cohen's κ = 0.62), with two out of nine guidelines rated "good quality" (>70%).

Conclusions: European national DDH guidelines appear scarce and of varying quality and content. A coordinated European initiative is warranted to urge countries to develop evidence-based DDH guidelines using validated tools and to publish these guidelines in peer-reviewed journals, thereby advancing equal diagnosis and treatment for children with DDH.

Keywords: developmental dysplasia of the hip; diagnosis; guideline; neonatal screening; therapeutics.

文獻出處：Mulder FECM, van Kouswijk HW, Witlox MA, Mathijssen NMC, de Witte PB. An Overview and Quality Assessment of European National Guidelines for Screening and Treatment of Developmental Dysplasia of the Hip. Children (Basel). 2025 Sep 3;12(9):1177. doi: 10.3390/children12091177. PMID: 41007042; PMCID: PMC12468116.

文獻5

髖臼周圍截骨術治療伴有嚴重股骨頭非球形畸形的髖關節發育不良臨床研究

譯者 陶可

背景：伴有股骨近端畸形的髖關節發育不良會導致青年人出現髖關節功能障礙和退行性髖骨關節炎。針對這些復雜的復合畸形，最佳的手術矯正方法仍存在爭議。

方法：我們回顧性分析了20例患者的24個髖關節，這些患者均接受了伯爾尼髖臼周圍截骨術，其中13個髖關節同時進行了股骨近端外翻截骨術，用于治療伴有股骨近端結構異常的髖關節發育不良。患者手術時的平均年齡為22.7歲，平均臨床隨訪時間為4.5年。采用Harris髖關節評分和患者對手術的總體滿意度來評估髖關節功能和臨床結果。X線片用于評估畸形矯正情況、截骨愈合情況以及退行性髖骨關節炎的進展情況。

結果：平均Harris髖關節評分由術前的68.8分提高到最近一次隨訪時的91.3分（p<0.0001）。16例患者（19個髖關節）臨床療效優良，1例患者（1個髖關節）療效良好，2例患者（2個髖關節）療效一般，1例患者（2個髖關節）療效差。24個髖關節中有22個臨床癥狀得到改善。Wiberg外側中心邊緣角平均改善27.6度（p<0.0001），Lequesne和de Seze前中心邊緣角平均改善33.1度（p<0.0001），髖臼頂傾斜度平均改善16.5度（p<0.0001）。髖關節中心平均向內側移位6.3 mm（p=0.0003）。20個髖關節的T?nnis骨關節炎分級保持不變，3個髖關節的分級升高1級，1個髖關節的分級升高2級。共發生3例主要技術并發癥。在最近一次隨訪時，所有髖關節均無需行全髖關節置換術。

結論：髖關節發育不良合并股骨近端畸形構成了一個復雜的重建難題。髖關節的活動范圍和影像學評估是選擇手術患者的主要因素。對于部分患者，在必要時，可采用髖臼周圍截骨術聯合同期股骨手術，以全面矯正畸形并改善髖關節功能。

圖1-A：圖1-A、1-B、1-C、1-D一名18歲女性患者，患有嚴重的髖關節發育不良和股骨近端內翻畸形，主訴右髖關節疼痛和跛行。術前髖關節屈曲角度為105°。圖1-A該患者既往有Legg-Calvé-Perthes病史，并曾接受過導致內翻畸形的股骨近端截骨術。她股骨頭呈橢圓形、股骨頸短和相對較高的股骨大轉子。髖關節發育不良明顯。

圖1-B：該患者接受了髖臼周圍截骨術，并展示了術中髖臼的矯正情況。

圖1-C：髖臼周圍截骨術后，術中內收位X線片顯示關節面吻合良好。隨后行股骨近端外翻截骨術、大轉子前移術及股骨頭頸交界處骨軟骨成形術。

圖1-D：術后24個月，X線片顯示截骨愈合良好，畸形已矯正。患者髖關節無疼痛，臨床療效極佳。

Periacetabular osteotomy for the treatment of acetabular dysplasia associated with major aspherical femoral head deformities

Background: Acetabular dysplasia associated with deformity of the proximal part of the femur can result in hip dysfunction and degenerative arthritis in young adults. The optimal method of surgical correction for these challenging combined deformities remains controversial.

Methods: We retrospectively analyzed twenty-four hips in twenty patients who underwent a Bernese periacetabular osteotomy, which was done with a proximal femoral valgus-producing osteotomy in thirteen hips, for the treatment of acetabular dysplasia associated with proximal femoral structural abnormalities. The average age of the patients at the time of surgery was 22.7 years, and the average duration of clinical follow-up was 4.5 years. The Harris hip score and overall patient satisfaction with surgery were used to assess hip function and clinical results. Plain radiographs were used to assess the correction of the deformity, healing of the osteotomy, and progression of degenerative arthritis.

Results: The mean Harris hip score increased from 68.8 points preoperatively to 91.3 points at the time of the most recent follow-up (p<0.0001). Sixteen patients (nineteen hips) had an excellent clinical result, and one patient (one hip) had a good result. Two patients (two hips) had a fair result, and one patient (two hips) had a poor result. Twenty-two of the twenty-four hips improved clinically. There was an average improvement of 27.6 degrees in the lateral center-edge angle of Wiberg (p<0.0001), an average improvement of 33.1 degrees in the anterior center-edge angle of Lequesne and de Seze (p<0.0001), and an average improvement of 16.5 degrees in the acetabular roof obliquity (p<0.0001). The hip center was translated medially an average of 6.3 mm (p=0.0003). The T?nnis osteoarthritis grade was unchanged in twenty hips, progressed one grade in three hips, and progressed two grades in one hip. There were three major technical complications. At the time of the most recent follow-up, none of the hips had required total hip arthroplasty.

Conclusions: The combination of acetabular dysplasia and proximal femoral deformities presents a complex reconstructive problem. The range of motion and radiographic assessment of the hip are major factors in the selection of patients for surgery. In selected patients, the periacetabular osteotomy combined with concurrent femoral procedures, when indicated, can provide comprehensive deformity correction and improved hip function.

文獻出處：John C Clohisy, Ryan M Nunley, Madelyn C Curry, Perry L Schoenecker. Periacetabular osteotomy for the treatment of acetabular dysplasia associated with major aspherical femoral head deformities. J Bone Joint Surg Am. 2007 Jul;89(7):1417-23. doi: 10.2106/JBJS.F.00493.

文獻6

股骨頭壞死中軟骨下骨折始于骨吸收區：一項顯微計算機斷層掃描研究

譯者 邱興

目的： 為成功實現股骨頭壞死（ONFH）的關節保留手術，理解塌陷機制至關重要。本研究旨在通過顯微CT成像觀察整個股骨頭，重點分析軟骨下骨折與骨吸收區之間的三維關系，探討ONFH中軟骨下骨折的起始過程。

方法： 選取37例患者共40個股骨頭標本（根據日本調查委員會標準均為3A或3B期ONFH，均在全髖關節置換術中獲取），采用層厚0.146毫米的顯微CT進行掃描。根據顯微CT測量的塌陷程度（以3毫米為界），將樣本分為早期塌陷期和晚期塌陷期。

結果: 通過對整個股骨頭多徑向平面圖像的分析，發現兩個重要現象：首先，在全部18個早期塌陷期股骨頭標本中，初始骨折裂紋均貫穿前上部分離的骨吸收區；其次，在22個晚期塌陷期標本中有19個觀察到硬化邊界的壞死骨骨折，以及沿硬化邊界壞死側出現纖維性、肉芽樣低密度組織。當骨吸收始于支持帶和圓韌帶附著點周圍并引發軟骨下骨折后，股骨頭前上部區域的骨吸收擴展可能導致骨折蔓延并引發大面積塌陷。

結論: 三維顯微CT顯示股骨頭壞死中的軟骨下骨折始于修復區周圍的骨吸收。

關鍵詞: 股骨頭壞死；顯微CT；軟骨下骨折；骨吸收；塌陷

圖1 基于三維顯微CT的全股骨頭分析：重點顯示骨壞死中的骨吸收區與軟骨下骨折。

圖2 a 早期塌陷階段各徑向平面內初始軟骨下骨折與骨吸收的發生率分布。圖中實線表示各徑向平面的軟骨下骨折發生率，大點線代表股骨頭外側三分之一區域的骨吸收發生率，小點線顯示中間三分之一區域，虛線標示內側三分之一區域。b 早期塌陷階段各徑向平面內與軟骨下骨折相連的骨吸收發生率分布。實線標示各徑向平面的軟骨下骨折發生率，大點線表示股骨頭外側三分之一區域內與軟骨下骨折相連的骨吸收發生率，小點線對應中間三分之一區域，虛線顯示內側三分之一區域。

圖3 a 在早期塌陷階段，所有股骨頭的軟骨下骨折裂紋均穿行于兩個不同的骨吸收區之間；b 部分股骨頭外側三分之一的骨吸收區已延伸至皮質外；c 在晚期塌陷階段，大面積塌陷似乎由壞死骨的粉碎性骨折導致，沿硬化邊界可見纖維性、肉芽樣低密度組織；d 晚期塌陷階段，骨折裂紋從骨吸收區出發，在靠近垂直走向的硬化邊界處的壞死骨內延伸。

Subchondral fracture begins from the bone resorption area in osteonecrosis of the femoral head: a micro-computerised tomography study

Purpose: For successful joint preservation in osteonecrosis of the femoral head (ONFH), it is important to understand the mechanism of collapse. The purpose of this study was to investigate the initiation of subchondral fracture in ONFH by using micro-CT imaging of the whole femoral head, focusing on the three-dimensional relationship between the subchondral fracture and the bone resorption area.

Methods: A total of 40 femoral heads from 37 patients retrieved during total hip arthroplasty for stage 3A or 3B ONFH by Japanese Investigation Committee criteria were scanned using micro-CT with a 0.146-mm thickness cuts. We divided the cohort into early and late collapsed stages according to a threshold of 3 mm of collapse as measured by micro-CT.

Results: According to the analysis on multiple radial plane views in the whole femoral head, there were two interesting findings. First, the initial fracture cracks ran between separated bone resorption areas at the anterosuperior portions of all 18 femoral heads in the early collapsed stage. Second, fractures of the necrotic bone at the sclerotic boundary and a fibrous, granulation-like, low-density tissue along the necrotic side of the sclerotic boundary were seen in 19 of the 22 in the late collapsed stage. After bone resorption around the retinaculum and teres insertion initiates the subchondral fracture, bone resorption expanding at the anterosuperior portion of the femoral head may result in the spread of fracture and the potential for massive collapse.

Conclusions: Three-dimensional micro-CT showed bone resorption around the reparative zone initiates the subchondral fracture in ONFH.

Keywords: Bone resorption; Collapse; Micro-CT; Osteonecrosis of the femoral head; Subchondral fracture.

文獻出處：Hidetoshi,Hamada,Masaki,et al. Subchondral fracture begins from the bone resorption area in osteonecrosis of the femoral head: a micro-computerised tomography study[J].International Orthopaedics, 2018.

來源：304關節學術

作者：304關節團隊

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