髖膝關節文獻精譯薈萃（第368期）

本期目錄：

1、全膝關節置換術后運動恐懼癥的患病率及其影響因素

2、MAKO 機器人輔助髖關節置換術與傳統全髖關節置換術的比較

3、全膝關節置換對線方法對軟組織平衡以及運動模式的影響

4、機器人輔助并未減少全髖關節置換術中的并發癥

5、當股骨頭骨骺出現時感染后髖脫位處理措施

6、通過比較影像形態學分析來評估印度人群中成人髖關節的正常影像形態

7、髖關節撞擊綜合征的三維無創評估髖關節撞擊綜合征的三維無創評估

8、骨科手術并發癥分級系統的可靠性：保髖截骨手術隨訪驗證

9、機械力、激素及代謝因素對血管、血流和骨骼的影響

第一部分：關節置換及保膝相關文獻

文獻1

全膝關節置換術后運動恐懼癥的患病率及其影響因素：一項系統回顧和薈萃分析

譯者 張軼超

背景：膝關節骨關節炎是老年人常見的退行性疾病，全膝關節置換術是治療終末期膝關節疾病的有效方法。然而，術后運動恐懼癥會阻礙患者的康復，影響膝關節功能的恢復。對其相關影響因素的研究存在差異。

目的：本薈萃分析研究了TKA后運動恐懼癥的患病率和危險因素。

方法：檢索了Science、MEDLINE、Pubmed、Cochrane Library、中國知網（CNKI）、Embase、Web of Science等數據庫中關于TKA術后患者運動恐懼癥患病率及危險因素的相關文獻。排除重復文獻、低質量文獻、觀察指標不一致的文獻和沒有全文的文獻。兩名獨立研究人員使用紐卡斯爾-渥太華量表（NOS）評估納入文獻的質量。數據提取后，使用Stata17.0進行meta分析。

結果：本薈萃分析共納入11篇文章，涉及4039個病例，以評估TKA術后運動恐懼癥的患病率。總患病率為35% （95% CI: 27-44%）。亞組分析顯示，不同年齡、受教育程度、收入和居住地的患病率各不相同，65歲以下以及受教育程度和收入水平較低的人群患病率最高。影響運動恐懼癥患病率的關鍵因素包括疼痛（OR=2.313, 95% CI: 1.556-3.07）、低社會支持（OR=1.681, 95% CI: 1.000-2.361）和消極應對（OR=1.344, 95% CI: 1.165-1.523）。

結論：TKA術后運動恐懼癥發生率高。不同居住地、不同教育水平、不同月收入的人群中，運動恐懼癥的患病率存在差異。同時還受到術后疼痛、社會支持低、主動性差、消極應對、年齡大、文化程度低等因素的影響。

Prevalence and influencing factors of kinesiophobia after total knee arthroplasty: a systematic review and meta-analysis

Background：Knee osteoarthritis is a common degenerative disease in the elderly, and total knee arthroplasty is an effective treatment for end-stage knee joint diseases. However, kinesiophobia after surgery can impede patients’ rehabilitation and affect the recovery of knee joint function. There are differences in the research on its related influencing factors.

Objectives：This meta-analysis examined the prevalence and risk factors of kinesiophobia after TKA.

Methods：Pubmed, The Cochrane Library, China National Knowledge Infrastructure (CNKI), Embase, Web of Science on the prevalence and risk factors of kinesiophobia after TKA was searched in science, MEDLINE and other databases. Duplicate literature, low quality literature, literature with inconsistent observation indicators, and literature without full text were excluded. Two independent researchers used Newcastle-Ottawa Scale (NOS) to evaluate the quality of the

included literature. After data extraction, Meta-analysis was performed using Stata17.0.

Results：A total of 11 articles involving 4039 cases were included in this meta-analysis to assess the prevalence of kinesiophobia after TKA. The overall prevalence was found to be 35% (95% CI: 27-44%). Subgroup analyses revealed varying prevalence rates based on age, education, income, and residence, with the highest prevalence observed in individuals under 65 years and those with lower levels of education and income. Key factors influencing the prevalence of kinesiophobia included pain (OR=2.313, 95% CI: 1.556–3.07), low social support (OR=1.681, 95% CI: 1.000-2.361), and negative coping strategies (OR=1.344, 95% CI: 1.165–1.523).

Conclusion：The prevalence of kinesiophobia after TKA is high. There are differences in the prevalence of kinesiophobia among people with different places of residence, different education levels, and different monthly incomes. At the same time, it is affected by many factors such as postoperative pain, low social support, low selfefficacy, negative coping, old age, and low education level.

文獻出處：Du X, Shao Y, Xue J, Kong J. Prevalence and influencing factors of kinesiophobia after total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2025 Apr 1;20(1):332. doi: 10.1186/s13018-025-05752-w. PMID: 40170179; PMCID: PMC11959722.

文獻2

MAKO 機器人輔助髖關節置換術與傳統全髖關節置換術的比較：系統綜述和薈萃分析

譯者 馬云青

研究背景：全髖關節置換術（THA）是治療終末期髖關節骨關節炎的金標準。為提高手術可重復性和安全性，機器人輔助系統（尤其是MAKO系統）已被引入THA。然而，目前尚缺乏比較MAKO輔助THA（MAKO-THA）與傳統THA C-THA的薈萃分析，且既往綜述常合并多種手術指征，導致異質性較高。

作者對因單純髖關節骨關節炎接受THA的患者，進行了MAKO機器人輔助THA與傳統THA的隨機對照研究療效的薈萃分析。評估指標包括臨床療效（Harris髖關節評分[HHS]、遺忘關節評分[FJS]和牛津髖關節評分[OHS]）、影像學參數（假體定位準確性）、下肢長度差異、手術時長及并發癥。

研究結果：共納入20項對比研究。MAKO輔助THA術后HHS（MAKO-THA: 89.1, 95%CI: 86.4-91.7；C-THA: 87.0, 95%CI: 83.8-90.1）、FJS（MAKO-THA: 84.7, 95%CI: 79.9-89.6；C-THA: 74.9, 95%CI: 64.0-95.7）和OHS（MAKO-THA: 89.1, 95%CI: 86.4-91.7；C-THA: 87.0, 95%CI: 83.8-90.1）均更高。與傳統C-THA相比，FJS和OHS的改善幅度顯著更大（HHS WMD 2.2 [95%CI: -0.3-4.7], p = 0.09；FJS WMD: 8.7 [95%CI: 2.7-14.8], p = 0.005；OHS WMD: 1.5 [95% CI: 0.1-2.8], p = 0.03）。MAKO-THA分別有94.7%和90.3%的假體在Lewinnek及Callanan安全區內，而傳統THA僅為65.8%和57.1%。MAKO-THA平均手術時間較長，術后下肢長度差異較小，但均無統計學顯著性（手術時長WMD: 3.5 [95%CI: -2.5-9.5], p = 0.3；下肢長度差異WMD: -0.2 [95%CI: -0.7-0.4], p = 0.6）。兩組并發癥發生率均較低且無顯著差異（MAKO-THA: 3.0% [95%CI: 1.2-7.4]；C-THA: 3.5% [95% CI: 1.2-10.1], p = 0.3）。

作者最后得出結論：MAKO機器人輔助THA能顯著改善遺忘關節評分、牛津髖關節評分及假體位置精確度的可重復性，且未增加手術時長和并發癥發生率。

MAKO robotic-assisted compared to conventional total hip arthroplasty for hip osteoarthritis: a systematic review and meta-analysis

Background:Total Hip Arthroplasty (THA) is the gold standard for treating end-stage hip osteoarthritis. Robotic-assisted systems, particularly the MAKO system, have been introduced to enhance reproducibility and safety. However, meta-analyses comparing MAKO-assisted THAs (MAKO-THA) to conventional methods are lacking, and previous reviews often aggregate various indications, introducing heterogeneity.

Methods:A random-effects meta-analysis was conducted on comparative studies between MAKO robotic-arm-assisted and conventional THAs in patients undergoing THA for solely hip osteoarthritis. Clinical outcomes (Harris Hip Scores [HHS], Forgotten Joint Scores [FJS], and Oxford Hip Scores [OHS]), radiographic parameters (implant positioning accuracy), leg-length-discrepancy, surgical duration, and complications were evaluated.

Results:20 comparative studies were included. MAKO-assisted THAs resulted in higher postoperative HHS (MAKO-THA: 89.1, 95%CI: 86.4-91.7; C-THA: 87.0, 95%CI: 83.8-90.1), FJS (MAKO-THA: 84.7, 95%CI: 79.9-89.6; C-THA: 74.9, 95%CI: 64.0-95.7), and OHS (MAKO-THA: 89.1, 95%CI: 86.4-91.7; C-THA: 87.0, 95%CI: 83.8-90.1). FJS and OHS improvements were significantly greater compared to conventional THA (HHS WMD 2.2 [95%CI: -0.3-4.7, p = 0.09; FJS WMD: 8.7 [95%CI: 2.7-14.8], p = 0.005; OHS WMD: 1.5 [95% CI: 0.1-2.8], p = 0.03). MAKO-THA resulted in 94.7% and 90.3% of implants positioned within Lewinnek-and-Callanan zones, respectively, compared to 65.8% and 57.1% in conventional THA. MAKO-THA had longer mean surgical durations and lower postoperative leg-length discrepancy, but not significantly (Surgical Duration WMD: 3.5 [95%CI: -2.5-9.5], p = 0.3; Leg Length Discrepancy WMD: -0.2 [95%CI: -0.7-0.4], p = 0.6). Complication rates were low and non-significant (MAKO-THA: 3.0% [95%CI: 1.2-7.4]; C-THA: 3.5% [95% CI: 1.2-10.1), p = 0.3).

Conclusion:MAKO robotic-arm-assisted THA significantly improves Forgotten Joint Scores, Oxford Hip Scores and reproducibility in implant positioning without compromising on surgical duration and complication rates.

文獻出處：Loke RWK, Lim YH, Chan YK, Tan BWL. MAKO robotic-assisted compared to conventional total hip arthroplasty for hip osteoarthritis: a systematic review and meta-analysis. J Orthop Surg Res. 2025 May 16;20(1):466. doi: 10.1186/s13018-025-05866-1. PMID: 40380310; PMCID: PMC12083021.

文獻3

全膝關節置換對線方法對軟組織平衡以及運動模式的影響

一項對比運動對線與機械對線的隨機對照試驗

譯者 張薔

背景：在最近10年中，多名學者研發出多種不同的全膝關節置換（TKA）對線方法，期待膝關節假體可以更好的恢復接近正常的膝關節運動力學并改善關節功能。本研究的目的是計算并評估基于嚴格的運動對線（KA）或機械對線（MA）手術技術的假體軟組織平衡和運動模式。

方法：共入組109例初次后叉保留型（CR）TKAs手術病例，并被隨機分入機械對線組或運動對線組。我們應用墊片內置的壓力感受器分別在10°、45°和90°屈曲時測量內、外側間室壓力和接觸應力點變化模式。

結果：最初截骨完成后，全活動范圍內膝關節內、外側間隙平衡的比例KA對線法顯著高于MA（KA 61% VS. MA 12%, P<0.001），且各個屈伸角度內均存在顯著性差異。在間隙不平衡的病例中，MA對線的病例需要進行更多的軟組織松解（P=0.008）和對線調整（P<0.001）。兩種對線方法的松解前和松解后假體后滾運動模式并無顯著性差異（松解前P=0.29，松解后P=0.29）。運動模式的首要驅動因素并非對線，而是內、外側間室在45°和90°（45° P<0.001，90° P<0.001）的壓力差異，屈膝時膝關節依從更緊的間室完成后滾。

結論：在初次CR TKA手術中，更嚴格的KA對線方法可以獲得一個間隙更為平衡的關節，軟組織松解或再截骨顯著減少。原始膝關節以內側間室為軸心旋轉并引導后滾，為了恢復這種自然的運動模式，我們需要在軟組織平衡時創造一個非對稱性的屈曲間隙：伸直時內、外側間隙平衡，在屈膝的過程中保持內側韌帶張力的同時允許外側軟組織松弛度適度增加。本隨機對照試驗的相關信息收錄在澳洲/新西蘭臨床試驗登記庫中（ACTRN12616001705471）。

Influence of Total Knee Arthroplasty Alignment on Soft-Tissue Balance and Pivot Patterns

A Randomized Controlled Trial of Kinematic Versus Mechanical Alignment

Background: Over the last decade alternative alignment techniques in primary total knee arthroplasty (TKA) have been developed in the hope to allow knee prostheses to better replicate normal knee kinematics and improve clinical outcomes. The purpose of this study was to quantify prosthesis soft-tissue balance and pivot patterns based on a restricted kinematic alignment (KA) or mechanical alignment (MA) surgical technique.

Methods: A total of 109 primary cruciate retaining TKAs were randomized to either a mechanical or KA technique. Medial and lateral compartmental pressures and contact point patterns were quantified at 10, 45, and 90 degrees of flexion using an insert pressure sensor.

Results: A significantly greater proportion of KA knees were balanced through a full range of motion (ROM) after the initial bone resections (61 KA versus 12% MA, P < 0.001) and the differences were significant at all positions of ROM. For the unbalanced prostheses, the MA knees required significantly more soft-tissue releases (P = 0.008) and bone alignment adjustments (P < 0.001). The initial and final rollback pivot patterns were not significantly different between techniques (initial P = 0.29, final P = 0.29). The primary driving factor for the pivot patterns was not alignment, but instead the differential pressure between the medial and lateral compartments at 45 and 90 degrees flexion (45? P < 0.001, 90? P < 0.001), with the knee pivoting on the tighter compartment in flexion.

Conclusions: In primary cruciate retaining TKA a restricted KA technique achieves a balanced prosthesis with significantly fewer soft-tissue releases or bone recuts. The knee’s natural medial pivot pattern can be replicated with a prosthesis by controlling the soft tissue balance to achieve a non-symmetrical flexion gap: equal balance in extension, with medial ligament tension maintained through ROM while allowing increased lateral soft-tissue laxity in flexion. The trial and protocol were registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001705471).

文獻4

機器人輔助并未減少全髖關節置換術中的并發癥

譯者 沈松坡

目標：本研究的目的在于評估機器人輔助全髖關節置換術（rTHA）是否在長期隨訪中減少并發癥。機器人輔助全髖關節置換術是一種應用越來越廣泛的關節置換技術，旨在提高手術準確性并減少人為錯誤。然而，目前缺乏足夠的臨床證據支持其在長期并發癥或手術結局方面的優勢，盡管如此，其使用率仍持續上升。本研究比較了接受傳統全髖關節置換術（cTHA）與機器人輔助全髖關節置換術（rTHA）患者在長期隨訪中的并發癥發生率。

資料與方法：研究使用 TriNetX 研究網絡的數據，通過電子病歷篩選出具有至少五年隨訪記錄的患者。第一隊列為接受傳統 THA 的患者，第二隊列為接受機器人輔助 THA 的患者。研究對已知影響臨床結局的因素進行了 1:1 傾向性評分匹配，以減少混雜因素；并排除與原發 THA 無關的情況，如病理性骨折或翻修手術。研究在術后 1 年、3 年和 5 年分別觀察五類并發癥的發生率：假體關節感染、脫位、翻修、松動以及假體周圍骨折。

結果：數據庫共包含 95,085 名 THA 患者，最終分析納入匹配后每組各 2241 名患者。在 5 年隨訪時，傳統 THA 與機器人輔助 THA 兩組在全因并發癥發生率方面無顯著差異［OR（95% CI），1.073（0.772–1.491）］。在翻修率［OR（95% CI），1.604（0.726–3.543）］與脫位率［OR（95% CI），1.775（0.976–3.228）］方面同樣未觀察到差異。

結論：盡管已有數據表明機器人輔助技術可提高手術精確性并減少操作錯誤，但在全髖關節置換術后的五年隨訪期內，機器人輔助并未減少并發癥發生率。

關鍵詞：關節成形術；髖關節；機器人；回顧性；TriNetX。

Robotic-assistance did not reduce complications in total hip arthroplasty

Aims & objectives: Robotic-assisted total hip arthroplasty (rTHA) is an increasingly common method of joint arthroplasty used to improve surgical accuracy and reduce human error. Despite not having compelling clinical data on long-term complications or outcomes to justify additional time costs, its rate of use is increasing. In this study we compare the longitudinal rates of complications between patients undergoing conventional total hip arthroplasty (cTHA) and rTHA.

Materials & methods: Data from the TriNetX Research Network identified subjects with at least 5 years of patient follow up data through electronic health records. The first cohort were patients undergoing cTHA, and the second cohort included patients undergoing rTHA. Propensity score matching of known factors that can affect clinical outcomes at 1:1 ratio was performed to reduce confounding variables. Records with conditions unrelated to primary THA such as pathological fracture or revision arthroplasty were excluded. Rates of complication in five outcomes were observed at 1, 3 and 5 years: prosthetic joint infection, dislocation, revision, loosening, and periprosthetic fracture.

Results: The database contained 95,085 THA patients. Analysis was performed with 2241 patients in each matched cohort. At 5 years, there was no difference in all-cause complications between the cTHA cohort and rTHA cohort [OR (95 % CI), 1.073 (0.772-1.491)]. Also, no differences were noted in rates of revision [OR (95 % CI), 1.1.604(0.726, 3.543)] or dislocation [OR (95 % CI), 1.775(0.976, 3.228)].

Conclusion: Despite evidence for improved surgical accuracy and reduced errors, robotic assistance did not reduce the rate of complications over a 5-year period after total hip arthroplasty.

Keywords: Arthroplasty; Hip; Retrospective; Robotic; TriNetX.

第二部分：保髖相關文獻

文獻1

當股骨頭骨骺出現時感染后髖脫位處理措施

譯者 羅殿中

兒童延誤或漏診的感染性髖關節炎預后表現多種多樣。當股骨頭骨骺出現時感染后髖脫位當前尚無廣為認可的分型。本中心在63例感染髖患兒中，有30例出現髖關節脫位；本文回顧了18例兒童21髖，在干預時股骨頭骨骺（CFE）已經顯影。治療后平均隨訪6.3年，最少隨訪2年。

干預措施包括：閉合復位±內收肌松解、切開復位±股骨補充截骨、髖臼側手術。治療結果采用Ponseti髖關節評分進行臨床評估、采用改良Severin分級進行影像學評估。

結果：20髖中7髖成功采用閉合復位（35%），14髖中13髖進行了切開復位。隨訪時，18髖中9髖臨床療效為良好（50%）；所有患兒隨訪時平均頸干角為129°、股骨截骨患兒頸干角為124°。有1例出現再脫位，有3例出現半脫位。改良Severin影像學評估II型5髖（好）、III型12髖（可）、IV型3髖（差）、VI型1髖（失敗）。

結論：在股骨頭骨骺出現時感染后髖脫位是一個獨特的群體，MRI檢查有助于治療決策。多數患兒需要進行切開復位聯合其它手術，股骨內翻截骨或可導致髖內翻。短期療效顯示，手術干預可得到一個穩定的、有功能的、可活動的髖關節。

圖1. 兒童感染髖分型。I型：股骨頭骨骺（CFE）/股骨頸消失，干骺端殘留喙突，關節穩定；II型：股骨頭骨骺（CFE）/股骨頸消失，不穩定；IIIA型：股骨頭骨骺（CFE）存在，不穩定，脫位；IIIB型：半脫位，股骨頭骨骺（CFE）存在，不穩定；IV型：關節不匹配，股骨頭壞死，大頭畸形，骺板損害（短髖、髖內翻、髖外翻、大轉子高位），穩定；V型：股骨頸假關節形成，穩定或不穩定。

圖2. 感染后髖脫位干預流程。AI，髖臼指數；ATD，髖臼大轉子高度差；CR，閉合復位；EUA，麻醉下檢查；LR，外移指數；MRI，核磁共振成像；NSA，頸干角；US，超聲檢查；VDRO，內翻去旋轉截骨術。

病例1：

圖3, 病例1，2歲男孩感染后雙髖脫位。

圖4, 病例1，右髖成功閉合復位。

圖5, 病例1，3歲6個月時左髖行切開復位、內翻去旋轉截骨、股骨短縮、Dega髖臼截骨。

圖6, 病例1，8歲時右髖輕度內翻、頭臼匹配可；左髖髖臼大轉子高度差降低（大轉子高位）。

病例2：

圖7, 病例2，1歲女孩雙髖雙膝多部位感染性關節炎。

圖8, 病例2，嘗試閉合復位，左髖復位失敗；左髖切開復位后1年。

圖9, 病例2，患兒3歲時。

圖10, 病例2，患兒5歲時，右髖大頭畸形；左股骨頭骨骺受損扁平。

文獻出處：Johari AN. Residual problems in septic arthritis of the hips in childhood. Thesis submitted for the M.Ch Ortho, University of Liverpool, 1988 in ‘Current Concept: Septic Arthritis in Childhood’ in Trends in Paediatric Orthopaedics, Editor: Mathew Varghese, Macmillan (I) Ltd., pg 25–32, 2002. ISBN 0333 938194.）

文獻2

通過比較影像形態學分析來評估印度人群中成人髖關節的正常影像形態

譯者 任寧濤

目的：分析印度人群正常成人髖關節的影像學形態學參數，并與標準測量值和其他人群進行比較，評估其變化。

方法：對800人(1600髖)正常骨盆x線片進行前瞻性分析。我們計算了正常成人骨盆X線片上的臼頂傾斜角、髖臼指數、外側CE角(LCEA)和頸干角(NSA)、股骨頭球形度、關節匹配、髖臼前后傾、髖臼深度和股骨頭外移情況。我們使用RadiAnt DICOM viewer版本4.6.5.18450(64位)進行測量。采用SPSS軟件進行統計分析和均值計算。

結果：男性髖關節978例，女性髖關節622例。臼頂傾斜角為1 ~ 9°，平均髖臼指數為26.5°，LCEA在20 ~ 50之間，頸干角平均為133°。有35例髖關節，股骨頭非球形，94.2%髖關節匹配好，2.9%髖臼后傾，3.3%股骨頭外移大。

結論：多數參數與標準值相當，但是髖臼指數較低，LCEA和NSA較高，髖臼傾斜角較低。在我們的一般人群中，有一小部分存在股骨頭非球形、關節不匹配和股骨頭外移。

A comparative radiographic morphometric analysis to assess the normal radiological morphology of the adult hip in indian population

Objective: Our objective is to analyze the normal radiological morphologic parameters of the adult hip joint of the Indian population and compare it with standard measurements and with other populations to assess the variations.

Methods: A prospective analysis of the normal pelvis X-rays of 800 persons (1600 hips) was done. We have calculated the acetabular inclination, acetabular index, lateral center edge angle (LCEA) and neck-shaft angle (NSA), sphericity of the femoral head, congruity of the joint, version of the acetabulum, depth of acetabulum, and lateralization of the femoral head in normal X-rays of the pelvis in adult persons. We used RadiAnt DICOM viewer version 4.6.5.18450 (64bit) for measurement. Statistical analysis and mean values were calculated using SPSS software.

Results: There were 978 X-rays of the male hip and 622 female. The acetabular inclination varied from 1 to 9. The mean acetabular index was 26.5. The LCEA was between 20 and 50. The mean neck-shaft angle was 133. There were 35, hips with an aspherical head. 94.2% X-rays the hip joint was congruent. There was 2.9% of the retroversion of acetabulum, 3.3% lateralization.

Conclusion: Most of the parameters were comparable to standard values the acetabular index was lower. LCEA and NSA were higher. The acetabular angle was lower. There were femoral head asphericity, joint incongruity, and lateralization of the femoral head in a small proportion of our general population.

文獻出處; Zacharia B, Fawas KM. A comparative radiographic morphometric analysis to assess the normal radiological morphology of the adult hip in indian population. J Clin Orthop Trauma. 2020 Oct 17;15:117-124. doi: 10.1016/j.jcot.2020.10.015. PMID: 33717925; PMCID: PMC7920144.

文獻3

髖關節撞擊綜合征的三維無創評估

譯者 李勇

我們開發、驗證并在臨床初步研究中應用了一種基于 CT 的無創三維評估髖關節撞擊綜合征（FAI）的方法——“HipMotion”。該方法可基于解剖結構計算髖關節活動度（ROM），精確定位撞擊區域，并模擬量化手術操作以治療 FAI。在塑料骨模型中，HipMotion 的精度為 0.7°±3.1°；在尸體標本中為 –5.0°±5.6°。除外旋（ICC = 0.48）外，所有測量的信度與可重復性均極佳（組內相關系數 ICC > 0.87）。研究納入 150 例正常髖關節建立正常 ROM 數據庫，并與 31 例連續 FAI 患者對比。FAI 患者屈曲、內旋及外展活動度均顯著低于正常組（p < 0.001）。現有多部骨科教材普遍高估了正常髖關節的屈曲和內旋范圍。HipMotion 為深入評估撞擊髖并精確規劃手術干預量提供了有用工具，是今后采用髖關節鏡等微創手段計算機輔助治療的基石。

Noninvasive Three-Dimensional Assessment of Femoroacetabular Impingement

ABSTRACT: A CT-based method ("HipMotion") for the noninvasive three-dimensional assessment of femoroacetabular impingement (FAI) was developed, validated, and applied in a clinical pilot study. The method allows for the anatomically based calculation of hip range of motion (ROM), the exact location of the impingement zone, and the simulation of quantified surgical maneuvers for FAI. The accuracy of HipMotion was 0.7 ±3.1° in a plastic bone setup and -5.0 ± 5.6° in a cadaver setup. Reliability and reproducibility were excellent [intraclass correlation coefficient (ICC) > 0.87] for all measures except external rotation (ICC= 0.48). The normal ROM was determined from a cohort of 150 patients and was compared to 31 consecutive hips with FAI. Patients with FAI had a significantly decreased flexion, internal rotation, and abduction in comparison to normal hips (p < 0.001). Normal hip flexion and internal rotation are generally overestimated in a number of orthopedic textbooks. HipMotion is a useful tool for further assessment of impinging hips and for appropriate planning of the necessary amount of surgical intervention, which represents the basis for future computerassisted treatment of FAI with less invasive surgical approaches, such as hip arthroscopy.

文獻出處：Tannast M, Kubiak-Langer M, Langlotz F, Puls M, Murphy SB, Siebenrock KA. Noninvasive three-dimensional assessment of femoroacetabular impingement. J Orthop Res. 2007 Jan;25(1):122-31. doi: 10.1002/jor.20309. PMID: 17054112.

文獻4

骨科手術并發癥分級系統的可靠性：保髖截骨手術隨訪驗證

譯者 陶可

背景：醫療質量和安全一直受到各專業機構和政府部門的重視。然而，目前尚無標準化的骨科手術并發癥分級和報告方法。若缺乏標準化、客觀的并發癥分級方案，則對手術結果的結論是不完整的。普通外科文獻中已有符合上述標準的Clavien-Dindo分級系統。

問題/目的：我們探討了之前報道的分級系統在應用于骨科手術（特別是保髖截骨手術）后，是否仍具有較高的觀察者內和觀察者間可靠性。因此，我們確定了該改良分級系統應用于保髖截骨手術時的觀察者間和觀察者內可靠性。

方法：我們改良了已驗證的Clavien-Dindo并發癥分級系統，并測試了其在骨科手術（特別是保髖截骨手術）中的可靠性。該系統根據并發癥所需的治療方案和潛在的長期并發癥風險，將并發癥分為5個等級。

本研究基于前瞻性多中心保髖截骨手術數據庫和文獻資料，構建了44個并發癥情景。來自3個國家8個中心的10位髖關節手術醫師在兩個不同時間點對這些情景進行分級。分別采用Fleiss' κ系數和Cohen's κ系數評估觀察者間和觀察者內的一致性。

結果：觀察者間一致性的總體Fleiss' κ值為0.887（95% CI，0.855-0.891）。加權κ值分別為：I級0.925（95% CI，0.894-0.956），II級0.838（95% CI，0.807-0.869），III級0.87（95% CI，0.835-0.866），IV級0.898（95% CI，0.866-0.929）。觀察者內信度Cohen's κ值為0.891（95% CI，0.857-0.925）。

結論：該改良分類系統在應用于保髖截骨手術并發癥時，顯示出較高的觀察者間信度和觀察者內信度。該分級方案有助于并發癥報告的標準化，并使結果研究更具可比性。

表 . 并發癥分級表（修訂版）

Reliability of a complication classification system for orthopaedic surgery

Background: Quality of health care and safety have been emphasized by various professional and governmental groups. However, no standardized method exists for grading and reporting complications in orthopaedic surgery. Conclusions regarding outcomes are incomplete without a standardized, objective complication grading scheme applied concurrently. The general surgery literature has the Clavien-Dindo classification that meets the above criteria.

Questions/purposes: We asked whether a previously reported classification would show high intraobserver and interobserver reliabilities when modified for orthopaedic surgery specifically looking at hip preservation surgery. We therefore determined the interreader and intrareader reliabilities of the adapted classification scheme as applied to hip preservation surgery.

Methods: We adapted the validated Clavien-Dindo complication classification system and tested its reliability for orthopaedic surgery, specifically hip preservation surgery. There are five grades based on the treatment required t manage the complication and the potential for long-term morbidity. Forty-four complication scenarios were created from a prospective multicenter database of hip preservation procedures and from the literature. Ten readers who perform hip surgery at eight centers in three countries graded the scenarios at two different times. Fleiss' and Cohen's κ statistics were performed for interobserver and intraobserver reliabilities, respectively.

Results: The overall Fleiss' κ value for interobserver reliability was 0.887 (95% CI, 0.855-0.891). The weighted κ was 0.925 (95% CI, 0.894-0.956) for Grade I, 0.838 (95% CI, 0.807-0.869) for Grade II, 0.87 (95% CI, 0.835-0.866) for Grade III, and 0.898 (95% CI, 0.866-0.929) for Grade IV. The Cohen's κ value for intraobserver reliability was 0.891 (95% CI, 0.857-0.925).

Conclusions: The adapted classification system shows high interobserver and intraobserver reliabilities for grading of complications when applied to orthopaedic surgery looking at complications of hip preservation surgery. This grading scheme may facilitate standardization of complication reporting and make outcome studies more comparable.

文獻出處：Ernest L Sink, Michael Leunig, Ira Zaltz, Jennifer Claire Gilbert, John Clohisy; Academic Network for Conservational Hip Outcomes Research Group. Reliability of a complication classification system for orthopaedic surgery. Multicenter Study, Clin Orthop Relat Res. 2012 Aug;470(8):2220-6. doi: 10.1007/s11999-012-2343-2.

文獻5

機械力、激素及代謝因素對血管、血流和骨骼的影響

譯者 邱興

骨骼組織具有高度血管化特征，這源于骨骼血管在骨組織及骨髓功能中承擔的多重作用。例如，血管系統對骨骼的發育、維持與修復至關重要，負責輸送氧氣、營養物質、代謝廢物清除、全身性激素以及為骨重塑提供前體細胞。此外，骨骼血管還是血液和免疫細胞進出骨髓的通道。越來越多的證據表明，血管系統與骨骼系統在代謝調控、生理及病理過程中存在密切聯系。本文綜述了機械負荷、甲狀旁腺激素、雌激素、維生素D和降鈣素等被認為具有促成骨作用的因子如何對骨骼血管系統產生顯著影響。事實上，這些因子在影響骨骼之前會先作用于骨骼血管。數據進一步顯示，骨骼血管的舒張能力與骨小梁體積之間存在強關聯性，而雌激素狀態及子宮質量與骨小梁體積的關聯性較弱。此外，本文重點探討了骨微循環（特別是血管內皮和一氧化氮介導的信號傳導）在調節骨血流量、骨間質液流動與壓力以及骨細胞旁分泌信號傳導中的重要作用。最后，文章還分析了血管內皮作為骨骼健康與疾病中介因子的潛在意義。

關鍵詞：血管生成；骨形成與骨吸收；內皮；雌激素；運動

圖1 骨骼中的缺氧機制。急性缺氧（數秒至數分鐘）會引發骨骼動脈和小動脈的快速血管舒縮反應（即血管舒張和/或血管收縮），從而增加血流量并使局部環境中的氧分壓恢復正常。慢性缺氧（數天至數月）則是由于動脈和小動脈無法充分增加組織血流量和氧氣供應所致。在此情況下，為滿足組織需求將啟動血管生成過程。關于血管系統如何影響骨骼健康，需指出的是：隨著年齡增長和/或疾病發展，骨骼血管系統功能失調會導致小動脈舒張與收縮功能失衡，并限制血管生成能力。其結果是流向骨骼的血流量減少、氧氣輸送能力下降。在此情形下，缺氧的病因應歸結于骨骼血管網絡的功能障礙，而非骨骼代謝活動的增強。

圖A用于幫助讀者識別示意圖中的各種細胞結構。為簡化圖示，小動脈和小靜脈中的血管平滑肌細胞未予顯示，因此所描繪的細胞均為血管內皮細胞。圖B展示了破骨細胞進行骨吸收的過程（1）。在代謝增強過程中，破骨細胞釋放多種因子（如二氧化碳[CO?]、氫離子[H?]、磷酸鹽[PO?]、ADP、乳酸等），這些因子擴散至小動脈并引發代謝性血管舒張（2）。小動脈的代謝性血管舒張會進一步引起上游供血動脈和傳導動脈的上行性血管舒張（圖示未顯示）。這一過程被稱為傳導性血管舒張，它能確保代謝組織中血流量增加。圖C顯示了血管舒張及隨之增加的血流量（3）如何促進毛細血管（4）向骨間質空間（5）的濾過作用和壓力提升。骨間質壓力和液體流動的增加會對骨細胞產生剪切應力（圖D，6）。成骨細胞在剪切應力作用下釋放PGE?和一氧化氮（7），從而增強成骨細胞活性并抑制破骨細胞活性，減緩骨吸收并促進骨形成。此外，傳導性血管舒張帶來的血流量增加會增強血管內皮細胞的剪切應力（圖E，8）。 consequently，血管內皮細胞釋放的活性因子（如一氧化氮、PGE?、前列環素[PGI?]）會擴散至骨間質空間，刺激成骨細胞活性并抑制破骨細胞活性（9）。關于血管促進骨形成的理論此前已由Michael Delp實驗室提出（Colleran等，2000年）。需要說明的是，這些過程并非必須始于破骨細胞活動。例如，誘導骨血管網絡發生血管舒張的循環因子同樣可以啟動類似過程。

Mechanical, hormonal and metabolic influences on blood vessels, blood flow and bone

Bone tissue is highly vascularized due to the various roles bone blood vessels play in bone and bone marrow function. For example, the vascular system is critical for bone development, maintenance and repair and provides O2, nutrients, waste elimination, systemic hormones and precursor cells for bone remodeling. Further, bone blood vessels serve as egress and ingress routes for blood and immune cells to and from the bone marrow. It is becoming increasingly clear that the vascular and skeletal systems are intimately linked in metabolic regulation and physiological and pathological processes. This review examines how agents such as mechanical loading, parathyroid hormone, estrogen, vitamin D and calcitonin, all considered anabolic for bone, have tremendous impacts on the bone vasculature. In fact, these agents influence bone blood vessels prior to influencing bone. Further, data reveal strong associations between vasodilator capacity of bone blood vessels and trabecular bone volume, and poor associations between estrogen status and uterine mass and trabecular bone volume. Additionally, this review highlights the importance of the bone microcirculation, particularly the vascular endothelium and NO-mediated signaling, in the regulation of bone blood flow, bone interstitial fluid flow and pressure and the paracrine signaling of bone cells. Finally, the vascular endothelium as a mediator of bone health and disease is considered.

Keywords: angiogenesis; bone formation and resorption; endothelium; estrogen; exercise.

文獻出處：Prisby, Rhonda D. "Mechanical, hormonal and metabolic influences on blood vessels, blood flow and bone." Journal of Endocrinology 235, no. 3 (2017): R77-R100.

來源：304關節學術

作者：304關節團隊

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