髖膝關(guān)節(jié)文獻(xiàn)精譯薈萃（第373期）

本期目錄：

1、未置換髕骨的全膝關(guān)節(jié)置換術(shù)中，髕骨周緣去神經(jīng)化不能減輕膝前痛

2、全髖關(guān)節(jié)置換術(shù)治療髖臼周圍截骨術(shù)后患者在中期隨訪中髖關(guān)節(jié)功能顯著改善且翻修率較低

3、預(yù)期難以預(yù)料的意外：日間手術(shù)中心施行初次關(guān)節(jié)置換手術(shù)術(shù)中并發(fā)癥的發(fā)生率和處理

4、全膝關(guān)節(jié)置換中使用止血帶與不使用止血帶的中長期術(shù)后隨訪比較

5、機(jī)器人輔助全膝關(guān)節(jié)置換術(shù)聯(lián)合金屬墊塊增強(qiáng)治療合并脛骨缺損的嚴(yán)重膝內(nèi)翻畸形

6、胚胎期和胎兒早期骨盆骨骼的軟骨形成

7、不同測量方法評(píng)估股骨扭轉(zhuǎn)的差異在股骨過度扭轉(zhuǎn)的髖關(guān)節(jié)中顯著增大

8、髖臼周圍截骨術(shù)治療發(fā)育性髖關(guān)節(jié)發(fā)育不良：首批44例病例的初步經(jīng)驗(yàn)和結(jié)果

9、股骨頭壞死中軟骨下骨深部變化的CT與MRI表現(xiàn)用于區(qū)分ARCO 2期與3A期

01

第一部分：關(guān)節(jié)置換及保膝相關(guān)文獻(xiàn)

文獻(xiàn)1

未置換髕骨的全膝關(guān)節(jié)置換術(shù)中，髕骨周緣去神經(jīng)化不能減輕膝前痛：前瞻性比較

譯者 張軼超

背景：本研究旨在評(píng)估髕骨周緣去神經(jīng)化在髕骨未行表面置換的全膝關(guān)節(jié)置換術(shù)（TKA）后減輕膝前痛（AKP）和改善臨床結(jié)果的有效性。

材料和方法：這項(xiàng)前瞻性、非隨機(jī)、觀察性研究納入了2023年8月至2024年1月期間在我院接受初次TKA的患者。患者分為兩組：接受髕骨去神經(jīng)化的患者（PD組）和未接受髕骨去神經(jīng)化的患者（NPD組）。主要結(jié)果是通過視覺模擬評(píng)分（VAS）評(píng)測膝前痛（AKP）的減輕情況。次要結(jié)果包括Kujala膝關(guān)節(jié)評(píng)分、西安大略和麥克馬斯特大學(xué)關(guān)節(jié)炎指數(shù)（WOMAC）和活動(dòng)范圍（ROM）。術(shù)前及術(shù)后3、6個(gè)月進(jìn)行評(píng)估。

結(jié)果：PD組4例、NPD組5例患者因未能完成隨訪而被排除在研究之外。最終納入女性74例，男性16例，平均年齡67.4±4.2歲。兩組患者在年齡、性別、手術(shù)側(cè)、身高、體重、BMI、髕股關(guān)節(jié)骨關(guān)節(jié)炎分級(jí)、術(shù)前ROM、VAS評(píng)分、Kujala評(píng)分和WOMAC評(píng)分方面無顯著差異（所有變量p: 無差異）。VAS、Kujala和WOMAC評(píng)分在任何時(shí)間點(diǎn)組間均無顯著差異（p: n.s）。重復(fù)測量方差分析表明，隨著時(shí)間的推移，這些評(píng)分有了顯著的改善（兩組的p=0.001）。兩兩比較顯示術(shù)前至術(shù)后第3個(gè)月和第6個(gè)月以及術(shù)后第3個(gè)月至第6個(gè)月均有顯著改善（所有比較p=0.001）。兩組在第3個(gè)月時(shí)膝關(guān)節(jié)活動(dòng)度均有所下降，6個(gè)月時(shí)恢復(fù)到術(shù)前水平，兩組間無顯著差異。研究期間無并發(fā)癥發(fā)生。

結(jié)論：與未行髕骨置換的TKA未去神經(jīng)化相比，髕骨周緣去神經(jīng)化在減輕膝前痛或改善功能效果方面沒有額外的益處。

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.

文獻(xiàn)出處：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.

文獻(xiàn)2

全髖關(guān)節(jié)置換術(shù)治療髖臼周圍截骨術(shù)后患者在中期隨訪中髖關(guān)節(jié)功能顯著改善且翻修率較低

譯者 馬云青

研究背景：伯爾尼髖臼周圍截骨術(shù)能改善髖臼發(fā)育不良患者的癥狀并延緩?fù)诵行愿淖儭Ｈ欢渲性S多患者最終仍需接受全髖關(guān)節(jié)置換術(shù)。PAO對(duì)后續(xù)THA結(jié)果的影響尚不明確。

作者研究旨在明確：1）臨床結(jié)果，2）術(shù)后并發(fā)癥，3）既往同側(cè)PAO后接受THA患者的假體生存率。

研究方法：本研究在三家機(jī)構(gòu)進(jìn)行了回顧性分析，以確定在同側(cè)PAO術(shù)后接受THA且至少隨訪1年的患者。收集了術(shù)前和末次隨訪時(shí)的患者報(bào)告結(jié)局指標(biāo)。通過查閱醫(yī)療記錄，記錄了手術(shù)細(xì)節(jié)、影像學(xué)和臨床結(jié)果，以及根據(jù)改良Dindo-Clavien分級(jí)系統(tǒng)判定的主要并發(fā)癥。使用回歸分析t檢驗(yàn)比較術(shù)前和術(shù)后結(jié)局評(píng)分。采用Kaplan-Meier分析評(píng)估假體生存率。

結(jié)果：作者共確定112名患者的113例THA。其中103例髖關(guān)節(jié)獲得至少1年隨訪，平均隨訪時(shí)間為5±4年（范圍1至20年）。10例髖關(guān)節(jié)（9%）失訪，剩下103例（91%）可供研究，且隨訪時(shí)間至少1年（平均5年）。從PAO到THA的平均間隔時(shí)間為7.7年（范圍2-15年）。與術(shù)前評(píng)分相比，術(shù)后平均mHHS評(píng)分提高了37分（從50分提高到87分，P < 0.001）。8名患者（7.1%）發(fā)生了主要（III-V級(jí)）手術(shù)并發(fā)癥。包括2例關(guān)節(jié)不穩(wěn)、2例髖臼假體松動(dòng)，以及各1例假體周圍骨折、傷口裂開、假體周圍感染、髖臼假體松動(dòng)和肺炎。失敗發(fā)生較早，平均為術(shù)后3.2年。全因翻修的生存率分析顯示，5年和10年生存率均為96%。

結(jié)論：在PAO術(shù)后接受THA可獲得顯著的臨床改善，中期隨訪顯示生存率令人滿意（96%），主要并發(fā)癥發(fā)生率為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.

文獻(xiàn)出處：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.

文獻(xiàn)3

預(yù)期難以預(yù)料的意外：日間手術(shù)中心施行初次關(guān)節(jié)置換手術(shù)術(shù)中并發(fā)癥的發(fā)生率和處理

譯者 張薔

背景：初次關(guān)節(jié)置換手術(shù)（TJA）在近些年逐漸由中心手術(shù)室轉(zhuǎn)為日間手術(shù)中心（ASCs）施行。然而，日間手術(shù)中心通常手術(shù)資源有限，包括手術(shù)器械和翻修假體的選擇均受到限制。術(shù)前難以預(yù)料的術(shù)中并發(fā)癥通常需要翻修假體，而這會(huì)顯著增加手術(shù)時(shí)間、花費(fèi)和患者相關(guān)風(fēng)險(xiǎn)。既往文獻(xiàn)中鮮有資料記載需要特殊假體來處理的初次關(guān)節(jié)置換術(shù)中并發(fā)癥率。因此，本研究旨在評(píng)估初次關(guān)節(jié)置換術(shù)中計(jì)劃外并發(fā)癥的發(fā)生率、指證和類型，以改善日間手術(shù)患者的準(zhǔn)備狀態(tài)、優(yōu)化日間手術(shù)中心資源配置。

方法：我們選擇單一醫(yī)療中心自2021年1年至2024年10月間初次全髖關(guān)節(jié)置換（THA）和初次全膝關(guān)節(jié)置換（TKA）的手術(shù)病例來施行回顧性研究。本研究包含了施行初次關(guān)節(jié)置換手術(shù)時(shí)術(shù)中遇到計(jì)劃外并發(fā)癥并應(yīng)用特殊假體的病例。特殊假體包括Cone錐度補(bǔ)塊、環(huán)扎鋼纜、鋼板、組配或一體式翻修柄、內(nèi)-外翻限制性假體（VVC）和帶延長桿的股骨假體。通過病例回顧，我們篩選出了必須使用翻修假體的病例。此外，我們還收集了患者一般信息，如年齡、性別、吸煙情況和Charlson合并癥指數(shù)等。

結(jié)果：在1307例TKA病例中，有5例（0.4%）因?yàn)閮?nèi)（n = 3）或外（n = 2）側(cè)副韌帶損傷而需要應(yīng)用內(nèi)-外翻限制性假體。在1061例THA病例中，有9例（0.9%）需要特殊假體，包括8例術(shù)中假體周圍骨折而進(jìn)行鋼纜環(huán)扎的病例，其中1例應(yīng)用了組配式股骨柄。另外1例因?yàn)楣晒沁^度后傾而應(yīng)用了一體化股骨柄。

結(jié)論：據(jù)我們所知，本文是第一篇評(píng)估日間手術(shù)中心施行的初次關(guān)節(jié)置換術(shù)中并發(fā)癥率的文章，揭示出較低的術(shù)中并發(fā)癥率（TKA 0.4%，THA 0.9%）。確保備好關(guān)鍵假體可以減少日間關(guān)節(jié)置換手術(shù)延遲情況、降低手術(shù)風(fēng)險(xiǎn)，維持最佳的術(shù)后療效。

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.

文獻(xiàn)出處：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.

文獻(xiàn)4

全膝關(guān)節(jié)置換中使用止血帶與不使用止血帶的中長期術(shù)后隨訪比較

譯者 丁云鵬

背景：在全膝關(guān)節(jié)置換術(shù)（TKA）中應(yīng)用非止血帶技術(shù)日益普及，但其對(duì)膝關(guān)節(jié)假體使用壽命的影響尚未形成共識(shí)。本研究通過探討止血帶使用對(duì)骨水泥滲透及假體周圍透亮線（RLL）的影響，評(píng)估TKA術(shù)中止血帶應(yīng)用是否影響假體生存率。

方法：回顧性分析2014年1月1日至2015年6月1日期間收治的符合入選標(biāo)準(zhǔn)的166例患者，根據(jù)術(shù)中使用止血帶情況分為止血帶組（80例）與非止血帶組（86例）。比較兩組術(shù)前資料及相關(guān)并發(fā)癥，基于術(shù)后影像學(xué)數(shù)據(jù)測量髖-膝-踝角（HKA）、脛骨近端內(nèi)側(cè)角（MPTA）及截骨面骨水泥滲透深度，并觀察假體周圍出現(xiàn)透亮線的概率。

結(jié)果：共納入166例患者，平均年齡68.52±4.74歲，平均隨訪時(shí)間105.67±5.98年。兩組人口統(tǒng)計(jì)學(xué)資料無顯著差異（P>0.05）。兩組各有1例因假體無菌性松動(dòng)行翻修手術(shù)。術(shù)前及術(shù)后膝關(guān)節(jié)協(xié)會(huì)功能評(píng)分（HSS）、膝關(guān)節(jié)活動(dòng)度、HKA、MPTA在兩組間均無顯著差異（P>0.05）。在股骨3A區(qū)外側(cè)觀察區(qū)及股骨平均觀察區(qū)，兩組截骨面骨水泥滲透深度存在顯著差異（P<0.05）。不同觀察區(qū)域透亮線發(fā)生率兩組間略有差異，但翻修率無顯著統(tǒng)計(jì)學(xué)差異（P>0.05）。

結(jié)論：長期隨訪顯示，非止血帶TKA在假體穩(wěn)定性、假體生存率、再手術(shù)率、膝關(guān)節(jié)活動(dòng)度及膝關(guān)節(jié)功能等多個(gè)方面均可達(dá)到與使用止血帶相當(dāng)?shù)呐R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.

文獻(xiàn)出處：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.

文獻(xiàn)5

機(jī)器人輔助全膝關(guān)節(jié)置換術(shù)聯(lián)合金屬墊塊增強(qiáng)治療合并脛骨缺損的嚴(yán)重膝內(nèi)翻畸形

譯者 沈松坡

背景

對(duì)于合并非包容性脛骨內(nèi)側(cè)骨缺損的重度膝內(nèi)翻畸形患者行全膝關(guān)節(jié)置換術(shù)（TKA），由于需要額外的骨切除以去除骨缺損區(qū)域、應(yīng)用金屬增強(qiáng)墊塊以及調(diào)整軟組織平衡，技術(shù)上仍然對(duì)骨科醫(yī)生構(gòu)成挑戰(zhàn)。機(jī)器人技術(shù)已被證實(shí)可在TKA中實(shí)現(xiàn)精確的骨切除和最佳的軟組織平衡。本研究旨在報(bào)告機(jī)器人輔助TKA聯(lián)合金屬增強(qiáng)塊治療嚴(yán)重膝內(nèi)翻畸形的病例系列。

方法

本研究納入15例患者，共22膝，術(shù)后隨訪時(shí)間均超過12個(gè)月。所有患者均在機(jī)器人技術(shù)輔助下行初次TKA聯(lián)合金屬增強(qiáng)墊塊。評(píng)估內(nèi)容包括假體植入位置、軟組織平衡及臨床療效。

結(jié)果

視覺模擬評(píng)分（VAS）及膝關(guān)節(jié)損傷與骨關(guān)節(jié)炎結(jié)局評(píng)分（KOOS）均較術(shù)前顯著改善。此外，下肢力線及假體在冠狀位和矢狀位的植入位置在影像學(xué)上均表現(xiàn)出較高的準(zhǔn)確性。術(shù)后內(nèi)側(cè)膝關(guān)節(jié)穩(wěn)定性得以維持，而外側(cè)松弛度明顯降低。

結(jié)論

在傳統(tǒng)TKA中，將骨缺損區(qū)域切除至與金屬增強(qiáng)塊深度完全一致在技術(shù)上具有較大難度。然而，借助機(jī)器人技術(shù)，不僅可完成初始骨切除，還可對(duì)殘余骨缺損進(jìn)行評(píng)估、調(diào)整軟組織平衡，并準(zhǔn)確完成額外骨切除。因此，機(jī)器人技術(shù)在合并內(nèi)側(cè)脛骨骨缺損的嚴(yán)重膝內(nèi)翻畸形患者行金屬墊塊增強(qiáng)TKA中具有潛在優(yōu)勢。

關(guān)鍵詞（Keywords）：膝骨關(guān)節(jié)炎；全膝關(guān)節(jié)置換術(shù)；脛骨骨缺損；金屬墊塊增強(qiáng)；機(jī)器人技術(shù)

圖1術(shù)前影像學(xué)表現(xiàn)及術(shù)前手術(shù)規(guī)劃。

（a）–（c）為一名79歲女性患者的術(shù)前影像學(xué)資料，分別為正位、側(cè)位及下肢全長正位片。股脛角（FTA）為201°，髖-膝-踝角（HKA）為 -24°。

（d）術(shù)前手術(shù)規(guī)劃顯示，在完成初次脛骨骨切除后，預(yù)測內(nèi)側(cè)脛骨骨缺損仍將殘留。虛線圓圈表示骨缺損區(qū)域。圖1–3及補(bǔ)充資料1–3所示數(shù)據(jù)均來源于同一名患者。

圖2初次脛骨骨切除。

（a）術(shù)前脛骨規(guī)劃顯示，藍(lán)色區(qū)域?yàn)轭A(yù)測將在初次脛骨骨切除中被切除的區(qū)域。

（b）預(yù)測的初次脛骨切除后骨面顯示內(nèi)側(cè)脛骨仍殘留骨缺損。

肉眼觀察結(jié)果顯示，殘余脛骨骨缺損的形態(tài)（c）及深度（d）與（a）和（b）所示一致。虛線圓圈表示骨缺損區(qū)域。

圖3額外脛骨骨切除。

（a）額外5 mm脛骨切除的術(shù)前規(guī)劃顯示，藍(lán)色區(qū)域?yàn)轭A(yù)測將被切除的部分。

（b）實(shí)施額外脛骨切除（白色區(qū)域），其尺寸與半塊金屬增強(qiáng)塊完全一致。

（c）切除的骨塊證實(shí)了額外脛骨切除的準(zhǔn)確性。

（d）切除后的骨面平整，并與術(shù)前規(guī)劃圖像高度一致。虛線圓圈表示額外骨切除區(qū)域。

圖4術(shù)后肉眼及影像學(xué)表現(xiàn)。

（a）聯(lián)合金屬增強(qiáng)塊的假體與脛骨貼合良好。

影像學(xué)評(píng)估顯示，假體位置及下肢力線均準(zhǔn)確恢復(fù)（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.

文獻(xiàn)出處：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：保髖相關(guān)文獻(xiàn)

文獻(xiàn)1

胚胎期和胎兒早期骨盆骨骼的軟骨形成

譯者 任寧濤

骨盆骨骼是通過軟骨內(nèi)骨化形成的。然而，目前尚不清楚正常軟骨是如何在骨化發(fā)生前形成的。此外，骨盆軟骨形成的總體時(shí)間和軟骨形態(tài)尚不清楚。本研究使用相位對(duì)比計(jì)算機(jī)斷層掃描和7T磁共振成像，觀察了25例人類胎兒(冠-臀長[CRL] = 11.9-75.0 mm)骨盆骨骼的軟骨形成。髂骨、坐骨、恥骨的軟骨中心在卡內(nèi)基期(CS) 18首次同時(shí)出現(xiàn)，位于髖臼周圍，后期呈放射狀生長。髂嵴在CS20階段形成，而髂體中央部分仍呈軟骨狀。髂骨體在CS22階段形成一個(gè)盤狀結(jié)構(gòu)。髂骨的生長速率大于骶骨-尾骨、恥骨和坐骨。在有限的時(shí)間內(nèi)形成連接和關(guān)節(jié)，骶髂關(guān)節(jié)在CS21階段形成。在CS23階段可觀察到恥骨聯(lián)合關(guān)節(jié)、骶髂關(guān)節(jié)連接、髖骨三部分與髖臼Y形連接;在胎兒早期（EF）觀察到坐骨和恥骨分支的連接。此外，在不同的樣本中，骶骨中心的連接程度也不同。大多數(shù)盆腔測量數(shù)據(jù)顯示與CRL高度相關(guān)。小骨盆入口的橫向徑和前后徑在不同的樣本中存在差異(R2 = 0.11)。恥骨下角也有變化(65 ~ 90°)，與CRL無關(guān)(R2 = 0.22)。此外，軟骨結(jié)構(gòu)的形成似乎影響骨結(jié)構(gòu)。這項(xiàng)研究為骨盆結(jié)構(gòu)的形態(tài)發(fā)生提供了有價(jià)值的信息。

圖1 盆腔環(huán)形成。骨盆骨骼軟骨形成的三維重建視圖。藍(lán)色：股骨; 綠色：恥骨; 淺藍(lán)色：尾骨; 橙色：主動(dòng)脈和髂總動(dòng)脈。紫色：髂骨; 紅色：骶骨; 黃色：坐骨。括號(hào)中的數(shù)字為CRL (mm)。刻度條表示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.

文獻(xiàn)出處：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.

文獻(xiàn)2

不同測量方法評(píng)估股骨扭轉(zhuǎn)的差異在股骨過度扭轉(zhuǎn)的髖關(guān)節(jié)中顯著增大

譯者 李勇

背景：準(zhǔn)確量化股骨扭轉(zhuǎn)對(duì)于診斷扭轉(zhuǎn)畸形、確定手術(shù)適應(yīng)證以及規(guī)劃矯形量至關(guān)重要。然而，截至目前，尚無研究針對(duì)股骨過度扭轉(zhuǎn)的髖關(guān)節(jié)明確評(píng)估不同股骨扭轉(zhuǎn)測量方法之間的差異。

研究目的：(1) 五種常用的基于 CT 的股骨扭轉(zhuǎn)測量方法之間有何差異？(2) 在股骨過度扭轉(zhuǎn)的髖關(guān)節(jié)中，這些測量方法之間的差異是否會(huì)隨之增大？(3) 這五種扭轉(zhuǎn)測量方法各自的信度和重復(fù)性如何？

方法：在 2016 年 3 月至 8 月期間，我院（三級(jí)醫(yī)療中心）門診接診了 86 名（95 側(cè)髖關(guān)節(jié)）主訴為髖部疼痛且體格檢查懷疑為股骨頭髖臼撞擊綜合征（FAI）的新診患者。其中，56 名患者（62 側(cè)髖關(guān)節(jié)）接受了包含股骨遠(yuǎn)端在內(nèi)的全長盆腔 CT 掃描以測量股骨扭轉(zhuǎn)。我們排除了 7 名（7 側(cè)）既往接受過髖關(guān)節(jié)手術(shù)的患者、2 名（2 側(cè)）Legg-Calvé-Perthes 病（股骨頭缺血性壞死）后遺癥患者以及 1 名（1 側(cè)）創(chuàng)傷后畸形患者。最終納入的研究小組包含 46 名患者（52 側(cè)髖關(guān)節(jié)），平均年齡 28 ± 9 歲（范圍 17-51 歲），女性 27 名（59%）。

研究對(duì)比了五種常用的評(píng)估方法，即：Lee 法、Reiker?s 法、Jarrett 法、Tomczak 法和 Murphy 法。這些方法的主要區(qū)別在于股骨頸近端軸線的解剖參考層面：Lee 法采用的定義最靠近近端，其次是位于股骨頸基底部的 Reiker?s 法、Jarrett 法和 Tomczak 法，而 Murphy 法采用的定義最靠近遠(yuǎn)端（位于小轉(zhuǎn)子層面）。所有五種方法的股骨頭中心定義和遠(yuǎn)端參考標(biāo)準(zhǔn)均保持一致。

我們使用 Murphy 法作為股骨扭轉(zhuǎn)測量的基準(zhǔn)方法，因?yàn)閾?jù)報(bào)道該方法最接近真實(shí)的股骨解剖扭轉(zhuǎn)。采用該方法測得的平均股骨扭轉(zhuǎn)角為 28° ± 13°。使用多變量方差分析比較五種方法測得的股骨扭轉(zhuǎn)平均值。通過在整個(gè)股骨扭轉(zhuǎn)范圍內(nèi)繪制任意兩種測量方法之間的差異曲線，以評(píng)估在股骨過度扭轉(zhuǎn)的髖關(guān)節(jié)中差異是否增加。所有測量由兩名不知情的骨科住院醫(yī)師（FS, TDL）在兩個(gè)不同時(shí)間點(diǎn)獨(dú)立完成，并使用組內(nèi)相關(guān)系數(shù)（ICCs）評(píng)估觀察者內(nèi)重復(fù)性和觀察者間信度。

結(jié)果：我們發(fā)現(xiàn)，隨著股骨頸近端軸線定義越趨向遠(yuǎn)端，測得的股骨扭轉(zhuǎn)值越高：Lee 法（定義最靠近端：11° ± 11°）、Reiker?s 法（15° ± 11°）、Jarrett 法（19° ± 11°）、Tomczak 法（25° ± 12°）以及 Murphy 法（定義最靠遠(yuǎn)端：28° ± 13°）。差異最顯著的是 Lee 法與 Murphy 法之間的對(duì)比，平均差值達(dá) 17° ± 5°（95% 置信區(qū)間，16°-19°；p < 0.001）。在 10 組可能的兩兩比較中，有 6 組顯示方法間的差異隨股骨扭轉(zhuǎn)角的增大而增大，隨其減小而減小。任何方法與 Murphy 法相比，以及 Reiker?s 法和 Jarrett 法與 Tomczak 法相比，均觀察到中度至強(qiáng)度的線性相關(guān)（R 范圍為 0.306-0.622；所有 p 值 < 0.05）。例如，根據(jù) Murphy 法測量扭轉(zhuǎn)角為 10° 的髖關(guān)節(jié)，根據(jù) Reiker?s 法測得僅為 1°，差異為 9°；而在過度扭轉(zhuǎn)的髖關(guān)節(jié)中，這一差異增加到了 20°（例如：Murphy 法測得 60°，則 Reiker?s 法測得約為 40°）。所有五種測量方法在觀察者內(nèi)重復(fù)性（ICC 0.905-0.973）和觀察者間信度（ICC 0.938-0.969）方面均表現(xiàn)優(yōu)異。

結(jié)論：由于股骨扭轉(zhuǎn)角在過度扭轉(zhuǎn)的髖關(guān)節(jié)中因測量方法不同而存在顯著差異，因此在報(bào)告股骨扭轉(zhuǎn)數(shù)值時(shí)，必須注明所采用的具體測量方法，并保持測量方法的一致性。在制定手術(shù)決策和規(guī)劃矯正角度時(shí)，必須考慮到這些差異。忽視不同測量方法之間的量化差異，可能會(huì)導(dǎo)致誤診及手術(shù)規(guī)劃錯(cuò)誤。

圖1 示意圖展示了用于基于CT測量股骨扭轉(zhuǎn)的五種不同方法。藍(lán)色線條代表基于真實(shí)軸位切面的方法（A-D）；綠色線條代表基于軸斜位圖像的方法（E）。所有五種方法均以股骨頭中心和股骨遠(yuǎn)端后髁作為標(biāo)志點(diǎn)。它們的區(qū)別在于對(duì)近端股骨參考軸的定義，該參考軸的位置從近端（A）向遠(yuǎn)端（D）逐步移動(dòng)。

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., Reiker?s 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 Reiker?s, 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°), Reiker?s 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 Reiker?s 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 Reiker?s, 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 Reiker?s. 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.

文獻(xiàn)出處：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.

文獻(xiàn)3

髖臼周圍截骨術(shù)治療發(fā)育性髖關(guān)節(jié)發(fā)育不良：首批44例病例的初步經(jīng)驗(yàn)和結(jié)果

譯者 陶可

目的：描述伯爾尼髖臼周圍截骨術(shù)(PAO)治療發(fā)育性髖關(guān)節(jié)發(fā)育不良的手術(shù)技巧、適應(yīng)癥和初步結(jié)果。

材料與方法：2011年5月至2020年5月，共對(duì)44例患者（35例女性，平均年齡30歲，23-38歲）進(jìn)行了44次髖臼周圍截骨術(shù)（PAO）。所有患者均被診斷為癥狀性髖關(guān)節(jié)發(fā)育不良。平均中心邊緣角為17°（9-20°），平均髖臼指數(shù)為18°（15-20°）。其中22例患者在同一手術(shù)階段通過髖關(guān)節(jié)鏡評(píng)估并修復(fù)了髖關(guān)節(jié)內(nèi)病變。評(píng)估了矯正效果、截骨愈合情況以及隨訪結(jié)束時(shí)的功能結(jié)果。

結(jié)果：22例患者存在與髖關(guān)節(jié)發(fā)育不良相關(guān)的髖臼唇肥厚和撕裂。10例患者發(fā)現(xiàn)髖臼唇旁囊腫。術(shù)后平均中心邊緣角為32°（27°至35°），髖臼指數(shù)為6°（4°至9°）。PAO手術(shù)時(shí)間為130分鐘；若同時(shí)進(jìn)行關(guān)節(jié)鏡手術(shù)，則手術(shù)時(shí)間為148分鐘。

結(jié)論：PAO手術(shù)技術(shù)難度較高，但對(duì)于髖關(guān)節(jié)軟骨完整且畸形可矯正的患者，其療效可預(yù)測。截骨術(shù)前進(jìn)行髖關(guān)節(jié)鏡檢查有助于評(píng)估軟骨狀況，診斷和治療與該病理相關(guān)的髖關(guān)節(jié)內(nèi)病變，并判斷是否需要矯正軟組織缺損。

圖1 A.一名21歲右髖關(guān)節(jié)發(fā)育不良癥狀患者的術(shù)前髖關(guān)節(jié)正位X線片。B.術(shù)前影像顯示髖臼前后壁交叉征。C.術(shù)后影像顯示伯爾尼髖臼周圍截骨術(shù)的骨愈合情況；注意髖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.

文獻(xiàn)出處：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.

文獻(xiàn)4

股骨頭壞死中軟骨下骨深部變化的CT與MRI表現(xiàn)用于區(qū)分ARCO 2期與3A期

譯者 邱興

目的： 探討股骨頭壞死中軟骨下骨以遠(yuǎn)深部變化對(duì)于區(qū)分國際骨循環(huán)研究協(xié)會(huì)分期中ARCO 2期與3A期的診斷價(jià)值。
方法： 這項(xiàng)回顧性研究納入了2017年5月至2022年8月期間的124例股骨頭壞死髖關(guān)節(jié)，包括2期49例和3A期75例，所有病例均接受了CT檢查，其中85例同時(shí)接受了MRI檢查。分析CT上的深部變化以及MRI上的深部變化。評(píng)估了這些征象診斷3A期的效能，并進(jìn)行了多變量分析。
結(jié)果： 與2期相比，3A期更頻繁地出現(xiàn)骨吸收區(qū)、囊性變、骨髓水腫及關(guān)節(jié)積液。對(duì)于診斷3A期，骨吸收區(qū)和囊性變顯示出較低的敏感性但較高的特異性；而骨髓水腫和關(guān)節(jié)積液則顯示出較高的敏感性但較低的特異性。多變量分析顯示，預(yù)測3A期的征象按效力高低依次為：骨吸收區(qū)、囊性變、關(guān)節(jié)積液；而骨吸收區(qū)合并囊性變的組合具有最佳的預(yù)測價(jià)值。
結(jié)論： 在深部變化中，骨吸收區(qū)和囊性變對(duì)診斷ARCO 3A期具有高特異性，而骨髓水腫和關(guān)節(jié)積液則具有高敏感性。骨吸收區(qū)合并囊性變的組合對(duì)于預(yù)測ARCO 3A期具有最佳的診斷價(jià)值。
關(guān)鍵點(diǎn)： ? 準(zhǔn)確區(qū)分ARCO 2期與3A期至關(guān)重要，但僅依靠軟骨下骨折有時(shí)難以鑒別，尤其是在股骨頭輪廓尚存的早期塌陷后階段。? 預(yù)測3A期的征象效力順序?yàn)椋汗俏諈^(qū)、囊性變、關(guān)節(jié)積液；骨吸收區(qū)合并囊性變的組合預(yù)測價(jià)值最佳。? 分析軟骨下骨以遠(yuǎn)的深部變化可能有助于更輕松地區(qū)分ARCO 2期與3A期。
關(guān)鍵詞： 股骨頭壞死；磁共振成像；骨壞死；體層攝影術(shù)，X線計(jì)算機(jī)

圖1 2019版修訂ARCO 3期標(biāo)準(zhǔn)中介紹的軟骨下骨折、壞死區(qū)內(nèi)骨折及股骨頭變平的CT表現(xiàn)：冠狀面重組CT圖像顯示：(a) 與新月征相關(guān)的軟骨下骨折（粗箭頭，新月征用細(xì)箭頭標(biāo)示）；(b) 伴有骨吸收區(qū)的軟骨下骨折（粗箭頭，骨吸收區(qū)用細(xì)箭頭標(biāo)示）；(c) 連接骨吸收區(qū)的壞死區(qū)內(nèi)骨折（粗箭頭，骨吸收區(qū)用細(xì)箭頭標(biāo)示）；(d) 股骨頭變平（粗箭頭），伴壞死區(qū)與硬化反應(yīng)界面之間的塌陷（細(xì)箭頭標(biāo)示）。

圖2 軟骨下骨深部變化的CT表現(xiàn)，包括骨吸收區(qū)與囊性變：骨吸收區(qū)與囊性變的定位劃分方法如下：(a) 在冠狀面重組圖像上，通過兩條線劃分為C1–C3區(qū)；(b) 在軸位圖像上，通過兩條線將股骨頭劃分為四個(gè)象限。這些表現(xiàn)還可根據(jù)其與硬化反應(yīng)界面的位置關(guān)系，分為界面內(nèi)側(cè)或外側(cè)。(c, d) 骨吸收區(qū)表現(xiàn)為與硬化反應(yīng)界面相連的透亮區(qū)（d圖中細(xì)箭頭標(biāo)示界面），且無周圍硬化邊（c和d圖中粗箭頭標(biāo)示）。此病例報(bào)告為骨吸收區(qū)位于C1及A1–2區(qū)，且在硬化反應(yīng)界面內(nèi)側(cè)。注意伴隨骨吸收區(qū)的軟骨下骨折（c圖中箭頭標(biāo)示），提示為ARCO 3A期。(e, f) 囊性變表現(xiàn)為囊性病灶形成，與硬化反應(yīng)界面相連（f圖中細(xì)箭頭標(biāo)示界面），且有周圍硬化邊（e和f圖中粗箭頭標(biāo)示）。此病例報(bào)告為囊性變位于C2及A2區(qū)，且在硬化反應(yīng)界面的外側(cè)。注意伴隨新月征的軟骨下骨折（e圖中箭頭標(biāo)示），提示為ARCO 3A期。

圖3 軟骨下骨深部變化的MRI表現(xiàn)，包括骨髓水腫與關(guān)節(jié)積液: 冠狀位T2加權(quán)脂肪抑制圖像顯示股骨頭壞死區(qū)（圖a-d中的細(xì)箭頭標(biāo)示）。(a) 壞死區(qū)周圍可見T2高信號(hào)的肉芽組織，而非骨髓水腫（分級(jí)為0級(jí)，即無骨髓水腫）。注意關(guān)節(jié)積液量極少，寬度<5 mm（箭頭標(biāo)示），歸類為關(guān)節(jié)積液“陰性”。(b) 壞死區(qū)伴有1級(jí)骨髓水腫，局限于股骨頭內(nèi)（粗箭頭標(biāo)示）。注意明確的關(guān)節(jié)積液伴關(guān)節(jié)囊隱窩擴(kuò)張（箭頭標(biāo)示），歸類為關(guān)節(jié)積液“陽性”。(c) 壞死區(qū)伴有2級(jí)骨髓水腫，延伸至股骨頸（粗箭頭標(biāo)示）。注意明確的關(guān)節(jié)積液伴關(guān)節(jié)囊隱窩擴(kuò)張（箭頭標(biāo)示），歸類為關(guān)節(jié)積液“陽性”。(d) 壞死區(qū)伴有3級(jí)骨髓水腫，延伸至轉(zhuǎn)子間區(qū)域（粗箭頭標(biāo)示）。注意明顯的關(guān)節(jié)積液，寬度≥5 mm（箭頭標(biāo)示），歸類為關(guān)節(jié)積液“陽性”。

圖4 維持股骨頭球形輪廓的ARCO 3A期病例及其相關(guān)的CT與MRI深部變化表現(xiàn)
a–c 一位42歲女性，患有伴新月征的3A期病變：圖a、b冠狀位重組CT圖像顯示位于硬化反應(yīng)界面內(nèi)側(cè)的骨吸收區(qū)，以及伴有新月征的軟骨下骨折，提示為ARCO 3A期。圖c冠狀位T2加權(quán)脂肪抑制圖像顯示高信號(hào)的新月征、延伸至股骨頸的骨髓水腫以及擴(kuò)張的關(guān)節(jié)囊隱窩。d–f 一位64歲男性，患有伴軟骨下及皮質(zhì)骨折的3A期病變：圖d、e冠狀位重組CT圖像顯示位于硬化反應(yīng)界面外側(cè)的囊性變，以及伴有骨吸收區(qū)的軟骨下及皮質(zhì)骨折，提示為ARCO 3A期。圖f冠狀位T2加權(quán)脂肪抑制圖像顯示延伸至股骨頸的骨髓水腫以及擴(kuò)張的關(guān)節(jié)囊隱窩。

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.

文獻(xiàn)出處：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.

來源：304關(guān)節(jié)學(xué)術(shù)

作者：304關(guān)節(jié)團(tuán)隊(duì)

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