髖膝關節(jié)文獻精譯薈萃（第377期）

本期目錄：

1、關節(jié)液細胞因子和MSIS標準不能用于確定假體周圍感染清除后感染是否真的得到控制

2、全髖關節(jié)翻修術中應用全新骨刀系統(tǒng)行股骨柄假體取出的效果分析

3、采用傳統(tǒng)器械的非骨水泥型、保留交叉韌帶初次全膝關節(jié)置換術：技術要點與術中注意事項

4、技術的應用是否會影響全膝關節(jié)置換術中麻醉下松解術的發(fā)生率

5、基于“步態(tài)-肌肉-骨骼系統(tǒng)-有限元”個性化建模方法的步態(tài)周期內髖關節(jié)接觸應力變化

6、計算機輔助與傳統(tǒng)髖臼周圍截骨術治療髖關節(jié)發(fā)育不良的療效比較

7、計算機輔助手術可預防髖臼周圍截骨術并發(fā)癥

8、人類股骨頭軟骨下骨密度分布

第一部分：關節(jié)置換及保膝相關文獻

文獻1

關節(jié)液細胞因子和MSIS標準不能用于確定假體周圍感染清除后感染是否真的得到控制

譯者 張軼超

背景：診斷假體周圍感染（PJI）需要結合臨床和實驗室檢查結果，這些措施可能比較昂貴且難以明確診斷。關節(jié)液細胞因子已被證明可以準確鑒別感染性和無菌性全膝關節(jié)（TKA）和全髖關節(jié)（THA）置換術的失敗。然而，經(jīng)過第一階段清理術后，在第二階段再植入手術之前，仍然沒有可靠的測試來排除是否還存在PJI。

問題/目的：(1)哪個關節(jié)液細胞因子對PJI的診斷準確性最高？(2)同一患者，在一期清理后和再植入新假體之前，哪種細胞因子的明顯下降與感染的控制相關？(3)關節(jié)液細胞因子和肌肉骨骼感染學會（MSIS）標準在第一期清理后排除PJI的準確性如何？(4)文獻中研究最多的用于診斷PJI的關節(jié)液細胞因子是什么？它們的累計診斷準確率是多少？

方法：2013年5月至2014年3月，104名THA和TKA經(jīng)評估為可能存在PJI的患者被納入我們的研究。其中，90例（87%）測量了關節(jié)液細胞因子水平的病例作為這項前瞻性研究（33例髖關節(jié)，57例膝關節(jié)）的一部分。第二組35名患者（n = 36個樣本）在使用抗生素間隔器期間，在二期再植入前也測量了關節(jié)液細胞因子。對于第一組90例患者，在手術時采用MSIS標準將每個關節(jié)分為感染（n = 31）和未感染（n = 59），并作為檢測診斷PJI準確性的標準。在35例二期手術前有關節(jié)液標志物檢測數(shù)據(jù)的患者中，15例患者在清理術中和再植入術中都做了細胞因子測量，并用于量化兩期之間細胞因子的變化。再植入組至少隨訪1年（4例[11%]患者失訪），并根據(jù)基于delphi的共識數(shù)據(jù)將其分為治療成功或治療失敗，用于測試這些細胞因子檢測再植入后感染是否得到控制的準確性。

結果：白細胞介素(IL)-1b和干擾素-c表現(xiàn)出最高的診斷效用（曲線下面積分別為0.92、0.91）；IL-1b和IL-6的敏感性最高（0.90[95%可信區(qū)間{CI}， 0.74 ~ 0.98]和0.81[0.63 ~ 0.93]）。作為感染是否得到控制的測量指標，IL-1b下降幅度最大（12.4倍，清理術時：232.4[范圍，23.1-1545.7]，再植入時水平：18.8[范圍，1.2-298.9]；平均差值：325.5 [95% CI, 65.0-596.0]；p = 0.0001)， IL-6幾乎有相似的下降（11.2倍；清理術時：228.1[范圍，10,158.4-182,725.0]；再植入時水平：2518.2[范圍，10.4-41,319.3]；平均差值：33,176.0 [95% CI, 7543.6-58,808.3]; p

< 0.0001）。細胞因子和MSIS標準在排除關節(jié)感染是否得到控制的敏感性較低。

結論：IL-6和IL-1b對PJI的診斷具有較高的敏感性，且IL-6和IL-1b在一、二期之間下降幅度最大，有可能可被用于監(jiān)測PJI的治療反應。然而，在再植入前，細胞因子和MSIS標準對排除感染的敏感性較低。

Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation

Background：Diagnosing periprosthetic joint infection (PJI) requires a combination of clinical and laboratory parameters, which may be expensive and difficult to interpret. Synovial fluid cytokines have been shown to accurately differentiate septic from aseptic failed total knee (TKA) and hip (THA) arthroplasties. However, after firststage explantation, there is still no reliable test to rule out PJI before a second-stage reimplantation procedure.

Questions/purposes：(1) Which synovial fluid cytokines have the highest diagnostic accuracy for PJI? (2) Which cytokine shows the greatest decrease associated with the resolution of infection in the same patient between explantation and subsequent reimplantation of an infected arthroplasty? (3) What is the accuracy of synovial fluid cytokines and the Musculoskeletal Infection Society (MSIS) criteria to rule out PJI after first-stage explantation? (4) What are the most studied synovial fluid cytokines for diagnosing PJI as reported in the literature and what are

their cumulative diagnostic accuracy?

Methods：Between May 2013 and March 2014, 104 patients with painful THA and TKA evaluated for possible PJI were included in our study. Of these, 90 (87%) had cytokine levels measured from synovial fluid samples collected as part of this prospective study (n = 33 hips, n = 57 knees). A second group of 35 patients (n = 36 samples) who presented during the same time period with an antibiotic spacer also had synovial cytokines measured before second-stage reimplantation. For the first group of 90 patients, the MSIS definition classified each joint at the time of surgery as infected (n = 31) or not infected (n = 59) and was used as the standard to test the accuracy in diagnosing PJI. Of the 35 patients with synovial marker data before second-stage surgery, 15 patients had cytokine measurements both at explantation and reimplantation and were used to quantify the change between stages. The reimplantation group had a minimum 1-year followup

(with four [11%] patients lost to followup) and was classified into successful or failed treatment based on Delphi-based consensus data and was used to test the accuracy in detecting infection resolution at reimplantation.

Results：Interleukin (IL)-1b and interferon-c demonstrated the highest diagnostic utility (area under the curve 0.92, 0.91, respectively); IL-1b and IL-6 had the highest sensitivities (0.90 [95% confidence interval {CI}, 0.74– 0.98] and 0.81 [0.63–0.93]). As a measure of infection resolution, IL-1b had the greatest decrease (12.4-fold; level at explantation: 232.4 [range, 23.1–1545.7]; level at reimplantation: 18.8 (range 1.2–298.9); mean difference: 325.5 [95% CI, 65.0–596.0]; p = 0.0001), and IL-6 had a nearly similar decrease (11.2-fold; level at explantation: 228.1 [range, 10,158.4–182,725.0]; level at reimplantation: 2518.2 [range, 10.4–41,319.3]; mean difference: 33,176.0 [95% CI, 7543.6–58,808.3]; p \ 0.0001). Cytokines and MSIS criteria had low sensitivity to rule out infection in a joint treated for PJI.

Conclusions：IL-6 and IL-1b demonstrated high sensitivities to diagnose PJI and showed the greatest decrease between first and second stages, which may potentially be used to monitor treatment response to PJI. However, cytokines and MSIS criteria had low sensitivity to rule out infection before reimplantation.

文獻出處：Frangiamore SJ, Siqueira MB, Saleh A, Daly T, Higuera CA, Barsoum WK. Synovial Cytokines and the MSIS Criteria Are Not Useful for Determining Infection Resolution After Periprosthetic Joint Infection Explantation. Clin Orthop Relat Res. 2016 Jul;474(7):1630-9. doi: 10.1007/s11999-016-4710-x. Erratum in: Clin Orthop Relat Res. 2016 Jul;474(7):1740-1741. doi: 10.1007/s11999-016-4824-1. PMID: 26821163; PMCID: PMC4887354.

文獻2

全髖關節(jié)翻修術中應用全新骨刀系統(tǒng)行股骨柄假體取出的效果分析-技巧，局限性及相關并發(fā)癥

譯者 張薔

背景：全髖關節(jié)翻修術有多項獨特的挑戰(zhàn)，完整取出已有骨長入的生物型股骨柄就是其中之一。傳統(tǒng)處理方法包括廣泛的轉子間截骨，而這通常與更多的術后并發(fā)癥和更高的病死率相關。近期，新型骨刀系統(tǒng)的問世改良了股骨柄取出技術，使得不應用截骨而完整取出假體成為可能。本研究描述了我們應用某新型骨刀系統(tǒng)進行THA翻修手術的相關經(jīng)驗。

方法：我們從醫(yī)院數(shù)據(jù)庫中調取2017年12月至2024年7月間所有行股骨柄翻修的全髖翻修手術病例。我們分析了所有在翻修時生物型股骨柄被確認已有骨長入的病例。且所有取出均應用了股骨柄取出專用的新型骨刀系統(tǒng)。

A.平、直骨刀用于分離股骨柄與前后皮質；B.內側骨距骨刀用于分離股骨柄與內側股骨距；C.側方視圖顯示骨距骨刀有專門容納股骨柄錐度的設計；D.弧形外側骨刀與股骨柄外側曲度接近，應用時可避免損傷大轉子；E.標本演示可見弧形外側骨刀可打通股骨柄外側通道而不傷及大轉子。

結果：在所有入組的92例病例中，65%為單錐度楔形柄；16%為髓腔填充匹配型柄；9%為全羥基磷灰石噴涂型柄。使用該新型骨刀系統(tǒng)，我們成功（無術中骨折或需截骨等情況）取出了73%的股骨柄。10%的病例需術中截骨，但均非單錐度楔形柄。在所有髓腔填充匹配型柄或全羥基磷灰石噴涂型柄的病例中，57%需要術中截骨或術中出現(xiàn)取出相關的骨折。術中出現(xiàn)取出相關骨折的發(fā)生率為13%。

結論：在本大樣本量全髖翻修系列研究中，我們應用專為股骨柄假體取出而設計的新型骨刀系統(tǒng)并成功取出了73%的股骨柄。相對較低的術中截骨率（10%）提示此技術的實用性，但目前現(xiàn)代股骨柄更多應用帶領、全涂層且三錐度的設計趨勢也預示著該技術的局限性，并在未來需要更多的研究與創(chuàng)新。

Results?of?a?Novel?Osteotome?System?for Femoral?Stem?Extraction?in?Revision?Total Hip?Arthroplasty-Technique, Limitations, and Associated Complications

Background: Revision total hip arthroplasty (THA) presents several unique challenges, one of which is the removal of osseointegrated uncemented femoral stems. Traditional techniques, such as extended trochanteric osteotomy, are associated with complications and patient morbidity. Recently, the advent of osteotome systems designed to facilitate femoral stem extraction has improved the capacity for complete fixation disruption without the need for osteotomy. This study describes our experience with one such novel system in a large series of revision THAs.

Methods: Patients undergoing femoral component revision during revision THA from December 2017 to July 2024 were identified from our institutional database. We included and analyzed patients undergoing revision for any indication so long as the revised femoral component was cementless and confirmed to be osseointegrated at the time of revision surgery. Extraction was attempted with the femoral-extraction osteotome system of interest in all cases.

Results: Of the 92 included cases, 65% involved single-taper wedge stems; 16%, fit-and-fill style designs; and 9%, fully hydroxyapatite (HA)-coated stems. Using the osteotome system, femoral extraction was successful (no intraoperative fracture or requirement for osteotomy) in 73% of the cases. Osteotomy was required in 10% of the cases but was not required for extraction of any single-taper wedge stem. Of those with fit-and-fill or fully HA-coated stems, 57% required osteotomy or sustained an extraction-related fracture. Extraction-related intraoperative fractures occurred in 13% of the cases.

Conclusions: In this large series of revision THAs, the use of a novel osteotome system designed for femoral component extraction led to successful extraction in 73% of the cases. The relatively low rate of osteotomy (10%) suggests that this technique is useful, but it also highlights limitations and the need for further innovation given the contemporary shift toward the use of collared, fully coated triple-tapered stems.

文獻3

采用傳統(tǒng)器械的非骨水泥型、保留交叉韌帶初次全膝關節(jié)置換術：技術要點與術中注意事項

譯者 丁云鵬

背景：全膝關節(jié)置換術（TKA）通常適用于保守治療失敗的嚴重脛股關節(jié)炎患者。TKA是美國最常實施的骨科手術之一，可顯著改善疼痛、功能和生活質量。該手術可采用骨水泥型、非骨水泥型或混合型假體?，F(xiàn)代假體設計的非骨水泥TKA已被證實對適應證合適的患者具有優(yōu)異的長期生存率和臨床效果。資深術者的偏好是在可行時，采用保留交叉韌帶的假體設計，并遵循機械對線原則指導截骨。需注意的是，幾乎所有近期關于非骨水泥TKA療效的研究均采用傳統(tǒng)機械對線。其他對線策略（如間隙平衡和運動學對線）在非骨水泥TKA中研究較少，但短期初步研究表明，接受非骨水泥TKA的患者采用限制性運動學對線或間隙平衡時，其假體生存率與機械對線相當。

描述：我們首選的生物型（非骨水泥）全膝關節(jié)置換術手術技術始于患者仰臥位。應用大腿止血帶，并在止血帶水平處設置外翻支撐。同時放置90度屈曲墊和20度支撐桿。無菌皮膚準備和鋪單完成后，進行術前核對并止血帶加壓。術者在膝關節(jié)屈曲90度狀態(tài)下，使用手術刀沿內側髕旁作切口，起自髕骨內側緣1厘米處，自脛骨結節(jié)延伸至髕骨近極上方兩橫指處。隨后用剪刀在筋膜上方尋找脂肪層，并沿同一平面向遠端分離。采用手術刀實施高位股肌劈開式內側髕旁關節(jié)切開術。繼而用鑷子和剪刀行部分內側滑膜切除術，并用電刀進行內側剝離。隨著操作進一步向內側推進，切除髕下脂肪墊及股前滑膜組織。術者在膝關節(jié)屈曲狀態(tài)下先切斷前交叉韌帶止點及起點，再鋸除脛骨棘以降低脛骨骨塊高度。準備股骨時，將階梯鉆插入股骨髓腔，安裝髓內對準導向器，并將股骨遠端截骨導向器設置為5°外翻角。隨后將股骨遠端截骨導向器緊壓于股骨遠端，確保內側與骨面接觸，并通過動力工具在截骨導向器中置入螺紋釘。接著使用配備21毫米×90毫米×1.27毫米鋸片的擺動鋸精確截除股骨遠端。術者特別注意從骨皮質處開始切割，以避免皮質爆裂。利用對準桿和遠端截骨導向器雙重驗證截骨面的均勻性與平整度。評估完成后移除導向釘和導向器，用咬骨鉗精細清除殘留的股骨髁骨贅。術者使用股骨尺寸測量導板確定股骨尺寸，并復核旋轉角度以完成剩余股骨遠端截骨準備。隨后鉆孔定位四合一截骨導板的旋轉方位。安裝四合一截骨導板時，需謹慎對準鉆孔位置以防止非預期旋轉不良。通過在全速動力下精準插入2根螺紋針以確保骨塊的牢固固定，隨后采用更可控的慢速緊固流程防止螺紋滑絲。接著用擺動鋸進行前方截骨，再次強調需先切開骨皮質再深入切割。后方截骨采用可控的輕柔彈跳技術完成，通過觸覺反饋確保精確切割每個后髁的內外側骨皮質，并同樣完成前斜面與后斜面截骨。隨后輕柔移除四合一截骨導板。本階段最后使用弧形骨鑿與槌棒精細取出切除的后髁骨質，必要時清除后方骨贅。操作時精確運用弧形骨鑿凹面沿髁部輪廓細致修整，確保截骨精準。術者于膝下放置墊塊并伸直膝關節(jié)，依次檢查內側副韌帶、股四頭肌腱、髕腱及后交叉韌帶是否完整。進行脛骨截骨時，需放置髓外定位導向器，并將截骨槽高度設定至軟骨下骨水平，同時使旋轉對位線與冠狀軸對齊第二跖骨。此步驟還需設定脛骨后傾角，目標是通過截骨匹配患者原有的脛骨后傾角度。通常通過目測截骨導向器的運動軌跡來實現(xiàn)匹配，也可使用探針確認合適的脛骨后傾角。隨后使用擺動鋸完成脛骨截骨。接著用單邊往復鋸垂直于內側平臺截骨，注意避免切至未截骨的完整脛骨平臺部分。移除內側平臺骨塊后，在內側間隙放置椎板撐開器；以相同方式在外側進行二次截骨，形成完全保留后交叉韌帶止點的三角形骨塊。切除內外側半月板后，使用間隙測量塊和對位桿檢查間隙。術者隨后測量脛骨尺寸，并用雙手食指觸診內外側確認是否存在懸突。另一種方法是在屈曲狀態(tài)下充分暴露脛骨，在完全直視脛骨邊緣的情況下確定尺寸。確保適當外旋和最佳脛骨覆蓋無懸突后，用鋼針固定脛骨試模。置入股骨與脛骨試驗組件后，外科醫(yī)生需測試7項內容：(1)完全伸直狀態(tài)下的整體內外翻對線；(2)伸直程度（特別觀察有無反屈或屈曲攣縮）；(3)重力作用下屈曲度；(4)屈曲狀態(tài)前后穩(wěn)定性（通過手動前后推移脛骨測試）；(5)在伸直、中屈曲及完全屈曲位采用手動動態(tài)內外翻應力測試評估穩(wěn)定性；(6)髕骨軌跡；(7)組件旋轉度。若此時任何測試項超出可接受范圍，可能需進行額外韌帶松解或截骨。待術者對試驗組件位置及穩(wěn)定性滿意后，通過將脛骨襯套底座嵌入托盤、鉆脛骨孔及沖出龍骨槽完成脛骨準備。隨后移除定位針與托盤，撤出拉鉤，使膝關節(jié)恢復伸直位。最后打開假體組件，連接到插入器上并用塑料套包裹。先植入并敲擊固定最終的脛骨基板，隨后以相同方式植入股骨組件。確保敲擊后軟組織未被卡壓在假體下方。放入試模襯墊，伸展膝關節(jié)。隨后用約500毫升無菌0.35%聚維酮碘溶液沖洗關節(jié)腔，再用1升無菌無抗生素的等滲氯化鈉溶液進行脈沖灌洗。再次通過前述(7)個檢查點測試關節(jié)穩(wěn)定性。此時唯一可調整的是聚乙烯襯墊的增厚或減薄。我們認為，若需移除或重新定位已植入的非骨水泥型股骨/脛骨組件，則應改為骨水泥型全膝關節(jié)置換術。一旦對真實植入物和試驗脛骨關節(jié)面的穩(wěn)定性滿意，就插入最終的聚乙烯組件。最后，釋放止血帶。然后外科醫(yī)生再次沖洗傷口并關閉關節(jié)切開術和皮膚。我們傾向于使用無結倒刺縫線進行關節(jié)切開術閉合，然后使用2-0 Vicryl （Ethicon）進行皮下閉合，2-0單絲無結倒刺縫線進行皮膚閉合。一些外科醫(yī)生可能會選擇使用無倒刺縫合；然而，在一項針對TKA患者的大型薈萃分析中，使用倒刺縫合已被證明與非倒刺縫合更快，同樣有效。最終閉合前，將浸透碘伏的切口周圍抗菌切口布剝開，將無菌的10%聚維酮碘敷于切口周圍皮膚。角質層下閉合后，應用粘膠皮膚膠，然后在膝關節(jié)彎曲時進行防水敷料。

替代方案：針對脛股骨關節(jié)炎有多種非手術治療方法可供選擇。根據(jù)2021年美國骨科醫(yī)師學會發(fā)布的《膝關節(jié)骨關節(jié)炎（非關節(jié)置換術）治療臨床實踐指南》，這些方法包括支具固定、非甾體抗炎藥、對乙酰氨基酚、監(jiān)督下運動訓練、患者教育、減重以及關節(jié)內皮質類固醇注射等13項措施。當非手術治療無效時，對于癥狀持續(xù)影響生活質量的患者則需考慮手術治療。脛股骨關節(jié)炎的手術治療主要包括單間室膝關節(jié)置換術或全膝關節(jié)置換術，但根據(jù)疾病嚴重程度和患者年齡，某些特定病例也可采用脛骨近端截骨術。2022年美國骨科醫(yī)師學會最新修訂的《膝關節(jié)骨關節(jié)炎（非關節(jié)置換術）治療臨床實踐指南》為上述所有治療方案提供了循證依據(jù)。

理由：歷史上，與骨水泥型關節(jié)置換術相比，無骨水泥型全膝關節(jié)置換（TKA）植入物的初始設計存在較高的失敗率和較差的臨床效果。然而，隨著現(xiàn)代植入物設計采用了新型生物材料和多孔涂層，人們對無骨水泥型TKA重新產(chǎn)生了興趣，最近的一些研究顯示，其短期、中期甚至在某些研究的長期隨訪中與骨水泥型組件效果相當。Kim等人在最近的一項研究中表明，術后22至25年無因無菌性松動而翻修的生存率達到98%。除了與骨水泥型TKA相比至少相當?shù)拈L期功能效果外，多項研究還報告了無骨水泥固定的短期優(yōu)勢，包括成本降低和避免與骨水泥碎屑相關的并發(fā)癥。此外，由于不需要攪拌水泥，減少了人員培訓的負擔，消除了可能影響水泥完整性的變量，從而提高了操作效率，縮短了操作時間。據(jù)報道，骨水泥植入綜合征（BCIS）在高達28%的骨水泥TKA病例中存在，并且具有很大的發(fā)病率和死亡率風險。如果在水泥固化后和縫合前沒有取出水泥碎片，也會留在膝關節(jié)內，這被認為會導致不適和聚乙烯磨損。當使用無骨水泥植入物時，也可以避免這種并發(fā)癥。導致我們偏好無水泥TKA的其他因素，在指出時，尚未在文獻中得到證實，但是直觀的概念。例如，骨水泥的缺乏會導致在翻修手術中更容易取出部件，而保留骨量對于進行成功的翻修TKA很重要。

預期結果：采用現(xiàn)代設計的非骨水泥型全膝關節(jié)置換術在長達25年的隨訪中表現(xiàn)出優(yōu)異的長期效果。Kim等人對261例雙側同期行全膝關節(jié)置換的患者進行評估，采用隨機分配方式在對側膝關節(jié)分別植入骨水泥型和非骨水泥型假體。該研究平均年齡63歲，平均隨訪24年，作者發(fā)現(xiàn)25年無菌性松動未翻修生存率達98%。類似結果在老年患者群體中也得到驗證：Goh等人2022年針對75歲以上患者的研究顯示，現(xiàn)代假體設計的7年生存率為100%。該研究將120例非骨水泥型全膝關節(jié)置換術與采用同款現(xiàn)代設計骨水泥型假體的手術按1:3比例匹配，最終兩組患者在術后最終評分及2年評分改善方面無差異。骨水泥型假體組7年無菌性翻修生存率為99.4%，非骨水泥型假體組達100%。

重要提示：在決定采用非骨水泥型全膝關節(jié)置換術時，我們會綜合考慮多種術前因素，包括骨質疏松病史、術前X光片顯示的骨質缺損區(qū)域，以及與骨密度低下相關的既往病史。術中因素也可作為選擇非骨水泥或骨水泥型假體的考量依據(jù)。例如，截骨時的觸覺反饋有助于判斷骨質是否堅硬硬化——我們認為這更適宜采用非骨水泥型假體。需注意：內翻膝的脛骨平臺準備過程中，由于長期負重差異，內側脛骨平臺通常會出現(xiàn)顯著硬化，而外側平臺則相對骨質疏松；外翻膝則呈現(xiàn)相反模式。總體而言，我們建議骨質完整性的判斷應以非硬化側為主要依據(jù)。采用本文所述技術時，我們對非骨水泥型全膝關節(jié)置換術不設置術前力線閾值或膝關節(jié)活動度標準。然而，當采用個性化的對齊策略時，需要對非水泥TKA的長期結果進行更多的研究，這可能會決定相對于解剖軸的大量內翻或外翻的組件放置位置。當使用龍骨脛骨植入物時，我們建議反向鉆孔，用骨填充鉆孔壁，而不是將其磨出，我們認為這樣可以增加對骨生長的支持。如果在反向鉆井時幾乎沒有阻力，我們認為這是非水泥TKA的不良預后信號，應該考慮固井。在確定脛骨基板的尺寸時，目標是使脛骨的尺寸最大化，以適應皮質骨邊緣的頂部而不突出。尺寸過小可能會增加種植體下沉的可能性。非水泥構件的骨切口需要完美。圓頂形狀的切口有搖晃和/或切換的風險，隨著時間的推移，這可能會導致松動。檢查脛骨的所有四個象限以確認其表面是平坦的。軟組織可能會嵌頓在種植體下，這對于非骨水泥種植體來說是特別值得關注的，因為這可能會損害骨的長入。在試驗期間，確保試驗完全與骨骼齊平，這是防止切換和/或松動的額外檢查。當撞擊股骨假體時，我們建議施加延伸力，使插入器的重量不會使假體屈曲；然而，過大的拉伸力也可能導致骨折。

文獻出處：Andrew B Harris , Julius K Oni ,Cementless, Cruciate-Retaining Primary Total Knee Arthroplasty Using Conventional Instrumentation: Technical Pearls and Intraoperative Considerations.JBJS Essent Surg Tech. 2024 Sep 13;14(3):e23.00036. doi: 10.2106/JBJS.ST.23.00036. eCollection 2024 Jul-Sep.

文獻4

技術的應用是否會影響全膝關節(jié)置換術中麻醉下松解術的發(fā)生率？

譯者 沈松坡

背景：關節(jié)纖維化是全膝關節(jié)置換術（total knee arthroplasty，TKA）患者術后不滿意的重要原因之一。對于部分病例，可通過麻醉下松解術（manipulation under anesthesia，MUA）來改善關節(jié)活動度。近年來，計算機導航及機器人輔助技術被廣泛推廣，旨在在減少軟組織松解的同時，提高假體部件的植入位置精度。本研究旨在探討這些技術是否會影響MUA的發(fā)生率。

方法：本研究為一項單中心回顧性研究，納入2010年1月至2022年12月期間接受初次、擇期、單側TKA的18,815例患者。根據(jù)手術方式將患者分為傳統(tǒng)組（C-TKA，n=12,659）、計算機導航組（N-TKA，n=4,071）和機器人輔助組（R-TKA，n=2,085）。收集患者的人口學資料及假體相關數(shù)據(jù)，包括固定方式及假體限制程度（保留交叉韌帶型［CR］與后穩(wěn)定型［PS］）。MUA發(fā)生率為主要結局指標。統(tǒng)計分析采用方差分析（ANOVA）及Tukey事后檢驗，并行多因素Logistic回歸分析。

結果：總體MUA發(fā)生率為1.7%。傳統(tǒng)TKA和導航TKA的MUA發(fā)生率分別為1.6%和1.5%，顯著低于機器人輔助TKA的3.2%（p<0.001）。然而，在多因素分析中，與傳統(tǒng)技術相比，導航和機器人輔助TKA在MUA發(fā)生率方面并無顯著差異。機器人輔助TKA中無骨水泥或混合固定方式以及CR假體設計的使用比例更高。多因素回歸分析顯示，全無骨水泥固定（OR：1.80，95%CI：1.16–2.78，p=0.008）和混合固定（OR：2.92，95%CI：1.77–4.81，p<0.001）均顯著增加未來發(fā)生MUA的風險。假體限制程度亦顯著影響MUA發(fā)生率，其中CR假體的MUA發(fā)生率更高（OR：1.51，95%CI：1.16–1.96，p=0.002）。

結論：在控制混雜因素后，計算機導航和機器人輔助TKA與傳統(tǒng)TKA相比，其MUA發(fā)生風險相當。然而，機器人輔助TKA更傾向于采用無骨水泥或混合固定方式及CR假體設計，而上述因素均與MUA風險的獨立升高相關。在進行MUA風險分層及術前患者宣教時，應充分考慮這些手術相關因素。

Does Use of Technology Affect Manipulation Under Anesthesia Rates in Total Knee Arthroplasty?

Background: Arthrofibrosis can be a major source of dissatisfaction for patients undergoing total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) may be offered to improve motion in selected cases. Advancements in computer-navigated and robotic-assisted technology have been championed to improve component positioning with fewer soft tissue releases. We sought to investigate whether these technologies impact MUA rates.

Methods: An institutional retrospective review was conducted on 18,815 patients who underwent a primary, elective, unilateral TKA between January 2010 and December 2022. Patients were stratified into conventional (C-TKA; n=12,659), computer-navigated (N-TKA; n=4,071), or robotic-assisted (R-TKA; n=2,085) cohorts. Patient demographics and implant data, including mode of fixation and level of constraint (cruciate-retaining [CR] vs posterior-stabilized [PS]) were collected. MUA rates were the primary outcome. Data was analyzed using ANOVA with Tukey post hoc testing and multivariate logistic regression analysis.

Results: We report a 1.7% overall MUA rate, with a rate of 1.6% for conventional and 1.5% for navigated TKA, which were significantly lower than robotic-assisted TKA at 3.2% (p<0.001). However, on multivariate analysis, there was no difference in MUA rates for navigated and robotic-assisted when compared to conventional techniques. Cementless and hybrid fixation and CR implant designs were higher with robotic-assisted compared to conventional and navigated TKA. Multivariate regression revealed that TKA with fully cementless (OR: 1.80 [95%CI: 1.16-2.78] p=0.008) or hybrid fixation (OR: 2.92 [95%CI: 1.77-4.81] p<0.001) increased the risk for future MUA. Constraint also significantly influenced MUA rates, with CR designs yielding higher MUA rates (OR: 1.51 [95%CI: 1.16-1.96] p=0.002).

Conclusions: When controlling for confounding factors, navigated and robotic-assisted TKA generated comparable odds for MUA when compared to conventional techniques. However, robotic-assisted TKA were more likely to utilize cementless or hybrid fixation and CR implant constraint, each of which were independently associated with increased odds of MUA. These operative factors should be considered when risk-stratifying and counseling patients on the likelihood of MUA.

第二部分：保髖相關文獻

文獻1

基于“步態(tài)-肌肉-骨骼系統(tǒng)-有限元”個性化建模方法的步態(tài)周期內髖關節(jié)接觸應力變化

譯者 任寧濤

目的

構建一種“步態(tài)-肌肉骨骼系統(tǒng)(MS)-有限元(FE)”的綜合仿真方法，分析髖關節(jié)動力學特性以及在一個步態(tài)周期內髖關節(jié)內接觸應力的變化。

方法

招募了兩名健康志愿者(男性和女性)。獲得志愿者正常行走時的三維步態(tài)軌跡以及包括髖關節(jié)和股骨在內的CT圖像。提取DICOM格式的CT成像數(shù)據(jù)進行三維髖關節(jié)重建。利用重建的三維模型文件實現(xiàn)全身肌肉骨骼模型骨盆和大腿節(jié)段的對象特異性配準。捕獲的標記物軌跡數(shù)據(jù)用于驅動受試者特定的肌肉骨骼模型，完成逆動力學分析。導出動力學逆分析的結果，并應用于ABAQUS中髖關節(jié)有限元的邊界和載荷設置。最后，通過有限元分析(FEA)對左腳在一個步態(tài)周期內髖關節(jié)的接觸應力進行分析。

結果

在逆向動力學分析中，繪制了主要髖-股肌肌力相對于單個步態(tài)周期各階段的動態(tài)變化。髖關節(jié)反作用力達到最大值2.9%BW(體重)，出現(xiàn)在終末站立階段結束時。在初始接觸階段和最終支撐階段分別出現(xiàn)雙峰。有限元分析顯示髖臼接觸應力的時間變化。視覺應力云圖中，單個步態(tài)周期中髖臼接觸應力主要分布在髖臼頂和股骨頭頂部前外側區(qū)域。髖臼接觸面積為293.8 ~ 998.4 mm2，最大接觸面積出現(xiàn)在步態(tài)的支撐期中期或負重初始期。模型1和模型2在站立期末端髖臼最大接觸應力分別為6.91 MPa和6.92 MPa。

結論

結合“步態(tài)-MS-FE”技術，構建了全面的仿真框架?；谌梭w步態(tài)軌跡及其CT圖像，可實現(xiàn)個性化仿真建模。受試者特定的步態(tài)結合MS的逆向動力學分析為有限元模擬提供了更準確的髖關節(jié)生物力學分析的預處理參數(shù)。

圖1 受試者特定的肌肉骨骼模型在正常步態(tài)周期中的肌力模式

圖2 使用受試者特定運動學模型的步態(tài)周期中的8個階段示意圖。一個步態(tài)周期:階段1，初始接觸階段; 階段2，站立初期;階段3，站立中期階段; 階段4，終末支撐階段; 階段5，預起步階段; 階段6，初始起步階段; 階段7，中期搖擺階段; 階段8，最后搖擺階段

Changes in hip joint contact stress during a gait cycle based on the individualized modeling method of "gait-musculoskeletal system-finite element"

Objective: To construct a comprehensive simulation method of "gait-musculoskeletal system (MS)-finite element (FE)" for analysis of hip joint dynamics characteristics and the changes in the contact stress in the hip throughout a gait cycle.

Methods: Two healthy volunteers (male and female) were recruited. The 3D gait trajectories during normal walking and the CT images including the hip and femur of the volunteers were obtained. CT imaging data in the DICOM format were extracted for subjected 3D hip joint reconstruction. The reconstructed 3D model files were used to realize the subject-specific registration of the pelvis and thigh segment of general musculoskeletal model. The captured marker trajectory data were used to drive subject-specific musculoskeletal model to complete inverse dynamic analysis. Results of inverse dynamic analysis were exported and applied as boundary and load settings of the hip joint finite element in ABAQUS. Finally, the finite element analysis (FEA) was performed to analyze contact stress of hip joint during a gait cycle of left foot.

Results: In the inverse dynamic analysis, the dynamic changes of the main hip-femoral muscle force with respect to each phase of a single gait cycle were plotted. The hip joint reaction force reached a maximum value of 2.9%BW (body weight) and appeared at the end of the terminal stance phase. Twin peaks appeared at the initial contact phase and the end of the terminal stance phase, respectively. FEA showed the temporal changes in contact stress in the acetabulum. In the visual stress cloud chart, the acetabular contact stress was mainly distributed in the dome of the acetabulum and in the anterolateral area at the top of the femoral head during a single gait cycle. The acetabular contact area was between 293.8 and 998.4 mm2, and the maximum contact area appear at the mid-stance phase or the loading response phase of gait. The maximum contact stress of the acetabulum reached 6.91 MPa for the model 1 and 6.92 MPa for the model 2 at the terminal stance phase.

Conclusions: The "Gait-MS-FE" technology is integrated to construct a comprehensive simulation framework. Based on human gait trajectories and their CT images, individualized simulation modeling can be achieved. Subject-specific gait in combination with an inverse dynamic analysis of the MS provides pre-processing parameters for FE simulation for more accurate biomechanical analysis of hip joint.

文獻出處：Xiong B, Yang P, Lin T, Xu J, Xie Y, Guo Y, Liu C, Zhou Q, Lai Q, He W, Wei Q, Zhang Q. Changes in hip joint contact stress during a gait cycle based on the individualized modeling method of "gait-musculoskeletal system-finite element". J Orthop Surg Res. 2022 May 14;17(1):267. doi: 10.1186/s13018-022-03094-5. PMID: 35568957; PMCID: PMC9107226.

文獻2

計算機輔助與傳統(tǒng)髖臼周圍截骨術治療髖關節(jié)發(fā)育不良的療效比較

譯者 李勇

研究目的 比較計算機輔助髖臼周圍截骨術（PAO）與傳統(tǒng)PAO治療髖關節(jié)發(fā)育不良（DDH）的療效。

方法 本研究共納入91例患者（98髖）。每例DDH患者均接受傳統(tǒng)PAO（術中通過X線檢查確定截骨角度和方向）或計算機輔助PAO（使用3D導航系統(tǒng)）治療。其中40髖接受傳統(tǒng)PAO，58髖接受計算機輔助PAO。

結果 傳統(tǒng)PAO患者術前的日本骨科協(xié)會髖關節(jié)評分從70.0分顯著提高至術后的90.7分；計算機輔助PAO患者則從74.5分提高至94.2分。所有計算機輔助PAO患者術后的髖臼頭指數(shù)（AHI）和垂直中心角（VCA角）均在影像學目標范圍內。部分傳統(tǒng)PAO患者術后的AHI和VCA角超出目標范圍。平均隨訪5.4年后，98髖中有5髖（5.1%）接受了全髖關節(jié)置換術（THA）。58髖計算機輔助PAO患者中無一例（0%）需翻修。

討論 計算機輔助PAO可在術中確認截骨部位，并能實時確認截骨塊的位置。與傳統(tǒng)PAO相比，計算機輔助PAO為股骨頭提供了充分的前方和外側覆蓋，因此無需早期轉為THA。

結論 計算機輔助PAO不僅提高了手術的精確性和安全性，還實現(xiàn)了充分的前方和外側移位，從而有效阻止了DDH的進展。

Outcomes of computer-assisted peri-acetabular osteotomy compared with conventional osteotomy in hip dysplasia

Aim of the study To compare the outcomes after computer-assisted peri-acetabular osteotomy (PAO) and conventional PAO performed for hip dysplasia (DDH).

Methods Ninety-one patients (98 hips) were enrolled in this study. In each case, DDH was treated with either conventional PAO, in which the angle and direction of the osteotomy was determined by intra-operative X-ray examination, or with computer-assisted PAO, which used the 3D navigation system. Forty hips underwent conventional PAO and 58 hips underwent computer-assisted PAO.

Results Japanese Orthopaedic Association hip scores improved significantly from 70.0 points pre-operatively to 90.7 points post-operatively in patients with conventional PAO, and from 74.5 points pre-operatively to 94.2 points post-operatively in patients with computer-assisted PAO. In all patients with computer-assisted PAO, the post-operative AHI and VCA angle were within the radiographic target zone. Some patients with conventional PAO had post-operative AHI and VCA angle outside of the target zone. We performed total hip arthroplasty (THA) on five of the 98 PAO hips (5.1%) after an average follow-up period of 5.4 years. None of 58 hips (0%) with computer-assisted PAO was revised.

Discussion Computer-assisted PAO enabled intra-operative confirmation of osteotomy sites, and the position of the osteotomized bone fragment could be confirmed in real time. Adequate anterior and lateral coverage of the femoral head in patients with computer-assisted PAO resulted in no need for early conversion to THA, in contrast to conventional PAO.

Conclusion Computer-assisted PAO not only improved accuracy and safety but also achieved sufficient anterior and lateral displacement to prevent the progression of DDH.

文獻出處：Imai H, Kamada T, Miyawaki J, Maruishi A, Mashima N, Miura H. Outcomes of computer-assisted peri-acetabular osteotomy compared with conventional osteotomy in hip dysplasia. Int Orthop. 2020 Jun;44(6):1055-1061. doi: 10.1007/s00264-020-04578-x. Epub 2020 Apr 28. PMID: 32342143; PMCID: PMC7260271.

文獻3

計算機輔助手術可預防髖臼周圍截骨術并發(fā)癥

譯者 陶可

目的：本研究旨在評估導航系統(tǒng)在弧形髖臼周圍截骨術(CPO)中的準確性。

方法：納入47例髖關節(jié)發(fā)育不良患者（53個髖關節(jié)），分別接受術中導航輔助或非導航輔助的CPO手術。術后對導航組和非導航組進行臨床和影像學評估，并進行比較。

結果：導航組和非導航組的臨床結果無顯著差異。此外，兩組術后髖臼骨塊的復位情況相似。然而，與非導航組相比，導航組的術前計劃線與術后截骨線之間的偏差顯著改善（p < 0.05）。此外，導航組的并發(fā)癥發(fā)生率也顯著降低（p < 0.001）。

結論：導航技術顯著提高了截骨定位的準確性。因此，在髖臼周圍截骨術中使用導航技術可以避免并發(fā)癥的發(fā)生。

圖1 導航系統(tǒng)界面。a術前使用半徑為100 mm的球體進行三維規(guī)劃。b術前使用帶有光學傳感器的指針檢查球體的位置和方向。c旋轉髖臼碎片后，使用導航指針檢查髖臼碎片的側緣。

圖2 病例示例，包括術前和術后X線片（a、b）以及術后CT圖像（c）。

圖3 測量術前規(guī)劃中確定的半徑為100 mm的球體線與術后髂骨表面之間的距離（誤差距離），分別在a冠狀面和b軸位面上進行測量。a誤差距離位于骨盆外側，在冠狀面上為45.5 mm（50–45.5 mm = 4.5 mm）。b骨盆內軸位平面距離誤差（57.8–50 mm = 7.8 mm）

圖4 術前確定的球形線和術后髂骨表面（誤差距離）在a軸位平面和b冠狀位平面上的位置。內：骨盆內。外：骨盆外。

圖5 一例關節(jié)內截骨術。白色箭頭指示關節(jié)內截骨部位。黃色圓圈指示術前截骨線。

Computer-assisted surgery prevents complications during peri-acetabular osteotomy

Purpose: The aim of study is to evaluate the accuracy of a navigation system during curved peri-acetabular osteotomy (CPO).

Methods: Forty-seven patients (53 hips) with hip dysplasia were enrolled and underwent CPO with or without navigation during surgery. Clinical and radiographical evaluations were performed and compared between the navigation group and non-navigation group, post-operatively.

Results: The clinical outcomes were not significantly different between the navigation and non-navigation groups. Furthermore, post-operative reorientation of the acetabular fragment was similar between the navigation and non-navigation groups. However, the discrepancy between the pre-operative planning line and post-operative osteotomy line was significantly improved in the navigation group compared with that in the non-navigation group (p < 0.05). Further, the complication rate was significantly improved in the navigation group (p < 0.001).

Conclusion: The accuracy of the osteotomy's position was significantly improved by using the navigation. Therefore, the use of navigation during peri-acetabular osteotomy can avoid complications.

文獻出處：Shinya Hayashi, Shingo Hashimoto, Tomoyuki Matsumoto, Koji Takayama, Nao Shibanuma, Kazunari Ishida, Kotaro Nishida, Ryosuke Kuroda. Computer-assisted surgery prevents complications during peri-acetabular osteotomy. Int Orthop. 2018 Nov;42(11):2555-2561. doi: 10.1007/s00264-018-3906-y. Epub 2018 Mar 26.

文獻4

人類股骨頭軟骨下骨密度分布

譯者 邱興

目的 本研究旨在利用計算機斷層掃描（CT）測得的骨密度數(shù)據(jù)，結合通用參考坐標系，對人類股骨頭的軟骨下骨密度分布進行定量表征。

材料與方法 研究納入了30例患者（男性14例，女性16例，平均年齡67.2歲）。通過對重建的CT數(shù)據(jù)進行半自動分割，構建雙側股骨頭表面模型，并用于繪制骨密度圖。具體方法為：將模型表面向軟骨下骨內部映射，計算關節(jié)面下方5 mm范圍內灰度值（與骨密度呈線性關系）的平均值。隨后，對密度圖進行空間標準化：以股骨頭中心為原點，股骨機械軸（FMA）對齊垂直方向，后髁軸（PCA）對齊水平方向。通過將密度圖自水平軸起每隔30°劃分為三個同心環(huán)帶，再沿前后軸和內外側軸劃分為四個象限，共定義十二個興趣區(qū)。采用重復測量方差分析及Bonferroni法事后檢驗比較各區(qū)的平均骨密度，并使用Pearson相關系數(shù)分析雙側對應區(qū)域的相關性。

結果 股骨頭上部內側區(qū)域的骨密度顯著高于其他區(qū)域（p<0.05）。所有區(qū)域均顯示出顯著的雙側相關性（r2=0.81至r2=0.16），其中高密度區(qū)域的相關性最強。在股骨頭前外側部分的兩個區(qū)域中，雙側骨密度測量值存在顯著差異（p<0.05）。

結論 左右側股骨頭骨密度的高度相關性表明，該方法或有助于理解患有單側髖關節(jié)疾?。ㄈ绻晒穷^缺血性壞死、骨折、髖關節(jié)發(fā)育不良、股骨頭骨骺骨軟骨病及股骨頭骨骺滑脫）的患者中，其健側或“正?！钡墓敲芏确植寄Ｊ?。

圖1 研究發(fā)現(xiàn)，對應股骨頭上部內側的1區(qū)與4區(qū)平均骨密度最高。總體而言，骨密度集中分布于股骨頭中心的內側與后方。

圖2 在左側與右側股骨頭中，1區(qū)與4區(qū)的骨密度均顯著高于所有其他區(qū)域（*表示p<0.05水平顯著）。左側的一個例外是5區(qū)，其密度顯著低于1區(qū)，但與4區(qū)無顯著差異（p=0.595）。僅3區(qū)與11區(qū)存在側別間差異。

Subchondral bone density distribution in the human femoral head

Objective: This study aims to quantitatively characterize the distribution of subchondral bone density across the human femoral head using a computed tomography derived measurement of bone density and a common reference coordinate system.

Materials and methods: Femoral head surfaces were created bilaterally for 30 patients (14 males, 16 females, mean age 67.2 years) through semi-automatic segmentation of reconstructed CT data and used to map bone density, by shrinking them into the subchondral bone and averaging the greyscale values (linearly related to bone density) within 5 mm of the articular surface. Density maps were then oriented with the center of the head at the origin, the femoral mechanical axis (FMA) aligned with the vertical, and the posterior condylar axis (PCA) aligned with the horizontal. Twelve regions were created by dividing the density maps into three concentric rings at increments of 30° from the horizontal, then splitting into four quadrants along the anterior-posterior and medial-lateral axes. Mean values for each region were compared using repeated measures ANOVA and a Bonferroni post hoc test, and side-to-side correlations were analyzed using a Pearson's correlation.

Results: The regions representing the medial side of the femoral head's superior portion were found to have significantly higher densities compared to other regions (p < 0.05). Significant side-to-side correlations were found for all regions (r(2) = 0.81 to r(2) = 0.16), with strong correlations for the highest density regions. Side-to-side differences in measured bone density were seen for two regions in the anterio-lateral portion of the femoral head (p < 0.05).

Conclusions: The high correlation found between the left and right sides indicates that this tool may be useful for understanding 'normal' density patterns in hips affected by unilateral pathologies such as avascular necrosis, fracture, developmental dysplasia of the hip, Perthes disease, and slipped capital femoral head epiphysis.

文獻出處：Wright, D. A. , Meguid, M. , Lubovsky, O. , & Whyne, C. M. . (2012). Subchondral bone density distribution in the human femoral head. Skeletal Radiology, 41(6), 677-683.

來源：304關節(jié)學術

作者：304關節(jié)團隊

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