髖膝關節文獻精譯薈萃（第380期)

本期目錄：

1、機器人輔助全膝關節置換術的趨勢和流行病學：減少并發癥和縮短住院時間

2、國際共識研討會對膝關節翻修術中骨缺損的處理

3、應用高交聯聚乙烯和傳統聚乙烯墊片的同期雙側后交叉韌帶保留型（CR）全膝關節置換病例的比較研究

4、擇期全關節置換術中加速康復外科（ERAS）路徑

5、DDH幼年治療后的患者成年后的生活質量

6、兒童創傷性三角軟骨損傷的回顧性分析

7、骨盆再定位截骨術前髖臼三維形態分析方法

8、髖關節不同姿勢對坐骨神經位置的影響

9、外側柱是支撐塌陷前股骨頭壞死的關鍵：基于傾向評分匹配隊列的有限元模型分析

第一部分：關節置換及保膝相關文獻

文獻1

機器人輔助全膝關節置換術的趨勢和流行病學：減少并發癥和縮短住院時間

譯者 張軼超

介紹：本研究對機器人輔助全膝關節置換術（RA - TKA）與傳統全膝關節置換術（C - TKA）的即時術后結果和影響進行了深入分析，特別是在死亡率、并發癥、住院時間和費用方面，研究數據來自全國范圍內的綜合數據集。

方法：全國住院患者樣本（NIS）數據庫是美國最大的包括各種付款人住院醫療保健數據庫，從中找出從2016年至2019年期間接受RA - TKA或C - TKA的所有患者。共有527,376例，相當于2,638,679名接受擇期TKA的患者，其中88,415例為RA - TKA。為了減輕兩組之間基線特征的潛在差異和選擇偏差，采用傾向評分匹配分析來進一步平衡和完善我們的數據集，結果176,830名患者均勻分布在兩組之間。對一般情況、即時術后并發癥和經濟數據（包括付款人類別、住院時間和總費用）進行分析。

結果：RA - TKA有明顯的變化，從2016年最初的0.70%到2019年顯著的7.30%。與C - TKA組（66.7±SD年）相比，接受RA - TKA的患者略年輕（66.2±SD年）。RA - TKA組和C - TKA組住院時間分別為1.89天和2.29天。收費指標顯示RA - TKA的收費略高。RA - TKA組術后并發癥較少，如失血、貧血、急性腎損傷、靜脈血栓栓塞、肺栓塞、肺炎和手術傷口并發癥。即使按照傾向評分匹配，這些結論仍然是一致的，具有統計學意義。

結論：與C - TKA相比，RA - TKA在美國的使用在過去幾年中有了顯著的增長，并且顯著減少了術后并發癥和住院時間，為TKA患者提供了更安全的手術治療。對RA - TKA短期和長期結果的進一步研究將提高對該技術全部潛力的理解。

Trends and epidemiology in robotic‐assisted total knee arthroplasty: Reduced complications and shorter hospital stays

Introduction: This study provides an in‐depth analysis of the immediate postoperative outcomes and implications or robotic‐assisted total knee arthroplasty (RA‐TKA) compared with conventional TKA (C‐TKA), particularly with regard to mortality, complications, hospital stay and costs, drawing from a comprehensive nationwide data set.

Methods: The Nationwide Inpatient Sample (NIS) database, the largest all‐payer inpatient healthcare database in the United States, was used to identify all patients who underwent RA‐TKA or C‐TKA from 2016 to 2019. A total of 527,376 cases, representing 2,638,679 patients who underwent elective TKA were identified, of which 88,415 had RA‐TKA. To mitigate potential variations and selection bias in baseline characteristics between the two groups, a propensity score‐matched analysis was employed to further balance and refine our data set, resulting in 176,830 patients evenly distributed between the groups. Analysis was performed according to demographics, immediate post‐operative complications, and economic data, including payor class, length of stay and total charges.

Results: There was a marked shift towards RA‐TKA, from an initial 0.70% in 2016 to a notable 7.30% by 2019. Patients who underwent RA‐TKA were slightly younger (66.2 ± SD years), compared to the C‐TKA group (66.7 ± SD years). Hospital stay was 1.89 days and 2.29 days for RA‐TKA and C‐TKA, respectively. Charges metrics revealed slightly higher charges for RA‐TKA. Less postoperative complications were found in the RA‐TKA group, such as blood loss, anaemia, acute kidney injury, venous thromboembolism, pulmonary embolism, pneumonia and surgical wound

complication. Even following the propensity score matching, these findings remained consistent and statistically significant.

Conclusions: RA‐TKA use in the United States has grown substantially in the last few years and has been associated with significantly reduced immediate post‐operative complications and length of hospital stay compared to C‐TKA, offering safer surgical management for TKA patients. Further studies on the short‐ and long‐term outcomes of RA‐TKA would improve the understanding of the full potential of this technology.

文獻出處：Maman D, Laver L, Becker R, Takrori LA, Mahamid A, Finkel B, Gan-Or H, Yonai Y, Berkovich Y. Trends and epidemiology in robotic-assisted total knee arthroplasty: Reduced complications and shorter hospital stays. Knee Surg Sports Traumatol Arthrosc. 2024 Dec;32(12):3281-3288. doi: 10.1002/ksa.12353. Epub 2024 Jul 17. PMID: 39016343; PMCID: PMC11605021.

文獻2

國際共識研討會對膝關節翻修術中骨缺損的處理

譯者 馬云青

在膝關節翻修術（rTKA）中，對全膝置換（TKA）術后嚴重骨缺損的評估、分型與治療，仍是復雜且存在爭議的課題。盡管已有新證據與新技術用于指導翻修膝嚴重骨缺損的診療策略，但目前仍缺乏一份能系統整合這些新型外科技術的文獻。因此，有必要對翻修全膝關節置換術中嚴重骨缺損的治療進行全面綜述。

美國特種外科醫院（HSS）復雜關節重建中心，以翻修髖、膝關節置換的臨床與研究為核心，于2022年6月24日主辦了翻修TKA骨缺損處理共識研討會。會議邀請了42位國際專家并分為若干小組，每組圍繞以下4大主題中的一項展開討論：

1. 術前評估與影像學檢查、預期骨缺損、分型系統及假體隨訪監測

2. 翻修全膝關節置換術中嚴重骨缺損情況下如何實現可靠固定

3. 嚴重骨缺損病例中髕骨骨缺損與伸膝裝置的處理

4. 復雜模塊化置換系統的應用：鉸鏈式假體、股骨遠端置換與脛骨近端置換

在充分文獻復習與互動討論基礎上，各小組盡可能形成共識意見。文章對上述4個領域、各組共識及未來研究方向進行綜述。

Management of Bone Loss in Revision Total Knee Arthroplasty: An International Consensus Symposium

The evaluation, classification, and treatment of significant bone loss after total knee arthroplasty (TKA) continue to be a complex and debated topic in revision TKA (rTKA). Despite the introduction of new evidence and innovative technologies aimed at addressing the approach and care of severe bone loss in rTKA, there is no single document that systematically incorporates these newer surgical approaches. Therefore, a comprehensive review of the treatment of severe bone loss in rTKA is necessary. The Stavros Niarchos Foundation Complex Joint Reconstruction Center Hospital for Special Surgery, dedicated to clinical care and research primarily in revision hip and knee replacement, convened a Management of Bone Loss in Revision TKA symposium on June 24, 2022. At this meeting, the 42 international invited experts were divided into groups; each group was assigned to discuss questions related to 1 of the 4 topics: (1) assessing preoperative workup and imaging, anticipated bone loss, classification system, and implant surveillance; (2) achieving durable fixation in the setting of significant bone loss in revision TKA; (3) managing patellar bone loss and the extensor mechanism in cases of severe bone loss; and (4) considering the use of complex modular replacement systems: hinges, distal femoral, and proximal tibial replacements. Each group came to consensus, when possible, based on an extensive literature review and interactive discussion on their group topic. This document reviews each these 4 areas, the consensus of each group, and directions for future research.

文獻出處：Sculco PK, Flevas DA, Jerabek SA, Jiranek WA, Bostrom MP, Haddad FS, Fehring TK, Gonzalez Della Valle A, Berry DJ, Brenneis M, Bornes TD, Rojas Marcos CE, Wright TM, Sculco TP. Management of Bone Loss in Revision Total Knee Arthroplasty: An International Consensus Symposium. HSS J. 2024 May;20(2):141-181. doi: 10.1177/15563316231202750. Epub 2024 Jan 25. PMID: 39281983; PMCID: PMC11393633.

文獻3

應用高交聯聚乙烯和傳統聚乙烯墊片的同期雙側后交叉韌帶保留型（CR）全膝關節置換病例的比較研究

譯者 張薔

背景：目前文獻中并無相關文章比較高交聯聚乙烯（HXLPE）和傳統聚乙烯（CP）對CR全膝關節置換（TKAs）術后翻修率的影響。本文章的目的是比較應用HXLPE和CP的CR TKAs病例長期隨訪的臨床療效、平片和計算機掃描（CT）結果，以及骨溶解發生率、翻修率和假體生存率。

方法：本研究納入了410例連續的單一麻醉下同期雙側TKAs韓國患者（平均年齡，62.6±8歲）。其中164例男性和246例女性。每例均為一側應用HXLPE墊片的CR高屈曲全膝假體（NexGen CR-Flex TKA; Zimmer Biomet），另一側應用CP墊片的CR高屈曲NexGen TKA假體。平均隨訪時間為17.5年（范圍15年-19年）。

結果：在末次隨訪時，兩組間的膝關節協會評分（KSS，94分 vs. 93分），WOMAC評分（19.2分 vs. 19.2分），活動度（125° vs. 126°），平片和CT結果，或翻修率（2.0% vs. 2.2%）均無顯著性差異。兩組內均未出現骨溶解病例。如果以翻修或無菌性松動作為終末點，在17.5年的預測假體生存率分別為：HXLPE組 98.0%（95%置信區間, 92% - 100%），CP組 97.8%（95%置信區間, 92% - 100%）。

結論：本長期隨訪（最低15年隨訪）研究顯示應用HXLPE墊片和CP墊片的CR高屈曲全膝關節置換病例均獲得了優異的臨床療效和假體生存率。然而，在本組病例中，我們并未發現高交聯聚乙烯墊片相對傳統墊片的優勢。

Comparison?of?Highly?Cross-Linked?and Conventional?Polyethylene?During Simultaneous?Bilateral?Cruciate-Retaining Total?Knee?Arthroplasties

Results at a Minimum Follow-up of 15 Years

Background: There have been no long-term studies comparing the revision rates of a highly cross-linked polyethylene (HXLPE) bearing with those of a conventional polyethylene (CP) bearing among cruciate-retaining (CR) total knee arthroplasties (TKAs). The aim of the current long-term study was to compare CR TKAs with HXLPE and CP bearings in terms of clinical, radiographic, and computed tomographic (CT) scan results; prevalence of osteolysis; revision rate; and implant survivorship.

Methods: This study enrolled a consecutive series of 410 Korean patients (mean age, 62.6±8 years) who underwent simultaneous bilateral TKAs during the same anesthetic session. This study included 164 men and 246 women. Each patient underwent a posterior CR high-flexion TKA (NexGen CR-Flex TKA; Zimmer Biomet) with an HXLPE bearing on 1 side and a NexGen CR-Flex TKA with a CP bearing on the opposite side. The mean follow-up period was 17.5 years (range, 15 to 19 years).

Results: At the latest follow-up, there were no significant differences between the HXLPE and CP groups with regard to the Knee Society score (94 compared with 93 points), Western Ontario and McMaster Universities Osteoarthritis Index (19.2 points for both groups), range of motion (125° compared with 126°), radiographic and CT results, or revision rate (2.0% compared with 2.2%). No knee showed osteolysis in either group. The estimated survival rate at 17.5 years, using revision or aseptic loosening as the end point, was 98.0% (95% confidence interval, 92% to 100%) for the group with the CR-Flex TKA with an HXLPE bearing and 97.8% (95% confidence interval, 92% to 100%) for the group with the CR-Flex TKA with a CP bearing.

Conclusions: The findings of this long-term study (minimum follow-up of 15 years) indicate that CR-Flex TKAs with HXLPE and CP bearings both yielded excellent clinical outcomes and implant survivorship. However, no significant clinical advantage was observed for HXLPE over CP bearings in this patient population.

文獻出處：Kim YH, Park JW, Jang YS, Kim EJ. Comparison of Highly Cross-Linked and Conventional Polyethylene During Simultaneous Bilateral Cruciate-Retaining Total Knee Arthroplasties: Results at a Minimum Follow-up of 15 Years. J Bone Joint Surg Am. 2025 Dec 29. doi: 10.2106/JBJS.25.00621. Epub ahead of print. PMID: 41460951.

文獻4

擇期全關節置換術中加速康復外科（ERAS）路徑

譯者 沈松坡

加速康復外科（ERAS）方案在全髖關節和全膝關節置換術中的應用日益增多，旨在改善結局、減少并發癥并縮短住院時間。這涉及一種從術前到術后的多學科、循證醫學方法。本文綜述了ERAS在擇期全髖關節置換術（THA）和全膝關節置換術（TKA）中實施的當前文獻，重點關注住院時間（LOS）、阿片類藥物使用、并發癥/再入院等臨床結局，以及麻醉標準化、使用阿片節約型鎮痛藥物、早期活動和患者滿意度等其他關鍵組成部分。

我們檢索了 PubMed、Embase 和 Google Scholar 數據庫（最后檢索時間為2025年5月），以尋找評估ERAS方案在擇期THA和TKA中應用的研究。在無地域限制的前提下，納入了2000年至2025年間以英文發表的相關文章，包括臨床試驗、觀察性研究、病例系列、病例報告和綜述文章。關鍵詞包括“enhanced recovery after surgery”“ERAS”“fast-track”“rapid recovery”“total joint arthroplasty”“total knee replacement”“total hip replacement”以及“outcomes”。文章的選擇基于與主題的相關性，并強調臨床結局。鑒于本綜述為敘述性綜述，未進行正式的定量綜合分析。

納入的文獻（涵蓋多項研究中約294,000例患者）一致表明，ERAS路徑可在不增加再入院率或并發癥發生率的情況下，將LOS顯著縮短1至3天。多模式、阿片節約型鎮痛方案可帶來更優的疼痛控制并減少阿片暴露，從而促進早期活動并減少不良反應。功能恢復得到加速，許多ERAS患者可在術后數小時內下地行走。患者報告結局和滿意度較高，且早期生活質量改善較為常見。從衛生系統角度看，ERAS的實施可帶來顯著的成本節約，這主要歸因于更短的住院時間和更少的術后并發癥。ERAS的發展也促進了在適當篩選患者中門診關節置換術（當日出院）的增長。

全關節置換術（TJA）中的ERAS代表了圍手術期照護模式的范式轉變，融合了安全性、效率和以患者為中心的康復。其實施可改善臨床結局并提升醫療價值，支持其繼續推廣，并作為髖、膝關節置換術全球照護標準加以采用。

Enhanced Recovery After Surgery (ERAS) Pathways in Elective Total Joint Arthroplasty

Enhanced recovery after surgery (ERAS) protocols are increasingly used in total hip and knee arthroplasty to improve outcomes, reduce complications, and shorten hospital stays. This involves a multidisciplinary, evidence-based approach covering the preoperative to postoperative period. This review explores the current literature on ERAS implementation in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA), focusing on clinical outcomes such as length of stay (LOS), opioid use, complications/readmissions, and other key components such as anesthetic standardization, use of opioid-sparing analgesia agents, early mobilization, and patient satisfaction. We performed a literature search of PubMed, Embase, and Google Scholar databases (last searched May 2025) for studies evaluating the use of ERAS protocols in elective THA and TKA. Relevant articles, including clinical trials, observational studies, case series, case reports, and review articles, were identified without geographic restrictions, limited to English-language publications from 2000 to 2025. Key search terms included "enhanced recovery after surgery," "ERAS," "fast-track," "rapid recovery," "total joint arthroplasty," "total knee replacement," "total hip replacement," and "outcomes." The selection of articles was based on relevance to the topic, emphasizing clinical outcomes. No formal quantitative synthesis was performed, given the narrative scope. The included literature (spanning approximately 294,000 patients across multiple studies) consistently demonstrates that ERAS pathways significantly reduce LOS by one to three days without increasing readmission or complication rates. Multimodal, opioid-sparing analgesia regimens lead to superior pain control and reduced opioid exposure, enhancing early mobilization and minimizing adverse effects. Functional recovery is accelerated, with many ERAS patients ambulating within hours of surgery. Patient-reported outcomes and satisfaction are high, and early quality-of-life improvements are commonly observed. ERAS implementation results in substantial cost savings from a systems perspective, largely due to shorter inpatient stays and fewer postoperative complications. The evolution of ERAS has also facilitated the growth of outpatient (same-day discharge) arthroplasty in appropriately selected patients. ERAS in total joint arthroplasty (TJA) represents a paradigm shift in perioperative care, combining safety, efficiency, and patient-centred recovery. Its implementation leads to improved clinical outcomes and enhanced healthcare value, supporting its continued expansion and adoption as a global standard of care in hip and knee arthroplasty.

文獻出處：Ishaku Z, Koshy DI, Adamu Bala M. Enhanced Recovery After Surgery (ERAS) Pathways in Elective Total Joint Arthroplasty. Cureus. 2025 Sep 2;17(9):e91481. doi: 10.7759/cureus.91481. PMID: 40917910; PMCID: PMC12412062

第二部分：保髖相關文獻

文獻1

DDH幼年治療后的患者成年后的生活質量

譯者 張振東

髖關節發育不良（DDH）如果治療不當可導致髖關節功能過早喪失，然而很少有研究關注DDH幼年治療后的長期臨床隨訪結果。

本研究對兒童時期接受過髖關節脫位治療的DDH 患者進行了一項健康相關生活質量調查。 研究者向在其機構接受過兒童期髖關節脫位治療的 287 名DDH 患者發放了調查問卷。使用SF-36調查了患者的人口統計學特征、特定疾病病史以及與健康相關的生活質量。將患者的身體功能評分（PCS）、心理功能評分（MCS）和社會認知評分（RCS）與日本標準值進行了比較。 最終納入 68 例患者進行了評估。

結果顯示：患者的 PCS、MCS 和 RCS 總平均值與標準值相當。PCS可一直保持到 50 歲，但有 10 例50 歲以上的患者 PCS 顯著下降。接受切開復位術的患者的 PCS 明顯低于接受保守復位術的患者。在各年齡組和治療組中，患者的 MCS 和 RCS 與標準值無差異。 此外，PCS、MCS 和 RCS 在雙側、診斷年齡或是否需要額外手術方面也沒有差異。

DDH患者的身體生活質量在50歲之前一直保持不變，但之后迅速下降，尤其是那些在幼年時期就需要進行切開復位的患者。

Quality of life in adult patients with developmental dysplasia of the hip who were treated for hip dislocation during childhood

Developmental dysplasia of the hip (DDH) can lead to premature loss of hip function if not properly treated; however, few studies have focused on the long-term outcomes of DDH. We conducted a survey of health-related quality of life in adult patients with DDH who were treated for hip dislocation during childhood. We sent a questionnaire to 287 adult patients with DDH who were treated for hip dislocation during childhood in our institutions. We examined patient demographics, disease-specific medical history, and health-related quality of life using the short form-36. Physical component summary (PCS), mental component summary (MCS) and role/social component summary (RCS) were compared between the patients and Japanese standard values. Sixty-eight patients were evaluated after exclusion. The overall mean PCS, MCS and RCS scores of the patients were comparable to the standard values. The PCS was maintained until the age of 50, but it was significantly decreased in 10 patients over 50 years old. In addition, PCS was significantly lower in patients who underwent open reduction than in those who were conservatively reduced. The MCS and RCS of the patients did not differ from the standard values in each age and treatment group. Additionally, the PCS, MCS and RCS did not differ according to bilaterality, age at diagnosis, or requirement for additional surgeries. Physical quality of life was maintained until the age of 50 but rapidly declined thereafter in patients with DDH, especially in those who required open reduction during childhood.

文獻出處：Sawamura K, Kitoh H, Matsushita M, Mishima K, Kamiya Y, Imagama S. Quality of life in adult patients with developmental dysplasia of the hip who were treated for hip dislocation during childhood. J Pediatr Orthop B. 2025 Jan 1;34(1):38-43.

文獻2

兒童創傷性三角軟骨損傷的回顧性分析

譯者 任寧濤

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

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

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

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

Retrospective analysis of traumatic triradiate cartilage injury in children

Background: To summarize and analyze the epidemiological characteristics, treatment and corresponding curative effect of triradiate cartilage injury(TCI) in children after trauma, to provide a theoretical basis for early diagnosis and improvement of treatment.

Methods: The TCI was classified according to Bucholz classification, and the final curative effect was evaluated with Harris Hip Score and imaging examination during follow-up. Finally, a comprehensive analysis was made by reviewing the cases in the literature combined with the patients in our hospital.

Results: A total of 15 cases (18 hips) of triradiate cartilage injuries were collected in our hospital. There was 1 hip with type I injury, nine hips with type II injury, two hips with type IV injury, one hip with type V injury and five hips with type VI injury. Among the 12 cases with complete follow-up, the bone bridge was found in or around the triradiate cartilage in 8 cases, early fusion of triradiate cartilage occurred in 5 patients, 3 cases had hip dysplasia, 4 cases had a subluxation of the femoral head, and HHS was excellent in 8 cases and good in 4 cases.

Conclusion: The early diagnosis of TCI is still a difficult problem. Conservative treatment is often the first choice. The overall prognosis of acetabular fractures involving triradiate cartilage is poor. The formation of the bone bridge in triradiate cartilage usually indicates the possibility of premature closure, which may lead to severe complications of post-traumatic acetabular dysplasia and subluxation of the femoral head.

文獻出處：Dong Y, Wang J, Qin J, Nan G, Su Y, He B, Cai W, Chen K, Gu K, Liang X, Yan G, Wang Z. Retrospective analysis of traumatic triradiate cartilage injury in children. BMC Musculoskelet Disord. 2021 Aug 10;22(1):674. doi: 10.1186/s12891-021-04565-2. PMID: 34376165; PMCID: PMC8356404.

文獻3

骨盆再定位截骨術前髖臼三維形態分析方法：范圍綜述

譯者 李勇

背景： 髖臼周圍截骨術是治療髖臼發育不良的金標準。髖臼發育不良的巨大變異性要求通過三維重建和計算機輔助手術進行個性化的術前規劃。為了規劃通過骨盆截骨術移動髖臼骨塊，需要定義一個參考平面和一種描述髖臼三維方向的方法。

方法： 在PubMed上進行了一項范圍綜述，檢索那些在三維參考系中描述原生髖關節髖臼形態的 articles。從3815篇報告中篩選出98篇 articles 納入分析。研究確定了三種可重復的參考平面：骨盆前平面、步態分析中使用的標準化與術語委員會平面以及骶骨基底平面。用于髖臼三維分析的不同方法被分為四組：整體方向、三平面測量、分割和股骨頭表面覆蓋率。

結論： 研究發現有兩種方法適用于再定位截骨術：通過向量法的整體方向法和三平面法。整體方向法依賴于從髖臼緣、髖臼面或連續平面創建向量。通過將整體髖臼向量標準化至一個理想向量，可以通過一次對齊操作來矯正髖臼發育不良。三平面法基于在股骨頭中心進行角度測量，涉及通過考慮軸面、冠狀面和矢狀面來矯正異常。盡管其他兩種方法不直接適用于再定位，但它們有助于篩選患者以及驗證規劃和術后結果。

Methods for three-dimensional characterization of the acetabulum prior to pelvic reorientation osteotomy: a scoping review

? Periacetabular osteotomy is the gold standard treatment for acetabular dysplasia. The great variability of acetabular dysplasia requires a personalized preoperative planning improved by 3D reconstruction and computer-assisted surgery. To plan the displacement of the acetabular fragment by a pelvic osteotomy, it is necessary to define a reference plane and a method to characterize 3D acetabular orientation.
? A scoping review was performed on PubMed to search for articles with a method to characterize the acetabulum of native hips in a 3D reference frame. Ninety-eight articles out of 3815 reports were included. Three reproducible reference planes were identified: the anterior pelvic plane, the Standardization and Terminology Committee plane used in gait analysis, and the sacral base plane. The different methods for 3D analysis of the acetabulum were divided in four groups: global orientation, triplanar measurements, segmentation, and surface coverage of the femoral head.
? Two methods were found appropriate for reorientation osteotomies: the global orientation by a vector method and the triplanar method. The global orientation method relies on the creation of a vector from the acetabular rim, from the acetabular surface or from successive planes. Normalization of the global acetabular vector would correct acetabular dysplasia by a single alignment maneuver on an ideal vector. The triplanar method, based on angle measurements at the center of the femoral head, would involve correction of anomalies by considering axial, frontal, and sagittal planes. Although not directly fit for reorientation, the two others would help to candidate patients and verify both planning and postoperative result.

文獻出處：du Cluzel de Remaurin X, Khouri N, Georges S, Gajny L, Vergari C, Badina A. Methods for three-dimensional characterization of the acetabulum prior to pelvic reorientation osteotomy: a scoping review. EFORT Open Rev. 2024 Aug 1;9(8):762-772. doi: 10.1530/EOR-22-0126. PMID: 39087510; PMCID: PMC11370718.

文獻4

髖關節不同姿勢對坐骨神經位置的影響：一項MRI研究

譯者 陶可

背景：在考慮進行髖關節手術（特別是骨盆三聯截骨術或髖臼周圍截骨術中的坐骨截骨術）時，必須重視坐骨神經位置的變化，以確定最安全的下肢位置。由于坐骨神經靠近截骨部位，因此在這些手術過程中可能會受到損傷，導致嚴重的功能障礙。本研究首次通過實驗證實了髖關節位置對坐骨神經位置的影響。

方法：我們研究了改變髖關節位置如何使坐骨神經靠近或遠離髖臼下溝（進行骨盆三聯截骨術或髖臼周圍截骨術時，坐骨截骨的理想起始點位于髖臼下方）。我們對11名健康兒童（5名男孩和6名女孩，年齡7至17歲，均無髖關節手術史）進行了左髖關節磁共振成像掃描，掃描體位分別為：中立位/仰臥位、屈髖30至45度、屈髖/外展/外旋30至45度。在磁共振圖像上測量了坐骨神經與髖臼下溝之間的距離。計算了每位受試者在屈曲位和屈曲/外展/外旋位下，以中立位為基準的距離比值。

結果：髖關節屈曲但不外展時，坐骨神經向坐骨截骨部位移動（平均屈曲/中立位比值為0.79，P<0.01）。然而，當髖關節屈曲30°至45°，并外展和外旋時，坐骨神經則遠離截骨部位（平均屈髖/外展/外旋/中立位比值為1.34），這意味著神經到髖臼下溝的距離顯著增加（P<0.01）。中立位時平均距離為14.8 mm（11至20 mm），屈曲位時為11.8 mm（9至16 mm），屈髖/外展/外旋位時為20.0 mm（9至30 mm）。

結論：在進行骨盆三聯截骨術或髖臼周圍截骨術時，進行坐骨截骨術最安全的髖/下肢位置可能是屈髖、外展和外旋位。在此位置，可以通過內側或前側入路進行截骨術，使坐骨神經遠離截骨部位。

圖1. 左側髖關節磁共振成像掃描在三種不同體位下進行：中立/仰臥位、屈髖30至45度、以及屈髖/外展/外旋30至45度。

圖2. 軸位T1加權磁共振成像掃描示例及坐骨神經至髖臼下溝的距離測量：中立位11至20毫米（平均14.8毫米），屈髖位9至16毫米（平均11.8毫米），屈髖/外展/外旋9至30毫米（平均20.0毫米）。

圖3. 髖關節屈曲但不外展時，坐骨神經向坐骨截骨部位移動。平均屈髖/中立位比值為0.79 (P<0.01)。然而，在髖關節屈曲/外展/外旋30至45度時，坐骨神經會顯著遠離截骨部位（平均比值為1.34，P<0.01）。

圖4. 示例：一名體型偏瘦的男孩，其坐骨神經周圍脂肪組織極少，在髖關節中立位和屈髖/外展/外旋位（Flex/Abd/ER）時，坐骨神經的位置變化極小。

The effect of hip position upon the location of the sciatic nerve: an MRI Study

Background: Allowance for the positional changes of the sciatic nerve is important when considering the safest position of the leg to perform hip operations, specifically the ischial osteotomy during a pelvic triple or periacetabular osteotomy. As for its proximity to the osteotomy site the sciatic nerve can be injured during these operations with the consequence of severe functional impairment. This is the first in-vivo study that demonstrates the effect of hip position upon the location of the sciatic nerve.

Methods: We determined how altering the position of the hip moves the nerve toward or away from the infracotyloid groove, the desired starting point of the ischial osteotomy site just inferior to the acetabulum when performing a pelvic triple or periacetabular osteotomy. Magnetic resonance imaging scans of the left hip in 3 different positions (neutral/supine, 30 to 45 degrees flexion, 30 to 45 degrees flexion/abduction/external rotation) were performed in 11 healthy children (5 boys and 6 girls, age 7 to 17 y) without prior hip surgery. The distance between the sciatic nerve and the infracotyloid groove was measured on the magnetic resonance images. Distance ratios based on the neutral position were calculated for flexion and flexion/abduction/external rotation for each of the participants.

Results: The sciatic nerve moves toward the ischium osteotomy site in hip flexion without abduction (mean flexion: neutral ratio 0.79, P<0.01). However the nerve moves away from the osteotomy site when the hip is 30 to 45 degrees flexed, abducted, and externally rotated (mean flexion/abduction/external rotation: neutral ratio 1.34), meaning the distance from nerve to infracotyloid groove increases significantly (P<0.01). The mean distances were 14.8 mm (11 to 20 mm) in neutral, 11.8 mm (9 to 16 mm) in flexion, and 20.0 mm (9 to 30 mm) in flexion/abduction/external rotation.

Conclusions: The likely safest position of the hip/leg to perform the ischium osteotomy as part of a pelvic triple or periacetabular osteotomy is in flexion, abduction, and external rotation. In this position the osteotomy can be performed via a medial or anterior approach with the nerve the furthest away from the osteotomy site.

文獻出處：Oliver Birke, Piers D Mitchell, Ella Onikul, David G Little. The effect of hip position upon the location of the sciatic nerve: an MRI Study. J Pediatr Orthop. 2011 Mar;31(2):165-9. doi: 10.1097/BPO.0b013e31820a1345.

文獻5

外側柱是支撐塌陷前股骨頭壞死的關鍵：基于傾向評分匹配隊列的有限元模型分析

譯者 邱興

背景： 本研究設計為一項隊列研究，采用傾向評分匹配法，根據年齡、性別和體重指數進行匹配，對塌陷組和非塌陷組髖關節塌陷前的CT圖像進行有限元模型分析。通過有限元分析，可獲得髖關節周圍整體的應力分布圖形結果，直觀地展示應力集中或分散的簡單印象。

方法： 回顧性分析了32例國際骨循環研究會ARCO 2期或3期股骨頭壞死患者的髖關節，這些患者接受了超過一年的隨訪。將16例隨訪期間無進行性塌陷的髖關節設為研究組，然后采用傾向評分匹配法，選取了16例因塌陷進展而需行關節置換術的髖關節作為對照組。使用Mechanical Finder軟件為每位患者建立有限元模型，然后在髂嵴頂部1000平方毫米區域施加4500牛的載荷，分析模型在屈服應力方面的等效值。

結果： 兩組的年齡、性別和體重指數無顯著差異，但塌陷組中病灶位于外側的比例（p = 0.015）顯著更高，且病灶尺寸（p = 0.015）顯著更大。非塌陷髖關節主要表現為應力分散至內側柱和外側柱，而塌陷髖關節則表現為應力集中于外側柱和原發性壓力骨小梁（p = 0.001）。

結論： 通過有限元模型分析，外側柱和原發性壓力骨小梁區域的應力集中可用于高概率地預測股骨頭壞死的未來塌陷。研究結果提供了簡單直觀且對臨床醫生有重要參考價值的信息。因此，尤其對于年輕患者，通過保髖手術支撐外側柱可能是防止進一步塌陷的關鍵。

Lateral pillar is the key in supporting pre-collapse osteonecrosis of the femoral head: a finite element model analysis of propensity-score matched cohorts

Background: This study was designed as a cohort study using propensity-score matching to age, gender, and body mass index (BMI) for finite element model (FEM) analysis from pre-collapse CT images of collapsed and non-collapsed hips. Through FEM analysis, a global graphical output around the hip joint can provide simple impression of stress distribution: concentration or dispersion.

Methods: A total of 32 hips with ARCO stage 2 or 3 ONFH who were on follow up for over a one-year period were retrospectively reviewed. 16 hips with no interval progression of collapse were set as the study group, then 16 hips with progression of collapse which required arthroplasty were set as the control group using propensity-score matching. FEM was generated through Mechanical Finder for each patient, then 4500 N of load was applied to 1000 mm2 area at the top of iliac crest to analyze the models in terms of equivalents for yield stress.

Results: Age, sex, and BMI had no significant differences between the two groups, while location (p = 0.015) was lateral, and size (p = 0.015) was significantly greater in the collapsed group. Non-collapsed hips mostly exhibited stress dispersion allocated to medial and lateral pillars, while collapsed hips exhibited stress concentration focused on the lateral pillar and the primary compression trabecula. (p = 0.001).

Conclusion: Through FEM analysis, stress concentration to the lateral pillar and the primary compression trabeculae can be used to predict future collapse in ONFH with high probability. Results provide a simple and intuitive, yet valuable information to aid surgeons. Therefore, especially for young patients, holding out the lateral pillar through joint preserving procedures might be the key in preventing further collapse.

Keywords: Femoral head collapse; Finite element analysis; Lateral pillar; Osteonecrosis of the femoral head; Propensity-matched score.

文獻出處：Bahk JH, Jo WL, Kim SC, Kwon SY, Lim YW. Lateral pillar is the key in supporting pre-collapse osteonecrosis of the femoral head: a finite element model analysis of propensity-score matched cohorts. J Orthop Surg Res. 2021 Dec 20;16(1):728. doi: 10.1186/s13018-021-02875-8. PMID: 34930357; PMCID: PMC8686362.

來源：304關節學術

作者：304關節團隊

聲明：本文內容及圖片均為轉載內容，如涉及版權問題請相關權利人及時與我們聯系，我們會立即處理配合采取保護措施，以保障雙方利益。

為什么要投稿？是為了記錄自己的醫學之路！是為了與更多的骨科同道交流分享！是為了讓更多的人看到而受益！讓傳播知識成為一種習慣，是“玖玖骨科”讓你投稿的理由！