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本期目录： 1、各种影像技术诊断髋关节假体周围感染的准确性：一项系统性回顾和Meta分析 2、髋膝关节置换术中关节周围注射镇痛：在哪注射和注射什么 3、全膝置换术后冠状位力线对垫片磨损的影响：一项假体回收研究 4、切开复位克氏针固定治疗不稳定型股骨头骨骺滑脱 5、三维CT重建和图像处理技术在髋关节发育不良患者个性化手术设计中的应用 6、髋关节镜术中使用最小牵引和初始囊切开技术治疗髋股撞击症的临床结果：最少两年随访 7、早期股骨头坏死分类方法比较 第一部分：关节置换相关文献 文献1 各种影像技术诊断髋关节假体周围感染的准确性：一项系统性回顾和Meta分析 译者：张轶超 背景: 有很多影像学方法被用来排除或诊断髋关节假体周围感染，但却不能确定哪种方法更准确。本研究的目的是明确目前在使用的影像学方法的准确性。 方法：我们系统的回顾了收录于MEDLINE和Embase中的关于研究使用不同影像学方法诊断髋关节假体周围感染的文献并做了Meta分析。将各种影像学结果与相应的微生物化验结果、组织学分析结果、术中所见及6个月以上的临床随访结果进行了对比，确定了每种影像学方法的敏感性和特异性。 结果：从1988年到2014年有31项研究被纳入本Meta分析研究中，共1753例髋关节置换病例。纳入研究的质量评估更加注重内部效度而不是外部效度（由于超过50%的研究都缺乏各种资料）。由于临床资料不全所以没做X片、超声、CT和核磁共振的Meta分析。白细胞显像（leukocyte scintigraphy）的累积敏感性和特异性分别为88% (95% 可信区间 [CI], 81% to 94%) 和92% (95% CI, 88% to 96%)；氟脱氧葡萄糖正电放射扫描 (FDG PET) 的累积敏感性和特异性分别为86% (95% CI, 80%to 90%) 和93% (95% CI, 90% to 95%)；白细胞和骨髓显像（bone marrow scintigraphy）的累积敏感性和特异性分别为69% (95% CI, 58% to 79%) 和96% (95% CI, 93%to 98%)；抗粒细胞显影（antigranulocyte scintigraphy）的累积敏感性和特异性分别为84% (95% CI, 70% to 93%) 和 75% (95% CI, 66% to 82%)；骨显像的累积敏感性和特异性分别为80% (95% CI, 72% to 86%) 和 69% (95% CI, 64%to 73%)。 结论：近段时期在临床中使用的方法中，白细胞显像对于确定或者排除髋关节周围假体感染的准确性更好。白细胞和骨髓显像技术的特异性更强，但没有明显的区别。FDG PET具有更加适当的确定或排除感染的准确性。但由于条件受限及费用问题，没有绝对的哪种更好。 The Accuracy of Imaging Techniques in the Assessment of Periprosthetic Hip Infection: A Systematic Review and Meta-Analysis BACKGROUND: Various imaging techniques are used for excluding or confirming periprosthetic hip infection, but there is no consensus regarding the most accurate technique. The objective of this study was to determine the accuracy of current imaging modalities in diagnosing periprosthetic hip infection. METHODS: A systematic review and meta-analysis of the literature was conducted with a comprehensive search of MEDLINE and Embase to identify clinical studies in which periprosthetic hip infection was investigated with different imaging modalities. The sensitivity and specificity of each imaging technique were determined and compared with the results of microbiological and histological analysis, intraoperative findings, and clinical follow-up of >6 months. RESULTS: A total of 31 studies, published between 1988 and 2014, were included for meta-analysis, representing 1,753 hip prostheses. Quality assessment of the included studies identified low concerns with regard to external validity but more concerns with regard to internal validity including risk of bias (>50% of studies had insufficient information). No meta-analysis was performed for radiography, ultrasonography, computed tomography, and magnetic resonance imaging because of insufficient available clinical data. The pooled sensitivity and specificity were 88% (95% confidence interval [CI], 81% to 94%) and 92% (95% CI, 88% to 96%), respectively, for leukocyte scintigraphy; 86% (95% CI, 80% to 90%) and 93% (95% CI, 90% to 95%) for fluorodeoxyglucose positron emission tomography (FDG PET); 69% (95% CI, 58% to 79%) and 96% (95% CI, 93% to 98%) for combined leukocyte and bone marrow scintigraphy; 84% (95% CI, 70% to 93%) and 75% (95% CI, 66% to 82%) for antigranulocyte scintigraphy; and 80% (95% CI, 72% to 86%) and 69% (95% CI, 64% to 73%) for bone scintigraphy. CONCLUSIONS: Of the currently used imaging techniques, leukocyte scintigraphy has satisfactory accuracy in confirming or excluding periprosthetic hip infection. Although not significantly different, combined leukocyte and bone marrow scintigraphy was the most specific imaging technique. FDG PET has an appropriate accuracy in confirming or excluding periprosthetic hip infection, but may not yet be the preferred imaging modality because of limited availability and relatively higher cost. 文献出处：Verberne SJ, Raijmakers PG, Temmerman OP. The Accuracy of Imaging Techniques in the Assessment of Periprosthetic Hip Infection: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am. 2016 Oct 5;98(19):1638-1645. 文献2 髋膝关节置换术中关节周围注射镇痛：在哪注射和注射什么 译者：马云青 背景：关节内注射已成为髋膝关节置换术多模式镇痛的重要手段。但注射技术在外科医生中差别很大，缺乏标准化。 方法：我们进行了广泛的文献检索，以确定髋膝关节周围痛觉纤维的位置。并探讨了关节周围鸡尾酒镇痛不同成分的药理作用。 结果：膝关节周围的各个组织中都存在大量的痛觉感受器。髌下脂肪垫、关节囊、韧带、骨膜、软骨下骨和侧副韧带的是痛觉感受器高度集中的部位。髋关节内的痛觉感受器的分布情况缺乏相关的经验性证据，但目前所知的是髋关节囊的位置分布是相对弥漫性的。关节盂唇和圆韧带的分布较多。局麻药是鸡尾酒配方的基础。大多数注射鸡尾酒和功能的成分是阻断钠离子通道。脂溶性麻醉剂可能比传统的麻醉药物提供更长的镇痛时间。非甾体类消炎止痛药物能够控制炎性因子和皮质类固醇以及周围的炎症介质的产生，降低痛觉受器的敏感性。中枢神经系统的阿片受体分布密度处于较低水平，但在局部注射中加入也会缓解疼痛。还有的药物可以为关节周围的鸡尾酒提供辅助作用，以延长药物的作用时间和药效。 结论：通过了解特定部位的痛觉感受器分布情况可能有助于进一步减轻膝关节和髋关节置换术后的疼痛症状。改变关节周围注射的鸡尾酒配方成分可能有助于多模式的疼痛控制。 膝关节周围痛觉敏感部位分布图
髋关节周围痛觉敏感部位分布图 Periarticular Injections in Knee and Hip Arthroplasty: Where and What to Inject BACKGROUND: Periarticular injections have become a valuable adjunct to multimodal pain control regimens after knee and hip arthroplasties. Injection techniques vary greatly among surgeons with little standardization of practice. METHODS: We performed an extensive literature search to determine where nociceptive pain fibers are located in the hip and the knee and also to explore the pharmacology of periarticular cocktail ingredients. RESULTS: Large concentrations of nociceptors are present throughout the various tissues of the knee joint with elevated concentrations in the infrapatellar fat pad, fibrous capsule, ligament insertions, periosteum, subchondral bone, and lateral retinaculum. Less empiric evidence is available on nociceptor locations in the hip joint, but they are known to be located diffusely throughout the hip capsule with elevated concentrations at the labral base and central ligamentum teres. Local anesthetics are the base ingredient in most injection cocktails and function by blocking voltage-gated sodium channels. Liposomal anesthetics may offer longer duration of action over traditional anesthetics. Nonsteroidal anti-inflammatory agents and corticosteroids block peripheral production of inflammatory mediators and may desensitize nociceptors. Opioid receptors are present in lower densities peripherally as compared with the central nervous system, but their inclusion in injections can lead to pain relief. Sympathetic drugs can provide adjunct effects to periarticular cocktails to increase duration of action and effectiveness of medications. CONCLUSION: Targeting specific sites of nociceptors may help to further decrease pain after knee and hip arthroplasties. Altering periarticular cocktail ingredients may aid in multimodal pain control with injections. 文献出处：Ross JA, Greenwood AC, Sasser P , Jiranek WA. Periarticular Injections in Knee and Hip Arthroplasty: Where and What to Inject. J Arthroplasty. 2017 Sep;32(9S):S77-S80. 文献3 全膝置换术后冠状位力线对垫片磨损的影响：一项假体回收研究 译者：张蔷 背景：全膝置换术后的冠状位力线是造成垫片长期磨损的重要原因之一。 方法：这是一项基于95例翻修假体回收的研究，对聚乙烯垫片磨损的程度及类型进行统计，并与患者膝关节术后力线以及胫骨假体位置进行交叉分析。 基本数据 结果：随着术后总体力线内翻程度加大，垫片磨损加剧。但相比于外翻组，内翻组外侧间室磨损更严重，胫骨假体的内外翻对磨损并无明显影响。 实验数据 这一现象（内翻组外侧间室磨损严重，外翻组内侧间室磨损严重）早有报道，有人将其归因于股骨髁的抬起（Lift-off）导致应力异常引发的。 Lift-off 结论：随着内翻的加剧，垫片磨损加重，同时外侧间室磨损大于内侧间室。这一独特的现象可用外侧髁lift-off现象诱发的垫片撞击及剪切应力增加来解释。 The Impact of Coronal Plane Alignment on Polyethylene Wear and Damage in Total Knee Arthroplasty: A Retrieval Study Background: Coronal plane alignment is one of the contributing factors to polyethylene wear in total knee arthroplasty. Methods: Based on 95 retrieved polyethylene inserts, wear and damage patterns were analyzed in relationship to the overall mechanical alignment and to the position of the tibial component. Results: A progression of wear was observed with progressively mechanical varus alignment. However, there was significantly more damage in the lateral compartment in the mild and moderate varus group compared to the valgus group. No difference in damage was seen between all groups for tibial component positioning in valgus or varus. Conclusion: Progressive wear was observed with progressively varus alignment with more damage at the lateral side. This observation is unique and might be explained by lateral condylar lift-off inducing impact and shear loading in the varus group. 文献出处：Vandekerckhove PTK, Teeter MG, Naudie DDR. The Impact of Coronal Plane Alignment on Polyethylene Wear and Damage in Total Knee Arthroplasty: A Retrieval Study. J Arthroplasty. 2017 Jun;32(6):2012-2016. 第二部分：保髋换相关文献 文献1 切开复位克氏针固定治疗不稳定型股骨头骨骺滑脱 译者：罗殿中 背景：不稳定型股骨头骨骺滑脱的治疗方法选择多存在争议，尤其对于严重的病例，复位股骨头骨骺常常会导致股骨头坏死发生。本研究分析了关节囊切开关节内清理、股骨头骨骺轻柔复位并行克氏针固定治疗股骨头骨骺滑脱的疗效及并发症发生情况。 方法：作者对其所在机构行切开复位克氏针固定治疗的64例患者进行研究，其中男37例，女27例。所有患者诊断均依据病史（摔伤或绊倒后突发髋关节疼痛）及影像学检查（X线见股骨头骨骺滑脱；B超见髋关节积液）明确为不稳定型股骨头骨骺滑脱。手术方式为：关节囊切开，清理关节内血肿或积液，轻柔复位股骨头骨骺，克氏针固定（图1）。所有手术均为急诊手术，手术距发病时间小于24小时。 图1 手术技术示意图：A 不稳定型股骨头骨骺滑脱，克氏针止于骺板边缘；B 手指轻轻摇动使其轻柔复位；C 复位满意后，加深克氏针固定股骨头；D 再植入两根克氏针增加稳定性。 结果：64例患者中，包括20例轻度滑脱（滑脱角小于31°）、24例中度滑脱（滑脱角界于31至50度之间）以及20例重度滑脱（滑脱角界于51至90度之间）。其中61例患者术后无股骨头坏死发生，其余3例（包括女2例、男1例）发生部分股骨头坏死，发生率为4.7%。中度滑脱患者中2例股骨头坏死，重度滑脱患者中1例股骨头坏死，轻度滑脱患者中无股骨头坏死发生。60例患者（34男26女）获得平均4.9年（范围：18月-104月）临床及影像学随访，末次随访Iowa髋关节评分达平均94.5分。 结论：急诊行切开复位关节清理、克氏针固定治疗不稳定型股骨头骨骺滑脱，手术技术安全可靠，且股骨头坏死并发症发生率低。股骨头骨骺滑脱程度并不影响股骨头坏死的发生率。 附：典型病例1： 图2 男，13岁7月，摔伤，不能负重。蛙式位测量滑脱角为25度。 图3 该于患者伤后20小时接受手术治疗，手术方式为切开复位克氏针固定。术后滑脱角残留4度。 图4 术后22年，Iowa髋关节评分为97分。 附：典型病例2：
图5 男，14岁2月，骑自行车摔伤。蛙式位测量滑脱角为65度。
图6 伤后8小时接受切开复位克氏针固定术。
图7 蛙式位测量术后滑脱角残留10度。 图8 术后16年5个月正位片。
图 9 术后16年5个月蛙式位片。 Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis BACKGROUND: Reduction of unstable slipped capital epiphysis has a bad reputation, especially in severe slips. Treatment frequently causes avascular necrosis (AVN). This study analyzes the role of capsulotomy with evacuation of intraarticular fluid and gentle reduction done as an emergency procedure followed by fixation with unthreaded Kirschner wires (K-wires). METHODS: We treated 64 consecutive cases of unstable slips (37 boys and 27 girls) following the same protocol. Instability was recognized in those children who had experienced a fall or a stumble, followed by acute hip pain, with radiological evidence of capitalfemoral separation and ultrasonographic evidence of joint effusion. The protocol consisted of capsulotomy, evacuation of intraarticular effusion or hematoma, controlled gentle reduction, and fixation of the reduced physis by smooth K-wires. Surgery was done as an emergency procedure if possible within 24 hours after the onset of acute symptoms. RESULTS: There were 20 mild slips with slip angles less than 31 degrees, 24 moderate with slip angles between 31 and 50 degrees, 20 slips were severe with slip angles between 51 and 90 degrees. In 61 cases, reduction was successful without being followed by AVN. Three patients, 2 girls and 1 boy, developed partial AVN (4.7%). Two avascular necroses occurred in moderate slips, one in a severe slip, and none in the mild slips. The outcome of 60 patients (34 boys and 26 girls) with unstable slips could be evaluated clinically and radiographically with a mean follow-up of 4.9 years (range, 18 months-104 months). The Iowa hip score in these 60 cases reached an average of 94.5 points out of 100. CONCLUSIONS: Open reduction and evacuation of intraarticular hemarthrosis or effusion detected by ultrasound and smooth K-wirefixation done as an emergency is a safe and reliable treatment option for unstable slips with a low AVN rate. The severity of the slip does not influence the rate of AVN and the outcome measured by the Iowa hip score. 文献出处：Parsch K, Weller S, Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. J Pediatr Orthop. 2009 Jan-Feb;29(1):1-8. 文献2 三维CT重建和图像处理技术在髋关节发育不良患者个性化手术设计中的应用 译者：程徽 目的：髋关节发育不良（DDH）患者的髋臼覆盖不足表现各异。因此，在进行伯尔尼髋臼周围截骨术（PAO）时，髋臼的矫正方向和角度是也各不相同。本文介绍了一种使用三维CT和图像处理技术进行定制手术计划的可行方法。 方法：本研究纳入60例DDH患者（男性15例，女性45例，平均年龄30±8/14〜49岁）和53例正常髋关节（男性13例，女性37例，平均年龄52±13/16岁〜69岁）使用商业软件Mimics和Imageware重建。在矫正骨盆倾斜和旋转后，测量每个髋关节的几何参数与前骨盆平面的关系。通过与正常髋关节比较来确定DDH患者髋臼发育不良的类型和程度，并在虚拟PAO后分析股骨头覆盖的改善。为每位DDH患者设计了个性化的手术程流程，并为实际手术提供了参考。
图1 模拟PAO手术 结果：我们使用图像处理软件制作3D骨盆模型，进行精确测量并进行PAO模拟手术。对照组正常髋关节的外侧CE角（LCEA），前CE角（ACEA），髋臼前倾角（AAVA），髋臼前角（AASA）和髋臼后角（PASA）分别为35.128± 6.337，57.052±6.853，19.215±5.504，61.537±7.291和99.434±8.372°。手术前，患髋上述角度分别为11.46±11.19，35.79±13.75，22.77±6.13，43.58±9.15和88.46±8.24，术后分别矫正为33.81±2.36，55.38±2.09，20.16±2.18，58.29±7.60，和4.71 ±7.75°。经过虚拟伯尔尼髋臼周围截骨（PAO），LCEA，ACEA，AAVA，AASA和PASA纠正效果显著（p <0.01）。在虚拟PAO后，LCEA，ACEA和AAVA与正常髋关节之间没有统计学性差异（分别为p = 0.06，p = 0.23，p= 0.06）。 AASA术后明显改善（p = 0.002），其代价是PASA所代表的后方覆盖明显减少，显着小于的正常值和DDH患者组的术前测量值（p <0.01）。
图2 参考值的测量 结论：DDH患者骨盆的几何特征可以通过三维CT重建和图像处理技术综合评估。使用这种方法，外科医生可以设计个性化的治疗方案，提高PAO的疗效。 Application of three-dimensional computerised tomography reconstruction and image processing technology in individual operation design of developmental dysplasia of the hip patients PURPOSE: Acetabular coverage deficiency displays individual difference among patients with developmental dysplasia of the hip (DDH). Therefore, the correct direction and degree of the acetabular fragment is patient-specific during Bernese periacetabular osteotomy (PAO). This paper introduces a feasible method using 3D computed tomography (CT) and computer image processing technology for customised surgical planning. METHODS: CT data of 96 hips in 60 DDH patients (male 15, female 45; average age/range 30 ± 8/14-49 years) and 53 normal hips (male 13, female 37; average age/range 52 ± 13/16-69 years) were reconstructed using commercially available software Mimics and Imageware. Geometric parameters of each hip were measured in relation to the anterior pelvic plane after correcting for pelvic tilt and rotation. Deficiency types and degrees of acetabular dysplasia in patients with DDH were determined by comparison with normal hips, and improvement in femoral-head coverage was analysed again after virtual PAO. A customised surgery programme for each DDH patient was designed and provided the reference for the actual operation. RESULTS: We produced a 3D pelvic model using image processing software, doing precise measurement and with close approximation to the actual PAO. Lateral centre-edge angle (LCEA), anterior centre-edge angle (ACEA), acetabular anteversion angle (AAVA), anterior acetabular sector angle (AASA) and posterior acetabular sector angle (PASA) of normal hips in the control group were 35.128 ± 6.337, 57.052 ± 6.853, 19.215 ± 5.504, 61.537 ± 7.291 and 99.434 ± 8.372°, respectively. Angles of hips with DDH before surgery were 11.46 ± 11.19, 35.79 ± 13.75, 22.77 ± 6.13, 43.58 ± 9.15 and 88.46 ± 8.24, which were corrected to 33.81 ± 2.36, 55.38 ± 2.09, 20.16 ± 2.18, 58.29 ± 7.60, and 4.71 ± 7.75°, respectively, after surgery. After virtual Bernese PAO, LCEA, ACEA, AAVA, AASA and PASA were corrected significantly (p < 0.01). There was no statistically significant differences between LCEA, ACEA and AAVA after virtual Bernese PAO and normal hips (p = 0.06, p = 0.23, p = 0.06°, respectively). AASA improved significantly (p = 0.002) post-operatively at the cost of reducing posterior coverage represented by PASA, which is significantly smaller than in normal and pre-operative hips of DDH patients (p < 0.01). CONCLUSIONS: The geometric feature of the pelvis for patients with DDH can be assessed comprehensively by using 3D-CT reconstruction and image processing technology. Based on this method, surgeons can design individualised treatment scheme and improve the effect of PAO. 文献出处：Xuyi W, Jianping P, Junfeng Z, Chao S, Yimin C, Xiaodong C. Application of three-dimensional computerised tomography reconstruction and image processing technology in individual operation design of developmental dysplasia of the hip patients. Int Orthop. 2016 Feb;40(2):255-65. 文献3 髋关节镜术中使用最小牵引和初始囊切开技术治疗髋股撞击症的临床结果：最少两年随访 译者：肖凯 目的：尽管关节镜在治疗FAI中的应用逐渐增多，但是却有因下肢牵引力导致严重并发症的报道。我们发明了髋关节镜初始关节囊切开技术及最小牵引技术。本研究的目的是分析应用此项技术治疗FAI术后至少两年的临床疗效。 方法：我们选取了47例连续的均接受了FAI手术治疗的患者。最初的手术切口有2个：近端前外侧切口及远端前侧切口。创建关节前方操作空间，于前关节囊做T形切口以减小关节张力。应用最短牵引时间（小于20分钟），可以满足手术中探查髋臼中心区域的需求。对于夹钳型撞击症的患者，应用髋臼成形术治疗。之后去除下肢牵。对于Cam型撞击症患者，给予行股骨头颈部成形术。所有患者进行了3.3±1年的随访，应用Harris髋关节评分和QOL牛津评分评价预后。所有患者均无失随访。
患者仰卧位，下肢应用牵引床牵引。图中两个切口分别为近端前外侧切口及远端前侧切口
a：沿髋臼前上外缘及股骨颈轴线方向T形切开关节囊；b：可以进行关节探查并可减小下肢牵引力量
此关节囊切开方法可以在不损伤盂唇的情况下进行 结果：术后共有3例患者出现并发症，2例为异位骨化，1例为股皮神经损伤，但在末次随访时恢复。5例患者（10％）术后平均1.4年后接受再次手术，其中3例接受人工全髋关节置换术、1例接受髋臼周围截骨术、1例接受二次髋关节镜清理术。患者Harris评分从术前60±10分显著增加至术后86±15分（p <0.0001）。QOL牛津评分由术前34±15改善至术后50±11分。只有25%的患者在末次随访时达到“忘记髋关节做过手术”的状态。 结论：我们的临床研究结果与先前用其他手术技术治疗FAI的研究结果相当。但是，尽管本研究明确患者术后临床效果良好，但达到“忘记髋关节做过手术”这种状态的患者的比例较低，这点应引起我们的注意，并应告知患者。 Clinical outcomes following arthroscopic treatment of femoro-acetabular impingement using a minimal traction approach and an initial capsulotomy. Minimum two year follow-up PURPOSE: Although the arthroscopic management of femoroacetabular impingement (FAI) is increasing, severe complications have been reported due to traction. We developed an arthroscopic technique based on an initial capsulotomy and a minimal traction approach. The main purpose of this study was to analyze the clinical outcomes of FAI treatment using this technique after at least two years of follow-up. METHODS: Forty-seven consecutive patients underwent surgery for FAI. There were two initial portals: a proximal anterolateral portal and a distal anterior instrumental portal. An anterior working space was created and a T-shaped incision was made in the anterior capsule to relieve joint distraction. Short traction (less than 20 min) made it possible to approach the central compartment. Acetabuloplasty was performed in the presence of pincer impingement. Traction was then released. A head-neck femoral osteochondroplasty was performed in case of bump impingement. All patients underwent a mean 3.3 ± one years of follow-up based on two self-administered questionnaires: the Harris hip score and the QOL Oxford score. None of the patients were lost to follow-up. RESULTS: There were three complications: two ossifications and one case of injury to the femoral cutaneous nerve with good clinical outcomes at the final follow-up. Five patients (10%) underwent surgical revision after a mean 1.4 years of follow-up: three total hiparthroplasties, one peri-acetabular osteotomy, and one repeat arthroscopic hip debridement. The Harris score increased significantly from 60 ± 10 to 86 ± 15 (p < 0.0001) and the Oxford score improved from 34 ± 15 to 50 ± 11. Only 25% of patients had a 'forgotten hip' at the final follow-up. CONCLUSION: Our clinical results were comparable to previously reported outcomes with other surgical techniques for the management of FAI. However, it should also be noted that despite these good clinical outcomes, the percentage of patients with a 'forgotten hip' is low, and patients should be informed of this. 文献出处：Sariali E, Vandenbulcke F. Clinical outcomes following arthroscopic treatment of femoro-acetabular impingement using a minimal traction approach and an initial capsulotomy. Minimum two year follow-up. Int Orthop. 2018 Mar 23. 文献4 早期股骨头坏死分类方法比较 译者：张振东 背景：股骨头坏死患者股骨头坏死区的大小及位置是股骨头塌陷与否及疾病预后的主要影响因素。股骨头坏死的多种分类方法也多依据坏死区大小及位置，然而何种分类方法最为合适，目前尚无统一意见。 研究目的：通过比较Steinberg（图1）、改良Kerboul（图2）以及JIC（JapaneseInvestigation Committee，图3）股骨头坏死分类方法，以明确：1）三种分类方法之间的相关性；2）各分类方法的观察者间及观察者内一致性；3）各分类方法中不同分级患者股骨头塌陷风险比较。 方法：自2000年1月至2014年12月，作者所在机构共治疗74例（101髋）股骨头未塌陷的股骨头坏死患者，其确诊依据髋关节平片或核磁检查。其中1例患者（1%）死亡，6例患者（8%）失访，2例患者（3%）于两年前接受截骨术治疗，其余65例患者（86髋）纳入该研究进行分析。患者均接受3D-扰相梯度回波序列（Threedimensional spoiledgradient-echo sequence，3D-SPGR）核磁，股骨头坏死依据该核磁序列上观察到低信号密度带诊断。对所有患者分别行Steinberg、改良Kerboul以及JIC分类方法分类，比较各分类方法的相关性。使用Kappa一致性检验确定各分类方法的观察者间及观察者内一致性。此外，经平均随访9年（范围：2-16年），以股骨头塌陷及接受关节置换作为研究终点，计算各分类方法中不同分级患者的累积生存率，并比较各分类方法中不同分级患者股骨头塌陷风险。
图1 Steinberg分类方法：通过3D-SPGR核磁测量坏死区体积（红色区域所示）与股骨头整体体积（白色区域所示）的比值，确定Steinberg分级（A、B、C）。
图2 改良Kerboul分类方法：A为中冠状面测量角度，B为中矢状面测量角度。Grade 1(< 200°), Grade 2 (200°-249°), Grade 3 (250°-299°), Grade 4 ( 300°以上)。
图3 JIC分类方法：A：坏死区外缘位于负重区内1/3；B：坏死区外缘位于负重区内2/3；C1：坏死区外缘超过负重区2/3，但未超过髋臼外缘；C2：坏死区外缘超过髋臼外缘。 结果：Steinberg与改良Kerboul分类方法之间存在强相关性（相关系数0.83，p < 0.001），Steinberg与JIC分类方法之间相关系数为0.77（p < 0.001），改良Kerboul与JIC分类方法之间的相关系数为0.80（p < 0.001）。JIC分类方法观察者间一致性高于Steinberg分类方法（分别为0.72，范围0.30-0.90；0.56，范围0.24-0.84；P < 0.001），亦高于改良Kerboul分类方法（0.57，范围0.35-0.80；p < 0.001）。对于Steinberg分类方法，通过至少2年随访，以股骨头塌陷为研究终点的累积生存率分别为：A级（82%；95%CI：66%-97%）、B级（43%；95%CI：21.9%-64.8%）、C级（20%；95%CI：4.3%-35.7%），A与B比较、A与C比较、B与C比较均有统计学差异（p = 0.007；p < 0.001；p = 0.029）。对于改良Kerboul分类方法4级，其生存率为12%（95%CI：0%-27.1%），低于Steinberg分类方法C级，亦低于JIC分类方法C2分型（18%；95%CI：2.8%-34.0%）。由于JIC分类方法A型患者中，无1例股骨头塌陷发生，为确定低塌陷风险股骨头的最好方法。 结论：相比Steinberg及改良Kerboul分类方法，早期股骨头坏死使用JIC分类更为可靠且实用。 Which Classification System Is Most Useful for Classifying Osteonecrosis of the Femoral Head? BACKGROUND: Many studies have confirmed that the size and location of necrotic lesions are major factors that affect the prevalence of collapse and prognosis in patients with osteonecrosis of the femoral head (ONFH). Although several classification systems categorize and quantify ONFH, there is no agreement on which one is most useful for the purpose. QUESTIONS/PURPOSES: We compared the Steinberg, modified Kerboul, and Japanese Investigation Committee (JIC) classifications of ONFH in terms of (1) the correlation among the three different classification systems. We further examined (2) the inter- and intraobserver reliability of the three classification systems and (3) the association of higher grades within each classification and the risk of subsequent collapse. METHODS: Between January 2000 and December 2014, we treated 101 hips in 74 patients for precollapse ONFH, diagnosed either on plain radiographs or MRI. Of those, one patient (1%) died, six patients (8%) were lost to followup, and two patients (3%) underwent osteotomy before 2 years, leaving 86 hips in 65 patients (88%) for analysis here. Three-dimensional spoiled gradient-echo sequence (3D-SPGR) MRI was performed for all hips, and the presence of ONFH was determined by finding the area surrounded by the outer margin of the low-signal-intensity band on 3D-SPGR MRI. Patients with ONFH were categorized using the Steinberg, modified Kerboul, and JIC classification systems, and correlations among these three classification systems were investigated. Inter- and intraobserver reliability was assessed by 10 orthopaedic surgeons using 40 sets of 3D-SPGR MR images. The reliability of each system was evaluated using the kappa coefficient. The cumulative survival rate with collapse and undergoing hip arthroplasty as the endpoints was evaluated for each of the three classification systems (mean followup, 9 years; range, 2-16 years), and the association of higher grades within each classification and the risk of subsequent collapse were also evaluated. RESULTS: We found strong correlations between the Steinberg and modified Kerboul classifications (ρ = 0.83, p < 0.001), the Steinberg and JIC classifications (ρ = 0.77, p < 0.001), and the modified Kerboul and JIC classifications (ρ = 0.80, p < 0.001). Interobserver reliability in the JIC classification (0.72; range, 0.30-0.90) was higher than that in the Steinberg classification (0.56; range, 0.24-0.84; p < 0.001) and the modified Kerboul classification (0.57; range, 0.35-0.80; p < 0.001). The cumulative survival rate with collapse as the endpoint after a minimum of 2 years of followup in the Steinberg classification differed between Grades A (82%; 95% confidence interval [CI], 66%-97%) and B (43%; 95% CI, 21.9%-64.8%; p = 0.007), Grades A and C (20%; 95% CI, 4.3%-35.7%; p < 0.001), and Grades B and C (p = 0.029). Survival was lower for modified Kerboul Grade 4 hips (12%; 95% CI, 0%-27.1%) than for Steinberg Grade C hips (20%; 95% CI, 4.3%-35.7%) and JIC Type C2 hips (18%; 95% CI, 2.8%-34.0%). The JIC classification was best able to identify hips at low risk of collapse because no JIC Type A hips collapsed. CONCLUSIONS: The JIC classification was more reliable and effective, at least for early-stage ONFH, than the Steinberg or modified Kerboul classifications. Further investigation might be useful to identify whether each classification system emphasizes specific risk factors for collapse. LEVEL OF EVIDENCE: Level III, diagnostic study.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. 文献出处：Takashima K, Sakai T, Hamada H, Takao M, Sugano N.Which Classification System Is Most Useful for Classifying Osteonecrosis of the Femoral Head? Clin Orthop Relat Res. 2018 Mar 15. |
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