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本期目录： 1、全膝关节置换术中胫骨假体的旋转 2、全关节置换术后假体周围感染术前风险计算器的研发和评价 3、用钽金属髋臼杯翻修初次髋关节置换--5年随访 4、121例股骨头骨骺滑脱患者的长期随访 5、骨的分形式分层构象始于纳米量级 6、髋臼周围截骨术治疗髋臼后倾导致的髋关节前方撞击症 7、股骨/髋臼前倾角 第一部分：关节置换相关文献 文献1 全膝关节置换术中胫骨假体的旋转 译者：张轶超 背景：在全膝关节置换手术中，运动(ROM)定位法和胫骨结节解剖(TTL)定位法均被用于胫骨假体的旋转定位。本研究的目的是评估在计算机导航初次全膝关节置换术中采用这两种方法的差别。假定运动定位法是可以重复验证的方法，它所确定的胫骨假体旋转角度与解剖定位法不同。 方法：这个前瞻性观察研究评估了这两种方法确定的胫骨假体位置的前后轴线，没有评估术后的临床效果。一共有20位病人的20个膝使用计算机导航系统测量了这两种方法的差异，这些病例均采用后稳定型固定垫片假体，均做了髌骨置换。 结果：运动定位法是一种可重复验证的方法，其组内相关系数为0.84（p<0.001）。相对解剖定位法，运动定位法的轴线平均外旋4.56°，有统计学差异(p= 0.028)。两种方法间在术中关节最大屈曲度和术前机械轴线上存在显著差异。 结论：外科医生应该知道这两种方法在确定胫骨假体旋转位置上存在很显著的差异。这直接影响关节的最大屈曲度和机械轴线。 Tibial component rotation in total knee arthroplasty Background: Both the range of motion (ROM) technique and the tibial tubercle landmark (TTL) technique are frequently used to align the tibial component into proper rotational position during total knee arthroplasty (TKA). The aim of the study was to assess the intra-operative differences in tibial rotation position during computer-navigated primary TKA using either the TTL or ROM techniques. The ROM technique was hypothesized to be a repeatable method and to produce different tibial rotation positions compared to the TTL technique. Methods: A prospective, observational study was performed to evaluate the antero-posterior axis of the cut proximal tibia using both the ROM and the TTL technique during primary TKA without postoperative clinical assessment. Computer navigation was used to measure this difference in 20 consecutive knees of 20 patients who underwent a posterior stabilized total knee arthroplasty with a fixed-bearing polyethylene insert and a patella resurfacing. Results: The ROM technique is a repeatable method with an interclass correlation coefficient (ICC2) of 0.84 (p < 0.001). The trial tibial baseplate was on average 4.56 degrees externally rotated compared to the tubercle landmark. This difference was statistically significant (p = 0.028). The amount of maximum intra-operative flexion and the pre-operative mechanical axis were positively correlated with the magnitude of difference between the two methods. Conclusions: It is important for the orthopaedic surgeon to realise that there is a significant difference between the TTL technique and ROM technique when positioning the tibial component in a rotational position. This difference is correlated with high maximum flexion and mechanical axis deviations. 文献出处：Feczko PZ, Pijls BG, van Steijn MJ. Tibial component rotation in total knee arthroplasty. BMC Musculoskelet Disord. 2016 Feb 16;17:87. 文献2 全关节置换术后假体周围感染术前风险计算器的研发和评价 译者：马云青 研究背景：对准备接受全髋或全膝关节置换患者发生假体周围感染（PJI）的风险进行术前评估，并提出针对性预防和治疗干预措施是有重要意义的。本研究的目的是建立术前PJI风险计算器，评估患者发生PJI的独立风险因素，由金黄色葡萄球菌引起的PJI和由耐药菌引起的PJI。 方法：对27717例患者(12086例全膝和31167例全髋)进行回顾性分析，其中包括1035例确认感染病例，所有病例均为2000年至2014年在同一医疗机构接受的治疗。共列举了42个危险因素，包括患者自身因素和手术相关因素，用多变量相关分析。外部验证使用了在单中心医疗机构中接受全关节置换手术的29252例患者的相关数据。 结果：在42项危险因素中，25项不是PJI的显著危险因素。在其余17项危险因素中最高危的因素包括：既往的开放手术史、药物滥用、翻修手术和人体免疫缺病毒(HIV)/后天免疫功能丧失综合症(AIDS)。在内外部验证模型中曲线下的面积分别为：所有PJI为0.83和0.84。耐药菌PJI分别为0.86和0.83，金黄色葡萄球菌感染导致的PJI为0.86和0.73。PJI发生率最低为0.56%和0.61%，最高为15.85%和20.63%。 结论：在这项大型队列研究中，我们能够确认和验证预测PJI的风险因素及其相对权重。危险因素例如存在既往手术史和存在的联合危险因素。需要在全关节置换手术前确认是否有手术指正并向患者进行咨询。 所有PJI危险因素计算结果，金葡菌引起的PJI危险因素和耐药菌引起的PJI危险因素 Development and Evaluation of a Preoperative Risk Calculator for Periprosthetic Joint Infection Following Total Joint Arthroplasty Background: Preoperative identification of patients at risk for periprosthetic joint infection (PJI) following total hip arthroplasty (THA) or total knee arthroplasty (TKA) is important for patient optimization and targeted prevention. The purpose of this study was to create a preoperative PJI risk calculator for assessing a patient’s individual risk of developing (1) any PJI, (2) PJI caused by Staphylococcus aureus , and (3) PJI caused by antibiotic-resistant organisms. Methods: A retrospective review was performed of 27,717 patients (12,086 TKAs and 31,167 THAs), including 1,035 with confirmed PJI, who were treated at a single institution from 2000 to 2014. A total of 42 risk factors, including patient characteristics and surgical variables, were evaluated with a multivariate analysis in which coefficients were scaled to produce integer scores. External validation was performed with use of data on 29,252 patients who had undergone total joint arthroplasty (TJA) at an independent institution. Results: Of the 42 risk factors studied, 25 were found not to be significant risk factors for PJI. The most influential of the remaining 17 included a previous open surgical procedure, drug abuse, a revision procedure, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). The areas under the curves were 0.83 and 0.84 for any PJI, 0.86 and 0.83 for antibiotic-resistant PJI, and 0.86 and 0.73 for S. aureus PJI in the internal and external validation models, respectively. The rates of PJI were 0.56% and 0.61% in the lowest decile of risk scores and 15.85% and 20.63% in the highest decile. Conclusions: In this large-cohort study, we were able to identify and validate risk factors and their relative weights for predicting PJI. Factors such as prior surgical procedures and high-risk comorbidities should be considered when determining whether TJA is indicated and when counseling patients. 文献出处：Tan TL, Maltenfort MG, Chen AF. Development and Evaluation of a Preoperative Risk Calculator for Periprosthetic Joint Infection Following Total Joint Arthroplasty. J Bone Joint Surg Am. 2018 May 2;100(9):777-785. 文献3 用钽金属髋臼杯翻修初次髋关节置换--5年随访 译者：张蔷 髋翻修手术中，髋臼侧的重建至关重要。鉴于髋臼侧重建的复杂性，钽金属假体被引入市场。钽金属与宿主骨有良好的生物相容性，同时其还具备不俗的生物力学特性，用钽金属制造的假体表面摩擦系数极高，可以最大化假体的初始稳定性。其良好的生物学特性配合多孔结构可以显著提高假体表面骨长入。该类假体已经被证实具备良好的短期效果，本篇研究探讨其中期随访结果。 2000年至2002年间，5家外科中心共263例连续髋翻修病例入组。感染及肿瘤病例被除外。基本资料如下： Harris评分、WOMAC评分及UCLA评分均有显著提升。病人主观评估显示87.3%的病人认为髋关节功能有显著改善，85.9%的病人对疗效非常满意或比较满意。最近一次随访显示，所有髋臼杯均稳定在位，无松动而再翻修的需要。髋臼翻修的成功率高达87%。
B：髋臼侧翻修配合同种异体骨植骨，术后7年 A：髋关节脱位，Cage松动 B：翻修配合打压植骨失败 C：再翻修配合垫块，术后6年 结论：从至少5年的随访结果看，钽金属髋臼翻修假体是髋臼翻修手术中一种可靠的假体选择。 Revision of failed total hip arthroplasty acetabular cups to porous tantalum components: a 5-yearfollow-up study We reviewed 263 consecutive patients with failed acetabular components after total hip arthroplasty that were revised using porous tantalum acetabular components and augments when necessary. The mean follow-up was 73.6 months (range, 60-84 months). The improvement of mean Harris hip score, Western Ontario and McMaster Osteoarthritis Index, and University of California Los Angeles activity scales were statistically significant (P b .001). Subjective assessments showed that 87.3% of patients reported “improvement” and 85.9% were “very or fairly pleased” with the results. At the most recent follow-up, all acetabular components were radiographically stable and none required rerevision for loosening. The acetabular revision was considered successful in 87% of cases. From this study, we conclude that the acetabular component used was reliable in creating a durable composite without failure for a minimum of 5 years. 文献出处：Fernández-Fairen M, Murcia A, Blanco A, et al. Revision of failed total hip arthroplasty acetabular cups to porous tantalum components: a 5-yearfollow-up study. J Arthroplasty. 2010 Sep;25(6):865-72. 第二部分：保髋相关文献 文献1 121例股骨头骨骺滑脱患者的长期随访 译者：罗殿中 本研究目的为明确：1、股骨头骨骺滑脱程度与预后是否相关；2、滑脱畸形愈合未手术治疗者结果如何；3、急性与慢性滑脱患者预后区别。 本研究评估了121例（149髋）股骨头骨骺滑脱患者的长期随访结果，随访时间为21年至47年。共83髋未行复位治疗，其中大多数随访结果优良。共54髋行骨骺滑脱复位手术治疗，存在较多的并发症且随访结果欠佳，但整体来说，该54例髋股骨头骨骺滑脱较重。经配比滑脱严重程度后发现，即使是中至重度滑脱患者，原位固定治疗的效果要优于切开复位固定。13例急性滑脱的患者中，12例行复位股骨头骨骺治疗，经随访后发现，其中3例出现股骨头骨骺坏死，其余9例随访效果为优。 典型病例： 图1-A14岁男。左髋间歇性疼痛2年，左股骨头骨骺中度滑脱，未治疗。 图1-B（正位）、图1-C（蛙式位） 26年后，左髋关节无症状，该患者可正常滑雪、打猎和钓鱼等。但是由于左下肢较右下肢短缩2cm，存在跛行步态。左髋内旋受限。 图2-A14岁男，左髋疼痛1年后检查，诊断为左股骨头骨骺滑脱。
图2-B 确诊后7月拍片。查体见左髋屈曲、外展受限，无内旋，左下肢轻度短缩。患者无症状，未治疗。
图2-C（正位）、图2-D（蛙式位）2-A后38年，拍片见髋关节间隙正常，无关节炎等退变表现。无髋关节疼痛等症状，左髋内旋受限，外展20度。
图3-A15岁男。右股骨头骨骺严重滑脱，且滑脱畸形愈合。右下肢短缩2cm，右髋15度屈曲挛缩畸形，屈髋115度。内收-外展受限。
图3-B（正位）、图3-C（蛙式位）3-A后30年，劳累后右髋关节疼痛，无其他不适，但髋关节活动受限。
图4-A14岁男，左髋疼痛2年半，髋关节疼痛。急性滑脱。接受闭合复位克氏针固定。
图4-B 术后1年，左股骨头坏死，右侧股骨头骨骺轻度滑脱，行右侧克氏针原位固定术。
图4-C 术后1年，取出双侧内固定。
图4-D28年后，右髋无症状，左髋间歇性疼痛，左髋活动明显受限。 Slipped capital femoral epiphysis. Long-term follow-up study of one hundred and twenty-one patients We evaluated 121 patients who had had slipped capital femoral epiphysis (149 involved hips) twenty-one to forty-seven years after the diagnosis was made. The results were very good in most of the eighty-three hips with the slip left unreduced. Fifty-four hips that were treated by procedures designed to improve the alignment of the slipped femoral head had more complications and less favorable results, but in general, these were the more severe slips. However, there were enough slips of comparable severity that were treated unreduced to suggest that the long-term results, even in moderate and severe slips, were better after in situ fixation than after operative and manipulative treatment (as performed between 1915 and 1952). Twelve of the thirteen hips with acute slips were reduced (the thirteenth was one of the eighty-three unreduced hips) and aseptic necrosis developed in three, while nine had good results. 文献出处：Boyer DW, Mickelson MR, Ponseti IV. Slipped capital femoral epiphysis. Long-term follow-up study of one hundred and twenty-one patients. J Bone Joint Surg Am. 1981 Jan;63(1):85-95. 文献2 骨的分形式分层构象始于纳米量级 译者：程徽 简介：骨的分层构象使骨具有足够的硬度和韧性。意欲解释骨的具体结构和骨的主要成分（矿物质和胶原蛋白）的关系，需回答以下三个主要问题：矿物质相与胶原蛋白的关联是纤维内还是纤维外，矿物质基本结构基本单元的形态是针状还是小片形状，以及矿物质相如何在广泛交联的胶原原纤维网络中保持连续性。为了解决这些问题，必须了解骨的纳米级三维结构特征。 推理：因为骨具有多层次的三维构象，二维成像方法不能详细描述样本结构的全貌，容易造成观察偏差。对于具有分析样本区域已知方向层状骨的特定点聚焦离子束的制备，使得我们能够通过二维高分辨率透射电镜（HRTEM）获得成像数据，并识别单个晶体方向。之后，我们通过扫描电镜（STEM）断层扫描成像进行三维重建，同时观察电子衍射来确定晶体形态和方向模式，研究细胞外基质中更高级的骨矿物质组织结构。断层扫描数据可以使矿物质相三维信息可视化为具有原子级分辨率的单晶和聚集体电镜图像，以及相应的衍射模式。透射电镜、扫描电镜成像与晶体学数据的整合产生了三维矿物质形态模型及其与有机基质的关联。 结果：为了使细胞外基质中的微晶可视化和特征化，我们记录了关于矿化胶原纤维阵列的两个正交投影的骨矿物质成像数据。我们观察到三种矿物质组织的图案：先前已经报道过的“丝状”（纵向或平面内）和“蕾丝边”（平面外）图案，以及包含六方晶体的第三个“玫瑰花结”图案。断层重建显示，这三个图案是同一三维结构的投影。我们的数据显示，针状弯曲的纳米晶体横向合并以形成小片，进一步组织成大致平行的小片堆，上述小片由大约2纳米的间隙分开。这些小片堆、单体小片、单个针状晶体聚结成的超过胶原纤维的横径的多晶聚集体，跨越相邻的原纤维，成为连续的，与纤维相互交织的矿物质。 结论：我们的研究结果为骨的微观结构创建了一个骨内矿物质和胶原蛋白相结合的模型，其中矿物质结构达到纳米量级。首先，数据显示，矿物质矿物质基本结构基本单元的既不全是针状的也不全是小片状，而是两者的组合，因为只有弯曲的针状元件侧向合并才能形成轻微扭曲的板。这只在保存在有机细胞外基质的样本中才检测到。其次，矿物质颗粒并非只存在于纤维内或者只存在于纤维外，其中弯曲和合并的结晶延伸超过单一胶原纤维的典型尺寸时，可形成连续的纤维相互交织的矿物质相，第三，骨的矿物质相结构中，可以识别出螺旋图案。以上三维观察，与以前关于骨层级和结构的研究相结合，揭示了骨（作为材料，作为组织和器官）内较一致的微观分形式结构。了解了骨的鸟巢状、螺旋状微观结构有助于解释增强骨强度和韧性的对立统一，将以往对骨分层结构的认识扩展至至少12个层级。 Fractal-like hierarchical organization of bone begins at the nanoscale INTRODUCTION: The components of bone assemble hierarchically to provide stiffness and toughness. Deciphering the specific organization and relationship between bone’s principal components—mineral and collagen— requires answers to three main questions: whether the association of the mineral phase with collagen follows an intrafibrillar or extrafibrillar pattern, whether the morphology of the mineral building blocks is needle- or platelet-shaped, and how the mineral phase maintains continuity across an extensive network of cross-linked collagen fibrils. To address these questions, a nanoscale level of threedimensional (3D) structural characterization is essential and has now been performed. RATIONALE: Because bone has multiple levels of 3D structural hierarchy, 2D imagingmethods that do not detail the structural context of a sample are prone to interpretation bias. Site-specific focused ion beam preparation of lamellar bone with known orientation of the analyzed sample regions allowed us to obtain imaging data by 2D high-resolution transmission electron microscopy (HRTEM) and to identify individual crystal orientations. We studied higher-level bone mineral organization within the extracellular matrix by means of scanning TEM (STEM) tomography imaging and 3D reconstruction, as well as electron diffraction to determine crystal morphology and orientation patterns. Tomographic data allowed 3D visualization of the mineral phase as individual crystallites and/or aggregates that were correlated with atomic-resolution TEM images and corresponding diffraction patterns. Integration of STEM tomography with HRTEM and crystallographic data resulted in a model of 3D mineral morphology and its association with the organic matrix. RESULTS: To visualize and characterize the crystallites within the extracellular matrix, we recorded imaging data of the bone mineral in two orthogonal projections with respect to the arrays of mineralized collagen fibrils. Three motifs of mineral organization were observed: “filamentous” (longitudinal or in-plane) and “lacy” (out-of-plane) motifs, which have been reported previously, and a third “rosette” motif comprising hexagonal crystals. Tomographic reconstructions showed that these three motifs were projections of the same 3D assembly. Our data revealed that needle-shaped, curved nanocrystals merge laterally to form platelets, which further organize into stacks of roughly parallel platelets separated by gaps of approximately 2 nanometers. These stacks of platelets, single platelets, and single acicular crystals coalesce into larger polycrystalline aggregates exceeding the lateral dimensions of the collagen fibrils, and the aggregates span adjacent fibrils as continuous, cross-fibrillar mineralization. CONCLUSION: Our findings can be described by a model of mineral and collagen assembly in which the mineral organization is hierarchical at the nanoscale. First, the data reveal that mineral particles are neither exclusively needle- nor platelet-shaped, but indeed are a combination of both, because curved acicular elements merge laterally to form slightly twisted plates. This can only be detected when the organic extracellular matrix is preserved in the sample. Second, the mineral particles are neither exclusively intrafibrillar nor extrafibrillar, but rather form a continuous cross-fibrillar phase where curved and merging crystals splay beyond the typical dimensions of a single collagen fibril. Third, in the organization of the mineral phase of bone, a helical pattern can be identified. This 3D observation, integrated with previous studies of bone hierarchy and structure, illustrates that bone (as a material, as a tissue, and as an organ) follows a fractal-like organization that is self-affine. The assembly of bone components into nested, helix-like patterns helps to explain the paradoxical combination of enhanced stiffness and toughness of bone and results in an expansion of the previously known hierarchical structure of bone to at least 12 levels. 文献出处：Reznikov N, Bilton M, Lari L, Stevens MM, Kröger R. Fractal-like hierarchical organization of bone begins at the nanoscale. Science. 2018 May 4;360(6388). pii: eaao2189. 文献3 髋臼周围截骨术治疗髋臼后倾导致的髋关节前方撞击症 译者：肖凯 背景：本研究的目的是评估是否可以通过髋臼周围截骨术治疗因髋臼后倾引起的有症状的髋关节前方撞击症。 方法：髋关节撞击症的诊断依靠临床症状、髋关节前撞击试验阳性、磁共振成像显示髋臼病变。X线片上诊断髋臼后倾的指标包括髋臼缘交叉征阳性及后壁征阳性。本研究共纳入22例患者，共29髋，平均年龄23岁，均接受髋臼周围截骨术治疗。对其中的26髋同时进行了关节切开术，以明确关节内病变，病纠正较小的头颈偏心距。所有患者均进行了髋关节活动度的测量，应用Merle d'Aubigné和Poste发明的评分对患者进行临床评估。术前及末次随访时均行假斜位X现片测量前CE角。
屈髋位MRI（开放技术）显示髋臼前缘于股骨头颈交界处发生撞击，髋臼后倾
27岁男性患者，术前X线片显示双侧髋臼交叉征阳性（右髋实线为髋臼前缘，虚线为髋臼后缘）、后壁征阳性
髋臼周围截骨术后，髋臼前缘及后缘位置正常 结果：术后平均随访时间30个月（24-49个月）。术前前CE角平均36°（26-52°），术后前CE角降低至平均28°（16-46°），差异有统计学意义（P=0,002）。术后髋关节活动度明显改善，其中内旋平均增加10°（P=0.006），屈曲增加7°（P=0.014），外展增加8°（P=0.017）。Merled'Aubigné评分由术前平均14分（12-16分）增加至术后平均16.9分（15-18分）（P<0.001），结果为优良的例数为26髋。有3髋进行了再次手术：1髋由于术后早期矫形角度丢失，1髋由于矫形导致髋关节后撞击，1髋由于术后症状再次出现髋关节前方撞击症状。 结论：髋臼周围截骨术可以通过有效地旋转髋臼，从而治疗由髋臼后倾而引起髋关节前方撞击症的年轻患者。 Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy BACKGROUND: This study was performed to evaluate whether symptomatic anterior femoro-acetabular impingement due to acetabularretroversion can be treated effectively with a periacetabular osteotomy. METHODS: The diagnosis of femoro-acetabular impingement was based on clinical symptoms, a positive anterior impingement test, and findings of acetabular rim lesions on magnetic resonance imaging. The radiographic diagnosis of acetabular retroversion was based on the cross-over and posterior wall signs. Twenty-nine hips in twenty-two patients (average age, twenty-three years) underwent a periacetabular osteotomy. An arthrotomy was performed in twenty-six hips in order to visualize intra-articular lesions and, in selected cases, to improve a low femoral head-neck offset. The range of motion of the hip was measured, clinical evaluation was performed with use of the score described by Merle d'Aubigné and Postel, and the anterior center-edge angle of Lequesne and de Sèze was measured on radiographs preoperatively and at the time of the latest follow-up. RESULTS: The duration of follow-up averaged thirty months (range, twenty-four to forty-nine months). The anterior center-edge angle of Lequesne and de Sèze decreased significantly from a preoperative average of 36 degrees (range, 26 degrees to 52 degrees ) to a postoperative average of 28 degrees (range, 16 degrees to 46 degrees ) (p = 0.002). There was a significant increase in the average range of internal rotation (10 degrees, p = 0.006), flexion (7 degrees, p = 0.014), and adduction (8 degrees, p = 0.017). The average Merle d'Aubigné score increased from 14.0 points (range, 12 to 16 points) preoperatively to 16.9 points (range, 15 to 18 points) postoperatively (p < 0.001), and the result was good or excellent for twenty-six hips. Three hips underwent subsequent surgery: one, because of early postoperative loss of reduction; one, for correction of posteroinferior impingement; and one, because of recurrent signs of anteriorimpingement. CONCLUSION: Periacetabular osteotomy is an effective way to reorient the acetabulum in young adults with symptomatic anterior femoro-acetabular impingement due to acetabular retroversion. 文献出处：Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003 Feb;85-A(2):278-86. 文献4 股骨/髋臼前倾角 译者：张振东 股骨/髋臼前倾角大小与下肢力线、髋膝关节骨关节炎发生相关。股骨前倾角增加、髋臼前倾角减小可造成髋关节骨关节炎发生；股骨前倾角增加还与膝关节疼痛、膝关节骨关节炎及髌骨不稳相关。此外，股骨前倾角减小或股骨后倾可表现为外八字步态，而股骨前倾角增大会造成内八字步态。 一、股骨前倾角 股骨前倾角随生长发育会发生相应变化： 1、胎儿期 有研究对144例胎儿标本研究，测量24周内髋关节发育成形的胎儿，解剖后标本，屈曲膝关节90度，测量股骨颈前倾角。结果显示：20~24周时，前倾角为-10~30°，怀孕中后期胎儿股骨前倾角逐渐增大，出生时平均35°。 2、出生后（儿童-青少年） 一研究对994例1-18岁人群进行股骨前倾角测量，结果为：2岁时平均股骨前倾角45°；另一研究测量400例1-20岁人群，结果为：2岁时平均股骨前倾角48°。总体来讲，随年龄增长，股骨前倾角逐渐减小。 其中使用的股骨前倾角测量方法：Dunn-Rippstein-Muller方法（见下图）。具体方法为患者仰卧位，髋关节屈曲90°、外展20°（Dunn位，图1-a），拍片示意图见图1-b，X线图见图1-c，两线夹角即为股骨颈前倾角。
图1-a
图1-b
图1-c 3、成人 32例尸体（死亡时年龄均为80岁以上）研究：其中4例股骨后倾，前倾角范围为-10.8至22.1度。 根据股骨前倾角大小，可将其分为以下几级： -3：小于10度，严重减小； -2：10-14度，中度减小； 1：15-20度，正常； 2：21-25度，中度增加； 3：大于25度，严重增加。 股骨前倾角减小多见于以下情况： 1、股骨头骨骺滑脱； 2、近端股骨灶性缺损； 3、髋内翻； 4、深髋臼； 5、幼年手术史（股骨去旋转、股骨干骨折等）； 6、此外，亦可见于髋关节发育不良患者，但较为少见。 但应注意，多数情况下，前倾角减小为先天异常而无特殊病因。 股骨前倾角变化会导致胫骨扭转： 1、股骨前倾角小--胫骨代偿性扭转（胫骨内旋）（图2-a）
图2-a 6岁女孩，股骨前倾角减小患者，胫骨代偿性内旋。左：双足平行朝前时，髌骨朝向外侧；右：膝关节放置于中立位置时，下肢代偿性内旋。 2、股骨前倾角大--胫骨代偿性扭转（胫骨外旋）（图2-b）
图2-b 9岁女孩，股骨前倾角增大患者，胫骨代偿性外旋。左：双足平行朝前时，髌骨朝向内侧；右：膝关节放置于中立位置时，下肢代偿性外旋。 二、髋臼前倾角 测量应保证骨盆片正(无倾斜、旋转)。因骨盆前倾会造成髋臼前倾角减小；骨盆后倾会造成髋臼前倾角增大；向一侧旋转时----同侧减小、对侧增大。保证骨盆X线片标准的情况下，可初步评估髋臼前倾角（图3-a）。因髋臼边缘不是直线，该测量值仅为近似值。当该测量值小于1.5cm时，提示髋臼前倾减小（图3-b）；当该测量值约等于0时，提示髋臼无前倾；当该测量值大于1.5cm时，提示髋臼前倾角增大（图3-c）。
图3-a 正常情况下，骨盆正位片上测量髋臼前后缘距离大约为1.5cm。
图3-b 前后缘距离减小，提示髋臼前倾角较小
图3-c 前后缘距离增大，提示髋臼前倾角增大 文献报道对181例（356髋）前倾角情况进行测量，其中男93例、女88例，年龄7-71岁（图4）。测量结果显示：髋关节发育不良25例、32髋；深髋臼35例、40髋、髋臼内凸8例12髋；髋内翻22例、39髋；髋外翻13例、21髋；股骨头骨骺滑脱22例、33髋；此外，还包括基本正常者35例、39髋。
图4 髋臼前倾角测量方法为Anda方法（图5），选择股骨头圆且前缘覆盖好的层面测量。因髋臼前缘下半部会退化，亦有其他文献建议于髋关节上半部测量髋臼前倾角。 正常值：15~20° 男性：18.5±4.5° 女性：21.5±5°
图5 髋臼前倾角测量示意图 三、股骨、髋臼前倾角之和（McKibbin instability inde，不稳定指数即联合前倾，图6）
图6 由-3至3级分别为低不稳定性至高不稳定性。 研究表明，不稳定指数小于20度者共73髋（73/152），其中发生髋关节骨关节炎者占41%。发生率高于不稳定指数高的患者，因此，低不稳定性与髋关节骨关节炎发生相关。
总结： 1、股骨、髋臼前倾角正常值：15-20° 2、不稳定指数（股骨、髋臼前倾角之和）正常值：30-40° 3、当股骨、髋臼前倾角减小，不稳定指数小于20时，更易发生骨关节炎及出现疼痛症状 4、股骨前倾角减小者是前倾角增大者的两倍之多 5、多种病因可致前倾角减小，如深髋臼、髋内翻、股骨头骨骺滑脱等，因此这部分患者更易出现关节炎。 (本文为会元文献的概括总结，详细内容请参照原文)
文献出处：TönnisD, Heinecke A. Acetabular and femoral anteversion: relationship withosteoarthritis of the hip. J Bone Joint Surg Am. 1999 Dec;81(12):1747-70.
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