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本期目录： 1、初次全膝关节置换术中彻底松解内侧副韧带后的韧带松弛 2、手术时间延长会导致初次全关节置换术(TJA)术后继发假体周围感染(PJI)率升高 3、应用福尔马林固定石蜡包埋的手术组织切片评价荧光原位杂交技术对假体周围感染的诊断价值 4、经皮褶比基尼切口行前入路全髋关节置换术 5、迟发性髋关节发育不良：15年的观测性研究 6、髋关节镜治疗股骨前倾角过大合并临界DDH患者是否有效？一项病例匹配对照研究 7、病例报道：髋臼撞击征导致前下方臼缘损伤 8、髋关节发育不良的诊断与治疗：儿童骨科医师的处理现状 第一部分：关节置换及保膝相关文献 文献1 初次全膝关节置换术中彻底松解内侧副韧带后的韧带松弛 译者：张轶超 目的：对于内翻膝患者的全膝关节置换术（TKA），内侧副韧带（MCL）的松解是达到软组织平衡的一个基本技术。当内翻畸形很重的时候，经常需要将内侧副韧带彻底松解以达到内外侧软组织平衡。但是，MCL的彻底松解有导致灾难性的关节松弛的可能。本前瞻性研究的目的是对比彻底松解和部分松解后在外翻应力位X片上内侧关节间隙的张开程度。 方法：统计了多于209例骨关节炎的初次TKA病例，有33例（一组）使用骨膜剥离器行骨膜下止点剥离以达到MCL的彻底松解。176例（二组）行MCL部分松解。使用改良的Telos仪在术后6个月和1年时来评估两组病例于膝关节屈曲0°、45°和90°时在外翻应力X片上的关节间隙。其它分析的参数包括于内外翻应力X片上在膝关节完全伸直的情况下术前、术后的下肢机械力线。在术后1年时记录患者的关节活动度（ROM）和临床评分。 结果：术后6个月和1年时当膝关节处于伸直位、屈曲45°和90°位时，外翻时的关节张开的平均值组一与组二间没有明显的差异。两组临床评分没有明显差异。术前和术后两组间关节的活动度存在明显差异，分别差5°。 结论：本研究提示彻底松解MCL用以达到软组织平衡的方法是安全的，不会导致术后的关节松弛。 图1 图片显示的是骨膜下松解MCL的技术。A.用骨膜剥离器松解MCL。B.MCL胫骨止点被完全松解。（白色箭头指示完全被松解的MCL止点） 图2 图示为使用改良Telos设备拍摄外翻应力位片子（a）。膝关节屈曲位时如何拍外翻应力位片（b） 图3 图示如何采用PACS系统在外翻应力位片上测量膝关节屈曲0°（a）、45°(b)和90°(c)时的关节开放间隙。（黄线指示关节张开间隙，即股骨假体面最远端到相对的胫骨垫片的最近距离） Laxity after complete release of the medial collateral ligament in primary total knee arthroplasty PURPOSE: Medial collateral ligament (MCL) release is one of the essential steps toward the achievement of ligament balancing during the total knee arthroplasty (TKA) in patients with varus deformity. When the varus deformity is severe, complete release of the MCL until balanced is often required. However, it is believed that complete MCL release may lead to catastrophic laxity. The purpose of this prospective study is to compare the medial joint gap opening in postoperative valgus stress radiograph in patients with complete MCL release against patients with partial release. METHODS: Out of 209 primary TKAs performed for degenerative osteoarthritis, complete MCL release was required in 33 cases (group I) by sub-periosteal detachment at proximal tibia using periosteal elevator. For the remaining 176 knees (group II), partial release of MCL was done. At postoperative 6 months and 1 year, both groups were evaluated for comparing the joint gap on valgus stress radiographs using modified Telos device in 0°, 45°, and 90° of flexion. Additional parameters which were analyzed included preoperative varus and valgus stress radiographs in full extension and pre- and postoperative mechanical alignment in each group. The knee range of motion (ROM) and clinical scores were evaluated at 1-year follow-up. RESULTS: The mean values of the joint opening on the postoperative valgus stress test with the knee joint extended, and in the 45° and 90° flexed states at 6 months and at 1 year postoperatively in group I were not statistically significantly different from those of group II. The clinical scores also did not show a statistically significant difference between two groups. There was a statistically significant difference in ROM between two groups, pre- and postoperatively and the difference was 5°, respectively. CONCLUSION:This study suggests that complete MCL release for ligament balancing is a safe procedure and does not lead to postoperative laxity. 文献出处：Cho WS, Byun SE, Lee SJ, Yoon J. Laxity after complete release of the medial collateral ligament in primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2015 Jun;23(6):1816-23. doi: 10.1007/s00167-014-3288-7. Epub 2014 Sep 16. 文献2 手术时间延长会导致初次全关节置换术(TJA)术后继发假体周围感染(PJI)率升高 译者：马云青 背景：手术时间延长是否是全关节置换(TJA)术后继发手术部位感染(SSI)和假体周围感染(PJI)的独立危险因素，仍是一个有意义的临床问题。本研究旨在探讨初次TJA患者手术时间与继发SSI和PJI风险的关系。 方法：回顾性分析2005年至2016年在单中心进行的17342例初次单侧全膝关节置换术和全髋关节置换术，至少随访1年。采用多因素Logistic回归分析，确定手术时间与术后90天内SSI和术后1年内PJI的关系。 结果：术后90天SSI和1年PJI的发生率分别为1.2%和0.8%.手术时间>90 min的患者SSI和PJI的发生率(2.1%和1.4%)明显高于手术时间在60~90 min(1.1%和0.7%)和时间小于60 min(0.9%和0.7%)的患者(P<0.01)。在多因素分析中，手术时间每增加20min 90天内SSI增加1.346(95%可信区间1.114~1.627)，PJI风险增加1.253(95%可信区间1.060~1.481)。 结论：在接受初次TJA手术的患者中，每增加20分钟的手术时间，就会增加25%的继发PJI风险。我们主张外科医生在确保手术安全的同时，密切注意这一被低估的危险因素，尽量减少不必要的手术步骤和在手术室内浪费的时间。 Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty BACKGROUND: Whether prolonged operative time is an independent risk factor for subsequent surgical site infection (SSI) and periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant and underexplored issue. The aim of this study is to investigate the association between operative time and the risk of subsequent SSI and PJI in patients undergoing primary TJA. METHODS: We retrospectively reviewed 17,342 primary unilateral total knee arthroplasty and total hip arthroplasty performed at a single institution between 2005 and 2016, with a minimum follow-up of 1 year. A multivariate logistic regression model was conducted to identify the association between operative time and the development of SSI within 90 days and PJI within 1 year. RESULTS: Overall, the incidence of 90-day SSI and 1-year PJI was 1.2% and 0.8%, respectively. Patients with an operative time of >90 minutes had a significantly higher incidence of SSI and PJI (2.1% and 1.4%, respectively) compared to cases lasting between 60 and 90 minutes (1.1% and 0.7%), and those lasting ≤60 minutes (0.9% and 0.7%, P < .01). In the multivariate model, the risk for infection increased by an odds ratio of 1.346 (95% confidential interval 1.114-1.627) for 90-day SSI and 1.253 (95% confidential interval 1.060-1.481) for 1-year PJI for each 20-minute increase in operative time. CONCLUSION: In patients undergoing primary TJA, each 20-minute increase in operative time was associated with nearly a 25% increased risk of subsequent PJI. We advocate that surgeons pay close attention to this underappreciated risk factor while maintaining safe operative practices, which minimize unnecessary steps and wasted time in the operating room. 文献出处：Wang Q, Goswami K, Shohat N, Aalirezaie A, Manrique J, Parvizi J. Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty. J Arthroplasty. 2019 Jan 18. pii: S0883-5403(19)30054-3. doi: 10.1016/j.arth.2019.01.027. 文献3 应用福尔马林固定石蜡包埋的手术组织切片评价荧光原位杂交技术对假体周围感染的诊断价值 译者：张蔷 背景：随着置换手术数量增加，假体周围感染逐步成为常见而有挑战性的问题。肌骨感染学会（MSIS）推荐应用其制定的指南诊断假体周围感染。本篇文章的目的是为了评估应用荧光原位杂交（FISH）技术分析福尔马林固定石蜡包埋的假体周围包膜能否增加植入假体患者的感染诊断率。 方法：我们应用FISH技术回顾性分析了88例假体周围包膜，探针固定在细菌最常见的序列。接着将该结果与应用常规诊断方法如MSIS指南、微生物培养和Morawietz/Krenn组织病理学诊断标准的结果进行比较。此外，我们对几例培养阳性的病例进行了双探针物种特异性FISH分析。 结果：FISH技术成功的在40例临床确定感染的假体周围包膜组织中辨识出38例（95%）假体周围感染。相比临床诊断方法，FISH技术可达到95%的敏感性(95%置信区间[CI],83.08% to 99.39%)，85.42%的特异性(95%CI,72.24% to 93.93%)，阳性预测值84.44%(95%CI, 70.55% to 93.50%)，阴性预测值95.35%(95%CI, 84.19% to 99.43%)。相比组织病理学诊断方法，FISH技术可达到95.12%的敏感性(95% CI, 83.47% to 99.40%)，87.23%的特异性(95% CI, 74.26% to 95.17%)，阳性预测值86.67% (95% CI, 73.21% to 94.95%)，阴性预测值95.35%(95% CI, 84.19% to 99.43%)。我们还应用FISH物种特异性探针成功的检测出培养明确阳性的铜绿假单胞菌和金黄色葡萄球菌。 应用FISH显影技术检测出铜绿假单胞菌（红点内） 结论：基于荧光原位杂交技术的假体周围感染诊断方法可行，并可作为目前常规诊断方法的有益补充。FISH技术不仅能够检查假体周围组织包膜内的细菌，还能够应用特异性探针鉴别致病微生物种类。联合临床与组织病理学诊断方法，荧光原位杂交技术是一种检测组织内假体周围感染的快速可靠的诊断工具。 Fluorescence in Situ Hybridization (FISH) for the Diagnosis of Periprosthetic Joint Infection in Formalin-Fixed Paraffin-Embedded Surgical Tissues Background: As the number of arthroplasties performed increases, periprosthetic joint infection (PJI) represents a common and challenging problem. The Musculoskeletal Infection Society (MSIS) recommends diagnosing PJI according to its guidelines. The aim of the current study was to assess whether fluorescence in situ hybridization (FISH) analysis of formalin-fixed paraffin-embedded periprosthetic membranes can successfully improve the diagnosis of infection in patients with orthopaedic implants. Methods: We retrospectively analyzed 88 periprosthetic membranes of joint prostheses using FISH analysis according to a standard protocol, with a probe targeting a sequence found in most bacteria. We compared the results with routine clinical classification according to the guidelines of the MSIS, microbiological culture, and histopathological classification according to Morawietz and Krenn. We additionally performed FISH analysis using 2 species-specific probes for several culture-positive cases. Results: FISH successfully detected bacteria in 38 (95%) of 40 periprosthetic membranes that were rated positive by clinical classification. FISH results compared with clinical classification demonstrated a sensitivity of 95% (95% confidence interval [CI], 83.08% to 99.39%), a specificity of 85.42% (95%CI, 72.24% to 93.93%), a positive predictive value of 84.44% (95%CI, 70.55% to 93.50%), and a negative predictive value of 95.35% (95%CI, 84.19% to 99.43%). FISH results compared with histopathological classification demonstrated a sensitivity of 95.12% (95% CI, 83.47% to 99.40%), a specificity of 87.23% (95% CI, 74.26% to 95.17%), a positive predictive value of 86.67% (95% CI, 73.21% to 94.95%), and a negative predictive value of 95.35% (95% CI, 84.19% to 99.43%). We successfully detected Pseudomonas aeruginosa and Staphylococcus aureus with species-specific FISH probes in all cases that were positive for these respective bacteria by microbiological culture. Conclusions: FISH-based diagnosis of PJI is feasible and can be used as an additional diagnostic criterion. FISH not only can detect bacteria in periprosthetic membranes but can also differentiate pathogens at the species level. FISH represents a fast and reliable tool for detecting PJI in periprosthetic membranes, especially in combination with clinical and histopathological classification. 文献出处：Lippmann T, Braubach P, Ettinger M, Kuehnel M, Laenger F, Jonigk D. Fluorescence in Situ Hybridization (FISH) for the Diagnosis of Periprosthetic Joint Infection in Formalin-Fixed Paraffin-Embedded Surgical Tissues. J Bone Joint Surg Am. 2019 Jan 16;101(2):e5. doi: 10.2106/JBJS.18.00243. 文献4 经皮褶比基尼切口行前入路全髋关节置换术 译者：程徽 目的：髋关节手术直接前方入路（DAA）的经典纵行切口不遵循皮肤张力线，可能导致愈合不良和外观不佳。本回顾性研究的目的是从患者对瘢痕的满意度、术后功能和影像学三方面，对DAA经典纵行切口和改良比基尼切口进行比较。 图2 术前准备：a)经典纵行切口，b) 比基尼切口。 患者和方法：共有964名患者（51％女性; 59％纵向切口，41％比基尼切口）完成了术后2至4年的随访问卷，包括牛津髋关节评分（OHS），北卡罗来纳大学'4P'瘢痕量表（UNC4P）和同时进行了瘢痕美学满意度和瘢痕麻木症状的评估。假体的安放位置，异位骨化（HO）的比率和翻修率也纳入评估。 图4 术后随访：a)经典纵行切口，b)比基尼切口几乎不可见。 结果：平均OHS两组间无差别（p = 0.41）。比基尼组平均UNC4P总分略高（p = 0.01），对瘢痕美容非常满意的患者比例较高（p <0.001）。瘢痕麻木发生率在纵行切口组中较高（分别为14.5％和7.5％，p<0.001）。两组间，髋臼假体的外展角，股骨柄的位置和HO的发生率无差异。两组翻修率无差异，纵向为2.3％，“比基尼”组为1.5％（p = 0.911）。 结论：我们发现，短斜“比基尼”皮肤皱褶切口用于DAA入路THA，是安全的，不会影响假体安装的位置，也不增加股外侧皮神经损伤的发生率。虽然比基尼切口可以带来更好的疤痕满意度，但可伸展范围有限，对经典纵切口有经验的医生才应该使用。 译者注：我们保髋的患友以年轻女性居多。在PAO治疗成功率已经比较满意的今天，我们团队越来越多的关注瘢痕的美观。我们已经通过比基尼入路进行了一些PAO手术，早期观察手术切口确实美观得多，一般三角内裤可以掩盖，目前没有观察到因为切口出现的并发症，期待更长时间的随访。 Skin crease 'bikini' incision for the direct anterior approach in total hip arthroplasty. AIMS: The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease 'bikini' when the DAA is used for total hip arthroplasty (THA). PATIENTS AND METHODS: A total of 964 patients (51% female; 59% longitudinal, 41% 'bikini') completed a follow-up questionnaire between two and four years postoperatively, including the Oxford Hip Score (OHS), the University of North Carolina '4P' scar scale (UNC4P) and two items for assessing the aesthetic appearance of the scar and symptoms of numbness. The positioning of the components, rates of heterotopic ossification (HO) and rates of revision were assessed. RESULTS: The mean OHS was similar in both groups (p = 0.41). The mean UNC4P total score was slightly better (p = 0.01) and the proportion of patients who were very satisfied with the cosmetic aspects of the scar was higher in the 'bikini' group (p < 0.001). The proportion of patients reporting numbness in the scar was higher in the longitudinal group (14.5% vs 7.5%, respectively, p < 0.001). The abduction angle of the acetabular component, the position of the stem and rates of HO did not differ between the groups. There were no differences in the revision rates of both groups, being 2.3% in the longitudinal and 1.5% in the 'bikini' group (p = 0.911). CONCLUSION: We found that a short oblique 'bikini' skin crease incision is safe when used for the DAA at THA, without compromising the positioning of the components or increasing the rate of lateral femoral cutaneous nerve dysaesthesia. Although it leads to a superior scar satisfaction, as it is less extensile, it should be used after having gained experience with the classic longitudinal incision. Cite this article: Bone Joint J 2018;100-B:853-61. 文献出处：Leunig M, Hutmacher JE, Ricciardi BF, Impellizzeri FM, Rüdiger HA, Naal FD. Skin crease 'bikini' incision for the direct anterior approach in total hip arthroplasty. Bone Joint J. 2018 Jul;100-B(7):853-861. doi: 10.1302/0301-620X.100B7.BJJ-2017-1200.R2. 第二部分：保髋相关文献 文献1 迟发性髋关节发育不良：15年的观测性研究 译者：罗殿中 目的：尽管已经有新生儿DDH筛查系统，但是婴儿可能会出现迟发的DDH，这会给患者带来很大影响。本研究的目的是评估那些尽管进行了DDH普查或选择性筛查，但表现为迟发性髋关节脱位的患儿。 方法：自1997年1月1日至2011年12月31日，对64670名新生儿进行了前瞻性纵向研究。我们将出生后3个月后发生的髋脱位定义为迟发性髋脱位。通过超声及普通X线片明确有无髋脱位。记录患儿的人口统计学因素、转诊类型、转诊原因、危险因素（臀位产/家族史）、临床及影像学发现。 结果：共有31名婴儿出现了不可思议的髋脱位，发生比例为0.48‰（95% CI 0.34-0.68‰）。在发生髋脱位的患儿中，有18名（0.28‰（95% CI0.17-0.44‰）；58%）为迟发性髋脱位。这些患儿中出生时临床查体记录均无异常且6-8周检查时仍无异常。18名迟发性髋脱位患儿中有13名（72%）没有危险因素，16名由全科医生转诊，2名因错过预约而转诊延迟。平均诊断时间为62.4周（19-84周）。 结论：尽管有针对DDH的普查及选择性筛查系统，迟发性不可复位的髋脱位仍然会在随访过程中被发现。我们建议对DDH筛查系统进行升级，审查参与新生儿和婴儿体检的医疗保健专业人员的培训和教育情况，并在出生后6-8周检查后增加进一步的评估。 经全科医生转诊的迟发性髋脱位患儿的情况，RF：危险因素；FHx：家族史；LLD：下肢不等长；OR：切开复位；FO：股骨截骨；PO：骨盆截骨 Late presentation of developmental dysplasia of the hip : a 15-year observational study AIMS: Despite the presence of screening programmes, infants continue to present with late developmental dysplasia of the hip (DDH), the impact of which is significant. The aim of this study was to assess infants with late presenting dislocation of the hip despite universal clinical neonatal and selective ultrasound screening. PATIENTS AND METHODS: Between 01 January 1997 to 31 December 2011, a prospective, longitudinal study was undertaken of a cohort of 64 670 live births. Late presenting dislocation was defined as presentation after three months of age. Diagnosis was confirmed by ultrasound and plain radiography. Patient demographics, referral type, reason for referral, risk factors (breech presentation/strong family history) and clinical and radiological findings were recorded. RESULTS: There were 31 infants with an irreducible dislocation of the hip, an incidence of 0.48 (95% confidence interval (CI) 0.34 to 0.68) per 1000 live births. Of these, 18 (0.28 (95% CI 0.17 to 0.44) per 1000 live births; 58%) presented late. All infants had a documented normal newborn clinical examination and no abnormality reported in the six to eight week check. Of the 18 late presenting cases 72% (n = 13) had no risk factors: 16 were referred by GPs and two were late due to administrative issues (missed appointments). The mean time to diagnosis was 62.4 weeks (19 to 84). CONCLUSION: Despite universal clinical neonatal and selective ultrasound screening, late cases of irreducible hip dislocation still occur. We recommend an update of the national screening programme for DDH, a review of training and education of healthcare professionals involved in the physical examination of neonates and infants, and the addition of a further assessment after the six to eight week check. 文献出处：Talbot C, Adam J, Paton R. Bone Joint J. Late presentation of developmental dysplasia of the hip : a 15-year observational study. 2017 Sep;99-B(9):1250-1255. 文献2 髋关节镜治疗股骨前倾角过大合并临界DDH患者是否有效？一项病例匹配对照研究 译者：肖凯 背景：将髋关节镜用于治疗临界DDH患者时，病例的选择尤为重要。股骨前倾角过大合并临界DDH（excessive femoral anteversion and borderline dysplasia，EFABD）可能是关节镜治疗的禁忌症。 假设：与髋臼覆盖正常及前倾角正常的患者相比，我们假设EFABD患者在接受关节镜下保留盂唇治疗及关节囊缝合后短期预后更差。 方法：自2010年4月至2014年1月，前瞻性收集接受髋关节镜治疗患者的数据，并对数据进行了回顾性分析。EFABD组患者纳入标准包括外侧CE角18°-25°、盂唇损伤、进行关节囊缝合、前倾角≥20°、术前评分（改良Harris评分、非关节炎髋关节评分、髋关节预后-运动相关量表、疼痛VAS评分）完整。排除标准包括术前Tönnis骨关节炎＞1期、进行微骨折、外展肌病变、既往同侧髋关节手术史。按照1:2的比例匹配对照组，对照组髋臼覆盖及前倾角正常，匹配指标包括手术年龄±6岁、性别、BMI±5、髋臼软骨Outbridge分级（0, 1 vs 2, 3, 4）、髂腰肌部分松解。 结果：EFABD组共纳入16名患者，术后超过2年的随访率为100%。EFABD组中12名患者与24名对照组患者进行匹配。EFABD组平均前倾角22.4°，对照组平均10.2°（P=0.01）。EFABD组平均外侧CE角22.1°，对照组平均31.5°（P＜0.0001）。对照组进行髋臼成形的概率更高（P = 0.0006）。其余的人口统计学数据、术前发现、手术操作及术前评分两组间均无差别。末次随访时，EFABD组各项评分显著低于对照组，其中改良Harris评分（76.1 vs 85.9; P = .005），非关节炎髋关节评分（74.8 vs88.5; P < .0001），髋关节预后-运动相关量表（58.3 vs 78.4; P = .02），患者满意度（7.1 vs 8.3; P =.005）。EFABD组中有3名（33.3%）患者接受了后续手术治疗，而对照组中仅有1名（4.2%）（P=0.03）。两组患者中各有1名患者接受了人工关节置换术。 结论：EFABD患者接受髋关节镜下盂唇修复及关节囊缝合后症状功能较术前明显改善。但是，相比对照组患者，EFABD组患者的预后更差。EFABD患者必要时应进行髋臼周围截骨术或股骨截骨术。 Is Hip Arthroscopy Effective in Patients With Combined Excessive Femoral Anteversion and Borderline Dysplasia? A Match-Controlled Study BACKGROUND: Appropriate patient selection is critical when hip arthroscopy is considered in the setting of borderline dysplasia (BD). It is presumable that excessive femoral anteversion (EFA) and BD may contraindicate arthroscopy. HYPOTHESIS: Patients with combined EFA and BD (EFABD) demonstrate significantly inferior short-term outcomes after arthroscopic labral preservation and capsular closure when compared with a similar control group with normal lateral coverage and femoral anteversion. METHODS: Data were prospectively collected and retrospectively reviewed on patients undergoing hip arthroscopy between April 2010 and November 2014. The EFABD group's inclusion criteria were BD (lateral center-edge angle, 18°-25°), labral tear, capsular closure, and femoral version ≥20°, as well as preoperative modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale. Exclusion criteria were workers' compensation, preoperative Tönnis grade >1, microfracture, abductor pathology, or previous ipsilateral hip surgery or conditions. Patients in the EFABD group were matched 1:2 to a similar control group with normal coverage and femoral anteversion by age at surgery ± 6 years, sex, body mass index ± 5, acetabular Outerbridge grade (0, 1 vs 2, 3, 4), and iliopsoas fractional lengthening. RESULTS: Sixteen EFABD cases were eligible for inclusion, and 100% follow-up was obtained at ≥2 years postoperatively. Twelve EFABD cases were matched to 24 control cases. Mean femoral version was 22.4° in the EFABD group and 10.2° in the control group ( P = .01). Mean lateral center-edge angle was 22.1° in the EFABD group and 31.5° in the control group ( P < .0001). Acetabuloplasty was performed significantly more frequently in the control group ( P = .0006). No other significant differences were found regarding demographics, findings, procedures, or preoperative scores. At latest follow-up, the EFABD group demonstrated significantly lower mean modified Harris Hip Score (76.1 vs 85.9; P = .005), Nonarthritic Hip Score (74.8 vs 88.5; P < .0001), Hip Outcome Score-Sports Specific Subscale (58.3 vs 78.4; P = .02), and patient satisfaction (7.1 vs 8.3; P = .005). There were 4 secondary surgical procedures (33.3%) in the EFABD group and 1 (4.2%) in the control group ( P = .03). One patient in each group required arthroplasty. CONCLUSION: Patients treated with arthroscopic labral preservation and capsular closure in the setting of EFABD demonstrated significant improvements from presurgery to latest follow-up. However, their results are significantly inferior when compared with a matched-controlled group. Consideration of periacetabular osteotomy or femoral osteotomy may be warranted in the setting of EFABD to achieve optimal benefit. 文献出处：Chaharbakhshi EO, Hartigan DE, Perets I, Domb BG. Is Hip Arthroscopy Effective in Patients With Combined Excessive Femoral Anteversion and Borderline Dysplasia? A Match-Controlled Study. Am J Sports Med. 2019 Jan;47(1):123-130. doi: 10.1177/0363546518812859. 文献3 病例报道：髋臼撞击征导致前下方臼缘损伤 译者：任宁涛 背景：髋臼盂唇及软骨损伤最常见于前上方，并出现屈曲内旋时疼痛。本文将描述前下方盂唇撕裂、腱鞘瘤形成、软骨软化，患者通常在髋关节伸直内旋时疼痛。 病例描述：单纯前下方盂唇增生最早发现于髋外翻患者，对本机构既往病历进行回顾，仅发现7例患者、9例髋为单纯髋臼前下方损伤，1例患者为双侧股骨头骺滑脱并髋外翻，股骨干骺端前内侧撞击髋臼3、6点方位，5例存在股骨颈干角增大，所有患者髋臼均为前倾，并仅限于前下方盂唇损伤。 文献回顾：文献报道髋关节MR曾发现前下方盂唇损伤，并与上方臼缘损伤相邻，但这并非单纯前下方盂唇损伤，另外关于股骨头骺滑脱并髋外翻的文献也未描述此部位的损伤。 临床相关：本组患者为单纯髋臼前下方软骨盂唇损伤，潜在的发病机制为（1）髋关节后伸内旋时股骨撞击；（2）关节外后方撞击，如坐骨转子撞击可继发髋关节前方不稳定。其病理解剖显示可能有多种病因，因此应进行个体化评估及治疗。 图1A-D（A）患者女性，33岁，骨盆平片显示髋外翻，髋后伸内旋时疼痛。（B）周围及（C）矢状位MR显示前下方盂唇退变、骨内及盂唇内腱鞘瘤形成（箭头）。（D）使用外科脱位、盂唇修复、股骨颈内翻截骨术，术后症状完全缓解，随访6年时平片显示骨愈合，关节间隙无狭窄。 图2A-D（A）患者女性，15岁，骨盆平片示双侧外翻型股骨头骺滑脱，并导致内侧干骺端相对突出（箭头），与髋臼前下方产生撞击。（B）骨盆平片示双侧髋关节外科脱位、股骨头缩小、滑脱骨骺内固定术后；术中像（C）内侧干骺端突出，骨膜在干骺端（箭头）表面受牵拉；（D）仅在髋臼前下方（箭头）见软骨软化，与内侧干骺端撞击位置一致。 Case Reports: Anteroinferior Acetabular Rim Damage Due to Femoroacetabular Impingement Background The most common location of labral tears and chondral damage in the hip is the anterosuperior region of the acetabulum, which is associated with pain in flexion and rotation. We describe a case series of patients with labral tears, ganglion formation, and chondromalacia isolated to the anteroinferior acetabulum. Clinically, patients had pain in extension and internal rotation. Case Descriptions Isolated anteroinferior labral hypertrophy and ganglion were first observed in a patient with coxa valga. We retrospectively reviewed clinical and radiographic records and identified nine hips in seven patients with isolated anteroinferior damage. One patient with bilateral valgus femoral head tilt after slipped capital femoral epiphysis (SCFE) had impingement of the anteromedial metaphysis on the acetabulum from 3 to 6 o’clock. Five of seven had valgus neck-shaft angles and all had acetabular anteversion with damage isolated to the anteroinferior acetabular rim. Literature Review Series on the diagnostic efficacy of MR arthrogram have noted anteroinferior damage adjacent to superior acetabular rim lesions. However, these do not describe isolated anteroinferior rim damage. In addition, available case series of patients with valgus SCFE do not describe a location of impingement or intraarticular damage. Purposes and Clinical Relevance In this small case series of patients with isolated anteroinferior chondrolabral damage, there are two potential causative mechanisms: (1) primary anteroinferior impingement with femoral extension and internal rotation and (2) posterior extraarticular ischiotrochanteric impingement causing secondary anterior instability of the femur. The pathoanatomy appears to be multifactorial, necessitating an individualized treatment approach. 文献出处：Anteroinferior acetabular rim damage due to femoroacetabular impingement. Tibor LM, Ganz R, Leunig M.Clin Orthop Relat Res. 2013 Dec;471(12):3781-7. doi: 10.1007/s11999-013-2921-y. 文献4 髋关节发育不良的诊断与治疗：儿童骨科医师的处理现状 译者：张利强 背景：发育性髋关节发育不良（DDH）是年轻人常见的肌肉骨骼疾病之一，是该年龄段髋关节发生骨关节炎病的主要原因。文献并没有很好地确定需要进行外科手术治疗的最佳年龄，缺乏DDH的管理指南和治疗标准导致了世界各地治疗方法的不同。本研究旨在调查全世界儿童骨科医师诊断与治疗DDH的现况，并找出相同与不同之处。 方法：采用在线问卷进行横断面研究，探讨世界各地儿童骨科医师对DDH诊断和治疗的不同观点和方法。 结果：共收到91名外科医生的回复，回复率为45.5%。绝大多数受访者在3个月以下的儿童中使用超声波检查，在3个月以上的儿童中使用骨盆平片来诊断DDH。Pavlik吊带是治疗6个月以下的DDH儿童最流行的方法。对于年龄较大的儿童，闭合复位髋人字石膏是最可取的治疗方法。不同一线治疗方法的最长持续时间差异较大。双侧DDH的治疗方法在外科医生中差异很大。 结论：本研究明确表明，儿童骨科医师对DDH的诊断和治疗方案意见不一致，故对该常见病采用不同的治疗方法。缺乏国际指南促使儿童骨科医生讨论并制定一个统一的、基于证据的DDH诊断和治疗方案。 Diagnosis and treatment of developmental dysplasia of the hip: A current practice of paediatric orthopaedic surgeons Background: Developmental dysplasia of the hip (DDH) is one of the prevalent musculoskeletal conditions in young adults and is a leading cause of hip osteoarthrosis in this age group. The optimum age for surgical intervention when needed is not well established in the literature and the lack of management guidelines and standard practice of DDH leads to different practices worldwide. This study aims to investigate the current practice of paediatric orthopaedic surgeons in diagnosing and treating DDH worldwide and identify points of agreement and disagreement. Methods: A cross-sectional study utilizing an online questionnaire was designed to examine the different points of view and current practice of paediatric orthopaedic surgeons worldwide regarding DDH diagnosis and treatment. Results: Ninety-one surgeons responded, with an overall response of 45.5%. The vast majority of respondents use ultrasonography in children less than 3 months of age and pelvic radiography in over 3 months to diagnose DDH. Pavlik harness is the most popular DDH treatment for children younger than 6 months. For older children, closed reduction with hip spica cast is the most preferable treatment. The maximum duration of first-line treatment has a broad range. The treatment of bilateral DDH varies widely among surgeons. Conclusion: This study shows clearly that paediatric orthopaedic surgeons do not agree on the diagnosis and treatment protocol of DDH, hence different approaches to this common disease are practised. The lack of an international guideline should motivate paediatric orthopaedic surgeons to discuss and formulate a uniform and evidence-based protocol for the diagnosis and treatment of DDH. 文献出处：Rakan S Al-Essa, Fares H Aljahdali, Rakan M Alkhilaiwi, Winnie Philip, Ayman H Jawadi, Khalid I Khoshhal. Diagnosis and treatment of developmental dysplasia of the hip: A current practice of paediatric orthopaedic surgeons. J Orthop Surg (Hong Kong) 2017;25(2):2309499017717197 doi:10.1177/2309499017717197 张洪主任好大夫网站zhanghongmd.haodf.com 张洪主任门诊时间：周三上午 关节外科护士站：01066867304 转848810（请在14:00-18:00拨入） 膝关节置换:张轶超 13261817537 髋关节置换:马云青 13811705624 保髋疗法:罗殿中 18911358880 |
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