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本期目录： 1、内翻膝全膝置换术后残留的伸直位内侧软组织紧张可以得到自行矫正 2、全关节置换术后血糖测量的最佳时机 3、传统方法与机器人辅助下单间室膝关节置换术后早期功能康复与出院时间的比较研究：一项前瞻性队列研究 4、股骨头坏死区域范围测量 5、中青年患者慢性髋关节疼痛的误诊漏诊：回顾性描述性分析 6、基于CT三维重建骨盆统计模型对骨盆变异的研究 7、图像重叠法在慢性桡骨头脱位截骨治疗中的应用 8、发育性髋关节发育不良：从出生到6个月诊断和治疗的最新进展 9、股骨头骨骺滑脱时的髋臼形态：治疗开始和骨骼发育成熟时的比较 第一部分：关节置换及保膝相关文献 文献1 内翻膝全膝置换术后残留的伸直位内侧软组织紧张可以得到自行矫正 译者：张轶超 目的：尽管软组织平衡对于全膝关节置换术（TKA）来说是非常重要的，但其平衡性和松弛度在术后是否会有所变化目前还不是很清楚。最近有研究表明麻醉对于TKA术后的关节松弛度有明显的影响；但没有对于采用相同麻醉方式的情况下TKA术后即刻和术后内外翻松弛度的比较。因此，我们采用定量压力关节测量研究来明确TKA术后膝关节冠状面上的韧带松弛度的自发改变。 方法：我们前瞻性的研究了连续的28名内翻超过5°行分期双侧TKA手术的患者。术后于腰麻没恢复时即刻测量了膝关节内外翻的松弛度；然后当对侧TKA时，在腰麻的情况下再次测量这个膝关节的内外翻松弛度。两次测量间隔时间平均9.7±7.3个月。 结果：内侧的松弛度有明显的变化，从第一次手术后即刻的平均2.4°±1.6°增加到了第二次测量时的3.8°±1.4°(p < 0.001)，但外侧软组织的松弛度没有明显变化（从第一次的5.6°±2.4°到第二次的5.7°±2.1°）。术后即刻松弛度与内侧和外侧软组织的前后松弛度变化量间不存在相关性(R = −0.53, p < 0.001)。 讨论：TKA术后软组织张力可以得到自行矫正。本研究提示手术医生在术中不必一定要松解内侧软组织以达到内外侧绝对平衡，这样可能会导致由于松解过度而导致关节不稳。当在手术中遇到用薄垫片过松而厚垫片过紧的情况下，要使用厚一点的垫片，使得软组织张力略紧点，防止术后随着时间的延长出现关节松弛。本研究为手术医生提供了一个术后保持合适关节稳定性的合理技术。 TKA术后内侧的紧张在做对侧关节置换时（4个月后），检查发现已经自行矫正了。 Residual medial tightness in extension is corrected spontaneously after total knee arthroplasty in varus knees PURPOSE: Although soft tissue balancing is considered important for successful total knee arthroplasty (TKA), it is unclear whether the laxity and balance achieved intraoperatively change postoperatively. A recent study demonstrated anaesthesia significantly influenced knee joint laxity after TKA; however, there has been no comparison of the varus-valgus laxity immediately after TKA and in the postoperative period under the same anesthetic conditions. Therefore, quantitative stress arthrometric studies were conducted under identical conditions to identify changes in coronal ligament laxity after TKA spontaneously. METHODS: A consecutive series of 28 knees with varus of more than 5° in 28 patients undergoing staged bilateral TKAs was prospectively evaluated. Postoperative varus-valgus laxity was measured immediately after surgery, with the patient still under spinal anaesthesia; and again at the time of the contralateral TKA, again under anaesthesia. The mean time between the first and second operations was 9.7 ± 7.3 months. RESULTS: Mean medial laxity significantly changed from 2.4° ± 1.6° just after the first operation under anaesthesia to 3.8° ± 1.4° just aftercontralateral TKA under anaesthesia (p < 0.001), but no significant change occurred in lateral laxity (5.6° ± 2.4° just after the first operation and 5.7° ± 2.1° after contralateral TKA, n.s.). Significant negative correlations were identified between laxity immediately after surgery and the amount of laxity change on both the medial (R = - 0.63, p < 0.001) and lateral sides (R = - 0.53, p < 0.001). CONCLUSION: Spontaneous soft tissue correction occurs after TKA. The findings from this study provides a rationale that it is not necessary for surgeons to perform the medial soft tissue release until the soft tissue tension is equalized on both the medial and lateral sides which has the risk of excessive release leading to instability. In situations where the surgeon is confronted with a knee that becomes too tight or too loose depending on the insert thickness, it is recommended to choose the thicker insert with the understanding that the knee will initially have a slightly tighter medial compartment that will loosen over time. The results of this study provide technical considerations that can help a surgeon achieve adequate postoperative stability. 文献出处：Tsukeoka T, Tsuneizumi Y. Residual medial tightness in extension is corrected spontaneously after total knee arthroplasty in varus knees. Knee Surg Sports Traumatol Arthrosc. 2018 May 4. doi: 10.1007/s00167-018-4967-6. 文献2 全关节置换术后血糖测量的最佳时机 译者：马云青 简介：全关节置换术(TJA)术后血糖水平的监测非常重要，因为高血糖与假体周围感染等并发症有关。本研究的目的是确定术后血糖值在围手术期的变化情况，并确定检查血糖的最佳时间，以便对高血糖做出最有价值的评估。 方法： 从2017年9月至2018年9月对314例膝关节和髋关节置换术患者进行回顾性研究。分别于术前即刻、术后5pm(手术当天DOS)、9pmDOS和术后1d(术后第一天POD)测定血糖水平。高血糖患者按：严格标准≥126 mg/dl、中间标准≥137 mg/dl和宽泛标准≥180 mg/dl三种血糖阈值评定是否为高血糖。对每个测血糖时间段进行描述性统计，并对所有时间点的血糖平均值和高血糖患者数量进行调整后比较。 结果：术前患者平均血糖值为105.7±2.1mg/d(±95%CI)，术后即刻为117.3±2.5mg/dL，术后当日5pm为138.6±4.3mg/dL，9pm为142.9±4.3mg/dL9pmDOS，第二日清晨为116.7±3.1mg/dL。糖尿病组和非糖尿病组在5pm和9pm的血糖值均显著高于其他时间点(P<0.001)。在所有的三种高血糖阈值中，9 pm时高血糖者血糖值最高：严格标准=205(65.3%)，中间标准=177(56.4%)，宽泛标准=90(28.7%)。 结论：TJA患者术后大部分血糖升高，与传统观点认为的POD 1相比，术后当日晚9pm可能是检测糖尿病和非糖尿病患者是否高血糖的最敏感时间。 Optimal Timing of Glucose Measurements After Total Joint Arthroplasty Introduction: Postoperative glucose levels after total joint arthroplasty (TJA) are important to monitor, as hyperglycemia has been linked to complications such as periprosthetic joint infection. The purposes of this study were to identify how postoperative glucose values vary during the perioperative period and determine the optimal time to check glucose levels to best evaluate for hyperglycemia. Methods: A retrospective study was conducted from September 2017-September 2018 on 314 knee and hip arthroplasty patients. Blood glucose levels were collected immediately preoperatively, immediately postoperatively, 5PM day of surgery (DOS), 9PM DOS, and postoperative day (POD) 1 morning. The total number of hyperglycemic patients was assessed at three glucose thresholds: strict ≥126mg/dl, intermediate ≥137mg/dl, and lenient ≥180mg/dl. Descriptive statistics were performed for each glucose time period, and adjusted comparisons were made between the mean glucose values and number of hyperglycemic patients at all time points. Results: Mean (±95% CI) glucose values were 105.7±2.1 mg/d L preoperatively, 117.3±2.5mg/dL immediately postoperatively, 138.6±4.3mg/dL 5PM DOS, 142.9±4.3mg/dL 9PM DOS, and 116.7±3.1mg/dL POD1 morning. The 5PM and 9PM values were significantly higher than all other time points in both diabetics and nondiabetics (p<0.001 for all). For all three hyperglycemia thresholds, the highest number of patients were hyperglycemic at 9PM DOS: strict=205 (65.3%) patients; intermediate=177 (56.4%) patients; and lenient=90 (28.7%) patients. Conclusion: The majority of TJA patients are hyperglycemic postoperatively, and 9PM on the night of surgery may be the most sensitive time for detecting hyperglycemia in both diabetic and nondiabetic patients, in contrast to traditional POD1 levels. 文献出处：Varady NH, Schwab PE, Jones T, Collins JE, Fitz W, Chen AF. Optimal Timing of Glucose Measurements After Total Joint Arthroplasty. J Arthroplasty. 2019 Jan 9. pii: S0883-5403(19)30011-7. doi: 10.1016/j.arth.2019.01.004. 文献3 传统方法与机器人辅助下单间室膝关节置换术后早期功能康复与出院时间的比较研究：一项前瞻性队列研究 译者：张蔷 目的：本篇文章的目的是比较施行传统方法与机器人辅助单间室膝关节置换手术的术后疼痛、镇痛药用量、早期功能康复、出院时间以及并发症等。 方法：该前瞻性队列研究的研究对象为一组146例症状性内侧间室膝关节骨关节炎患者，均由同一名主刀医生施行了初次单髁置换手术，前73例连续病例为传统方法施行的移动平台单髁置换手术，后73例连续病例为机器人辅助下的固定平台单髁置换手术。所有手术均采用标准的髌旁内侧入路，同时接受相同术后康复计划。我们记录了术后疼痛评分以及住院期间的阿片类镇痛药用量，同时，独立观察员还记录了达到预期功能状态的时间、出院时间以及术后并发症情况。 结果：与传统方法相比，应用机器人辅助的单髁置换病例术后疼痛评分更低(p < 0.001)，阿片类镇痛药用量更少(p < 0.001)，达成直腿抬高的时间更短(p < 0.001)，物理治疗次数减少(p < 0.001)，出院时膝关节最大屈曲角度增加(p < 0.001)。同时，机器人辅助的单髁置换病例出院时间更短(42.5小时(SD 5.9) vs 71.1小时(SD 14.6); p < 0.001)，而术后90天内的并发症率无明显差异。 疼痛评分 镇痛药 出院时间 结论：与传统方法的单髁置换手术相比，应用机器人辅助下的单髁置换手术可以减少术后疼痛、降低镇痛药用量，提高早期功能康复效果并缩短缩短出院时间。 An assessment of early functional rehabilitation and hospital discharge in conventional versus robotic-arm assisted unicompartmental knee arthroplasty：A Prospective Cohort Study Aims：The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA. Patients and Methods：This prospective cohort study included 146 patients with symptomatic medial compartment knee osteoarthritis undergoing primary UKA performed by a single surgeon. This included 73 consecutive patients undergoing conventional jig-based mobile bearing UKA, followed by 73 consecutive patients receiving robotic-arm assisted fixed bearing UKA. All surgical procedures were performed using the standard medial parapatellar approach for UKA, and all patients underwent the same postoperative rehabilitation programme. Postoperative pain scores on the numerical rating scale and opiate analgesia consumption were recorded until discharge. Time to attainment of predefined functional rehabilitation outcomes, hospital discharge, and postoperative complications were recorded by independent observers. Results: Robotic-arm assisted UKA was associated with reduced postoperative pain (p < 0.001), decreased opiate analgesia requirements (p < 0.001), shorter time to straight leg raise (p < 0.001), decreased number of physiotherapy sessions (p < 0.001), and increased maximum knee flexion at discharge (p < 0.001) compared with conventional jig-based UKA. Mean time to hospital discharge was reduced in robotic UKA compared with conventional UKA (42.5 hours (SD 5.9) vs 71.1 hours (SD 14.6), respectively; p < 0.001). There was no difference in postoperative complications between the two groups within 90 days’ follow-up. Conclusion: Robotic-arm assisted UKA was associated with decreased postoperative pain, reduced opiate analgesia requirements, improved early functional rehabilitation, and shorter time to hospital discharge compared with conventional jig-based UKA. 文献出处：B. Kayani, S. Konan, J. Tahmassebi, F. E. Rowan, F. S. Haddad. An assessment of early functional rehabilitation and hospital discharge in conventional versus robotic-arm assisted unicompartmental knee arthroplasty: A Prospective Cohort Study. Cite this article: Bone Joint J 2019; 101-B: 24–33. 第二部分：保髋相关文献 文献1 股骨头坏死区域范围测量 译者：罗殿中 背景：股骨头坏死早期的治疗方式仍然存在争议。用一种统一有效的方式来描述股骨头坏死的分期及坏死面积，将有助于改善治疗的预后。目前还没有明确坏死区面积的最佳方法。本研究的目的是比较不同方法测量股骨头坏死面积的准确性及可操作性。 方法：通过MRI对25例I期及II期股骨头坏死髋关节进行评估。以3D MRI测量骨头坏死面积的结果为基准，与肉眼评估及其它评估坏死区范围的参数进行比较，包括Kerboul坏死角、坏死指数、坏死调整指数。 结果：3D MRI测量显示患者股骨头坏死容积在2.2-59.2%。3D MRI测量结果与股骨头坏死面积参数间存在粗糙的相关性，其中股骨头坏死指数比Kerboul坏死角要更接近3D MRI测量结果。肉眼直接观测每张MRI的评估结果与测量参数间准确性无差异。 结论：简单的肉眼直接观测每张MRI可以较为准确地评估股骨头坏死的面积，满足临床需要。股骨头坏死面积参数测量可以用于评估预后和治疗，但是不够精确，不同方法间存在差异。3D MRI测量坏死区容量的方法最为准确。通过现有的技术及软件可以简化其操作，相比其它股骨头坏死面积参数的测量，并不会耗费更多的时间和精力。当临床研究及发表文章需要非常精确的测量数据时，应首选3D MRI方法。 通过在MRI冠状位位T1相进行股骨头坏死容积的测量。a 股骨头坏死区域的轮廓；b 整个股骨头的轮廓；c 股骨头坏死区与整个股骨头的轮廓 Lesion size measurement in femoral head necrosis BACKGROUND: Management of patients with early stages of osteonecrosis of the femoral head remains controversial. Uniform use of an effective method of evaluation and classification, including both stage and lesion size, would allow for comparison and would significantly improve treatment of patients. There is no consensus on how best to determine lesion size. The purpose of this study was to evaluate and compare accuracy and ease of use of different techniques for determining the size of femoral head lesions. METHODS: Twenty-five hips with stages I or II osteonecrosis were evaluated with radiographs and MRI. 3-D MRI measurements of lesionsize were used as the standard against which to compare visual estimates and angular measurements: necrotic angle of Kerboul, index of necrosis, and adjusted index of necrosis. RESULTS: 3-D measurements (necrotic volume) showed regular progression from 2.2 to 59.2% of the femoral head. There was a rough correlation with angular measurements; index of necrosis was closer than the necrotic angle. Visual estimates from serial MRI images were as accurate as angular measurements. CONCLUSIONS: Simple visual estimates of lesion size from serial MRI images are reasonably accurate and are satisfactory for clinical use. Angular measurements provide some indication of prognosis and treatment; however, they have limited accuracy, with considerable variability between techniques. 3-D MRI volumetric measurements are the most accurate. Using current techniques and software, they are easier to use, requiring similar time and effort to angular measurements. They should be considered for clinical research and publications when the most accurate measurements are required. 文献出处：Steinberg ME, Oh SC, Khoury V, Udupa JK, Steinberg DR. Lesion size measurement in femoral head necrosis. Int Orthop. 2018 Jul;42(7):1585-1591. doi: 10.1007/s00264-018-3912-0. Epub 2018 Apr 25. 文献2 中青年患者慢性髋关节疼痛的误诊漏诊：回顾性描述性分析 译者：程徽 背景：髋关节疼痛是常见的骨关节系统疾病症状之一。尽管全面的检查对明确诊断、指导治疗至关重要，在初诊中出现误诊漏诊仍然比较常见。本研究的目的是描述性分析从基层医院转诊到三级医院髋关节疼痛患者，特别是不超过50岁的中青年患者的误诊漏诊的情况。 方法：我们通过研究转诊表格，回顾性分析了连续150名被漏诊、误诊的慢性髋关节疼痛患者（年龄不超过50岁）。 结果：在本组观察中，平均每个月出现32例误诊、漏诊。在入组的150患者中，146名可以通过分析常规临床检查数据，正确的完成最终诊断。四种最常见的最终诊断分别为：股髋撞击综合征（FAI，55.3％），髋关节发育不良（HD，13.3％），腰椎源性疼痛（9.3％）和脊柱关节炎（SpA，7.3％）。在FAI综合征患者中，37例患者（44.0％）为夹钳型FAI，33例患者（39.8％）为联合型。虽然诊断和疼痛部位或性别没有准确的对应，但最终诊断的分布随髋痛位置和性别的不同，存在显著差别。特别是，当按参与者的平均年龄分层时，在青年女性亚组（16-37岁）和中年男性亚组（38-50）中未观察到SpA或HD。 图1 不同亚组间疾病分布的不同 结论：大多数（> 80％）中青年患者的髋部疼痛的诊断，对于许多基层医师尚存在困难。主要包括股髋撞击综合征（FAI），髋关节发育不良（HD），腰椎源性疼痛和脊柱关节炎（SpA）这四种疾病。本研究可以提供髋关节疼痛病例漏诊误诊的反馈信息，并提示基层医生需要熟悉这4种疾病的诊断方法。 Causes of Chronic Hip Pain Undiagnosed or Misdiagnosed by Primary Physicians in Young Adult Patients: a Retrospective Descriptive Study BACKGROUND: Hip pain is a common musculoskeletal complaint in general practice. Although comprehensive diagnostic approach on hip pain is mandatory for adequate treatment, un- or mis-diagnosis is not rare in primary care. The aim of this study was to analyze descriptively un- or mis-diagnosed hip pain cases referred from primary care to a tertiary hospital, especially in young adults ≤ 50 years old. METHODS: We retrospectively analyzed a consecutive cohort of 150 patients (≤ 50 years old) with chronic hip pain (≥ 6 weeks), which was not diagnosed or misdiagnosed based on the information provided on the referral form. RESULTS: Overall an average 32 cases/month were referred due to hip pain without a diagnosis or with an incorrect diagnosis. Among them, 150 patients were enrolled in this study and 146 (97.3%) could be allocated to a specific disease by using data from routine clinical practice. Four common final diagnoses were femoroacetabular impingement (FAI) syndrome (55.3%), hip dysplasia (HD, 13.3%), referred pain from the lumbar spine (9.3%), and spondyloarthritis (SpA, 7.3%). In patients with FAI syndrome, 37 (44.0%) had pincer-type FAI and 33 (39.8%) had combined-type. Although the pain site or gender was not tightly clustered, the distribution of final diagnosis was significantly different according to hip pain location or gender. Especially, SpA or HD was not observed in younger women subgroup or elder men subgroup, respectively, when stratified by the mean age of participants. CONCLUSION: Most (> 80%) young patients with hip pain, a difficult issue to diagnosis for many primary physicians, had FAI syndrome, HD, spine lesions, and SpA. This study could give a chance to feedback information about cases with un- or mis-diagnosed hip pain, and it suggests that primary physicians need to be familiar with the diagnostic approach for these 4 diseases. 参考文献：Lee YJ, Kim SH, Chung SW, Lee YK, Koo KH. Causes of Chronic Hip Pain Undiagnosed or Misdiagnosed by Primary Physicians in Young Adult Patients: a Retrospective Descriptive Study. J Korean Med Sci. 2018 Dec 11;33(52):e339. doi: 10.3346/jkms.2018.33.e339. eCollection 2018 Dec 24. 文献3 基于CT三维重建骨盆统计模型对骨盆变异的研究 译者：肖凯 骨盆环结构复杂，对维持人类的身体稳定性和活动能力具有重要作用。不同个体间骨盆解剖结构的主要差异取决于无名骨骼和骶骨的形态变异，进而是这些骨骼之间空间排列的差异。本研究的目的是生成整个骨盆环的三维统计模型，进一步分析观察到个体间差异和解剖变异。我们对50名未受过伤的日本成年人（30名男性，20名女性，平均年龄74.9岁，标准差16.9岁）进行了骨盆CT扫描，通过三维重建得到骨盆模型，计算整体平均模型和单独的男性、女性平均模特。通过对所有模型进行主成分分析显示，最主要的变异为骨盆大小变异（20.39％），其次是形状变异（14.13％），再次为骶骨相对无名骨在空间排列的变异（11.39和8.85％）。此外，我们选择性手动测量了骨盆内部和外部的参数，以便进一步评估和量化观察到的个体间差异及不同性别的差异。通过在独立的模型上进行灰度赋值，基于Hounsfield单位（HU）值的灰度值分布评估骨密度分布，这样便得到了利用灰度值作为放射密度的定量描述的骨质量评估指标。分析显示，在骶髂关节和髋臼与弓状线之间区域的灰度值最高。骶窝区域，髂窝区域以及耻骨联合旁的耻骨支灰度值最低。本模型可以对观察到的骨盆环的个体间变化进行差异分析并评估其中的灰度值分布。该模型除了有助于对解剖变异的更好理解，还可用作教学、术前设计及假体设计。 不同性别间在骨盆形态上的差异，颜色越接近红色的部位表明两者间形态差异越大 骨盆3D模型在正位、入口位、出口位、侧位显示灰度值分布 3D statistical model of the pelvic ring - a CT-based statistical evaluation of anatomical variation The pelvic ring is a highly complex construct with a central role for human stability and mobility. The observable interindividual differences in skeletal anatomy are caused by anatomical variation in the innominate bones as well as the sacrum, further to differences in the spatial arrangement of these bones to each other. The aim of this study was to generate a 3D statistical model of the entire pelvic ring in order to analyse the observed interindividual differences and anatomical variation. A series of 50 anonymized pelvic CT scans of uninjured Japanese adults [30 males, 20 females, average age of 74.9 years, standard deviation (SD) 16.9 years] were processed and analysed, resulting in a 3D statistical overall mean model and separate male and female mean models. Principal component analysis (PCA) of the overall statistical model predominantly showed size variation (20.39%) followed by shape variation (14.13%), and a variation of the spatial arrangement of the sacrum to the innominate bones in different anatomical peculiarities (11.39 and 8.85%). In addition, selected internal and external pelvic parameters were manually measured with the objective of further evaluating and quantifying the observed interindividual as well as the known sex-specific differences. A separate statistical model of the grey value distribution based on the given Hounsfield unit (HU) values was calculated for assessing bone mass distribution, thus an indication of bone quality utilizing grey values as a quantitative description of radiodensity was obtained. A consistent pattern of grey value distribution was shown, with the highest grey values observed between the sacro-iliac joint and the acetabulum along the pelvic brim. Low values were present in the sacral ala, in the area of the iliac fossa as well as in the pubic rami next to the symphysis. The present model allows a differentiated analysis of the observed interindividual variation of the pelvic ring and an evaluation of the grey value distribution therein. Besides providing a better understanding of anatomical variation, this model could be also used as a helpful tool for educational purposes, preoperative planning and implant design. 文献出处：Arand C, Wagner D, Richards RG, et al. 3D statistical model of the pelvic ring - a CT-based statistical evaluation of anatomical variation. J Anat, 2018. 文献4 图像重叠法在慢性桡骨头脱位截骨治疗中的应用 译者：任宁涛 目的：三维（3D）计算机断层扫描图像目前可用来制作3D模型，以便于骨科的术前设计，但3D模型制作过程耗时较长且花费较高。对于慢性桡骨头脱位的患者，我们设计了一种图像重叠的方法，采用选定的3D CT图像和相关软件，可以简化手术截骨位置的选择。 方法：我们研究了5名单侧桡骨头脱位的患者（2名为创伤性，3名为先天性）。这些患者基于传统影像学检查接受了手术治疗，但是他们同时有术前和术后完整的3D CT检查图像：我们将基于这些3D CT图像进行此项研究。基于术前术后的3D CT检查图像，每名患者有3组3D打印的骨模型：其中2组为患者术前的情况，1组为患者术后的情况。其中1组术前骨模型使用图像重叠法进行截骨和固定的选择。最后我们对此3组模型进行术前术后的旋转弧进行研究。 结果：这3组骨模型的旋转弧具有明显的差异，根据我们图像重叠技术进行截骨的骨模型具有最大的旋转弧。 结论：对于慢性桡骨头脱位的患者，图像重叠法可以简化截骨点选择的过程。3D打印骨模型显示，这种方法在实际的手术操作中，可以改善前臂的活动度。 图一：我们采用常规的测试仪器和特定的固定终板来固定骨模型，测量其旋转弧度。（A）旋后位 （B）中立位 （C）旋前位。 图二：我们采用立体摄影测量法，对前臂的旋转弧度和桡骨相对于尺骨的位移程度进行测量，摄像机可检测到桡骨头相对于尺骨的位移程度。
图三：男，19岁，双侧先天性桡骨头脱位，伴有明显的活动受限（屈曲125°，伸直-5°，旋前15°，旋后5°）。如图所示为术前（A）和术后（B）患者肘关节放射学检查。术后患者的桡骨头复位，肘关节的活动度得到改善（屈曲140°，伸直0°，旋前30°，旋后30°）。我们对桡骨头进行了切开复位，通过后方入路采用三头肌肌腱束进行了环状韧带重建。根据图像重叠法，对尺骨近端进行了截骨延长，桡骨近端进行截骨短缩并纠正其成角。尺桡骨近端放置脂肪以避免两者出现骨性连接。术后，患者肘关节稳定，肘关节总体运动弧度增加。
图四：A，我们从3D计算机断层扫描（CT）数据中，选择了6个三维图像，显示患侧和健侧的桡骨和尺骨每隔30°的旋转情况（此处只展示了患侧）。为了简化骨骼畸形的检测过程，我们将桡骨和尺骨分为三个节段，然后画出每一节段的中轴。B，我们制作了正常前臂6个旋转平面模板（此处展示了真实的侧位像），正常模板是6段中心轴的集合。C，对于每一个图像（此处只展示其侧位像），我们将正常的模板和患者的桡骨和尺骨的节段轴放置在同一个平面内，可以很容易比较出两者哪一个图像（旋转平面）差异最大，此最大差异的层面是下一步唯一要用到的平面。
图五：在最大差异的旋转平面上选择截骨点。A，将患侧的桡骨和尺骨分开，B，选择同一旋转平面的正常前臂的图像，在同一个Microsoft PowerPoint窗口中，将患侧的桡骨和尺骨与健侧重叠放置，使其远端重叠，（C）使其近端重叠，标记患侧骨骼与健侧未重叠部分。我们仅保留骨骼远端和近端准确的重叠部分，去除其明显的偏离部分，D，我们将患侧图像的剩余部分滑移到健侧，并将患侧的骨骼图像与健侧的重叠，保证其两端最佳重叠。通过检查患者前臂的旋转的量（包括延长或短缩）来确定矫正的量。然后将截骨区域通过钢板螺钉进行固定。 A Graphic Overlay Method for Selection of Osteotomy Site in Chronic Radial Head Dislocation: An Evaluation of 3D-printed Bone Models Purpose: Three-dimensional (3D) computed tomography imaging is now being used to generate 3D models for planning orthopaedic surgery, but the process remains time consuming and expensive. For chronic radial head dislocation, we have designed a graphic overlay approach that employs selected 3D computer images and widely available software to simplify the process of osteotomy site selection. Methods: We studied 5 patients (2 traumatic and 3 congenital) with unilateral radial head dislocation. These patients were treated with surgery based on traditional radiographs, but they also had full sets of 3D CT imaging done both before and after their surgery: these 3D CT images form the basis for this study. From the 3D CT images, each patient generated 3 sets of 3Dprinted bone models: 2 copies of the preoperative condition, and 1 copy of the postoperative condition. One set of the preoperative models was then actually osteotomized and fixed in the manner suggested by our graphic technique. Arcs of rotation of the 3 sets of 3D-printed bone models were then compared. Results: Arcs of rotation of the 3 groups of bone models were significantly different, with the models osteotomized accordingly to our graphic technique having the widest arcs. Conclusions: For chronic radial head dislocation, our graphic overlay approach simplifies the selection of the osteotomy site(s). Three-dimensional-printed bone models suggest that this approach could improve range of motion of the forearm in actual surgical practice. 文献出处： A Graphic Overlay Method for Selection of Osteotomy Site in Chronic Radial Head Dislocation: An Evaluation of 3d-Printed Bone Models. H. T. Kim, T. Y. Ahn, J. H. Jang, K. H. Kim, S. J. Lee, and D. Y. Jung, J Pediatr Orthop (2015). 文献5 发育性髋关节发育不良：从出生到6个月诊断和治疗的最新进展 译者：张利强 回顾目的：我们对发育性髋关节发育不良（DDH）的流行病学、诊断和管理的理解正在改变中。本文综述了从出生到6个月大的DDH患者的最新文献。 最新进展：众所周知的DDH危险因素包括家族史、女性性别和胎儿臀位。最近的证据表明，出生体重增加也是一种危险因素，而早产可能降低该风险。筛查包括对所有婴儿进行体格检查，并在出现异常发现或危险因素时进行影像学检查。前6个月的治疗包括Pavlik吊带，成功率为70-95%。失败的危险因素包括股神经麻痹、吊带限制髋关节活动、无法复位的髋关节、7周龄后开始治疗、右髋关节脱位、Graf IV型髋脱位和男性患儿。如果使用Pavlik吊带的复位治疗失败，可使用坚硬挽具治疗，如其也失败，可考虑闭合复位。如果髋关节仍然不能复位、非同心圆复位或不稳定，则需要考虑切开复位。证据不支持延迟髋关节复位直到出现骨化核。 总结：DDH影响1-7%的婴儿。应体检所有婴儿，并对体检异常或有危险因素的患儿行影像学筛查。早期治疗效果最佳。
α角是指基线（髋臼软骨顶的顶部向下做髂骨的切线）到髋臼骨顶线（髂骨下缘画骨顶的切线）的夹角。β角是指基线到髋臼软骨顶线（髋臼凹面-凸面交接点与盂唇中点的连线）的夹角。覆盖率是股骨头位于骨髋臼内的比例，即长度A/长度B。
IHDI（International Hip Dysplasia Institute）髋关节发育不良的分类。Hilgenreiner线为两侧Y形软骨顶部的连线，Perkin线从髋臼的外侧缘垂直于Hilgenreiner线划出，对角线从Hilgenreiner线和Perkin线的交点的45度划出。股骨颈干骺端上缘中点的位置（H点）可用于确定髋关节（I-IV）的分级。I级为正常髋关节，H点位于Perkin线上或内侧，II级为半脱位髋关节，H点位于Perkin线与对角线之间（包括对角线），III级为半脱位或脱位髋关节，H点位于对角线与Hilgenreiner线之间（包括Hilgenreiner线），IV级为脱位髋关节，H点高于Hilgenreiner线。 Developmental dysplasia of the hip: an update on diagnosis and management from birth to 6 months Purpose of review: Our understanding of the epidemiology, diagnosis, and management of developmental dysplasia of the hip (DDH) is evolving. This review focuses on the most up-to-date literature on DDH in patients from birth to six months of age. Recent findings: Well known risk factors for DDH include family history, female sex, and breech positioning. Recent evidence suggests higher birth weight is a risk, whereas prematurity may be protective. Screening includes physical examination of all infant hips and imaging when abnormal findings or risk factors are present. Treatment in the first six months consists of a harness, with 70–95% success. Failure risk factors include femoral nerve palsy, static bracing, irreducible hips, initiation after seven weeks of age, right hip dislocation, Graf-IV hips, and male sex. Rigid bracing may be trialed if reduction with a harness fails and closed reduction is indicated after failed bracing. If the hip is still irreducible, nonconcentric, or unstable, open reduction may be required following closed reduction. Evidence does not support delaying hip reduction until the ossific nucleus is present. Summary: DDH affects 1–7% of infants. All infants should be examined and selective screening with imaging should be performed for abnormal physical exams or risk factors. Early treatment is associated with optimal outcomes. 文献出处：Ishaan Swarup,Caitlin L Penny, Emily R Dodwell. Developmental dysplasia of the hip: an update on diagnosis and management from birth to 6 months .Curr Opin Pediatr 2018;30(1):84-92 doi:10.1097/MOP.0000000000000574. 文献6 股骨头骨骺滑脱时的髋臼形态：治疗开始和骨骼发育成熟时的比较 译者：陶可（北京大学人民医院骨关节科） 目的：调查在股骨头骨骺滑脱（SCFE）随访期间髋臼形态的变化，并寻找与骨骼成熟时髋臼发育不良的相关因素。 方法：评估了108名患有单侧SCFE（骨骺滑脱时的平均年龄，12.3±1.7岁）至骨骼成熟的患者，最小随访时间为2年（中位数为4.5年；四分位数间距为3.2-6.2）。从初始和最近的X线片获得的髋臼参数包括外侧中心-边缘角度（LCEA）、Tönnis角度（TA）和髋臼深度-宽度比率（ADR）。髋臼发育不良被定义为是LCEA<20°或TA>10°。股骨参数包括最近X线片上的股骨头直径、股骨颈干角、股骨颈长度、关节转子间距和α角。 结果：在SCFE开始时，受罹髋部与未受罹髋部相比，LCEA（26.4°±6.1°对27.3°±5.7°；p=0.01）和ADR（330±30对比340±30；p<0.001）略低。在最后随访中，与未受罹的髋关节相比，受罹髋部表现出较小的LCEA（24.5°±7.6°对比28.8°±6.6°；p<0.001）和ADR（330±40对比350±40；p<0.001），而较大的TA（5.5°±5.4°对比2.3°±4.2°；p<0.001）。在SCFE的108髋中，有27例（25%）观察到髋臼发育不良。同时，股骨头过度生长、骨骺滑脱时的年龄和SCFE严重程度是与髋臼发育不良相关的独立因素（p<0.05）。 结论：SCFE中髋臼的覆盖范围和深度没有增加，髋臼的覆盖率往往会下降，直至骨骼成熟。髋臼生长和重塑的潜在紊乱主要存在于严重SCFE的幼儿中，并且在SCFE的诊断和随访中可能观察到髋臼功能不全。
图1.人群的研究流程图（LCEA，外侧中心-边缘角）。
图2. 描述髋臼和股骨X线照片参数。一个右侧股骨头骨骺滑动男孩的单髋X线片。
图3. 一个女孩左侧股骨头骨骺滑脱（SCFE）的骨盆前后位X线片。
图4. 一位左侧股骨头骨骺滑脱（SCFE）的男孩立即行原位骨骺固定术后的骨盆前后位X线片。 Acetabular morphology in slipped capital femoral epiphysis: comparison at treatment onset and skeletal maturity Purpose: To investigate changes in acetabular morphology during the follow-up of slipped capital femoral epiphysis (SCFE) and search for factors associated with acetabular dysplasia at skeletal maturity. Methods: We evaluated 108 patients with unilateral SCFE (mean age at slip, 12.3 years sd 1.7) to skeletal maturity, with a minimum follow-up of two years (median 4.5 years; interquartile range 3.2 to 6.2). Acetabular parameters obtained from initial and most recent radiographs included the lateral centre-edge angle (LCEA), Tönnis angle (TA) and acetabular depth-width ratio (ADR). Acetabular dysplasia was considered for LCEA < 20° or TA > 10°. Femoral parameters consisted of the most recent head diameter, neck-shaft angle, neck length, articulotrochanteric distance and alpha angle. Results: At SCFE onset, the affected hip showed a slightly lower LCEA (26.4° sd 6.1° versus 27.3° sd 5.7°; p = 0.01) and ADR (330 sd 30 versus 340 sd 30; p < 0.001) compared with the uninvolved hip. At final follow-up, the affected hip showed lower LCEA (24.5° sd 7.6° versus 28.8°sd 6.6°; p < 0.001) and ADR (330 sd 40 versus 350 sd 40; p < 0.001), and TA was larger (5.5° sd 5.4° versus 2.3° sd 4.2°; p < 0.001) compared with the uninvolved hip. Acetabular dysplasia was observed in 27 (25%) of 108 hips with SCFE. Femoral head overgrowth, age at slip and SCFE severity were independent factors associated with acetabular dysplasia (p < 0.05). Conclusion: Acetabular coverage and depth are not increased in SCFE, and the acetabular coverage tends to decrease up to skeletal maturity. A potential disturbance in the acetabular growth and remodelling exists mainly for young children with severe SCFE, and a potential for acetabular insufficiency may be observed at the diagnosis and follow-up of SCFE. |
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