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1、全膝置换术中如何精确的判断软组织平衡 2、高危患者初次全髋、膝关节置换术后延长口服抗生素时间可显著降低术后90天感染率 3、软骨全层缺损是轻中度老年骨关节炎患者病情进展至关节置换的重要独立预测因素：数据源自《骨关节炎计划》 4、带血管腓骨移植治疗非塌陷期股骨头坏死：远期效果是否满意？ 5、症状性髋臼撞击征：偏距与软骨损伤关系的初步研究 6、髋关节镜术后发生髂胫束综合征：一项之前没报道过的并发症 7、术中稳定性测试可作为DDH切开复位时是否需要进行截骨的辅助因素 8、6月龄内婴幼儿超声检查异常髋关节的自然病史 9、股骨头骨骺滑脱术后股骨髋臼撞击的手术治疗 第一部分：关节置换相关文献 文献1 全膝置换术中如何精确的判断软组织平衡 译者：张轶超 背景：软组织平衡对于决定全膝关节置换术（TKA）后的效果是非常重要的。我们通过这个研究来对比外科医生对软组织平衡的判断（SDA）和压力感受器数据之间的关系，看看SDA的准确性如何。同时我们也评估了医生经验（学习曲线）和SDA准确性间的关系。 方法：我们前瞻性的分析了308个患者的322例TKA手术。在做软组织平衡前将股骨和胫骨试模置入关节。我们在膝关节屈曲10°、45°和90°时测量了手术医生的判断情况和压力感受器的数值。 结果：相比较压力感受器SDA的准确性分别为63%，57.5%和63.8%。SDA总的敏感性为81%，特异性为37.7%。SDA判断的特异性在越高的屈曲角度时就越差，分别为53.5%，34.8%和24.8%（10°对比45°时p=0.0004，10°对比90°时p<0.0001）。科恩Kappa指数在10°时为0.29，提示一致性一般，而在45°和90°时为0.14和0.12，提示一致性差。压力感受器不会因为使用次数的变化而影响对于软组织平衡的判断能力。 结论：对于软组织是否真正平衡的判断能力SDA不如压力感受器，尤其对于膝关节不平衡的评估。另外，使用压力感受器并不能提高手术医生对于膝关节平衡的判断能力。 图示：膝关节压力感受器数据接受器 How Accurately Can Soft Tissue Balance Be Determined in Total Knee Arthroplasty? BACKGROUND: Soft tissue balance is believed to be a major determinant of improved outcomes in total knee arthroplasty (TKA). We conducted this study to assess the accuracy of surgeon-defined assessment (SDA) of knee balance compared to pressure sensor data. We also assessed for any association between experience (learning curve) and accuracy of SDA. METHODS: A total of 308 patients undergoing 322 mechanically aligned TKA were prospectively analyzed. Femoral and tibial trial implants were inserted before performing knee balancing. We compared the surgeon determination on knee balance at 10°, 45°, and 90° of flexion to sensor data at the same flexion angles. RESULTS: Accuracy of SDA was 63%, 57.5%, and 63.8% at 10°, 45°, and 90°, respectively, when compared to sensor data. SDA had an overall sensitivity of 81% and specificity of 37.7%. Capacity to determine an unbalanced knee worsened at higher knee flexion angles with SDA test specificity of 53.5%, 34.8%, and 24.8% at 10°, 45°, and 90°, respectively (P = .0004 at 10° vs 45°, P < .0001 at 10° vs 90°). Cohen's kappa coefficient was 0.29 at 10° indicating fair agreement, and 0.14 and 0.12 at 45° and 90°, respectively, indicating poor agreement. The use of sensor had no time-based learning effect on capacity to determine knee balance. CONCLUSION: SDA is a poor predictor of the true soft tissue balance when compared to sensor data, particularly in assessing whether a knee is unbalanced. In addition, increased use of sensors did not improve surgeon capacity to determine knee balance. 文献出处：MacDessi SJ, Gharaibeh MA, Harris IA. How Accurately Can Soft Tissue Balance Be Determined in Total Knee Arthroplasty? J Arthroplasty. 2018 Oct 11. pii: S0883-5403(18)30877-5. doi: 10.1016/j.arth.2018.10.003. 文献2 高危患者初次全髋、膝关节置换术后延长口服抗生素时间可显著降低术后90天感染率 译者：马云青 背景：全关节置换术(TJA)分阶段付款的模式将假体周围感染(PJI)的风险和成本转移到了外科医生和医院一方，导致大家尽量避免治疗那些感染高危患者。此外，很少有数据支持优化术前患者自身的因素可以降低PJI，最近的文献支持翻修术后延长抗生素的预防应用时间。本研究的目的是评估感染高危患者在初次TJA后延长口服抗生素预防治疗时间是否能降低PJI的发生率。 方法：采用回顾性队列研究的方法，对2011~2016年在一所具有现代围手术期管理和感染预防方案的临床教学医院进行的2181例初次全膝关节置换(TKAS)和初次全髋关节置换(THAS)进行了回顾性研究。从2015年1月开始，对高危PJI患者实施出院后7天的延长口服抗生素预防方案。统计术后90天内确诊为PJI的患者比例，并与未接受延长口服抗生素预防的患者进行比较，P<0.05表明有显着性意义。 结果：TKAS和THAS术后 90天的感染率分别为1.0%和2.2%，无延长抗生素预防的高危患者在TKA和THA后发生PJI的可能性分别为接受延长口服抗生素治疗的高风险患者的4.9倍(p=0.009)和4.0倍(p=0.037)。 结论：延长术后抗生素预防可显著降低感染高危患者术后90天的感染率，具有统计学意义。我们建议在对高风险TJA患者术后延长口服抗生素预防的作为常规前应通过进一步的研究和审核，并适当权衡（如：增加细菌耐药性等）潜在的不良后果。 Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate BACKGROUND: Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients. METHODS:A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance. RESULTS: The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extendedantibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis. CONCLUSIONS: Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance. 文献出处：Inabathula A, Dilley JE, Ziemba-Davis M, Warth LC, Azzam KA, Ireland PH, Meneghini RM. Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate. J Bone Joint Surg Am. 2018 Dec 19;100(24):2103-2109. doi: 10.2106/JBJS.17.01485. 文献3 软骨全层缺损是轻中度老年骨关节炎患者病情进展至关节置换的重要独立预测因素：数据源自《骨关节炎计划》 译者：张蔷 背景：平片上显示的膝关节骨关节炎严重程度并不是症状严重程度的可靠预测指标。本篇文章的目的是确定软骨全层缺损或骨关节炎（OA）分级能否准确预测老年终末期骨关节炎患者的病情最终向关节置换发展。 方法：本研究入组了《骨关节炎计划》（一项前瞻性多中心平均9年的随访研究）中1319例成年患者，年龄45岁至79岁（平均年龄61.0 ± 9.2岁）。所有患者在平片上双侧膝关节骨关节炎Kellgren-Lawrence分级均为0-3级（无-中度），4级骨关节炎患者被排除出组。通过核磁明确每位患者胫骨平台或股骨髁负重区是否存在软骨全层缺损，如果存在则统计面积大小。最后根据是否存在缺损、缺损面积大小以及OA分级，将最终进行关节置换的危险度进行COX比例模型分析，分组前首先配平基本数据，包括年龄、性别、种族、体重、力线、症状严重程度、生活质量评分和运动水平等。 结果：496例患者（37.6%）存在软骨全层缺损。在没有软骨全层缺损的情况下，膝关节置换的概率是0.57%/人･年，而存在缺损的情况下，概率升至2.15%/人･年。去除了混杂因素后数据显示：无论OA分级如何，存在软骨全层缺损显著增加了患者最终接受关节置换手术的风险，大面积缺损(≧2cm2)的手术风险(风险比[HR]=5.27 [95%置信区间(CI)=2.70 to 10.3]; p<0.001)比小面积(<2cm2)更高(HR=2.65[95%CI=1.60to 4.37]; p<0.001)。与正常膝关节（0-1级）相比，轻度骨关节炎（2级）并没有明显增加最终接受全膝关节置换手术的风险(HR=0.71[95%CI=0.31 to 1.60])；中度骨关节炎（3级）只会显著增加没有软骨全层缺损患者的膝关节置换风险(HR=3.15[95%CI=1.34 to 7.40]; p=0.009)，而不会显著增加存在软骨全层缺损患者的置换风险(HR=0.64[95%CI=0.28 to 1.49]; p=0.30)。 结论：对于轻中度老年骨关节炎患者而言，软骨全层缺损是一项重要的未来接受膝关节置换手术的预测指标。而我们常用的基于平片的OA分级只在没有出现软骨全层缺损的情况下与未来关节置换存在相关性。 Full-Thickness Cartilage Defects Are Important Independent Predictive Factors for Progression to Total Knee Arthroplasty in Older Adults with Minimal to Moderate Osteoarthritis: Data from the Osteoarthritis Initiative Background: Knee osteoarthritis (OA) severity on radiographs is not a reliable predictor of symptom severity. The purpose of this study was to determine whether full-thickness defects or OA grade are predictive of the progression to total knee arthroplasty in older patients without end-stage arthritis. Methods: This study included 1,319 adults aged 45 to 79 years (mean age [and standard deviation], 61.0 ± 9.2 years) who were enrolled in the Osteoarthritis Initiative, a prospective multicenter study with median 9-year follow-up data. All participants had Kellgren-Lawrence grade-0 to 3 (no to moderate) OA on bilateral radiographs; patients with grade-4 (severe) OA were excluded. The presence and total surface area of full-thickness cartilage defects on the tibia or the weight-bearing portion of the femoral condyle were determined. The risk of total knee arthroplasty due to defect presence and size as well as OA grade was determined with Cox proportional-hazards modeling after controlling for baseline variables including, but not limited to, age, sex, race, weight, knee alignment, symptom severity, quality-of-life scores, and activity level. Results: Four hundred and ninety-six patients (37.6%) had full-thickness defects. The incidence of knee arthroplasty was 0.57% per person-year for adults without a full-thickness defect and 2.15% for those with a defect. After adjusting for confounders, the presence of a full-thickness defect increased the risk of total knee arthroplasty regardless of OA grade, with higher risk demonstrated for larger (≧2cm2) defects (hazard ratio [HR]=5.27 [95% confidence interval (CI) = 2.70 to 10.3]; p<0.001) compared with smaller (<2cm2) defects (HR=2.65 [95% CI = 1.60 to 4.37]; p<0.001). Compared with nonarthritic knees (grade 0 to 1), mild arthritis (grade 2) did not increase total knee arthroplasty risk (HR=0.71 [95% CI = 0.31 to 1.60]); moderate arthritis (grade 3) increased total knee arthroplasty risk in adults without a full-thickness defect (HR=3.15 [95% CI = 1.34 to 7.40] ; p=0.009) but not in adults with a defect ( HR=0.64 [95% CI =0.28 to 1.49 ]; p=0.30). Conclusions: Full-thickness cartilage defects were a major determinant of future knee arthroplasty in older adults with minimal to moderate OA, even after adjusting for baseline knee symptom severity. Baseline radiographic severity grade was only associated with future total knee arthroplasty risk in the absence of a full-thickness defect. 文献出处：Everhart JS, Abouljoud MM, Kirven JC, Flanigan DC. Full-Thickness Cartilage Defects Are Important Independent Predictive Factors for Progression to Total Knee Arthroplasty in Older Adults with Minimal to Moderate Osteoarthritis: Data from the Osteoarthritis Initiative. J Bone Joint Surg Am. 2019 Jan 2;101(1):56-63. doi: 10.2106/JBJS.17.01657. 第二部分：保髋相关文献 文献1 带血管腓骨移植治疗非塌陷期股骨头坏死：远期效果是否满意？ 译者：罗殿中 背景：股骨头坏死是一种可以导致年轻患者关节功能受限的疾病。带血管腓骨移植可能为保头成功带来希望。当将此治疗方案用于非塌陷的股骨头坏死患者可能会改变疾病的发展进程。 问题/目的：我们提出一下问题：1、带血管腓骨移植治疗股骨头坏死的10年以上成功率是多少？2、长期预后不好的患者，股骨头术后维持了多久？3、人口统计学因素及病因会不会影响到预后？4、患者远期功能及日常活动有哪些改善？ 方法：我们回顾性分析了61名（65髋）接受带血管腓骨移植的股骨头坏死患者。我们记录股骨头存活时间、SF-12评分、日常活动水平、Harris评分。术后最短随访时间10.5年（平均14.4年，10.5-26年）。65髋中的49髋（75%）术后股骨头至少存活了10年。末次随访时，65髋中的39髋（60%）股骨头仍然存活，存活时间平均15年（10.5-26.1年）。26髋（40%）在术后平均8年时接受人工关节置换术。人口统计学因素、坏死区位置、额外的手术操作、术前功能不佳并不会影响手术预后。保髋成功的患者与接受人工关节置换的患者在术后疼痛及功能上相似。保髋成功的患者更倾向于参加激烈的运动。 结论：大多数非塌陷期股骨头坏死患者在接受带血管腓骨移植后股骨头可存活10年以上，且疼痛轻微，功能满意。对于需要接受人工关节置换的患者，置换的时间平均为术后8年。我们将继续应用此技术治疗50岁以内有症状未塌陷的股骨头坏死患者。 The vascularized fibular graft in precollapse osteonecrosis: is long-term hip preservation possible? BACKGROUND: Osteonecrosis of the femoral head (ONFH) is a debilitating condition affecting primarily young patients. Free vascularizedfibular grafting (FVFG) may provide a durable means to preserve the femoral head. When used in the precollapse stages of ONFH, this treatment may alter the course of disease. QUESTIONS/PURPOSES: We asked: (1) In what percentage of patients does FVFG preserve the femoral head beyond 10 years? (2) When long-term preservation is not achieved, what is the duration of femoral head preservation? (3) Do demographic or etiologic factors predict FVFG survivorship? (4) What long-term improvements in function and activity can be anticipated? METHODS: We retrospectively reviewed 61 patients (65 hips) who underwent FVFG for precollapse ONFH. We calculated graft survivorship, SF-12 scores, activity levels, and Harris hip scores. Minimum followup was 10.5 years (mean, 14.4 years; range, 10.5-26 years). Results Forty-nine of 65 hips (75%) had surviving FVFG for at least 10 years. At last followup, 39 of 65 hips (60%) had surviving FVFG, with a mean graft survival time of 15 years (range, 10.5-26.1 years). Twenty-six of the 65 hips with FVFG (40%) underwent conversion to THA at a mean of 8 years postoperatively. Demographic factors, lesion size, additional procedures, and low preoperative function were not associated with changes in graft survivorship. Pain and function were similar in patients with surviving FVFG and patients who had conversion to THA. Patients with surviving FVFG were more likely to engage in impact sports or active events than were patients who had conversion to THA. CONCLUSIONS: When patients with precollapse ONFH undergo FVFG, the majority have preservation of the hip lasting for greater than 10 years with low levels of pain and reasonable function. In patients who ultimately undergo conversion surgery to THA, the mean duration of hip preservation before conversion is 8 years. We continue to use FVFG for treating patients younger than 50 years with symptomatic, precollapse ONFH. 文献出处：Eward WC, Rineer CA, Urbaniak JR, Richard MJ, Ruch DS. The vascularized fibular graft in precollapse osteonecrosis: is long-term hip preservation possible? Clin Orthop Relat Res. 2012 Oct;470(10):2819-26. doi: 10.1007/s11999-012-2429-x. Epub 2012 Jun 26. 文献2 症状性髋臼撞击征：偏距与软骨损伤关系的初步研究 译者：程徽 背景：股骨头颈偏距减少可见于股骨头骺滑脱残余畸形等疾病，目前常以α角作为评估手段，但α角仅测量了头颈部位的圆度，并没有涉及髋臼异常，因此不能完全代表畸形的严重程度及后果。β角（股骨头颈结合部与髋臼缘夹角）包括了髋臼及股骨侧的形态学异常，因此可能对于评估股骨头骺滑脱畸形更合适。 问题/目的：本研究旨在评估（1）MRI上是否可准确测量β角；（2）β角是否与软骨病变相关。 方法：招募10名成人症状性凸轮撞击征患者（平均年龄28年），另招募15名无症状志愿者（平均年龄24岁），行3-DMRI检查，包括延迟相钆增强（dGEMRIC）以显示软骨，测量相应α角、β角、以及髋臼软骨7个平面上的dGEMRIC指数（前-上-后） 结果：α角、β角测量的可重复性较高，髋臼前下方、上方软骨dGEMRIC指数与β角相关，与α角无关。 结论：髋关节放射状位MR上β角测量可重复性高，并与关节上方软骨损伤有关，可用来评估股骨头骺滑脱畸形，其作用还需进一步证实。 图1：以30°为间隔，从前方向上，再向后方依次对髋关节进行放射状多平面重建（MPR）：a =前方；a-s=前上；s-a=前下； s = 上方； s-p=上后； p-s = 后上； p = 后方，用来替代双侧髋关节钟表位标示。 图2A-B：放射状重建MRI图像上测量α角、β角。1名患者的髋上方测量（A），另一名患者的髋前方测量（B）。α角均为73°，但β角有显著差异。 图3A-B：双相回波稳态序列（DESS）（A），相应T1Gd像（B）分析髋臼软骨。 图4A-C：dGEMRIC指数（T1Gd）（A），α角（B），β角（C），示症状性凸轮撞击患者及对照组髋关节不同区域的平均值。研究组T1Gd值在各区域均低于对照组，表明有软骨退变（A），α角反映股骨偏距，其减少的典型部位在前方及上方（B），对照组β角为一直线，但凸轮撞击组前上方、上方区域出现尖峰，表明此部位存在撞击及软骨损伤。 图5A-B：α角（A）、β角（B）散点图，及与髋臼上方软骨dGEMRIC 指数的回归线、相关系数、P值。仅β角与dGEMRIC 指数线性相关（r = 0.671; p = 0.034），α角与dGEMRIC 指数不相关（r = 0.607; p = 0.063）。 Symptomatic Femoroacetabular Impingement: Does the Offset Decrease Correlate With Cartilage Damage? A Pilot Study Background Current measures of the reduced head-neck offset such as residual deformity of slipped capital femoral epiphysis (SCFE) including the alpha angle, which measures the femoral head-neck sphericity but does not account for acetabular abnormalities, do not represent the true magnitude of the deformity and the mechanical consequences. The beta angle (angle between the femoral head-neck junction and acetabular rim) accounts for the morphology of both the acetabulum and femur and, thus, may be the more appropriate parameter for assessing SCFE deformity. Questions/purposes We determined (1) whether the beta angle could be reliably measured on MRI; and (2) whether the beta angle correlates with the cartilage status. Methods We recruited 10 adult patients (mean age,28 years)with symptomatic camfemoroacetabular impingement and 15 asymptomatic volunteers (mean age, 24 years) to have three-dimensional MRI including delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) for cartilage status assessment. Corresponding alpha angles, beta angles, and acetabular dGEMRIC indices were obtained in seven radial reformats to assess the hip in seven regions (anterior to superior and posterior). Results We noted high reproducibility for both alpha and beta angle measurements. The dGEMRIC indices correlated with beta angles in the superoinferior and superior regions but not the alpha angles. Conclusions Beta angle measurement in radial MR images is reproducible and appears to correspond to cartilage damage in the superior regions of the hip. The beta angle may be a useful parameter to assess hip deformity in the followup of SCFE although further confirmation is warranted. 文献出处：Symptomatic femoroacetabular impingement: does the offset decrease correlate with cartilage damage? A pilot study.Zilkens C, Miese F, Krauspe R, Bittersohl B.Clin Orthop Relat Res. 2013 Jul;471(7):2173-82. doi: 10.1007/s11999-013-2812-2. 文献3 髋关节镜术后发生髂胫束综合征：一项之前没报道过的并发症 译者：肖凯 背景：由于髋关节手术并发症相对较低，因此被认为是一项比较安全的手术操作。尽管其它文献报道了髋关节镜术的一些严重并发症，但我们发现之前并无术后发生髂胫束综合征的报道。本研究的目的是通过分析162例接受髋关节镜的病例，发现并报道随访过程中发生髂胫束综合征的病例。 方法：回顾性分析了2007年9月至2011年6月间就诊的接受髋关节镜治疗的患者，共162例。所有病例为经保守治疗失败，有症状的股髋撞击症患者。筛选出术后随访过程中发生髂胫束综合征的患者。其诊断结合临床症状及查体，症状为髂胫束远端股骨髁处的疼痛。 结果：患者术后最短随访时间为2年，共有9例（5.5%）发生髂胫束综合征。所有的患者均在术后45天随访时被诊断髂胫束综合征。其中6例经过保守治疗症状缓解，另外3例接受进一步手术治疗。术后内旋活动增加、内收活动增加及局部滑囊炎是导致髂胫束综合征发生的因素。 结论：髂胫束综合征是髋关节镜术后一项新的并发症。本研究有助于帮助骨科医生制定患者术后康复计划，包括通过拉伸练习预防此并发症。 a 髂胫束侧面观 b 髋关节镜术后发生髂胫束综合征患者疼痛部位（星号标记处） Iliotibial band syndrome following hip arthroscopy: An unreported complication BACKGROUND: Hip arthroscopy is considered a safe procedure, considering the relatively low rate of complications. Despite several complications have been described following this surgical procedure, the present event has not yet been described. The purpose of the present study is to report an unpublished complication following hip arthroscopy, after reviewing 162 hip arthroscopies and finding iliotibial band syndrome (ITBS) in the knee during followup. MATERIALS AND METHODS: A retrospective review of 162 hip arthroscopies performed between September 2007 and June 2011 was carried out, evaluating patients who presented ITBS during followup. Indication for hip arthroscopy was failure of conservative treatment in patients with symptomatic femoroacetabular impingement. RESULTS: During a minimum followup of 2 years, nine patients (5.5%) developed ITBS. All patients were diagnosed with ITBS within the first 45 postoperative days. Conservative treatment was successful in 6 patients while 3 had to undergo surgery. The increased internal rotation, synovitis and increased adduction of the hip can be attributed as predisposing factors to the development of ITBS. CONCLUSIONS: This is a newly described observation within followup of hip arthroscopy. These findings may help orthopedic surgeons when planning rehabilitation after hip arthroscopy, including stretching exercises to prevent this syndrome. 文献出处：Seijas R, Sallent A, Galán M, Alvarez-Diaz P, Ares O, Cugat R. Iliotibial band syndrome following hip arthroscopy: An unreported complication. Indian J Orthop. 2016 Sep;50(5):486-491. 文献4 术中稳定性测试可作为DDH切开复位时是否需要进行截骨的辅助因素 译者：任宁涛 先天性髋关节发育不良（DDH）的患儿进行切开复位时，有时需进行骨盆或股骨截骨来维持同心复位的稳定。我们对82例DDH的患儿（共95例髋）采用前方入路切开复位，在术中进行稳定性测试来评估是否需要进行截骨，并对其术后临床和影像学疗效进行报道。患儿的平均手术年龄为28个月（9到79月），平均末次随访年龄为17岁（12到25岁）。我们对所有患者进行随访，直到其Y形软骨闭合。平均随访时间为15年（8到23年）。 在切开复位缝合关节囊之前，我们对最佳稳定性的位置进行了评估。如果髋关节需要屈曲外展获得稳定性，我们则认为其需要进行髋部截骨。如果髋关节需要内旋和外展才能获得稳定，我们则对其股骨近端去旋转内翻截骨。对于有假臼伴有前外侧缺损时，我们则采用Pemberton髋臼成形截骨。在中立位可维持稳定的髋关节则不需要进行截骨。 总体来说，86%的患儿术后获得满意的影像学疗效（Severin分组为Ⅰ和Ⅱ），7%的患儿由于残余发育不良需要再次手术，其中包括一例患儿发生再次脱位。在年龄小于2岁的患儿中疗效较好（P=0.04）。患侧肢体长度的增加与髋臼发育不良和关节发育不良复发有关（P=0.01）。术后股骨头发生缺血性坏死的发生率为7%。在18%的患儿中，我们发现在青少年生长高峰期中出现骨骺过早生长停滞现象（Kalamchi-MacEwen分类为Ⅱ和Ⅲ）。这些并发症也与关节发育不良的复发相关（P=0.01）。因此，随访时间较短的研究可能会降低差的影像学疗效患儿的比例。 图一：稳定性检查示意图。 图二： 7个月龄，女孩，双侧DDH。保守治疗失败后，于12个月龄时接受了双侧切开复位和股骨近端去旋转内翻截骨术，随访时获得了满意的影像学和临床疗效（Severin 1）。 图三： 22个月龄，女孩，单纯左侧DDH。在保守治疗失败后， 24个月龄时接受了双侧切开复位和股骨近端去旋转内翻截骨术。早期影像学检查未显示出缺血性坏死的明确证据。10岁时影像学检查发现外侧骨骺接近闭合和生长停滞。在骨骼成熟度方面，伴有中度的股骨颈畸形和髋外翻，其关节发育不良为Severin 2。
图四： 30个月龄，女孩，双侧DDH。我们采用双侧切开复位和髋部截骨同时股骨近端短缩截骨术。早期左髋影像学检查未显示出缺血性坏死的明确证据。在患儿11岁时左侧出现骨骺中央接近闭合并出现生长停滞表现，影像学检查表现为短髋畸形。其关节发育不良为Severin 2。
图五： 41个月龄，女孩，单纯左侧DDH。我们采用切开复位和股骨近端去旋转内翻截骨术。早期影像学检查未显示出缺血性坏死的明确证据。在患儿9岁时左侧出现骨骺外侧接近闭合并出现生长停滞表现。虽然影像学检查未显示关节半脱位表现，其髋膨大和髋外翻导致了复发性髋关节发育不良（CE角小于20°），其关节发育不良为Severin 3。
图六： 25个月龄，女孩，单侧DDH。我们采用切开复位和股骨近端去旋转内翻截骨术。早期影像学检查未出现缺血性坏死的明确证据。在患儿5岁时，其患肢比健侧长2cm。影像学检查显示髋外翻，伴有股骨前倾角增大，髋臼倾斜（长腿侧发育不良）。患儿7岁时接受了股骨近端去旋转内翻截骨术。后期患儿再次出现生长发育不良，其关节发育不良为Severin4。 Test of stability as an aid to decide the need for osteotomy in association with open reduction in developmental dysplasia of the hip After open reduction for developmental dysplasia of the hip (DDH), a pelvic or femoral osteotomy may be required to maintain a stable concentric reduction. We report the clinical and radiological outcome in 82 children (95 hips) with DDH treated by open reduction through an anterior approach in which a test of stability was used to assess the need for a concomitant osteotomy. The mean age at the time of surgery was 28 months (9 to 79) and at the latest follow-up, 17 years (12 to 25). All patients have been followed up until closure of the triradiate cartilage with a mean period of 15 years (8 to 23). At the time of open reduction before closure of the joint capsule, the position of maximum stability was assessed. A hip which required flexion with abduction for stability was considered to need an innominate osteotomy. If only internal rotation and abduction were required, an upper femoral derotational and varus osteotomy was carried out. For a ‘double-diameter’ acetabulum with anterolateral deficiency, a Pemberton-type osteotomy was used. A hip which was stable in the neutral position required no concomitant osteotomy. Overall, 86% of the patients have had a satisfactory radiological outcome (Severin groups I and II) with an incidence of 7% of secondary procedures for persistent dysplasia including one hip which redislocated. The results were better (p = 0.04) in children under the age of two years. Increased leg length on the affected side was associated with poor acetabular development and recurrence of joint dysplasia (p = 0.01). The incidence of postoperative avascular necrosis was 7%. In a further 18%, premature physeal arrest was noted during the adolescent growth spurt (Kalamchi-MacEwen types II and III). Both of these complications were also associated with recurrence of joint dysplasia (p = 0.01). Studies with a shorter follow-up are therefore likely to underestimate the proportion of poor radiological results. 文献出处：'Test of Stability as an Aid to Decide the Need for Osteotomy in Association with Open Reduction in Developmental Dysplasia of the Hip', H. G. Zadeh, A. Catterall, A. Hashemi-Nejad, and R. E. Perry, J Bone Joint Surg Br, 82 (2000), 17-27. 文献5 6月龄内婴幼儿超声检查异常髋关节的自然病史 译者：张利强 目的 收集和描述6个月以内婴儿超声异常（US）髋关节的自然史资料，为髋关节发育不良儿童的筛查方案和治疗方案的设计提供参考。 方法在PubMed中搜索“DDH”和“超声”两个词，找出髋关节超声异常且没有治疗的病例。某些患儿有多个随访期，则分别评估每个随访期内的graf分型。 结果收集并分析了13561例髋16991个随访期的资料。大多数可量化的分型和随访期是根据Graf分型（14876）进行的，少数髋关节（2115）的随访期使用股骨头覆盖分型（FHC）。6月龄内未经治疗而发育为正常髋关节的Graf 2a型在89%到98%之间，Graf 2c型在80%到100%之间，Graf 2a到2c的在80%到97%之间。据报道，对于Graf 3型的髋关节，超过50%的患者在未经治疗的情况下发展为正常髋关节。对于Graf 4型髋关节，该百分比报告低于50%。对于FHC小于50%的儿童，报告的正常化率在78%到100%之间。 结论髋关节发育不良（DDH）的自然病程是良好的，尤其是在良好复位的髋关节。这一结果可能说明以下事实：所有关于用髋关节超声筛查DDH来改善治疗结果的研究都被认为可信度不足。 The natural history of abnormal ultrasound findings in hips of infants under six months of age Purpose To collect and describe data on the natural history of abnormal ultrasound (US) findings in hips of infants under six months of age to serve as a reference to the design of screening programmes and treatment algorithms in the care for children with hip dysplasia. Methods A search in PubMed of the terms “DDH” and “ultrasound” was done to find hips with abnormal US findings that were not treated. In cases of multiple periods of follow-up, the classification of every period was evaluated separately (individual hip follow-up periods). Results Data of 13561 hips with 16991 follow-up periods were collected and analyzed. Most quantifiable classifications and follow-up periods were according to Graf (14876) and a minor number of the hips had follow-up periods with femoral head coverage (FHC) (2115). Normal development without treatment in the first six months was for Graf 2a between 89% and 98%, for Graf 2c between 80% and 100% and for clustered data Graf 2a to 2c between 80% and 97%. For Graf 3 hips more than 50% were reported to develop into normal hips without treatment. As for Graf 4 hips this percentage was reported below 50%. For children with an FHC less than 50%, normalization was reported between 78% and 100%. Conclusion The natural history of developmental dysplasia of the hip (DDH) shows a benign course, especially in the well-centered hips. This outcome probably contributes to the fact that all studies on US screening of hips for detection of relevant DDH in order to improve outcomes of treatment are rated as substantially underpowered. 文献出处：Cite this article: Sakkers R, Pollet V. The natural history of abnormal ultrasound findings in hips of infants under six months of age. J Child Orthop 2018;12:302-307. DOI 10.1302/1863- 2548.12.180056 文献6 股骨头骨骺滑脱术后股骨髋臼撞击的手术治疗 译者：陶可（北京大学人民医院骨关节科） 综述目的：继发于股骨头骨骺滑脱（SCFE）的股骨髋臼撞击症（FAI）可能导致髋关节退行性改变。我们已经回顾了目前文献中的诊治流程，旨在纠正SCFE以防止FAI和治疗FAI后产生的SCFE。最新发现：处理中度或重度SCFE的趋势是通过切开内固定术关节血肿减压纠正不稳定的髋关节移位以及Dunn改良法甚至适用于不稳定和稳定（髋关节移位）状况。然而，在FAI解决后，可供选择的往往是通过关节镜或髋关节外科脱位相关或不相关的转子下截骨而进行的骨软骨成形术。总结：股骨髋臼撞击可能发生在轻度滑脱和肯定会发生在中度及重度滑脱情况下。最初处理取决于滑脱的严重程度和稳定性。改良Dunn手术法是治疗不稳定SCFE好的选择。只要外科医生对改良的Dunn手术不满意时，就可以考虑采用关节囊切开成形术（Parsch）而行闭合复位。伴有开放性特点和稳定的中度或重度SCFE的髋关节是改良的Dunn手术适应症。闭合性特点的病例常采用股骨转子间截骨联合骨成形术。在继发于SCFE的症状性FAI存在的情况下，术者应考虑关节镜下骨成形术或髋关节外科脱位（行或不行截骨术）作为治疗选择。
图1. 患有慢性不稳定性股骨头骨骺滑脱急性发作的14岁男孩
图2. 采用改良的Dunn手术法对股骨头骨骺滑脱进行内固定术后两年
图3. 股骨髋臼撞击症后出现的股骨头骨骺滑脱行原位内固定
图4.术中关节镜观察：骨软骨成形术
图5.内固定未成功的股骨头骨骺滑脱所继发的股骨髋臼撞击
图7.股骨转子间截骨术和开放的骨软骨成形术后的侧位X线片 Surgical treatment of femoroacetabular impingement after slipped capital femoral epiphysis PURPOSE OF REVIEW:Femoroacetabular impingement (FAI) post slipped capital femoral epiphysis (SCFE) may lead to degenerative changes on the hip. We have reviewed the current procedures in the literature, aiming to correct the SCFE to prevent FAI and the ones that treat FAI post SCFE. RECENT FINDINGS: The trends of managing moderated or severe SCFE is to correct the displacement by reduction and fixation with articular hematoma decompression in unstable hips and Dunn modified procedure even for unstable and stable situations. However, after FAI is settled, the options are osteochondroplasty by arthroscopy or surgical hip dislocation, associated or not to subtrocanteric osteotomy. SUMMARY: Femoroacetabular impingement may occur in mild slips and certainly occur in cases of moderate and severe slips. The initial management depends on the severity and the stability of the slip.The modified Dunn procedure is a good option for the treatment of unstable SCFEs. Gentle closed reduction with capsulotomy (Parsch) may be considered whenever the surgeon is not comfortable with the modified Dunn procedure.Hips with open physis and stable moderate or severe SCFE, the modified Dunn procedure can be indicated. Cases with closed physis are managed with intertrochanteric osteotomy combined with osteoplasty.In the presence of symptomatic FAI secondary to SCFE, one should consider arthroscopic osteoplasty or surgical hip dislocation (with or without osteotomies) as treatment options. |
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