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本期目录： 1、在膝关节翻修手术中影响选择限制性假体的因素 2、膝关节术后麻醉和非麻醉状态下膝关节内外翻应力试验的比较 3、肿瘤型股骨近端置换假体用于非骨肿瘤患者髋关节翻修手术的疗效研究 4、屈髋位骨牵引后进行经皮克氏针固定治疗不稳定股骨头骺滑脱：11例患者的研究 5、评估髋臼方向的一种新放射学参数 6、髋关节发育不良的畸形严重程度是否会影像髋臼周围截骨术的预后？一项病例对照研究 7、采用Hansson钉固定股骨头骨骺滑脱不影响股骨颈持续生长 8、Tönnis骨盆三联截骨术治疗晚期残余髋臼发育不良：54例中长期随访研究 9、股骨头骨骺滑脱后的缺血性坏死：一种分阶段铰接式髋关节牵引的治疗流程：中期结果 第一部分：关节置换相关文献 文献1 在膝关节翻修手术中影响选择限制性假体的因素 译者：张轶超 目的 本研究的目的是评估在膝关节翻修手术中选择假体限制性的程度和确定什么使得我们决定选择限制性假体。 方法 我们回顾了274例膝关节翻修手术。平均术后随访7.2年。通过影像学资料测量了股骨胫骨角（FTA），关节线的高度（JLH）及Insall–Salvati指数（ISR）。评估的对我们选择使用限制性假体的因素范围包括年龄，性别，体重指数，初次术前诊断，翻修原因，安德森骨科中心分级（AORI）以及JLH和ISR的变化。 结果 分别有247膝(90.1%)用了后稳定型假体，11膝(4.0%)用了髁限制性假体，9膝(3.4%)用了旋转铰链膝。经过多变量分析发现，翻修的原因（松动，术后不稳）和JLH和ISR的变化是选择使用限制性假体的独立影响因素。 结论 本研究中有7.4%的病例选择了限制性假体完成了膝关节翻修手术。翻修的原因与JLH和ISR的变化影响了外科医生在做翻修手术时对于采用多大程度的限制性假体的选择。 图1 全膝置换术后垫片磨损导致的骨溶解和胫骨假体松动。采用了后稳定型假体做了翻修手术。胫骨侧的骨缺损使用了自体和异体骨植骨。 图2 全膝置换术后假体松动，股骨侧严重的骨缺损。使用了髁限制性假体做了TKA翻修手术。使用了同种异体股骨头做了股骨侧的结构植骨。 Factors affecting the choice of constrained prostheses when performing revision total kneearthroplasty PURPOSE: The purposes of the present study were to assess the levels of prosthetic constraint chosen during revision total kneearthroplasty (TKA) and to identify factors influencing the choice of a constrained prosthesis. METHODS: We retrospectively reviewed data on 274 revision TKAs. The mean follow-up period after revision TKA was 7.2 years. The femorotibial angle (FTA), joint line height (JLH), and Insall-Salvati ratio (ISR) were radiographically evaluated. Factors affecting the extent of constraint chosen were evaluated in terms of age, gender, body mass index, primary diagnosis, the cause of revision TKA, the Anderson Orthopedic Research Institute (AORI) classification, and changes in the JLH and ISR. RESULTS: Totals of 247 (90.1%), 11 (4.0%), and 9 (3.4%) knees received posteriorly stabilized prostheses, constrained condylar knees, and rotating hinge prostheses, respectively. On multivariate analysis, the cause of revision TKA including loosening and instability and the changes in the JLH and ISR affected independently the choice of a constrained prosthesis. CONCLUSIONS: The frequency of implantation of constrained prostheses was 7.4% in the present study. Consideration of various factorsincluding the cause of revision TKA and changes in the JLH and ISR will aid the TKA surgeon in selecting prostheses with appropriate constraints when performing revision TKAs. 文献出处：Park CH, Bae JK, Song SJ. Factors affecting the choice of constrained prostheses when performing revision total kneearthroplasty. Int Orthop. 2018 Oct 16. doi: 10.1007/s00264-018-4200-8. 文献2 膝关节术后麻醉和非麻醉状态下膝关节内外翻应力试验的比较 译者：马云青 介绍：采用回顾性研究表明软组织平衡与全膝关节置换术(TKA)后的长期的疗效相关。然而，大多数的此类研究只对在术后没有麻醉的情况下关节松弛程度进行评估。因此麻醉对膝关节松弛的影响是非常重要的，特别是对于手术时膝关节软组织平衡评估。本研究的目的是麻醉状态下对TKA后内翻、外翻应力试验的影响。 材料与方法：对26个连续接受分期双侧TKA的患者进行评估。全膝关节置换术后膝关节内翻、外翻松弛是在对侧TKA手术前几天测量的而且是在没有麻醉的状态下。TKA后立即测量对侧TKA 的松弛度，手术均在硬膜外麻醉下进行。 结果：内侧麻醉状态下的松弛程度由3° 显著增加到3.6°(p =0.005)，外侧松弛度从4.7°增加到5.7° (p = 0.007)。没有麻醉的情况下测量松弛程度时有6例(23%)患者松弛度较大，大于3°。 结论：麻醉对TKA术后的膝关节松弛度膝关节有明显影响。该研究的结果表明肌力可以给关节稳定性提供重要的保证。 Varus and valgus stress tests after total knee arthroplasty with and without anesthesia INTRODUCTION: Retrospective studies demonstrated inadequate soft tissue balance is associated with the long-term outcome of total knee arthroplasty (TKA). However, most of these studies have evaluated the joint laxity only postoperatively without anesthesia. Therefore information about the effect of anesthesia on knee laxity is important for soft tissue balancing at the time of surgery. This study was conducted to determine how anesthesia affects the varus and valgus stress tests after TKA. MATERIALS AND METHODS: A consecutive series of 26 patients undergoing staged bilateral TKA was evaluated. Varus and valgus laxity of the knee with the TKA implant was measured a few days before the contralateral TKA without anesthesia and again immediately after the contralateral TKA under spinal anesthesia. RESULTS: The laxity was significantly increased from 3.0° to 3.6° (p = 0.005) and from 4.7° to 5.7° (p = 0.007) in medial and lateral side, respectively, when the stress tests were performed under anesthesia in comparison to the laxity measured without anesthesia. The major change in laxity (≥3°) was measured in 6 (23%) patients tested without anesthesia. CONCLUSIONS: Anesthesia significantly influenced knee joint laxity after TKA. The findings of this study suggest that muscular forces impart a stabilizing force across the joint. 文献出处：Tsukeoka T, Tsuneizumi Y. Varus and valgus stress tests after total knee arthroplasty with and without anesthesia. Arch Orthop Trauma Surg. 2016 Mar;136(3):407-11. doi: 10.1007/s00402-015-2405-5. Epub 2016 Jan 7. 文献3 肿瘤型股骨近端置换假体用于非骨肿瘤患者髋关节翻修手术的疗效研究 译者：张蔷 目的：遇到股骨近端破坏严重的复杂髋翻修手术时，我们会不时的运用股骨近端置换假体(PFRs)解决严重骨缺损的问题。本篇文章的目的是为了探究将股骨近端置换假体用于非骨肿瘤患者的髋翻修手术时的临床疗效、并发症和长期生存率。 方法：本文章为回顾性研究，回顾了2004年至2013年间所有在我院接受应用单一股骨近端置换假体的复杂髋翻修手术病例。共40例（41髋），平均年龄64岁（29-90岁）。根据Paprosky骨缺损分型，15例为IIIB型，26例为IV型。平均随访5年（2-10年）。平均的重建长度为150mm。应用Kaplan-Meier曲线分析长期生存率。 应用PFR技术重建20cm长度近端股骨 结果：共有9例（22%）接受了再翻修手术，3例因为感染，2例因为脱位，2例因为无菌性松动，还有2例因为假体周围骨折。若以无菌性松动作为生存率终点的话，5年时的平均生存率为95.1%。我们发现：重建的长度以及初次翻修原因并不是再翻修假体失效的危险因素。 结论：将股骨近端置换假体用于非骨肿瘤患者伴有股骨侧严重骨缺损的复杂髋翻修手术可以获得良好的效果。在这些复杂髋翻修手术中，外展肌通常已受到严重破坏，应用限制性内衬可以降低这类患者的脱位风险。 Proximal femoral replacement in non-oncologic patients undergoing revision total hiparthroplasty PURPOSE: Proximal femoral replacements (PFRs) have been recently utilized in complex revision arthroplasties where proximal femoralbone is compromised. The purpose of this study is to evaluate the clinical outcomes, complications, and survivorship of PFRs as a salvage treatment for severe bone loss after non-oncologic revision total hip arthroplasty. METHODS: This is a retrospective review of all patients who underwent femoral revision surgery using a single design PFR between 2004 and 2013 at our institution. Forty patients (41 hips) were included with a mean age of 64 years (29-90). According to Paprosky classification, 15 femurs had type IIIB defect, and 26 had type IV defect. Patients were followed for a mean of five years (2-10). The average length of reconstruction was 150 mm (81-261). A Kaplan-Meier analysis was used to determine the survival of the PFR. RESULTS: A total of nine patients (9 PFRs, 22%) were re-operated upon. Three re-operations were for infection, two for dislocation, two for aseptic loosening, and two for periprosthetic fracture. The survivorship at five years was 95.1% for revision of the femoral stem for aseptic loosening. We did not find length of the segmental reconstruction or the indication for revision, to be a risk factor for implant failure or re-revision. CONCLUSIONS: Proximal femoral replacements have shown an acceptable survivorship in non-oncologic revision hip arthroplasties for severe proximal femoral bone loss. The frequent use of constrained liners may decrease the risk of dislocation due to the loss of the abductor mechanism encountered in these complex reconstructions. 文献出处：De Martino I, D'Apolito R, Nocon AA, Sculco TP, Sculco PK, Bostrom MP. Proximal femoral replacement in non-oncologic patients undergoing revision total hiparthroplasty. Int Orthop. 2018 Nov 10. doi: 10.1007/s00264-018-4220-4. 第二部分：保髋相关文献 文献1 屈髋位骨牵引后进行经皮克氏针固定治疗不稳定股骨头骺滑脱：11例患者的研究 译者：罗殿中 背景：不稳定股骨头骺滑脱（SCFE）发生股骨头坏死的风险较高。对于不稳定SCFE的标准治疗方案仍存在争议。我们对应用骨牵引后经皮克氏针固定治疗的不稳定SCFE患者进行回顾分析。 方法：对不稳定SCFE患者先进行至少一周的屈髋45°位骨牵引，然后在不刻意复位的情况下进行经皮克氏针固定。2003至2013年间共有11名患者于我中心进行治疗。通过分析病历及影像学资料，收集性别、年龄、BMI、是否有激素水平异常、发生滑脱至手术的时间、颈干角、后倾斜角、改良Harris评分。 结果：11名患者中有8名男性3名女性，平均年龄11.7岁，平均BMI24.5 kg/mm。所有患者无激素水平异常。发生滑脱至手术的时间8-16天不等。术前及术后平均颈干角为126°及141°。术后倾斜角平均30.7°，随访期间降至平均21.5°。1名患者发生轻度股骨头坏死（只能通过核磁发现），幸运的是不需要接受额外治疗。所有患者术后Harris评分满意，平均91分。 结论：屈髋位延长牵引有助于复位向后方滑脱的头骺，同时还可降低手术前关节囊内压力。虽然通过经皮克氏针固定会残留轻度畸形，但是随着生长发育还可能发生重新塑形。 A 术前影像学显示患者左侧股骨头骺重度滑脱，颈干角为104°；B、C 术后骨盆正位及水平侧位显示头骺复位，颈干角为146°，后倾斜角为33°；D、E 术后3.2年骨盆正位及水平侧位显示股骨头轮廓良好，无坏死表现 Percutaneous pinning after prolonged skeletal traction with the hip in a flexed position for unstable slipped capital femoral epiphysis: A case series of 11 patients BACKGROUND: Unstable slipped capital femoral epiphysis (SCFE) has a relatively high risk of avascular necrosis of the femoral head. Standard treatment for unstable SCFE is still controversial. We reviewed unstable SCFE case series treated with the standardized protocol, which consisted of percutaneous pinning after prolonged skeletal traction. METHODS: Our treatment regimen for unstable SCFE patients included 1 week or more of skeletal traction with the hip in a flexed position of 45 degrees, and subsequent percutaneous pinning after unintentional reduction. Eleven patients were treated in our institution and an affiliated hospital between 2003 and 2013. Sex, age at surgery, body mass index, the presence of hormonal abnormality, duration between onset and surgery, head shaft angle, posterior tilting angle, and modified Harris hip score were investigated from the medical records and radiographs. RESULTS: There were 8 male and 3 female with an average age of 11.7 years and an average body mass index of 24.5 kg/mm. No patients had hormonal abnormalities. The duration between onset and surgery ranged from 8 to 16 days. The average preoperative and postoperative head shaft angles were 126 and 141 degrees, respectively. Postoperative posterior tilting angle was averaged of 30.7 degrees, which decreased to 21.5 degrees during follow-up period. One patient showed mild avascular necrosis only confirmed by magnetic resonance imaging, but he was uneventfully treated without additional procedures. As a result, all patients had a perfect modified Harris hip score of 91 points. CONCLUSIONS: Prolonged traction with the hip in a flexed position may not only provide gradual reduction of posteriorly displaced epiphysis but also decrease intra-articular pressure before surgery. Although percutaneous pinning after unintentional reduction leaves mild displacement of the femoral epiphysis, remodeling could be expected during remaining growth period. 文献出处：Matsushita M, Mishima K, Iwata K, Hattori T, Ishiguro N, Kitoh H. Percutaneous pinning after prolonged skeletal traction with the hip in a flexed position for unstable slipped capital femoral epiphysis: A case series of 11 patients. Medicine (Baltimore). 2017 May;96(19):e6662. doi: 10.1097/MD.0000000000006662. 文献2 评估髋臼方向的一种新放射学参数 译者：程徽 背景：定性评估髋臼后倾的方法有多种，但仍缺少定量评估髋臼角度的方法，定量评估将有利于科研，也可能会用于临床协助诊断及治疗髋关节疾病。 问题/方法：本研究对髋臼方向采用一种新的定量指标（p/a 比），测量出平均p/a值，与髋臼后倾放射学征象对比，评估其与髋臼解剖方向的关系。 方法：在骨盆正位平片上，测量p（髋臼关节面至后壁的距离）、a（髋臼关节面至前壁的距离），计算p/a值， p、a均在根据泪滴低点至髋臼外侧缘连线的垂直平分线上。我们对185例怀疑股骨头坏死的患者进行了测量，并与髋臼后倾的定量指标进行对比。再使用62例无关节炎患者CT，测量其股骨头中部平面处的解剖前倾角，并与p/a比值对比。 结果：185例髋平均 p/a值为2.05，多数大于2.05的患者后倾指标阴性。解剖前倾角与p/a 比值具有相关性（r = 0.84）。 结论：骨盆正位平片评估髋臼方向时，p/a比值是简单可靠的定性指标。 图1A-B（A）p/a 比值由p（髋臼关节面至后壁的距离）除以a（髋臼关节面至前壁的距离）得出，p、a均在根据泪滴低点至髋臼外侧缘连线的垂直平分线上。（B）如上述垂直平分线与髋臼关节面交点在卵圆窝，则是关节面弧形延长线与上述垂直平分线交点作为p、a的近端参考点。 图2A-D（A）正常髋关节。（B）当髋臼前壁轮廓在髋臼后壁的外侧时，为COS阳性。（C）当髋臼后壁边缘在股骨头中心内侧时，PWS为阳性。（D）PRISS征关注坐骨棘是否突入骨盆内，突入则为髋臼后倾。 图3：Zed髋关节软件能重建3-D模型，并显示多平面重建（MPR）、数字X线片（DRR）影像，以替代普通平片。在3个垂直于TTP的横截面测量髋臼前倾角：中心前倾角（(AV), AV1, AV2），使用DRR，在TPP代表的冠状面上测量p/a比值。 图4：示后倾征分布率，后倾征阳性的髋关节p/a比值很少超过2.05（p＜0.001）（185例髋的平均值）。但对于p/a比值小于2.05的髋关节，其后倾征阳性及阴性混杂。 图5A-C：p/a比值与(A) 中心前倾角AV, (B)AV1, (C) AV2的关系。p/a比值与此3个前倾角值均相关（中心前倾角AV: r = 0.84, p＜0.001; AV1: r = 0.80, p＜0.001; AV2: r = 0.74, p ＜0.001）。回归分析显示p/a比值与中心前倾角AV存在以下关系：中心前倾角AV=9.6Xp/a –0.3°。 New Radiographic Index for Evaluating Acetabular Version Background Several qualitative radiographic signs have been describedto assess acetabular retroversion. However, quantitative assessment ofacetabular version would be useful for more rigorous research purposes andperhaps to diagnose and treat hip disorders. Questions/purposes We developed a new quantitative index for acetabularversion (p/a ratio). We determined the average p/a, compared it with previousradiographic signs for acetabular retroversion, and evaluated its relationship withanatomic acetabular version. MethodsWe calculated the p/a ratio bymeasuring p (distance from acetabular articular surface to posterior wall) anda (distance from acetabular articular surface to anterior wall) on plain hip AP radiographs and dividing p bya. P and a were assessed on the perpendicular bisector of the line between theteardrop and the lateral edge of the acetabulum. Using 185 hip radiographs frompatients with suspected idiopathic osteonecrosis, we measured p/a and comparedit with previous qualitative signs for acetabular retroversion. Using 62 hip CTimages from patients with no osteoarthritis, we measured the anatomicanteversion at the height of the central femoral head and investigated its relationshipwith p/a. ResultsThe average p/a was 2.05 in 185 hips,and most patients with a p/a greater than 2.05 had a negative qualitativeretroversion sign. A correlation was observed between central anteversion and p/a(r = 0.84). Conclusions We believe this ratio can be considered a simplequantitative parameter to assess acetabular version using plain AP radiographs. 文献出处：New radiographic index for evaluating acetabular version.Koyama H, Hoshino H, Suzuki D, Nishikino S, Matsuyama Y.ClinOrthop Relat Res. 2013 May;471(5):1632-8. doi: 10.1007/s11999-012-2760-2. 文献3 髋关节发育不良的畸形严重程度是否会影像髋臼周围截骨术的预后？一项病例对照研究 译者：肖凯 背景：影响髋臼周围截骨术（PAO）预后的每个因素都可能会对治疗方案的确定产生影响。 方法：本研究为前瞻性多中心研究，其中轻度畸形组共纳入接受PAO治疗的患者61例（其中51例为女性），患者臼顶倾斜角< 15°，外侧CE角> 15°。根据患者的年龄、性别、BMI、Tönnis骨关节炎分期、关节匹配度匹配对照组患者。对照组共183例，畸形相对较重。通过比较两组患者评分评估髋臼畸形严重程度是否影响PAO手术预后。同时比较两组患者手术中将畸形纠正到理想范围的比例差异。 结果：术后随访时间平均4±1.5年，两组患者手术并发症发生率及再手术率无明显差异（P=0.29）。轻度畸形组术前及术后Hip Disability and Osteoarthritis Outcome评分均比严重畸形组低（术前52 vs 59，术后73 vs 78），但两组相比术前改善的程度相仿。轻度畸形组患者中同时进行股骨侧骨软骨成形术的术后评分更低，其中Hip Disability and Osteoarthritis Outcome评分平均48±18分。轻度畸形组术中更容易将畸形纠正到理想位置（80% vs 59%, P =0 .4）。 结论：PAO是一种安全有效治疗髋关节发育不良的措施。未来需要进一步探讨治疗髋关节发育不良合并股骨Cam畸形的最佳手术方式。 Does Severity of Acetabular Dysplasia Influence Clinical Outcomes After PeriacetabularOsteotomy?-A Case-Control Study BACKGROUND: Detailed characterization of factors influencing post-periacetabular osteotomy (PAO) outcome could guide treatment offered. METHODS: Using a prospective, multicenter database of PAOs, 61 hips/patients (51 females) with lesser dysplasia (acetabular index < 15° and lateral center-edge angle > 15°) were case-control matched for age, gender, body mass index, Tönnis grade, and joint congruency (P = .6-.9) with a 'comparison group' of pronounced dysplasia (n = 183), aiming to assess whether severity of acetabular dysplasia has an effect on outcome following PAO and/or the ability to achieve desired acetabular correction. RESULTS:At 4 ± 1.5 years, no differences in complication or reoperation rates were detected between the groups (P = .29). Lesser dysplastic hips had inferior Hip Disability and Osteoarthritis Outcome Score, both preoperatively (52 vs 59) and postoperatively (73 vs 78); however, similar improvements were seen. Among the lesser dysplastic hips, those that required a femoral osteochondroplasty at PAO had significantly inferior preoperative Hip Disability and Osteoarthritis Outcome Score (48 ± 18). Increased ability to achieve optimum correction was seen (80% vs 59%, P = .4) in lesser dysplasia. CONCLUSION: A PAO is safe and efficacious in the treatment of lesser dysplasia. Further study on the identification of the optimum treatment modality for the mildly dysplastic hips with cam deformity is required. 文献出处：Grammatopoulos G, Beaulé PE, Pascual-Garrido C, Nepple JJ; ANCHOR Group, Clohisy JC. Does Severity of Acetabular Dysplasia Influence Clinical Outcomes After PeriacetabularOsteotomy?-A Case-Control Study. J Arthroplasty. 2018 Jul;33(7S):S66-S70. doi: 10.1016/j.arth.2018.03.028. Epub 2018 Mar 17. 文献4 采用Hansson钉固定股骨头骨骺滑脱不影响股骨颈持续生长 译者：任宁涛 背景：对于股骨头骨骺滑脱（SCFE）的最佳治疗方式，目前仍然存在争议。在瑞典，标准的治疗方法是采用无螺纹钉通过骺板进行固定，从而不影响股骨颈继续生长。本研究的目的是验证和量化在使用Hansson钉进行原位固定后，股骨颈纵向生长情况。 方法：我们回顾性研究了从2001年至2009年采用Hansson钉治疗SCFE的患者共54例。对患者术后即刻和骨骺闭合后（平均间期34个月）的影像学检查进行了分析。由于无螺纹的Hansson钉只能通过握持力对骨骺进行固定，所以我们只能通过前后两次影像学检查中，钉从侧方皮质突出的差异来判断股骨颈的生长情况。同时，我们在影像学图像中测量股骨颈偏心距。 结果：在骨骺滑脱侧和接受预防性治疗的对侧髋关节，均可以看到显著的纵向生长，平均分别为7.1mm（P<0.001）和10.0mm（P<0.001）。不同性别的患者在生长方面无明显差异，纵向生长的程度与骨骺滑脱的严重性（范围，4.0至71.6度，平均27.3度）无相关关系。年轻患者（小于11岁）的生长程度大于年长患者（大于14岁），分别为12.1mm和4.2mm（P=0.002）。股骨偏心距平均增加了16%，平均从30.0增加到35.2mm（P<0.001）。股骨颈纵向生长程度与股骨偏心距的增加相关（R=0.51，P<0.001）。 结论：采用无螺纹Hansson钉固定治疗SCFE不影响股骨颈持续生长。术后股骨颈的继续生长可使患者获得接近正常解剖的髋关节偏心距。这些对于患者获得良好的外展力量，从而在行走中使骨盆保持稳定非常重要。将来需要更深入的研究，探索纵向生长能否改善股骨近端的重塑。
图一：A，一名13岁男性患儿出现左髋关节轻度滑脱（22度），我们采用Hansson钉在原位进行固定，此图为术后影像学检查（前后位）。我们同样对其右侧进行了预防性治疗。B，在术后33个月，也就是患儿16岁时骨骺闭合，我们对其进行随访影像学检查。其螺钉的突出部分分别减少了15mm和18mm。
图二：我们采用以下方式对股骨偏心距（FO）进行测量。其为股骨头旋转中心到股骨干中轴的距离，我们通过近端股骨两个水平对股骨干中轴进行定位。
图三：从旋转差异来计算测量误差的公式。从患者的病历中我们可以得知钉子的长度。
图四：滑脱侧髋关节与对侧髋关节股骨颈生长数据，配对值。
图五：男性与女性患儿当中，股骨颈生长与手术时年龄的关系。
图六：A，一名12岁女性患儿出现右髋关节中度滑脱（30度），我们采用Hansson钉在原位进行固定，此图为术后影像学检查（前后位）。我们同样对其左侧进行了预防性治疗。B，同一患者术后影像学检查（蛙式位）。由于滑脱的方向偏前，钉子置入滑脱髋关节的方向更加偏前。 Unthreaded Fixation of Slipped Capital Femoral Epiphysis Leads toContinued Growth of the Femoral Neck Background: The optimaltreatment for slipped capital femoral epiphysis (SCFE) remains controversial.In Sweden, the standard treatment is unthreaded fixation over the physis, withthe purpose to permit continued growth of the femoral neck. The aim of thepresent study was to verify and quantify longitudinal growth of the femoralneck after in situ pinning with the Hansson hook-pin. Methods: We performed aretrospective study of 54 patients treated with the Hansson hook-pin for SCFEbetween 2001 and 2009. The immediate postoperative radiograph and theradiograph after physeal closure (mean interval, 34 mo) were analyzed. Becausethe smooth Hansson hook-pin only has a grip fixation in the epiphysis, the femoralneck growth was determined as the difference in nail protrusion from thelateral cortex between the 2 radiographs. The femoral neck offset was alsomeasured in all radiographs. Results: Significantlongitudinal growth occurred both in the slipped and the prophylacticallytreated contralateral hip by mean 7.1mm (P<0.001) and 10.0mm (P<0.001),respectively. There was no difference in growth between genders and nocorrelation between the amount of longitudinal growth and slip severity (range,4.0 to 71,6 degrees; mean 27.3 degrees). Young patients (less than 11 y) grewmore than older patients (more than 14 y), 12.1 vs. 4.2 mm, P=0.002. Thefemoral offset increased by mean 16% from mean 30.0 to 35.2mm (P<0.001). Thelongitudinal growth of the femoral neck correlated with the increase in femoraloffset (R=0.51, P<0.001). Conclusions: Unthreadedfixation of SCFE with the Hansson hook-pin allows continued growth of thefemoral neck. The remaining growth enables the patient to achieve an almost anatomicoffset of the hip. This is essential to optimize the abduction forces thatstabilize the pelvis during gait. Future studies need to establish whether thelongitudinal growth also results in improved remodelling of the proximal femur. 文献出处： 'UnthreadedFixation of Slipped Capital Femoral Epiphysis Leads to Continued Growth of theFemoral Neck', J. Ortegren, L. Bjorklund-Sand, M. Engbom, C. Siversson, and C.J. Tiderius, J Pediatr Orthop (2015). 文献5 Tönnis骨盆三联截骨术治疗晚期残余髋臼发育不良：54例中长期随访研究 译者：张利强 作者回顾了54例（58髋）发育性髋关节脱位（DDH）伴髋臼发育不良的患者，这些患者都行Tönnis骨盆三联截骨术治疗。本研究的目的是报告该术式的临床和影像学的长期随访结果，患者平均随访12年（7至20年）。初始诊断时，所有患者都有髋部疼痛，Wiberg角小于20°，没有骨关节炎的影像学表现。结果显示，根据Harris评分， 82.7%随访患者的手术髋关节显示出优良或良好的效果，Wiberg角平均为34°（从26°到45°）。其中共出现五例并发症：一例髋臼旋转不良和四例无症状坐骨骨不连。总之，虽然目前认为Bernese髋臼周围截骨术是外科治疗DDH残留髋臼发育不良的金标准，但是Tönnis骨盆三联截骨术仍是一个很好的治疗选择：它技术上简单，可直视的三联截骨，较少的并发症和较短的学习曲线。此外术前无骨关节炎的影像学表现和髋臼与股骨的良好匹配是手术成功的基本要求。
16岁女孩双侧髋臼发育不良的X线片，没有任何骨关节炎征象。Wiberg角右侧为15°，左侧为17°(a)。双髋行Tonnis骨盆三联截骨术治疗。随访17年后，双侧Wiberg角改善，右侧45°和左侧37°，无髋关节骨关节炎的征象(b)。
14岁男孩双侧髋臼发育不良的X片，左侧有症状，无骨关节炎的征象。Wiberg角右侧22°，左侧为10°，左侧颈干角160°(a)。左髋行Tonnis骨盆三联截骨加股骨近端截骨术（b）。随访9年后，Wiberg角改善到36°，没有任何骨关节炎征象（c）。 Tönnis triple pelvic osteotomy for the management of late residual acetabular dysplasia: mid-term to long-term follow-up study of 54 patients The authors reviewed 54 (58 hips) patients with acetabular dysplasia following developmental dislocation of the hip (DDH), treated by triple pelvic osteotomy according to the Tönnis technique. The aim of our study was to report the long-term clinical and radiographic results of the operation at a mean follow-up of 12 years (from 7 to 20). At diagnosis, all the hips were painful, the Wiberg angle measured less than 20°, and no radiographic signs of osteoarthritis were present. At follow-up, 82.7% of the operated hips showed either excellent or good results, according to Harris, and the Wiberg angle measured an average of 34° (from 26° to 45°). We encountered five complications: one acetabular malrotation and four asymptomatic ischial nonunions. In conclusion, we believe that, although Bernese periacetabular osteotomy is nowadays considered the gold standard for the surgical treatment of the dysplastic hip following DDH, Tönnis osteotomy represents a good treatment option: it is technically easy, enables direct visualization of the three osteotomies, leads to few complications, and its learning curve is short. The absence of radiographic signs of osteoarthritis and hip congruency before surgery are the basic requirements to achieve a successful result. 文献出处：Pasquale Farsetti, Roberto Caterini, Fernando De Maio, Vito Potenza, Kristian Efremov and Ernesto Ippolito . Tönnis triple pelvic osteotomy for the management of late residual acetabular dysplasia: mid-term to long-term follow-up study of 54 patients. Journal of Pediatric Orthopaedics B 2018, 00:000–000 文献6 股骨头骨骺滑脱后的缺血性坏死：一种分阶段铰接式髋关节牵引的治疗流程：中期结果 译者：陶可（北京大学人民医院骨关节科） 背景：股骨头骨骺滑脱（SCFE）引起的股骨头缺血性坏死（AVN）的治疗是困难的。我们设想以确定分期髋关节牵引是否可以防止塌陷并恢复股骨头的正常结构。方法：对髋关节数据库进行回顾性研究检索了16名患有不稳定SCFE和AVN的儿童。所有患者均通过外科脱位进行股骨头重组，然后进行第二阶段的铰链式髋关节牵引。将患者人口学信息以及髋关节畸形、AVN和关节炎放射学等参数进行了收集和统计分析；此外，患者在干预前后和随访时的改良的Harris髋关节评分和非关节炎髋关节评分被用于评价髋关节功能。结果：本研究由7名男孩和9名女孩组成（n = 16）。手术时的平均年龄为12.7岁（9 - 16岁），共8个右髋和8个左髋。平均随访时间为45个月（33 - 66个月）。A组（n = 7）只有在随访X线片显示AVN变化和塌陷时才会进行髋关节牵引。根据A组的观察结果，B组（n = 9）改变了方案，为：在股骨头重新调整6周时进行髋关节牵引，以获得股骨头的无血管性。在A组中，所有患者在随访时均有进一步塌陷和晚期关节炎；B组所有患者均恢复髋关节间隙、髋关节功能良好且随访时无疼痛。结论：对于已经证实缺乏股骨头血流的儿童，早期应用髋关节牵引器是阻碍AVN进展和帮助恢复髋关节功能的一项潜在选择。
图1. 术前灌注MRI显示无血管股骨头骨骺滑脱。
图2.同一患者的术后股骨头重组MRI显示，灌注MRI中缺乏血管，尽管存在金属伪影。
图3. 上图显示用于夜间锁定髋部牵引力器的夜间栏（TSF支柱）。
图4. （a）一名11岁男孩的急性严重SCFE和（b）通过股骨头方向调整进行管理，术中没有出现头部出血。
图5. （a, b）AVN塌陷后重新进行方向调整，（c）髋关节间的铰接式牵引，（d）7个月时移除外牵引架发现股骨头进一步塌陷，（e）使用Ilizarov环架固定骨盆部分切除支撑截骨术进行抢救性治疗。
图6. （a）一名10岁女孩严重骨骺滑脱术前的AP放射学照片和（b）原位钉固定后未见血流。
图7.（a）AVN股骨头方向重新调整后，（b）股骨头塌陷前的铰链式髋关节牵引，（c）移除外固定架12个月，（d）术后第3年随访，关节一致性良好。Avascular necrosis post unstable slipped capitalfemoral epiphysis: a treatment algorithm with staged hinged hip distraction:mid-term resultsBACKGROUND: Management of avascularnecrosis (AVN) of the femoral headin slipped capital femoral epiphysis (SCFE) isdifficult. We proposed to ascertainif staged hip distraction could prevent collapse andrecover the femoral head. METHODS:Aretrospective review of the hip database retrieved 16 childrenwith unstable SCFE and AVN. All underwent capital realignmentby surgical dislocation followed by 2nd-stage hinged hip distraction.Patient demographics and radiographic parameters of deformity, AVN andarthritis were collected. The patients scored their hip function bothbefore and after intervention and at follow-up using the modified Harris Hip Scoreand Nonarthritic Hip score. RESULTS:7 boys and9 girls formed the study group ( n = 16). The average age at surgery was 12.7years (9-16years). 8rights hips and 8 left hips were involved. The average follow-up was 45months(33-66months).Group A ( n = 7) had hip distraction onlyif the follow-up radiographs showed AVN changes and collapse. Based on theobservations in Group A, the protocol was changed for Group B. Group B ( n = 9)underwent hip distraction at 6 weeks of capital realignment for avascularity of the femoral head. In Group A, all patients had further collapse and advanced arthritis atfollow-up. In Group B all patients had hip jointspace restored and good hip function without pain at follow-up. CONCLUSIONS: Pre-emptiveapplication of hip distractor for those children with proven lack ofblood flow to the femoral head is a potential option to stall theprogression of AVN and to help recover useful hip function. 文献出处： Balakumar B, Madan S.Avascular necrosis post unstable slipped capital femoral epiphysis: a treatmentalgorithm with staged hinged hip distraction: mid-term results. Hip Int. 2018Nov 20:1120700018811313. doi: 10.1177/1120700018811313. |
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