髋膝文献精译荟萃（第69期）

本期目录：

1、全膝置换翻修术骨长上干骺端袖套中的分布情况：一项取出物分析报告

2、全髋关节置换术中应用生物型短柄和传统柄的长期对比研究

3、关节置换术后的髋关节囊生物力学：假体、入路和手术修复的影响

4、透析相关淀粉样变性引起的持续性发热和破坏性关节炎：病例报告

5、立体摄像增强现实导航系统应用于颌面矫形外科的精度

6、非髋关节发育不良人群盂唇肥大的患病率及临床意义

7、LCPD：分型和预后因素

8、臀中肌的血流—一项动物实验

9、不稳定股骨头骨骺滑脱的关节囊切开术及AVN的几率：回顾性研究的Meta分析

第一部分：关节置换及保膝相关文献

文献1

全膝置换翻修术骨长上干骺端袖套中的分布情况：

一项取出物分析报告

译者：张轶超

背景：干骺端骨被认为对翻修后关节稳定性起到重要作用。多孔钛合金干骺端袖套多被用于全膝置换术后翻修手术中骨缺损的重建，可以增加生物固定强度，临床效果令人鼓舞。对于干骺端袖套达到生物固定稳定的范围的研究还很少。我们观察了取出的干骺端袖套标本上骨长上的情况。

材料和方法：我们研究了从16名置换患者取出的干骺端袖套，胫骨侧14件，股骨侧11件。我们复习了翻修前的片子，确定袖套生物固定和假体柄孔的填充率。骨长上情况按取出袖套的前、后和内、外部位来进行定位。

结果：胫骨袖套多孔表面的骨长上覆盖率平均为14.7±3.4%。胫骨袖套骨长上多位于外侧和前侧(P<0.05)。股骨侧袖套多孔表面的骨长上覆盖率平均为21.3±2.6%。股骨袖套上骨长上分布部位没有差别。临床效果，年龄，放射学因素和骨长上的形态或数量间不存在明显的相关性。

讨论：本研究证明只需要有限的骨长上量（胫骨袖套14.7%，股骨袖套21.3%）就可以达到满意的固定效果。

Distribution of Bone Ongrowth in Metaphyseal Sleeves for Revision Total Knee Arthroplasty:A Retrieval Analysis

BACKGROUND: The metaphyseal region of the bone has been recognized by its importance to the overall stability of a revision construct. Porous titanium metaphyseal sleeves toenhance biologic fixation can be used to manage bone loss encountered during revision total knee arthroplasty. While clinical resultsfor metaphyseal sleeves are encouraging, there is little information on the extent to which biologic fixation is achievable with metaphyseal sleeves.We examined retrieved metaphyseal sleeves to determine theamount of bone ongrowth.

MATERIALS AND METHODS: We studied 14 tibial and 11 femoral retrieved metaphyseal sleeves from16 typical arthroplasty patients. Prerevision radiographs werereviewed for the presence of biologic fixation to the sleeves and thestem canal fill ratio. Bone ongrowth was assessed regionally inthe anterior, posterior, medial, and lateral areas of the retrieved implants.

RESULTS: Bone ongrowth covered on average 14.7 ± 3.4% of the entire porous surface of the tibial sleeves.The lateral and anterior surfaces had a significantly greater proportion (P< .05) of bone ongrowth compared with the posterior andmedial surfaces of the tibial components. Bone ongrowth coveredon average 21.3 ± 2.6% of the entire porous surface of the femoral sleeves.No differences were found in the proportion of bone ongrowth amongthe posterior, medial, lateral, and anterior surfaces of the femoral. Nosignificant association was found between the clinical, demographic, or radiographic factors and the pattern or quantity of bone ongrowth.

DISCUSSION: This study demonstrates that sufficient fixation can be achieved with only limited amountsof bone ongrowth (14.7% in tibial sleeves and 21.3% infemoral sleeves).

文献出处：Ihekweazu UN, WeitzlerL, Wright TM, Padgett DE. Distribution of Bone Ongrowth in Metaphyseal Sleeves for Revision Total Knee Arthroplasty: A Retrieval Analysis. J Arthroplasty.2019 Apr;34(4):760-765. doi: 10.1016/j.arth.2018.12.033. Epub 2019 Jan 7.

文献2

全髋关节置换术中应用生物型短柄和

传统柄的长期对比研究

译者：马云青

背景:全髋关节置换术(THA)中应用生物型短柄越来越受到欢迎，短柄既允许微创切口，也尽可能的保留了宿主骨量。然而，并没有长期的相关研究和常规使用的建议还。本研究的目的是比较短柄与传统柄的生存率和翻修原因。本研究是基于注册登记系统的患者的研究。

方法: 探讨生物型髋关节假体(RIPO)的登记应用情况，自2000年至2016年。股骨柄分为短柄(<12厘米)和常规柄。然后，根据Feyen和Shimmin的分类：短柄保留股骨颈截骨(A组1684髋)、短柄标准截骨(B组2727髋)、常规截骨(C组57359例)。对人口统计学资料、假体生存率和翻修的原因进行分析和比较。

结果:年轻患者和正常股骨解剖结构的患者均优先植入短柄。传统柄在长期随访中显示出相似的存活率(15年的>90%)。3组间无菌性松动、术中骨折、假体周围骨折发生率相似。B组由于原发性不稳定(早期脱位和撞击事件；P < . 05)导致的翻修增加，但因疼痛引起的翻修率无显著性升高。

结论:在长期随访中，短柄是可靠的股骨假体选择。与常规柄比较没有出现早期无菌性松动和术中及假体周围骨折的额外风险。然而，由于疼痛和原发不稳定而导致的高翻修率应在临床研究中需要进一步研究。

Short Stems Versus Conventional Stems in cementless total Hip Arthroplasty: A Long-Term Registry Study

BACKGROUND: Short stems in total hip arthroplasty (THA) have recently gained increasing popularity, allowing mini-invasive exposures andbone-sparing approaches. However, long-term studies and recommendations for theroutine use are not available. The aim of this report was to compare thesurvival rates and the reasons for revision of short stems versus conventional stems in cementless THAs, in a registry-based population.

METHODS: The Registry of Prosthetic Orthopedic Implants (RIPO)was inquired about cementless THAs performed since 2000 to 2016. The stems weredivided into short (<12 cm) and conventional ones, and then, classifiedaccording to the classification by Feyen and Shimmin: short stems withneck-retaining osteotomy (group A: 1684 hips), short stems with standardosteotomy (group B: 2727 THAs), and conventional stems (group C: 57,359 cases). Demographics, survivorships, and reasons for revision were investigated andcompared.

RESULTS: Short stems were preferentially implanted in younger patients and normal morphologies. Short and conventional stems showed comparable survival rates at long-term follow-up (>90% at 15 years). Therates of stem aseptic loosening, intraoperative fractures, and periprosthetic fractures were similar in the 3 groups. Group B had higher rates of revisionsdue to primary instability (early dislocations and impingement-related events;P < .05). Revisions due to pain were nonsignificantly higher in group B.

CONCLUSION: Short stems are reliable implants at long-termfollow-up. The comparison with conventional stems showed no additional risk ofpremature aseptic loosening and intraoperative and periprosthetic fractures.However, the high rate of revisions due to pain and, mostly, primary instability should be investigated in clinical trials.

文献出处：Giardina F, Castagnini F, Stea S, Bordini B, MontaltiM, Toni A1. Short Stems Versus Conventional Stems in Cementless Total hip arthroplasty: A Long-Term Registry Study. J Arthroplasty. 2018Jun;33(6):1794-1799. doi: 10.1016/j.arth.2018.01.005. Epub 2018 Jan 11.

文献3

关节置换术后的髋关节囊生物力学：

假体、入路和手术修复的影响

译者：张蔷

目的：髋关节囊通过对股骨头/颈部的包绕以达到被动限制关节极度活动的作用。我们通过试验来验证髋关节表面重建（HRA）、双动全髋关节置换（DM-THA）、传统全髋关节置换（THA）和手术入路对关节囊功能的影响。

方法：共有八具尸髋入组，去除肌肉并留下关节囊。分别在表面重建、双动全髋置换和传统全髋置换前后测量尸髋的内外旋活动度，右髋行后入路手术，左髋行前入路手术。

结果：与原始髋相比，髋关节表面重建后的内/外旋活动度提高了5度至17度（大约为9%-33%）；双动全髋置换提高了9度至61度（大约为18%-121%）；而传统全髋置换提高了52度至100度（大约为94%-199%）。因此，对传统全髋置换来讲，髋关节囊对活动度的限制作用基本消失，行双动全髋置换可以部分恢复限制作用，而行表面重建可以接近完全恢复。在低度屈/伸位时，后入路相比前入路髋关节功能更佳，可能是因为修复后方关节囊后，关节囊短缩引起的。而在高屈曲体位下，前入路髋关节功能更佳。

结论：关节置换术中选用接近原始股骨头大小的假体和关节囊修补可以保留更多的关节囊功能。前入路和后入路对术后关节囊的生物力学影响各不相同。

Hip capsule biomechanics after arthroplasty: The effect of implant, approach, and surgical repair

Aims: The hip’s capsular ligaments passively restrain extreme range of movement (ROM) by wrapping around the native femoral head/neck. We determined the effect of hip resurfacing arthroplasty (HRA), dual-mobility total hip arthroplasty (DM-THA), conventional, and surgical approach on ligament function.

Materials and Methods:Eight paired cadaveric hip joints were skeletonized but retained the hipcapsule. Capsular ROM restraint during controlled internal rotation (IR) andexternal rotation (ER) was measured before and after HRA, DM-THA, and conventional THA, with a posterior (right hips) and anterior capsulotomy (lefthips).

Results: Hip resurfacing provides a near-native ROM with between 5° to 17° increase in IR/ER ROM compared with the native hip for thedifferent positions tested, which was a 9% to 33% increase. DM-THA generated a9° to 61° (18% to 121%)increase in ROM. Conventional THA generated a 52° to100° (94% to 199%) increase in ROM. Thus, forconventional THA, the capsule function that exerts a limit on ROM is lost. Itis restored to some extent by DM-THA, and almost fully restored by hipresurfacing. In positions of low flexion/extension, the posterior capsulotomyprovided more normal function than the anterior, possibly because the capsulewas shortened during posterior repair. However, in deep flexion positions, theanterior capsulotomy functioned better.

Conclusion: Native head-size andcapsular repair preserves capsular function after arthroplasty. The anteriorand posterior approach differentially affect postoperative biomechanical function of the capsular ligaments.

文献出处：K. Logishetty, R. J. van Arkel, K. C. G. Ng, S. K. Muirhead-Allwood, J. P. Cobb, J. R. T. Jeffers. Hipcapsule biomechanics after arthroplasty: The effect of implant, approach, andsurgical repair. Cite this article: Bone Joint J 2019;101-B:426–434.

第二部分：保髋相关文献

文献1

透析相关淀粉样变性引起的持续性发热和

破坏性关节炎：病例报告

译者：罗殿中

介绍：与透析相关的淀粉样变性（DRA）常发生于长期血液透析患者，临床表现与风湿病类似。DRA的典型关节症状包括腕管综合征、大关节积液、脊柱关节病、骨囊性变，这些病变通常伴有非炎症过程。

患者情况：一名64岁男性男性患者，既往接受血液透析治疗超过30年，因间歇性发热、多发关节炎和血清C-反应蛋白（CRP）水平升高持续2年而引起我们关注。入院前3个月应用几种抗生素治疗无效。在体格检查中，在双侧腕关节、膝关节、踝关节和髋关节均观察到肿胀。实验室检测显示血清炎症标志物和β2-微球蛋白（β2-MG）升高。关节滑液显示中性粒细胞浸润和β2-MG水平的增加。

诊断：在来自滑膜、皮肤和回肠的活检样品中发现了β2-MG沉积与炎性细胞浸润。

干预：我们决定改用含有能有效吸收循环中β2-MG的血液透析设备。

结果：通过改变透析设备，患者症状缓解和CRP水平减低，最终诊断DRA。

经验教训：我们的病例表明，DRA关节病可能具有炎症性和破坏性，并且还会出现全身性炎症体征和症状。在这种情况下，积极吸收循环中的β2-MG可能有助于改善症状。

（A）右肩CT显示低密度软组织包裹了病变的肩部（箭头）。（B）右膝的T2相MRI显示低信号区域（粗箭头）淀粉样沉积物和高信号区域（细箭头）液体聚集。（C）18F-FDG正电子发射计算机断层扫描的图像显示大关节中的FDG摄取（箭头）

Persistent fever and destructive arthritis caused by dialysis-related amyloidosis: A case report

RATIONALE: Dialysis-related amyloidosis (DRA) can present rheumatic manifestations in patients on long-term hemodialysis. Typical articular symptoms with DRA involve carpal-tunnel syndrome, effusion in large joints, spondyloarthropathy, or cystic bone lesions, which are usually with non-inflammatory processes.

PATIENT CONCERNS: A 64-year-old man on hemodialysis for >30 years wasadmitted because of intermittent fever, polyarthritis, and elevated serumC-reactive protein (CRP) level, which was continuous for 2 years. Several antibiotics were ineffective for 3 months before his admission. On physical examination, joint swelling was observed at bilateral wrists, knees, ankles,and hip joints. Laboratory tests revealed elevation of serum inflammatory markers and β2-microglobulin (β2-MG). Synovial fluid showed predominant infiltration of polymorphonuclear leukocytes and the increase of β2-MG level.

DIAGNOSIS: Significant deposition of β2-MG with inflammatory cellinfiltration was found in biopsied samples from synovium, skin, and ileum.

INTERVENTIONS: We decided to switch to the hemodialysis column withmembrane that can effectively absorb β2-MG in circulation.

OUTCOMES: The relief of symptoms and a decrease of CRP level bychanging the membrane lead to the final diagnosis of DRA.

LESSONS: Our case demonstrates that DRA arthropathy can be inflammatory and destructive, and also develop systemic inflammatory signs and symptoms. In such cases, aggressive absorption of β2-MG in circulation mighthelp the amelioration of symptoms.

文献出处：Matsumoto K, Kikuchi J, Kaneko Y, Yasuoka H, Suzuki K,Tokuyama H, Kameyama K, Yamaoka K, Takeuchi T. Persistent fever and destructivearthritis caused by dialysis-related amyloidosis: A case report. Medicine(Baltimore). 2018 Jan;97(1):e9359. doi: 10.1097/MD.0000000000009359.

文献2

立体摄像增强现实导航系统应用于颌面矫形外科的精度

译者：程徽

目的：追踪精度对于增强现实（AR）导航是否有助于在颌面畸形的诊断和矫形手术，最重要的因素是其精度。本研究使用三维颅骨模型研究了，立体摄像增强现实导航系统应用于LeFort I截骨术的精度，并与目前常用的红外线导航系统的精度进行比较。

材料和方法：使用6自由度咬合架设计了五个上颌骨手术计划，允许定量建立上颌运动（目标距离，5mm）。为了评估立体摄像增强现实导航系统的准确性，并将这些数据与进行比较。

结果：红外线导航系统的平均误差为0.0584mm，立体摄像增强现实导航的平均误差为0.0596mm。红外线导航系统的平均准确率为98.83％，立体摄像增强现实导航系统平均准确度为98.81％。

结论：作者在本研究中，分析了立体摄像增强现实导航系统的精度。实验表明，该系统具有较好的可靠性和准确性。该立体摄像增强现实导航与现有的高成本进口设备具有类似的精度，而成本更低。除手术外，本导航系统的潜在应用还包括患者沟通和新临床医生的培训。

译者的话：髋臼周围截骨术也是对精度要求很高的手术，学习曲线很长。为了缩短初学者的学习曲线，给更多患者减轻痛苦，我们保髋团队与深圳妙智公司合作，共同开发了术中导航系统，在目前的标本试验中显示出满意的精度。希望可以尽快完成后续试验，今早应用与临床，为患者造福。

Tracking Accuracy of a Stereo Camera-Based Augmented reality navigation System for Orthognathic Surgery

PURPOSE: Tracking accuracy is critical to successful augmented reality (AR) in the diagnosis and surgical correction of maxillofacial deformities. The present study investigated the tracking accuracy of an AR navigation system combined with a stereo camera during repositioning of the maxilla after a Le Fort I osteotomy using a 3-dimensional skull model and compared the tracking accuracy with that of an existing infrared (IR)-based optical tracking system (OTS).

MATERIALS AND METHODS: Five maxillary surgery plans weredesigned using a 6 degrees-of-freedom articulator that allowed maxillarymovement to be set up quantitatively (target distance, 5 mm). To evaluate theaccuracy of the stereo camera AR navigation system, it was compared with acommercially available and commonly used IR-based OTS.

RESULTS: The mean error was 0.0584 mm in the IR-based OTSand 0.0596 mm in the AR navigation system. The mean accuracy was 98.83% in theIR-based OTS and 98.81% in the AR navigation system.

CONCLUSIONS: In this study, the stereo camera-based ARnavigation system fabricated and analyzed by the authors was designed foraccuracy. The experiments showed its reliability and accuracy. The hardwaredeveloped for this AR navigation system displayed accuracy similar to that ofexisting high-cost imported devices at a substantially lower cost. In additionto surgery, potential applications of the AR navigation system include patientcommunication and training for novice clinicians.

参考文献：Ahn J, Choi H, Hong J, Hong J.Tracking Accuracy of a Stereo Camera-Based Augmented Reality Navigation Systemfor Orthognathic Surgery. J Oral Maxillofac Surg. 2019May;77(5):1070.e1-1070.e11. doi: 10.1016/j.joms.2018.12.032. Epub 2019 Jan 4.

文献3

非髋关节发育不良人群盂唇肥大的患病率及临床意义

译者：肖凯

背景：髋关节发育不良患者盂唇肥大的报道较为常见。但是，目前尚无非髋关节发育不良人群盂唇肥大的报道。本研究的目的是定义盂唇肥大，并调查非发育不良髋关节出现盂唇肥大的几率和临床意义。

方法：在2007年至2014年期间，对464名（470髋）患有慢性腹股沟疼痛和撞击试验阳性或Faber试验阳性的患者进行了直接关节造影CT检查。有189名男性（192髋）和275名女性（278髋）患者。平均年龄为46.8岁（范围16-74岁）。我们将宽度超过平均值标准差2倍的盂唇定义为肥大盂唇。单个外科医生在髋关节镜检查中记录了与盂唇肥大相关的手术情况。

结果：17髋（3.6％）存在肥肥大盂唇，其平均宽度为11.2mm（±1.1）（9.8-14.1mm）。非肥大盂唇的平均宽度是5.5mm（±2.4）（2-9.8mm）。髋关节镜下与肥大盂唇相关的发现包括盂唇软骨交界处的裂隙和纵向撕裂，并且它们与病变附近的软骨异常有关。

结论：没有髋关节发育不良的肥厚性盂唇并不罕见，且发生盂唇撕裂的概率较高。在对盂唇肥大患者进行手术时，应小心操作，避免入路时对盂唇造成损伤。

A 直接关节造影CT冠状面重建显示a为外侧中心边缘角，b为软组织覆盖角；Bc为盂唇宽度，d为盂唇厚度

Prevalence and clinical significance of hypertrophic labrum in non-dysplastic hips.

BACKGROUND: Hypertrophiclabrum in dysplastic hip has been frequently reported and is known as limbus in developmental dysplasia of the hip. However, hypertrophic labrum without hip dysplasia has not been reported to date. The purpose of this study was to define hypertrophic labrum and to investigate the prevalence and clinical significance of an abnormally hypertrophic labrum in non-dysplastic hips.

METHODS: Between 2007 and2014, direct CT arthrography was performed in 464 patients (470 hips) who hadchronic groin pain and positive impingement or Faber test. There were 189 male(192 hips) and 275 female (278 hips) patients. The mean age was 46.8 years(range, 16-74 years). The hypertrophic labrum was defined as a labrum widerthan two standard deviations away from the mean. Surgical correlation of hypertrophic labrum was obtained in cases with hip arthroscopy by a single surgeon.

RESULTS: Seventeen hips(3.6%) were found to have a hypertrophic labrum which had a mean width of11.2 mm (±1.1) (range, 9.8-14.1 mm). The average width (±SD) of thelabrum without hypertrophy was 5.5 mm (±2.4) (range, 2-9.8 mm).Arthroscopic findings of the hypertrophic labrum included fissure and longitudinal tear at the chondrolabral junction and they were associated withchondral abnormality adjacent to the lesion.

CONCLUSIONS: Hypertrophiclabrum without hip dysplasia is not rare with a high incidence of tears. Care should be taken during arthroscopic access to the hip joint in patients with this morphologic variation as iatrogenic damage can occur more easily.

文献出处：Ha YC, Lee YK, Koo KH,Kwon KB, Song SH. Prevalence and clinical significance of hypertrophic labrumin non-dysplastic hips. J Orthop Sci. 2017 May;22(3):512-516. doi:10.1016/j.jos.2017.01.010. Epub 2017 Feb 4.

文献4

LCPD：分型和预后因素

译者：任宁涛

介绍：LCPD是儿童常见的特发性股骨头缺血坏死，治疗适应症主要取决于股骨头形态和头臼匹配程度，本文旨在探讨LCPD的预后因素。

方法：使用PubMed进行文献检索，关键词为预后因素和/或LCPD分型，总共纳入33篇文献。

结论：预后不良的临床因素有超重、女性、6岁以上、髋关节外展受限，影像学上，与Herring分型一致，因为此分型有高的预测价值和容易掌握。股骨头“危险”症状，髋关节外展受限都可作为晚期预后因素。MRI可作为预测LCPD进展的工具，更好的了解LCPD病因可能或精准预测预后。

图1 女，4岁，Catterall 1, Herring A

图2 上述病人，1年后影像

图3 同一个病人，最近随访时影像，Stulberg I

图4 男，10岁，Catterall 1, Herring B

图5 上述同一个病人MRI

图6 同一个病人1年后影像Catterall 3-4, Herring C  

图7 同一个病人，行三联截骨

图8 最近随访时影像

Legg-Calvé-Perthes disease: classifications and prognostic factors

INTRODUCTION: Legg-Calvé-Perthes Disease (LCPD) represents idiopathic avascular necrosis of femoral head in pediatric population. Indications fortreatment depend mostly on prognosis about femoral head sphericity and hipcongruence at the end of growth. The aim of this review is to highlineprognostic factors of LCPD.

METHODS: Bibliographic searchin PubMed allowed selection of 33 articles concerning prognostic factors and/orclassification of LCPD.

CONCLUSION: Clinicalfactors of poor prognosis are overweight, female sex, age exceeding 6 years old,and lack of hip abduction. Radiologically, Herring's classification isconsensual because of its high prognostic value and very good reproducibility.The other signs of femoral head 'at-risk' and the assessment of thereduction in abduction of the femoral head in the acetabulum are alsoprognostic of late evolution. MRI seems to be a future tool in assessing thefate of hips in LCPD. It is likely that a better understanding of LCPD etiologywould precise the prognosis of this disease.

文献出处：Rampal V, Clément JL, Solla F.Legg-Calvé-Perthes disease: classifications and prognostic factors. Clin CasesMiner Bone Metab. 2017 Jan-Apr;14(1):74-82. doi:10.11138/ccmbm/2017.14.1.074. Epub 2017 May 30.

文献5

臀中肌的血流—一项动物实验

译者：张利强

我们采用氢冲洗技术研究了骨膜下切开术对成年家兔臀中肌血流的影响。测定对照血流量后，根据解剖方向将8只家兔分为2组。10髋臀中肌从髂嵴近端向远端剥离。在另外6髋，行大转子切除，臀中肌由髂嵴远端向近端方向剥离。臀中肌中三分之一的的解剖导致血液流量的显著减少，两组均超过50%。这一结果表明，尽量减少臀中肌中段的损伤对于降低术后并发症的发生率是非常重要的。

大转子切除术后臀中肌血管造影。左，远端三分之二解剖后的血管造影；右，远端三分之一解剖后的血管造影

Blood flow of the gluteus medius muscle: An animal study

We investigated the effects of subperiosteal dissection on blood flow in the gluteal medius muscle in adult rabbits usingthe hydrogen washout technique. After the control blood-flow rate was determined, 8 rabbits were separated into 2 groups according to the direction of the dissection. The gluteal medius muscle was dissected from the iliac crestin the proximal-distal direction in 10 hips. In another 6 hips, the greater trochanter was osteomised and the gluteus medius muscle was dissected from theilium in the distal-proximal direction. Dissection of the middle third of thegluteus medius muscle caused the most significant reduction in blood flow, morethan 50% in both groups. This result indicates that minimising damage to themid-portion of the gluteus medius muscle is important for reducing theincidence of post-operative complications.

文献出处：Y. Akiyoshi · M. Naito et al. Blood flow of the gluteus medius muscle. An animal study. Int Orthop 1999;23(4):202-4

文献6

不稳定股骨头骨骺滑脱的关节囊切开术及AVN的几率：

回顾性研究的Meta分析

译者：陶可（北京大学人民医院骨关节科）

背景：不稳定股骨头骨骺滑脱（SCFE）可能导致多达60%患者出现股骨头缺血性坏死（AVN）。本研究的目的是评估最佳临床证据，以确定关节囊减压术（CD）对不稳定SCFE发生AVN几率的影响。

方法：系统搜索Medline、Embase和Cochrane数据库进行比较研究，研究用或不用CD（抽吸、经皮或开放）治疗的不稳定SCFE发生AVN几率。采用纽卡斯尔渥太华量表评估控制研究质量。我们计算了使用随机效应建模的汇总效应估计进行比较分析；二级分析汇总了比较研究和病例系列的AVN几率。

结果：对比分析包括17项回顾性研究，共453髋（201例CD和252例无CD）。有CD的201例（17%）臀部中有34例发生了AVN，而没有CD的252例（27%）臀部中有67例发生了AVN。接受或不接受CD治疗的患者AVN的几率[优势比= 0.80，95%可信区间（CI）：0.48-1.35]无统计学差异。对原位钻孔或位置缩小和钻孔治疗的患者进行亚组分析显示，无论有无CD，AVN率均无差异（优势比= 0.97，95%CI：0.44-2.10）。在17项比较研究和23个病例系列的二次分析中，CD治疗组（60/447髋）和28%，0.28（95）的平均AVN率为17%，0.17（95% CI：0.13-0.23）。对于没有CD治疗的患者（129/464髋），95% CI：0.22-0.35）。

结论：关节囊减压术（CD）对AVN的几率没有统计学意义上的显着降低。然而，研究受到其回顾性质和CD技术记录不足的限制；大多数人缺乏股骨头血流监测以证明足够的减压。未来的前瞻性研究与仔细记录的完全减压可能有助于阐明CD对AVN风险的影响。尽管有或没有CD的AVN的概率没有统计学差异，但即使这种大量分析也不足，并且无法得出结论，如果没有适当的血流动力学研究，AVN的几率确实没有差异。因此，我们建议所有不稳定SCFE的常规CD等待进一步研究，因为CD对外科手术过程几乎没有增加，并且可以最大限度地降低对股骨头造成毁灭性损伤的风险。

图1. 研究纳入流程的PRISMA图。AVN：缺血性坏死。

表1.不稳性股骨头骨骺滑脱的缺血性坏死的Meta分析中所包括的研究特征/参数

图2. 漏斗图显示没有发表偏倚的证据。

图3. 福雷斯特图（Forrestplot）显示关节囊切开术与未切开术后AVN的几率无显着差异。优势比=0.80，95% CI：0.48-1.35。AVN：缺血性坏死；CI：置信区间。

Capsulotomy in Unstable Slipped Capital Femoral Epiphysis and the Odds of AVN: AMeta-analysis of Retrospective Studies

BACKGROUND: Unstableslipped capital femoral epiphysis (SCFE) may lead to avascular necrosis (AVN)in up to 60% of patients. The aim of this study was to assess the best clinicalevidence to determine the effect of capsular decompression (CD) on odds of AVNinunstable SCFE.

METHODS: Medline,Embase, and Cochrane databases were systematically searched for comparativestudies investigating AVN rates in unstable SCFE treated with or without CD(aspiration, percutaneous, or open). Quality was evaluated by the NewcastleOttawa Scale. A comparative analysis with pooled effect estimates usingrandom-effects modeling was calculated. Secondary analysis pooledAVN rates fromboth comparative studies and case series.

RESULTS: Comparative analysis included 17 retrospective studies with 453 hips (201 with CD, 252without CD). Thirty-four of 201 (17%) hips with CD developed AVN, while 67 of252 (27%) hips without CD developed AVN. The odds of AVN for patients treatedwith or without CD [odds ratio=0.80, 95% confidence interval (CI): 0.48-1.35]was not statistically different. Subanalysis on patients treated with in situpinning or positional reduction and pinning showed no difference in AVN rateswith or without CD (odds ratio=0.97, 95% CI: 0.44-2.10). In the secondary analysis of 17 comparative studies and 23 case series, the average rate of AVNwas 17%, 0.17 (95% CI: 0.13-0.23) for patients treated with CD (60/447 hips)and 28%, 0.28 (95% CI: 0.22-0.35) for patients treated without CD (129/464hips).

CONCLUSIONS: There wasno statistically significant decrease in odds of AVN with CD. However, studieswere limited by theirretrospective nature and inadequate documentation of CDtechniques; the majority lacked femoral head blood flow monitoring todemonstrate adequate decompression. Future prospective studies with carefullydocumented complete decompression may help to elucidate the effect of CD on AVNrisk. Although there was no statistically different odds of AVN with or withoutCD, even this largemeta-analysis was underpowered, and one cannot conclude thatthere was truly no difference in odds of AVN without an appropriately poweredstudy. Therefore, we recommend routine CD for all unstable SCFEs pendingadditional research, as CD adds little to the surgical procedure and mayminimize the risk of a devastating insult to the femoral head.

文献出处：Kaushal N, Chen C, Agarwal KN, Schrader T, Kelly D, DodwellER. Capsulotomy inUnstable Slipped Capital Femoral Epiphysis and the Odds of AVN: A Meta-analysisof Retrospective Studies. J Pediatr Orthop. 2019 Jul;39(6):e406-e411. doi:10.1097/BPO.0000000000001359.