|
本期目录： 1、活动平台假体全膝置换术后膝过伸的危险因素及与临床效果的关系 2、更好的证据证明髋臼侧发育不良会导致骨关节炎 3、开放楔形胫骨高位截骨术正常矫正与过度矫正术后临床和影像学结果的比较 4、髋关节动态超声能否可准确地评估股骨头前移？ 5、髋关节发育不良患者的骨盆前平面（APP）角与解剖学骨盆倾斜度（PT）和髋臼形态的相关性：横断面研究 6、患有髂胫束综合征的长跑运动员的髋关节外展肌无力 7、关于学步后DDH患儿髋臼和股骨颈前倾的研究 8、悬崖征：髋关节不稳的一项新影像学特征 9、原发性甲状旁腺功能亢进表现为股骨头骨骺滑脱 第一部分：关节置换及保膝相关文献 文献1 活动平台假体全膝置换术后膝过伸的 危险因素及与临床效果的关系 译者：张轶超 介绍：评估活动平台假体全膝置换术（TKA）后膝过伸的发生率及危险因素，以及其临床预后。 材料和方法：本研究为回顾性病例对照研究，共纳入了387例初次全膝置换患者，平均随访5年。评估了术后的临床效果及影像学指标（包括后髁的偏心距 PCO，股骨和胫骨的后倾角以及两者间的夹角）。所有病例被分为两组：第1组术后无膝过伸；第二组术后有膝过伸。当在末次随访时用量角器测量存在5°以上的过伸就被认为是存在术后过伸。采用逻辑和线性回归分析来对数据进行处理。 结果：有43膝（11.1%）在末次随访时存在膝关节过伸。尽管第二组膝关节功能评分比第一组差，但总体的临床效果两组间却没有明显差异。术后影像学中PCO (第一组比第二组；− 0.2 mm ± 3.8 比 − 2.4 mm ± 3.0, p = 0.003)、股骨远端截骨面的后倾角(− 9.1° ± 2.1比− 12.1° ± 1.7, p < 0.000)及股骨-胫骨后倾角间的夹角(0.3° ± 4.5比− 3.6° ± 3.9, p < 0.000)有统计学差异，其它的指标均无明显差异。PCO [优势比(OR) 0.86, p = 0.012]、后倾角夹角(OR 0.8136, p = 0.000)及术前股骨-胫骨机械轴夹角(OR 1.09, p = 0.003)的差异与术后膝关节过伸存在相关性。 结论：尽管没有严重的并发症发生，但在中期随访时发现活动平台假体的TKA出现超过5°的膝关节过伸时，功能预后较差。我们术中要尽量保持后髁的偏心距，同时避免股骨和胫骨截骨面不平行造成的术后膝关节过伸与功能欠佳。 A、在影像学上测量股骨后髁偏心距（PCO）。即股骨后髁最高点到股骨后皮质延长线的垂直距离。B、胫骨后倾角（a）即胫骨假体下表面和胫骨解剖轴线垂线之间的夹角；股骨后倾角（b）股骨假体远端内侧面与股骨解剖轴垂线间的夹角。 Risk factors of hyperextension and its relationship with the clinical outcomes following mobile-bearing total knee arthroplasty INTRODUCTION: To evaluate the incidence and risk factors of postoperative hyperextension after mobile-bearing total knee arthroplasty (TKA) and its clinical outcomes. MATERIALS AND METHODS: This retrospective case-control study included 387 knees of primary TKA patients after a 5-year follow-up. The clinical outcomes and radiographs including posterior condylar offset (PCO), femur and tibial slope angle and its discrepancy were evaluated. The patients were divided into two groups (group 1: non-hyperextension, group 2: hyperextension). An extension greater than 5° measured using a goniometer at the final follow-up was defined as hyperextension. Logistic and linear regression analyses were performed. RESULTS: Overall, 43 knees (11.1%) with hyperextension were observed at the last follow-up. There was no significant difference between groups in terms of the clinical outcomes although the functional scores were worse in group 2. There was no significant difference in the postoperative radiologic evaluation except for a change in PCO (group 1 vs. group 2; - 0.2 mm ± 3.8 vs. - 2.4 mm ± 3.0, p = 0.003), distal femoral resection slope angle (- 9.1° ± 2.1 vs. - 12.1° ± 1.7, p < 0.000) and discrepancy of the slope angle (0.3° ± 4.5 vs. - 3.6° ± 3.9, p < 0.000). The change in PCO [odds ratio (OR) 0.86, p = 0.012], discrepancy of the slope angle (OR 0.8136, p = 0.000) and the preoperative mechanical femorotibial angle (OR 1.09, p = 0.003) were associated with hyperextension. CONCLUSION: Mobile-bearing TKA with hyperextension over 5° showed worse functional outcomes at the mid-term follow-up, even though no serious complications were observed. Care should be taken to maintain the posterior condylar offset and to match the resection angles in femur and tibia due to the risk of hyperextension and worse functional outcomes. 文献出处：Lee HJ, Park YB, Lee DH, Kim KH, Ham DW, Kim SH. Risk factors of hyperextension and its relationship with the clinical outcomes following mobile-bearing total knee arthroplasty. Arch Orthop Trauma Surg. 2019 Sep;139(9):1293-1305. doi: 10.1007/s00402-019-03231-6. Epub 2019 Jul 12. 文献2 更好的证据证明髋臼侧发育不良会导致骨关节炎 译者：马云青 背景:骨科文献中一个常见的说法是髋臼中心边缘角（CE角）小于20°诊断为髋臼发育不良（AD），而AD会导致骨关节炎(OA)。文章的目的是评估AD和OA的关联性。 方法:对AD与OA有关联的现实证据和相关理论进行评价和讨论。此外，测试已有的理论，即认为当髋臼CE角小于20°时，患者65岁时会患上OA，并寻找这个理论的例外。 结果:Wiberg和Cooperman及其同事研究了30例理想的病例来评估AD与OA的关系。开始每例患者都无关节炎表现，AD稳定，CE角<20°，无半脱位，所有病例都被长期随访且均发展为OA。在Stulberg及其同事，Jacobsen及其同事的研究中的每例患者也表现为骨关节炎，因此很难确定什么样的髋关节会发展为OA。在Murphy的研究中，也有同样的问题，很难确定患者在初次评估时是否已经患有OA。原因是所有这些研究使用了不同的OA诊断方案，研究难度比较大。研究中大多数患者来自欧洲北方血统，使得结果很难延伸到其他人群。而且有4例患者CE角<20°在65岁时没有患上严重的关节炎。 结论:现有的结论只适用于欧洲北方血统患者。只有少数患者AD稳定，轻度CE角异常（15到19°)在65岁时没有关节炎。几乎所有的AD稳定的患者在65岁时发生OA。不稳定AD (CE角<20°，并有半脱位)在65.岁时常会发生OA。将这些结论扩展到其他人群可能是合理的，但随着更多数据积累，必须做好重新评价的准备。 How Good is the Evidence Linking Acetabular Dysplasia to Osteoarthritis? BACKGROUND: A common claim in the orthopaedic literature is that acetabular dysplasia (AD) exists when the center-edge angle of Wiberg (CE angle) is <20 degrees and that AD leads to osteoarthritis (OA). Our purpose is to evaluate the validity of the linkage between AD and OA. METHODS: We assess and discuss the theories and the empirical evidence relating AD to OA. Moreover, we test the rule that hips with a CE angle <20 degrees will develop OA by 65 years of age, by looking for exceptions to this rule. RESULTS: Wiberg and Cooperman and colleagues present 30 ideal patients for assessing the relationship between AD and OA. Each was arthritis free, with stable AD, CE angle <20 degrees, without signs of subluxation. They were all followed and all developed OA. In the studies by Stulberg and colleagues, and Jacobsen and colleagues, every patient presented with OA, making it difficult to be certain about the appearance of the hip before the onset of OA. In the study by Murphy and colleagues, we have the same problem, as an unknown number of patients already had OA at first assessment. All of these studies used different schemes for diagnosing OA, making the studies difficult to compare. Most of the patients in the studies were of Northern European ancestry, making the results difficult to generalize to other populations. Four patients had CE angles <20 degrees and did not develop severe arthritis by 65 years of age. CONCLUSIONS: Our conclusions apply directly to patients of Northern European ancestry. A few patients with stable, mild AD (CE angle 15 to 19 degrees) will be arthritis free at 65 years of age. Almost all patients with stable AD develop OA by 65 years of age. Unstable AD (CE angle <20 degrees, with subluxation) always leads to OA by 65 years of age. It is probably reasonable to extend these conclusions to other populations, but the reader must be prepared to re-evaluate them, as more data accumulates. 文献出处：Cooperman DR. How Good is the Evidence Linking Acetabular Dysplasia to Osteoarthritis? J Pediatr Orthop. 2019 Jul;39(Issue 6, Supplement 1 Suppl 1):S20-S22. doi: 10.1097/BPO.0000000000001360. 文献3 开放楔形胫骨高位截骨术正常矫正与 过度矫正术后临床和影像学结果的比较 译者：张蔷 目的：评估过度矫正的胫骨平台内侧角（MPTA）是否影响开放楔形胫骨高位截骨术的临床疗效，并探究膝关节线倾斜角改变与髋、踝关节代偿性变化的关系。 方法：入组2006年7月至2015年8月连续的开放楔形胫骨高位截骨术病例。排除标准为双侧开放楔形截骨术和随访不足两年。我们回顾性的根据术后胫骨平台内侧角（MPTA）将病例分为两组，正常矫正组（MPTA <95°）和过度矫正组（MPTA≥95°）。比较术后组间临床和影像学结果。临床结果指标包括日本骨科协会评分（JOA）、牛津膝关节评分（OKS）和膝关节损伤与骨关节炎评分（KOOS）。影像学指标包括髋-膝-踝角（HKA）、关节线汇聚角（JLCA）、MPTA、膝关节线倾斜角（KJLO）、踝关节线倾斜角（AJLO）和髋关节外展角（HAA），分别在术后和末次随访时采集。 A． 膝关节线倾斜角（KJLO），踝关节线倾斜角（AJLO）；髋关节外展角（HAA） 关节线汇聚角（JLCA） 结果：共入组94例（正常矫正组52例，过度矫正组42例）。开放楔形胫骨高位截骨术后，HKA和MPTA分别平均增加11.0°±3.2°和10.4°±2.7°，膝关节线倾斜角变化为3.7°±2.9°，而术后踝关节线倾斜角(4.3±3.9 to -1.3±3.3, P < .001)和髋关节外展角(3.7±2.5 to -1.1±2.3, P < .001)显著降低。过度矫正组术后平均MPTA为96.9°±1.5°，而术后平均膝关节线倾斜角（KJLO）变化为3.1°±2.0°。末次随访时两组间所有临床评分均无显著性差异。 结论：由于髋关节和踝关节的代偿性变化，一定程度的胫骨平台内侧角（MPTA）过度矫正（≥95°）并不会改变开放楔形胫骨高位截骨术的临床效果。 Comparison of Clinical and Radiologic Outcomes between Normal and Overcorrected Medial Proximal Tibial Angle Groups after Open-Wedge High Tibial Osteotomy Purpose: To evaluate whether the overcorrected medial proximal tibial angle (MPTA) affects the clinical outcomes after open-wedge high tibial osteotomy (OWHTO) and to assess the correlation between knee joint line obliquity (KJLO) changes and the compensatory changes in the hip and ankle joints. Methods: Consecutive patients who underwent OWHTO from July 2006 to August 2015 were included. Exclusion criteria were bilateral OWHTO and follow-up of <2 years. The patients were retrospectively divided into 2 groups according to postoperative MPTA; a normal group (MPTA <95°) and an overcorrected MPTA group (MPTA≥95°). The groups were compared with respect to the clinical and radiologic outcomes after OWHTO. Clinical parameters, including Japanese Orthopedic Association (JOA) score, Oxford Knee Score (OKS), and Knee Injury and Osteoarthritis Outcome Score (KOOS), were evaluated. Radiologic outcomes, including the hip-knee-ankle angle (HKA), joint line convergence angle (JLCA), MPTA, KJLO, ankle joint line obliquity (AJLO), and hip abduction angle (HAA), were evaluated preoperatively and at the final follow-up. Results: Ninety-four patients (normal group; n=52, overcorrected group; n=42) were included in this study. After OWTHO, the mean increases in HKA and MPTA were 11.0°±3.2°and 10.4°±2.7°, respectively, whereas the change in KJLO was only 3.7°±2.9°. The mean AJLO (4.3±3.9 to -1.3±3.3, P < .001) and HAA (3.7±2.5 to -1.1±2.3, P < .001) significantly decreased after OWHTO. The mean postoperative MPTA in the overcorrected group was 96.9°±1.5°, whereas the mean postoperative KJLO was only 3.1°±2.0°. No significant differences were noted in all clinical scores between the groups at the final follow-up. Conclusions: A certain degree of overcorrected MPTA (≥95°) did not affect the clinical outcomes after OWHTO because of compensatory changes in the hip and ankle joints. 文献出处：Goshima K, Sawaguchi T, Shigemoto K, Iwai S, Fujita K, Yamamuro Y. Comparison of Clinical and Radiologic Outcomes Between Normal and Overcorrected Medial Proximal Tibial Angle Groups After Open-Wedge High Tibial Osteotomy. Arthroscopy. 2019 Oct;35(10):2898-2908.e1. doi: 10.1016/j.arthro.2019.04.030. 第二部分：保髋相关文献 文献1 髋关节动态超声能否可准确地评估股骨头前移？ 译者：罗殿中 背景：髋关节微不稳定性作为引起髋关节疼痛的潜在原因，最近已受到关注。该诊断目前仍缺乏循证客观的诊断标准。之前的研究表明在髋关节处于极端位置时，股骨头会发生移位。然而，目前仍缺乏对股骨头移位的可靠标准。 问题/目的：（1）明确肌骨超声在测量髋关节前方不稳定试验时股骨头移位的精度（2）明确动态超声检查在评估股骨头前方移位时的组内和组间一致性。 方法：我们招募了10名（共20髋）年龄在22至50岁的受试者，其中女性7名，男性3名，所有受试者均没有髋关节疼痛或功能受限的病史。使用了重复测量方法。受试者平均年龄为27岁（标准差8.7岁）；平均体重指数为22.6 kg / m（标准差2.2 kg / m）。所有受试者均由三位不同的医生在相隔1周的时间内进行了动态髋部超声检查。每个髋关节均处于两个中立位置（中立位和对侧髋关节屈曲中立位[NF]）和两个动态位进行超声检查，受试者对髋关节病理并不知情，因此检查过程中不会分心。第一个动态检查时(EER1)，使髋关节保持伸展外旋，且使其不靠近检查床的侧面；第二个动态检查时(EER2)，保持髋部离开检查床的尾端。共进行了120次超声扫描（480张图像）。计算NF和EER1与NF和EER2之间的超声测量值差（mm）的绝对值，进一步计算平均值及标准差，对每位医生的测量数据及三个人的平均值均进行统计分析。应用同类相关系数（ICC）检查组内及组间测量一致性。 结果：在第一次试验时，NF和EER1的平均绝对差为0.84 mm（SD 0.93 mm），而NF和EER2的平均绝对差为0.62 mm（SD 0.40 mm）。在第二次试验时，NF和EER1位置的平均绝对差为0.90mm（SD 0.74mm），NF和EER2平均绝对差1.03mm（SD 1.18mm）。ICC分析的累积值表明，在所有四个体位，观测者组内一致性都非常好：中立位0.794（95％置信区间[CI]，0.494-0.918），NF 0.927（95％CI，0.814-0.971），EER1 0.929（95％CI，0.825） -0.972）和EER2 0.945（95％CI，0.864-0.978）。同样，ICC分析的累积值显示组间 一致性在NF、EER1和EER2非常好，中立位较好：中立位0.725（95％CI，0.526-0.846），NF 0.846（95％CI，0.741-0.913），EER1 0.812（95％CI，0.674-0.895）和EER2 0.794（95％CI，0.652-0.884）。 结论：这项研究首次位我们提供了应用超声测量股骨头向前移位的方法。当评估复杂的髋部疼痛和可疑的微不稳定时，髋关节动态超声可以帮助提供精确客观的基于临床的诊断依据。肌骨超声是一种可靠的测量股骨头向前移位的方法，不同经验水平的医生均可以使用。后期需要进一步评估性别、既往髋关节手术史、髋关节骨形态和韧带松弛对股骨头移位的影响。 A 平卧位、髋关节中立位进行超声检查；B NF检查，即对侧髋关节屈曲 A EER1检查，即髋关节保持伸展外旋，且使其不靠近检查床的侧面；B EER2检查，即保持髋部离开检查床的尾端 应用超声机内部软件测量股骨头向前移位距离，移位距离即股骨头硬化缘前方至髋臼水平的垂直距离 Can Dynamic Ultrasonography of the Hip Reliably Assess Anterior Femoral Head Translation? BACKGROUND: Hip microinstability has gained attention recently as a potential cause of hip pain. Currently there is a lack of evidence-based objective diagnostic criteria surrounding this diagnosis. Previous studies have shown translation of the femoral head during extreme hip positions. However, reliable assessment of femoral head translation is lacking. QUESTIONS/PURPOSES: (1) How precise is musculoskeletal ultrasound for measuring anterior femoral head translation during the hip anterior apprehension test? (2) What is the intra- and interrater reliability of dynamic ultrasonography in assessing anterior femoral head translation? METHODS: We recruited 10 study participants (20 hips) between the ages of 22 and 50 years with no history of hip pain or functional limitations. Test-retest methodology was used. Seven females and three males were enrolled. The mean age of study participants was 27 years (SD 8.7 years); mean body mass index was 22.6 kg/m (SD 2.2 kg/m). All study participants underwent dynamic hip ultrasonography by three different physicians 1 week apart. Each hip was visualized in two neutral positions (neutral and neutral with the contralateral hip flexed [NF]) and two dynamic positions, which sought to replicate the apprehension test, although notably study participants had no known hip pathology and therefore no apprehension. The first maintained the hip in extension and external rotation off to the side of the examination table (EER1), and the second held the hip off of the bottom of the examination table (EER2). One hundred twenty ultrasound scans (480 images) were performed. Mean and SD were calculated using absolute values of the difference in ultrasound measurements (mm) between positions NF and EER1 and NF and EER2 calculated for each physician as well as an average of all three physicians. Intraclass correlation coefficient (ICC) analysis was used to examine intra- and interrater reliability. RESULTS: The mean absolute difference for NF and EER1 was 0.84 mm (SD 0.93 mm) and for NF and EER2 0.62 mm (SD 0.40 mm) on Study Day 1. Similarly, on Study Day 2, the mean absolute difference for NF and EER1 position was 0.90 mm (SD 0.74 mm) and for NF and EER2 1.03 mm (SD 1.18 mm). Cumulative values of ICC analysis indicated excellent intrarater reliability in all four positions: neutral 0.794 (95% confidence interval [CI], 0.494-0.918), NF 0.927 (95% CI, 0.814-0.971), EER1 0.929 (95% CI, 0.825-0.972), and EER2 0.945 (95% CI, 0.864-0.978). Similarly, interrater ICC analysis cumulative values were excellent for NF, EER1, and EER2 and fair to good for the neutral position: neutral 0.725 (95% CI, 0.526-0.846), NF 0.846 (95% CI, 0.741-0.913), EER1 0.812 (95% CI, 0.674-0.895), and EER2 0.794 (95% CI, 0.652-0.884). CONCLUSIONS: This study offers the first ultrasound protocol of which we are aware for measuring anterior femoral head translation. Hip dynamic ultrasound may assist in providing precise objective clinical-based diagnostic evidence when evaluating complex hip pain and suspected microinstability. Musculoskeletal ultrasound is a reliable office-based method of measuring anterior femoral head translation that can be utilized by physicians with varying experience levels. Future studies are needed to investigate ultrasound anterior femoral head translation taking into account sex, prior hip surgery, hip osseous morphology, and ligamentous laxity. 文献出处：d'Hemecourt PA, Sugimoto D, McKee-Proctor M, Zwicker RL, Jackson SS, Novais EN, Kim YJ, Millis MB, Stracciolini A. Can Dynamic Ultrasonography of the Hip Reliably Assess Anterior Femoral Head Translation? Clin Orthop Relat Res. 2019 May;477(5):1086-1098. doi: 10.1097/CORR.0000000000000457. 文献2 髋关节发育不良患者的骨盆前平面（APP）角与 解剖学骨盆倾斜度（PT）和髋臼形态的 相关性：横断面研究 译者：程徽 背景：既往文献报道，髋关节发育不良会导致骨盆前倾，代偿性的增加股骨头骨性覆盖。本研究的目的是了解骨盆的解剖参数（如PI和PT）与脊柱-骨盆的功能参数（如骨盆前平面角）之间的相关性。 方法：对作者所在机构的84名因双侧髋关节发育不良进行髋臼周围弧形截骨术的女性患者进行观察。脊柱-骨盆功能参数使用术前的站立位胸腰椎X线片和骨盆X线片进行测量。髋臼的形态学参数，包括前CE角、后CE角、外侧CE角和髋臼前角，均在术前CT三维重建出的骨盆模型上进行测量。使用Pearson相关分析评估参数之间的相关性。 图1 骨盆参数的测量方法 图2 髋臼参数的测量（译者注：不同于我们常用的测量方法，本文中的各向CE角均在CT上进行测量） 结果：在功能参数中，SS值（r = 0.666）与PI相关性最高，而在解剖参数中，解剖学SS值（r = 0.789）与PI相关性最高。骨盆前平面角（APPA）与PT（r =-0.594）和解剖学PT（r = 0.646）均存在中度相关。关于脊柱-骨盆功能参数与髋臼的骨形态参数之间的相关性，PT与髋臼前倾角（AA）中度相关（r= 0.424）， APPA与前CE角（r =-0.478），后CE角（r = 0.432）和AA（r = 0.565）均中度相关。与AA相比，解剖PT与APPA的相关性强得多（r = 460.646）。 结论：与髋臼的参数（外侧CE角，前CE角，后CE角和髋臼的骨覆盖度）相比，骨盆的倾斜受骨盆的形态参数（解剖学PT）的影响更大。本研究是第一个脊柱-骨盆功能参数（除PI以外）与髋臼形态参数之间的相关性的研究。 译者的话：最终的结论是，骨盆前后倾与髋关节旋转中心在骨盆上的前后位置有关。 Correlation of tilt of the anterior pelvic plane angle with anatomical pelvic tilt and morphological configuration of the acetabulum in patients with developmental dysplasia of the hip: a cross-sectional study BACKGROUND: It was previously reported that pelvises with developmental dysplasia of the hip are tilted anteriorly, which increases bony coverage of the femoral head. This study aimed to investigate the correlation between anatomical parameters of the pelvis such as pelvic incidence and anatomical pelvic tilt and functional parameters of the spine and pelvis such as tilt of the anterior pelvic plane. METHODS: We examined 84 female patients with bilateral developmental dysplasia of the hip who had undergone curved periacetabular osteotomy at author's institution. Radiographs of the thoracic to lumbar spines and the pelvis were obtained in the standing position to measure spino-pelvic parameters before surgery. Morphological parameters of the acetabulum such as the anterior center-edge (CE) angle, posterior CE angle, lateral CE angle, and acetabular anteversion were measured using a preoperative three-dimensional pelvic model reconstructed from computed tomography images. Pearson's correlation analysis was conducted to evaluate the relationship of these parameters. RESULTS: With regard to correlations between pelvic incidence (PI) and other parameters, the sacral slope (SS) value (r = 0.666) was the highest among functional parameters and the anatomical-SS value (r = 0.789) was the highest among morphological parameters. There were moderate correlations of the anterior pelvic plane angle (APPA) with pelvic tilt (PT) (r = - 0.594) and anatomical-PT (r = 0.646). With regard to correlations between spino-pelvic parameters and bony morphological parameters of the acetabulum, there was a moderate correlation between anatomical-PT and acetabular anteversion (AA) (r = 0.424). There were moderate correlations of APPA with the anterior CE angle (r = - 0.478), posterior CE angle (r = 0.432), and AA (r = 0.565). APPA had a stronger correlation with anatomical-PT (r = 0.646) than with AA. CONCLUSIONS: The tilt of the pelvis may be more dependent on anatomical-PT, a morphological parameter of the pelvis, than the lateral CE angle, anterior CE angle, posterior CE angle, and acetabular anteversion on bony coverage of the acetabulum. This study is the first to investigate the correlation between functional parameters of the pelvis and spine and morphological parameters of the pelvis and acetabulum besides PI. 文献出处：Imai N, Suzuki H, Nozaki A, Hirano Y, Endo N. Correlation of tilt of the anterior pelvic plane angle with anatomical pelvic tilt and morphological configuration of the acetabulum in patients with developmental dysplasia of the hip: a cross-sectional study. J Orthop Surg Res. 2019 Oct 17;14(1):323. doi: 10.1186/s13018-019-1382-8. 文献3 患有髂胫束综合征的长跑运动员的 髋关节外展肌无力 译者：肖凯 目的：检查患有髂胫束带综合征（ITBS）的长跑运动员的髋关节外展肌力量，将他们的受伤肢体力量与未受影响的肢体和健康长跑运动员（对照组）进行比较；明确通过康复计划改善患者髋外展肌力量是否可以使其成功返回跑步赛场。 设计：病例队列研究。 设置：斯坦福大学运动医学诊所。 参与者：自就诊于我们跑步者伤病诊所的患者中随机选择24名患有ITBS的长跑运动员（14名女性，10名男性），患者均具有ITBS典型的病史和体格检查结果。从斯坦福大学越野与田径队中随机选择30名长跑运动员作为对照组（14名女性，16名男性）。 主要观察指标：分别测量病例组受伤侧肢体、未受伤肢体及对照组的髋关节外展扭矩，用于评估髋外展肌力量，应用t检验比较各组间是否存在差异。经过6周的康复计划后，比较受伤运动员康复前髋外展肌扭矩与康复后扭矩的差异。 结果：用尼古拉斯手动肌肉测试仪（kg）测量髋关节外展肌扭矩，并以体重百分比乘以身高（％BWh）的单位标准化受试者的身高和体重差异。受伤女性的平均康复前髋关节外展扭矩为7.82％BWh，而未受伤肢体的平均为9.82％BWh，对照组为10.19％BWh。受伤男性的平均康复前髋关节外展扭矩为6.86％BWh，未受伤肢体的平均水平为8.62％BWh，对照组为男性跑步者的9.73％BWh。康复前各组的差异在p <0.05水平上均具有统计学意义。然后将受伤的跑步者纳入为期6周的标准化康复方案，并特别注意加强臀中肌训练。康复后，女性受伤肢体的髋关节外展扭矩平均增加34.9％，男性平均增加51.4％。康复6周后，24名运动员中有22名无疼痛，并且能够恢复奔跑，并且在6个月的随访中没有复发的报道。 结论：与未受影响的肢体和未受影响的长跑运动员相比，患有ITBS的长跑运动员患侧肢体的髋关节外展肌强度较弱。此外，髋关节外展肌的强化伴随着患者症状的缓解，患者可以回到伤病前的正常训练。 Hip abductor weakness in distance runners with iliotibial band syndrome OBJECTIVE: To examine hip abductor strength in long-distance runners with iliotibial band syndrome (ITBS), comparing their injured-limb strength to their nonaffected limb and to the limbs of a control group of healthy long-distance runners; and to determine whether correction of strength deficits in the hip abductors of the affected runners through a rehabilitation program correlates with a successful return to running. DESIGN: Case series. SETTING: Stanford University Sports Medicine Clinics. PARTICIPANTS: 24 distance runners with ITBS (14 female, 10 male) were randomly selected from patients presenting to our Runners' Injury Clinic with history and physical examination findings typical for ITBS. The control group of 30 distance runners (14 females, 16 males) were randomly selected from the Stanford University Cross-Country and Track teams. MAIN OUTCOME MEASURES: Group differences in hip abductor strength, as measured by torque generated, were analyzed using separate two-tailed t-tests between the injured limb, non-injured limb, and the noninjured limbs of the control group. Prerehabilitation hip abductor torque for the injured runners was then compared with postrehabilitation torque after a 6-week rehabilitation program. RESULTS: Hip abductor torque was measured with the Nicholas Manual Muscle Tester (kg), and normalized for differences in height and weight among subjects to units of percent body weight times height (%BWh). Average prerehabilitation hip abductor torque of the injured females was 7.82%BWh versus 9.82%BWh for their noninjured limb and 10.19%BWh for the control group of female runners. Average prerehabilitation hip abductor torque of the injured males was 6.86%BWh versus 8.62%BWh for their noninjured limb and 9.73%BWh for the control group of male runners. All prerehabilitation group differences were statistically significant at the p < 0.05 level. The injured runners were then enrolled in a 6-week standardized rehabilitation protocol with special attention directed to strengthening the gluteus medius. After rehabilitation, the females demonstrated an average increase in hip abductor torque of 34.9% in the injured limb, and the males an average increase of 51.4%. After 6 weeks of rehabilitation, 22 of 24 athletes were pain free with all exercises and able to return to running, and at 6-months follow-up there were no reports of recurrence. CONCLUSIONS: Long distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners. Additionally, symptom improvement with a successful return to the preinjury training program parallels improvement in hip abductor strength. 文献出处：Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000 Jul;10(3):169-75. 文献4 关于学步后DDH患儿髋臼和股骨颈前倾的研究 译者：任宁涛 使用CT对27名（17名女孩，10名男孩；年龄分布：18-48个月）学步后的DDH患儿（17名为双侧，10名为单侧）的髋臼和股骨颈前倾的关系进行定量分析，包括54个髋关节，其中25例完全脱位、19例半脱位和10例正常，在标准的骨盆片上测量CE角和AI，2维CT上测量髋臼和股骨颈的前倾，采用Ishida分型标准进行髋关节脱位程度的诊断。研究结果发现3组患儿CE角、AI和髋臼前倾有统计学差异，3组股骨颈前倾角无统计学差异。正常髋关节髋臼前倾角为13.4±2.8度（平均值±SD），半脱位组为16.7±1.9度，完全脱位组为19.8±2.5度，3组之间具有统计学差异，各组髋臼前倾角值范围广泛（9-26度），脱位侧髋臼前倾角增加，未见髋臼后倾。各组之间股骨颈前倾角无差异。因此学步后早期年龄的DDH患儿治疗计划中需要通过二维计算机断层扫描确定髋臼和股骨颈的前倾角。 表1 10例正常髋关节和44例受影响髋关节CE角、AI、髋臼和股骨颈前倾角 表2 使用post hoc Tukey’s test对各组CE角、AI、髋臼和股骨颈前倾角进行比较
表3 CE角、AI、髋臼和股骨颈前倾角之间的Pearson相关系数
Anteversion of the acetabulum and femoral neck in early walking age patients with developmental dysplasia of the hip Computed tomography measurements were made to quantify the relationship between the anteversion of the acetabulum and femoral neck in 27 early walking age patients (age range; 18-48 months) with developmental dysplasia of the hip. The centre-edge angle and acetabular index were measured in standard pelvis radiographs, and anteversion of acetabulum and femoral neck were measured by use of two-dimensional computed tomography in 25 complete dislocated, 19 subluxated and 10 unaffected hips (a total of 54 hips). The diagnosis of dysplasia, subluxation and complete dislocation of developmental hip dysplasia were determined radiographically using Ishida's criteria. There were statistically significant differences between the three groups for the centre-edge angle, the acetabular index, and acetabulumanteversion. There was no statistically significant difference between the three groups for femoral neck anteversion. The acetabular anteversion was found to be 13.4 /-2.8 degrees (mean /-SD) in unaffected hips, 16.7 /-1.9 degrees in subluxated hips and 19.8 /-2.5 degrees in complete dislocated hips. There was statistically significant difference between the three groups, with a wide range of acetabular anteversion values noted in all groups (9-26 degrees ). The acetabular anteversion was increased on the dislocated side in each patient and we found no retroverted acetabulum. On the other hand there was no significant difference between the groups with regards to femoral neckanteversion. We conclude that confirming anteversion of the acetabulum and the femoral neck by two-dimensional computed tomography is needed in treatment planning of early walking age patients with developmental hip dysplasia. 文献出处：Sarban S, Ozturk A, Tabur H, Isikan UE. Anteversion of the acetabulum and femoral neck in early walking age patients with developmental dysplasia of the hip. J Pediatr Orthop B. 2005 Nov;14(6):410-4. 文献5 悬崖征：髋关节不稳的一项新影像学特征 译者：张利强 背景：髋关节微不稳定的术前诊断是具有挑战性的。虽然有与微不稳定相关的临床查体和磁共振的描述，但对X线的描述却很少。在微不稳定的患者中，我们发现在股骨头的外侧边缘可见一个很高发生率的快速下降区域，我们称之为“悬崖征”。 目的：1）确定悬崖征和术中微不稳定相关测量值之间的关系；2）确定这些测量值在观察者之间的可靠性。 方法：对115例髋关节镜手术患者进行回顾性分析。排除有髋关节手术史、Legg- Calve-Perthes病、骨折、色素沉着绒毛结节性滑膜炎或滑膜软骨瘤病的患者，结果纳入96例患者。骨盆前后位片显示股骨头轮廓呈完美的圆圈。如果股骨头外侧没有完全填满完美的圆圈，这被认为是悬崖征阳性。同时计算了与悬崖征相关的五项额外测量值。术中根据（1）牵开髋关节所需的牵引力，（2）初始牵引力释放关节松弛后髋关节复位不足，或（3）术中与髋关节微不稳定相一致的发现来诊断微不稳定。用非配对t检验和离散变量Fisher精确检验对连续变量进行分析。确定每次测量观察者间的可靠性（n =3）。 结果：总的来说，89%（39/44）的有微不稳定患者有悬崖征，而27%（14/52）没有不稳定的患者中有悬崖征（p<0.0001）。相反，74%有悬崖征的患者有微不稳定，而只有12%没有悬崖征的患者有不稳定（p<0.0001）。在32岁以下有悬崖征的女性中，100%（20/20）被诊断为不稳定。在5个额外的测量中没有发现任何差异。观察者间对于悬崖征的存在和悬崖角度的测量具有极好的可靠性。 结论：我们发现了一个与术中髋关节微不稳定诊断相关的影像学表现，即悬崖征。其具有良好的观察者间可靠性。结果显示，100%有悬崖征的年轻女性术中发现微不稳定。悬崖征对髋关节微不稳的术前诊断有一定价值。
图1.悬崖征。上排骨盆前后位片显示股骨头轮廓呈完美的圆圈。如果股骨头外侧没有完全填满完美的圆圈，这被认为是悬崖征阳性。下排显示了股骨头外侧完全填满了完美的圆圈，被认为是悬崖征阴性。
图2.另外五个测量值：（a）悬崖角；（b）反向α角；（c）悬崖/股骨颈cobb角；（d）悬崖/股骨干cobb角；（e）悬崖长度/股骨头直径比。
图3.微不稳定患者的术中透视图像。手动牵引髋关节（左）。在关节空气造影后（中间），髋关节在牵引力释放后仍然半脱位（右侧）。 The Cliff Sign: A New Radiographic Sign of Hip Instability Background: The preoperative diagnosis of hip microinstability is challenging. Although physical examination maneuvers and magnetic resonance imaging findings associated with microinstability have been described, there are limited reports of radio- graphic features. In patients with microinstability, we observed a high incidence of a steep drop-off on the lateral edge of the femoral head, which we have named the “cliff sign.” Purpose: (1) To determine the relationship of the cliff sign and associated measurements with intraoperative microinstability and (2) to determine the interobserver reliability of these measurements. Methods: A total of 115 consecutive patients who underwent hip arthroscopy were identified. Patients with prior hip surgery, Legg- Calve-Perthes disease, fractures, pigmented villonodular synovitis, or synovial chondromatosis were excluded, resulting in the inclusion of 96 patients in the study. A perfect circle around the femoral head was created on anteroposterior pelvis radiographs. If the lateral femoral head did not completely fill the perfect circle, it was considered a positive cliff sign. Five additional measurements relating to the cliff sign were calculated. The diagnosis of microinstability was made intraoperatively by the (1) amount of traction required to distract the hip, (2) lack of hip reduction after initial traction release following joint venting, or (3) intraoperative findings consistent with hip microinstability. Continuous variables were analyzed through use of unpaired t tests and discrete variables with Fisher exact tests. Interobserver reliability (n=3) was determined for each measurement. Results: Overall, 89%(39/44) of patients with microinstability had a cliff sign, compared with 27% of patients (14/52) without instability (P<.0001). Conversely, 74% of patients with a cliff sign had microinstability, while only 12% of patients without a cliff sign had instability (P < .0001). In women younger than 32 years with a cliff sign, 100% (20/20) were diagnosed with instability. No differences were found in any of the 5 additional measurements. Excellent interobserver reliability was found for the presence of a cliff sign and the cliff angle measurement. Conclusion: We have identified a radiographic finding, the cliff sign, that is associated with the intraoperative diagnosis of hip microinstability and has excellent interobserver reliability. Results showed that 100% of young women with a cliff sign had intraoperative microinstability. The cliff sign may be useful in the preoperative diagnosis of hip microinstability. 文献出处：Packer J D , Cowan J B , Rebolledo B J , et al. The Cliff Sign: A New Radiographic Sign of Hip Instability[J]. Orthopaedic Journal of Sports Medicine, 2018, 6(11). 文献6 原发性甲状旁腺功能亢进表现为股骨头骨骺滑脱 译者：陶可（北京大学人民医院骨关节科） 一个15岁的男孩出现隐匿性双侧大腿活动性疼痛6个月。髋部检查显示内旋受限。骨盆X线照片（图1）显示双侧股骨头骨骺滑脱（SCFE），右下耻骨和髂骨软骨下骨吸收。手部X线照片（图2）显示在中指骨桡侧的骨膜下骨吸收。 考虑到非典型的（SCFE）放射学结果，我们为患者做了骨骼检查，显示血清钙12.3 mg/dL（正常8.5-10.5），磷2.3 mg/dL（正常2.5-5.0），碱性磷酸酶（ALP）832 IU/L（正常35–140）和甲状旁腺激素（PTH）2512 pg/mL（正常10–65）。放射性核素扫描证实为右下甲状旁腺腺瘤（图3）。 最终诊断为患有原发性甲状旁腺功能亢进引起的慢性稳定行SCFE。该患者接受了伽马探针引导的右甲状旁腺切除术。术后他出现了饥饿性骨骼综合症，予以静脉注射及口服钙剂治疗。一个月后，他的骨骼轮廓恢复正常（钙8.7 mg/dL，磷2.6 mg/dL，ALP 200 IU/L，PTH 15 pg/mL）。 SCFE是青少年常见的髋部疾患（1：10000）。伴有原发性甲状旁腺功能亢进的SCFE非常罕见，文献共报道11例。骨膜下骨吸收和小梁变粗等放射学发现提示了这一点。血清PTH和放射性核素扫描有助于确定诊断。 如果未能及时确诊甲状旁腺功能亢进症，从全身和髋关节角度来看，患者的预后可能很差。在SCFE中，有非典型的影像学表现时，临床医生应保持警惕，以完善进一步检查，因为甲状旁腺功能亢进症的治疗应优先于SCFE。
图1. 骨盆前后位显示整个骨骺位于SCFE诊断线（Klein线）下方。在正常髋关节中，三分之一的骨骺应该在这条线以上。骨盆中骨小梁普遍变粗，可见沿髂骨（黑色箭头）和耻骨下支（白色箭头）的骨膜下骨吸收。SCFE，股骨头骨骺滑脱。
图2. 在手第四指中指骨的桡侧缘上存在骨膜下骨吸收。这是甲状旁腺功能亢进症的病理学特征。
图3. 右下甲状旁腺的摄取延迟提示甲状旁腺腺瘤。
图4. 双侧原位螺钉固定后的骨盆前后位影像学检查结果。 Primary hyperparathyroidism presenting as slipped capital femoral epiphysis A 15-year-old boy presented with insidious onset bilateral thigh pain for 6 months. Examination of hips showed restricted internal rotation. Pelvis radiograph (figure 1) showed bilateral slipped capital femoral epiphysis (SCFE) with subchondral bone resorption in right inferior pubic rami and ilium . Hand radiograph (figure 2) showed subperiosteal bone resorption along the radial aspect of middle phalanges. In view of the atypical radiology, a bone profile was done which revealed serum calcium 12.3 mg/dL (normal 8.5–10.5), phosphorus 2.3 mg/dL (normal 2.5–5.0), alkaline phosphatase (ALP) 832 IU/L (normal 35–140) and parathormone (PTH) 2512 pg/mL (normal 10–65). Sestamibi scan confirmed a right inferior parathyroid adenoma (figure 3). The final diagnosis was chronic stable SCFE1 with primary hyperparathyroidism. The patient underwent gamma probe guided right parathyroidectomy. Postoperatively he had an episode of hungry bone syndrome managed with intravenous followed by oral calcium. A month later, his bone profile normalised (calcium 8.7 mg/dL, phosphorus 2.6 mg/dL, ALP 200 IU/L, PTH 15 pg/mL). He underwent bilateral in situ pinning for physis (figure 4) uneventfully. SCFE is a common hip pathology (1:10 000) in adolescents.2 SCFE with primary hyperparathyroidism is very rare with 11 cases3 described. Radiological findings like subperiosteal bone resorption and coarsened trabeculae suggest this. Serum PTH and sestamibi scans help in confirming the diagnosis. If hyperparathyroidism is missed, patient is likely to have a poor outcome from a systemic and also hip standpoint. In SCFE, with atypical radiological findings like this case, the clinician should be vigilant to get further tests as hyperparathyroidism management takes precedence4 over SCFE. 文献出处：Kumar G, Mathew V, Kandathil JC, Theruvil B. Primary hyperparathyroidism presenting as slipped capital femoral epiphysis. Postgrad Med J. 2019 Oct 15. pii: postgradmedj-2019-136811. doi: 10.1136/postgradmedj-2019-136811. 张洪主任门诊时间：周三上午 关节外科护士站：01066867304 转848810（请在14:00-18:00拨入） 膝关节置换:张轶超 13261817537 髋关节置换:马云青 13811705624 保髋疗法:罗殿中 18911358880 |
|
|
