髋膝文献精译荟萃（第90期）

本期目录：

1、伴有膝反张的膝关节退行性骨关节炎的全膝置换效果

2、关节假体周围感染的一种新辅助诊断指标：血小板计数和血小板平均体积

3、何等程度的下肢不等长会对全髋关节置换术后的运动机能产生影响

4、成人髋膝关节化脓性关节炎的趋势：对过去50年接受治疗患者的回顾性分析

5、大转子截骨术对臀中肌功能的影响

6、髋关节镜下关节囊切开技术及缝合策略：系统综述

7、DDH继发骨关节炎的髋关节三维解剖

8、轻度或临界髋关节发育不良：用外侧中心边缘角(LCEA)为18°到25°描述恰当吗？

9、股骨头骨骺滑脱的诊断和治疗方案

第一部分：关节置换及保膝相关文献

文献1

伴有膝反张的膝关节退行性骨关节炎的

全膝置换效果

译者：张轶超

背景：本文的目的是评估非神经肌肉病变导致的反张膝行导航辅助全膝关节置换术（TKA）的效果，评估其短期的影像学和临床效果，根据术前过伸的度数、假体和垫片的类型评估其效果。

方法：本文回顾了从2005年1月到2011年12月的510例行导航辅助TKA的病例。用导航测量以膝关节过伸≥5°（膝反张）定义为过伸并评估其力线。使用倾向评分匹配法评估反张膝组和对照组的影像学指标，术中情况和临床效果。

结果：有465膝因退行性骨关节炎做了导航辅助TKA手术。反张膝有55例(11.8%)。其中，41膝(74.5%)的过伸角度在5到10°间，47膝(85.4%)为内翻膝。反张组(7.6 ± 1.6 mm)股骨远端的截骨量少于对照组(8.4 ± 1.4 mm, P= 0.001)。反张组(12.5 ± 2.3 mm)垫片厚度高于对照组(10.8 ± 1.5 mm,P<0.001)。随访最终矢状位伸直力线为对照组1.3 ± 3.4°，反张组−0.1 ± 0.7°(P= 0.003)。对于反张组各亚组的分析显示：根据术前过伸度数和假体/垫片类型不同的分组间，矢状位伸直力线及患者主观效果没有明显差异（所有参数的P>0.05）。

结论：初次TKA中反张膝不常见。这批病例由于减少了股骨远端截骨量并增加了垫片厚度，获得了满意的术后短期疗效和影像学结果。

采用导航测量矢状面力线：（A）麻醉下测量矢状面力线；（B）采用导航测量力线夹角度数。

Outcomes of total knee arthroplasty in degenerative osteoarthritic knee with genu recurvatum

BACKGROUND: This study aimed to assess the incidence of genu recurvatum without neuromuscular disorders in knees that underwent navigation-assisted total knee arthroplasty (TKA), to evaluate short-term radiologic and clinical results of navigation-assisted TKA in genu recurvatum, and to evaluate differences in results according to the degree of pre-operative hyperextension and type of implant and insert.

METHODS: This study retrospectively reviewed 510 knees that underwent navigation-assisted TKA from January 2005 to December 2011. The incidence of knees that showed hyperextension of ≥5° (genu recurvatum) on navigation, and the accompanying alignment were evaluated. It assessed radiologic, intraoperative, and clinical results in recurvatum and control groups by using propensity score matching.

RESULTS: A total of 465 knees underwent navigation-assisted TKA for degenerative osteoarthritis. Genu recurvatum was observed in 55 knees (11.8%). Of these, 41 knees (74.5%) had degree of hyperextension between five degrees and 10°, and 47 (85.4%) had varus alignment. The thickness of the resected distal femur in the recurvatum group (7.6±1.6mm) was less than that in the control group (8.4±1.4mm, P=0.001). The thickness of the insert in the recurvatum group (12.5±2.3mm) was greater than in the control group (10.8±1.5mm, P<0.001). The sagittal alignment at the final follow-up was 1.3±3.4° in the control group and -0.1±0.7° in the recurvatum group (P=0.003). Subgroup analyses in the recurvatum group showed no significant difference in sagittal alignment and patient-related outcomes by degree of pre-operative hyperextension and implant/insert type (P>0.05 for all parameters).

CONCLUSIONS: Genu recurvatum was not uncommon among patients undergoing primary TKA. This review obtained satisfactory short-term clinical and radiologic results, with a smaller distal femoral resection and thicker insert.

文献出处：Seo SS, Kim CW, Lee CR, Seo JH, Kim DH, Kim OG. Outcomes of total knee arthroplasty in degenerative osteoarthritic knee with genu recurvatum. Knee. 2018 Jan;25(1):167-176. doi: 10.1016/j.knee.2017.10.008. Epub 2018 Jan 9.

文献2

关节假体周围感染的一种新辅助诊断指标：

血小板计数和血小板平均体积

译者：马云青

背景：关节假体周围感染(PJI)的诊断困难，通常需要结合临床客观指标。本研究的目的是确定血小板(一种已知的急性反应物)是否能进一步有助于PJI的诊断。

方法：对2000年至2016年进行的全髋关节和膝关节翻修术(n=4939)进行单机构回顾性研究。PJI诊断按肌肉骨骼感染协会(MSIS)标准 (n=949)。从每例患者的术前全血计数分析中分别测定血小板计数(PC)和平均血小板体积(MPV)，对患者的血小板计数(PC)和平均血小板体积(MPV)的比值进行ROC曲线分析。

结果：PJI患者PC/MPV比值为33.45，无菌翻修组为25.68(p<0.001)。ROC曲线分析表明，当比值为31.70时，敏感度为48.10(95%CI 44.9~51.4)，特异度为80.85(95%CI 18 79.6~82.1)。这一特异性高于同一组研究对象中ESR和CRP的特异性，是ROC曲线分析确定的最佳值。当与ESR和CRP联合使用时，用于评估本研究队列中PJI的诊断准确性优于单独采用ESR和CRP，两者相比有显着性差异(P<0.05)。

结论：我们的研究表明，血小板及其相关的血清标志物与PJI相关，在怀疑为潜在的PJI患者诊断中值得考虑。

A Novel Adjunct Indicator of Periprosthetic Joint Infection: Platelet Count and Mean Platelet Volume

BACKGROUND: Diagnosing a periprosthetic joint infection (PJI) is difficult and often requires a combination of objective findings. The purpose of this study is to determine whether platelets, a known acute phase reactant, would be able to further aid in the diagnosis of PJI.

METHODS: A single-institution retrospective review study was performed on all revision total hip and knee arthroplasties done between 2000 and 2016 (n = 4939). PJI was defined by Musculoskeletal Infection Society criteria (n = 949). Platelet count and mean platelet volume were assessed from each patient's preoperative complete blood count. These values were then assessed as a ratio via receiver operating characteristic (ROC) curve analysis.

RESULTS: The platelet count to mean platelet volume ratio for PJI patients was 33.45 compared to 25.68 for patients in the aseptic revision cohort (P < .001). ROC curve analysis demonstrates that a ratio of 31.70 has a sensitivity of 48.10 (95% confidence interval 44.9-51.4) and a specificity of 80.85 (95% confidence interval 79.6-82.1). This specificity was higher than that of both estimated sedimentation ratio (ESR) and C-reactive protein (CRP) for the same cohorts using optimal values determined via ROC curve analysis. When used in conjunction with ESR and CRP, there was a statistically significant increase in the diagnostic performance of the model used to assess PJI relative to the model that just employed ESR and CRP (P < .05).

CONCLUSION: Our study demonstrates that platelets and their associated serum biomarkers are associated with PJI and warrant consideration in patients who are being evaluated for potential PJI.

文献出处：Paziuk T, Rondon AJ, Goswami K, Tan TL, Parvizi J. A Novel Adjunct Indicator of Periprosthetic Joint Infection: Platelet Count and Mean Platelet Volume. J Arthroplasty. 2019 Oct 15. pii: S0883-5403(19)30970-2. doi: 10.1016/j.arth.2019.10.012.

文献3

何等程度的下肢不等长会对

全髋关节置换术后的运动机能产生影响

译者：张蔷

本篇文章的目的是评估全髋关节置换术后2cm以内的下肢延长对日常活动中髋关节运动机能的影响。20名患者（年龄49至80岁不等）接受了采用Link公司Lubinus假体的全髋关节置换手术，均采用外侧入路，平均随访16个月，评估项目包括平地步行和上下台阶时的步态分析。得出的时间与运动学参数进行健侧-患侧对比。使用12项量表评估患者满意度及对肢体延长的接受程度。全髋关节置换术后平均延长11mm（标准差6mm）。结果显示在平地行走和上台阶时健侧与患侧髋关节的运动机能无显著性差异。满意度量表显示全髋关节置换术后患者满意度较高，只有两人反应存在跛行，且跛行与肢体不等长无相关性。从此研究中，我们可以得出结论：1-20mm的下肢不等长不会影响平路行走和爬台阶时的髋关节运动机能。患者的步态分析数据与肢体不等长的接受度并无相关性。尽管有证据显示：全髋关节置换术后2cm以内的肢体延长并不需要对侧垫鞋垫来纠正，但是否垫鞋垫需要患者根据自身情况来决定。

To what extent does leg length discrepancy impair motor activity in patients after total hip arthroplasty

The aim of this study was to evaluate the effects of limb lengthening up to 20 mm after THA on symmetry of hip kinematics and kinetics during common activities of daily living. Twenty patients (age range 49–80 years) operated on with Link Lubinus II THA, with lateral access and a mean follow-up of 16 months, were assessed by gait analysis during level walking, stair ascending and descending. The time-distance, hip kinetics and kinematics values were statistically compared between the operated side and the non-operated side in order to assess symmetry. The 12-item Questionnaire was used to assess satisfaction and personal perception of limb lengthening. Mean value of limb lengthening after THA was 11 mm (SD 6). Minor abnormalities were found in the kinematics and kinetics of the operated and non-operated hips during level walking and stair climbing. The score of the questionnaire corresponded to a high level of satisfaction after THA and only two patients complained of limping independent from the amount of discrepancy. From this study we can conclude that a leg length inequality in the range of 1–20 mm does not impair the symmetry of time–distance parameters and of hip kinematics and kinetics during gait and stairs walking. Although objective, gait analysis data did not correspond to patient’s perception of discrepancy, which is subjective and irrespective of the amount of lengthening. There is biomechanical evidence that a limb lengthening of up to two centimeters after THA in general does not need to be corrected by means of a contralateral shoe lift. Individual decisions to the contrary need to be justified.

文献出处：Maria Grazia Benedetti & Fabio Catani & Emanuela Benedetti & Lisa Berti & Annalisa Di Gioia & Sandro Giannini. To what extent does leg length discrepancy impair motor activity in patients after total hip arthroplasty. International Orthopedics (SICOT) (2010) 34:1115–1121

第二部分：保髋相关文献

文献1

成人髋膝关节化脓性关节炎的趋势：

对过去50年接受治疗患者的回顾性分析

译者：罗殿中

本项研究是对1955年至2005年在日本Tottori大学医院接受治疗的53例成人髋/膝关节化脓性关节炎（SA）患者进行的回顾性分析。本研究排除了术后感染、创伤引起的感染和假体周围感染的患者。将1955年至2005年期间的50年分为五个时期：第一个十年有5名患者，第二个十年有9名患者，第三个十年有11名患者，第四个十年有10名患者，第五个十年有18名患者。在第四个十年之前，所有SA都发生在膝关节。在第五个十年中发生了5例髋关节SA。与直接感染减少（关节内注射）相比，1986年后血源性感染病例增加。由金黄色葡萄球菌（包括耐甲氧西林的金黄色葡萄球菌，MRSA）引起的SA发生率在50年来最高。在第五个十年，由MRSA引起的感染占所有葡萄球菌感染的22%。在50年期间，患有糖尿病等合并症的患者人数有所增加。这项研究表明，SA患者的数量一直在增加。此外，血源性SA一直在增加。SA发生率的升高可能是由于机会性感染增加所致。髋关节SA的发生率及MRSA感染比例均有所增加。

不同时期SA例术及感染不稳的分布

不同时期血源性感染及直接感染的分布

不同时期致病菌分布

不同时期伴随疾病分布 RA：类风湿性关节液；DM：糖尿病

Recent trends in adult-onset septic arthritis of the knee and hip: retrospective analysis of patients treated during the past 50 years

This study was a retrospective analysis of 53 adult patients with septic arthritis (SA) of the knee or hip treated during the years from 1955 to 2005 in Tottori University Hospital in Japan. Patients with postoperative infection, infection caused by trauma, and periprosthetic infection were excluded. The 50-year period between 1955 and 2005 was divided into five periods: there were 5 patients in the first decade, 9 in the second decade, 11 in the third decade, 10 in the fourth decade, and 18 in the fifth decade. All SA occurred in the knee until the fourth decade. Five cases of septic arthritis in the hip occurred in the fifth decade. In contrast to the decrease in direct infections (post intraarticular injection), hematogenous infections were observed to increase after 1986. The rate of SA caused by Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus, MRSA) had been highest during the 50 years. Infections caused by MRSA, comprising 22% of all staphylococcal infection, occurred in the fifth decade. The numbers of patients with comorbid conditions such as diabetes increased during the 50-year period. This study indicated that patients with SA have been increasing in number. Furthermore, hematogenous SA has been increasing. The increase in occurrence of SA could result from increase in opportunistic infection, occurrence of SA of the hip, and increase in MRSA infection.

文献出处：Okano T, Enokida M, Otsuki R, Hagino H, Teshima R.  Recent trends in adult-onset septic arthritis of the knee and hip: retrospective analysis of patients treated during the past 50 years. J Infect Chemother. 2011 Oct;17(5):666-70. doi: 10.1007/s10156-011-0244-z. Epub 2011 May 17.

文献2

大转子截骨术对臀中肌功能的影响

译者：程徽

目的: 大转子的高度影响臀中肌的功能。然而，以往已有临床研究和力臂研究，尚没有文献分析大转子高度对肌肉功能的影响。本研究的目的是在实验室条件下分析大转子截骨后，臀中肌的力学变化。

方法: 对4个髋关节进行了臀中肌起止点的解剖学研究。在臀中肌解剖的基础上，建立了将肌肉分为5部分的弦模型。测量原始解剖位、上移、下移时，肌纤维长度在每10°屈髋、内旋、外旋、外展时的变化。

图1肌肉拉伸模型

结果: 大转子的下移导致肌肉运动的不平衡，使肌肉的等长扇区前移，在屈肌时肌束活动更多，伸髋时肌束活动较少。肌肉的拉伸增加了被动收缩力，但降低了肌肉主动收缩产生的力，同时增加了肌纤维的拉伸可能需要更多的能量消耗，这可能解释了大转子下移后外展肌组织较早出现疲劳。对于外展，肌肉附着点的下移导致收缩模式的变化，使等长收缩变成等张收缩。当大转子的尖端与髋旋转中心处同一水平时，肌肉的平衡和拉伸情况最佳。

结论: 对于大转子高位的髋关节，下移的最佳位置在髋旋转中心水平。应该避免过度的下移。由于结论和考虑是基于实验室设置，在临床实践中不一定适用。

Osteotomy of the greater trochanter: effect on gluteus medius function.

PURPOSE: Advancement of the greater trochanter alters the function of the gluteus medius muscle. However, with the exception of clinical studies and biomechanical lever arm studies, no publications that analyze the consequences of advancement of the greater trochanter on the muscle function exist. The aim of the study was to analyze the mechanical changes of gluteus medius after osteotomy of the greater trochanter in a lab setting.

METHODS: An anatomical study of origin and insertion of the gluteus medius was carried out on four hips. Based on the dissections, a string model was developed dividing the muscle into five sectors. Changes in muscle fiber length were measured for every 10° of flexion, internal and external rotation and abduction with the trochanter in anatomic, proximalized and distalized positions.

RESULTS: Distalization of the trochanter leads to an imbalance of muscle action, moving the isometric sector of the muscle anteriorly with more muscle sectors being active during flexion and less during extension. Stretching of the muscle increases passive forces but decreases the force generation capacity of the muscle and at the same time increased muscle fiber excursion may require more energy consumption, which may explain earlier fatigue of the abductor musculature after distalization of the trochanter. For abduction, distalization of the muscle attachment leads to a change in contraction pattern from isometric to isotonic. Optimal balancing and excursion of the muscle is when the tip of the greater trochanter is at level with the hip rotation center.

CONCLUSIONS: In hips with high riding trochanter, the optimal position is at the level of the center of hip rotation. Excessive distalization should be avoided. As the conclusions and considerations are based on a lab setting, transfer to clinical practice may not necessarily apply.

文献出处：Beck M, Krüger A, Katthagen C, Kohl S. Osteotomy of the greater trochanter: effect on gluteus medius function. Surg Radiol Anat. 2015 Aug;37(6):599-607. doi: 10.1007/s00276-015-1466-z. Epub 2015 Apr 1.

文献3

髋关节镜下关节囊切开技术及缝合策略：

系统综述

译者：肖凯

目的：髋关节镜越来越多地用于处理髋关节病变。据报道，医源性髋关节不稳是一种潜在的并发症，因此我们需要对各种囊处理策略进行评估。这综述的目的是（1）报道髋关节镜下进行关节囊切开术的技术；（2）了解髋关节囊缝合的技术和适应症；（3）报道不同关节囊处理策略的预后。

方法：在MEDLINE、EMBASE和PubMed数据库进行文章检索，并一式两份进行筛选以进行相关研究。收集内容包括患者人口统计学数据、手术适应症、手术技术、康复策略和并发症发生率。使用非随机研究方法索引（MINORS）准则，一式两份评估研究质量。

结果：本综述纳入82篇文章，包括循证等级为IV级（80 %）及一般质量的研究，共包括4504名患者，平均年龄为35岁（1.2-82岁）。百分之五十的患者是男性。平均随访时间为24.9个月（范围为5天至13年）。在68篇文章报告了关节囊切开术技术的研究中（仅占所有其他符合条件的研究的7％），有55％的患者进行了“一”字形切开，而24％的患者进行了“T”形切开。在36项报告了关节镜术后关节囊处理的研究中，有22％的没有修复囊，有6％的进行了部分修复，有50％的进行了完全修复。在直接比较关节囊处理策略的三项研究中（206例患者），只有一篇研究发现关节囊完全修复与部分修复之间的术后运动特异性预后评分存在统计学上的显着差异，尽管该差异在临床并不一定具有实际意义（83.6与87.3）。术后关节脱位、不稳定性的总发生率为0.3％（5例）。

结论：关于髋关节镜下关节囊切开和术后关节囊缝合技术细节的文献并不多。最常见的关节囊切开方式为“一”字形切开，多术近期的研究对关节囊进行了常规缝合。总体而言，术后髋关节不稳定较为罕见，关节囊的处理策略目前没有一致的趋势。根据现有的证据，手术中对关节囊的处理技术与术后不稳定或长期随访后果（例如运动学改变）之间无明确关系。因此，尽管囊的缝合或紧缩缝合可能适合于特定人群（如发育不良或韧带松弛患者），但是对于关节囊修复的基于证据支持的适应症仍不清楚。

关节囊切开及缝合技术 a 关节囊未切开前；b 关节囊“一”字形切开；c 关节囊“T”形切开；d 关节囊“一”字形缝合；e 关节囊“T”形切口部分缝合；f 关节囊“T”形切开完全缝合

Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review

PURPOSE: Hip arthroscopy is increasingly used to address hip joint pathology. Iatrogenic instability has been reported as a potential complication, leading to the evaluation of various capsular management strategies. The purpose of this review was to (1) report the techniques used for capsulotomy in hip arthroscopy, (2) understand techniques and indications for capsular closure, and (3) report outcomes based on capsular management strategy.

METHODS: MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, indications, surgical technique, rehabilitation strategies, and complication rates were obtained. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies (MINORS) Criteria.

RESULTS: Eighty-two studies of primarily level IV evidence (80 %) and of fair quality involving 4504 patients with a mean age of 35 years old (range 1.2-82 years) were included. Fifty percent of patients were male. Mean follow-up was 24.9 months (range 5 days to 13 years). Of 68 studies reporting capsulotomy technique (only 7 % of all otherwise eligible studies), 55 % performed an interportal capsulotomy while 24 % performed a T-capsulotomy. Of 36 studies reporting capsular management strategy post-arthroscopy, 22 % did not repair the capsulotomy, 6 % routinely performed partial repair, and 50 % performed complete repair. Of three studies (206 patients) directly comparing capsular management strategies, only one study found a statistically significant difference between complete and partial repair on the Hip Outcome Score-Sport Specific Subscale, though this difference was less than the minimal clinically important difference (83.6 versus 87.3). The total rate of reported post-operative dislocation, instability, or instability was 0.3 % (5 patients).

CONCLUSIONS: Technical details regarding capsulotomy and capsular management post-hip arthroscopy are not consistently reported in the literature. Capsulotomies are most often performed using an interportal technique, and more recent studies report routine closure. Overall, post-operative instability is rare and there is no consistent trend for capsular management strategy. Given current evidence, there is little basis on which to establish the relationship between surgical technique and post-operative instability or long-term consequences (e.g., kinematic changes). Thus, while capsular closure/plication may be suitable for specific populations (i.e., dysplasia or laxity), evidence-based indications for capsular repair remain unclear.

文献出处：Ekhtiari S, de Sa D, Haldane CE, Simunovic N, Larson CM, Safran MR, Ayeni OR. Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017 Jan;25(1):9-23. doi: 10.1007/s00167-016-4411-8. Epub 2017 Jan 24.

文献4

DDH继发骨关节炎的髋关节三维解剖

译者：任宁涛

本文应用X线和CT对69名成人（高加索人种）的83个髋关节进行形态学研究，83个髋关节为DDH继发性骨关节炎，以先前发表的310个髋关节原发性骨关节炎系列作为对照组。根据Crowe分型，33个髋关节为I型，27个髋关节为II型，23个髋关节为III 或IV型。与对照组相比，股骨髓腔内外径和前后径均减小，仅在CroweⅡ型髋关节中，股骨颈干角增加。在所有发育不良组中股骨近端前倾角均增大，范围从2度到80度。髋臼大小测量在X片和CT上测量相互一致。我们此次的研究结果也证实了先前仅对于日本人测量的观察结果。

图1 左股骨X片，FHC 股骨头中心，CLT 小转子中心， MC 髓腔轴， 影像学测量包括 MO内侧偏移，HFHC 股骨头中心高度，IP 峡部位置，N-S颈干角

图2 CT上测量髋臼前后径

图3 CT上前倾角测量，上面选择为小转子中心上20mm。

Three-dimensional anatomy of the hip in osteoarthritis after developmental dysplasia

Using radiography and computer tomography (CT) we studied the morphology of 83 hips in 69 Caucasian adults with osteoarthritis secondary to developmental dysplasia of the hip (DDH). A previously published series of 310 hips with primary osteoarthritis was used as a control group. According to the Crowe classification, 33 of the dysplastic hips were graded as class I, 27 as class II and 23 as class III or class IV. The intramedullary femoral canal had reduced mediolateral and anteroposterior dimensions in all groups compared with the control group. Only in Crowe class II hips was the femoral neck-shaft angle increased. The proximal femur had more anteversion in all the developmental dysplasia of the hip groups, ranging from 2 degrees to 80 degrees. Templated measurement of acetabular dimensions for plain radiography closely matched measurements taken by CT. The results of our study confirm the observations previously confined to the Japanese population.

文献出处：Argenson JN, Ryembault E, Flecher X, Brassart N, Parratte S, Aubaniac JM. Three-dimensional anatomy of the hip in osteoarthritis after developmental dysplasia. J Bone Joint Surg Br. 2005 Sep;87(9):1192-6.

文献5

轻度或临界髋关节发育不良：

用外侧中心边缘角(LCEA)为18°到25°描述恰当吗？

译者：张利强

背景：对于外侧中心边缘角(LCEA)为18°到25°之间的髋关节的分型和治疗是有争议的，还不确定行髋臼周围截骨术(PAO)或者髋关节镜手术是否是治疗这类患者的最佳方法。

假设：通过其它相关的影像学测量方法评估的髋臼前后壁、髋臼对股骨头的前覆盖和股骨头颈的球形改变发现有疼痛症状和用LCEA为18°到25°定义的轻度或临界髋臼发育不良的患者的髋臼和股骨形态是不同的。

方法：回顾性分析2010年1月到2015年12月LCEA为18°到25°行PAO或髋关节镜手术的患者。在前后位、Dunn位和假侧位片上测量LCEA、Tonnis角、前中心边缘角(ACEA)、前壁指数 (AWI) 、后壁指数 (PWI), 股骨骨骺臼顶 (FEAR) 指数、后前壁指数、α角和颈干角。然后对连续放射学变量进行分层聚类分析，以确定研究队列中不同类型的髋关节病理形态学。髋关节形态有性别差异，因此我们对每种性别分别进行了聚类分析。多因素回归分析用于确认女性髋关节镜手术患者与PAO患者的影像学参数的区别。

结果：研究期间98例髋关节疼痛和LCEA为18°-25°患者接受了手术治疗，77例（78%）为女性，81例（82%）有完整的X线片进行聚类分析。平均年龄22.6岁。髋关节镜40例（41%），PAO58例（59%）。ACEA（45%）、FEAR指数（34%）和AWI（30%）是所有患者中最常见的异常影像学参数。女性患者中，ACEA（55%）、FEAR指数（42%）和AWI（34%）是最常见的异常影像学参数。男性患者中，PWI（48%）是最常见的异常影像学。女性患者的髋臼形态分为3组：伴有凸轮的髋臼缺损、外侧髋臼缺损和前外侧髋臼缺损。对于男性患者的髋臼形态同样分为3组：具有全局凸轮的后外侧髋臼缺损、具有局灶凸轮的后外侧髋臼缺损和没有凸轮的外侧髋臼缺损。ACEA（比值比[OR]，47.7[95%CI，9.6-237.6]；P＜.001）和AWI（OR，3.9[95%CI，1.0-15.0]；P=.049）被确定为预测女性患者进行哪种手术的独立因素。

结论：综合评价LCEA为18°-25°患者的影像学参数，可发现髋关节形态的性别特异性，并显示出这些患者中很大比例的发育不良特征。仅对LCEA评估是一种过于简单的方法，可能会危及对患者行适当的分类，对于其他发育不良和不稳的髋关节治疗可能提供不足的指导。

1：股骨头中心；2：眉弓外侧点；3：眉弓内侧点；4：股骨头半径5股骨头骨骺内侧点；6：股骨头骨骺外侧点；白虚线：双侧股骨头中心连线；白实线：股骨颈轴线；白箭头：骶骨中轴线通过耻骨联合；黑虚线：髋臼后壁；黒实线：髋臼前壁；黑箭头：股骨颈的中心

A、外侧中心边缘角；B 、Tonnis角；C、前壁指数 (AWI)、后壁指数 (PWI)；D、后前壁指数；E、前中心边缘角(ACEA)；F、α角；G、颈干角；H、股骨骨骺臼顶 (FEAR) 指数

女性患者的髋臼形态分组：前外侧髋臼缺损（A）、外侧髋臼缺损（B）和伴有凸轮（箭头所指）的髋臼缺损（C）

男性患者的髋臼形态分为3组：具有全局凸轮的后外侧髋臼缺损  A）、具有局灶凸轮的后外侧髋臼缺损（B）和没有凸轮的外侧髋臼缺损（C）

Mild or Borderline Hip Dysplasia: Are We Characterizing Hips With a Lateral Center-Edge Angle Between 18 ° and 25 ° Appropriately?

Background: Controversy surrounds the classification and treatment of hips with a lateral center-edge angle (LCEA) between 18° and 25°. It remains undetermined as to whether periacetabular osteotomy (PAO) or arthroscopic surgery is best used to treat this patient population.

Hypothesis: Patients with hip pain and mild or borderline acetabular dysplasia defined by an LCEA between 18° and 25° have different features of acetabular and femoral morphology, as determined by other relevant radiographic measures assessing the anterior and posterior acetabular walls, anterior coverage of the femoral head by the acetabulum, and femoral head and neck junction sphericity.

Methods: A retrospective review of patients who had an LCEA between 18° and 25° undergoing hip preservation between January 2010 and December 2015 with either PAO or hip arthroscopic surgery was performed. Anteroposterior, Dunn lateral, and false profile radiographs were used to measure the LCEA, Tonnis angle, anterior center-edge angle (ACEA), anterior wall index (AWI) and posterior wall index (PWI), femoral epiphyseal acetabular roof (FEAR) index and posterior to anterior wall index, and alpha angle and femoral neck-shaft angle. An agglomerative hierarchical clustering analysis was then performed on the continuous radiographic variables to identify different subtypes of hip pathomorphology among the study cohort. There were sex-specific trends in hip morphology. Therefore, we proceeded to perform separate cluster analyses for each sex. Multivariate logistic regression was used to identify radiographic parameters for distinguishing between female patients who underwent hip arthroscopic surgery versus PAO.

Results: Ninety-eight patients with hip pain and an LCEA between 18° and 25° underwent surgery in the study period, 77 (78%) were female, and 81 (82%) had complete radiographs for cluster analyses. The mean age was 22.6 years. Hip arthroscopic surgery was performed in 40 (41%) patients, and PAO was performed in 58 (59%) patients. The ACEA (45%), FEAR index (34%), and AWI (30%) were the most commonly abnormal radiographic parameters among all patients. In female patients, the ACEA (55%), FEAR index (42%), and AWI (34%) were the most commonly abnormal radiographic parameters. In male patients, the PWI (48%) was the most common radiographic abnormality. For female patients, 3 clusters representing different patterns of hip morphology were identified: acetabular deficiency with cam morphology, lateral acetabular deficiency, and anterolateral acetabular deficiency. For male patients, 3 clusters were also identified: posterolateral acetabular deficiency with global cam morphology, posterolateral acetabular deficiency with focal cam morphology, and lateral acetabular deficiency without cam morphology. The ACEA (odds ratio [OR], 47.7 [95% CI, 9.6-237.6]; P＜.001) and AWI (OR, 3.9 [95% CI, 1.0-15.0]; P = .049) were identified as independent factors predicting which procedure was performed in female patients.

Conclusion: A comprehensive evaluation of radiographic parameters in patients with an LCEA between 18° and 25° identified sex-specific trends in hip morphology and showed a large proportion of dysplastic features among these patients. An isolated assessment of the LCEA is an oversimplistic approach that may jeopardize appropriate classification and may provide insufficient data to guide the treatment of hips with additional features of dysplasia and instability.

文献出处：Mcclincy M P , Wylie J D , Yen Y M , et al. Mild or Borderline Hip Dysplasia: Are We Characterizing Hips With a Lateral Center-Edge Angle Between 18° and 25° Appropriately?[J]. American Journal of Sports Medicine, 2019, 47(1):112-122.

文献6

股骨头骨骺滑脱的诊断和治疗方案

译者：陶可（北京大学人民医院骨关节科）

股骨头骨骺滑脱（SCFE）是青少年中最常见的髋部疾病，每10万名儿童中有10.8例患病。SCFE通常发生在8-15岁的儿童中，并且是儿童中最常见的漏诊诊断之一。滑脱的股骨头骨骺根据其稳定性而分类为稳定或不稳定型。该病与肥胖症和快速生长发育有关，偶尔与内分泌失调有关，例如甲状腺功能减退，生长激素补充，性腺功能减退和广泛的垂体功能减退。患者通常在臀部、腹股沟、大腿或膝盖处出现跛行和局部疼痛。通过双侧髋部X射线照相术可以确诊，对于稳定的SCFE患者，需要包括前后位和蛙式位X线片，而对于不稳定型SCFE患者，需要包括前后位和穿桌侧位片。治疗的目标是防止滑脱进展并避免并发症，如股骨头坏死和软骨溶解。通常使用原位螺钉固定治疗稳定的SCFE。不稳定的SCFE的治疗通常涉及原位固定，但手术时机、切开复位价值以及是否应使用牵引尚存在争议。

图1. 发育中的髋部解剖图。

图2. 臀部的强制性外旋。

图3. 轻度稳定型SCFE的蛙式位放射照相。

图4. 左侧SCFE前后位X线片。放射学征象包括：（A）钢圈征-在前后X线片上，在干骺端发现双倍密度（由骨骺后唇重叠在干骺端上引起的）；（B）与未受累侧相比，生长板（体部）变宽；（C）与未累及侧位相比，患侧骨骺高度降低；（D）克勒氏线（Klein's line）-在前后X线片中，沿股骨颈上缘绘制的线通常应穿过骨骺；SCFE的骨骺将跌至此线以下；（E）股骨外旋导致小转子突出。

图5. SCFE的放射学征象图。

（由上向下依次是：钢圈征；体部增宽；骨骺高度相对减少；骨骺不能与Klein线相交）

图6. Southwick法使用蛙式位X线片确定SCFE的滑脱严重程度。第一条线（a）是从骨骺的前缘到后缘连线。接下来，垂直于第一条线绘制一条线（b）。第三条线（c）是股骨干解剖轴向下绘制。线b和c形成的角度是骨骺骨干外侧轴角（LESA）。实际的滑脱角度是SCFE髋关节的LESA与未累及髋关节的LESA之间的差值。

图7. 经单螺钉原位固定治疗的双侧稳定型SCFE的前后位X线片。

Slipped Capital Femoral Epiphysis: Diagnosis and Management

Slipped capital femoral epiphysis is the most common hip disorder in adolescents, and it has a prevalence of 10.8 cases per 100,000 children. It usually occurs in children eight to 15 years of age, and it is one of the most commonly missed diagnoses in children. Slipped capital femoral epiphysis is classified as stable or unstable based on the stability of the physis. The condition is associated with obesity and growth surges, and it is occasionally associated with endocrine disorders such as hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Patients usually present with limping and poorly localized pain in the hip, groin, thigh, or knee. Diagnosis is confirmed by bilateral hip radiography, which needs to include anteroposterior and frog-leg lateral views in patients with stable slipped capital femoral epiphysis, and anteroposterior and cross-table lateral views in patients with the unstable form. The goals of treatment are to prevent slip progression and avoid complications such as avascular necrosis and chondrolysis. Stable slipped capital femoral epiphysis is usually treated using in situ screw fixation. Treatment of unstable slipped capital femoral epiphysis usually involves in situ fixation, but there is controversy about the timing of surgery, value of reduction, and whether traction should be used.

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