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本期目录： 1、血浆纤维蛋白原在假体周围感染的诊断中比血浆D-二聚体有更好的应用价值 2、髋臼周围截骨术治疗髋关节发育不良10年及20年的关节生存率 3、应用静态型和关节型占位器治疗全膝关节置换术后感染的随机对照研究 4、转子间旋转截骨术后股骨头坏死区出现的进行性塌陷导致骨关节炎改变 5、回顾骨科随机对照试验的样本量和统计效能20年前后的变化 6、磁共振测量髋关节盂唇宽度与术中评估的比较 7、髋关节假斜位片准确度和精确度评估 8、成人髋关节发育不良的影像学测量 9、股骨头缩小术和其他包容手术可改善股骨头球形度和包容性并减轻Legg-Calvé-Perthes病的疼痛 第一部分：关节置换及保膝相关文献 文献1 血浆纤维蛋白原在假体周围感染的诊断中比 血浆D-二聚体有更好的应用价值： 一项多中心回顾性研究 译者：张轶超 背景：我们一直在不懈的去寻找快速、准确的诊断假体周围感染（PJI）的标记物。既往的研究都聚焦于炎症标记物而很少研究与凝集指标相关的标记物。本研究的目的是通过多中心回顾性研究来评估血浆纤维蛋白原、D-二聚体和其它血液标记物对于假体周围感染诊断的价值。 方法：本研究观察了从2016年1月到2017年12月间的565例全髋、全膝翻修病例，其中有126例出现凝血相关并发症，对这些病例进行了分析。选取了439例病例，其中76例PJI病例和363例非PJI病例。PJI的诊断遵循国际共识会议（ICM）对于假体周围感染的标准。采用受试者操作特征（ROC）曲线对D-二聚体、血浆纤维蛋白原、血沉（ESR）、C-反应蛋白（CRP）水平和白细胞（WBC）计数进行分析。 结果：ROC曲线显示血浆纤维蛋白原具有最大的曲线下面积（AUC），0.852；紧随其后的是CRP和ESR，分别为0.810和0.808。D-二聚体排在倒数第二位，为0.657；最后是白细胞计数，为0.590。血浆D-二聚体的最佳阈值是1.25μg/mL，其敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）分别为0.645、0.650、0.278和0.897。血浆纤维蛋白原的最佳阈值是4.01g/L，其敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）分别为0.763、0.862、0.537和0.946。 结论：血浆D-二聚体对于诊断PJI的价值是有限的，而血浆纤维蛋白原显示了很好的利用价值。血浆纤维蛋白原具有很好的敏感性和特异性，与传统的指标（包括CRP、ESR）价值相当。 Plasma Fibrinogen Exhibits Better Performance Than Plasma D-Dimer in the Diagnosis of Periprosthetic Joint Infection: A Multicenter Retrospective Study BACKGROUND: The search for potential markers for a timely and accurate diagnosis of periprosthetic joint infection (PJI) is ongoing. Previous studies have focused on inflammatory markers and have rarely examined coagulation-related indicators. The purpose of this study was to evaluate the values of plasma fibrinogen, D-dimer, and other blood markers for the diagnosis of PJI through a multicenter retrospective study. METHODS: A total of 565 revision total hip and knee arthroplasty cases were enrolled in this study from January 2016 through December 2017, 126 of which had coagulation-related comorbidities and were analyzed separately. The remaining 439 cases included 76 PJI and 363 non-PJI patients. The definition of PJI was based on the International Consensus Meeting (ICM) on Periprosthetic Infection criteria. The diagnostic values of D-dimer, plasma fibrinogen, the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and white blood-cell (WBC) count were analyzed using receiver operating characteristic (ROC) curves. RESULTS: ROC curves showed that plasma fibrinogen had the highest area under the curve (AUC), 0.852, followed by 2 classical markers, the CRP level and ESR, which had an AUC of 0.810 and 0.808, respectively. D-dimer had an AUC of 0.657, which was the second lowest value and only slightly higher than that of the WBC count, 0.590. The optimal threshold for plasma D-dimer was 1.25 μg/mL, with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 0.645, 0.650, 0.278, and 0.897, respectively. The optimal threshold for plasma fibrinogen was 4.01 g/L, which showed good sensitivity, specificity, PPV, and NPV, with values of 0.763, 0.862, 0.537, and 0.946, respectively. CONCLUSIONS: Plasma D-dimer may have a very limited diagnostic value for PJI, while plasma fibrinogen, another coagulation-related indicator, exhibits promising performance. Plasma fibrinogen has good sensitivity and specificity for diagnosing PJI, with values similar to those of classical markers, including CRP level and ESR. 文献出处：Rui, Li, Hong-Yi, et al. Plasma Fibrinogen Exhibits Better Performance Than Plasma D-Dimer in the Diagnosis of Periprosthetic Joint Infection: A Multicenter Retrospective Study.[J]. The Journal of bone and joint surgery. American volume, 2019. 文献2 髋臼周围截骨术治疗髋关节发育不良 10年及20年的关节生存率 译者：马云青 背景：髋臼发育不良是一种多因素引起的疾病，其特征是髋臼变浅，容易导致髋关节骨关节炎。 Reinhold Ganz于1984年首次提出伯尔尼髋臼周围截骨术(PAO)治疗发育不良的髋关节，以期提供更好的股骨头覆盖，并延长患者自身髋关节寿命。自1987年以来，对430多名患者进行了PAO手术。本研究对这一组患者进行了横断面回顾性研究，以确定PAO后的10年和20年患者自身关节生存情况，以及评估术后功能和放射学结果。 方法：从1987年到2014年，由资深外科医生对434例髋臼发育不良患者进行PAO治疗。以回顾性方式以病历和/或邮件/电话问卷的方式获得了258名患者的302髋的资料。功能包括术后髋关节炎评分和UCLA活动评分。术前和术后X线片用于确定外LCE角、前CE角、Tonnis角/骨关节炎级和股骨头至髂耻线的距离。通过Kaplan-Meier分析确定了患者自身髋关节的存活率。 结果：在纳入研究的302个髋关节中，248个髋关节至本研究数据收集时仍然存在，54髋接受了全髋关节置换术(THA)。在PAO的整个队列中，患者的平均年龄为32.7岁（13至63岁）。女性患者有215例（83.3%)，男性患者43例(16.8%）。关节生存组PAO患者的平均年龄为32.3岁，THA组患者的平均年龄为36.6岁(P<0.01)。在数据采集时，随访时间为2至27年（平均11.2年）。髋关节骨关节炎的结果评分和UCLA活动评分报告了PAO后r仍生存的髋关节。通过存活和PAO失败的X线分析表明术前和术后Tonnis角和骨关节炎分级是转换为THA的主要预测因子(P<0.01)。PAO后髋关节的存活率在10年时为86%，在20年时为60%。髋关节生存情况按年龄分类，20岁、30岁、40岁和50岁的10年存活率分别为93.3%、90.1%、81.6%和63.2%。男性和女性患者的生存率没有显著差异；然而，男性患者与女性患者相比，15年以后的生存率呈下降趋势。 结论：在302个髋关节的队列研究中，PAO后患者自身髋关节10年和20年生存率分别约为86%和60%。年龄较大的PAO和较高的Tonnis分级是PAO后关节生存的反向预测因素。即使术后20年，存活的髋关节仍有良好的功能。本研究是PAO后最多患者和最长随访时间时间的生存率研究，本研究的结果与其他研究一致。 Ten- and 20-year Survivorship of the Hip After Periacetabular Osteotomy for Acetabular Dysplasia INTRODUCTION: Acetabular dysplasia is a multifactorial condition characterized by a shallow hip socket with predisposition to osteoarthritis of the hip. The Bernese periacetabular osteotomy (PAO), developed by Reinhold Ganz in 1984, reorients the dysplastic hip joint to provide more uniform coverage of the femoral head and to extend the longevity of the native hip. Since 1987, the senior author performed the Bernese PAO on more than 430 patients. We performed a cross-sectional retrospective study on this cohort of patients to determine the 10- and 20-year survivorship after PAO in addition to assessing functional outcomes and radiographic parameters. METHODS: Four hundred thirty-four patients were treated for acetabular dysplasia with PAO by the senior surgeon from 1987 to 2014. Data were obtained for 302 hips in 258 patients in a retrospective fashion from medical records and/or mail-in/phone questionnaires. Functional outcome data consisted of postoperative Hip Osteoarthritis Outcome Score and University of California-Los Angeles Activity Score. Pre- and postoperative radiographs were used to determine lateral center-edge angle, anterior center-edge angle, Tönnis angle/grade, and head-to-ilioischial line distance. Survivorship of the native hip was determined by Kaplan-Meier analysis. RESULTS: Of the 302 hips analyzed, 248 were still surviving native hips and 54 had gone on to a total hip arthroplasty (THA) at the time of data acquisition. The average age of patients in the entire cohort at PAO was 32.7 years (range, 13 to 63 years). Of the 258 patients, 215 were female patients (83.3%) and 43 male patients (16.8%). The average age of patients in the surviving group at PAO was 32.3 years, and the average age of patients in the THA group was 36.6 years (P < 0.01). At the time of data acquisition, follow-up ranged from 2 to 27 years (average, 11.2 years). Hip Osteoarthritis Outcome Score and University of California-Los Angeles Activity Score are reported for the surviving native hips after PAO. Radiographic analyses for surviving and failed hips are described, with pre- and postoperative Tönnis grade being statistically significant predictors for conversion to THA (P < 0.01). Survivorship of the native hip was 86% at 10 years and 60% at 20 years in the surviving cohort. Survivorship stratified by age at the time of PAO demonstrated a 10-year survivorship of 93.3%, 90.1%, 81.6%, and 63.2% at ages 20, 30, 40, and 50 years, respectively. No notable difference exists in survivorship between male and female patients; however, male patients had a trend toward lower survivorship compared with female patients at 15 years. CONCLUSION: The 10- and 20-year survivorship of the native hip after PAO is approximately 86% and 60%, respectively, in our cohort of 302 hips. Older age at the time of PAO and higher Tönnis grade are negative prognostic factors for joint survival after PAO. Surviving hips after PAO have good functional outcomes even up to 20 years after surgery. This survivorship analysis represents one of the largest and longest survival studies of patients after PAO, and our results are consistent with other published studies. 文献出处：Ziran N, Varcadipane J, Kadri O, Ussef N, Kanim L, Foster A, Matta J. Ten- and 20-year Survivorship of the Hip After Periacetabular Osteotomy for Acetabular Dysplasia. J Am Acad Orthop Surg. 2019 Apr 1;27(7):247-255. doi: 10.5435/JAAOS-D-17-00810. 文献3 应用静态型和关节型占位器治疗 全膝关节置换术后感染的随机对照研究 译者：张蔷 背景：目前对于二期感染翻修间应用静态型还是关节型抗生素骨水泥占位器依然没有定论。本篇多中心随机对照研究的目的是比较静态型和关节型抗生素骨水泥占位器用于全膝关节置换术后感染（根据MSIS标准）二期翻修的治疗效果。 方法：共68例二期翻修病例，随机分入静态型占位器组（32例）或关节型占位器组（36例）。统计学效力分析显示：为了检测到组间13°以上的活动度差异，我们最少需要28例病例。随机化分组后排除6例，6例最终死亡，7例失随访。 A.静态型占位器；B.关节型占位器 结果：静态占位器组的住院时长比关节占位器组多1天（6.1天 vs 5.1天；95%置信区间[CI]，分别为5.3天-6.9天和4.6天-5.6天；p=0.032），围术期未发现其他差异。在平均3.5年的随访（2.0年-6.4年）后，49名患者可再次接受评估。关节占位器组平均活动度为113°（95% CI, 108.4°-117.6°），而静态占位器组为100.2°（95% CI, 94.2°-106.1°）（p=0.001）。关节占位器组（79.4分）的平均KSS评分也高于静态占位器组（69.8分）（95% CI, 分别为72.4-86.3和63.6-76.1; p=0.043）。静态占位器组在二期手术时的切口暴露大于关节占位器组（16.7% vs 4.0%；95% CI，分别为0.6%-38.9%和0.5%-26.3%，p=0.189），且再手术率也高于关节组（25% vs 8.0%；95% CI，分别为9.8%-46.7%和1.0%-26%；p=0.138），但并没有显著性差异。 结论：3.5年的随访后，关节型占位器组的关节活动度更佳，KSS评分更高。取出感染假体后静态型占位器组的住院时间更长。在软组织条件允许同时骨量充足的情况下，选择关节型占位器显然效果更佳。 A Randomized Trial of Static and Articulating Spacers for the Treatment of Infection Following Total Knee Arthroplasty Background: There is no consensus whether the interim antibiotic spacer utilized in the 2-stage exchange arthroplasty should immobilize the joint or allow for motion. The purpose of this multicenter, randomized clinical trial was to compare static and articulating spacers as part of the 2-stage exchange arthroplasty for the treatment of chronic periprosthetic joint infection complicating total knee arthroplasty as defined with use of Musculoskeletal Infection Society criteria. Methods: Sixty-eight patients undergoing 2-stage exchange arthroplasty were randomized to either a static (32 patients) or an articulating (36 patients) spacer. An a priori power analysis determined that 28 patients per group would be necessary to detect a 13°difference in range of motion between groups. Six patients were excluded after randomization, 6 died, and 7 were lost to follow-up before 2 years. Results: Patients in the static group had a hospital length of stay that was 1 day greater than the articulating group after stage 1 (6.1 compared with 5.1 days; 95% confidence interval [CI], 5.3 to 6.9 days and 4.6 to 5.6 days, respectively; p = 0.032); no other differences were noted perioperatively. At a mean of 3.5 years (range, 2.0 to 6.4 years), 49 patients were available for evaluation. The mean motion arc was 113.0°(95% CI, 108.4° to 117.6°) in the articulating spacer group, compared with 100.2°(95% CI, 94.2° to 106.1°) in the static spacer group (p = 0.001). The mean Knee Society Score was higher in the articulating spacer cohort (79.4 compared with 69.8 points; 95% CI, 72.4 to 86.3 and 63.6 to 76.1, respectively; p = 0.043). Although not significantly different with the sample size studied, static spacers were associated with a greater need for an extensive exposure at the time of reimplantation (16.7% compared with 4.0%; 95% CI, 0.6% to 38.9% and 0.5% to 26.3%, respectively; p = 0.189) and a higher rate of reoperation (25.0% compared with 8.0%; 95% CI, 9.8% to 46.7% and 1.0% to 26.0%, respectively; p = 0.138). Conclusions: Articulating spacers provided significantly greater range of motion and higher Knee Society scores at a mean of 3.5 years. Static spacers were associated with a longer hospital stay following removal of the infected implant. When the soft-tissue envelope allows and if there is adequate osseous support, an articulating spacer is associated with improved outcomes. 文献出处：Nahhas CR, Chalmers PN, Parvizi J, Sporer SM, Berend KR, Moric M, Chen AF, Austin MS, Deirmengian GK, Morris MJ, Della Valle CJ. A Randomized Trial of Static and Articulating Spacers for the Treatment of Infection Following Total Knee Arthroplasty. J Bone Joint Surg Am. 2020 Feb 20. doi: 10.2106/JBJS.19.00915. 第二部分：保髋相关文献 文献1 转子间旋转截骨术后股骨头坏死区出现的 进行性塌陷导致骨关节炎改变—— 转子间旋转截骨术治疗股骨头坏死的中期随访 译者：罗殿中 背景：股骨头坏死的塌陷往往是渐进性的，一旦股骨头塌陷进展，关节的破坏则会不可避免的出现。因此，对于股骨头部分坏死的患者，已有多种截骨术方案尝试挽救股骨头以保持关节的正常功能。 方法：我们对接受Sugioka转子间旋转截骨术的21名患者（25髋）进行了平均6.4年随访。 结果：末次随访时20髋（80%）临床预后好或非常好，15髋（60%）达到影像学上的成功，表现为既没有新建负重区的塌陷，也没有关节间隙的狭窄。10髋（40%）出现了坏死区进行性塌陷，这其中有7髋随访期间出现了关节间隙的狭窄。16髋（64%）存在骨赘增生，其中股骨头外侧及前方常见。 结论：尽管转子间旋转截骨术可以避免新建负重区的塌陷，但是原坏死区的塌陷可以导致关节前方不稳定，导致关节骨关节炎改变。因此，如何避免术后出坏死区的塌陷对改善术后远期预后至关重要。 一名47岁男性股骨头坏死患者，术前股骨头坏死II期，对其进行了90°的前旋截骨。a, b显示术后1年时股骨头轮廓完整。c, d现术术后5年股骨头坏死区出现了塌陷，关节间隙变窄，股骨头骨赘增生。 Progressive Collapse of Transposed Necrotic Area After Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head Induces Osteoarthritic Change：Mid-term Results of Transtrochanteric Rotational Osteotomy for Osteonecrosis of the Femoral Head Introduction: Osteonecrosis of the femoral head is usually progressive, and once collapse of the femoral head develops, joint destruction almost invariably follows. Therefore, for partial osteonecrosis of the femoral head, various types of osteotomies have been developed in an attempt to save the femoral head and maintain the natural function of the hip joint. Materials and methods: We reviewed 25 hips in 21 patients for a mean follow-up period of 6.4 years after Sugioka's transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head. Results: The clinical results were excellent or good in 20 hips (80%), and radiological success was observed in 15 hips (60%) with an absence of both collapse of the newly established weight-bearing area of the femoral head and narrowing of the joint space. Progressive collapse of the transposed necrotic area was noted in 10 hips (40%), and of these 10 hips, narrowing of the joint space was observed in 7 (70%) at follow-up. A significant correlation was demonstrated between progressive collapse of the transposed necrotic area and narrowing of the joint space. Growth of an osteophyte of the femoral head was observed postoperatively in 16 hips (64%), particularly at anterior and lateral sites of the femoral head. Conclusions: Though collapse of a new weight-bearing area can be prevented, progressive collapse of the transposed necrotic area induces anterior joint instability, giving rise to osteoarthritic change. It is therefore concluded that prevention of the collapse of the transposed necrotic area is important for satisfactory long-term results. 文献出处：Hisatome T , Yasunaga Y , Takahashi K , et al. Progressive collapse of transposed necrotic area after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head induces osteoarthritic change[J]. Archives of Orthopaedic & Trauma Surgery, 2004, 124(2):77-81. 文献2 回顾骨科随机对照试验的样本量和 统计效能20年前后的变化 译者：程徽 背景：2001年发表的一项研究报告称，1997年发表在骨科主要期刊上的随机对照试验(RCTs)的样本量都过小，导致检测研究效果的统计效能较低。科学研究方法的基石是统计，统计效能低是研究结果无法重复的根本原因。本研究的目的是，观察在过去的20年里骨科研究质量的进步。 方法：按时间顺序进行检索7种骨科主要期刊2016年和2017年发表的随机对照试验。通过研究中报道的样本大小计算Cohen d值，来检测小、中、大不同效应量后验效能。还计算了最常用的患者自测疗效测量法(PROMs)相关的效应量的检验销量。最后，统计了所有纳入研究是否使用了样本量的估算。 结果：共有233项研究纳入最终分析。所有的阴性研究都没有纳入足够的样本(≥0.80)来检测小的效应量。只有15.0%至32.1%的阴性研究有足够的能力检测中等的效应量。当按解剖区域分类时，0%至52.6%的的研究有足够的统计效能测算出效应量的最小重要性差值(MCID)的大小。233项研究中的196项(84%)采用了样本量估算。然而，46%的使用均值比较的研究中，样本量的估算无法重复。 结论：尽管在过去20年里，骨科随机对照试验取得了小小的进步，但许多随机对照试验的统计效能仍不尽人意：样本量仍然太小，不足以检测出哪些临床疗效真正来自于治疗。 Revisiting the Sample Size and Statistical Power of Randomized Controlled Trials in Orthopaedics After 2 Decades Background: A study published in 2001 reported that sample sizes in the randomized controlled trials (RCTs) published in major orthopaedic journals in 1997 were too small, resulting in low power to detect reasonable effect sizes. Low power is the fundamental reason for the poor reproducibility of research findings and serves to erode a cornerstone of the scientific method. The aim of this study was to ascertain whether improvements have been made in orthopaedic research during the past 2 decades. Methods: The electronic table of contents from the 2016 and 2017volumes of 7 major orthopaedic journals were searched issue by issue in chronological order to identify possible RCTs. A posteriori (after-the fact)power to detect small, medium, and large effect sizes, defined by the Cohen d value, were calculated from the sample sizes reported in the studies. The power to detect effect sizes associated with the most commonly used patient-reported outcome measures (PROMs) was also calculated. Finally, the use of a priori power analysis in the included studies was assessed. Results: In total, 233 studies were included in the final analyses. None of the negative studies had sufficient power (≥0.80) to detect a small effect size. Only between 15.0% and 32.1% of the negative studies had adequate power to detect a medium effect size. When categorized by anatomic region, 0% to 52.6% had adequate power to detect an effect size corresponding to the minimal clinically important difference(MCID). An a priori power analysis was employed in 196 (84%) of the 233studies. However, the power analysis could not be replicated in 46% of the studies that used a mean comparison. Conclusions: Although small improvements in orthopaedic RCTs have occurred during the past 2 decades, many RCTs are still underpowered: the sample sizes are still too small to have adequate power to detect what would be deemed clinically relevant. 文献3 磁共振测量髋关节盂唇宽度与术中评估的比较 译者：肖凯 目的：明确关节直接造影MRI或普通MRI是否可以准确测量髋关节盂唇的宽度。 方法：选择2017年12月至2018年6月间连续就诊的接受髋关节镜手术治疗的FAI患者，年龄在18岁至65岁之间。术前MRI的纳入标准包括：系统中存在可用的MRI图像；有1.5T或3T MRI图像或3T造影MRI图像；图像质量正常且没有盂唇钙化。根据时钟定位，在术中对标准化位置的盂唇宽度进行测量。使用校准的探针进行测量。盂唇宽度的定义为盂唇自髋臼缘向外侧延伸的距离。MRI测量是由两名在肌肉骨骼方向的放射科医生独立进行的。测量的点位分别是在冠状位质子密度相测量11:30位置，在斜轴位质子密度相测量3:00位置，在矢状面抑脂相测量1:30位置。外科医生与放射科医生的测量数据均不知情。使用组内相关系数（ICC），绝对一致性和2随机效应模型比较术中和影像学盂唇宽度测量值的差异。使用相同的ICC模型比较2位放射科医生的测量结果之间的一致性。 结果：共纳入51例患者（30例女性，26例右髋）。通过关节镜测量在3:00、11:30和1:30位置的平均盂唇宽度为5.8 mm（范围;标准偏差2-8;±1.4），6.3 mm（2-10;±1.5）和6.0 mm（2-9;±1.5），MRI测量结果分别为6.3 mm（2-10;±1.5），6.7 mm（3-10;±1.4）和6.1 mm（2-9;±1.6）。外科医生术中评估与放射科医生MRI测量在3:00、11:30以及1:30之间的ICC一致性为0.82（P <.001），0.78（P <.001），0.84 （P <.001）。放射科医生在同一点的ICC一致性为0.88（P <.001），0.93（P <.001）和0.88（P <.001）。 结论：MRI测量盂唇宽度和关节镜下测量盂唇宽度的结果存在高度一致性，这表明MRI是测量盂唇宽度的一种准确方法。不同的MRI方式之间没有显着差异。术前用MRI准确测量盂唇宽度可能有助于手术决策。 术中（A）及冠状位MRI（D）测量11:30盂唇宽度，术中（B）及矢状位MRI（E）测量1:30盂唇宽度，术中（A）及斜轴位MRI（D）测量3:00盂唇宽度 Measurement of Hip Labral Width Compared With Intraoperative Assessment Purpose: To determine if magnetic resonance angiography (MRA) and/or magnetic resonance imaging (MRI) could accurately determine the width of the labrum. Methods: Consecutively enrolled patients between the ages of 18 and 65 indicated for hip arthroscopy for femoroacetabular impingement were included between December 2017 and June 2018. Inclusion criteria for preoperative MRIs included: MRI availability in picture archiving and communication system; performance on a 1.5T or 3T MRI or 3T MRA; and adequate quality and lack of labrum ossification. Intraoperative labral width measurements were taken at standardized locations using an established acetabular 'clockface' paradigm. Measurement was performed using a calibrated probe. The labral width was defined as the distance from the labrum extended laterally from the acetabular rim. MRI measurements were taken by 2 blinded musculoskeletal fellowship-trained radiologists at the same positions. Measurements were made at the 11:30 o'clock position (indirect rectus) on coronal proton density (PD) sequence, at 3 o'clock position (psoas-U) on axial oblique PD sequence, and at 1:30 (a point halfway between the 2) on sagittal fat-suppressed PD. The surgeons were blinded to the radiologists' measurements and vice versa. Intraoperative and radiographic labral width measurements were compared using an intraclass correlation coefficients (ICC), absolute agreement, and 2-way random effects model. The 2 radiologists' measurements were compared for interrater reliability using the same ICC model. Results: Fifty-one patients were included (30 females, 26 right hips). Average labrum width at the 3:00, 11:30, and 1:30 o'clock positions by arthroscopic measurement were 5.8 mm (range; standard deviation, 2-8; ±1.4), 6.3 mm (2-10; ±1.5) and 6.0 mm (2-9; ±1.5), and by MRI were 6.3 mm (2-10; ±1.5), 6.7 mm (3-10; ±1.4), and 6.1 mm (2-9; ±1.6), respectively. When including all MRI modalities, ICC agreement between intraoperative assessment, and radiologist assessment at the 3:00 o'clock, 11:30, and point halfway between was 0.82 (P < .001), 0.78 (P < .001), 0.84 (P < .001), respectively. Radiologist interrater ICC agreement at the same points was 0.88 (P < .001), 0.93 (P < .001), and 0.88 (P < .001). Conclusions: Strong agreement was found between radiologic and arthroscopic measurement of labrum width when using MRI, suggesting MRI is an accurate way to measure labral width. There was not a significant difference between different MRI modalities. Accurately measuring labral width preoperatively with MRI may aid in surgical decision making. 文献出处：Kaplan DJ, Samim M, Burke CJ, Meislin RJ, Youm T. Validity of Magnetic Resonance Imaging Measurement of Hip Labral Width Compared With Intraoperative Assessment. Arthroscopy. 2020 Mar;36(3):751-758. doi: 10.1016/j.arthro.2019.09.027. Epub 2019 Nov 29. 文献4 髋关节假斜位片准确度和精确度评估 译者：任宁涛 目的：旨在评估现存髋关节假斜位片准确度和精确度，并设计一种提高髋关节假斜位片准确性和精确性的方法。 方法：设计一种髋关节假斜位片的成像方法，前后3个月的髋关节假斜位片检查各采用现存成像方法和新的成像方法。采用Student t检验和方差分析确定两组骨盆旋转的均值和方差。通过C臂获得10个骨盆的正位和旋转图像，验证骨盆旋转的计算方法，测定各假斜位图像髋关节中心距离合AP图像髋关节中心距离的比值（WP/W）。采用组内相关系数（ICC）检验WP/W与骨盆旋转的关系。 结果：平均WP/W为0.47 (95% CI, 0.45-0.49)。现存方法组（47.6°；95%CI，45.6-49.5°）和新方法组（60.0°；95%CI，58.7-61.3°）的平均骨盆旋转度有显著性差异（p<0.0001）。此外，与新方法组（SD=5.7，p=0.0035）相比，现存方法组（SD=7.9°）的测量值分布更广。 结论：在临床中获得的假斜位片质量可能不一致，标准化假斜位片产生更精确的图像。恰当的假斜位片应在髋关节中心之间的距离约为前后（AP）片上相同距离的0.5倍。 图1 正位片上股骨头中心距离与假斜位片上股骨头中心距离之间的几何关系。 图2 股骨头之间的距离，（a）假斜位，（b）正位，通过这些距离之间的比率计算旋转程度。 图3 射线照相足印和假斜位标准体位。受试者先站在第一组足印上进行AP位照相，然后旋转至第二组脚印进行假斜位照相。 图4 不同骨盆旋转程度WP/W比值（虚线95%CI），尸体研究发现65度斜位时WP/W=0.47. 图5 标准化方法实施后骨盆旋转的准确度和精确度出现显著差异的统计盒型图。 表1 研究对象人口统计学情况 Assessing precision and accuracy of false-profile hip radiographs Purpose: The purpose of this study was to assess the accuracy and precision of pelvic rotation in existing false-profile (FP) radiographs and to devise a method to improve accuracy and precision of FP radiographs. Methods: An imaging protocol was developed to obtain FP radiographs. Pelvic rotation was calculated using the described method for FP images obtained in the 3 months prior to and after implementation of this protocol. Student's t-test and variance ratio tests were used to determine differences in mean and variance of pelvic rotation between the 2 cohorts. Pelvic rotation calculation methodology was validated by using fluoroscopic C-arm to obtain AP and rotated images of 10 osteologic pelvises. The ratio of the distance between hip centres of each rotated image and AP image (WP/W) was determined. Intraclass coefficient correlation (ICC) was used to verify the relationship between WP/W and pelvic rotation. Results: Mean WP/W was 0.47 (95% CI, 0.45-0.49). There were significant differences in mean pelvic rotation of the pre-protocol group (47.6°; 95% CI, 45.6-49.5°) and the post-protocol group (60.0°; 95% CI, 58.7-61.3°, p < 0.0001). Additionally, there was a significantly wider distribution of measurements in the pre-protocol group (SD = 7.9°) compared to the post-protocol group (SD = 5.7°, p = 0.0035). Conclusions: The quality of FP radiographs obtained in the clinical setting may be inconsistent. Standardising FP imaging produces more accurate images. Appropriate FP radiographs should have a distance between hip centres that is approximately 0.5 times the same distance found on an anteroposterior (AP) radiograph. 文献出处：Ryan T Li , Mithun Neral , Heath Gould , Emily Hu , Raymond W Liu , Michael J Salata . Assessing precision and accuracy of false-profile hip radiographs. Hip Int. 2019 Sep 23:1120700019877848. doi: 10.1177/1120700019877848. 文献5 成人髋关节发育不良的影像学测量 张利强 髋关节发育不良在成人中是一种常见疾病，从轻微的髋臼发育不良到髋关节发育不良的复杂后遗症。本文介绍了评估成人髋关节的最有用的影像学测量方法。骨盆的前后位片允许测量中心边缘角（CE角）和臼顶倾斜角（HTE角），这两个角度都可以评估髋臼顶的覆盖范围。股骨颈干角（NSA）也在此视图上测量。骨盆的假侧位片允许测量前垂直中心边缘角（VCA角），可确定髋臼前部的覆盖范围，并检测早期退行性髋关节疾病。当考虑手术时，计算机断层扫描（CT）有助于利用前髋臼扇形角（AASA）更好地确定前髋臼的覆盖范围，而利用后髋臼扇形角（PASA）更好地确定后髋臼的覆盖范围。CT也可以测量股骨前倾角。这些测量对髋臼发育不良的评估和髋关节发育不良的术前评估特别有用。 CE角为通过两侧股骨头中心的连线的垂线和股骨头中心与髋臼外侧缘的连线的夹角，正常值为大于25° THE角为双侧股骨头中心的连线和髋臼负重区内外侧缘连线的夹角，正常值为小于10°
髋臼指数为髋臼深度/髋臼宽度
假斜位片拍摄技术：足的轴位平行于底板，骨盆与底板成65°
VCA角（前中心边缘角）：在假斜位片上，通过股骨头中心与髋臼前缘的连线和股骨头中心的垂线的夹角，正常值大于25°
CT显示髋臼的覆盖，示意图展示为通过股骨头中心的水平面，AASA决定前覆盖，PASA决定后覆盖，HASA为总覆盖
股骨头的髋臼覆盖率：(A/B) ×100，<75%考虑病理性
22岁女性，A 平片显示双侧髋关节发育不良，B CT显示AASA 和 PASA都减少 Radiographic measurements of dysplastic adult hips Hip dysplasia is a not uncommon feature in adults and can vary from subtle acetabular dysplasia to complex sequelae of developmental dysplasia of the hip. This review article describes the most useful radiographic measurements used to evaluate the adult hip. The frontal projection of the pelvis permits measurement of the center-edge angle(CE angle) and “horizontal toit externe” angle (HTE angle), both of which assess the superior coverage of the acetabulum. The femoral neck-shaft angle (NSA) is also measured on this view. The false profile radiograph of the pelvis is described. It allows measurement of the vertical-center-anterior angle (VCA angle), which determines the anterior acetabular coverage and detects early degenerative hip joint disease. When surgery is contemplated, computed tomography (CT) is useful to better determine the anterior acetabular coverage by use of the anterior acetabular sector angle (AASA), and the posterior acetabular coverage by use of the posterior acetabular sector angle (PASA). CT also permits measurement of femoral anteversion. These measurements are particularly useful in the evaluation of acetabular dysplasia and for the preoperative assessment of the dysplastic hip. 文献出处：Delaunay S , Dussault R G , Kaplan P A , et al. Radiographic measurements of dysplastic adult hips[J]. Skeletal Radiology, 1997, 26(2):75-81. 文献6 股骨头缩小术和其他包容手术可改善股骨头球形度和 包容性并减轻Legg-Calvé-Perthes病的疼痛 译者：陶可（北京大学人民医院骨关节科） 背景：髋部疾病如Legg-Calvé-Perthes病（LCPD）在冠状位可见严重股骨头畸形而髋臼未受累，并导致关节合页状外展和撞击症。这些罕见畸形不能仅通过切除来解决，因为切除会危及头部血管。股骨头复位截骨术可改善股骨头形状，以改善股骨头球形度、包容性和髋部功能。 问题/目的：在股骨头严重非球性的髋关节中，股骨头缩小术是否会导致（1）改善头部球形度和包容性；（2）缓解疼痛，改善髋关节功能；（3）随后的再次手术或并发症？ 方法：在10年时间里，我们对11例（11髋）严重非球性股骨头进行了股骨头缩小术，这些患者术前诊断为LCPD（10髋）或髋关节发育不良（一侧髋）经保守治疗而引起的骨骺灌注不平衡。11髋中有5例接受了髋臼包容手术，包括2例三联截骨术，2例髋臼周围截骨术（PAO）和1例Colonna成形术。平均对患者进行了5年（1-10年）的复查，没有患者丢失随访。股骨头切开截骨术时的患者平均年龄为13岁（范围7-23岁）。我们获得了球形指数（定义为骨盆前后位片上最适合股骨头关节表面绘制的椭圆的短轴与长轴之比）以评估头形球度。评估包容性是用具有完整Shenton线、挤压指数和外侧中心边缘（LCE）角度的患者比例评估的。评估Merled' Aubigné-Postel得分和运动范围（屈曲、屈曲90°的内旋/外旋）以测量疼痛和功能。通过图表检查确定并发症和再次手术。 结果：在最新的随访中，股骨头的球形度（术前72％，64％-81％对比术后85％，73％-96％；p = 0.004），挤压指数（术前47％，范围25％-60％对比术后20％，范围3％-58％；p = 0.006）和LCE角（术前1°，范围-10°至16°对比术后26°，范围4°-40°；p = 0.0064）等都有明显改善。此外，完整的Shenton线比例（64％对100％；p = 0.087）和Merled' Aubigné-Postel总体得分（术前14.5，范围12-16对比术后15.7，范围12-18；p = 0.072）在最新随访中保持不变。Merled' Aubigné-Postel疼痛评分得到改善（术前3.5，范围1-5对比术后5.0，范围3-6；p = 0.026）。没有观察到运动范围随病例量的增加而改善（p范围从0.513到0.778）。除了两个髋部的内固定物去除外，在平均间隔为2.3年（0.2-7.5年）后，对11髋中的5个进行了后续手术，以改善包容性。其中，两髋行三联截骨术，一髋行三联 粗隆间外翻截骨术，一髋行转子间内翻截骨术，一髋行粗隆间外翻截骨术。股骨头未发生缺血坏死。 结论：股骨头缩小术可以改善股骨头的球形度。这些髋关节经常有发育异常的髋臼，从而改善了头部的头部包容性，因此需要最好同时进行额外的髋臼包容性手术。这可以减轻疼痛，并且股骨头缺血坏死似乎很少发生。随着患者数量的增加，功能并未改善。因此，未来的研究应使用更精确的仪器评估临床结果，并包括更长的随访时间以确认保髋疗效。
图1. 为了进行股骨头缩小术，将患者置于侧卧位。髋关节通过臀大肌和臀肌之间的间隔（Gibson间隔）进行外科脱位以完成粗隆间截骨术。支持带软组织瓣延长确保了股骨头活动片段的血管供应。软组织瓣通过大转子的后侧骨膜下解剖而形成，包括旋股内侧动脉和附着短的外旋肌。通过沿矢状方向进行股骨头截骨术去除股骨头的中央坏死部分。最终，股骨头的活动部分被固定到稳定部分，目的是改善头部球形度并减小头部尺寸。
图2A–B. （A）股骨头缩小术可以治疗冠状位股骨头表面严重的非球性。首先，进行了粗隆截骨术，切除典型的高位大转子的稳定部分（相对股骨颈延长）。沿矢状方向进行截骨术切除股骨头坏死的中央部分。可移动的股骨头片块血供通过延伸包括旋股内侧动脉的支持带血管软组织瓣得以确保。稳定部分的股骨头血供来源于流经Weitbrecht韧带上方的支持带下动脉和干骺端血流。（B）然后将股骨头的可移动片块固定到稳定部分，目的是恢复股骨头球形并使其适合于髋臼。股骨颈的骨缺损被大转子的稳定部分充填。股骨转子片段被固定在较高位置。
图3A–D. 一名9岁的男性患者（A）由于LCPD而导致股骨头外侧柱塌陷。（B）病人行股骨头缩小术，切除中央坏死区域以改善股骨头球形度。另外，大转子进行了改良采用转子稳定部分的切除和头颈偏移的改善（股骨颈相对延长）。（C）头部的包容不足，股骨头仍处于半脱位状态（Shenton线中断；虚线）。（D）在进行了三联截骨术后，经过2年的随访，获得了良好的股骨头球形度。
图4A–E. （A）一名22岁的女性患者患有LCPD后遗症。（B）在外展中，由于股骨头非球形大，导致关节铰链外展，而股骨头不能进入髋臼。（C）股骨头缩小术后，由于股骨头尺寸减小和球形度提高，股骨头能够进入髋臼，从而改善了外展。（D）伴随的PAO改善了包容度。（E）在5年的随访中，头部和转子的截骨术均已愈合，并保持了关节间隙。
图5A–B. （A）一名18岁的男性患者，表现为股骨头中央坏死和半脱位。（B）股骨头缩小术和随后的股骨粗隆间内翻截骨术后，在10年的随访中获得了球形的股骨头并获得了良好的临床效果。 Head reduction osteotomy with additional containment surgery improves sphericity and containment and reduces pain in Legg-Calvé-Perthes disease BACKGROUND: Severe femoral head deformities in the frontal plane such as hips with Legg-Calvé-Perthes disease (LCPD) are not contained by the acetabulum and result in hinged abduction and impingement. These rare deformities cannot be addressed by resection, which would endanger head vascularity. Femoral head reduction osteotomy allows for reshaping of the femoral head with the goal of improving head sphericity, containment, and hip function. QUESTIONS/PURPOSES: Among hips with severe asphericity of the femoral head, does femoral head reduction osteotomy result in (1) improved head sphericity and containment; (2) pain relief and improved hip function; and (3) subsequent reoperations or complications? METHODS: Over a 10-year period, we performed femoral head reduction osteotomies in 11 patients (11 hips) with severe head asphericities resulting from LCPD (10 hips) or disturbance of epiphyseal perfusion after conservative treatment of developmental dysplasia (one hip). Five of 11 hips had concomitant acetabular containment surgery including two triple osteotomies, two periacetabular osteotomies (PAOs), and one Colonna procedure. Patients were reviewed at a mean of 5 years (range, 1-10 years), and none was lost to followup. Mean patient age at the time of head reduction osteotomy was 13 years (range, 7-23 years). We obtained the sphericity index (defined as the ratio of the minor to the major axis of the ellipse drawn to best fit the femoral head articular surface on conventional anteroposterior pelvic radiographs) to assess head sphericity. Containment was assessed evaluating the proportion of patients with an intact Shenton's line, the extrusion index, and the lateral center-edge (LCE) angle. Merle d'Aubigné-Postel score and range of motion (flexion, internal/external rotation in 90° of flexion) were assessed to measure pain and function. Complications and reoperations were identified by chart review. RESULTS: At latest followup, femoral head sphericity (72%; range, 64%-81% preoperatively versus 85%; range, 73%-96% postoperatively; p = 0.004), extrusion index (47%; range, 25%-60% versus 20%; range, 3%-58%; p = 0.006), and LCE angle (1°; range, -10° to 16° versus 26°; range, 4°-40°; p = 0.0064) were improved compared with preoperatively. With the limited number of hips available, the proportion of an intact Shenton's line (64% versus 100%; p = 0.087) and the overall Merle d'Aubigné-Postel score (14.5; range, 12-16 versus 15.7; range, 12-18; p = 0.072) remained unchanged at latest followup. The Merle d'Aubigné-Postel pain subscore improved (3.5; range, 1-5 versus 5.0; range, 3-6; p = 0.026). Range of motion was not observed to have improved with the numbers available (p ranging from 0.513 to 0.778). In addition to hardware removal in two hips, subsequent surgery was performed in five of 11 hips to improve containment after a mean interval of 2.3 years (range, 0.2-7.5 years). Of those, two hips had triple osteotomy, one hip a combined triple and valgus intertrochanteric osteotomy, one hip an intertrochanteric varus osteotomy, and one hip a PAO with a separate valgus intertrochanteric osteotomy. No avascular necrosis of the femoral head occurred. CONCLUSIONS: Femoral head reduction osteotomy can improve femoral head sphericity. Improved head containment in these hips with an often dysplastic acetabulum requires additional acetabular containment surgery, ideally performed concomitantly. This can result in reduced pain and avascular necrosis seems to be rare. With the number of patients available, function did not improve. Therefore, future studies should use more precise instruments to evaluate clinical outcome and include longer followup to confirm joint preservation. 文献出处：Siebenrock KA, Anwander H, Zurmühle CA, Tannast M, Slongo T, Steppacher SD. Head reduction osteotomy with additional containment surgery improves sphericity and containment and reduces pain in Legg-Calvé-Perthes disease. Clin Orthop Relat Res. 2015 Apr;473(4):1274-83. 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 |
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