本期目錄：
1、全膝關(guān)節(jié)置換術(shù)后麻醉下推拿的危險(xiǎn)因素、效果和時(shí)機(jī)
2、下肢關(guān)節(jié)置換術(shù)前是否需要治療抑郁癥？
3、及以下年齡初次全髖關(guān)節(jié)置換病例的10年生存隨訪
4、股骨轉(zhuǎn)子間后旋截骨治療股骨頭壞死：平均11年隨訪
5、股骨轉(zhuǎn)子間截骨治療非創(chuàng)傷性股骨頭壞死的長(zhǎng)期隨訪
6、髖關(guān)節(jié)疾病患者關(guān)節(jié)周圍軟組織的差異
7、髖關(guān)節(jié)發(fā)育不良繼發(fā)髖外翻的治療
第一部分：關(guān)節(jié)置換相關(guān)文獻(xiàn)
文獻(xiàn)1
全膝關(guān)節(jié)置換術(shù)后麻醉下推拿的危險(xiǎn)因素、效果和時(shí)機(jī)
譯者：張軼超
背景：全膝關(guān)節(jié)置換術(shù)（TKA））后膝關(guān)節(jié)僵直的病人在麻醉下進(jìn)行推拿松解（MUA））的效果不理想，但是目前我們還不清楚MUA的危險(xiǎn)因素和時(shí)機(jī)選擇。
方法：回顧了在一個(gè)醫(yī)療中心完成的初次全膝關(guān)節(jié)置換術(shù)。比較了術(shù)后做過(guò)MUA和沒做過(guò)的病例的一些臨床變量。利用那些存在差異的變量來(lái)選擇條件相匹配的未行MUA病例作為對(duì)照組來(lái)進(jìn)行比較。MUA組被分為早期組（≤6周）和晚期組（＞6周）兩個(gè)亞組。比較多個(gè)時(shí)間點(diǎn)的屈曲度值。
結(jié)果：一共1729名TKA病人；有62名實(shí)行了MUA。做了MUA的病人更加年輕(55.2歲對(duì)65.3歲,P<.001)，有較高的近期(21.0%對(duì)7.3%,P<.001)和以往(59.7%對(duì)40.4%, P=0.002)吸煙率，更多的病人之前做過(guò)關(guān)節(jié)鏡手術(shù)；在沒有做MUA的病例中匹配選擇這些變量相似的做為對(duì)照組。兩組間術(shù)前的屈曲度沒有明顯差異，早期MUA組(106.7°)中最終的屈曲度與對(duì)照組(115.6°)相似，而晚期MUA組則存在差異(101.3°, P=0.001)。
結(jié)論：TKA術(shù)后做過(guò)MUA的病人趨于更加年輕，近期有吸煙史及既往曾有膝關(guān)節(jié)手術(shù)史。術(shù)后即使活動(dòng)受限嚴(yán)重，只要在6周內(nèi)進(jìn)行MUA，最終效果與不需要實(shí)行MUA病人的效果相近。
Risk Factors, Outcomes, and Timing of Manipulation Under Anesthesia After Total Knee Arthroplasty
BACKGROUND: Knee stiffness requiring manipulation under anesthesia (MUA) is an undesirable outcome following total knee arthroplasty(TKA), but risk factors for, and optimal timing of, MUA remain unclear.
METHODS: Primary TKAs performed at a single center were retrospectively reviewed. Clinical variables were compared between patients who underwent MUA and those who did not; variables that differed were utilized to identify an appropriately matched control group of non-MUA patients. The MUA group was divided into early (MUA ≤6 weeks from index) and late (>6 weeks) subgroups. Flexion values at multiple time points were compared.
RESULTS: In total, 1729 TKA patients were reviewed; MUA was performed in 62 patients. Patients undergoing MUA were younger (55.2 vs 65.3 years, P < .001) and had higher rates of current smoking (21.0% vs 7.3%, P < .001) and prior procedure (59.7% vs 40.4%, P = .002), most commonly arthroscopy; a control group of patients not requiring MUA, matched on the basis of these variables, was identified. While no difference in pre-TKA flexion existed across groups, final flexion in the early MUA group (106.7°) was equivalent to that of controls (115.6°), while final flexion in the late MUA group was not (101.3°, P = .001).
CONCLUSION: TKA patients undergoing MUAs were younger, more likely to be current smokers, and more likely to have undergone prior knee surgery. Even in patients with severe initial postoperative limitations in range of motion, MUA within 6 weeks may allow for final outcomes that are equivalent to those experienced by similar patients not requiring manipulation.
文獻(xiàn)出處：Newman ET, Herschmiller TA, Attarian DE, Vail TP, Bolognesi MP, Wellman SS. Risk Factors, Outcomes, and Timing of Manipulation Under Anesthesia After Total Knee Arthroplasty. J Arthroplasty. 2018 Jan;33(1):245-249.
文獻(xiàn)2
下肢關(guān)節(jié)置換術(shù)前是否需要治療抑郁癥？
譯者：馬云青
背景：為確保手術(shù)療效，患者的術(shù)前優(yōu)化教育在關(guān)節(jié)置換術(shù)前變得越來(lái)越重要。有人認(rèn)為抑郁癥是關(guān)節(jié)置換圍手術(shù)期的危險(xiǎn)因素，應(yīng)在術(shù)前加以糾正。手術(shù)前的心理干預(yù)措施是否能改善預(yù)后療效仍有待確定。我們的認(rèn)為，使用術(shù)前抑郁量表預(yù)測(cè)術(shù)后的療效可能受到關(guān)節(jié)炎引起的疼痛和關(guān)節(jié)功能異常的影響。為了確定抑郁是否是術(shù)前應(yīng)糾正的一個(gè)可改變的危險(xiǎn)因素，我們提出了以下問題：(1)關(guān)節(jié)置換術(shù)前患者抑郁的發(fā)生率是多少？(2)術(shù)后抑郁癥狀是否有所改善？(3)術(shù)前抑郁是否與預(yù)后療效有關(guān)？
方法：擇期關(guān)節(jié)置換手術(shù)的患者完成患者健康問卷(PHQ-9)，評(píng)估患者術(shù)前及術(shù)后1年抑郁癥的發(fā)生率和嚴(yán)重程度。
結(jié)果：282例患者中65例PHQ-9>10分，表現(xiàn)為中等程度抑郁，57例(88%)術(shù)后改善為<10分(P=0.0012)。PHQ-9>20分者10例，表現(xiàn)為重度抑郁，9例(90%)術(shù)后改善為<10分(P=0.10)。術(shù)前PHQ-9評(píng)分>10分的65例患者中，術(shù)后髖關(guān)節(jié)功能障礙和骨關(guān)節(jié)炎評(píng)分中位數(shù)為92.3，膝關(guān)節(jié)損傷和骨關(guān)節(jié)炎評(píng)分中位數(shù)為84.6。非抑郁患者術(shù)后髖關(guān)節(jié)功能障礙和骨關(guān)節(jié)炎評(píng)分中位數(shù)為96.2，膝關(guān)節(jié)損傷和骨關(guān)節(jié)炎評(píng)分中位數(shù)為84.6分(P=0.9041)。
結(jié)論：通過(guò)關(guān)節(jié)置換術(shù)減輕疼痛和改善功能，抑郁癥狀可以得到明顯改善。與非抑郁患者相比，術(shù)前有抑郁癥狀的患者有相似的術(shù)后功能評(píng)分。因此，不應(yīng)通過(guò)關(guān)節(jié)置換術(shù)前優(yōu)化程序包括的抑郁量表測(cè)試值來(lái)推遲或拒絕抑郁患者的手術(shù)安排。
Should Depression Be Treated Before Lower Extremity Arthroplasty?
Background: Patient optimization is becoming increasingly important before arthroplasty to ensure outcomes. It has been suggested that depression is a modifiable risk factor that should be corrected preoperatively. It remains to be determined whether psychological intervention before surgery will improve outcomes. We theorized that the use of preoperative depression scales to predict postoperative outcomes may be influenced by the pain and functional disability of arthritis. To determine whether depression is a modifiable risk factor that should be corrected preoperatively we asked the following questions: (1) What is the prevalence of depression in arthroplasty patients preoperatively? (2) Do depressive symptoms improve after surgery? (3) Is preoperative depression associated with outcome?
Methods: Patients scheduled for surgery completed a patient health questionnaire (PHQ-9) to assess the presence and severity of depression pre-operatively and one year post-operatively.
Results: Sixty-five of the 282 patients had a PHQ-9 score >10 indicating moderate depression and 57 (88%) improved to <10 postoperatively (P ? .0012). Ten patients had a PHQ-9 score >20 indicating severe depression and 9 (90%) improved to <10 postoperatively (P ? .10). Of the 65 patients who had a PHQ-9 score >10 preoperatively, the median postoperative Hip Disability and Osteoarthritis Outcome Score (N ? 40) was 92.3, while the median postoperative Knee Injury and Osteoarthritis Outcome Score (N ? 25) was 84.6. The median postoperative Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score in nondepressed patients were 96.2 and 84.6, respectively (P ? .9041).
Conclusion: By diminishing pain and improving function through arthroplasty, depression symptoms improve significantly. Patients with depressive symptoms preoperatively had similar postoperative outcome scores compared to non-depressed patients. Patients should not be denied surgical intervention through optimization programs that include a depression scale threshold.
文獻(xiàn)出處：Fehring TK, Odum SM, Curtin BM, Mason JB, Fehring KA, Springer BD. Should Depression Be Treated Before Lower Extremity Arthroplasty? J Arthroplasty. 2018 Jun 4. pii: S0883-5403(18)30521-7.
文獻(xiàn)3
30歲及以下年齡初次全髖關(guān)節(jié)置換病例的10年生存隨訪
譯者：張薔
目標(biāo)：這篇回顧性隊(duì)列研究比較了30歲及以下年齡（年輕）患者和60歲及以上（老年）患者初次全髖關(guān)節(jié)置換術(shù)后的再翻修率、假體生存率、翻修適應(yīng)證、并發(fā)癥和患者自評(píng)療效。
方法：我們回顧了醫(yī)院數(shù)據(jù)庫(kù)里2000年至2015年間所有初次全髖置換病例，共有145例年輕病例和1359例老年病例，平均隨訪5.3年（1~18年）。應(yīng)用廣義估計(jì)方程比較患者基本參數(shù)和翻修率，應(yīng)用Kaplan-Meier曲線計(jì)算生存率并應(yīng)用Cox回歸分析計(jì)算風(fēng)險(xiǎn)率。
結(jié)果：年輕患者組總體翻修率為11%（16/145），老年患者組總體翻修率為3.83%（52/1359）（概率比(OR)2.58, 95%置信區(qū)間(CI) 1.43至4.63）。在匹配了組間ASA評(píng)分、性別和既往手術(shù)史后，年輕患者組匹配后翻修率依然更高（匹配后風(fēng)險(xiǎn)比(HR)2.48, 95% CI 1.34至4.58）。年輕患者組10年生存率為82%（95% CI, 71 to 89），老年患者組10年生存率為96%（95% CI,94 to 97）（p < 0.001）。由金對(duì)金摩擦界面引起并發(fā)癥而導(dǎo)致的翻修方面，年輕患者組明顯更高（p < 0.001）。末次隨訪時(shí)，與老年患者組相比，年輕患者組的關(guān)節(jié)功能更佳（p= 0.002），精神健康水平更低（p = 0.001），疼痛情況類似（p = 0.670）。
結(jié)論：年輕患者組的總體翻修率更高。這也可能是由于組內(nèi)的金對(duì)金界面比例較高引起的。年輕患者應(yīng)用非金對(duì)金摩擦界面的生存率較高，并發(fā)癥情況也與老年患者組近似。
Ten-year survivorship of primary total hip arthroplasty in patients 30 years of age or younger
Aims: For this retrospective cohort study, patients aged ≤ 30 years (very young) who underwent total hip arthroplasty (THA) were compared with patients aged ≥ 60 years (elderly) to evaluate the rate of revision arthroplasty, implant survival, the indications for revision, the complications, and the patient-reported outcomes.
Patients and Methods: We retrospectively reviewed all patients who underwent primary THA between January 2000 and May 2015 from our institutional database. A total of 145 very young and 1359 elderly patients were reviewed. The mean follow-up was 5.3 years (1 to 18). Logistic generalized estimating equations were used to compare characteristics and the revision rate. Survival was evaluated using Kaplan–Meier curves and hazard rates were created using Cox regression.
Results: The overall revision rate was 11% (16/145) in the very young and 3.83% (52/1359) in the elderly groups (odds ratio (OR) 2.58, 95% confidence interval (CI) 1.43 to 4.63). After adjusting for the American Society of Anesthesiologists (ASA) score, gender, and a history of previous surgery in a time-to-event model, the risk of revision remained greater in the very young (adjusted hazard ratio (HR) 2.48, 95% CI 1.34 to 4.58). Survival at ten years was 82% (95% CI, 71 to 89) in the very young and 96% (95% CI, 94 to 97) in the elderly group (p < 0.001). The very young had a higher rate of revision for complications related to metal-on-metal (MoM) bearing surfaces (p < 0.001). At last follow-up, the very young group had higher levels of physical function (p = 0.002), lower levels of mental health (p = 0.001), and similar levels of pain (p = 0.670) compared with their elderly counterparts.
Conclusion: The overall revision rate was greater in very young THA patients. This was largely explained by the use of MoM bearings. Young patients with non-MoM bearings had high survivorship with similar complication profiles to patients aged≥60 years.
文獻(xiàn)出處：C. A. Makarewich, M. B. Anderson, J. M. Gililland, C. E. Pelt, C. L. Peters. Ten-year survivorship of primary total hip arthroplasty in patients 30 years of age or younger. Bone Joint J 2018; 100-B: 867–74.
第二部分：保髖相關(guān)文獻(xiàn)
文獻(xiàn)1
股骨轉(zhuǎn)子間后旋截骨治療股骨頭壞死：平均11年隨訪
譯者：羅殿中
背景：既往研究認(rèn)為術(shù)后股骨頭負(fù)重區(qū)完整比值（旋轉(zhuǎn)后股骨頭負(fù)重區(qū)外側(cè)完好部分的寬度/負(fù)重區(qū)寬度，圖1）為股骨轉(zhuǎn)子間旋轉(zhuǎn)截骨術(shù)治療股骨頭壞死的預(yù)后因素之一，Miyanishi等人報(bào)道稱當(dāng)該比值大于34%時(shí)，股骨頭發(fā)生塌陷進(jìn)展的可能性小。然而有些病例，雖然沒有發(fā)生股骨頭塌陷，該比值也位于34%以上，但卻發(fā)生關(guān)節(jié)間隙進(jìn)行性狹窄。目前尚無(wú)相關(guān)報(bào)道分析與術(shù)后關(guān)節(jié)間隙狹窄相關(guān)的因素。因此本研究從影像學(xué)角度，分析股骨轉(zhuǎn)子間后旋截骨術(shù)治療股骨頭壞死，術(shù)后發(fā)生股骨頭塌陷及關(guān)節(jié)間隙狹窄的預(yù)后影響因素。
圖1 股骨頭負(fù)重區(qū)完整比值（Intact ratio）示意圖
方法：研究納入47例（51髖）患者，平均年齡為34歲（范圍12-54歲），包括男性29例、女性18例。平均隨訪時(shí)間為11年（范圍：5-20年）。根據(jù)影像學(xué)結(jié)果，將患者分為以下2組：I，股骨頭塌陷和/或關(guān)節(jié)間隙狹窄；II，無(wú)股骨頭塌陷或關(guān)節(jié)間隙狹窄。通過(guò)單因素分析及多因素分析明確預(yù)后影響因素。
結(jié)果：截止末次隨訪，I組6髖、II組45髖。術(shù)后股骨頭負(fù)重區(qū)完整比值及術(shù)前股骨頭壞死分期均與術(shù)后股骨頭塌陷或關(guān)節(jié)間隙狹窄相關(guān)（單因素分析分別為：P﹤0.0001,P = 0.006；多因素分析分別為P = 0.0014, P = 0.0039）。術(shù)后股骨頭負(fù)重區(qū)完整比值的臨界值為36.8%，即當(dāng)該比值為36.8%以上時(shí)，術(shù)后發(fā)生股骨頭塌陷及關(guān)節(jié)間隙狹窄的可能性小。（圖2-4）
圖2 女性，41歲。a 術(shù)前，股骨頭壞死3A期、C1型；b 股骨轉(zhuǎn)子間后旋90度，術(shù)后股骨頭負(fù)重區(qū)完整比值為45.7%；c 術(shù)后10年，壞死區(qū)范圍縮小
圖3 男性，27歲。a 術(shù)前，股骨頭壞死3A期； b 術(shù)前核磁，股骨頭壞死分型為C2；c 股骨轉(zhuǎn)子間后旋70度，術(shù)后股骨頭負(fù)重區(qū)完整比值為27.4%；d 術(shù)后13年，股骨頭無(wú)塌陷，但關(guān)節(jié)間隙狹窄、關(guān)節(jié)邊緣骨贅出現(xiàn)，為骨關(guān)節(jié)炎表現(xiàn)
圖4 K-M生存分析圖：縱軸表示生存率，橫軸表示隨訪時(shí)間，終點(diǎn)事件為股骨頭塌陷進(jìn)展和/或關(guān)節(jié)間隙進(jìn)行性狹窄。Intact ratio：股骨頭負(fù)重區(qū)完整比值
結(jié)論：該研究指出術(shù)后股骨頭負(fù)重區(qū)完整比值為股骨轉(zhuǎn)子間后旋截骨治療股骨頭壞死的主要預(yù)后因素之一，旋轉(zhuǎn)后改值應(yīng)至少為36.8%。這也為該手術(shù)的術(shù)前設(shè)計(jì)及手術(shù)適應(yīng)證選擇提供臨床指導(dǎo)。
Radiological outcome analyses of transtrochanteric posterior rotational osteotomy for osteonecrosis of the femoral head at a mean follow-up of 11 years
Background: This study investigated the radiological factors that correlated with progression of collapse and joint space narrowing after transtrochanteric posterior rotational osteotomy (PRO) for osteonecrosis of the femoral head.
Methods: This study reviewed 51 hips in 47 patients with a mean follow-up of 11 years (5-20). The subjects included 29 males and 18 females with a mean age of 34 years (12-54) at the time of surgery. The 51 hips were divided into two groups based on the radiological outcome (group I: evidence of progression of collapse and/or joint space narrowing, group II: no evidence of either progression of collapse or joint space narrowing). Both clinical and radiological factors were analyzed by both univariate and multivariable analyses.
Results: Six hips were categorized as group I and 45 hips were categorized as group II. The postoperative intact ratio and preoperative stage were significantly correlated with the radiological outcome in both univariate (P < 0.0001, P = 0.006) and multivariate (P = 0.0014, P = 0.0039) analysis. The cutoff point for the postoperative intact ratio (the minimum ratio required to prevent both progression of collapse and joint space narrowing) was 36.8 %.
Conclusions: The results of this study indicate that the postoperative intact ratio is one of the main influences on progression of collapse and/or joint space narrowing after PRO, and should be at least 36.8 %. An increased awareness of this critical ratio would be useful for planning the optimal use of this procedure.
文獻(xiàn)出處：Zhao, Garida & Yamamoto, Takuaki & Motomura, Goro & Iwasaki, Kenyu & Yamaguchi, Ryosuke & Ikemura, Satoshi & Iwamoto, Yukihide. (2013). Radiological outcome analyses of transtrochanteric posterior rotational osteotomy for osteonecrosis of the femoral head at a mean follow-up of 11 years. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. 18. 10.1007/s00776-012-0347-0.
文獻(xiàn)2
股骨轉(zhuǎn)子間截骨治療非創(chuàng)傷性股骨頭壞死的長(zhǎng)期隨訪
譯者：程徽
目的：對(duì)于患有非創(chuàng)傷性股骨頭壞死（ONFH）的年輕患者可以通過(guò)股骨轉(zhuǎn)子間旋轉(zhuǎn)截骨術(shù)（TRO）保護(hù)髖關(guān)節(jié)。我們的目的是在此過(guò)程15年后調(diào)查長(zhǎng)期結(jié)果和失敗的風(fēng)險(xiǎn)因素。
患者與方法：這項(xiàng)研究包括95名通過(guò)TRO治療ONFN的患者（111髖），平均年齡40歲（21至64）。平均隨訪時(shí)間為18.2年（3至26）。以全髖關(guān)節(jié)置換術(shù)（THA）、影像可見的股骨頭的二次塌陷和骨關(guān)節(jié)為終點(diǎn)事件，進(jìn)行Kaplan-Meier生存分析。行多變量分析以評(píng)估每種結(jié)果的風(fēng)險(xiǎn)因素。
結(jié)果：以THA為終點(diǎn)事件分析髖關(guān)節(jié)的15年生存率是59％（95％可信區(qū)間（CI）為49至67），以影像學(xué)可見的塌陷和骨關(guān)節(jié)炎分析髖關(guān)節(jié)的15年生存率是30％（95％CI為22至39），轉(zhuǎn)行THA的危險(xiǎn)因素，壞死型為C2型的ONFH（病變橫向延伸至髖臼邊緣）和年齡> 40歲，風(fēng)險(xiǎn)比（HR）分別為3.9和2.5。出現(xiàn)影像可見的股骨頭的二次塌陷和骨關(guān)節(jié)的危險(xiǎn)因素為，大于3a級(jí)的 ONFH和年齡> 40歲，風(fēng)險(xiǎn)比分別是2.0和1.9。
結(jié)論：TRO治療ONFH后的15年效果不佳，因?yàn)樾g(shù)后5年骨關(guān)節(jié)炎發(fā)生率較高。
Long-term outcomes of transtrochanteric rotational osteotomy for non-traumatic osteonecrosis of the femoral head
AIMS: Transtrochanteric rotational osteotomy (TRO) is performed for young patients with non-traumatic osteonecrosis of the femoral head (ONFH) to preserve the hip. We aimed to investigate the long-term outcomes and the risk factors for failure 15 years after this procedure.
PATIENTS AND METHODS: This study included 95 patients (111 hips) with a mean age of 40 years (21 to 64) who underwent TRO for ONFH. The mean follow-up was 18.2 years (3 to 26). Kaplan-Meier survivorship analyses were performed with conversion to total hip arthroplasty (THA) and radiological failure due to secondary collapse of the femoral head or osteoarthritic changes as the endpoint. Multivariate analyses were performed to assess risk factors for each outcome.
RESULTS: Survival rates at 15 years with conversion to THA and radiological failure as the endpoint were 59% (95% confidence interval (CI) 49 to 67) and 30% (95% CI 22 to 39), respectively. Necrotic type C2 ONFH (lesions extending laterally to the acetabular edge) (hazards ratio (HR) 3.9) and age > 40 years (HR 2.5) were risk factors for conversion to THA. Stage > 3a ONFH (HR 2.0) and age > 40 years (HR 1.9) were risk factors for radiological failure.
CONCLUSION: The 15 year outcomes after TRO for ONFH are unfavorable because osteoarthritic changes occur after five years post-operatively. Cite this article: Bone Joint J 2017;99-B:175-83.
文獻(xiàn)出處：Morita D, Hasegawa Y, Okura T, Osawa Y, Ishiguro N. Long-term outcomes of transtrochanteric rotational osteotomy for non-traumatic osteonecrosis of the femoral head. Bone Joint J. 2017 Feb;99-B(2):175-183.
文獻(xiàn)3
髖關(guān)節(jié)疾病患者關(guān)節(jié)周圍軟組織的差異
譯者：肖凱
背景：臨床上，了解不同髖關(guān)節(jié)疾病患者關(guān)節(jié)周圍軟組織差異情況，將會(huì)進(jìn)一步指導(dǎo)手術(shù)治療與非手術(shù)治療。很少有研究將軟組織因素作為潛在的病因，在術(shù)前與其它關(guān)節(jié)病變進(jìn)行鑒別診斷。
目的：明確不同髖關(guān)節(jié)疾病患者髖關(guān)節(jié)造影MRI上軟組織結(jié)構(gòu)是否存在差異。
方法：我們將57例患者分為3組：DDH組17例（女性11例，男性6例，平均年齡35.1歲，19.6-53.6歲），單純盂唇損傷組20例（女性17例，男性3例，平均年齡38.4歲，15.2-62.1歲），Cam型髖關(guān)節(jié)撞擊癥組20例（女性11例，男性9例，平均年齡38.8歲，18.9-51.2歲）。所有患者術(shù)前均進(jìn)行髖關(guān)節(jié)造影MRI檢查。測(cè)量指標(biāo)包括：盂唇寬度，關(guān)節(jié)囊厚度，腰大肌、骨直肌、臀肌大小，所有測(cè)量均用標(biāo)準(zhǔn)化數(shù)值，便于統(tǒng)計(jì)分析。
髖關(guān)節(jié)造影MRI上關(guān)節(jié)囊厚度及盂唇寬度測(cè)量方法
髖關(guān)節(jié)軸位MRI上髂腰肌、骨直肌及臀肌的大小測(cè)量。圖1圖2交叉十字分別代表肌肉的最長(zhǎng)軸與最短軸，圖3的白線代表肌肉的最短軸
結(jié)果：DDH組（標(biāo)準(zhǔn)化值，NV：0.30）髖臼上方盂唇的寬度顯著大于FAI組（NV:0.25, P < 0.05）。此外，DDH組（NV:0.24）在髖臼12點(diǎn)方向關(guān)節(jié)囊的厚度顯著大于單純盂唇損傷組（NV: 0.15, P < 0.05）及FAI組（NV: 0.16, P < 0.05）。另外，DDH組（NV: 0.18）在髖臼3點(diǎn)方向的關(guān)節(jié)囊厚度也顯著大于單純盂唇損傷組（NV: 0.13, P < 0.05）。DDH組（NV: 1.39）骨直肌橫向直徑大于FAI組（NV: 1.14, P < 0.05）。
結(jié)論：相比其它髖關(guān)節(jié)疾病患者，DDH患者骨直肌更發(fā)達(dá)、關(guān)節(jié)囊更厚、盂唇更寬。
Soft Tissue Structures Differ in Patients With Prearthritic Hip Disease
BACKGROUND: Clinically, understanding how the soft tissue envelope adapts to various forms of hip dysfunction could enhance both surgical and nonsurgical management. Very few studies have looked at soft tissue structures as preoperative discriminators between varying underlying etiologies of hip conditions.
PURPOSE: To demonstrate that the magnetic resonance arthrography assessment of soft tissue structures of the hip will preoperatively differ in patients with different underlying hip joint diseases.
METHODS: Fifty-seven patients who underwent preoperative magnetic resonance arthrography and corrective hip surgery were retrospectively identified yielding 3 groups: 17 with developmental dysplasia of the hip (DDH) (11 F, 6 M; mean age 35.1 years, range 19.6-53.6); 20 with isolated labral tears (LTs) (17 F, 3 M; mean age 38.4 years, range 15.2-62.1), and 20 with cam-type femoroacetabular impingement (FAI) (11 F, 9 M; mean age 38.8 years, range 18.9-51.2). Measurements of the hip labral length, capsule thickness, and psoas, rectus femoris, and gluteal muscle dimensions were performed, with normalization of the values for statistical analysis.
RESULTS: The superior labral length was significantly greater in the DDH group [normalized value (NV): 0.30] compared with the FAI group (NV: 0.25, P < 0.05). In addition, the superior (12 o'clock) capsular thickness (NV: 0.24) was significantly greater compared with the LT group (NV: 0.15, P < 0.05) and the FAI group (NV: 0.16, P < 0.05). The DDH group also had a significantly greater anterior (3 o'clock) capsular thickness (NV: 0.18) compared with the LT group (NV: 0.13, P < 0.05). The transverse dimension of the rectus femoris was larger in the DDH group (NV: 1.39) compared with the FAI group (NV: 1.14, P < 0.05).
CONCLUSION: An enlarged rectus femoris and thicker hip capsule as well as an enlarged labrum are characteristic findings in hip dysplasia.
文獻(xiàn)出處：Le Bouthillier A, Rakhra KS, Belzile EL, et al. Soft Tissue Structures Differ in Patients With Prearthritic Hip Disease. J Orthop Trauma. 2018 Feb;32 Suppl 1:S30-S34.
文獻(xiàn)4
髖關(guān)節(jié)發(fā)育不良繼發(fā)髖外翻的治療
譯者：張振東
股骨頭骨骺生長(zhǎng)發(fā)育障礙是兒童髖關(guān)節(jié)發(fā)育不良患者復(fù)位治療后的并發(fā)癥之一。若股骨頭外側(cè)骨骺生長(zhǎng)發(fā)育遲緩，可導(dǎo)致髖外翻畸形，多發(fā)生于復(fù)位治療后4-6年，并可能再次出現(xiàn)髖關(guān)節(jié)發(fā)育不良或坐骨-股骨撞擊征。一般認(rèn)為股骨近端內(nèi)翻截骨術(shù)是治療髖外翻畸形的有效方法，然而手術(shù)較大、術(shù)后恢復(fù)期長(zhǎng)且存在骨不連、內(nèi)固定失敗、繼發(fā)骨折以及股骨頭壞死的潛在風(fēng)險(xiǎn)。骨骺導(dǎo)向生長(zhǎng)手術(shù)（Guided growth）具有創(chuàng)傷小、恢復(fù)快的優(yōu)點(diǎn)，在糾正下肢畸形方面應(yīng)用越來(lái)越多。動(dòng)物實(shí)驗(yàn)已證實(shí)股骨頭骨骺?jī)?nèi)側(cè)阻滯可造成髖內(nèi)翻畸形，亦有一系列選擇性骨骺阻滯治療腦癱后遺癥或髖關(guān)節(jié)發(fā)育不良患兒髖外翻畸形的相關(guān)報(bào)道。本研究旨在明確：1）術(shù)后股骨形態(tài)改變情況；2）髖臼側(cè)形態(tài)改變與否；3）內(nèi)固定螺釘是否會(huì)損傷股骨頭骨骺？
研究納入了2011年至2014年共10例髖外翻畸形的患兒（既往均曾因髖關(guān)節(jié)發(fā)育不良行切開或閉合復(fù)位術(shù)，手術(shù)年齡平均為1.7歲）。接受骨骺導(dǎo)向生長(zhǎng)手術(shù)時(shí)平均年齡9.1歲（范圍：7-11.5歲），術(shù)后隨訪平均3.3年（范圍：2.5-4.5年）。術(shù)前及隨訪時(shí)測(cè)量指標(biāo)包括：髖關(guān)節(jié)中心邊緣角（center edgeangle）、頸干角（neck-shaft angle，NSA）、頭干角（head-shaft angle，HSA）、骨骺?jī)A斜角（physis tilt angle，PTA）以及關(guān)節(jié)面-大轉(zhuǎn)子間距（articulotrochanteric distance，ATD）（圖1）。
圖1 各指標(biāo)測(cè)量圖示：頸干角（neck-shaft angle，NSA）、頭干角（head-shaft angle，HSA）、骨骺?jī)A斜角（physis tilt angle，PTA）、關(guān)節(jié)面-大轉(zhuǎn)子間距（articulotrochanteric distance，ATD）以及髖臼指數(shù)（acetabular index，AI）
結(jié)果顯示，術(shù)后首先出現(xiàn)的改變?yōu)殛P(guān)節(jié)面-大轉(zhuǎn)子間距的減小，隨后于術(shù)后1.5年時(shí)出現(xiàn)骨骺?jī)A斜角逐漸增加。術(shù)后2年，CE角由術(shù)前平均18.3度改善至平均24.8度。術(shù)后1.5至2年內(nèi)，其中4例螺釘取出后出現(xiàn)PTA及HSA反彈，分別由平均25.3度降至21.5度、由平均149.9度增加至169.4度。這說(shuō)明骨骺阻滯為機(jī)械拉力阻滯，而非損傷骨骺所致。
圖2 男，10歲，既往右髖切開復(fù)位、骨盆Salter截骨手術(shù)史。a 術(shù)前X線示右側(cè)髖外翻伴髖關(guān)節(jié)發(fā)育不良（ATD: 33.6 mm, PTA: ? 6°, HSA: 175°, CEA: 18.8°）；b 術(shù)后2年（ATD: 30.8 mm,PTA: 13.9°, HSA: 158°, CEA:24.4°）
圖3 女，7歲，既往1.2歲時(shí)右髖閉合復(fù)位、4歲時(shí)Pemberton截骨術(shù)。a 骨盆X線片示右側(cè)髖外翻伴髖關(guān)節(jié)發(fā)育不良（ATD: 29.6 mm, PTA: 5.6°, HSA: 168°, CEA: 13.6°）；b 一枚經(jīng)骨骺螺釘固定內(nèi)側(cè)骨骺；c 術(shù)后1.5年（ATD: 25 mm,PTA: 22°, HSA: 153°, CEA: 15.7°）；d 術(shù)后3年，內(nèi)固定取出后（ATD:29 mm, PTA: 9.6°, HSA: 167°,CEA: 28.8°），可見髖關(guān)節(jié)發(fā)育不良明顯改善，但部分指標(biāo)反彈
Guided growth for caput valgum in developmental dysplasia of the hip
This study reported guided growth for caput valgum deformity and subsequent hip development. Ten children with unilateral hip dysplasia had guided growth by one eccentric transphyseal screw at age 9.1 years with minimum 2 years of follow-up. The first change was decreasing articulotrochanteric distance and then increasing physis tilt angle and head-shaft angle by 1.5 years. The center edge angle that was significantly less than the normal side (18.3 vs. 24.8°) preoperatively became comparable between both the hips 2 years later. Rebounding of physis inclination after screw back out suggested mechanical tethering, rather than permanent physis closure, resulted in morphologic changes in the femur.
文獻(xiàn)出處：Peng SH , Lee WC , Kao HK , Yang WE , Chang CH. Guided growth for caput valgum in developmental dysplasia of the hip. J Pediatr Orthop B 2018 Jun.
張洪主任好大夫網(wǎng)站zhanghongmd.haodf.com
張洪主任門診時(shí)間：周三上午
關(guān)節(jié)外科護(hù)士站：01066867304 轉(zhuǎn)848810（請(qǐng)?jiān)?4:00-18:00撥入）
膝關(guān)節(jié)置換:張軼超 13261817537
髖關(guān)節(jié)置換:馬云青 13811705624
保髖療法:羅殿中 18911358880
聯(lián)系客服
