髋膝关节文献精译荟萃（第318期）

全膝关节置换术治疗色素绒毛结节滑膜炎性骨关节炎:系统文献综述

译者 张轶超

目的:色素性绒毛结节性滑膜炎(PVNS)是一种起源于滑膜的增生性疾病，主要影响大关节，如膝关节(几乎占总数的80%)。由于疾病复发和整体手术并发症的原因，PVNS骨关节炎行全膝关节置换术与原发性骨关节炎相比翻修率更高。本系统综述的目的是总结和比较全膝关节置换术治疗PVNS骨关节炎的适应证、临床和功能效果、疾病相关和手术相关并发症。

材料和方法：通过PubMed在Medline上进行初步检索，对文献进行系统回顾。使用PRISMA 2009流程图和检查表编辑综述。被筛选纳入本综述的研究包括那些提供术前诊断、既往治疗、主要治疗、伴随策略、随访情况、手术效果和并发症的。    

结果：最终纳入8篇文献。大多数论文报道了手术使用非限制性假体，主要是后稳定(PS)型假体，在PVNS广泛累及关节的情况下，使用具有更高限制性的假体以获得尽可能的软组织平衡。PVNS的复发被认为是主要的并发症，其次是假体的无菌性松动和术后困难的训练过程使得僵硬的风险增加。

结论：全膝关节置换术是治疗PVNS终末期骨关节炎的有效方法，具有良好的临床和功能效果，即使长期随访也是如此。为减少复发和并发症的发生，建议多学科治疗，术后进行细致的康复和监测。

Total knee arthroplasty in pigmented villonodular synovitis osteoarthritis: a systematic review of literature

Purpose Pigmented Villonodular Synovitis (PVNS) is a proliferative disease arising from the synovial membrane, mainly afects large joints such as the knee (almost 80% of total). Prostheses implanted in PVNS osteoarthritis show a higher revision rate when compared to primary osteoarthritis, due to the recurrence of disease and the overall surgical complications. The purpose of this systematic review is to summarize and compare indications, clinical and functional outcomes, diseaserelated and surgical-related complications of total knee arthroplasty in PVNS osteoarthritis.

Materials and methods A systematic review of the literature was performed with a primary search on Medline through PubMed. The PRISMA 2009 fowchart and checklist were used to edit the review. Screened studies had to provide preoperative diagnosis, previous treatments, main treatment, concomitant strategies, mean follow-up, outcomes and complications to be included in the review.    

Results A total of 8 articles were finally included. Most of papers reported the use of non-constrained design implants, mainly posterior stabilized (PS) and in case of PVNS with extensive joint involvement implants with higher degree of constraint to obtain a fulfilling balancing. Recurrence of PVNS has been indicated as the major complication, followed by aseptic loosening of the implant and diffcult post-operative course with an increased risk of stiffness.

Conclusion Total knee arthroplasty represents a valid treatment for patients with PVNS end-stage osteoarthritis, with good clinical and functional results, even in longer follow-up. It would be advisable a multidisciplinary management and a meticulous rehabilitation and monitoring following the procedure, to reduce the emergence of recurrence and overall complications.

文献出处：Panciera A, Colangelo A, Di Martino A, Ferri R, Bulzacki Bogucki BD, Cecchin D, Brunello M, Benvenuti L, Digennaro V. Total knee arthroplasty in pigmented villonodular synovitis osteoarthritis: a systematic review of literature. Musculoskelet Surg. 2024 Jun;108(2):145-152. doi: 10.1007/s12306-023-00793-y. Epub 2023 Jun 20. PMID: 37338752; PMCID: PMC11133153.

在亚洲患者中龙骨到胫骨后皮质的距离过短与非骨水泥型 Oxford UKA术后骨折有关

译者 马云青

全髋翻修手术中应用头-颈万能适配器进行头、柄混搭：一项共纳入306例病例的并发症和假体生存分析研究

译者 张蔷

背景：由于产品适配的一些法律问题，在全髋关节置换手术（THA）中应用头-颈万能适配器（UHNA）进行头-柄“混搭”的效果和安全性依然存在争议。本研究旨在分析应用UHNA进行“混搭”的并发症率和再手术率，可能的危险因素和假体生存率。

方法：共有306例2006年-2022年间我们院的THA手术（94.1%为翻修）病例应用了UHNA。我们回顾性收集了所有病例的诊断、合并症、假体类型和UHNA的具体情况，并最终在加入对不同危险因素的考量后评估了治疗效果、并发症和假体生存情况。

结果：306例（58.5%为女性；中位年龄74岁；中位随访时间57个月）中19.9%的病例至少有一次并发症。有43例（14.1%）接受了1次或1次以上的再翻修手术。最常见的并发症为术后复发性脱位（n=27,8.8%）。有一例出现了假体柄颈部断裂的情况。术后复发性脱位和术后无菌性松动的显著危险因素分别为因脱位而后续进行了UHNA植入（P < 0.001）和假体柄颈过长（≥2XL; P = 0.004）。术后1年未翻修的假体生存率为92%，术后10年为82%。年龄在60岁以上、合并症更少（< 2）和颈长正常（S to XL）的病例术后假体生存率显著更高。

结论：本研究的结果证实了THA手术中应用UHNA进行“混搭”的总体安全性。只发现一例假体颈断裂的情况。在对不同患者的治疗进行决策时，我们务必要把假体失败的高危因素纳入考量。

图1. 翻修术中取出的带有头-颈万能适配器的假体，包括一个陶瓷股骨头和一个生物柄，柄表面有机械性磨损的痕迹和翻修手术取出过程中的划痕。

图2. 假体柄断裂病例。[A]2014年应用适配器的翻修术后平片, [B]术后16个月随访时显示的假体柄断裂影像, [C]第二次翻修术后影像。

Mix and Match Use of Revision Universal Head Neck Adapters in Hip Arthroplasty：Complications and Survival Analysis of 306 Cases

Background

Outcomes and safety of “mix and match” in total hip arthroplasty (THA) using universal head-neck adapters (UHNA) are a matter of ongoing discussion and concern due to legal affairs. This study aimed at analyzing the “mix and match” use of UHNA and evaluating complication and reoperation rates, possible risk factors, and the implant’s survival.

Methods

A total of 306 patients treated with THA (94.1% revisions) using a UHNA at our institution between 2006 and 2022 were identified and included. Diagnoses, comorbidities, implants, and UHNA specifications were retrospectively recorded. Outcomes, complications, and survival analyses were evaluated, taking account of various possible risk factors.

Results

There were 19.9% of the 306 included cases (58.5% women; median age 74 years; median follow-up 57 months) that had at least 1 complication. There were 43 patients (14.1%) who had to receive ≥ 1 re-revision surgery. The most common complication was postoperative recurrent dislocation (n = 27, 8.8%). There was one case of a prosthetic stem-neck fracture that was registered. Statistically significant risk factors for postoperative recurrent dislocations and postoperative aseptic loosening were, respectively, dislocation as an indication for UHNA implantation (P < 0.001) and oversized neck lengths (≥ 2XL; P = 0.004). The overall revision-free survival was 92% after one year and 82% at ten years. Statistically significant better survival rates were registered in patients ≥ 60 years old, who had fewer comorbidities (< 2), and normal neck lengths (S to XL).   

Conclusion

The results of this study underline the overall safety of UHNA use in THA through “mix and match.” Only one case of a stem-neck fracture was identified. The highlighted risk factors for failure must be kept in mind during the decision-making process with patients.

严重髌骨外侧面关节炎与外侧单髁膝关节置换术后平均10年的失败率增加无关

译者 沈松坡

背景：本研究的目的是确定严重髌骨外侧面骨关节炎是否与固定平台外侧单髁膝关节置换术（UKA）后较低的生存率和较差的患者报告结果的相关性。

方法：在2003年5月7日至2019年12月18日期间，61例患者接受了固定平台、非机器人辅助的外侧UKA，符合纳入标准。在UKA植入前，术中检查髌骨-股骨关节软骨损伤。严重髌骨外侧面关节炎（LFPOA）定义为外侧关节面的Outerbridge3或4级改变。所有患者在UKA后至少4年完成主观功能结局问卷和临床检查。

结果：28例（46%）患者出现严重LFPOA。在平均10.9年的随访中，患有和没有严重LFPOA的患者在膝骨关节炎结局评分（oos）亚量表或Kujala评分方面没有统计学上的显著差异。在KOOS亚量表得分达到患者可接受症状状态的患者百分比方面，两组间无统计学差异。无严重LFPOA患者的平均生存期为16.6年（95%可信区间，15.4 ~ 17.7），而严重LFPOA患者的平均生存期为18.9年（95%可信区间，17.6 ~ 20.2）（P = 0.62）。    

结论：与没有严重髌骨外侧面骨关节炎的患者相比，在固定平台外侧UKA术后平均10年的随访中，严重的LFPOA并没有导致UKA手术较低的生存率或较差的功能结果。

Severe Lateral Facet Patella Osteoarthritis Is Not Associated With Increased Failure at Mean 10 Years After Lateral Unicompartmental Knee Arthroplasty

Background: The purpose of this study was to determine if severe lateral patella facet osteoarthritis was related to lower survivorship and poor patient-reported outcomes following fixed-bearing lateral unicompartmental knee arthroplasty (UKA).

Methods: There were 61 patients who underwent a fixed-bearing, nonrobotically assisted, lateral UKA between May 7, 2003 and December 18, 2019 and met the inclusion criteria. The patello-femoral joint was examined intraoperatively for chondral damage prior to UKA implantation. Severe lateral facet patella osteoarthritis (LFPOA) was defined as Outerbridge grades 3 or 4 changes on the lateral facet. All patients completed subjective functional outcomes questionnaires and a clinical examination at a minimum of 4 years following UKA.

Results: Severe LFPOA was identified in 28 (46%) patients. At a mean follow-up of 10.9 years, there were no statistically significant differences in any Knee Osteoarthritis Outcomes Score (KOOS) subscale or Kujala scores between patients who had and did not have severe LFPOA. There was no statistically significant difference in the percentage of patients who achieved Patient Acceptable Symptom State for the KOOS subscale scores between groups. Mean survival in patients who did not have severe LFPOA was 16.6 years (95% confidence interval, 15.4 to 17.7) compared to 18.9 years (95% confidence interval, 17.6 to 20.2) in patients who had severe LFPOA (P = 0.62).    

Conclusions: Severe LFPOA did not result in lower survival or inferior functional outcomes compared to patients who did not have severe osteoarthritis at an average 10-year follow-up after fixed-bearing lateral UKA.

印度人群维生素D与膝骨关节炎的相关性：系统综述和荟萃分析

译者 张峻

背景：维生素D缺乏症（VDD）与膝骨关节炎（KOA）的发展和进展有关。印度人群中广泛报道了KOA患者VDD和骨质疏松症的患病率。然而，没有试图批判性地评估这些研究的结果。我们的目标是对这些研究进行系统综述。

方法：检索Pubmed、Google Scholar和Web of Science，最后更新时间为2023年3月。我们回顾了印度和亚洲人群中KOA与维生素D水平之间关系的符合条件的研究，以进行比较。计算维生素D水平的平均差异（MD）和维生素D状态的比值比（OR）。数据由RevMan 5.4软件解释。使用Cochrane偏倚风险工具评估偏倚风险。

结果：共纳入15项研究，涉及1503例KOA病例和1609例对照。在印度人群中，KOA患者的维生素D水平显著降低（MD-8.68 ng/mL，95%CI-12.21至-5.15；P=0.00001，I2=82%）。同样，在其他亚洲人群中，观察到KOA的维生素D水平显著降低（MD 18.36 ng/mL，95%CI-34.72至-2.00；P=<0.00001，I2=100%）。发现VDD与KOA风险增加呈正相关。   

结论：VDD的早期诊断和治疗可能为延缓KOA的持续退化过程提供机会，本研究表明，即使在阳光充足的地区，筛查VDD也很重要。

Association between vitamin D and knee osteoarthritis in Indian population: A systematic review and meta-analysis

Background: Vitamin D deficiency (VDD) has been implicated in knee osteoarthritis (KOA) development and progression. Prevalence of hypovitaminosis D and osteoporosis in KOA is widely reported in Indian population. However, there is no attempt to critically evaluate the outcome of these studies. We aimed a systematic review of these studies.

Methods: Pubmed, Google Scholar and Web of Science last updated March 2023, were searched. We reviewed eligible studies on the association between KOA and vitamin D levels in Indian and Asian population for comparison. The mean difference (MD) of vitamin D levels and odds ratio (OR) of vitamin D status were calculated. Data were interpreted by RevMan 5.4 software. The risk of bias was assessed using the Cochrane Risk of Bias tool.

Results: A total of 15 studies that involved 1503 KOA cases and 1609 controls were included. There was significantly reduced level of vitamin D in KOA (MD -8.68 ng/mL, 95%CI -12.21 to -5.15; P = <0.00001, I2 = 82 %) in Indian population. Similarly, in other Asian population significantly reduced vitamin D levels in KOA (MD 18.36 ng/mL, 95%CI -34.72 to -2.00; P = <0.00001, I2 = 100 %) was observed in KOA. VDD was found to be positively correlated with an increased risk of KOA.  

Conclusion: Early diagnosis and management of VDD may provide the opportunity to delay the ongoing degenerative process of KOA and this study indicates the importance of screening VDD even in sunlight rich regions.

文献出处：Annamalai R, Sujhithra A, Danis Vijay D. Association between vitamin D and knee osteoarthritis in Indian population: A systematic review and meta-analysis. J Clin Orthop Trauma. 2023 Nov 9;46:102278. doi: 10.1016/j.jcot.2023.102278. PMID: 38059053; PMCID: PMC10696121.

青少年终末期髋关节病治疗选择：置换、融合、或重建？

译者 罗殿中

背景介绍：本文对青少年髋骨关节炎的外科治疗适应证进行了回顾，并总结了当前骨科医生可进行髋关节重建的外科技术。

讨论：在北美社会中，髋关节骨关节炎仍然是不可忽视的负担。虽然在过去几十年人工全髋关节置换（THA）在年轻患者中的应用大幅度提升，但相对于中老年患者，年轻患者因其活动量大、预期寿命长、需要髋关节翻修的风险更高。对青少年患者来说，多次翻修手术需要认真对待。针对儿童髋疾患导致的终末期骨关节炎，虽然越来越多推荐采用THA治疗；但对于那些如感染髋后遗严重畸形、希望从事非常活跃的生活方式的患者，髋关节融合手术仍然是一个较好的选择。保髋手术适用于退变前期、或退变早期，可保留髋关节、并可达到理想的临床效果。对中期骨关节炎、个别严重骨关节炎的青少年和年轻成人，采用恰当的保髋技术进行手术治疗，也可获益。    

结论：对于有疼痛和功能障碍的终末期髋关节病青少年患者，治疗选择存在挑战和争议。THA和髋关节融合是两个常见选项，但在特殊情况下，保髋值得推荐。

图1. 一位14岁男孩，因延误治疗化脓性髋关节炎导致左髋疼痛、跛行2年来诊。A.术前骨盆前后位片显示：左髋终末期髋骨关节炎；B. 采用SP入路前侧钢板固定髋关节融合术后3年骨盆影像，患者可从事各种运动，包括美式橄榄球，迄今为止无疼痛症状。

图2. 一位10岁女孩左髋疼痛、僵硬，幼年行左髋切开复位，骨盆片显示，左股骨头前侧严重变形、后侧保留。A.骨盆前后位片显示，右髋正常，左髋严重畸形、并髋臼发育不良、股骨近端畸形、股骨头椭圆、大转子高位；B.分期行左髋关节外科脱位、股骨头骨软骨成形、股骨颈相对延长，然后行髋臼周围截骨术后最终影像。    

图3. 一位13岁男孩，在外院因不稳定股骨头骨骺滑脱，行闭合复位、原位固定术后3个月来诊。A.右髋前后位片显示，2枚螺钉在位，股骨头外侧部轻度塌陷；B.蛙氏侧位片显示，因股骨头坏死，头前部明显塌陷；C.右髋前后位（冠位）核磁片显示，股骨头广泛受累，外侧柱少部分保留；D.右髋矢状位核磁片显示，股骨头后侧部分保留（白色箭头）；E.采用右股骨近端屈髋、去旋转截骨术后3年复查，右髋前后位片显示，股骨头维持圆形；F.右髋蛙式侧位片显示，股骨头残留畸形。    

图4. 一位15岁男孩右髋严重疼痛、僵硬、外展受限，曾因LCPD治疗。A.右髋前后位片显示，股骨头外侧覆盖不足、半脱位，股骨头扁平、大转子高位、股骨颈短缩、髋臼发育不良；B.右髋蛙氏侧位片显示，股骨头严重畸形；C.术中大体照片显示，股骨头颈严重畸形；D.行髋关节外科脱位、股骨头颈成形、股骨头缩小截骨、股骨颈相对延长、髋臼周围截骨术后1年复查前后位片显示，股骨近端畸形明显改善、髋臼对股骨头的覆盖增加；E.术后1年蛙氏侧位片显示，股骨近端畸形明显改善；F.对股骨头颈前侧进行骨软骨成形、股骨颈相对延长、股骨头缩小截骨，术中大体照片显示，股骨头圆度显著改善。

文献出处：Novais EN. Treatment Options for End-Stage Hip Disease in Adolescents: To Replace, Fuse, or Reconstruct? J Pediatr Orthop. 2021 Jul 1;41(Suppl 1):S47-S52. doi: 10.1097/BPO.0000000000001780. PMID: 34096537.

在髋臼周围截骨术中使用透视斜位和延迟术后负重可减少一年后坐骨延迟愈合的发生

译者 程徽

这篇论文探讨了在髋臼周围截骨术（PAO）中使用斜位X射线透视和延迟术后负重对减少术后1年坐骨延迟愈合的影响。PAO是治疗发育性髋关节发育不良（DDH）的有效手术方法，但术后坐骨延迟愈合是一个常见的并发症，可能影响患者的康复和临床结果。

研究的背景源于PAO手术技术的不断改进和术后管理策略的优化。传统上，PAO术中主要依赖正前位X射线透视来指导骨切，术后也较早开始部分负重。然而，这种方法可能无法充分评估截骨的精确性，特别是在坐骨区域，同时过早负重可能影响骨愈合。

为了解决这些问题，研究者提出了一种新的方法：在手术中同时使用后前位和斜位X射线透视，并延迟开始术后部分负重。本研究旨在评估这种新方法是否能有效降低坐骨延迟愈合的发生率，并改善患者的临床结果。

研究设计采用了回顾性队列研究方法，共纳入104名患者的117个髋关节。患者被分为两组：斜位片组（58个髋关节）采用新方法，即使用斜位X射线透视和延迟开始部分负重；对照组（59个髋关节）采用传统方法，即仅使用正前位X射线透视和早期开始部分负重。研究的主要观察指标包括术后1年时坐骨延迟愈合的发生率、Harris髋关节评分（HHS）、外侧中心边缘角（LCEA）和臼顶倾斜角（ARO）等。

术中透视斜位

研究结果显示，斜位片组在多个方面表现优于对照组。首先，OL组的坐骨延迟愈合发生率显著低于对照组，这说明新方法能有效减少这一并发症。其次，OL组在术后1年时的HHS显著高于对照组，表明患者的临床功能恢复更好。此外，OL组在LCEA和ARO等解剖参数上也优于对照组，反映了更好的髋关节结构重建效果。

这些发现具有重要的临床意义。使用斜位X射线透视可能有助于更精确地评估截骨位置，特别是在坐骨区域，从而提高手术的准确性。延迟开始部分负重则可能为骨愈合提供更有利的环境，减少过早负重对骨愈合的不利影响。这种综合策略不仅降低了并发症风险，还改善了患者的功能恢复和解剖重建效果。

然而，本研究也存在一些局限性。作为回顾性研究，可能存在选择偏倚。同时，研究仅关注了术后1年的结果，长期效果还需要进一步观察。此外，研究未深入探讨导致延迟愈合的具体机制，这可能是未来研究的方向。

总的来说，这项研究为PAO手术的技术改进和术后管理提供了新的见解。它强调了手术中精确评估和术后适当管理的重要性，为提高PAO手术的成功率和患者预后提供了有价值的证据。未来的研究可能需要进行前瞻性随机对照试验，以进一步验证这些发现，并探索优化PAO手术和术后管理的其他策略。

Use of oblique view in periacetabular osteotomy and delayed postoperative weight bearing reduce delayed union in the ischium after one year

文献出处：Kinoshita K, Fujita J, Matsunaga T, Seo H, Hideshima Y, Yoshimura F, Yamamoto T. Use of oblique view in periacetabular osteotomy and delayed postoperative weight bearing reduce delayed union in the ischium after one year. Sci Rep. 2024 Oct 10;14(1):23720. doi: 10.1038/s41598-024-75593-w. PMID: 39390253; PMCID: PMC11467257.

儿童创伤性Y形软骨损伤的回顾性分析

译者 任宁涛

背景:总结分析儿童外伤后Y形软骨损伤(TCI)的流行病学特点、治疗方法及相应疗效，为早期诊断和改进治疗提供理论依据。

方法:采用Bucholz分型对TCI损伤进行分型，随访时采用Harris髋关节评分及影像学检查评价最终疗效。最后，通过查阅文献中的病例并结合我院的患者进行综合分析。

结果:本院共收治Y形软骨损伤15例(18髋)。I型损伤1例，II型损伤9例，IV型损伤2例，V型损伤1例，VI型损伤5例。随访完整的12例患者中，8例在Y形软骨内或周围发现骨桥，5例出现早期Y形软骨融合，3例髋关节发育不良，4例股骨头半脱位，HHS优8例，良4例。

结论:TCI损伤的早期诊断仍是一个难题。保守治疗通常是首选。髋臼骨折累及Y形软骨的整体预后较差。Y形软骨骨桥的形成通常预示着过早闭合的可能性，这可能导致创伤后髋臼发育不良和股骨头半脱位的严重并发症。

Retrospective analysis of traumatic triradiate cartilage injury in children

Background: To summarize and analyze the epidemiological characteristics, treatment and corresponding curative effect of triradiate cartilage injury(TCI) in children after trauma, to provide a theoretical basis for early diagnosis and improvement of treatment.

Methods: The TCI was classified according to Bucholz classification, and the final curative effect was evaluated with Harris Hip Score and imaging examination during follow-up. Finally, a comprehensive analysis was made by reviewing the cases in the literature combined with the patients in our hospital.    

Results: A total of 15 cases (18 hips) of triradiate cartilage injuries were collected in our hospital. There was 1 hip with type I injury, nine hips with type II injury, two hips with type IV injury, one hip with type V injury and five hips with type VI injury. Among the 12 cases with complete follow-up, the bone bridge was found in or around the triradiate cartilage in 8 cases, early fusion of triradiate cartilage occurred in 5 patients, 3 cases had hip dysplasia, 4 cases had a subluxation of the femoral head, and HHS was excellent in 8 cases and good in 4 cases.

Conclusion: The early diagnosis of TCI is still a difficult problem. Conservative treatment is often the first choice. The overall prognosis of acetabular fractures involving triradiate cartilage is poor. The formation of the bone bridge in triradiate cartilage usually indicates the possibility of premature closure, which may lead to severe complications of post-traumatic acetabular dysplasia and subluxation of the femoral head.

文献出处：Dong Y, Wang J, Qin J, Nan G, Su Y, He B, Cai W, Chen K, Gu K, Liang X, Yan G, Wang Z. Retrospective analysis of traumatic triradiate cartilage injury in children. BMC Musculoskelet Disord. 2021 Aug 10;22(1):674. doi: 10.1186/s12891-021-04565-2. PMID: 34376165; PMCID: PMC8356404.

髋关节发育不良的遗传学——一项系统性文献综述

译者 李勇

Genetics of hip dysplasia - a systematic literature review

文献出处：Jacobsen KK, Laborie LB, Kristiansen H, Schäfer A, Gundersen T, Zayats T, Rosendahl K. Genetics of hip dysplasia - a systematic literature review. BMC Musculoskelet Disord. 2024 Oct 1;25(1):762. doi: 10.1186/s12891-024-07795-2. PMID: 39354451; PMCID: PMC11445845.

临界发育性髋关节发育不良——髋关节镜或髋臼周围截骨术是最佳治疗?

译者 张利强

综述的目的

随着保髋领域的发展，临界发育性髋关节发育不良（定义为外侧中心边缘角在18°-25°之间）已被证明是治疗上更具挑战性的诊断之一。由于髋臼覆盖的细微差别被重视，用单独的髋关节镜、髋臼周围截骨术还是联合手术更好，是现在首要考虑的问题。这些手术的目的不仅是改善患者症状，而且是纠正潜在的病理学，并理想地减缓髋关节骨关节炎的发展。本综述回顾了近年来关于单纯髋关节镜和髋臼周围截骨术治疗临界发育性髋关节发育不良的文献和临床结果。  

最近的研究结果

目前的研究表明，在临界发育性髋关节发育不良的情况下单独进行髋关节镜检查和接受髋臼周围截骨术的患者术后临床结局评分均有所改善。两组患者的中期结局均显示，转为全髋关节置换术的比率较低。

总结

临界发育性髋关节发育不良的手术治疗没有金标准。在接受髋关节镜检查的患者和接受髋臼周围截骨术的患者中，观察到术后临床结局均改善。成功的临床结局似乎依赖于基础临床病理的治疗，并且主要基于适当的手术适应症和适当的手术技术。在这一患者人群中，手术决策应基于对患者的综合评估进行个体化治疗。

Borderline Hip Dysplasia - Best Treated with Hip Arthroscopy or Periacetabular Osteotomy?

Purpose of Review

As the field of hip preservation evolves, the diagnosis of borderline dysplasia (defined as a lateral center edge angle between 18°-25°) has shown itself to be one of the more challenging diagnoses to treat. As the nuances of acetabular coverage have come to light, the question of whether borderline hip dysplasia is best treated with isolated hip arthroscopy, periacetabular osteotomy, or whether a combined procedure is best, is now top of mind. The goal of these procedures is to not only improve patient symptoms, but to correct underlying pathology and ideally slow the development of hip osteoarthritis. The purpose of this review is to summarize the recent literature and clinical findings regarding both isolated hip arthroscopy and periacetabular osteotomy in the surgical management of borderline hip dysplasia.    

Recent Findings

Current research demonstrates improved postoperative clinical outcome scores for both patients who had isolated hip arthroscopy in the setting of borderline hip dysplasia and for those patients who underwent periacetabular osteotomy. Mid-term outcomes for patients in both groups have showed low rates of conversion to total hip arthroplasty.

Summary

No gold standard in the surgical management of borderline hip arthroscopy exists. Improved clinical outcomes have been seen postoperatively in patients who undergo hip arthroscopy and in patients who undergo periacetabular osteotomy. Successful clinical outcomes seem to rely on treatment of the underlying clinical pathology and are largely based on the appropriate surgical indications and appropriate surgical techniques. Surgical decision making in this patient population should be individualized based on a comprehensive evaluation of the patient.

文献出处 ：Wilson ES, Wagner KR, Spiker AM. Borderline Hip Dysplasia - Best Treated with Hip Arthroscopy or Periacetabular Osteotomy? Curr Rev Musculoskelet Med. 2024 Sep 28. doi: 10.1007/s12178-024-09928-5. Epub ahead of print. PMID: 39340721.    

既往髋臼周围截骨术是否与妊娠、分娩和围产期并发症有关？

译者 陶可

背景：髋臼周围截骨术的手术患者通常是有症状的髋臼发育不良的育龄妇女。然而，人们对这种手术干预如何影响怀孕决定、分娩产科咨询、分娩方式或妊娠相关并发症知之甚少。

问题/目的：(1)髋臼周围截骨术史是否会影响患者的怀孕决定或影响有关妊娠和分娩安全性？(2)与全国平均水平相比，髋臼周围截骨术史是否与剖宫产风险增加有关？(3)髋臼周围截骨术史是否与并发症增加、婴儿出生体重下降、早产有关？

方法：我们与产科医生同事合作，开展了一项调查，以调查接受过髋臼周围截骨术的女性患者对怀孕、分娩方式、妊娠相关并发症和产科咨询的态度。回顾性研究了2008年至2015年期间接受过髋臼周围截骨术的育龄女性患者，并完成了邮寄调查或电话采访。所有联系到的96名患者都被询问髋臼周围截骨术病史是否影响了她们怀孕的决定。我们的人群队列包括31名接受过髋臼周围截骨术并随后怀孕和分娩的患者，共怀孕38次，产下41名婴儿。使用二项式检验来确定剖宫产、低出生体重或早产的发生率是否与美国国家生命统计报告和CDC公布的美国全国平均水平不同。

结果：31名患者中有1名认为髋臼周围截骨术对孩子的外观产生了负面影响；6.5%的患者（31名中的2名）的手术史产生了积极影响。55%（31名中的17名）的患者报告称，他们的产科医生担心他们的髋臼周围截骨术病史可能会影响她们足月分娩或阴道分娩的能力。有髋臼周围截骨术病史的患者中，53%（38名中的20名）接受了剖宫产。这一比例高于全国平均水平32%（风险比0.424 [95%置信区间0.214至0.837]；p = 0.006）。只有一名接受髋臼周围截骨术的患者出现了妊娠相关并发症。在髋臼周围截骨术后的单胎妊娠中，早产率为14%（35例中的5例），低出生体重婴儿的比例为2.9%（35例中的1例）。这些百分比与美国国家生命统计报告公布的数据并无差异，该报告报告称，单胎妊娠的早产率为8%（OR 0.523 [95% CI 0.154至1.772]；p = 0.1723），低出生体重婴儿的比例为6.4%（OR 2.34 [95% CI 0.607至9.025]；p = 0.3878）。    

结论：在这项小型调查研究中，我们发现有髋臼周围截骨术病史的患者与妊娠和分娩并发症的规范性国家数据在并发症、早产或低出生体重婴儿方面没有差异。然而，我们确实注意到，有髋臼周围截骨术病史的患者更有可能通过剖宫产分娩，这可能归因于产科医生的偏好，因为另一项小型调查研究中的大多数产科医生都对有髋臼周围截骨术病史的患者表示担忧。未来的研究应旨在增加对髋臼周围截骨术与分娩方式之间关系的了解，特别是与分娩过程中分娩失败而转为剖宫产之间的关系。未来考虑使用髋臼保护结果研究学术网络库来开发国家外科质量改进计划数据，这可能有助于更清楚地阐明这种关系，并有助于指导在既往髋臼周围截骨术的情况下安排剖宫产的适当指征。

Is Previous Periacetabular Osteotomy Associated with Pregnancy, Delivery, and Peripartum Complications?

Background: Surgical candidates for periacetabular osteotomy are commonly women of reproductive age with symptomatic acetabular dysplasia. However, little is known about how this surgical intervention contributes to the decision to become pregnant, obstetrical counseling regarding delivery, mode of delivery, or pregnancy-related complications.

Questions/purposes: (1) Does a history of periacetabular osteotomy affect a patient's decision to become pregnant or does it affect obstetrical counseling regarding the safety of pregnancy and childbirth? (2) Is history of periacetabular osteotomy associated with in an increased risk of undergoing cesarean section compared with the national average? (3) Is a history of periacetabular osteotomy associated with increased complications, decreased infant birth weight, preterm delivery?    

Methods: In conjunction with obstetrician colleagues, we created a survey to investigate patient attitudes toward pregnancy, mode of delivery, pregnancy-related complications, and obstetrical counseling among female patients who previously underwent periacetabular osteotomy. A retrospective cohort of reproductive-age women who underwent periacetabular osteotomy between 2008 and 2015 completed a mailed survey or telephone interview. All 96 patients who were contacted were asked if the history of periacetabular osteotomy affected their decision to become pregnant. Our cohort included 31 patients who had undergone periacetabular osteotomy and had a subsequent pregnancy and delivery with a total of 38 pregnancies resulting in 41 births. A binomial test was used to determine if the rates of cesarean section, low birth weight, or preterm delivery were different from the documented US national average as published by the National Vital Statistics Report and CDC.

Results: One patient of 31 felt her periacetabular osteotomy negatively affected the appearance of her child; this surgical history affected 6.5% of patients (2 of 31) positively. Fifty-five percent (17 of 31) patients reported that their obstetrician expressed concern that their history of periacetabular osteotomy could affect their ability to carry to term or deliver vaginally. With a history of periacetabular osteotomy, 53% of deliveries (20 of 38) underwent cesarean section. This is higher than the national average of 32% (odds ratio 0.424 [95% confidence interval 0.214 to 0.837]; p = 0.006). Only one patient with a periacetabular osteotomy suffered a pregnancy-related complication. In singleton pregnancy after periacetabular osteotomy the preterm delivery rate was 14% (5 of 35) and the percentage of low-birth-weight infants was 2.9% (1 of 35). These percentages are not different from US data published by the National Vital Statistics Report, which reports an 8% preterm delivery rate (OR 0.523 [95% CI 0.154 to 1.772]; p = 0.1723) and 6.4% low birth weight (OR 2.34 [95% CI 0.607 to 9.025]; p = 0.3878) in singleton pregnancies.    

Conclusions: In this small survey study, we found no differences in terms of complications, preterm delivery or low birth weight infants between patients who had a history of periacetabular osteotomy and normative national data regarding complications of pregnancy and delivery. However, we did note that patients with a history of periacetabular osteotomy were more likely to deliver future children by cesarean section, which could be attributable to obstetrician preference as most obstetricians in another small survey study have expressed concern about patients with a history of periacetabular osteotomy. Future studies should aim to increase the knowledge of the association of periacetabular osteotomy and delivery method, specifically with transition to cesarean for failure to progress during labor. Future consideration of using the Academic Network of Conservational Hip Outcomes Research repository to develop National Surgical Quality Improvement Program data may help to elucidate this relationship more clearly and help guide appropriate indications for scheduled cesarean sections in the setting of prior pelvic osteotomy.    

文献出处：Kimberly Bartosiak, Chris Stockburger, Jennifer Stockburger, Sara Putnam, Shayna Conner, John Clohisy. Is Previous Periacetabular Osteotomy Associated with Pregnancy, Delivery, and Peripartum Complications? Clin Orthop Relat Res. 2020 Jan;478(1):68-76. doi: 10.1097/CORR.0000000000000921.