髋膝关节文献精译荟萃

文献1

全膝关节置换术会影响骨盆运动吗?

前瞻性比较研究

译者 张轶超

目的：脊柱-骨盆-下肢任何部位的病变都可能损害整体姿势平衡，导致其它部位的代偿性改变。本研究的目的是比较患有膝关节骨关节炎的患者与接受全膝关节置换术的患者和健康对照者的骨盆运动情况。

方法：本研究于2021年4月至2022年2月在Cankiri州立医院骨与创伤科诊所进行。这项研究包括84名参与者。其中，2018 - 2020年间行全膝关节置换术的31名患者归为全膝关节置换术组，膝关节骨性关节炎患者28名归为膝关节骨性关节炎组。在对照组中，有25名健康个体。排除标准包括患有任何类型的神经系统疾病的，不能独立行走超过100米的，或下肢有手术史的。使用无线三轴加速度计评估骨盆运动(即前后倾斜、旋转和左右倾斜)和步态参数(即步态速度、节奏和步幅长度)。

结果：与膝关节骨性关节炎组相比，全膝关节置换术组和对照组与骨关节炎组比较，骨盆前倾最小值减小，前倾最大值减小，骨盆倾斜范围减小。与对照组相比，骨关节炎组和全膝关节置换术组的步态速度和步幅均显著降低。

结论：在本研究中，发现全膝关节置换术会影响骨盆运动。这个结果被认为是全膝关节置换术改变了这些变量，可能是由于手术纠正了冠矢状面的力线。

Does total knee arthroplasty affect pelvic movements? A prospective comparative study

OBJECTIVE: Pathology in any segment of the spine-pelvis-lower extremity may impair the global postural balance, leading to compensatory alterations in other parts. The aim of this study was to compare the pelvic movements of patients suffering from knee osteoarthritis with patients who underwent total knee arthroplasty and healthy controls.

METHODS: This study was performed at the Department of Orthopedics and Traumatology Clinic of a Cankiri State Hospital between April 2021 and February 2022. This study included 84 participants. Of them, 31 patients who underwent total knee arthroplasty between 2018 and 2020 years were selected as the total knee arthroplasty group, while 28 patients with knee osteoarthritis were selected as the knee osteoarthritis group. In the control group, there were 25 healthy individuals. Exclusion criteria from the study included any kind of neurological disease, an inability to walk a distance of 100 m unassisted, or a history of surgery to the lower limb. Pelvic movements (i.e., tilt, rotation, and obliquity) and gait parameters (i.e., “gait velocity,” “cadence,” and “stride length”) were assessed using a wireless tri-axial accelerometer.    

RESULTS: Total knee arthroplasty and control groups had decreased minimum anterior tilt of the pelvis, decreased maximum anterior tilt, and decreased oblique range of the pelvis compared with the knee osteoarthritis group. In comparison with the control group, gait velocity and length of stride during gait were remarkably lower in both knee osteoarthritis and total knee arthroplasty groups.

CONCLUSION: In this study, total knee arthroplasty was found to affect pelvic movements. It was thought that total knee arthroplasty changed these variables, probably owing to the frontal and sagittal plane alignment correction through surgery.

文献出处：Polat EA, Polat Y, Karatay GM, Esmer M, Kafa N, Guzel NA. Does total knee arthroplasty affect pelvic movements? A prospective comparative study. Rev Assoc Med Bras (1992). 2023 Sep 18;69(9):e20221231. doi: 10.1590/1806-9282.20221231. PMID: 37729355; PMCID: PMC10508946.

文献2    

应用于具有挑战性股骨解剖畸形病例的钛锥型wagner 假体柄的中期结果: 存活率和独特的骨重建方式

译者 马云青

背景: 股骨近端的复杂解剖使全髋关节置换术(THA)更具挑战性。短直带凹槽和锥形的钛股骨柄，如wagner 柄可有助于解决小股骨髓腔，增加股骨颈偏心，优化的下肢长度差异或股骨近端畸形。髋关节发育不良患者的关节置换术后的结果不太确定，并发症发生率高。因此，作者进行了一项回顾性研究，旨在回答: 1) Wagner 锥型柄能否提供可接受的中长期假体生存率; 2)是否有助于最大限度地减少围手术期不良事件; 3)通过 WOMAC 评分进行评价能否产生有利的临床结果; 4)在最后的随访中与较好的影像学股骨侧畸形重塑相关？

假设: 在复杂全髋关节置换术中，Wagner 椎型柄是治疗股骨近端畸形的有利方法。

患者和方法: 研究队列来源于患者登记处，对88例(103髋)使用wagner 假体进行初次全髋关节置换的患者的病历进行了回顾性分析。然后，分析患者的人口统计学资料和手术资料，并比较术前、术后即刻和最后一次随访资料。11名患者(12髋)被排除(7髋随访不到2年或失访，3髋 Wagner 柄进行了翻修，2髋打入Wagner 柄时出现假体周围骨折)。在2003年3月至2017年2月期间，7名外科医生在3家学术医院为77名患者(91髋)植入了wagner 锥型柄，植入时间超过2年。最后随访记录假体翻修、再次手术、 WOMAC 评分和影像学分析。

结果: 平均随访7.8(范围2.0-16.2)年后，Wagner 柄生存率为98.9% (95% CI: 94-100%) ，其中1例(1.1%)翻修是因为骨整合失败。髋臼翻修5例(5.5%) ，无菌性松动1例，金属碎屑不良反应2例，感染2例。术中发生1例(1.1%)坐骨神经损伤和4例(4.4%)骨折。WOMAC 平均评分为90.5 ± 11.4(59-100)分。影像学检查82例(92.1%)有明显的骨整合和肥大性骨重建征象。

结论: 在复杂的股骨近端的病例中，Wagner 柄显示出低的并发症发生率，高发生率的适应性骨重建，良好的临床结果和中期生存率。是一种安全、可靠、有利于复杂初级全髋置换的选择。然而，继发性骨关节炎的潜在原因对假体柄的长期存活的影响仍有待证实。

Midterm results of titanium conical Wagner stem with challenging femoral anatomy: Survivorship and unique bone remodeling

Background:Complex anatomy of the proximal femur makes total hip arthroplasty (THA) more challenging. Short, straight, fluted and conical titanium stem like the Wagner Cone can be helpful to address small femoral canal, increased femoral neck version, important leg length discrepancy or proximal femoral deformity. The outcome in these patients is less assured and associated with high rate of complications. Therefore, we did a retrospective study aiming to answer: 1) can the Wagner Cone stem provide acceptable mid- to long-term implant survivorship; 2) help minimizing perioperative adverse events; 3) produce favorable clinical outcome measured by WOMAC score; and 4) be associated with a favorable radiographic femoral bone remodeling at the last follow-up?

Hypothesis:Wagner Cone stem is an advantageous solution for the distorted proximal femur in complex THA.

Patients and method:Our cohort was derived from the patient registries where medical records of 88 patients (103 hips) who underwent primary THA using the Wagner prosthesis were retrospectively reviewed. Then, data was analyzed for patients' demographics and surgical data, and comparing preoperative, immediate postoperative and last follow-up data. Eleven patients (12 hips) were excluded (7 hips followed up less than 2 years or lost to follow-up, 3 hips that had the Wagner stem for revision and 2 Wagner stems inserted for periprosthetic fracture). This left 77 patients (91 hips) with Wagner cone stems implanted for more than 2 years between March 2003 and February 2017 by 7 surgeons in 3 academic hospitals. Implant revision, reoperations, WOMAC score and radiographic analyses were recorded at last follow-up.    

Results:After a mean follow-up of 7.8 (range, 2.0-16.2) years, Wagner stem survivorship was 98.9% (95% CI: 94 to 100%) with one (1.1%) stem revision for failure of osteointegration. Five (5.5%) acetabular revisions, one for aseptic loosening, 2 for adverse reaction to metal debris and 2 for infection. One (1.1%) sciatic neuropathy and 4 (4.4%) intraoperative fractures were encountered. The mean WOMAC score was 90.5±11.4 (59-100). Radiographic analysis showed clear signs of stem osseointegration and hypertrophic bone remodeling in 82 cases (92.1%).

Conclusions:Used in complex cases with proximal distorted femurs, the Wagner Cone stem demonstrated a low complication rate, a high-rate consistent adaptive bone remodeling, excellent clinical results, and midterm survival. It is a safe, reliable and advantageous option in complex primary THA. However, the contribution of the underlying cause of the secondary osteoarthritis on the long-term survival of the stem remains to be demonstrated.

文献出处：Shahin M, Massé V, Belzile É, Bédard L, Angers M, Vendittoli PA. Midterm results of titanium conical Wagner stem with challenging femoral anatomy: Survivorship and unique bone remodeling. Orthop Traumatol Surg Res. 2023 Feb;109(1):103242. doi: 10.1016/j.otsr.2022.103242. Epub 2022 Feb 11. PMID: 35158103.

文献3

3D打印的干骺端锥形补块在膝关节翻修手术中的应用：740例补块术后5年随访显示极佳的假体生存率

译者 张蔷

背景：多孔造型的干骺端锥形补块常被用于膝关节翻修手术（Revision TKA）中。本研究的目的是评估3D打印干骺端锥形补块在膝翻修手术当中的应用效果，重点关注短期随访后的假体生存率、影像学检查和临床疗效。

方法：我们的病例选自单一医疗中心共533例膝关节翻修手术，740个干骺端锥形补块（498个胫骨侧补块，242个股骨侧补块）。翻修原因前三位分别是无菌性松动（n=199），假体周围感染（PJI）（n=183）和不稳定（n=84）。67%的病例中骨缺损类型为2B或3型。平均年龄66岁，平均BMI为34kg/m2，55%病例为女性。所有病例均有序列拍摄的影像学检查结果。平均随访时间为4年。

结果：锥形补块因无菌性松动而产生的5年累计翻修率为1%（95%置信区间[CI]，0%-3%）。任何原因而产生的5年累计翻修率为6%（95%置信区间，4%-9%）。最终，共有37个（19例股骨侧，18例胫骨侧）锥形补块接受翻修手术，PJI（n=23；14例复发性病例），股骨假体周围骨折（n=3），关节僵硬（n=3）以及股骨假体和锥形补块无菌性松动（n=3）是最常见的补块翻修原因。任意原因的5年累计再翻修率为14%（95%置信区间，11%-18%）。共有67例再翻修手术，其中PJI（n=38），持续渗出（n=6）和伸膝装置中断（n=3）是最常见的原因。影像学检查结果显示：2例未翻修股骨锥形补块和1例未翻修胫骨锥形补块的片子看上去有松动迹象；这3例均为股骨远端置换或铰链膝。    

结论：这一大样本量研究短期随访结果显示3D打印的钽金属干骺端锥形补块在翻修手术中效果可靠，无菌性松动的5年累计翻修率仅为1%。PJI是锥形补块翻修以及任意翻修手术的最常见原因。

A. 对称式股骨锥形补块。B. 双分叶式股骨锥形补块。C. 对称式胫骨锥形补块。D. 单分叶式胫骨锥形补块。    

股骨锥形补块无菌性松动而施行膝翻修手术前的正位和侧位片。前次手术为股骨远端应用长水泥柄穿过锥形补块固定的股骨远端置换手术。黑色箭头所指为锥形补块和宿主骨之间的透亮线，更近端的位置可以看到骨水泥与宿主骨之间的透亮线。   

双侧膝翻修术后3年正侧位片可见股骨侧对称式锥形补块和胫骨侧对称式锥形补块固定牢靠，骨小梁长入锥形补块多孔表面。

3D-Printed Metaphyseal Cones in Revision Total Knee Arthroplasties

Excellent Survivorship of 740 Cones at 5 Years

Background: Porous metaphyseal cones are frequently utilized during revision total knee arthroplasty (TKA) procedures. The purpose of the present study was to evaluate 3D-printed metaphyseal cones used for revision TKA, with specific emphasis on implant survivorship, radiographic appearance, and clinical outcomes after short-term follow-up.

Methods: We identified 740 cones (498 tibial, 242 femoral) that had been inserted during 533 revision TKA procedures that had been performed at a single tertiary care academic institution. Aseptic loosening (n = 199), periprosthetic joint infection (PJI) (n = 183), and instability (n = 84) were the most common reasons for the index revision. Type-2B or 3 bone loss was present in 67% of the knees. The mean age was 66 years, the mean body mass index was 34 kg/m2, and 55% of the patients were female. Serial radiographs were reviewed. The mean duration of follow-up was 4 years.    

Results: The 5-year cumulative incidence of cone revision for aseptic loosening was 1% (95% confidence interval [CI], 0% to 3%). The 5-year cumulative incidence of any cone revision or removal was 6% (95% CI, 4% to 9%). In total, 37 cones (19 femoral, 18 tibial) were revised, with PJI (n = 23; 14 recurrent), periprosthetic femoral fracture (n = 3), arthrofibrosis (n = 3), and aseptic loosening of the femoral component and femoral cone (n = 3) as the most common reasons for cone revision. The 5-year cumulative incidence of any TKA re-revision was 14% (95% CI, 11% to 18%). There were a total of 67 re-revisions, with PJI (n = 38), persistent drainage (n = 6), and extensor mechanism disruption (n = 3) being the most common reasons. Radiographically, 2 unrevised femoral cones and 1 unrevised tibial cone appeared to be possibly loose; all 3 cones were in knees with distal femoral replacements or hinged constructs.

Conclusions: This large series showed that 3D-printed titanium metaphyseal cones were very durable at short-term follow-up, with a 5-year cumulative incidence of cone revision for aseptic loosening of 1%. PJI was the most common reason for cone revision and any revision.

文献出处：Carender CN, Bothun CE, Taunton MJ, Perry KI, Bedard NA, Pagnano MW, Abdel MP. 3D-Printed Metaphyseal Cones in Revision Total Knee Arthroplasties: Excellent Survivorship of 740 Cones at 5 Years. J Bone Joint Surg Am. 2024 Jun 14. doi: 10.2106/JBJS.23.01196. Epub ahead of print. PMID: 38875316.

文献4

无水泥PEEK股骨假体的初始稳定性对BMI敏感:一项基于人群的有限元研究

译者 沈松坡

聚醚醚酮(PEEK)用于无水泥股骨全膝关节置换术(TKA)组件由于几个潜在的优点而引起了人们的兴趣，例如用于金属过敏患者。此外，PEEK的刚度更接近骨的刚度，因此可以避免假体周围的应力屏蔽。当引入一种新的假体材料用于无骨水泥TKA设计时，重要的是研究其对初始稳定的影响，这是长期稳定所必需的。有限元(FE)研究可用于研究PEEK作为植入材料对初始稳定的影响，这可能取决于患者的年龄、性别和体重指数(BMI)等因素。因此，本研究的研究目的是探讨PEEK与钴铬(CoCr)以及患者特征对无骨水泥股骨假体初次固定的影响。采用不同的植入材料、步态和深蹲活动，建立了70只股骨的280个FE模型。总体而言，PEEK模型比CoCr模型产生更大的峰值微运动。在步态和深蹲模型中，PEEK和CoCr模型之间的微运动分布存在明显差异。所有股骨模型的微运动均随BMI的增加而显著增加。患者的性别和年龄对微动均无显著影响。该人群研究对具有不同植入材料和患者特征的FE模型的无骨水泥股骨假体的初始固定进行了深入研究。

关键词:无水泥股骨膝关节假体;有限元模拟;微动;聚醚醚酮;人群研究;全膝关节置换术。

The primary stability of a cementless PEEK femoral component is sensitiveto BMI: A population-based FE study

The use of polyetheretherketone (PEEK) for cementless femoral total knee arthroplasty (TKA) components is of interest due to several potential advantages, e.g. the use in patients with metal hypersensitivity. Additionally, the stiffness of PEEK closer resembles the stiffness of bone, and therefore, peri-prosthetic stress-shielding may be avoided. When introducing a new implant material for cementless TKA designs, it is important to study its effect on the primary fixation, which is required for the long-term fixation. Finite element (FE) studies can be used to study the effect of PEEK as implant material on the primary fixation, which may be dependent on patient factors such as age, gender and body weight index (BMI). Therefore, the research objectives of this study were to investigate the effect of PEEK vs cobalt-chrome (CoCr) and patient characteristics on the primary fixation of a cementless femoral component. 280 FE models of 70 femora were created with varying implant material and gait and squat activity. Overall, the PEEK models generated larger peak micromotions than the CoCr models. Distinct differences were seen in the micromotion distributions between the PEEK and CoCr models for both the gait and squat models. The micromotions of all femoral models significantly increased with BMI. Neither gender nor age of the patients had a significant effect on the micromotions. This population study gives insights into the primary fixation of a cementless femoral component in a cohort of FE models with varying implant material and patient characteristics.    

Keywords: Cementless femoral knee component; Finite element simulation; Micromotion; Polyetheretherketone; Populationstudy; Total knee arthroplasty.

文献1

人类站立位矢状面中轴骨与重力中轴线之间的关系

译者 罗殿中

当人直立站立时，平衡链从脚开始，逐步由下肢（踝关节、膝关节、髋关节、骨盆）向上，到脊柱各节段，终止于颅骨，获得平视（水平视觉）、及最少肌肉活动获取平衡。但由于缺乏各部位骨骼元素的三维信息、与重力中轴线（GL）之间的关系，该平衡链及其细节并未得到清晰解读。

我们在正常人群中，通过EOS扇面扫描、三维X线摄像系统，同时进行压力板测量，研究并明晰了站立位整个中轴骨相对于重力中轴线之间的矢状面关系。

通过压力板，重力中轴线（GL）定义为通过垂直应力中心的中垂线。该研究通过136例健康个体（20-69岁，平均年龄39.7岁；40例男性，96例女性）的数据资料，揭示了站立位中轴骨完整的生理学排列数据。双侧外耳道中心与GL矢状面的平均偏心距为0.0cm。相对于GL的颈椎偏心距、胸椎椎体位于GL后侧，胸椎后凸顶椎是T7，位于GL后侧5.0cm。脊柱矢状面排列于L2水平过渡为前凸，腰椎前凸顶椎为L4，位于GL前侧0.6cm。骶椎上终板的中心（CBS）恰好位于GL后侧。髋关节中心轴（HA）位于GL前方1.4cm；膝关节中心位于GL后方2.4cm；踝关节中心位于GL后方4.8cm。年龄40几岁、50几岁、60几岁的个体，相对于20几岁的个体，L4、L5和CBS的偏心距显著向后偏移。年龄50几岁、60几岁的个体，相对于30几岁的个体，L5和CBS的偏心距也显著向后偏移。髋关节中心轴（HA）不会位于GL的后方。    

整体来说，C7椎体与矢状面垂直轴线（矢状面从骶骨后上角向上的垂直线）之间的偏心距与年龄呈正相关，而外耳道中心偏心距与年龄无相关性。颈椎前凸（CL）、骨盆倾斜（PT）、骨盆入射角（PI）、髋关节后伸、膝关节屈曲和踝关节背伸随年龄增加而增大。

我们的研究结果提示，正常人群随着年龄增大导致弯腰驼背，整体躯体平衡可通过颈椎前凸（CL）、骨盆前倾（PT）、膝关节屈曲获得维持，颈椎前凸（CL）、和骨盆前倾（PT）可维持站立位水平视线。    

图. 所有骨骼标志点与重力中轴线（GL）之间距离的测量方法。    

图. 维持水平视线的代偿机制。年龄增大导致弯腰驼背，整体躯体平衡可通过颈椎前凸（CL）、骨盆前倾（PT）、膝关节屈曲获得维持，颈椎前凸（CL）、和骨盆前倾（PT）可维持站立位水平视线。健康人群中颈椎前凸（CL）、骨盆前倾（PT）是主要的代偿机制。

Standing sagittal alignment of the whole axial skeleton with reference to the gravity line in humans    

Human beings stand upright with the chain of balance beginning at the feet, progressing to the lower limbs (ankles, knees, hip joints, pelvis), each of the spinal segments, and then ending at the cranium to achieve horizontal gaze and balance using minimum muscle activity. The details of the alignment and balance of the chain, however, are not clearly understood, due to the lack of information regarding the three-dimensional (3D) orientation of all bony elements in relation to the gravity line (GL). We performed a clinical study to clarify the standing sagittal alignment of whole axial skeletons in reference to the GL using the EOS slot-scanning 3D X-ray imaging system with simultaneous force plate measurement in a healthy human population. The GL was defined as a vertical line drawn through the centre of vertical pressure measured by the force plate. The present study yielded a complete set of physiological alignment measurements of the standing axial skeleton from the database of 136 healthy subjects (a mean age of 39.7 years, 20-69 years; men: 40, women: 96). The mean offset of centre of the acoustic meati from the GL was 0.0 cm. The offset of the cervical and thoracic vertebrae was posterior to the GL with the apex of thoracic kyphosis at T7, 5.0 cm posterior to the GL. The sagittal alignment changed to lordosis at the level of L2. The apex of the lumbar lordosis was L4, 0.6 cm anterior to the GL, and the centre of the base of the sacrum (CBS) was just posterior to the GL. The hip axis (HA) was 1.4 cm anterior to the GL. The knee joint was 2.4 cm posterior and the ankle joint was 4.8 cm posterior to the GL. L4-, L5- and the CBS-offset in subjects in the age decades of 40s, 50s and 60s were significantly posterior to those of subjects in their 20s. The L5- and CBS-offset in subjects in their 50s and 60s were also significantly posterior to those in subjects in their 30s. HA was never posterior to the GL. In the global alignment, there was a positive correlation between offset of C7 vertebra from the sagittal vertical axis (a vertical line drawn through the posterior superior corner of the sacrum in the sagittal plane) and age, but no correlation was detected between the centre of the acoustic meati-GL offset and age. Cervical lordosis (CL), pelvic tilt (PT), pelvic incidence, hip extension, knee flexion and ankle dorsiflexion increased significantly with age. Our results revealed that aging induces trunk stooping, but the global alignment is compensated for by an increase in the CL, PT and knee flexion, with the main function of CL and PT to maintain a horizontal gaze in a healthy population.    

文献出处：Hasegawa K, Okamoto M, Hatsushikano S, Shimoda H, Ono M, Homma T, Watanabe K. Standing sagittal alignment of the whole axial skeleton with reference to the gravity line in humans. J Anat. 2017 May;230(5):619-630. doi: 10.1111/joa.12586. Epub 2017 Jan 27. PMID: 28127750; PMCID: PMC5382592.

文献2

微创清洗坏死骨可改善股骨头缺血性骨坏死后的骨愈合

译者 张振东

背景：股骨头缺血性骨坏死在骨髓间隙产生坏死细胞碎片和炎症分子，引起慢性炎症修复反应。本研究的目的是确定清洗坏死细胞碎片和炎症蛋白对缺血性骨坏死幼年猪模型骨修复的影响。    

方法：在12只幼年猪中，通过在股骨颈上捆扎一条结扎线，诱导右后侧股骨头坏死。手术后一周，6只动物接受经皮穿刺清洗和右后肢非负重（NWB）治疗。总盐水溶液洗涤体积为每股骨头450 mL。收集并分析连续清洗的溶液。其余6只动物仅接受NWB治疗（NWB组）。手术后 8 周，使用X线、显微计算机断层扫描 （micro-CT） 和组织学分析对股骨头进行评估。此外，将以上结果与既往已经发表的结果（对幼年猪进行多次骨骺钻孔减压及非负重治疗）进行比较。

结果：坏死细胞和炎症蛋白存在于缺血诱导后 1 周收集的清洗液中。炎症蛋白和甘油三酯浓度随着连续洗涤而显着降低（p < 0.005）。在缺血诱导后8周，清洗组的骨组织体积明显高于多次骨骺钻孔减压组或非负重组（p < 0.0001）。与多次骨骺钻孔减压组（p = 0.002）或非负重组（p < 0.0001）相比，清洗组的组织学新骨形成指标也显着增加，且巨噬细胞数量显着减少。

结论：经皮穿刺清洗可冲洗掉股骨头中坏死细胞碎片和炎症蛋白，减少破骨细胞和巨噬细胞，并增加缺血性骨坏死后骨形成。微创手术可能有助于改善缺血性骨坏死后的坏死骨环境和骨修复。

Minimally Invasive Necrotic Bone Washing Improves Bone Healing After Femoral Head Ischemic Osteonecrosis: An Experimental Investigation in Immature Pigs

Background: Ischemic osteonecrosis of the femoral head produces necrotic cell debris and inflammatory molecules in the marrow space, which elicit a chronic inflammatory repair response. The purpose of this study was to determine the effects of flushing out the necrotic cell debris and inflammatory proteins on bone repair in a piglet model of ischemic osteonecrosis.    

Methods: Osteonecrosis of the femoral head of the right hindlimb was induced in 12 piglets by tying a ligature tightly around the femoral neck. One week after the surgery, 6 animals were treated with a percutaneous 3-needle bone washing procedure and non-weight-bearing (NWB) of the right hindlimb (wash group). The total saline solution wash volume was 450 mL per femoral head. Serial wash solutions were collected and analyzed. The remaining 6 animals were treated with NWB only (NWB group). At 8 weeks after the surgery, the femoral heads were assessed using radiography, micro-computed tomography (micro-CT), and histological analysis. In addition, we compared the results for these piglets with our published results for 6 piglets treated with multiple epiphyseal drilling (MED) plus NWB without bone washing (MED group).

Results: Necrotic cells and inflammatory proteins were present in the bone wash solution collected 1 week after ischemia induction. The protein and triglyceride concentrations decreased significantly with subsequent washing (p < 0.005). At 8 weeks after ischemia induction, the wash group had a significantly higher bone volume than the MED or NWB group (p < 0.0001). Histological bone-formation measures were also significantly increased in the wash group compared with the MED group (p = 0.002) or NWB group (p < 0.0001) while macrophage numbers were significantly decreased in the wash group.

Conclusions: The percutaneous 3-needle procedure flushed out cell debris and inflammatory proteins from the necrotic femoral heads, decreased osteoclasts and macrophages, and increased bone formation following induction of ischemic osteonecrosis.    

Clinical relevance: We believe that this is the first study to investigate the concept of washing out the necrotic femoral head to improve bone healing. The minimally invasive procedure may be useful to improve the necrotic bone environment and bone repair following ischemic osteonecrosis.

文献出处：Kim HKW, Park MS, Alves do Monte F, Gokani V, Aruwajoye OO, Ren Y. Minimally Invasive Necrotic Bone Washing Improves Bone Healing After Femoral Head Ischemic Osteonecrosis: An Experimental Investigation in Immature Pigs. J Bone Joint Surg Am. 2021 Jul 7;103(13):1193-1202. doi: 10.2106/JBJS.20.00578. PMID: 33877059.

文献3

在Perthes或Perthes样髋关节疾病患者中发现的致病基因变异

译者 任宁涛

目的:Legg-Calve-Perthes病(LCPD)是一种排除性诊断，各种情况，如骨骼发育不良，可以与LCPD相似，必须排除这些情况，以提供适当的治疗、预后和咨询。传统上，基因检测在儿科骨科实践中并不容易获得。此外，基因检测对LCPD患者的临床价值尚不明确。随着新一代测序(NGS)技术的进步，基因检测已经成为一种临床可用的实验室检测。本研究的目的是评估基因检测在选择的LCPD患者中的临床效用，并确定那些检测为骨骼发育不良阳性者的患者特征。

方法:这是一项经IRB批准的回顾性研究，连续纳入了63例有Perthes样症状和/或X线表现并进行了基因检测的患者。基因检测的原因包括双侧髋关节疾病、LCPD家族史、身材矮小、可疑骨骼发育不良、不典型影像学表现和(或)这些原因的组合。    

结果:63例患者中有19例(30%)存在致病基因变异。19例中有8例被诊断为各种骨骼发育不良。其余11例患者为常染色体隐性遗传病携带者。所有19例患者均接受了遗传咨询。在8例发现骨骼发育不良的患者中，3例患有双侧疾病，3例身高偏矮（低于正常身高的10%），1例有“LCPD”家族史，3例有不典型的x线表现。除了致病变异外，还发现了许多意义未知的遗传变异，其中2个基因变异在2个不相关的患者中发现了完全相同的变异。

结论:对部分Perthes样病患者进行基因检测，可发现30%的患者有致病结果，对发现潜在的遗传病或遗传病携带者有重要价值。

Pathogenic Gene Variants Identified in Patients Presenting With Perthes or Perthes-like Hip Disorder

Aims: Legg-Calve-Perthes disease (LCPD) is a diagnosis of exclusion. Various conditions, such as skeletal dysplasias, can closely mimic LCPD and these must be ruled out to provide appropriate treatment, prognosis, and counseling. Traditionally, genetic testing has not been readily available in pediatric orthopaedic practice. Furthermore, the clinical value of genetic testing patients with LCPD is unclear. With the advance of next-generation sequencing (NGS) technology, genetic testing has become clinically available as a lab test. The purposes of this study were to assess the clinical utility of genetic testing in select patients with LCPD and to determine the patient characteristics of those who tested positive for skeletal dysplasia.    

Methods: This is an IRB-approved, retrospective study of 63 consecutive patients who presented with Perthes-like symptoms and/or x-ray findings and who had genetic testing. The reason(s) for genetic testing included bilateral hip disease, family history of LCPD, short stature, suspected skeletal dysplasia, atypical radiographic findings, and/or combinations of these reasons.

Results: Of the 63 patients, 19 patients (30%) were found to have a pathogenic gene variant. In 8 of the 19, a variety of skeletal dysplasia was diagnosed. The remaining 11 patients were found to be carriers of autosomal recessive disorders. All 19 patients were referred for genetic counseling. Of the 8 patients found to have skeletal dysplasia, 3 had bilateral disease, 3 were <10 percentile in height, 1 had a family history of "LCPD," and 3 had atypical x-ray findings. In addition to the pathogenic variants, numerous genetic variants of unknown significance were found with 2 gene variants showing exactly the same variant found in 2 unrelated patients.

Conclusions: With 30% of the patients showing pathogenic results, genetic testing of select patients with Perthes-like disease is valuable in detecting an underlying genetic disorder or a carrier status of a genetic disorder.

文献出处：Marchelli G, Mercado C, Gill CS, Kim HKW. Pathogenic Gene Variants Identified in Patients Presenting With Perthes or Perthes-like Hip Disorder. J Pediatr Orthop. 2024 Aug 1;44(7):e612-e617. doi: 10.1097/BPO.0000000000002708. Epub 2024 Apr 23. PMID: 38651529.   

文献4

夹板固定对6个月以下儿童发育性髋关节发育不良(DDH)的非手术治疗

译者 李勇

背景:发育性髋关节发育不良(DDH)描述了儿童时期髋关节的异常发育，从髋关节完全脱位到股骨头在髋臼内固定和稳定的轻微发育不良。每1000例活产婴儿中约有10例发生DDH，但其中只有1例完全脱位。DDH的治疗方法存在差异，不同医院之间甚至同一医院内的临床医生之间的治疗方法存在差异。这种变异与需要治疗的发育不良的严重程度以及治疗发育不良的技术有关。目的:探讨6月龄以下婴儿DDH非手术治疗中夹板的效果及最佳治疗策略。

检索方法:我们检索了截至2021年11月的CENTRAL、MEDLINE、Embase、其他7个电子数据库和2个试验注册库。我们还检查了参考文献列表，联系了研究作者，并手工检索了相关的会议摘要。选择标准:纳入1980年以后进行的随机对照试验(RCT)，包括准RCT，以及非RCT和队列研究。参与者是所有DDH严重程度的婴儿，年龄在6个月以下。干预措施包括动态夹板、静态夹板或双重尿布(尿布)，与不夹板或延迟夹板相比。数据收集和分析:两位综述作者独立选择研究，提取数据并进行偏倚风险和GRADE评估。主要结果是:通过x线片(角度)测量第1年、第2年和第5年的髋臼指数:是否需要手术干预以实现复位和解决发育不良;和并发症。我们还调查了父母强调的其他重要结果，包括父母和孩子之间的联系以及母亲母乳喂养的能力。

主要结果:我们纳入6项随机对照试验或准随机对照试验(576名婴儿)。这些研究得到了16项非随机对照试验(8237名婴儿)的支持。5项研究有非商业资助，3项研究表示“没有资助”，14项研究没有说明资金来源。这些随机对照试验总体上存在不明确的偏倚风险，尽管我们判断有3项随机对照试验因结果数据不完整而存在高偏倚风险。非随机对照试验的偏倚风险为中度和重度。由于研究之间的方法学和临床差异，我们没有进行meta分析;相反，我们用叙述的方式总结了这些结果。动态夹板与延迟夹板固定或不用夹板固定4项随机对照试验和9项非随机对照试验比较了立即动态夹板和延迟动态夹板或不夹板固定的结果。在这些随机对照试验中，两个考虑髋部稳定，一个考虑髋部不稳定(脱位)，一个同时考虑髋部不稳定和稳定。没有研究只考虑髋关节脱位。两项随机对照试验(265名婴儿，极低确定性证据)报告了稳定或脱位髋关节一年时的髋臼指数。两项研究都发现，与主动监测策略相比，首次诊断时固定稳定髋关节可能没有证据差异:一项研究报告的平均差异(MD)为0.10(95%可信区间(Cl) -0.74至0.94)，另一项研究报告的MD为0.20(95%可信区间(Cl) -1.65至2.05)。两项关于稳定髋部的随机对照试验(181名婴儿，非常低确定性证据)报道，两组之间髋臼指数可能没有差异的证据:一项研究报告的MD为-1.90 (95% Cl -4.76至0.96)，另一项研究报告的MD为-0.10 (95% Cl-1.93至1.73)，但没有考虑同一儿童的髋部。没有研究报告5年的数据。四项随机对照试验(434名婴儿，极低确定性证据)报告了手术干预的必要性。三项研究报告未发生手术干预。在剩下的研究中，动态夹板组的两名婴儿出现不稳定，随后进行了手术治疗。这项研究没有明确说明这种治疗是否能达到同心复位或解决残留的发育不良。3项随机对照试验(390名婴儿，极低确定性证据)报告无并发症(缺血性坏死和股神经麻痹)。一项随机对照试验和五项非随机对照试验比较了动态和静态夹板。该随机对照试验(118髋)未报告发生缺血性坏死(非常低确定性证据)，未报告放射学结果或需要手术干预。一项准随机对照试验比较了双重尿布与延迟或不夹板，但没有报道有趣的结果。其他比较没有随机对照试验比较静态夹板固定与延迟夹板固定或不夹板固定或分阶段拆除与立即拆除。    

结论:对于DDH的非手术治疗，使用夹板的RCT证据不足:我们只纳入了6项576名婴儿的RCT。此外，研究之间存在相当大的异质性，因此无法进行meta分析。我们判断所有主要结果的RCT证据的确定性非常低，这意味着我们对真实效果非常不确定。个别研究的结果对不同严重程度的DDH的干预效果提供了有限的证据。在稳定性发育不良的髋关节中，没有证据表明任何阶段的治疗都能加速髋臼的发育。对于髋关节脱位，延迟治疗至6周似乎不会导致髋臼一年后发育的差异或手术风险增加。然而，延迟夹板固定可能会减少需要使用背带治疗的婴儿数量。没有随机对照试验比较静态夹板固定与延迟夹板固定或不夹板固定，分阶段拆除与立即拆除，双重尿布与延迟夹板固定或不夹板固定。在随机对照试验和非随机对照研究中，很少有手术干预或并发症。没有明显的信号表明在任何一个干预组中出现任何结果的频率更高。鉴于这种疾病的频率，以及许多国家进行强制性DDH筛查的事实，显然需要制定循证治疗途径。需要未来研究的特别不确定性是在稳定的发育不良髋关节中夹板固定的有效性，夹板固定开始的最佳时间，使用夹板的最佳类型以及“脱夹板”的需要。只有建立了强有力的治疗途径，我们才能正确评估DDH筛查干预措施的成本效益。

Splinting for the non-operative management of developmental dysplasia of the hip (DDH) in children under six months of age

Background: Developmental dysplasia of the hip (DDH) describes the abnormal development of a hip in childhood, ranging from complete dislocation of the hip joint to subtle immaturity of a hip that is enlocated and stable within the socket. DDH occurs in around 10 per 1000 live births, though only one per 1000 are completely dislocated. There is variation in treatment pathways for DDH, which differs between hospitals and even between clinicians within the same hospital. The variation is related to the severity of dysplasia that is believed to require treatment, and the techniques used to treat dysplasia.Objectives: To determine the effectiveness of splinting and the optimal treatment strategy for the non-operative management of DDH in babies under six months of age.Search methods: We searched CENTRAL, MEDLINE, Embase, seven other electronic databases, and two trials registers up to November 2021. We also checked reference lists, contacted study authors, and handsearched relevant meetings abstracts.Selection criteria: Randomised controlled trials (RCTs), including quasi-RCTs, as well as non-RCTs and cohort studies conducted after 1980 were included. Participants were babies with all severities of DDH who were under six months of age. Interventions included dynamic splints, static splints or double nappies (diapers), compared to no splinting or delayed splinting.Data collection and analysis: Two review authors independently selected studies, extracted data and performed risk of bias and GRADE assessments. The primary outcomes were: measurement of acetabular index at years one, two and five, as determined by radiographs (angle): the need for operative intervention to achieve reduction and to address dysplasia; and complications. We also investigated other outcomes highlighted by parents as important, including the bond between parent and child and the ability of mothers to breastfeed.    

Main results: We included six RCTs or quasi-RCTs (576 babies). These were supported by 16 non-RCTs (8237 babies). Five studies had non-commercial funding, three studies stated 'no funding' and 14 studies did not state funding source. The RCTs were generally at unclear risk of bias, although we judged three RCTs to be at high risk of bias for incomplete outcome data. The non-RCTs were of moderate and critical risk of bias. We did not undertake meta-analysis due to methodological and clinical differences between studies; instead, we have summarised the results narratively. Dynamic splinting versus delayed or no splinting Four RCTs and nine non-RCTs compared immediate dynamid splinting and delayed dynamic splinting or no splinting. Of the RCTs, two considered stable hips and one considered unstable (dislocatable) hips and one jointly considered unstable and stable hips. No studies considered only dislocated hips. Two RCTs (265 babies, very low-certainty evidence) reported acetabular index at one year amongst stable or dislocatable hips. Both studies found there may be no evidence of a difference in splinting stable hips at first diagnosis compared to a strategy of active surveillance: one reported a mean difference (MD) of 0.10 (95% confidence interval (Cl) -0.74 to 0.94), and the other an MD of 0.20 (95% Cl -1.65 to 2.05). Two RCTs of stable hips (181 babies, very low certainty evidence) reported there may be no evidence of a difference between groups for acetabular index at two years: one study reported an MD of -1.90 (95% Cl -4.76 to 0.96), and another study reported an MD of -0.10 (95% Cl-1.93 to 1.73), but did not take into account hips from the same child. No study reported data at five years. Four RCTs (434 babies, very low-certainty evidence) reported the need for surgical intervention. Three studies reported that no surgical interventions occurred. In the remaining study, two babies in the dynamic splinting group developed instability and were subsequently treated surgically. This study did not explicitly state if this treatment was to achieve concentric reduction or address residual dysplasia. Three RCTs (390 babies, very low-certainty evidence) reported no complications (avascular necrosis and femoral nerve palsy). Dynamic splinting versus static splinting One RCT and five non-RCTs compared dynamic versus static splinting. The RCT (118 hips) reported no occurrences of avascular necrosis (very low-certainty evidence) and did not report radiological outcomes or need for operative intervention. One quasi-RCT compared double nappies versus delayed or no splinting but reported no outcomes of interest. Other comparisons No RCTs compared static splinting versus delayed or no splinting or staged weaning versus immediate removal.    

Authors' conclusions: There is a paucity of RCT evidence for splinting for the non-operative management of DDH: we included only six RCTs with 576 babies. Moreover, there was considerable heterogeneity between the studies, precluding meta-analysis. We judged the RCT evidence for all primary outcomes as being of very low certainty, meaning we are very uncertain about the true effects. Results from individual studies provide limited evidence of intervention effects on different severities of DDH. Amongst stable dysplastic hips, there was no evidence to suggest that treatment at any stage expedited the development of the acetabulum. For dislocatable hips, a delay in treatment onset to six weeks does not appear to result in any evidence of a difference in the development of the acetabulum at one year or increased risk of surgery. However, delayed splinting may reduce the number of babies requiring treatment with a harness. No RCTs compared static splinting with delayed or no splinting, staged weaning versus immediate removal or double nappies versus delayed or no splinting. There were few operative interventions or complications amongst the RCTs and the nonrandomised studies. There's no apparent signal to indicate a higher frequency of either outcome in either intervention group. Given the frequency of this disease, and the fact that many countries undertake mandatory DDH screening, there is a clear need to develop an evidence-based pathway for treatment. Particular uncertainties requiring future research are the effectiveness of splinting amongst stable dysplastic hips, the optimal timing for the onset of splinting, the optimal type of splint to use and the need for 'weaning of splints'. Only once a robust pathway for treatment is established, can we properly assess the cost-effectiveness of screening interventions for DDH.

文献出处：Dwan K, Kirkham J, Paton RW, Morley E, Newton AW, Perry DC. Splinting for the non-operative management of developmental dysplasia of the hip (DDH) in children under six months of age. Cochrane Database Syst Rev. 2022 Oct 10;10(10):CD012717. doi: 10.1002/14651858.CD012717.pub2. PMID: 36214650; PMCID: PMC9549867.

文献5

股骨和髋臼扭转的变化与年轻人髋关节疼痛有何关联

译者 张利强

背景  髋股撞击症(femoroacetabular impingement, FAI)或髋关节发育不良患者的髋关节疼痛与髋臼和股骨扭转有关。然而，不同研究对股骨扭转的定义和测量方法不尽相同，导致临床医师对同一解剖测量的"正常"值存在差异。这可能导致不一致的甚至不适当的治疗建议。

问题/目的  在接受保髋手术的患者中，(1)初次诊断时髋臼和股骨扭转角的范围是多少，两种常用的测量技术(Murphy和Reikerås)有多大的差异?(2)髋臼和股骨扭转的差异与就诊时的临床因素和结局评分如何相关?

方法  本研究为回顾性分析，收集在三级医疗转诊中心接受保髋手术患者的纵向数据库。回顾性分析2020年6月至2021年12月收治的258例(282髋)单纯盂唇撕裂(9%[26髋])、髋关节发育不良(21%[59髋])、FAI(52%[147髋])、混合FAI和髋关节发育不良(17%[47髋])或儿童畸形(股骨头骨骺滑脱或Perthes病; 1% [3例髋关节]）患者，其中髋关节镜检查（71% [200例髋关节]）、髋臼周围截骨术(26%[74髋])、外科髋关节脱位(2.5%[7髋])或股骨去旋转截骨术(0.5%[1髋])。我们认为有完整的影像学数据(包括骨盆和股骨远端CT)和患者报告的结局评分的患者符合纳入标准。排除标准：年龄< 18岁或> 55岁(5髋，3例)，有髋关节骨关节炎征象(Tönnis分级≥2级;0)、儿童畸形(股骨头骨骺滑脱或Perthes病;既往股骨或髋臼截骨术2例(2髋)，股骨头缺血性坏死0例，神经肌肉疾病史(Ehlers-Danlos综合征;3髋，3例)或类风湿性疾病（强直性脊柱炎；1例髋关节，1例患者）；CT未包括膝关节(19髋，19例)。根据这些标准，227例患者的249髋纳入研究。双侧髋关节症状患者中，随机选取一侧纳入，227例患者共227髋纳入分析。患者中位年龄34岁(范围19 ~ 55岁)，中位BMI 27kg/m2 (范围16 ~ 55 kg/m2)，63%(144例)为女性；患者接受了髋关节镜(74%[168])或髋臼周围截骨术(23%[52])治疗。患者均行CT扫描，采用Murphy法 (低位< 10°;正常:10°~ 25°;高> 25°)或Reikeås法(低< 5°;正常:5°~ 20°;高> 20°)测量髋臼和股骨扭转角。计算McKibbin指数(低:< 20°;正常:20°~ 50°;高> 50°)。根据Murphy髋臼扭转角度将患者分为4组:高扭转角度组(高髋臼扭转+高股骨扭转)、中扭转角度组(高髋臼扭转+正常股骨扭转或正常髋臼扭转+高股骨扭转)、正常扭转角度组(正常髋臼扭转+正常股骨扭转)；代偿扭转角度组(低髋臼扭转+高股骨扭转或高髋臼扭转+低股骨扭转);撞击扭转组(低髋臼扭转+低股骨扭转):高(低髋臼扭转+低股骨扭转)或中(低髋臼扭转+正常股骨扭转或正常髋臼扭转+低股骨扭转)。由两名骨科住院医师对数字化图像进行手动X线评估，随机选择25%测量值由资深医师(一名专科医师培训的保髋和关节置换术医师)重复测量。使用双向混合模型相关系数计算观察者间和观察者内的可靠性，Murphy技术(组内相关系数0.908[95%可信区间0.80 ~ 0.97])和Reikerås技术(组内相关系数0.938[95%可信区间0.81 ~ 0.97])的一致性极好。使用国际髋关节结局工具(International Hip Outcome Tool, iHOT-33)记录患者报告指标(0 ~ 100：差到最好)。

结果  Murphy法测量髋臼扭转角平均为18°±6°，股骨扭转角Murphy法平均为24°±12°，Reikerås法为12°±11°。80%(181 / 227)的髋臼扭转角正常，42%(96 / 227)~ 63%(142 / 227)的股骨扭转角正常，67%(152 / 227)的McKibbin指数正常。撞击型髋(低髋臼扭转或股骨扭转)患者年龄(39±9)岁，高于不稳定型髋臼(高髋臼扭转或股骨扭转(33±9)岁;P = 0.004)、正常(33±9岁;P = 0.02)，或代偿型(高髋臼扭转与低股骨扭转，反之亦然；年龄(33±7)岁；P=0.08)扭转组。采用Murphy技术测量股骨扭转角比Reikerås法大12°(R2 0.85;P < 0.001)。不同组间iHOT-33评分差异无统计学意义(撞击组:32±17、正常组:35±21、代偿组:34±20、不稳定组:31±17;P = 0.40)。

结论  股骨扭转角的变异性是髋臼扭转角的2倍。撞击扭转组患者比扭转正常、代偿或不稳定的患者年龄更大，这表明在这些人群中，还有其他尚未完全解释的导致早期疼痛和表现的变量。测量方法之间存在重要差异。不同的股骨前倾角测量方法导致的数值不同；如果其他作者将他们的结果与其他研究的结果进行比较，他们应该使用本研究中建议的方法。

证据级别  III级，预后研究。

此处显示了（A）头侧和（B）髋臼中心扭转的测量。髋臼扭转定义为矢状线与对应髋臼前后边缘连线的角度。矢状线垂直于连接两个股骨头中心的连线。在两个水平面上测量髋臼扭转：（A）在股骨头的头侧（距离髋臼顶4mm远），对应于1点钟位置；（B）穿过股骨头的中心，对应于3点钟位置。

股骨颈轴线使用（A）Reikerås法、（B）Murphy法和（C）后髁线来测量股骨扭转。（A）使用Reikerås法，将股骨头的中心连接股骨颈底部的中心来确定股骨颈轴线，其中前方和后方皮质平行。（B）使用Murphy法，将股骨头中心连接到位于小转子上方的颈部底部中心来确定股骨颈轴线。（C）后髁线选取后髁最凸出处，通过连接内侧和外侧后髁的中心来确定的。近端角度基于股骨颈轴线和水平轴线测量，远端角度基于后髁线和水平轴线测量。然后根据近端和远端角度之和计算股骨扭转。例：根据Reikerås方法（A，C），右髋关节的股骨扭转角为6°+2°=8°，根据Murphy方法（B，C）为24°+2°=26°。根据Reikerås方法（A，C），左侧股骨角度为22°+8°=30°，根据Murphy方法（B，C）为38°+8℃=46°。

How Is Variability in Femoral and Acetabular Version Associated With Presentation Among Young Adults With Hip Pain?

Background Acetabular and femoral version contribute to hip pain in patients with femoroacetabular impingement (FAI) or dysplasia. However, definitions and measurement methods of femoral version have varied in different studies, resulting in different “normal” values being used by clinicians for what should be the same anatomic measurement. This could result in discrepant or even inappropriate treatment recommendations.

Questions/purposesIn patients undergoing hip preservation surgery, (1) what is the range of acetabular and femoral version at presentation, and how much do two commonly used measurement techniques (those of Murphy and Reikerås) differ? (2) How are differences in acetabular and femoral version associated with clinical factors and outcomes scores at the time of presentation?

Methods This was a retrospective analysis of data gathered in a longitudinally maintained database of patients undergoing hip preservation at a tertiary care referral center. Between June 2020 and December 2021, 282 hips in 258 patients were treated for an isolated labral tear (9% [26 hips]), hip dysplasia (21% [59 hips]), FAI (52% [147 hips]), mixed FAI and dysplasia (17% [47 hips]), or pediatric deformity (slipped capital femoral head epiphysis or Perthes disease; 1% [3 hips]) with hip arthroscopy (71% [200 hips]), periacetabular osteotomy (26% [74 hips]), surgical hip dislocation (2.5% [7 hips]), or femoral derotation osteotomy (0.5% [1 hip]). We considered those with complete radiographic data (CT including the pelvis and distal femur) and patient-reported outcome scores as potentially eligible. Exclusion criteria were age younger than 18 or older than 55 years (5 hips, 3 patients), signs of hip osteoarthritis (Tönnis grade ≥ 2; 0), pediatric deformity (slipped capital femoral head epiphysis or Perthes disease; 3 hips, 3 patients), previous femoral or acetabular osteotomy (2 hips, 2 patients), avascular necrosis of the femoral head (0), history of neuromuscular disorder (Ehlers-Danlos syndrome; 3 hips, 3 patients) or rheumatoid disease (ankylosing spondylitis; 1 hip, 1 patient), and when CT did not include the knees (19 hips, 19 patients). Based on these criteria, 249 hips in 227 patients were included. Of patients with bilateral symptomatic hips, one side was randomly selected for inclusion, leaving 227 hips in 227 patients for further analysis. The patients’ median age (range) was 34 years (19 to 55 years), the median BMI (range) was 27 kg/m2 (16 to 55 kg/m2), and 63% (144) were female; they were treated with hip arthroscopy (in 74% [168]) or periacetabular osteotomy (in 23% [52]). Patients underwent a CT scan to measure acetabular version and femoral version using the Murphy (low < 10°; normal: 10° to 25°; high > 25°) or Reikeås (low < 5°; normal: 5° to 20°; high > 20°) technique. The McKibbin index was calculated (low: < 20°; normal: 20° to 50°; high > 50°). Based on the central acetabular version and femoral version as measured by Murphy, hips were grouped according to their rotational profile into four groups: unstable rotational profile: high (high acetabular version with high femoral version) or moderate (high acetabular version with normal femoral version or normal acetabular version with high femoral version); normal rotational profile (normal acetabular version with femoral version); compensatory rotational profile (low acetabular version with high femoral version or high acetabular version with low femoral version); and impingement rotational profile (low acetabular version with low femoral version): high (low acetabular version with low femoral version) or moderate (low acetabular version with normal femoral version or normal acetabular version with low femoral version). Radiographic assessments were manually performed on digitized images by two orthopaedic residents, and 25% of randomly selected measurements were repeated by the senior author, a fellowship-trained hip preservation and arthroplasty surgeon. Interobserver and intraobserver reliabilities were calculated using the correlation coefficient with a two-way mixed model, showing excellent agreement for Murphy technique measurements (intraclass correlation coefficient 0.908 [95% confidence interval 0.80 to 0.97]) and Reikerås technique measurements (ICC 0.938 [95% CI 0.81 to 0.97]). Patient-reported measures were recorded using the International Hip Outcome Tool (iHOT-33) (0 to 100; worse to best).

Results The mean acetabular version was 18° 6 6°, and mean femoral version was 24° 6 12° using the Murphy technique and 12° 6 11° with the Reikerås method. Eighty percent (181 of 227) of hips had normal acetabular version, 42% (96 of 227) to 63% (142 to 227) had normal femoral version per Murphy and Reikerås, respectively, and 67% (152 to 227) had a normal McKibbin index. Patients with an impingement profile (low acetabular version or femoral version) were older (39 ± 9 years) than patients with an unstable (high acetabular version or femoral version; 33 ± 9 years; p = 0.004), normal (33 ± 9 years; p = 0.02), or compensatory (high acetabular version with low femoral version or vice versa; 33 ± 7 years; p = 0.08) rotational profile. Using the Murphy technique, femoral version was 12° greater than with the Reikerås method (R2 0.85; p < 0.001). There were no differences in iHOT-33 score between different groups (impingement: 32 ± 17 versus normal 35 ± 21 versus compensated: 34 ± 20 versus unstable: 31 ± 17; p = 0.40).

Conclusion  Variability in femoral version is twice as large as acetabular version. Patients with an impingement rotational profile were older than patients with a normal, compensatory, or unstable profile, indicating there are other variables not yet fully accounted for that lead to earlier pain and presentation in these groups. Important differences exist between measurement methods. This study shows that different measurement methods for femoral anteversion result in different numbers; if other authors compare their results to those of other studies, they should use equations such as the one suggested in this study.

Level of Evidence  Level III, prognostic study.

文献出处：Verhaegen JCF, Kerhoulas Z, Burke M, Galletta C, Wilkin G, Smit K, Carsen S, Beaule PE, Grammatopoulos G. How Is Variability in Femoral and Acetabular Version Associated With Presentation Among Young Adults With Hip Pain? Clin Orthop Relat Res. 2024 May 7. doi: 10.1097/CORR.0000000000003076. Epub ahead of print. PMID: 39031040.

文献6

白血病患者骨骼疼痛，应警惕骨坏死，应及时行核磁共振(MRI)检查

译者 陶可

一例14岁男孩因双膝关节疼痛就诊，既往患有急性淋巴细胞白血病B前体，已接受2年化疗。在诱导和巩固治疗后，给予甲氨蝶呤、巯嘌呤、地塞米松和长春新碱维持治疗。患者在维持治疗的第103周出现双膝关节疼痛。体格检查未发现异常，X线片显示骨结构完整。磁共振成像(MRI)显示骨梗塞，双侧股骨和胫骨呈“地图”状（图1、2和3）。根据MRI的特征性发现和病史，诊断为骨坏死，并停用皮质类固醇。停用皮质类固醇后，患者的症状有所改善，但骨病变图像保持不变。

图1  MRI显示双侧股骨和胫骨出现“地图”状骨梗死（箭头；T1加权图像的冠状图）。

骨坏死（缺血性坏死）是由骨骼血液供应中断引起的。疾病晚期可能会发生破坏和塌陷，可能需要手术干预。MRI是诊断方式的选择，具有高灵敏度。血液供应中断和骨髓局部坏死导致具有典型“地图”状骨梗死的MRI信号。创伤和长期使用皮质类固醇是主要诱发因素，医生应提高长期使用皮质类固醇患者的认识。及时诊断和去除诱发因素对于成功治疗至关重要。熟悉典型的表现和图像发现有助于早期诊断和及时治疗。

图2  MRI显示双侧股骨和胫骨出现骨梗塞，呈“地图”状（箭头；短T1反转恢复序列的冠状图）。

图3  MRI显示双侧股骨和胫骨出现骨梗塞，呈“地图”状（箭头；T1加权图像的矢状图）。

Osteonecrosis (Avascular Necrosis) of Knee and Tibia

A 14-year-old boy presented with bilateral knee pain. He had acute lymphoblastic leukemia, B precursor, and had received chemotherapy for 2 years. Following induction and consolidation therapy, maintenance therapy with methotrexate, mercaptopurine, dexamethasone, and vincristine was given. The patient complained of bilateral knee pain in week 103 of maintenance therapy. Physical examination yielded unremarkable findings, and an radiographs showed intact bony structures. Magnetic resonance imaging (MRI) showed bone infarction with a “map”-like appearance of bilateral femurs and tibias (Figures 1, 2, and 3; Figures 2 and 3 available at www.jpeds.com). Based on the characteristic findings of MRI and history, osteonecrosis was diagnosed, and corticosteroid was discontinued. The patient's symptoms improved after discontinuation of corticosteroid but the images of bony lesions remained unchanged.

文献出处：Ting-Huan Huang, Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Chien-Yu Lin. Osteonecrosis (Avascular Necrosis) of Knee and Tibia. J Pediatr. 2020 Feb:217:210-210.e1. doi: 10.1016/j.jpeds.2019.10.009.