髖膝關節文獻精譯薈萃（第363期）

本期目錄：

1、全膝關節置換術中的非骨水泥固定：目前的證據和未來的展望

2、哪些術前因素與全膝關節置換術后未能達到可接受的疼痛和功能水平相關

3、應用疊放式錐形補塊處理膝翻修手術中脛骨側廣泛骨缺損

4、以基尼指數量化的收入不平等可作為全膝關節置換術不良結局的指標

5、指甲-髕骨綜合征影像學表現

6、術后髖臼壁指數對髖關節發育不良患者行髖臼轉位截骨術后患者報告結局的影響

7、股骨頭壞死治療的預后因素

8、髖臼周圍截骨術治療嚴重髖關節發育不良-手術技術

9、股骨頭軟骨下不全骨折

第一部分：關節置換及保膝相關文獻

文獻1

全膝關節置換術中的非骨水泥固定：目前的證據和未來的展望

譯者 張軼超

介紹：非骨水泥固定在全膝關節置換術（TKA）中扮演著越來越重要的角色。這篇綜述文章的目的是分析非骨水泥TKA的功能效果和生存率。

材料和方法：對非骨水泥TKA的預后和生存率進行了全面的文獻檢索。該檢索基于PRISMA 2020指南，使用PubMed、Medline和Embase數據庫。由兩名獨立觀察員篩選出納入的研究文獻。

結果：搜索從2010 - 2022年間的文獻，有15項被納入研究。11項研究比較了非水泥TKA和水泥TKA。四項研究僅涉及非骨水泥假體。非骨水泥TKA的生存率和功能結果至少與骨水泥TKA相當。

結論：隨著制造技術的進步和手術工具的精確交付，以及機器人輔助TKA和3D打印植入物的使用，由于更多的生物固定技術的開展，獲得更好的生存率和結果，可以預期非骨水泥TKA的使用會逐漸增加。

Cementless fixation in total knee arthroplasty: current evidence and future perspective

Introduction：Cementless fixation plays an increasing role in total knee arthroplasty (TKA). The objective of this review article is to analyze functional outcomes and survivorship of cementless TKA.

Materials and Methods：A comprehensive literature search for studies reviewing the outcome and survivorship of cementless TKA was conducted. This search was based on the PRISMA 2020 guidelines using PubMed, Medline, and Embase. The included studies were screened by two independent observers.

Results：From 2010 to 2022, fifteen studies were included. Eleven studies compared cementless and cemented TKA. Four studies only covered cementless implants. Survivorship and functional outcomes of cementless TKA are at least comparable to those of cemented implants.

Conclusion：With improvement in manufacturing, and surgical tools for more precise delivery, such as robotic assisted TKA and 3D-printed implants, one can expect increase in usage of cementless TKA, due to a more biological fixation, better survivorship, and outcomes.

文獻出處：Haslhofer DJ, Kraml N, Stadler C, Gotterbarm T, Klotz MC, Klasan A. Cementless fixation in total knee arthroplasty: current evidence and future perspective. Arch Orthop Trauma Surg. 2024 Dec 28;145(1):101. doi: 10.1007/s00402-024-05670-2. PMID: 39731597; PMCID: PMC11682007.

文獻2

哪些術前因素與全膝關節置換術后未能達到可接受的疼痛和功能水平相關？一項國際多中心研究的發現

譯者 馬云青

背景：盡管全膝關節置換術（TKA）是治療終末期膝關節骨關節炎的常見可靠的術式，但仍有少數患者無法獲得滿意的疼痛緩解和功能改善。盡管已有研究試圖找出會影響臨床結果不佳的原因，但很少有研究從患者可接受的癥狀狀態（PASS）這一角度來探討此問題。PASS定義為患者自評療效指標量表上的一個閾值，高于此閾值表明患者認為其當前的治療狀態是可以接受的。

目的： (1) 在TKA術后1年時，未達到疼痛和功能PASS的患者比例是多少？(2) 哪些術前患者因素與TKA術后1年未達到疼痛PASS相關？(3) 哪些術前患者因素與TKA術后1年未達到功能PASS相關？

方法：本研究是一項回顧性研究，是對一項關于單一TKA系統的前瞻性、國際性、多中心研究的1年隨訪數據進行的二次分析。原研究的納入標準為：診斷為原發骨關節炎或創傷后關節炎、且能夠進行10年隨訪的患者；排除標準為：存在感染、骨髓炎以及既往關節置換失敗。在2011年至2014年間，共有449名患者在5個國家的10個中心接受了TKA。在1年時，13%（58/449）的患者失訪，2%（8/449；缺失1年KOOS數據）無法進行分析，剩下85%（383/449）的患者納入本次分析。主要結局指標是未達到證據推導出的膝關節損傷和骨關節炎結局評分（KOOS）疼痛分量表及日常生活活動（ADL）分量表的PASS閾值。研究構建了多變量二元邏輯回歸模型，考慮術前人口統計學、影像學及患者報告結局指標數據，并采用前向逐步剔除算法來得到最簡化的最佳擬合回歸模型。

結果：在TKA術后1年，38%（145/383）的患者未達到KOOS疼痛的PASS，36%（139/383）未達到KOOS ADL的PASS，29%（110/383）未達到KOOS疼痛或ADL中任一指標的PASS。在控制了性別、年齡、BMI和合并癥評分等潛在混雜變量后，我們發現，男性（比值比 2.09；p = 0.01）以及影像學顯示非嚴重骨關節炎的患者（比值比 2.09；p = 0.01）與未達到疼痛PASS顯著相關。在控制了相同的潛在混雜變量后，我們發現，影像學顯示非嚴重骨關節炎的患者（比值比 2.09；p = 0.01）也與未達到功能PASS顯著相關。

結論：我們發現，骨關節炎嚴重程度較輕的患者在TKA術后1年達到疼痛和功能PASS的可能性要低得多，并且男性在TKA術后1年達到疼痛PASS的可能性也低得多。基于這些發現，外科醫生應強烈考慮對于骨關節炎嚴重程度較輕的患者延遲手術，并對男性患者給予額外謹慎。外科醫生應就患者的期望及其獲得有意義的疼痛和功能改善的機會向其提供咨詢。未來的地區和國家注冊研究應評估TKA術后達到疼痛和功能PASS患者的真實比例，并驗證本研究中確定的術前因素在更大型、更多樣化的患者群體中是否仍然顯著。

Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study

Background:Although TKA is a common and proven reliable procedure for treating end-stage knee osteoarthritis, a minority of patients still do not achieve satisfactory levels of pain relief and functional improvement. Even though several studies have attempted to identify patients at risk of having poor clinical outcomes, few have approached this issue by considering the outcome of the patient-acceptable symptom state (PASS), defined as the value on a patient-reported outcome measure scale above which the patient deems their current symptom state acceptable.

Questions/purposes:(1) What is the proportion of patients who do not attain the PASS in pain and function at 1 year after TKA? (2) Which preoperative patient factors are associated with not achieving the PASS in pain at 1 year after TKA? (3) Which preoperative patient factors are associated with not achieving the PASS in function at 1 year after TKA?

Methods:This retrospective study is a secondary analysis of the 1-year follow-up data from a prospective, international, multicenter study of a single TKA system. Inclusion criteria for that study were patients diagnosed with primary osteoarthritis or post-traumatic arthritis and who were able to return for follow-up for 10 years; exclusion criteria were infection, osteomyelitis, and failure of a previous joint replacement. Between 2011 and 2014, 449 patients underwent TKA at 10 centers in five countries. At 1 year, 13% (58 of 449) were lost to follow-up, 2% could not be analyzed (eight of 449; missing 1-year KOOS), leaving 85% (383 of 449) for analysis here. The primary outcomes were not surpassing evidence-derived PASS thresholds in the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain and Activities in Daily Living (ADL) sub-scores. Multivariate binary logistic regressions considering preoperative demographic, radiographic, and patient-reported outcome measure data were constructed using a forward stepwise elimination algorithm to reach the simplest best-fit regression models.

Results:At 1 year after TKA, 38% of the patients (145 of 383) did not reach the PASS in KOOS Pain, 36% (139 of 383) did not reach the PASS in KOOS ADL, and 29% (110 of 383) did not achieve the PASS in either KOOS Pain or ADL. After controlling for potentially confounding variables such as gender, age, BMI, and comorbidity scores, we found that men (odds ratio 2.09; p = 0.01), and patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were strongly associated with not achieving the PASS in pain. After controlling for the same potentially confounding variables, we found that patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were also strongly associated with not achieving the PASS in function.

Conclusions:We found that patients with less severe osteoarthritis were much less likely to attain the PASS in pain and function at 1 year after TKA, and that men were much less likely to achieve the PASS in pain at 1 year after TKA. Based on these findings, surgeons should strongly consider delaying surgery in patients who present with less-than-severe osteoarthritis, with increased caution in men. Surgeons should counsel their patients on their expectations and their chances of achieving meaningful levels of pain and functional improvement. Future regional and national registry studies should assess the true proportion of patients attaining PASS in pain and function after TKA and confirm if the preoperative factors identified in this study remain significant in larger, more diverse patient populations.

文獻出處：Connelly JW, Galea VP, Rojanasopondist P, Nielsen CS, Bragdon CR, Kappel A, Huddleston JI 3rd, Malchau H, Troelsen A. Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study. Clin Orthop Relat Res. 2020 May;478(5):1019-1028. doi: 10.1097/CORR.0000000000001162. Erratum in: Clin Orthop Relat Res. 2020 Dec;478(12):2955. doi: 10.1097/CORR.0000000000001565. Erratum in: Clin Orthop Relat Res. 2021 Jul 1;479(7):1641-1643. doi: 10.1097/CORR.0000000000001831. PMID: 32039954; PMCID: PMC7170689.

文獻3

應用疊放式錐形補塊處理膝翻修手術中脛骨側廣泛骨缺損

譯者 張薔

背景：在處理膝翻修手術中脛骨近端廣泛骨缺損時，高孔隙率干骺端錐形補塊涌現為備受青睞的固定選擇。盡管既往關于疊放式錐形補塊的文獻稀少，這種方法卻逐步流行。本篇文章主要報道了全膝（TKA）翻修手術中應用疊放式錐形補塊的早期結果。

方法：我們選擇2010年1月至2022年12月間所有接受疊放式錐形補塊治療的病例，進行了一項單中心回顧性觀察研究。收集的資料包括一般資料、手術信息、影像學數據等。我們應用Kaplan-Meier曲線評估了全因再手術或脛骨側翻修的假體生存率，終末點均為影像學可觀察的假體松動。最終，共入組了22例疊放式錐形補塊的病例：其中，15例（68.2%）為男性；平均年齡64.1歲（范圍，42.8-87.8歲），BMI 34.2kg/m2（范圍，20.4-51.9kg/m2），既往手術中位數為4臺（范圍，1-12臺），平均隨訪時間為22.6個月（范圍，6.8-79.1個月）。

評估骨缺損的方法：在距離腓骨頭近端15mm的位置畫一條垂直于脛骨軸線的水平線標記原始關節線，內外側平臺皮質骨向關節線做垂線，估算骨缺損。

77歲老年男性，既往應用鉸鏈膝的二期膝翻修病史（A），因假體周圍感染行再翻修手術，一期應用含有抗生素的靜態間隔器（B），二期手術時可見AORI 3型的脛骨側廣泛非包容性骨缺損，分別應用遠端3D打印的多孔鈦金屬錐形補塊和近端高孔隙率鉭金屬錐形補塊疊放的技術處理骨缺損，術后1年隨訪時顯示假體結構穩定（C）。

結果：有20例應用了兩塊疊放的錐形補塊，而另外2例應用了三塊疊放的錐形補塊。應用疊放式錐形補塊的適應證包括：假體周圍感染（n = 11），無菌性松動（n = 9），脛骨側疼痛（n = 1）和假體周圍骨折（n = 1）。在術后中位數2.9個月后（范圍，0.4-37.3個月），5例病例接受了再手術，原因包括：伸膝裝置失效（n = 2），股骨假體松動（n = 1），淺表傷口開裂（n = 1）和術后血腫（n = 1）。在術后3年隨訪時，未出現因脛骨側假體松動而翻修的病例（有一例在術后15個月隨訪時片子顯示松動跡象，但最終未接受翻修治療）。

結論：在全膝翻修手術中遇到廣泛干骺端骨缺損時，疊放式錐形補塊是一種安全有效的治療選擇。

Stacked Cone Constructs for the Treatment of Extensive Tibial Bone Loss in Revision Total Knee Arthroplasty-A Series of 22 Patients

Background: Highly porous metaphyseal cones have emerged as a promising fixation strategy to address extensive proximal tibial bone loss in the multiply revised knee. Despite a paucity of literature regarding stacked cone constructs, they have gained popularity. This study reports on the early outcomes of stacked tibial cone constructs that are used during revision total knee arthroplasty (TKA).

Methods: A single-institution retrospective observational study was performed to identify patients who had been treated with a stacked cone construct during revision TKA between January 2010 and December 2022. Demographic, operative, clinical, and radiographic data were collected and assessed. Kaplan-Meier estimates were used to assess survival with all-cause reoperation, tibial-sided revision, and radiographic loosening as end points. In total, 22 stacked cone constructs were identified: 15 (68.2%) of the patients were men; the demographics included a mean age of 64.1 years (range, 42.8 to 87.8 years), a body mass index of 34.2 kg/m2 (range, 20.4 to 51.9 kg/m2), a median of 4 prior surgeries (range, 1 to 12 prior surgeries), and a mean follow-up of 22.6 months (range, 6.8 to 79.1 months).

Results: Twenty patients received 2-cone constructs, and 2 patients received 3-cone constructs. Patients received the stacked cone constructs during revision TKA for the following indications: periprosthetic joint infection (n = 11), aseptic loosening (n = 9), tibial stem pain (n = 1), and periprosthetic fracture (n = 1). At a median time of 2.9 months (range, 0.4 to 37.3 months), 5 patients underwent reoperation for the following indications: extensor mechanism failure (n = 2), femoral component loosening (n = 1), superficial wound dehiscence (n = 1), and postoperative hematoma (n = 1). At the 3-year follow-up, no patients had undergone revision for tibial component loosening (1 patient had radiographic evidence of loosening at the 15-month follow-up but did not undergo revision).

Conclusions: Stacked cone constructs are a viable option during revision TKA when extensive metaphyseal bone loss is encountered.

文獻4

以基尼指數量化的收入不平等可作為全膝關節置換術不良結局的指標

譯者 沈松坡

背景：全膝關節置換術（TKA）術后結局可能因非醫療因素（包括健康的社會決定因素，SDOH）而有所差異。雖然區域貧困指數（ADI）和社會脆弱性指數（SVI）等復合指標已將社區劣勢與不良結局聯系起來，但收入不平等在骨科領域中的作用尚未得到充分研究。基尼指數（GI）作為衡量收入差距的指標，可能為評估社會經濟因素對手術結果的影響提供一種更聚焦的方法。本研究旨在探討患者所處地區的GI是否與TKA術后短期并發癥相關。

方法：利用大型全國數據庫，通過國際疾病分類第10版（ICD-10）代碼篩選2017年至2021年接受原發性TKA的成年人。根據GI將患者分為低（<0.40）、中（0.40–0.49）和高（≥0.50）三組。結局指標包括術后一年內的翻修率、機械性并發癥和感染性并發癥。采用傾向評分匹配以控制人口學差異。

結果：高GI組患者的全因翻修率顯著高于中GI組，術后90天（0.9% vs 0.6%，比值比OR=1.42，P=0.01）及一年（1.5% vs 1.1%，OR=1.46，P<0.01）。高GI組脫位率亦較高，術后90天（2.6% vs 1.7%，OR=1.54，P<0.001）及一年（3.3% vs 2.1%，OR=1.58，P<0.001）。低GI組的翻修率及機械性并發癥與中GI組無顯著差異。感染率在各GI組間無差別。

結論：GI高于全國平均水平的患者TKA并發癥風險更高，而GI低于平均水平者無顯著差異。社區收入不平等程度可能是影響骨科結局的重要社會決定因素。

Income Inequality Quantified by the Gini Index Is an Indicator for Adverse Total Knee Arthroplasty Outcomes

Background: Postoperative outcomes following total knee arthroplasty (TKA) may vary due to non-medical factors, including social determinants of health (SDOH). While composite indices such as the Area Deprivation Index and Social Vulnerability Index link community disadvantage to adverse outcomes, the role of income inequality is underexplored in orthopaedics. The Gini Index (GI), a measure of income disparity, may provide a focused approach to assess socioeconomic influence on surgical outcomes. This study investigates whether a patient's GI is associated with short-term complications after TKA.

Methods: A large national database was queried to identify adults who underwent primary TKA from 2017 to 2021 via International Procedural Code - 10th Edition (ICD-10) codes. Patients were categorized by GI into low (< 0.40), average (0.40 to 0.49), and high (≥ 0.50) groups. Outcomes included revision rates, mechanical complications, and infectious complications within one year postoperatively. Propensity score matching was performed to control for demographic differences.

Results: Patients in the high-GI cohort had significantly increased rates of all-cause revision at 90 days (0.9 versus 0.6%, odds ratio (OR) 1.42, P = 0.01) and one year (1.5 versus 1.1%, OR 1.46, P < 0.01) compared to the average-GI group. Dislocation rates were also elevated at 90 days (2.6 versus 1.7%, OR 1.54, P < 0.001) and one year (3.3 versus 2.1%, OR 1.58, P < 0.001 in the high-GI group. There were no differences observed in revisions or mechanical complications in the low-GI group. Infection rates were similar across all GI categories.

Conclusion: Patients assigned a GI index greater than the national average demonstrated a higher risk for TKA complications, while there were no differences in patients who had a GI lower than the national average. The degree of income inequality in a community may be an influential SDOH driving variance in orthopaedic outcomes.

第二部分：保髖相關文獻

文獻1

指甲-髕骨綜合征影像學表現

譯者 任寧濤

指甲-髕骨綜合征（NPS）是一種罕見的常染色體顯性遺傳病，發病率1/50,000，NPS 是 LMX1B突變的結果。NPS典型的特征是指甲發育不全或發育不全、髕骨發育不良或發育不全、肘部發育不良和髂骨犄角。髂骨犄角被認為是特有的，與發育不全或發育不良的髕骨與指甲異常相結合是診斷此病的主要特征。早在70年前，Captain Fong就報道了髂骨犄角，髂骨犄角是該綜合征的特征，但并非在所有情況下都會出現。大多數情況下都存在肘關節發育不良，并且可以表現出該綜合征的典型特征。除了骨骼和關節異常外，NPS 患者的肌肉質量低，體型偏瘦，他們通常很難在中年之前增加體重。在此，我們展示了一名患有指甲-髕骨綜合征的女性的肘部、膝蓋和骨盆的影像學表現。

圖1 髂骨犄角

圖2 雙髕骨發育不良

圖3 肘關節發育不良，橈骨小頭后脫位

Radiographic findings in the nail-patella syndrome

Nail-patella syndrome is a rare disorder characterized classically by the tetrad of nail hypoplasia or aplasia, aplastic or hypoplastic patellae, elbow dysplasia, and the presence of iliac horns. Iliac horns are considered pathognomonic, and the presence of hypoplastic or aplastic patellae in conjunction with nail abnormalities is a cardinal feature of diagnosis. Elbow dysplasia is present in most cases and can exhibit features typical of the syndrome. Herein we present the radiographic findings of the elbows, knees, and pelvis of a woman with nail-patella syndrome.

文獻出處：James A West , Thomas H Louis. Radiographic findings in the nail-patella syndrome. Proc (Bayl Univ Med Cent) . 2015 Jul;28(3):334-6.

文獻2

術后髖臼壁指數對髖關節發育不良患者行髖臼轉位截骨術后患者報告結局的影響

譯者 李勇

引言： 本研究旨在確定術前變量和三維髖臼矯正對髖臼轉位截骨術（TOA）（一種球形髖臼周圍截骨術）后患者報告結局（PROMs）的影響。

方法： 我們回顧性分析了1998年至2019年間接受TOA治療的442例（582髖）髖關節發育不良患者，他們均完成了有效的問卷調查，包括疼痛和滿意度的視覺模擬評分（VAS）以及髖關節殘疾和骨關節炎結果評分（HOOS）。中位隨訪時間為12年。我們分析了患者報告結局與術前變量及術后髖臼覆蓋率（外側中心邊緣角、前壁指數和后壁指數）之間的關聯。

結果： 年齡較大與HOOS-ADL（日常生活活動）呈負相關（r = -0.26, P < 0.001），與HOOS-運動/娛樂呈負相關（r = -0.25, P < 0.001）。男性患者報告的HOOS-QOL（生活質量）中位數低于女性患者（P = 0.038）。T?nnis分級為0級的患者，其滿意度-VAS中位數高于2級患者（P = 0.031），且其HOOS-ADL、運動/娛樂和QOL子量表的中位數均高于1級或2級患者。對于術后前壁指數，（前壁）缺陷組的VAS-疼痛評分較高（P = 0.045），而HOOS-疼痛評分較低（P = 0.047）。對于術后后壁指數，（后壁）過度組的HOOS-疼痛評分低于正常組（P = 0.029）。

結論： 即使在TOA術后保留的髖關節中，髖臼的矢狀面矯正也會影響術后疼痛，而年齡、性別和T?nnis分級則會影響患者滿意度、功能能力和生活質量。這些見解對于優化手術適應證和髖臼重新定向策略，以及改善術后患者體驗具有重要意義。

Impact of Postoperative Acetabular Wall Index on Patient-Reported Outcomes After Transposition Osteotomy of the Acetabulum in Patients With Hip Dysplasia

Introduction: This study aimed to determine the effect of preoperative variables and three-dimensional acetabular correction on patient-reported outcome measures after transposition osteotomy of the acetabulum (TOA), a spherical periacetabular osteotomy.

Methods: We retrospectively reviewed 442 patients (582 hips) with hip dysplasia who underwent TOA between 1998 and 2019 and completed validated questionnaires, including the visual analog scale (VAS) for pain and satisfaction and the Hip disability and Osteoarthritis Outcome Score (HOOS). The median follow-up was 12 years. Associations between patient-reported outcome measures and preoperative variables and postoperative acetabular coverage (lateral center-edge angle, anterior wall index, and posterior wall index) were analyzed.

Results: Older age was negatively correlated with HOOS-ADL (r = -0.26, P < 0.001) and HOOS-sports/recreation (r = -0.25, P < 0.001). Male patients reported lower median HOOS-QOL than female patients (P = 0.038). Patients with T?nnis grade 0 had higher median satisfaction-VAS than those with grade 2 (P = 0.031), and higher median HOOS-ADL, sports/recreation, and QOL subscales than those with grade 1 or 2. For postoperative anterior wall index, the deficient group had higher VAS-pain (P = 0.045) and lower HOOS-pain (P = 0.047) than the normal group. For postoperative posterior wall index, the excessive group had lower HOOS-pain than the normal group (P = 0.029).

Conclusion: Even in preserved hips after TOA, sagittal plane acetabular correction influenced postoperative pain, whereas age, sex, and T?nnis grade affected satisfaction, functional capacity, and QOL. These insights have implications for refining surgical indications and acetabular reorientation strategies, improving postoperative patient experience.

文獻出處：Tanaka, Shiori MD; Fujii, Masanori MD, PhD; Kawano, Shunsuke MD, PhD; Ueno, Masaya MD, PhD; Nagamine, Satomi MD, PhD; Mawatari, Masaaki MD, PhD. Impact of Postoperative Acetabular Wall Index on Patient-Reported Outcomes After Transposition Osteotomy of the Acetabulum in Patients With Hip Dysplasia. JAAOS: Global Research and Reviews 9(10):e25.00154, October 2025. | DOI: 10.5435/JAAOSGlobal-D-25-00154

文獻3

股骨頭壞死治療的預后因素：一項系統綜述

譯者 張利強

背景：多種保髖技術描述用于治療股骨頭壞死（ONFH）。本系統綜述旨在確定與治療失敗及轉為全髖關節置換術（THA）相關的治療股骨頭壞死預后因素。

材料與方法：本研究遵循PRISMA指南。于2021年11月進行文獻檢索。獲取所有比較兩種或兩種以上股骨頭壞死治療方法的臨床試驗。通過多元分析來探究基線特征與手術結果之間的關聯。采用皮爾遜積矩相關系數（r）進行多元線性回歸分析。

結果：共檢索到88篇文章（6112例手術）。女性患者與轉為全髖關節置換術的時間延長（P = 0.03）和全髖關節置換率降低（P = 0.03）相關。治療前癥狀持續時間越長，治療失敗時間越短（P = 0.03）。治療前的視覺模擬評分（VAS）升高與失敗間隔縮短（P = 0.03）和全髖關節置換術（THA）間隔時間縮短（P = 0.04）相關。治療前髖關節功能降低與全髖關節置換術率升高（P = 0.02）和失敗率升高（P = 0.005）相關。患者年齡、體重指數（BMI）、病因、術后完全負重時間以及患側均未顯示出與手術結果有統計學顯著關聯的證據。

結論：男性、治療前癥狀持續時間較長、VAS評分較高以及HHS評分較低均為股骨頭壞死治療的不良預后因素。

Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review

Background: Several hip preserving techniques have been described for the management of osteonecrosis of the femoral head (ONFH). This systematic review identified prognostic factors in the treatment of ONFH that are associated with treatment failure and conversion to total hip arthroplasty (THA).

Material and methods: This study followed the PRISMA guidelines. The literature search was conducted in November 2021. All clinical trials comparing two or more treatments for femoral head osteonecrosis were accessed. A multivariate analysis was performed to investigate the association between baseline characteristics and the surgical outcome. A multiple linear model regression analysis through the Pearson Product-Moment Correlation Coefficient (r) was used.

Results: Data from 88 articles (6112 procedures) were retrieved. Female gender was associated with increased time to THA (P = 0.03) and reduced rate of THA (P = 0.03). Longer symptom duration before treatment was associated with shorter time to failure (P = 0.03). Increased pre-treatment VAS was associated with reduced time to failure (P = 0.03) and time to THA (P = 0.04). Reduced pre-treatment hip function was associated with increased rate of THA (P = 0.02) and failure (P = 0.005). Patient age and BMI, aetiology, time from surgery to full weight bearing and the side did not show evidence of a statistically significant association with the surgical outcome.

Conclusion: Male gender, longer symptom duration before treatment, higher VAS scores, and lower HHS scores were negative prognostic factors after treatment for osteonecrosis of the femoral head.

文獻出處：Migliorini F, Maffulli N, Baroncini A, Eschweiler J, Tingart M, Betsch M. Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review. Surgeon. 2023 Apr;21(2):85-98. doi: 10.1016/j.surge.2021.12.004. Epub 2022 Jan 4. PMID: 34991986.

文獻4

髖臼周圍截骨術治療嚴重髖關節發育不良-手術技術

譯者 陶可

背景：嚴重髖關節發育不良伴股骨頭半脫位或繼發性髖臼（解剖結構異常）的最佳治療方法仍存在爭議。本研究的目的是分析手術矯正的程度和使用伯爾尼髖臼周圍截骨術治療青少年和年輕成人患者的嚴重髖關節發育不良所獲得的早期臨床結果。

方法：平均年齡為17.6歲（范圍，13.0至31.8歲）的13名患者（16髖）被歸類為嚴重髖關節發育不良（根據Severin分類為IV型或V型）。8髖存在半脫位，8髖存在繼發髖臼（解剖結構異常）。術前，所有患者均出現髖關節疼痛，且X線片上的髖關節（股骨頭與髖臼）形合度完全一致，可考慮進行截骨術。所有16髖均接受了伯爾尼髖臼周圍截骨術，其中6個髖關節同時接受了股骨近端截骨術。術后，髖關節進行放射學評估，以評估畸形的矯正、截骨部位的愈合和骨關節炎的進展。術后采用Harris髖關節評分測量臨床結果和髖關節功能，平均隨訪4.2年。

結果：術前和隨訪X線片比較顯示Wiberg外側中心邊緣角平均改善44.6度（從-20.5度到24.1度），假斜位片上的前方中心邊緣角平均改善51.0度（從-25.4度到25.6度），及髖臼頂傾斜角平均改善25.9度（從37.3度到11.4度）。髖關節中心向內側平均平移10毫米（范圍，0至31毫米）。所有髂骨截骨部位均愈合。平均Harris髖關節評分從術前的73.4分提高到最近一次隨訪時的91.3分。13例患者中有11例（16髖中的14例）對手術結果表示滿意，14髖臨床效果良好或優良。主要并發癥包括一名患者的髖臼固定丟失，這需要額外的手術治療；另一名患者的髖臼過度矯正和相關的坐骨骨不連。在最近一次隨訪時，兩名患者的臨床結果都很好。沒有嚴重的神經血管損傷或關節內骨折。

結論：髖臼周圍截骨術是一種有效的手術矯正青少年和年輕成人嚴重髖關節發育不良的技術。本系列早期臨床效果非常好，平均術后4.2年；兩大并發癥并沒有影響良好的臨床效果。

圖1-A 患者仰臥位于可透射線的手術臺上。在受影響的髖關節下方放置一個小凸起襯墊，并將足部固定在手術臺上。放置神經監測導線以進行持續的周圍神經監測。

圖1-B 演示了改良Smith-Petersen入路的髖關節切口。ASIS = 髂前上棘。

圖2-A 圖 2-A改良的Smith-Petersen方法的示意圖。

圖2-B和 2-C 改良的Smith-Petersen方法的示意圖。

圖3-A 髖臼下坐骨切口。使用Metzenbaum剪刀（長彎組織剪）在髖關節前囊上方和腰大肌腱下方形成一個平面。

圖3-B 該平面向下，再向后進入前坐骨（坐骨體，髖臼下溝），進行第一次截骨。

圖3-C和 3-D 截骨的位置可以通過前后（圖3-C）和45°髂骨斜位（圖3-D）透視圖來確認。

圖3-E 注意因為靠近坐骨神經，而不要過度伸展切口的后外側。

圖4-A、4-B和 4-C 恥骨上支截骨術。圖4-A將窄、鈍、彎曲的牽開器前后放置，然后用尖頭Homan牽開器暴露恥骨上支。

圖4-B和4-C大部分截骨切口是用小擺鋸（圖4-B）完成的，深層皮質切開采用半英寸（1.27厘米）帶角度的骨刀完成（圖4-B和4-C)。

圖5-A 髂骨截骨術從髂前上棘直接朝向坐骨切跡進行，并在骨盆邊緣上外側約1cm處停止。高速磨鉆用于為髂骨切口而制作目標打孔。

5-B和5-C 使用擺鋸進行截骨術。ASIS =髂前上棘。

圖6-A 后柱切口與髂骨切口成120°角。圖6-B可以通過45°髂骨斜透視評估該切口的方向。

圖6-C 使用45°角骨刀完成截骨。

圖7-A至7-E 嚴重髖關節發育不良的髖臼周圍切口和髖臼復位的假骨模型。重要的是要注意，這個假骨模型中描述的復位是指矯正嚴重髖臼發育不良所需的積極復位的類型。具體而言，由于需要大量重新定位，髂骨間隙可能缺乏髖臼碎片和髂骨之間的骨與骨接觸（圖7-C）。此外，模型中明顯過度的前方矯正（圖7-E）不會出現在髖臼前方嚴重不足的髖關節。圖7-A、7-B和7-C重新定位的目標是增加股骨頭前外側的覆蓋范圍，保持或獲得髖臼前傾，并在需要時向內側平移髖關節（旋轉）中心。我們通過：(1)內旋（外側覆蓋和前傾）、（2）前傾或伸展（前覆蓋）和（3）內側平移（關節中心的內側化）進行髖臼復位。圖7-B和7-C展示了髖臼周圍的切口。圖7-D和7-E截骨部位通常用四枚螺釘固定，將切除的突出的髂前上棘移植入髂骨間隙。

圖8 髖臼截骨骨塊暫時用克氏針固定，最終用4.5毫米螺釘從髂嵴插入截開的髖臼（骨塊）。

9-A、9-B和9-C股骨頭頸交界處的股骨成形術。圖9-A髖臼周圍截骨術后中度髖關節發育不良的術中蛙式位片，顯示在前外側頭頸交界處存在非球形股骨頭（箭頭）。

圖9-B 這種畸形與關節切開術中觀察到的屈曲100°時的股骨髖臼前方撞擊有關。

圖9C 進行頭頸部交界處的骨成形術，以實現髖關節在運動范圍內無撞擊。

圖10 髖關節重建后檢查被動髖關節屈曲運動，以確保髖關節屈曲至少為90°（最好>100°）。

圖11-A至11-D 一名患有嚴重髖臼發育不良的16歲男孩的髖關節X線片。圖11-A和11-B前后位（圖11-A）和假斜位（圖11-B）X線片顯示嚴重的髖關節發育不良。該患者采用髖臼周圍截骨術和股骨近端內翻截骨術聯合治療。

圖11-C和11-D 術后3年拍攝X線片，顯示重建后實現了廣泛的重新定向、最小的骨盆變形和完全的骨愈合。該患者的臨床效果極佳。

Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique

Background: The optimal treatment of severe acetabular dysplasia with subluxation of the femoral head or the presence of a secondary acetabulum remains controversial. The purpose of this study was to analyze the extent of surgical correction and the early clinical results obtained with the Bernese periacetabular osteotomy for the treatment of severely dysplastic hips in adolescent and young adult patients.

Methods: Sixteen hips in thirteen patients with an average age of 17.6 years (range, 13.0 to 31.8 years) were classified as having severe acetabular dysplasia (Group IV or V according to the Severin classification). Eight hips were classified as subluxated, and eight had a secondary acetabulum. Preoperatively, all patients had hip pain and sufficient hip joint congruency on radiographs to be considered candidates for the osteotomy. All sixteen hips underwent a Bernese periacetabular osteotomy, and six of them underwent a concomitant proximal femoral osteotomy. Postoperatively, the hips were assessed radiographically to evaluate correction of deformity, healing of the osteotomy site, and progression of osteoarthritis. Clinical results and hip function were measured with the Harris hip score at an average of 4.2 years postoperatively.

Results: Comparison of preoperative and follow-up radiographs demonstrated an average improvement of 44.6 degrees (from -20.5 degrees to 24.1 degrees) in the lateral center-edge angle of Wiberg, an average improvement of 51.0 degrees (from -25.4 degrees to 25.6 degrees) in the anterior center-edge angle of Lequesne and de Seze, and an average improvement of 25.9 degrees (from 37.3 degrees to 11.4 degrees) in acetabular roof obliquity. The hip center was translated medially an average of 10 mm (range, 0 to 31 mm). All iliac osteotomy sites healed. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Eleven of the thirteen patients (fourteen of the sixteen hips) were satisfied with the result of the surgery, and fourteen hips had a good or excellent clinical result. Major complications included loss of acetabular fixation, which required an additional surgical procedure, in one patient and overcorrection of the acetabulum and an associated ischial nonunion in another patient. Both patients had a good clinical result at the time of the latest follow-up. There were no major neurovascular injuries or intra-articular fractures.

Conclusions: The periacetabular osteotomy is an effective technique for surgical correction of a severely dysplastic acetabulum in adolescents and young adults. In this series, the early clinical results were very good at an average of 4.2 years postoperatively; the two major complications did not compromise the good clinical results.

文獻出處：John C Clohisy, Susan E Barrett, J Eric Gordon, Eliana D Delgado, Perry L Schoenecker. Periacetabular osteotomy in the treatment of severe acetabular dysplasia. Surgical technique. Review J Bone Joint Surg Am. 2006 Mar;88 Suppl 1 Pt 1:65-83.

文獻5

股骨頭軟骨下不全骨折

譯者 邱興

股骨頭軟骨下不全骨折（SIF）是近期（2012）提出的一個概念，需與骨壞死相鑒別。臨床上，SIF常見于患有骨質疏松的老年女性或腎移植術后患者。早期影像學改變不明顯，但部分病例可出現軟骨下塌陷（新月征）。在T1加權磁共振圖像上，低信號帶是其特征性影像表現之一，組織學上對應骨折線及相關的骨折修復組織。因此，低信號帶的形態通常呈不規則、不連續且凸向關節面的特點。SIF的預后尚未明確，部分病例通過保守治療癥狀可緩解，而另一些病例則出現快速塌陷進展，如快速進展性髖關節病。

關鍵詞：股骨頭；骨壞死；骨質疏松；軟骨下不全骨折

圖1、一名68歲女性患者，患有右股骨頭軟骨下不全骨折。（A）于發病8周后拍攝的X線片顯示股骨頭外側部分出現軟骨下塌陷，并可見關節間隙狹窄。（B）在側位視圖中，可清晰觀察到新月征（箭頭所示）。該病例的最終組織病理學診斷為軟骨下不全骨折。

圖2、68歲女性，右股骨頭軟骨下不全骨折。（A）發病后4周拍攝的X光片顯示股骨頭未見明顯異常。（B、C）發病后4周進行MRI，存在彌漫性骨髓水腫模式，T1加權像呈低信號強度（B），T2加權像呈高信號強度（C）。同時可見一條與關節面平行的極低信號強度帶（箭頭所示）。（D）切除的股骨頭截面顯示，關節面正下方可見一條發白的線（箭頭所示）。（E）標本X光片顯示一條骨硬化線（箭頭所示），該硬化線由沿骨折線形成的骨痂構成（箭頭所示）。（F）線性硬化區域的組織學檢查顯示，原有的骨小梁骨折，伴有骨折骨痂形成，并且骨髓腔內有肉芽組織。未見既往存在的骨壞死證據（蘇木精-伊紅染色，×100）。

圖3、軟骨下不全骨折（A）與骨壞死（B）的帶狀影像比較。在軟骨下不全骨折中，該帶狀影像對應于骨折線，因此通常形態不規則、不連續、呈凸形且與軟骨表面平行。相比之下，骨壞死中的帶狀影像對應于壞死區域周圍形成的修復組織，其形態往往光滑、邊界清晰且呈凹形。

Subchondral insufficiency fractures of the femoral head

A subchondral insufficiency fracture (SIF) of the femoral head is a recently proposed concept, which needs to be differentiated from osteonecrosis. Clinically, SIF has generally been observed in the osteoporotic elderly women or renal transplant recipients. Radiographical changes are not obvious in its early phase, however, some cases undergo subchondral collapse (crescent sign). On the T1-weighted magnetic resonance images, a low intensity band is one of the characteristic imaging appearances, which corresponds histologically to the fracture line and associated fracture repair tissue. Therefore, the shape of the low intensity band generally tends to be irregular, disconnected, and convex to the articular surface. The prognosis of SIF is not clearly established. Some cases show resolution of the symptoms by the conservative treatments, while other cases show rapid progression of the collapse such as rapidly progressive arthrosis of the hip.

Keywords: Femoral head; Osteonecrosis; Osteoporosis; Subchondral insufficiency fracture.

文獻出處：Yamamoto, Takuaki. "Subchondral insufficiency fractures of the femoral head." Clinics in orthopedic Surgery 4, no. 3 (2012): 173.

來源：304關節學術

作者：304關節團隊

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