髖膝關節文獻精譯薈萃（第382期)

本期目錄：

1、未置換髕骨的全膝關節置換術后髕股關節過度填充對臨床療效的影響及相關因素分析

2、全髖關節翻修術中外科醫生與患者臨床結局認知的一致性

3、患者對全膝關節置換術后療效預期的來源

4、機器人技術對全膝關節置換術中手術流程與術者負擔的影響

5、影像學及患者因素與髖關節發育不良骨關節炎的相關性

6、髖臼周圍截骨術（PAO）中降低神經損傷風險的建議

7、髖臼周圍截骨術可改善髖關節活動過度

8、股骨頭保留厚度比對骨壞死塌陷預測的作用

第一部分：關節置換及保膝相關文獻

文獻1

未置換髕骨的全膝關節置換術后髕股關節過度填充對臨床療效的影響及相關因素分析

譯者 張軼超

目的：分析未置換髕骨的全膝關節置換術（TKA）后髕股關節（PFJ）過度填充的影響因素，探討PFJ過度填充對臨床療效的影響。

方法：回顧性分析2019年3月至2021年9月在我院行全膝關節置換術的168例終末期膝關節骨性關節炎患者，這些病例均未行髕骨置換。回顧性分析這些患者的臨床資料。在本研究中，PFJ過度填充被定義為術后PFJ距離比術前測量值大于1mm。統計術后PFJ過度填充的發生情況。將患者分為過度填充組（n=109）和非過度填充組（n=59），統計所有患者術前、術后髕骨厚度和股骨前髁厚度，分析患者術后PFJ過度填充的影響因素。隨訪2年，比較兩組患者術后疼痛恢復時間、視覺模擬評分（VAS）及屈曲活動情況。

結果：患者術前、術后髕骨厚度測量差異無統計學意義（P> 0.05）。但術后股骨前髁厚度及PFJ距離較術前明顯增加（P<0.05）。168例患者中有109例（64.88%）出現PFJ過度填充。女性患者PFJ過度填充的風險高于男性（P<0.05）。術前過度填充組股骨前髁厚度明顯小于非過度填充組（P<0.001）。與非過度填充物組相比，術后2年時過度填充物組術后疼痛恢復時間更長（P<0.05），屈曲活動度更差（P<0.001）。術后2年，過度填充物組與非過度填充物組相比VAS評分差異無統計學意義（P > 0.05）。Spearman秩相關分析顯示，女性患者術前股骨前髁厚度更薄（r=-0.424， P<0.001），術后更容易導致PFJ過度填充（r=0.237， P<0.05）。此外，術前股骨前髁厚度與術后PFJ過度填充間呈負相關（r=-0.540， P<0.001）。

結論：不進行髕骨置換的TKA術后出現PFJ過度填充的風險較高，尤其是女性患者和股骨前髁厚度較薄的患者。因此，臨床治療時應特別注意這些高危人群。

Effect of patellofemoral joint overstuffing following total knee arthroplasty without patella resurfacing on clinical efficacy and related factors analysis

Objective：To analyze the influencing factors for patellofemoral joint (PFJ) overstuffing following total knee arthroplasty (TKA) without patella resurfacing, and explore the effect of PFJ overstuffing on clinical efficacy.

Methods：A retrospective analysis was conducted on 168 patients with end-stage knee osteoarthritis who underwent TKA without patella resurfacing at our hospital between Match 2019 and September 2021. The clinical data of these patients were retrospectively analyzed. In this study, PFJ overstuffing was defined as a postoperative PFJ distance greater than 1 mm compared to the preoperative measurement. The occurrence of postoperative PFJ overstuffing was counted. The patients were divided into the overstuffing group (n=109) and the non-overstuffing group (n=59) to count the patellar thickness and thickness of femoral anterior condyle in all patients before and after surgery, and analyze the influencing factors for postoperative PFJ overstuffing in such patients. Patients were followed up for 2 years to compare the recovery time of postoperative pain, score of visual analogue scale (VAS) and flexion activity between the two groups.

Results：There was no significant difference in patellar thickness between preoperative and postoperative measurements of the patients (P>0.05). However, the thickness of the femoral anterior condyle and the PFJ distance after surgery increased significantly compared with those before surgery (P<0.05). Among the 168 patients, 109 cases (64.88%) experienced PFJ overstuffing. The risk of PFJ overstuffing was higher in female patients than in male (P<0.05). The preoperative thickness of the femoral anterior condyle in the overstuffing group was significantly

smaller compared to the non-overstuffing group (P<0.001). Compared with the non-overstuffing group, the overstuffing group had longer recovery time of postoperative pain (P<0.05), and had lower flexion activity at 2 years after surgery (P<0.001). However, no significant difference was found in VAS score between the overstuffing group and the non-overstuffing group at 2 years after surgery (P>0.05). Spearman rank correlation analysis indicated females tend to have a lower preoperative thickness of the femoral anterior condyle (r=-0.424, P<0.001), as well as a positive postoperative PFJ overstuffing (r=0.237, P<0.05). Furthermore, there was a negative correlation between preoperative thickness of the femoral anterior condyle and postoperative PFJ overstuffing (r=-0.540, P<0.001).

Conclusion：Following TKA without patella resurfacing, there is a high risk of PFJ overstuffing, particularly among female patients and those with a small thickness of the femoral anterior condyle. Therefore, special attention should be given to these high-risk groups during clinical treatment.

文獻出處：Wang F, Zhang G, Wei X. Effect of patellofemoral joint overstuffing following total knee arthroplasty without patella resurfacing on clinical efficacy and related factors analysis. J Orthop Surg Res. 2024 Jul 31;19(1):451. doi: 10.1186/s13018-024-04899-2. PMID: 39085885; PMCID: PMC11289916.

文獻2

全髖關節翻修術中外科醫生與患者臨床結局認知的一致性

譯者 馬云青

目的：全髖關節翻修術是一項復雜的手術，其功能結局存在很大個體差異性，且外科醫生的認知與患者的體驗常不一致。因此，本研究旨在：第一，根據翻修原因、翻修類型、髖臼缺損及既往翻修手術次數評估功能結局；第二，比較外科醫生與患者雙方的結局認知，以確定兩者之間是否存在一致性。

材料與方法：開展一項觀察性研究，研究對象為2013年1月至2018年12月期間在三級醫療中心接受全髖關節翻修術的患者，中位隨訪時間為41個月。該期間共完成149例手術。分析的變量包括翻修手術指征、翻修類型、是否存在髖臼缺損以及既往翻修手術次數。外科醫生的評估采用Harris髖關節評分，患者的評估采用WOMAC及SF-12。

結果：從外科醫生與患者雙重視角進行的變量分析顯示，在翻修指征與SF-12分量表方面存在統計學顯著差異，因感染或脫位而接受翻修的患者報告的功能結局較差。盡管其余變量未達到統計學顯著性差異，但外科醫生認為因感染而翻修的患者以及接受雙側（髖臼和股骨側）翻修的患者結局較差。相比之下，患者報告因感染或脫位手術、雙側翻修以及接受過多次翻修手術時，其功能結局較差。此外，觀察到麻醉風險增加與結局惡化之間存在統計學顯著差異。外科醫生評估與患者報告結局測量指標之間的線性回歸分析顯示存在統計學顯著關聯，表明外科醫生評分越高，患者報告的髖關節癥狀越少、功能越好。

結論：外科醫生通過harris髖關節評分進行的評估與患者通過患者報告結局測量指標（具體為SF-12和WOMAC問卷）所感知的健康狀況之間存在一致性。盡管無論翻修原因、翻修類型、缺損分級或翻修次數如何，總體結果均令人滿意；但因脫位或感染而翻修、接受雙側翻修以及多次翻修手術的病例，其結局略差。

文獻出處：Casas-Gallego V, Ortega MA, de la Torre-Escuredo BJ. Is There Agreement Between Clinical Outcomes as Perceived by the Surgeon and the Patient in Revision Total Hip Arthroplasty? J Clin Med. 2025 Oct 22;14(21):7488. doi: 10.3390/jcm14217488. PMID: 41226884; PMCID: PMC12608916.

文獻3

患者對全膝關節置換術后療效預期的來源

譯者 張薔

背景：理解患者對全膝關節置換（TKA）術后療效預期的不同來源才能讓人產生更加現實的預期。而這些預期的來源受臨床、心理等多種因素影響，也包括患者的總體取向和基本態度。

方法：接受全膝關節置換手術的患者術前完成了一個內含19小項（例：“完全”到“一點”）的調查問卷，其中包含了對癥狀改善、身體和心理狀態提升的預期評估。患者的預期來源會被分入不同類別。我們使用了正面與負面作用評估表（PANAS）來評估患者的總體取向和基本態度，分為正面（開放性）和負面（應激性）。臨床功能通過膝關節損傷與骨關節炎-關節置換評分（KOOS-JR）來評估。我們應用統計學方法將患者預期和預期來源與KOOS-JR、PANAS評分、一般資料和臨床特征（如癥狀期時長）等進行了比較。

結果：最終有232名患者（平均年齡65歲；60%女性；17%為拉丁裔或非白人族裔）在術前17±8天入組。預期內容少于15項的占72%，59%的預期內容有顯著改善。預期內容更多與術前KOOS-JR評分更高（p < 0.0001）、負面作用更多（p = 0.003）癥狀期更短（p = 0.01）和大學以下學歷（p = 0.04）呈相關性。患者描述了多種預期來源，包括既往成功的骨科手術經歷（11%）、周圍人成功（56%）或失敗（7%）的TKA手術經歷、其術者（15%）、避免膝關節病情惡化（10%）、網絡來源（16%）和樂觀的態度（18%）。描寫的來源越多，KOOS-JR評分（p = 0.02）越差且正面作用（p = 0.009）越少。不同的預期來源與不同的患者變量相關；具體的，其他人的成功經歷與KOOS-JR評分更高相關（p = 0.04），其他人的失敗經歷與負面作用更多相關（p = 0.04），樂觀的態度與正面作用更多相關（p = 0.01），而互聯網信息與癥狀期更長（p = 0.04）和負面作用更少相關（p = 0.02）。

結論：患者對TKA手術療效有著很高的預期，而這些預期通常來自于個人或社交的相關經歷。患者的預期和/或預期來源與術后關節功能和正面、負面作用相關。

Sources?of?Patients’?Expectations?of?Total Knee?Arthroplasty

Background: Understanding the sources of patients’ expectations of total knee arthroplasty (TKA) can foster realistic expectations. Sources of expectations may be influenced by clinical and psychological variables, including general disposition or attitude.

Methods: Patients undergoing TKA completed a 19-item survey preoperatively that addressed the amount of improvement expected (i.e., “complete” to “a little”) for symptoms and physical and psychological well-being. Patients reported the sources of these expectations, which were grouped into categories. Disposition or attitude was assessed for positive affect (e.g., openness to change) and negative affect (e.g., irritability) with use of the Positive and Negative Affect Schedule (PANAS). Clinical status was assessed using the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR). Expectations and sources of expectations were compared with KOOS-JR and PANAS scores and demographic and clinical characteristics (e.g., symptom duration) with use of statistical analyses.

Results: A total of 232 patients (mean age, 65 years; 60% women; 17% Latino ethnicity or non-White race) were enrolled 17 ± 8 days preoperatively. Seventy-two percent expected ＜15 of the survey items; Complete improvement was expected for 59% of items. Expecting more items was associated with better preoperative KOOS-JR scores (p < 0.0001), more negative affect (p = 0.003), a shorter duration of symptoms (p = 0.01), and not being a college graduate (p = 0.04). Patients volunteered multiple sources of expectations, including favorable outcomes from a previous orthopedic surgery (11% of patients), knowledge of favorable (56%) and unfavorable (7%) TKA outcomes in others, their current surgeon (15%), avoidance of further knee deterioration (10%), internet information (16%), and general optimism (18%). Citing more sources was associated with worse KOOS-JR scores (p = 0.02) and less positive affect (p = 0.009). Sources of expectations were associated with patient variables; specifically, knowledge of favorable outcomes was associated with better KOOS-JR scores (p = 0.04), knowledge of unfavorable outcomes was associated with more negative affect (p = 0.04), optimism was associated with more positive affect (p = 0.01), and information from the internet was associated with longer symptom duration (p = 0.04) and less negative affect (p = 0.02).

Conclusions: Patients had high expectations of TKA and derived these expectations from diverse sources spanning personal and social network experiences. Patients’ expectations and/or sources of expectations were associated with functional status and positive and negative effect.

文獻出處：Mancuso CA, Duculan R, Nocon AA, Kahlenberg CA, Sculco PK, Sculco TP. Sources of Patients' Expectations of Total Knee Arthroplasty. J Bone Joint Surg Am. 2026 Jan 21;108(2):128-133.

文獻4

機器人技術對全膝關節置換術中手術流程與術者負擔的影響

譯者 沈松坡

目的：本研究旨在通過觀察流程中斷（flow disruptions，FD；即任務自然進程中的偏離）來識別機器人輔助對全膝關節置換術（total knee arthroplasty，TKA）手術進展的影響，同時評估不同術式下術者認知負擔和軀體負擔的差異。

方法：于2022年連續3個月，在美國南加州一家非營利性學術醫學中心，對常規全膝關節置換術（C-TKA）和機器人輔助全膝關節置換術（R-TKA）進行了觀察。所有手術均在3個手術階段進行觀察：（1）患者入室至手術開始；（2）手術開始至手術結束；（3）手術結束至患者離室。記錄并將FD分為8類。同時發放SURG-TLX和Borg量表問卷。

結果：共觀察13例TKA手術（C-TKA：n = 6；R-TKA：n = 7）。C-TKA的平均總手術時長為159.2 ± 44.7分鐘，R-TKA為201.9 ± 25.8分鐘。第2階段平均時長，C-TKA為91.1 ± 34.1分鐘，R-TKA為134.0 ± 25.4分鐘。總體FD發生率，C-TKA為7.6 ± 1.4次/小時，R-TKA為9.9 ± 2.3次/小時。C-TKA的主要中斷類型為協調、培訓和溝通；R-TKA的主要中斷類型為協調、手術任務考量和環境。平均SURG-TLX評分中，C-TKA術后得分最高的是任務復雜性維度，而R-TKA術后得分最高的是軀體需求維度。

結論：對FD進行研究可為機器人技術對骨科手術的潛在影響提供見解，并可能有助于理解機器人輔助手術和常規骨科手術中效率受限的障礙。

關鍵詞：骨科手術，流程中斷，人因工程，工作負荷，機器人輔助手術，全膝關節置換術

The Impact of Robotics on Procedural Flow and Surgeon Strain in Total Knee Arthroplasty

Objectives: This study aimed to identify the impact of robot assistance on the progression of total knee arthroplasty (TKA) operations by observing flow disruptions (FD), deviations in the natural progression of a task, while also evaluating the differences in surgeon cognitive and physical strain with each approach.

Methods: Conventional (C-TKA) and robot-assisted (R-TKA) total knee arthroplasty procedures were observed at a nonprofit academic medical center in Southern California over 3 months in 2022. All procedures were observed in 3 operative phases: (1) wheels-in to procedure start; (2) procedure start to procedure end; and (3) procedure end to wheels-out. FDs were recorded and classified into 8 categories. SURG-TLX and Borg Scale questionnaires

were also administered.

Results: Thirteen TKA procedures (C-TKA: n = 6; R-TKA: n = 7) were observed. Mean total operative duration was 159.2 ± 44.7 minutes for C-TKA and 201.9 ± 25.8 minutes for R-TKA. Mean phase 2 durations were 91.1 ± 34.1 minutes for C-TKA and 134.0 ± 25.4 minutes for R-TKA. Overall FD rate was 7.6 ± 1.4 FDs/hour for C-TKA and 9.9 ± 2.3 FDs/hour for R-TKA procedures. Major disruption types consisted of coordination, training, and communication for C-TKA and coordination, surgical task considerations, and environment for R-TKA. Mean SURG-TLX values were highest for the Task Complexity domain following C-TKA procedures and for the Physical Demands domain following R-TKA procedures.

Conclusions: Investigating FDs provides insights on the potential impact of robotics on orthopedic procedures and may aid in understanding barriers to efficiency in robot-assisted and conventional orthopedic operations.

Key Words: orthopedic surgery, workflow disruptions, human factors, workload, robot-assisted surgery, TKA

第二部分：保髖相關文獻

文獻1

影像學及患者因素與髖關節發育不良骨關節炎的相關性

譯者 任寧濤

背景

髖關節發育不良可導致關節軟骨的異常應力，引起骨關節炎的發生，本研究旨在利用軟骨延遲增強磁共振成像(dGEMRIC) 指數作為疾病的標志，研究與發育不良髖關節骨關節炎早期發病相關的解剖學和人口統計學因素。

方法

納入74名患者，96例有癥狀性髖關節，均行標準放射學檢查和dGEMRIC掃描，在標準的骨盆前后位上測量外側CE角、臼頂傾斜角和Shenton線的連續性，在假斜位上測量前CE角來評估前覆蓋情況。在MRI造影時出現盂唇每個層面都可見到造影劑時診斷為盂唇撕裂，骨關節炎定義為 dGEMRIC 值 <390 ms（正常髖關節的 dGEMRIC 數值低于 dGEMRIC 數值的兩個標準偏差）。

結果

該隊列的平均 dGEMRIC 指數（和標準偏差）（473 +/- 104 ms）顯著低于形態正常的髖關節（570 +/- 90 ms）。在單變量分析中發現前CE角、關節間隙寬度和盂唇撕裂與否都與骨關節炎有關。第二個模型去除了前CE角，因為外側CE角和前CE角高度相關，并且外側CE角在臨床測量上更常見，該模型將年齡、外側CE角和盂唇撕裂與否確定為與骨關節炎相關的重要獨立因素。

結論

正如之前對髖關節的研究所證明的那樣，這項研究表明，骨關節炎與年齡增長和發育不良的嚴重程度有關，外側CE角和前CE角都證明了這一點。此外，我們將盂唇撕裂確定為骨關節炎的危險因素。

Radiographic and Patient Factors Associated with Pre-Radiographic Osteoarthritis in Hip Dysplasia

Background: Hip dysplasia leads to abnormal loading of articular cartilage, which results in osteoarthritis. The purpose of this study was to investigate the anatomic and demographic factors associated with the early onset of osteoarthritis in dysplastic hips by utilizing the delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) index as a marker of the disease.

Methods: Ninety-six symptomatic dysplastic hips in seventy-four patients were assessed with standard radiographs and a dGEMRIC scan. The lateral center-edge angle of Wiberg, the acetabular index of T?nnis, and the break in the Shenton line were measured on a standing anteroposterior radiograph. Anterior undercoverage was assessed by measuring the anterior center-edge angle on a Lequesne false-profile view. A labral tear was considered to be present when contrast agent was seen through the entire thickness of the labrum on magnetic resonance arthrography. Osteoarthritis was defined as a dGEMRIC value of <390 msec (two standard deviations below the dGEMRIC index in normal hips).

Results: The mean dGEMRIC index (and standard deviation) for this cohort (473 +/- 104 msec) was significantly lower than that of a morphologically normal hip (570 +/- 90 msec). The anterior center-edge angle, the joint space width, and the presence of a labral tear were all found to be associated with osteoarthritis in the univariate analysis. Multivariate analysis identified age, the anterior center-edge angle, and the presence of a labral tear as independent factors associated with osteoarthritis. A second model was fitted with omission of the anterior center-edge angle because the lateral and anterior center-edge angles were highly correlated and the lateral center-edge angle is a more common clinical measure. This model identified age, the lateral center-edge angle, and the presence of a labral tear as significant independent factors associated with osteoarthritis.

Conclusions: As has been demonstrated in previous studies of the hip, this investigation showed osteoarthritis to be associated with increasing age and the severity of dysplasia, as demonstrated both by the Wiberg lateral center-edge angle and the Lequesne anterior center-edge angle. Additionally, we identified a labral tear as being a risk factor for osteoarthritis.

文獻出處：Rebecca H Jessel , David Zurakowski, Christoph Zilkens, Deborah Burstein, Martha L Gray, Young-Jo Kim. Radiographic and Patient Factors Associated with Pre-Radiographic Osteoarthritis in Hip Dysplasia. J Bone Joint Surg Am . 2009 May;91(5):1120-9.

文獻2

髖臼周圍截骨術（PAO）中降低神經損傷風險的建議

譯者 李勇

髖臼周圍截骨術（PAO）是一種廣泛使用的手術方式，用于重新調整因發育性髖關節發育不良、髖臼后傾、髖臼內突或部分創傷性畸形所導致的發育不良的髖臼。在手術過程中，股外側皮神經（LFCN）以及閉孔神經、股神經和坐骨神經都可能受到損傷。三大主要神經之一的損傷對患者而言是毀滅性事件，隨后會經歷一段不確定的時期，既抱有神經恢復的希望，又擔憂終身殘疾。手術經驗是降低神經損傷發生率的關鍵因素，而術中透視和神經監測的價值仍有待證實。盡管已知例如復雜截骨中的坐骨截骨步驟會使坐骨神經處于風險之中，但在具體情況下導致神經損傷的操作往往不明確。現有文獻多局限于發生率的報告，缺乏分析性信息。

通過尸體解剖，我們直觀地展示了手術不同步驟對鄰近神經可能產生的影響，本報告闡述了如何通過牽開器的放置來保護神經，以及如何通過下肢擺放實現神經松弛——這是避免機械性損傷的重要手段。股外側皮神經的頻繁損傷完全與手術入路相關，坐骨神經損傷主要是坐骨截骨步驟的結果，而股神經損傷幾乎僅在髖臼骨塊矯正時出現。作者實施上述措施已有9年，在此期間約800例髖臼周圍截骨術中，共發生2例股神經損傷和2例坐骨神經損傷，神經損傷率為0.5%。其中3例髖的神經損傷在6至9個月內恢復，1例患者存在永久性足下垂，在撰寫報告時仍需佩戴支具。

RECOMMENDATIONS TO REDUCE RISK OF NERVE INJURY DURING BERNESE PERIACETABULAR OSTEOTOMY (PAO)

The Berneese periacetabular osteotomy (PAO) is a widely used procedure to reorient a dysplastic acetabulum resulting from developmental dysplasia of the hip, retroversion, protrusion, or some deformities with a traumatic etiology. Throughout the execution, the lateral femoral cutaneous nerve (LFCN) as well as the obturator, femoral, and sciatic nerves can be injured. Injury to 1 of the 3 major nerves is a devastating event for the patient followed by an ill-defined period of hope for nerve recovery and fear of lifelong disability. Surgical experience is an essential factor in reducing the prevalence of nerve injury, whereas proof of the value of intraoperative fluoroscopy and nerve monitoring still must be established. Although it is known that, for example, the ischial cuts of the complex osteotomy place the sciatic nerve at risk, the action causing the nerve injury is rarely clear in the individual situation. The literature has been mostly limited to reports of incidence and offers little analytic information.

Through the use of cadaveric dissections, we visualized the possible impacts of the different steps of the procedure on the nerves in their anatomic vicinity, and the present report demonstrates how nerves can be protected with retractor positioning and how lower-limb positioning can lead to nerve relaxation, an important means to avoid mechanical injury. While the frequent injuries of the LFCN are exclusively related to the approach, sciatic nerve injuries are mainly the result of the ischial osteotomy steps and femoral nerve injuries are seen nearly exclusively with the correction of the acetabular fragment. The authors implemented the demonstrated measures for 9 years, during which approximately 800 periacetabular osteotomies resulted in a total of 2 femoral and 2 sciatic nerve lesions—or a nerve injury rate of 0.5%. The nerves injuries resolved within 6 to 9 months in 3 hips, and 1 patient had a definitive foot drop requiring a splint at the time of writing.

文獻出處：Kalhor M, Collado D, Leunig M, Rego P, Ganz R. Recommendations to Reduce Risk of Nerve Injury During Bernese Periacetabular Osteotomy (PAO). JBJS Essent Surg Tech. 2017 Nov 22;7(4):e34. doi: 10.2106/JBJS.ST.17.00017. PMID: 30233969; PMCID: PMC6132992.

文獻3

髖臼周圍截骨術可改善髖關節活動過度

譯者 陶可

背景：髖關節發育不良常合并股骨形態異常，包括股骨頭非球形、頸干角外翻伴前傾角過大。目前尚不清楚這些股骨形態異常會對髖臼周圍截骨術后的髖關節活動度及撞擊區域產生何種影響。

問題 / 目的：

(1) 與正常髖關節相比，髖臼周圍截骨術（PAO）能否糾正發育不良髖關節常見的活動度過度增大問題；

(2) 發育不良髖關節行髖臼周圍截骨術前后的撞擊部位與正常髖關節存在哪些差異；

(3) 合并凸輪型股骨形態是否會對髖關節內旋功能產生不利影響；

(4) 同期行股骨轉子間內翻去旋轉截骨術（IO）是否會影響髖關節外旋功能。

方法：1999 年 1 月至 2002 年 3 月，我院共對 200 例髖關節發育不良患者實施髖臼周圍截骨術；其中 27 髖（14%）符合預設研究納入標準，即具備包含髖關節及股骨遠端的術前、術后 CT 影像資料。通常我們通過上述 CT 掃描評估術前、術后髖臼與股骨形態、髖臼重新定位角度以及截骨愈合情況。研究構建了 27例髖臼周圍截骨術前、術后及19例正常髖關節的 CT 三維表面模型。正常髖關節樣本來源于接受計算機輔助全髖關節置換術的患者群體，排除有癥狀或影像學解剖結構異常的髖關節后，選取對側正常髖關節作為對照。采用經驗證的計算機量化方法，測定髖關節活動度（屈曲/后伸、內旋/外旋、內收/外展），以及前側撞擊（屈曲內旋位）、后側撞擊（后伸外旋位）兩種運動模式。將計算得出的撞擊位點對應至骨盆與股骨的解剖部位。按是否合并凸輪型股骨形態（13 髖有、14 髖無）、是否同期行轉子間截骨術（9 髖有、18 髖無）分別計算髖關節活動度。基于主要研究問題開展檢驗效能分析，設定 α=0.05、β 誤差 = 0.20，結果顯示屈曲活動度的最小可檢測差異為 4.6°。

結果：髖臼周圍截骨術后，受試髖關節的屈曲、內旋、內收/外展活動度與非發育不良對照髖關節無統計學差異（p 值范圍 0.061~0.867）；后伸活動度降低（19°±15°，范圍 - 18°~30°，對照髖 28°±3°，范圍 19°~30°；p=0.017），0° 屈曲位外旋活動度升高（25°±18°，范圍 - 10°~41°，對照髖 38°±7°，范圍 17°~41°；p=0.002）。發育不良髖關節發生髂前下棘關節外撞擊的比例顯著高于正常髖關節（48%[13/27 髖] VS 5%[1/19 髖]，p=0.002）。髖臼周圍截骨術后，股骨頭關節內撞擊發生率由術前 30%（8/27 髖）升至 59%（16/27 髖）（p=0.027）。與股骨頭呈球形的髖關節相比，合并凸輪型畸形的髖關節屈曲內旋位活動度顯著降低（屈曲 95°~120° 時 p 值 0.002~0.047）。同期行轉子間截骨術可使髖關節后伸外旋位活動度恢復正常（如同期手術組 0° 屈曲位外旋 37°±7°，范圍 21°~41°；對照髖 38°±7°，范圍 17°~41°；p=0.777）。

結論：通過髖關節活動度計算機模擬分析證實，髖臼周圍截骨術可有效糾正發育不良髖關節常見的活動度過度增大的問題。但髖臼周圍截骨術會增加屈曲及內旋狀態下非球形股骨頭繼發性關節內撞擊、髂前下棘關節外撞擊的發生率。凸輪型股骨形態可引發髖關節前側撞擊并限制內旋活動；此外，頸干角外翻伴前傾角過大的髖關節可出現后側撞擊，導致后伸位外旋活動度降低，而行股骨內翻去旋轉轉子間截骨術可使該異常恢復正常。但是否選擇同期轉子間截骨術，需權衡其固有手術風險及潛在并發癥。本研究結論僅基于有限數量的髖臼周圍截骨術前后 CT 資料，未來仍需開展前瞻性研究，驗證本次計算機模擬結果并評估其臨床應用價值。

Periacetabular osteotomy restores the typically excessive range of motion in dysplastic hips with a spherical head

Background: Residual acetabular dysplasia is seen in combination with femoral pathomorphologies including an aspherical femoral head and valgus neck-shaft angle with high antetorsion. It is unclear how these femoral pathomorphologies affect range of motion (ROM) and impingement zones after periacetabular osteotomy.

Questions/purposes: (1) Does periacetabular osteotomy (PAO) restore the typically excessive ROM in dysplastic hips compared with normal hips; (2) how do impingement locations differ in dysplastic hips before and after PAO compared with normal hips; (3) does a concomitant cam-type morphology adversely affect internal rotation; and (4) does a concomitant varus-derotation intertrochanteric osteotomy (IO) affect external rotation?

Methods: Between January 1999 and March 2002, we performed 200 PAOs for dysplasia; of those, 27 hips (14%) met prespecified study inclusion criteria, including availability of a pre- and postoperative CT scan that included the hip and the distal femur. In general, we obtained those scans to evaluate the pre- and postoperative acetabular and femoral morphology, the degree of acetabular reorientation, and healing of the osteotomies. Three-dimensional surface models based on CT scans of 27 hips before and after PAO and 19 normal hips were created. Normal hips were obtained from a population of CT-based computer-assisted THAs using the contralateral hip after exclusion of symptomatic hips or hips with abnormal radiographic anatomy. Using validated and computerized methods, we then determined ROM (flexion/extension, internal- [IR]/external rotation [ER], adduction/abduction) and two motion patterns including the anterior (IR in flexion) and posterior (ER in extension) impingement tests. The computed impingement locations were assigned to anatomical locations of the pelvis and the femur. ROM was calculated separately for hips with (n = 13) and without (n = 14) a cam-type morphology and PAOs with (n = 9) and without (n = 18) a concomitant IO. A post hoc power analysis based on the primary research question with an alpha of 0.05 and a beta error of 0.20 revealed a minimal detectable difference of 4.6° of flexion.

Results: After PAO, flexion, IR, and adduction/abduction did not differ from the nondysplastic control hips with the numbers available (p ranging from 0.061 to 0.867). Extension was decreased (19° ± 15°; range, -18° to 30° versus 28° ± 3°; range, 19°-30°; p = 0.017) and ER in 0° flexion was increased (25° ± 18°; range, -10° to 41° versus 38° ± 7°; range, 17°-41°; p = 0.002). Dysplastic hips had a higher prevalence of extraarticular impingement at the anteroinferior iliac spine compared with normal hips (48% [13 of 27 hips] versus 5% [one of 19 hips], p = 0.002). A PAO increased the prevalence of impingement for the femoral head from 30% (eight of 27 hips) preoperatively to 59% (16 of 27 hips) postoperatively (p = 0.027). IR in flexion was decreased in hips with a cam-type deformity compared with those with a spherical femoral head (p values from 0.002 to 0.047 for 95°-120° of flexion). A concomitant IO led to a normalization of ER in extension (eg, 37° ± 7° [range, 21°-41°] of ER in 0° of flexion in hips with concomitant IO compared with 38° ± 7° [range, 17°-41°] in nondysplastic control hips; p = 0.777).

Conclusions: Using computer simulation of hip ROM, we could show that the PAO has the potential to restore the typically excessive ROM in dysplastic hips. However, a PAO can increase the prevalence of secondary intraarticular impingement of the aspherical femoral head and extraarticular impingement of the anteroinferior iliac spines in flexion and internal rotation. A cam-type morphology can result in anterior impingement with restriction of IR. Additionally, a valgus hip with high antetorsion can result in posterior impingement with decreased ER in extension, which can be normalized with a varus derotation IO of the femur. However, indication of an additional IO needs to be weighed against its inherent morbidity and possible complications. The results are based on a limited number of hips with a pre- and postoperative CT scan after PAO. Future prospective studies are needed to verify the current results based on computer simulation and to test their clinical importance.

文獻出處：Simon D Steppacher, Corinne A Zurmühle, Marc Puls, Klaus A Siebenrock, Michael B Millis, Young-Jo Kim, Moritz Tannast. Periacetabular osteotomy restores the typically excessive range of motion in dysplastic hips with a spherical head. Comparative Study, Clin Orthop Relat Res. 2015 Apr;473(4):1404-16. doi: 10.1007/s11999-014-4089-5.

文獻4

股骨頭保留厚度比對骨壞死塌陷預測的作用

譯者 邱興

目的： 股骨頭塌陷是股骨頭壞死（ONFH）的嚴重表現，可導致髖部疼痛及畸形。然而，一旦發生塌陷，幾乎無法通過非手術方式重建股骨頭。預測股骨頭塌陷對股骨頭壞死的預后評估具有重要價值。本研究旨在建立一種量化股骨頭保留厚度的新方法，并評估其在X線平片預測股骨頭塌陷中的診斷價值。

方法： 本研究為單中心回顧性研究，納入2008年1月至2016年12月期間ARCO分期Ⅱ期的101例髖關節（85例患者）。在標準正位（AP）及蛙式位（FL）X線片上測量保留厚度，計算正位保留厚度比（APTR）和蛙式位保留厚度比（FPTR），以分別反映股骨頭前側及外側的保留厚度比例。采用單因素及多因素Logistic回歸分析確定塌陷的危險因素，通過受試者工作特征（ROC）曲線確定APTR和FPTR的敏感度、特異度及截斷值，并應用Kaplan-Meier（K-M）分析評估股骨頭壞死患者的股骨頭生存率。

結果： 27例女性與58例男性患者的平均年齡為38.93歲。非塌陷組平均隨訪時間為74.62個月（36～124個月），塌陷組平均隨訪時間為18.66個月（3～82個月）。隨訪期間共62例髖關節發生股骨頭塌陷。Logistic回歸分析及ROC結果顯示，APTR < 24.79%及FPTR < 10.62%與股骨頭塌陷顯著相關。Kaplan-Meier生存曲線顯示，APTR ≥ 24.79%的患者5年及10年總體生存率為68.2%，FPTR ≥ 10.62%的患者5年及10年總體生存率為71.63%。末次隨訪時，26例髖關節發生股骨頭前側塌陷，12例發生外側塌陷，24例前側與外側均發生塌陷。

結論： 股骨頭壞死患者中，股骨頭塌陷主要發生于前側而非外側。APTR與FPTR的測量對預測股骨頭塌陷具有顯著意義，并為根據JIC分型中B型及C1型股骨頭壞死患者選擇治療方案提供參考依據。

關鍵詞： 股骨頭壞死；塌陷預測；正位保留厚度比；蛙式位保留厚度比

圖1 APTR與FPTR的測量方法。（A、B）示雙側髖關節正位X線片及人工智能軟件繪制的髖關節結構示意圖。“a”表示股骨頭直徑，“b”表示壞死灶最外緣至股骨頭外側緣的垂直距離。APTR = b/a × 100%。（C、D）示雙側髖關節蛙式位X線片及人工智能軟件繪制的髖關節結構示意圖。“c”表示股骨頭直徑，“d”表示壞死灶最外緣至股骨頭最外緣的垂直距離。FPTR = d/c × 100%。

圖2 股骨頭壞死患者隨訪期間股骨頭塌陷側別。（A）數據展示了股骨頭前側、外側或前側及外側同時發生塌陷的例數分布情況。（B）顯示股骨頭前側發生塌陷。（C）顯示股骨頭前側及外側均發生塌陷。

圖3 隨訪時間超過5年的股骨頭壞死患者預后情況。（A）展示了APTR為20.56%（<24.79%）且FPTR為13.34%（>10.62%）患者的預后；（B）展示了APTR為27.89%且FPTR為5.48%患者的預后；（C）展示了APTR為19.65%且FPTR為5.29%患者的預后；（D）展示了APTR為28.99%且FPTR為20.55%患者的預后。（A–C）顯示股骨頭已發生塌陷，而（D）顯示股骨頭保持完整超過5年。

The Preserved Thickness Ratio of the Femoral Head Contributes to the Collapse Predictor of Osteonecrosis

Objectives: The collapse of femoral head is a serious symptom of osteonecrosis of the femoral head (ONFH), resulting in hip pain and deformity. However, it is hardly possible to reestablish the femoral head nonoperatively once the collapse happens. Predicting femoral head collapse is of great value for the prognosis of ONFH. This study aimed to develop a new method to quantify the preserved thickness of femoral head and to assess its diagnostic contribution in predicting femoral head collapse on plain radiographs.

Methods: This was a single-center retrospective study. A total of 101 hips (85 patients) with ARCO stage II from January 2008 to December 2016 were included in this study. The preserved thickness was measured on standard anteroposterior (AP) and frog-leg (FL) radiographs. The anteroposterior view's preserved thickness ratio (APTR) and the frog-leg view's preserved thickness ratio (FPTR) were calculated to show the preserved thickness ratio of the femoral head anteriorly and laterally. Univariate and multivariate logistic regression was performed to determine the risk factors for collapse. Sensitivity, specificity, and cut-off values for APTR and FPTR were determined by the receiver operating characteristic (ROC) curve analysis. Kaplan-Meier (K-M) analysis was applied to determine femoral head survival in ONFH patients.

Results: The mean age of the 27 females and 58 males was 38.93 years old. The mean follow-up time was 74.62 (36-124) months in the non-collapse group and 18.66 (3-82) months in the collapse group. Femoral head collapse was observed in 62 hips during the follow-up period. Logistic regression analysis and ROC results showed that APTR <24.79% and FPTR <10.62% were significantly correlated with femoral head collapse. The Kaplan-Meier survival curve suggested that the overall survival rate of APTR ≥24.79% was 68.2% at 5 and 10 years and FPTR ≥10.62% was 71.63% at 5 and 10 years. At the last follow-up, 26 hips had collapse on the anterior side of the femoral head, 12 hips occurred on the lateral side, and 24 hips happened to collapse on both anterior and lateral sides.

Conclusion: Femoral head collapse predominantly occurred anteriorly rather than laterally in ONFH patients. The measurements of APTR and FPTR have noticeable implications for the prediction of femoral head collapse, and contribute to the selection of treatment options for ONFH patients with types B and C1 according to the JIC classification.

Keywords: Anteroposterior preserved thickness ratio; Collapse prediction; Frog-leg preserved thickness ratio; Osteonecrosis of the femoral head.

文獻出處：Zhang, J., C. Zhou, Y. Fan, H. Fang, W. Li, X. Wang, Z. Chen and Y. Liu (2024). "The Preserved Thickness Ratio of the Femoral Head Contributes to the Collapse Predictor of Osteonecrosis." Orthop Surg 16(2): 412–419.

來源：304關節學術

作者：304關節團隊

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