文獻(xiàn)1 

松解后交叉韌帶是否會(huì)影響全膝關(guān)節(jié)置換術(shù)后效果

譯者：張軼超

背景：對(duì)于后交叉韌帶（PCL）保留型假體的全膝置換手術(shù)（TKA），要想達(dá)到良好的功能可能需要通過(guò)松解后交叉韌帶來(lái)達(dá)到軟組織平衡。但是一直有意見(jiàn)認(rèn)為當(dāng)松解了PCL后，考慮到關(guān)節(jié)穩(wěn)定性和臨床效果是否就應(yīng)該將后交叉保留型（CR）假體換成后穩(wěn)定型（PS）假體。本文的目的就是確定松解PCL會(huì)不會(huì)影響CR假體TKA的效果。

方法：選取從2006年12月到2015年7月間由本文作者中最年長(zhǎng)的醫(yī)生(J.M.)完成的CR-TKA患者。通過(guò)西安大略和麥克馬斯特大學(xué)骨關(guān)節(jié)炎指數(shù)評(píng)分（WOMAC）、膝關(guān)節(jié)協(xié)會(huì)臨床等級(jí)系統(tǒng)（KSS）、簡(jiǎn)易生活質(zhì)量問(wèn)卷（SF-12）物理/精神混合評(píng)分及翻修率來(lái)評(píng)估臨床效果。

結(jié)果：對(duì)行CR-TKA患者的觀察顯示，無(wú)論是未對(duì)PCL松解的還是部分松解的或完全切斷的病例間各項(xiàng)評(píng)分均無(wú)明顯差異（WOMAC評(píng)分：P=0.54；KSS評(píng)分：P=0.42；SF-12精神混合評(píng)分：P=0.89；SF-12物理混合評(píng)分：P=0.527）。

結(jié)論：本研究表明當(dāng)做CR-TKA時(shí)，無(wú)論是完好保留PCL還是松解PCL其臨床效果相近。醫(yī)生更應(yīng)該注重的是軟組織平衡。做CR假體時(shí)，如果部分松解或完全切斷了PCL也不必更換成PS假體。

Does Recession of the Posterior Cruciate Ligament Influence Outcome in Total Knee Arthroplasty?

Background: For a PCL-retaining (posterior cruciate ligament) total knee arthroplasty (TKA) to function suitably, proper soft tissue balancing, including PCL recession, is required. Yet, when the recession of the PCL is needed, there is still a debate as to whether a cruciate-retaining (CR) TKA should be converted to a posterior-stabilized TKA due to the concern of instability and poorer clinical outcomes. The purpose of this study is to determine whether recession of the PCL adversely affects clinical outcomes in patients who undergo CR TKA.

Methods: CR TKAs of the same design performed by the senior author (J.M.) were identified between December 2006 and July 2015. Clinical outcome measurements were collected and included the Western Ontario and McMaster Universities Osteoarthritis Index score, the Knee Society Clinical Rating System, Short Form-12 Physical Composite Score/Mental Health Composite Score, and revision rates.

Results: There were no significant differences in clinical outcome when the PCL was retained, partially recessed, or completely released during PCL-retaining TKA (Western Ontario and McMaster Universities Osteoarthritis Index: P = .54, Knee Society Clinical Rating System: P = .42, Short Form-12 Mental Health Composite Score: P = .89, Short Form-12 Physical Composite Score: P = .527).

Conclusion: This study presents evidence of similar clinical outcomes when the PCL is retained or released during PCL-retaining TKA, provided attention is paid to appropriate soft tissue balancing. CR TKA undergoing partial or complete release of the PCL should not routinely be converted to a posterior-stabilized knee design.

文獻(xiàn)出處：Dion CB, Howard JL, Lanting BA, McAuley JP. Does Recession of the Posterior Cruciate Ligament Influence Outcome in Total Knee Arthroplasty? J Arthroplasty. 2019 Oct;34(10):2383-2387. doi: 10.1016/j.arth.2019.05.052. Epub 2019 Jun 5. PMID: 31326243.

文獻(xiàn)2

功能性安全區(qū)比Lewinnek安全區(qū)有更大的優(yōu)勢(shì)：

為什么Lewinnek安全區(qū)不總能有效預(yù)測(cè)關(guān)節(jié)穩(wěn)定性

譯者：馬云青

背景：以往提出的lewinnek“安全區(qū)”并不能很好的預(yù)測(cè)全髖關(guān)節(jié)置換術(shù)后關(guān)節(jié)的穩(wěn)定性。最近的研究主要集中在脊柱-骨盆-髖關(guān)節(jié)側(cè)位x線片所觀察到的髖關(guān)節(jié)功能安全區(qū)。本研究的目的是評(píng)估lewinnek安全區(qū)和功能安全區(qū)之間的相關(guān)性，本研究測(cè)量數(shù)據(jù)是基于髖關(guān)節(jié)和骨盆在矢狀面上的運(yùn)動(dòng)。

方法：應(yīng)用計(jì)算機(jī)導(dǎo)航技術(shù)對(duì)320髖(291例患者)進(jìn)行初次全髖關(guān)節(jié)置換術(shù)。其中296髖(92.5%)位于lewinnek安全區(qū)內(nèi)，外傾角為40°±10°，前傾角為15°±10°。所有患者術(shù)前和術(shù)后均行站位和坐位脊柱骨盆側(cè)位x線片檢查。每例患者均測(cè)量聯(lián)合矢狀指數(shù)(CSI)，聯(lián)合矢狀面髖臼位置和股骨頭位置，并用于評(píng)估功能安全區(qū)。對(duì)這些測(cè)量數(shù)據(jù)進(jìn)行分析，以確定在lewinnek安全區(qū)內(nèi)、外的患者是否在矢狀面功能安全區(qū)。評(píng)價(jià)處于功能安全區(qū)外的影響髖關(guān)節(jié)穩(wěn)定性的預(yù)測(cè)因素。

結(jié)果：在lewinnek安全區(qū)內(nèi)的296例髖關(guān)節(jié)中，有254髖(85.8%)處于功能安全區(qū)內(nèi)。42名患者在CSI的功能安全區(qū)之外，19例站立位CSI增加，23例坐姿csi減少，均被認(rèn)為有脫位的危險(xiǎn)。在功能安全區(qū)外的預(yù)測(cè)因素為股骨活動(dòng)度增加(p<0.001，r=0.632)、脊盆活動(dòng)度降低(p<0.001，r=0.455)和骨盆入射角(p<0.001，r=0.400)。

結(jié)論:在這項(xiàng)研究中，lewinnek安全區(qū)內(nèi)14.2%的髖關(guān)節(jié)位于功能安全區(qū)之外，雖然這些髖關(guān)節(jié)有既往認(rèn)為“正?！钡木时嵌取Ｐg(shù)前和術(shù)后不在功能安全區(qū)內(nèi)的最準(zhǔn)確預(yù)測(cè)指標(biāo)是患者股骨的活動(dòng)度，而不是矢狀位髖臼杯的位置(即，髖臼杯的前傾)。

Functional Safe Zone Is Superior to the Lewinnek Safe Zone for Total Hip Arthroplasty: Why the Lewinnek Safe Zone Is Not Always Predictive of Stability

Background: The Lewinnek 'safe zone' is not always predictive of stability after total hip arthroplasty (THA). Recent studies have focused on functional hip motion as observed on lateral spine-pelvis-hip x-rays. The purpose of this study was to assess the correlation between the Lewinnek safe zone and the functional safe zone based on hip and pelvic motion in the sagittal plane.

Methods: Three hundred twenty hips (291 patients) underwent primary THA using computer navigation. Two hundred ninety-six of these hips (92.5%) were within the Lewinnek safe zone as determined by inclination of 40° ± 10° and anteversion of 15° ± 10°. All patients had preoperative and postoperative standing and sitting lateral spinopelvic x-rays. The combined sagittal index (CSI), a combination of sagittal acetabular and femoral position, was measured for each patient and used to assess the functional safe zone. Data analysis was performed to identify hips in the Lewinnek safe zone inside and outside the sagittal functional safe zone. Predictive factors for hips outside the functional safe zone were identified.

Results: Of the 296 hips within the Lewinnek safe zone, 254 (85.8%) were also in the functional safe zone. Forty-two patients were outside the functional safe zone based on CSI; 19 had an increased standing CSI and 23 had a decreased sitting CSI, all were considered at risk for dislocation. Predictive factors for falling outside the functional safe zone were increased femoral mobility (P < .001, r = 0.632), decreased spinopelvic mobility (P < .001, r = 0.455), and pelvic incidence (P < .001, r = 0.400).

Conclusion: In this study, 14.2% of hips within the Lewinnek safe zone were outside the functional safe zone, identifying a potential reason hips dislocate despite having 'normal' cup angles. The best predictor for falling outside the functional safe zone, both preoperatively and postoperatively, was femoral mobility, not the sagittal cup position (ie, cup anteinclination).

文獻(xiàn)出處：Tezuka T, Heckmann ND, Bodner RJ, Dorr LD. Functional Safe Zone Is Superior to the Lewinnek Safe Zone for Total Hip Arthroplasty: Why the Lewinnek Safe Zone Is Not Always Predictive of Stability. J Arthroplasty. 2019 Jan;34(1):3-8. doi: 10.1016/j.arth.2018.10.034. Epub 2018 Nov 2. PMID: 30454867.

文獻(xiàn)3

重新考慮全膝關(guān)節(jié)置換術(shù)中常規(guī)應(yīng)用止血帶的合理性

譯者：張薔

目的：許多術(shù)者在全膝關(guān)節(jié)置換術(shù)中常規(guī)應(yīng)用止血帶。止血帶是環(huán)繞下肢的束帶裝置，減少流向下肢的血液。應(yīng)用的同時(shí)，我們需要考慮它的安全性，是否會(huì)給病人帶來(lái)收益或者傷害。本篇文章的目的就是確定全膝關(guān)節(jié)置換術(shù)中應(yīng)用止血帶的收益或損害。

方法：我們搜索了MEDLINE、EMBASE和Cochrane數(shù)據(jù)庫(kù)中截止2020年3月26日的數(shù)據(jù)。入組了所有比較全膝關(guān)節(jié)置換應(yīng)用止血帶和不應(yīng)用止血帶的隨機(jī)對(duì)照試驗(yàn)（RCT）。評(píng)價(jià)指標(biāo)包括：疼痛、功能、嚴(yán)重不良事件（SAEs）、失血、假體穩(wěn)定性、手術(shù)時(shí)間和住院時(shí)長(zhǎng)。

結(jié)果：我們?nèi)虢M了41項(xiàng)RCT試驗(yàn)共2819個(gè)病例。止血帶組的SAEs明顯多于非止血帶組（53/901 vs 26/898, 止血帶組 vs 非止血帶組）（風(fēng)險(xiǎn)概率比1.73，95%置信區(qū)間1.10-2.73）。止血帶組術(shù)后第一天的平均疼痛評(píng)分是非止血帶組的1.25倍（95%置信區(qū)間0.32-2.19）。組間失血量并無(wú)顯著性差異（平均差異8.61ml；95%置信區(qū)間-83.76-100.97）。止血帶組的平均住院時(shí)長(zhǎng)比非止血帶組長(zhǎng)0.34天（95%置信區(qū)間0.03-0.64），平均手術(shù)時(shí)間短3.7分鐘（95%-5.53-1.87）。

結(jié)論：全膝關(guān)節(jié)置換應(yīng)用止血帶與嚴(yán)重不良事件增多、疼痛加重和住院時(shí)間延長(zhǎng)相關(guān)。應(yīng)用止血帶的唯一優(yōu)勢(shì)是手術(shù)時(shí)間縮短。這一結(jié)果很難支持全膝關(guān)節(jié)置換術(shù)中常規(guī)應(yīng)用止血帶。

Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery

Aims: Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.

Results: We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87).

Conclusion: TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery.

文獻(xiàn)出處：Ahmed I, Chawla A, Underwood M, Price A, Metcalfe A, Hutchinson C, Warwick J, Seers K, Parsons H, Wall PDH. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. Bone Joint J. 2021 Mar 8:1-10. doi: 10.1302/0301-620X.103B.BJJ-2020-1926.R1. Epub ahead of print. PMID: 33683139.

文獻(xiàn)4

可溶性Pecam-1作為關(guān)節(jié)假體周?chē)腥镜纳飿?biāo)志物

譯者：沈松坡

目前尚缺乏一種可靠的、具有足夠敏感性和特異性的單一診斷指標(biāo)來(lái)確診關(guān)節(jié)假體周?chē)腥?PJI)。免疫反應(yīng)分子Pecam-1由特定病原體觸發(fā)后，通過(guò)激活促炎癥信號(hào)從t細(xì)胞表面脫落。因此我們推測(cè)可溶性Pecam-1 (sPecam-1)可以作為PJI的生物標(biāo)志物。58例患者被前瞻性地納入并被分配到一個(gè)各自的治療組(分為三組，一組為尚未做手術(shù)的膝關(guān)節(jié)，一組是非感染性膝關(guān)節(jié)置換術(shù)后翻修，另一組感染性全膝關(guān)節(jié)置換術(shù)(TKA術(shù)后)翻修)。通過(guò)采集滑膜樣本和ELISA檢測(cè)，建立局部sPecam-1水平數(shù)據(jù)庫(kù)。我們觀察到感染性翻修手術(shù)(n = 22)中sPecam-1的數(shù)量明顯高于無(wú)菌性TKA翻修手術(shù)(n = 20, p≤0.001)。此外，與初次置換的膝關(guān)節(jié)相比，在感染性翻修組和無(wú)菌性翻修組中發(fā)現(xiàn)了大量的sPecam-1 (n = 16, p≤0.001)。將其與金標(biāo)準(zhǔn)進(jìn)行對(duì)比，顯示出其對(duì)PJI檢測(cè)的高預(yù)測(cè)能力。局部的sPecam-1水平與植入物的感染狀態(tài)相關(guān)，因此具有很強(qiáng)的作為PJI的生物標(biāo)志物的潛力。雖然足以證明sPecam-1在感染中的明確作用，但還需要進(jìn)一步闡明分子自然功能的潛在機(jī)制。

Soluble Pecam-1 as a Biomarker in Periprosthetic Joint Infection

A reliable workup with regard to a single diagnostic marker indicating periprosthetic joint infection (PJI) with sufficient sensitivity and specificity is still missing. The immunologically reactive molecule Pecam-1 is shed from the T-cell surface upon activation via proinflammatory signaling, e.g., triggered by specific pathogens. We hypothesized that soluble Pecam-1 (sPecam-1) can hence function as a biomarker of PJI. Fifty-eight patients were prospectively enrolled and assigned to one of the respective treatment groups (native knees prior to surgery, aseptic, and septic total knee arthroplasty (TKA) revision surgeries). Via synovial sample acquisition and ELISA testing, a database on local sPecam-1 levels was established. We observed a significantly larger quantity of sPecam-1 in septic (n = 22) compared to aseptic TKA revision surgeries (n = 20, p ≤ 0.001). Furthermore, a significantly larger amount of sPecam-1 was found in septic and aseptic revisions compared to native joints (n = 16, p ≤ 0.001). Benchmarking it to the gold standard showed a high predictive power for the detection of PJI. Local sPecam-1 levels correlated to the infection status of the implant, and thus bear a strong potential to act as a biomarker of PJI. While a clear role of sPecam-1 in infection could be demonstrated, the underlying mechanism of the molecule’s natural function needs to be further unraveled.

文獻(xiàn)出處：Fuchs M, Trampuz A, Kirschbaum S, Winkler T, Sass FA. Soluble Pecam-1 as a Biomarker in Periprosthetic Joint Infection. J Clin Med. 2021 Feb 5;10(4):612. doi: 10.3390/jcm10040612. PMID: 33562828; PMCID: PMC7914675.

文獻(xiàn)5

阿司匹林預(yù)防全髖和全膝關(guān)節(jié)置換術(shù)后

靜脈血栓的臨床有效性和安全性：

關(guān)于RCT的系統(tǒng)綜述和Meta分析

譯者：張峻

研究重要性：全髖關(guān)節(jié)置換術(shù)（THR）和全膝關(guān)節(jié)置換術(shù)（TKR）的患者采取藥物預(yù)防靜脈血栓栓塞（VTE）。哪種抗凝藥物最佳仍不確定。觀察性數(shù)據(jù)提示阿司匹林能夠有效預(yù)防VTE。

目的：評(píng)價(jià)阿司匹林預(yù)防全髖和全膝關(guān)節(jié)置換術(shù)后靜脈血栓的有效性和安全性

數(shù)據(jù)來(lái)源：關(guān)于RCT的系統(tǒng)綜述和Meta分析，不限語(yǔ)種，自數(shù)據(jù)庫(kù)成立至2019年9月19日使用MEDLINE, Embase, Web of Science, Cochrane 圖書(shū)館, and bibliographic 搜索RCT。

基于計(jì)算機(jī)的搜索結(jié)合了與人群（如髖關(guān)節(jié)置換術(shù)、膝關(guān)節(jié)置換術(shù)、髖關(guān)節(jié)成形術(shù)和膝關(guān)節(jié)成形術(shù)）、藥物干預(yù)（如阿司匹林、肝素、氯氧烷、達(dá)比加群、利伐沙班和華法林）和結(jié)果（如靜脈血栓栓塞、深靜脈血栓形成，肺栓塞和出血）相關(guān)的術(shù)語(yǔ)和關(guān)鍵詞組合。

研究選擇：本研究包括評(píng)價(jià)成人行全髖和全膝關(guān)節(jié)置換術(shù)后阿司匹林與其它抗凝劑預(yù)防靜脈血栓的有效性和安全性對(duì)比的RCT。排除有安慰劑對(duì)照的RCT。搜索和研究選擇是獨(dú)立進(jìn)行的。

數(shù)據(jù)提取與合成：本研究遵循PRISMA聲明，使用Cochrane協(xié)作風(fēng)險(xiǎn)偏倚工具。數(shù)據(jù)由兩人獨(dú)立篩選和提取。特定研究的相對(duì)風(fēng)險(xiǎn)使用隨機(jī)效應(yīng)模型進(jìn)行匯總。證據(jù)質(zhì)量評(píng)估價(jià)采用建議分級(jí)評(píng)價(jià)、發(fā)展和評(píng)價(jià)(GRADE)的方法。

主要結(jié)果和測(cè)量指標(biāo)：主要結(jié)果是術(shù)后VTE（無(wú)癥狀或有癥狀）。次要結(jié)果是與治療相關(guān)的不良事件，包括出血。

結(jié)果：在437篇文章中，納入了13個(gè)隨機(jī)對(duì)照試驗(yàn)（6060名參與者；3466名女性（57.2%）；平均年齡63.0歲）。與其他抗凝劑相比，阿司匹林經(jīng)THR和TKR治療后VTE的RR為1.12（95%CI，0.78-1.62）。深靜脈血栓形成（DVT）（RR，1.04；95%CI，0.72-1.51）和肺栓塞（PE）（RR，1.01；95%CI，0.68-1.48）的結(jié)果具有可比性。服用阿司匹林和其它抗凝劑的患者發(fā)生嚴(yán)重出血、傷口血腫和傷口感染等不良事件的風(fēng)險(xiǎn)在統(tǒng)計(jì)學(xué)上沒(méi)有顯著差異。當(dāng)分別分析THRs和TKRs時(shí)，阿司匹林和其他抗凝劑之間發(fā)生VTE、DVT和PE的風(fēng)險(xiǎn)沒(méi)有統(tǒng)計(jì)學(xué)上的顯著差異。阿司匹林與低分子肝素（RR，0.76；95%CI，0.37-1.56）或利伐沙班（RR，1.52；95%CI，0.56-4.12）相比，VTE風(fēng)險(xiǎn)無(wú)統(tǒng)計(jì)學(xué)差異。證據(jù)的質(zhì)量從低到高不等。

結(jié)論和相關(guān)性：在臨床有效性和安全性方面，阿司匹林與其它用于THR和TKR術(shù)后VTE預(yù)防的抗凝劑在統(tǒng)計(jì)學(xué)上沒(méi)有顯著差異。未來(lái)的試驗(yàn)應(yīng)側(cè)重于阿司匹林與其他抗凝劑和成本效益的非劣效性分析。

Clinical Effectiveness and Safety of Aspirin for Venous Thromboembolism Prophylaxis After Total Hip and Knee Replacement: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Importance: Patients undergoing total hip replacement (THR) and total knee replacement (TKR) receive venous thromboembolism (VTE) pharmacoprophylaxis. It is unclear which anticoagulant is preferable. Observational data suggest aspirin provides effective VTE prophylaxis.

Objective: To assess the effectiveness and safety of aspirin for VTE prophylaxis after THR and TKR.

Data sources: A systematic review and meta-analysis was performed of randomized clinical trials (RCTs), with no language restrictions, from inception to September 19, 2019, using MEDLINE, Embase, Web of Science, Cochrane Library, and bibliographic searches. The computer-based searches combined terms and combinations of keywords related to the population (eg, hip replacement, knee replacement, hip arthroplasty, and knee arthroplasty), drug intervention (eg, aspirin, heparin, clexane, dabigatran, rivaroxaban, and warfarin), and outcome (eg, venous thromboembolism, deep vein thrombosis, pulmonary embolism, and bleeding) in humans.

Study selection: This study included RCTs assessing the effectiveness and safety of aspirin for VTE prophylaxis compared with other anticoagulants in adults undergoing THR and TKR. The RCTs with a placebo control group were excluded. The searches and study selection were independently performed.

Data extraction and synthesis: This study followed PRISMA recommendations and used the Cochrane Collaboration's risk of bias tool. Data were screened and extracted independently by both reviewers. Study-specific relative risks (RRs) were aggregated using random-effects models. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Main outcomes and measures: The primary outcome was any postoperative VTE (asymptomatic or symptomatic). Secondary outcomes were adverse events associated with therapy, including bleeding.

Results: Of 437 identified articles, 13 RCTs were included (6060 participants; 3466 [57.2%] women; mean age, 63.0 years). The RR of VTE after THR and TKR was 1.12 (95% CI, 0.78-1.62) for aspirin compared with other anticoagulants. Comparable findings were observed for deep vein thrombosis (DVT) (RR, 1.04; 95% CI, 0.72-1.51) and pulmonary embolism (PE) (RR, 1.01; 95% CI, 0.68-1.48). The risk of adverse events, including major bleeding, wound hematoma, and wound infection, was not statistically significantly different in patients receiving aspirin vs other anticoagulants. When analyzing THRs and TKRs separately, there was no statistically significant difference in the risk of VTE, DVT, and PE between aspirin and other anticoagulants. Aspirin had a VTE risk not statistically significantly different from low-molecular-weight heparin (RR, 0.76; 95% CI, 0.37-1.56) or rivaroxaban (RR, 1.52; 95% CI, 0.56-4.12). The quality of the evidence ranged from low to high.

Conclusions and relevance: In terms of clinical effectiveness and safety profile, aspirin did not differ statistically significantly from other anticoagulants used for VTE prophylaxis after THR and TKR. Future trials should focus on noninferiority analysis of aspirin compared with alternative anticoagulants and cost-effectiveness.

文獻(xiàn)出處：Matharu GS, Kunutsor SK, Judge A, Blom AW, Whitehouse MR. Clinical Effectiveness and Safety of Aspirin for Venous Thromboembolism Prophylaxis After Total Hip and Knee Replacement: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Intern Med. 2020 Mar 1;180(3):376-384. doi: 10.1001/jamainternmed.2019.6108. PMID: 32011647; PMCID: PMC7042877.

第二部分：保髖相關(guān)文獻(xiàn)

文獻(xiàn)1

股骨頭壞死圍塌陷期：保髖最后的機(jī)會(huì)

譯者：羅殿中

目的：提出一個(gè)新的概念：股骨頭壞死圍塌陷期，并回顧其診斷和治療價(jià)值。

數(shù)據(jù)來(lái)源：在PubMed、考克蘭電子圖書(shū)館、EmBase三個(gè)電子數(shù)據(jù)庫(kù)搜索符合條件的研究，截止到2018年8月10日，搜索關(guān)鍵詞“osteonecrosis”、“prognosis”和“treatment”。

文獻(xiàn)選擇：對(duì)不同時(shí)期股骨頭壞死的臨床癥狀、體征、影像學(xué)表現(xiàn)的評(píng)價(jià)均納入研究，對(duì)多種保髖手術(shù)預(yù)后的評(píng)價(jià)也進(jìn)行回顧。

結(jié)果：圍塌陷期指股骨頭壞死出現(xiàn)軟骨下骨折到早期塌陷（<2mm）的連續(xù)時(shí)期，具有特殊的影像學(xué)特征，包括MRI顯示骨髓水腫和關(guān)節(jié)積液、X線顯示新月征、臨床表現(xiàn)為突然加重的髖關(guān)節(jié)疼痛。越來(lái)越多的證據(jù)表明這些征像是軟骨下骨折的繼發(fā)表現(xiàn)。值得一提的是，針對(duì)軟骨下骨折的辨別，CT比MRI提供更多的信息，對(duì)圍塌陷期的分期更為敏感。圍塌陷期提示疾病進(jìn)展可能性很大，同時(shí)提示此時(shí)進(jìn)行保髖手術(shù)可以取得滿(mǎn)意的中長(zhǎng)期治療效果。實(shí)際上，如果股骨頭塌陷超過(guò)2mm，可以考慮關(guān)節(jié)置換。

結(jié)論：圍塌陷期具有明確的臨床和影像特征，并為保髖手術(shù)治療提供了較好的最后的機(jī)會(huì)。圍塌陷期作為一個(gè)獨(dú)特的分期，應(yīng)該從股骨頭壞死病程中區(qū)分出來(lái)，并為恰當(dāng)?shù)闹委煷胧┨峁┮罁?jù)。

圖1. 股骨頭壞死三柱理論與中日友好醫(yī)院分型示意圖。根據(jù)股骨頭壞死受累部位，股骨頭壞死可分為內(nèi)側(cè)型（M型）壞死累及內(nèi)側(cè)柱；中間型（C型）壞死累及中間柱；外側(cè)型（L型）壞死累及外側(cè)柱。L型又可分為：L1型外側(cè)柱部分完好；L2型壞死范圍超出外側(cè)柱；L3型內(nèi)中外三柱均受累及。ONFH:股骨頭壞死。

表1. SARS病人股骨頭壞死進(jìn)展到圍塌陷期自然病程；SARS: 嚴(yán)重急性呼吸窘迫綜合征；ONFH:股骨頭壞死。

Pericollapse Stage of Osteonecrosis of the Femoral Head: A Last Chance for Joint Preservation

Objective: To propose a new definition of the pericollapse stage of osteonecrosis of the femoral head (ONFH) and review its significance in disease diagnosis and treatment selection.

Data sources: A search for eligible studies was conducted in three electronic databases including PubMed, Cochrane Library, and Embase up to August 10, 2018, using the following keywords: 'osteonecrosis', 'prognosis', and 'treatment'.

Study selection: Investigations appraising the clinical signs, symptoms, and imaging manifestations in different stages of ONFH were included. Articles evaluating the prognosis of various joint-preserving procedures were also reviewed.

Results: The pericollapse stage refers to a continuous period in the development of ONFH from the occurrence of subchondral fracture to early collapse (<2 mm), possessing specific imaging features that mainly consist of bone marrow edema and joint effusion on magnetic resonance imaging (MRI), crescent signs on X-ray films, and clinical manifestations such as the sudden worsening of hip pain. Accumulating evidence has indicated that these findings may be secondary to the changes after subchondral fractures. Of note, computed tomography provides more information for identifying possible subchondral fractures than does MRI and serves as the most sensitive tool for grading the pericollapse lesion stage. The pericollapse stage may indicate a high possibility of progressive disease but also demonstrates satisfactory long- and medium-term outcomes for joint-preserving techniques. In fact, if the articular surface subsides more than 2 mm, total hip arthroplasty is preferable.

Conclusions: The pericollapse stage with distinct clinical and imaging characteristics provides a last good opportunity for the use of joint-preserving techniques. It is necessary to separate the pericollapse stage as an independent state in evaluating the natural progression of ONFH and selecting an appropriate treatment regimen.

文獻(xiàn)出處：Zhang QY, Li ZR, Gao FQ, Sun W. Pericollapse Stage of Osteonecrosis of the Femoral Head: A Last Chance for Joint Preservation. Chin Med J (Engl). 2018 Nov 5;131(21):2589-2598. doi: 10.4103/0366-6999.244111. PMID: 30381593; PMCID: PMC6213842.

文獻(xiàn)2

關(guān)節(jié)鏡治療臨界髖關(guān)節(jié)發(fā)育不良失敗原因的

多中心研究：注意T?nnis角

譯者：程徽

背景：有證據(jù)表明髖關(guān)節(jié)鏡是一種治療成人輕度髖關(guān)節(jié)發(fā)育不良的有效方法。有許多放射學(xué)參數(shù)用于髖關(guān)節(jié)發(fā)育不良分類(lèi)，但迄今為止很少有研究表明哪些參數(shù)對(duì)預(yù)測(cè)手術(shù)結(jié)果最重要。

目的：確定哪些術(shù)前影像學(xué)參數(shù)與關(guān)節(jié)鏡治療成人輕度髖關(guān)節(jié)發(fā)育不良預(yù)后不良相關(guān)。

研究設(shè)計(jì)：病例對(duì)照研究；證據(jù)等級(jí)3級(jí)。

方法：對(duì)2009年至2015年期間接受關(guān)節(jié)鏡手術(shù)的輕度髖關(guān)節(jié)發(fā)育不良患者進(jìn)行影像學(xué)分析。術(shù)前X線測(cè)量包括外側(cè)中心邊緣角、T?nnis角、頸干角、前中心邊緣角、alpha角、股骨頭突出指數(shù)和髖臼深度寬度比。失敗的定義為病情改善（用改良Harris髖關(guān)節(jié)評(píng)分判斷）未能利達(dá)到最小臨床重要差異(MCID)或需要進(jìn)行二次手術(shù)。X線攝影參數(shù)的分析采用等方差t檢驗(yàn)。P值為0.05確定統(tǒng)計(jì)學(xué)意義。

圖1 A. 髖臼深度寬度比；B. T?nnis角；C.  alpha角；D. 前中心邊緣角；E. 外側(cè)中心邊緣角；F. 股骨頭突出指數(shù)；G. 頸干角。

結(jié)果：共納入373髖，平均隨訪41個(gè)月(范圍24-102個(gè)月)。其中，46髖(12%)需要二次手術(shù)，95髖(25%)改善不理想?？偸÷蕿?2.4%。沒(méi)有某個(gè)或某些指標(biāo)與改善不理想相關(guān)。較高的術(shù)前T?nnis角與二次手術(shù)相關(guān)，二次手術(shù)組平均T?nnis角為6.7°(95% CI, 5.3°-8.1°)，一次手術(shù)組平均T?nnis角為4.8°(95% CI, 4.4°-5.3°；P = .006)。T?nnis角每次增加1度，進(jìn)行二次手術(shù)優(yōu)勢(shì)比為1.12 (95% CI, 1.0-1.2；P = 0.05)。在T?nnis角>10°的患者中，84%需要二次手術(shù)。

結(jié)論：T?nnis角度越高，手術(shù)風(fēng)險(xiǎn)越高。在T?nnis角每增加1度，二次手術(shù)的概率增加1.12。在角為T(mén)?nnis >10°的患者中，84%需要二次手術(shù)。

譯者的話：目前雖然有一些研究顯示髖關(guān)節(jié)鏡對(duì)髖關(guān)節(jié)發(fā)育不良有效。但必須提醒大家，32.4%的總失敗率對(duì)外科手術(shù)來(lái)說(shuō)還是比較高的，需要謹(jǐn)慎對(duì)待。

A Multicenter Study of Radiographic Measures Predicting Failure of Arthroscopy in Borderline Hip Dysplasia: Beware of the T?nnis Angle

Background: Hip arthroscopy has been previously demonstrated to be an effective treatment for adult mild hip dysplasia. There are many radiographic parameters used to classify hip dysplasia, but to date few studies have demonstrated which parameters are of most importance for predicting surgical outcomes.

Purpose: To identify preoperative radiographic parameters that are associated with poor outcomes in the arthroscopic treatment of adult mild hip dysplasia.

Study design: Case-control study; Level of evidence, 3.

Methods: Radiographic analysis was performed in patients with mild hip dysplasia who underwent arthroscopic surgery between 2009 and 2015. Preoperative radiographic measurements included lateral center edge angle, T?nnis angle, neck shaft angle, anterior center edge angle, alpha angle, femoral head extrusion index, and acetabular depth-to-width ratio. Failure was defined as failure to achieve the minimal clinically important difference (MCID) utilizing the modified Harris Hip Score or as the need for secondary operation. The equal variance t test was used to analyze radiographic parameters. Statistical significance was determined using a P value of .05.

Results: A total of 373 hips underwent analysis with an average follow-up of 41 months (range, 24-102 months). Of these, 46 hips (12%) required secondary operation, and 95 (25%) failed to meet the MCID. The overall failure rate was 32.4%. There was no single measurement or combination thereof associated with failure to reach the MCID. Higher preoperative T?nnis angles were associated with secondary operation, with a mean of 6.7° (95% CI, 5.3°-8.1°) in the secondary operation group versus 4.8° (95% CI, 4.4°-5.3°) in the nonsecondary operation group (P = .006). The odds ratio was 1.12 (95% CI, 1.0-1.2; P = .05) per degree increase in T?nnis angle for secondary operation. In patients with a T?nnis angle >10°, 84% required secondary operation.

Conclusion: Higher T?nnis angles portend a higher risk for revision surgery. The probability of secondary operation was increased by a magnitude of 1.12 with each degree increase in the T?nnis angle. In patients with a T?nnis angle >10°, 84% required a secondary operation.

文獻(xiàn)出處：Kade S McQuivey, Erwin Secretov, Benjamin G Domb, Bruce A Levy, Aaron J Krych, Matthew Neville, David E Hartigan. A Multicenter Study of Radiographic Measures Predicting Failure of Arthroscopy in Borderline Hip Dysplasia: Beware of the T?nnis Angle. Am J Sports Med. 2020 Jun;48(7):1608-1615. doi: 10.1177/0363546520914942. Epub 2020 Apr 28.

文獻(xiàn)3

跑步過(guò)程中的伸髖肌力量、軀干姿勢(shì)和伸膝肌的使用

譯者：肖凱

背景：已有研究證實(shí)髖關(guān)節(jié)肌肉力量下降可導(dǎo)致各種膝關(guān)節(jié)損傷。

目的：確定跑步時(shí)伸髖肌力量與矢狀面軀干姿勢(shì)之間的關(guān)系，以及伸髖肌力量與髖膝伸肌工作之間的關(guān)系。

設(shè)計(jì)：描述性實(shí)驗(yàn)室研究。

地點(diǎn)：肌肉骨骼生物力學(xué)實(shí)驗(yàn)室。

患者或其他參與者：共有40名無(wú)癥狀的休閑跑步者納入研究，其中20名男性（年齡= 27.1±7.0歲，身高= 1.74±0.69 m，體重= 71.1±8.2 kg）和20名女性（年齡= 26.2±5.8歲，身高= 1.65±0.74 m，體重= 60.6±6.6 kg）。

主要結(jié)果指標(biāo)：使用測(cè)力計(jì)評(píng)估伸髖肌的最大等距肌力。當(dāng)參與者以3.4 m / s的可控速度在地面上奔跑時(shí)，量化站立位的矢狀面軀干姿勢(shì)（相對(duì)于整個(gè)過(guò)程的垂直軸進(jìn)行計(jì)算）以及伸髖伸膝肌的工作（能量吸收和能量產(chǎn)生的總和）。我們使用Pearson積差相關(guān)性來(lái)明確伸髖肌力量、平均矢狀面軀干屈曲角度、伸髖肌工作和伸膝肌工作之間的關(guān)系。

結(jié)果：伸髖肌強(qiáng)度與軀干屈曲角（r = 0.55，P <.001）和伸髖肌工作（r = 0.46，P = .003）呈正相關(guān)。它與伸膝肌的工作成反比（r = -0.39，P = 0.01）。性別調(diào)整后，所有相關(guān)性均保持不變。

結(jié)論：我們的研究結(jié)果表明，跑步者髖關(guān)節(jié)伸肌無(wú)力會(huì)導(dǎo)致跑步過(guò)程中軀干姿勢(shì)更直立。這種情況導(dǎo)致對(duì)膝關(guān)節(jié)伸直肌肉的過(guò)度依賴(lài)，可能導(dǎo)致膝關(guān)節(jié)過(guò)度使用性跑步受傷。

Hip-Extensor Strength, Trunk Posture, and Use of the Knee-Extensor Muscles During Running

Context: Diminished hip-muscle performance has been proposed to contribute to various knee injuries.

Objective: To determine the association between hip-extensor muscle strength and sagittal-plane trunk posture and the relationships among hip-extensor muscle strength and hip- and knee-extensor work during running.

Design: Descriptive laboratory study.

Setting: Musculoskeletal biomechanical laboratory.

Patients or other participants: A total of 40 asymptomatic recreational runners, 20 men (age = 27.1 ± 7.0 years, height = 1.74 ± 0.69 m, mass = 71.1 ± 8.2 kg) and 20 women (age = 26.2 ± 5.8 years, height = 1.65 ± 0.74 m, mass = 60.6 ± 6.6 kg), participated.

Main outcome measure(s): Maximum isometric strength of the hip extensors was assessed using a dynamometer. Sagittal-plane trunk posture (calculated relative to the global vertical axis) and hip- and knee-extensor work (sum of energy absorption and generation) during the stance phase of running were quantified while participants ran over ground at a controlled speed of 3.4 m/s. We used Pearson product moment correlations to examine the relationships among hip-extensor strength, mean sagittal-plane trunk-flexion angle, hip-extensor work, and knee-extensor work.

Results: Hip-extensor strength was correlated positively with trunk-flexion angle (r = 0.55, P < .001) and hip-extensor work (r = 0.46, P = .003). It was correlated inversely with knee-extensor work (r = -0.39, P = .01). All the correlations remained after adjusting for sex.

Conclusions: Our findings suggest that runners with hip-extensor weakness used a more upright trunk posture. This strategy led to an overreliance on the knee extensors and may contribute to overuse running injuries at the knee.

文獻(xiàn)出處：Teng HL, Powers CM. Hip-Extensor Strength, Trunk Posture, and Use of the Knee-Extensor Muscles During Running. J Athl Train. 2016 Jul;51(7):519-24. doi: 10.4085/1062-6050-51.8.05. Epub 2016 Aug 11. PMID: 27513169; PMCID: PMC5317187.

文獻(xiàn)4

嬰幼兒DDH超聲檢查體位帶來(lái)的差異：

冠狀面屈曲位VS冠狀面中立位

譯者：任寧濤

背景：超聲（US）是診斷和治療嬰兒發(fā)育性髖關(guān)節(jié)發(fā)育不良（DDH）的首選影像學(xué)方法，目前公認(rèn)的在冠狀面上區(qū)分正常和發(fā)育不良髖關(guān)節(jié)的指標(biāo)包括股骨頭覆蓋率（FHC）、α角和β角。最近的數(shù)據(jù)表明，這些指標(biāo)可能存在顯著的操作者和掃描圖間的變異性。然而很少有研究對(duì)患兒體位帶來(lái)的潛在變異進(jìn)行比較，特別是冠狀面屈曲位和冠狀面中立位。本研究旨在對(duì)不同DDH嚴(yán)重程度冠狀面屈曲位和冠狀面中立位上測(cè)量指數(shù)變化進(jìn)行比較。

方法：采用回顧性研究，涵蓋正常髖關(guān)節(jié)和不同程度DDH的髖關(guān)節(jié)，在診斷、早期治療（2-3周）、中間時(shí)間（6-8周）和治療完成方面，由同一個(gè)研究小組對(duì)冠狀面屈曲位和中立位上US圖像進(jìn)行評(píng)估。對(duì)兩個(gè)體位每個(gè)時(shí)間點(diǎn)上的FHC、α角和β角進(jìn)行測(cè)量比較，并對(duì)所有指標(biāo)進(jìn)行觀察者間和觀察者內(nèi)可靠性評(píng)估。

結(jié)果：共納入168例髖關(guān)節(jié)（45例正常，45例Ortolani（ ），17例Barlow（ ），61例穩(wěn)定性發(fā)育不良），在正常嬰幼兒和所有DDH 三種嚴(yán)重程度時(shí)間點(diǎn)方面，冠狀面屈曲位的FHC中位數(shù)顯著低于冠狀面中立位（平均降低8.4%；范圍5.5%至10.9%；P<0.01）。在所有髖關(guān)節(jié)類(lèi)型的冠狀面屈曲位圖像上α角也降低，但僅是在某些時(shí)間點(diǎn)上（平均降低3.3度；范圍0至7.5度；P<0.01至0.35），β角較少的體位之間的變異，但可靠性較差。

結(jié)論：在DDH嚴(yán)重程度和治療時(shí)間點(diǎn)方面，冠狀面屈曲位和中立位的FHC和α角存在顯著差異，屈曲位可能與Barlow征檢查類(lèi)似，提示髖關(guān)節(jié)微不穩(wěn)定，所有髖關(guān)節(jié)FHC的顯著和持續(xù)的下降證明了這一點(diǎn)。因此，在屈曲位測(cè)量的指數(shù)可能代表更嚴(yán)格的標(biāo)準(zhǔn)來(lái)定義正常髖關(guān)節(jié)。

圖1 兩種體位

Coronal Flexion Versus Coronal Neutral Sonographic Views in Infantile DDH: An Important Source of Variability

Background: Ultrasound (US) is the preferred imaging modality for the diagnosis and treatment of infantile developmental dysplasia of the hip (DDH). Currently accepted indices that distinguish normal from dysplastic hips in the coronal plane include percent femoral head coverage (FHC), α angle, and β angle. Recent data suggests that significant user and interscan variability may exist for these metrics. Less studied, however, is potential variability because of patient positioning, specifically coronal flexion versus coronal neutral views. The purpose of this study was to compare standard DDH indices between coronal US views with hips in flexion versus neutral positions, for hips of varying DDH severity.

Methods: This retrospective study included normal infants and those treated for different severities of DDH. Coronal flexion and coronal neutral US images from the same study were evaluated at diagnosis, early treatment, start of weaning, and treatment resolution. FHC, α, and β angles were measured on both views at each time point and compared. Inter-rater and intra-rater reliability assessments were performed for all metrics.

Results: Among the 168 hips in this study (45 normals, 45 Ortolani positive, 17 Barlow positive, and 61 stable dysplasia), median FHC was significantly lower in coronal flexion compared with coronal neutral for normals and all 3 severities of DDH at each time point (mean decrease 8.4%; range 5.5% to 10.9%; P<0.01). Alpha angle also decreased on coronal flexion views, observed for all hip types, but only at certain time points (mean decrease 3.3 degrees; range 0 to 7.5 degrees; P<0.01 to 0.35). β angles demonstrated less variability between views, but also had poor reliability.

Conclusions: Coronal flexion and coronal neutral views demonstrated significant differences in FHC and α angle across a spectrum of DDH severities and treatment time points. Flexion views may represent a 'baby Barlow' test, revealing subtle instability as evidenced by the significant and consistent decrease in FHC across all hips. Indices measured in flexion, therefore, may represent more stringent criteria for defining normal hips.

文獻(xiàn)出處：Blake C Meza, Jie C Nguyen , Jacob L Jaremko , Wudbhav N Sankar .Coronal Flexion Versus Coronal Neutral Sonographic Views in Infantile DDH: An Important Source of Variability. J Pediatr Orthop . 2020 Jul;40(6):e440-e445.

文獻(xiàn)5

髖臼周?chē)毓切g(shù)后患者報(bào)告結(jié)果與股骨頭覆蓋率和

髖臼方向的相關(guān)性：單中心隊(duì)列研究

譯者：張利強(qiáng)

背景：更好地了解髖臼發(fā)育不良的三維基本模式將有助于更好地指導(dǎo)治療和優(yōu)化髖臼周?chē)毓切g(shù)（PAO）后的臨床結(jié)果。

目的：（1）探討髖臼發(fā)育不良行PAO治療前后股骨頭覆蓋率與患者報(bào)告的預(yù)后評(píng)分（PROM）之間的關(guān)系；（2）評(píng)估根據(jù)渥太華分類(lèi)是否可以預(yù)測(cè)髖臼矯正的方向。

研究設(shè)計(jì)：隊(duì)列研究；證據(jù)水平，3。

方法：回顧性分析單中心機(jī)構(gòu)注冊(cè)數(shù)據(jù)庫(kù)前瞻性收集的PAO資料，分析至少2年的PROM評(píng)分。共有79髖（67名患者[56名女性]；平均手術(shù)年齡27.5歲[范圍15.8-53.7歲]）符合納入標(biāo)準(zhǔn)。根據(jù)渥太華分類(lèi)，54髖（68.4%）有全髖關(guān)節(jié)發(fā)育不良，15髖（18.9%）有髖關(guān)節(jié)后方發(fā)育不良，10髖（12.7%）有髖關(guān)節(jié)前方發(fā)育不良。應(yīng)用Hip2Norm軟件分析股骨頭三維覆蓋情況。采用髖關(guān)節(jié)殘疾和骨關(guān)節(jié)炎結(jié)局評(píng)分（HOOS）日常生活活動(dòng)量表的最小臨床重要差異（MCID）對(duì)PROMs改善的顯著預(yù)測(cè)因子進(jìn)行統(tǒng)計(jì)分析。

結(jié)果：平均隨訪3.1年（2.0-7.4年），所有功能結(jié)果評(píng)分均明顯改善。術(shù)后股骨頭總覆蓋率＜75.7%，后方覆蓋率＜45.2%，股骨頭外移指數(shù)＞15.5%，均與HOOS日常生活活動(dòng)量表未達(dá)到MCID有關(guān)。多變量分析顯示PC是影響PAO治療髖臼發(fā)育不良后功能結(jié)果的唯一最重要因素，優(yōu)勢(shì)比為6.0（95%CI，1.8-20.4；P=0.004）。單因素方差分析顯示，根據(jù)渥太華分類(lèi)（P<0.001），與X線測(cè)量的平均變化相比，前覆蓋率、后覆蓋率和股骨總覆蓋率存在顯著差異。

結(jié)論：我們的研究表明，術(shù)后股骨頭覆蓋率和髖臼方向是PROM的重要預(yù)測(cè)因素。根據(jù)不穩(wěn)定平面將髖臼發(fā)育不良分為3組，可以更好地了解三維畸形，從而優(yōu)化PAO的規(guī)劃。

（A） 一位22歲女性患者的術(shù)前骨盆正位（AP）平片顯示，右髖臼為全髖發(fā)育不良（根據(jù)渥太華分類(lèi)為G級(jí)），圖示外移指數(shù)，未覆蓋股骨頭（a）與總水平股骨頭直徑（a b）的比率為27%，術(shù)后降至8%（插圖）。（B）髖臼周?chē)毓切g(shù)后在骨盆平片上利用Hip2Norm手動(dòng)標(biāo)識(shí)，包括骶尾關(guān)節(jié)（上藍(lán)十字）和恥骨聯(lián)合上緣（下藍(lán)十字），用于矢狀面參照；淚滴的下緣（紅十字），用于水平面參照；股骨頭（粉紅十字）和髖臼（綠十字）的中心；髖臼前緣（藍(lán)線）和后緣（紅線）的投影。利用前后視圖（插圖a）和上下視圖（插圖b）分析右髖。（C） 髖臼三維重建前后，在前后位上計(jì)算前覆蓋率，后覆蓋率，計(jì)算髖臼在上下方向（藍(lán)色箭頭）的總股骨覆蓋率（Hip2Norm軟件的插圖顯示了髖臼在上下方向的前（藍(lán)線）和后（紅線）的股骨頭覆蓋率）。髖臼硬化帶由粗黑線表示。

（A） 前覆蓋率（藍(lán)色斑塊）：髖臼前緣（實(shí)線）在前后方向覆蓋的股骨頭百分比。（B） 后覆蓋率（紅色斑塊）：股骨頭在后向前方向上被髖臼后緣（虛線）覆蓋的百分比。（C） 股骨總覆蓋率：髖臼在上下方向（藍(lán)色箭頭）覆蓋股骨頭的百分比，即上下覆蓋率。（D） 外側(cè)中心邊緣角：骨盆縱軸與連接股骨頭中心與髖臼外側(cè)邊緣的線（粗黑線）之間的角度。（E） 髖臼指數(shù)：骨盆水平軸與連接髖臼頂部硬化區(qū)最內(nèi)側(cè)和外側(cè)點(diǎn)的線（粗黑線）之間的角度。（F） 外移指數(shù)：未覆蓋股骨頭（a）與總水平頭直徑（a b）的比值。（G）后壁征：髖臼后緣（虛線）向股骨頭中心內(nèi)側(cè)突出（黑點(diǎn)）。交叉征：突出的前壁與后壁交叉。髖臼后傾指數(shù)：后傾的髖臼開(kāi)口長(zhǎng)度（a）與髖臼外側(cè)開(kāi)口全長(zhǎng)（b）的比值。

Correlation of Patient-Reported Outcomes After Periacetabular Osteotomy With Femoral Head Coverage and Acetabular Orientation: A Single-Center Cohort Study

Background: Gaining a better understanding of the underlying pattern of acetabular dysplasia 3-dimensionally can help better guide treatment and optimize clinical outcomes after periacetabular osteotomy (PAO).

Purpose: (1) To examine the relationship between femoral head coverage before and after PAO for dysplasia and patient-reported outcome measure (PROM) scores and (2) to assess if the direction/orientation of correction of the acetabulum can be predicted based on the Ottawa classification.

Study Design: Cohort study; Level of evidence, 3.

Methods: A retrospective analysis of a prospectively collected database from a single-center institutional registry of PAO was conducted, and PROM scores at a minimum of 2 years were analyzed. A total of 79 hips (67 patients [56 female]; mean age at surgery, 27.5 years [range, 15.8-53.7 years]) were available for inclusion. According to the Ottawa classification, 54 hips (68.4%) had global deficiency, 15 hips (18.9%) had posterior deficiency, and 10 hips (12.7%) had anterior deficiency. Hip2Norm software was used to analyze the 3-dimensional coverage of the femoral head. Statistical analysis was conducted to look at significant predictors of improvements in PROMs using the minimal clinically important difference (MCID) for the Hip disability and Osteoarthritis Outcome Score (HOOS) Activities of Daily Living subscale.

Results: At a mean follow-up of 3.1 years (range, 2.0-7.4 years), all functional outcome scores improved significantly. A postoperative total femoral coverage < 75.7%, posterior coverage (PC) < 45.2%, and femoral head extrusion index > 15.5% were all associated with not reaching the MCID for the HOOS Activities of Daily Living subscale. Multivariate analysis showed that PC was the single most important significant modifier influencing functional outcomes after PAO for the treatment of acetabular dysplasia, with an odds ratio of 6.0 (95% CI, 1.8-20.4; P = .004). One-way analysis of variance showed a significant difference comparing the mean change in radiographic measurements, that is, anterior coverage, PC, and total femoral coverage, per the Ottawa classification (P <.001).

Conclusion: Our study demonstrated that postoperative femoral head coverage and acetabular orientation were significant predictors of PROM scores. Classifying acetabular dysplasia into 3 groups based on the plane of instability could optimize the planning of PAO by giving a better understanding of the 3-dimensional deformity.

文獻(xiàn)出處：Ibrahim MM, Smit K, Poitras S, Grammatopoulos G, Beaulé PE. Correlation of Patient-Reported Outcomes After Periacetabular Osteotomy With Femoral Head Coverage and Acetabular Orientation: A Single-Center Cohort Study. Am J Sports Med. 2021 Mar 4:363546521992108. doi: 10.1177/0363546521992108. Epub ahead of print. PMID: 33661717.

文獻(xiàn)6

關(guān)節(jié)鏡與開(kāi)放性股骨髖臼撞擊癥的治療：

中長(zhǎng)期結(jié)果的系統(tǒng)評(píng)價(jià)

譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）

背景：癥狀性股骨髖臼撞擊癥（FAI）的外科治療旨在改善癥狀并可能延遲髖關(guān)節(jié)骨關(guān)節(jié)炎的發(fā)生，同時(shí)，防止進(jìn)展為終末期髖關(guān)節(jié)骨關(guān)節(jié)炎以及可能的全髖關(guān)節(jié)置換術(shù)（THA）。髖關(guān)節(jié)鏡檢查和開(kāi)放性髖關(guān)節(jié)外科脫位是用于治療FAI最常見(jiàn)的兩種手術(shù)方法。

目的：進(jìn)行一項(xiàng)對(duì)照性系統(tǒng)評(píng)價(jià)，以確定在最低限度的中期隨訪中，髖關(guān)節(jié)鏡和開(kāi)放性髖關(guān)節(jié)外科脫位治療FAI的臨床結(jié)果和進(jìn)展為T(mén)HA之間，是否存在顯著差異。

研究設(shè)計(jì)：系統(tǒng)評(píng)價(jià)和薈萃分析。

方法：使用PubMed界面對(duì)MEDLINE數(shù)據(jù)庫(kù)進(jìn)行了系統(tǒng)評(píng)價(jià)。納入研究的最低平均隨訪時(shí)間定為36個(gè)月。納入的研究是以英文發(fā)表的，具體為在關(guān)節(jié)鏡或開(kāi)放性FAI治療后，評(píng)估結(jié)果在最少平均中期時(shí)間框架內(nèi)。統(tǒng)計(jì)方法采用了獨(dú)立t檢驗(yàn)、Kaplan-Meier生存分析和加權(quán)平均合并隊(duì)列分析。

結(jié)果：共有16項(xiàng)研究符合納入標(biāo)準(zhǔn)。有9項(xiàng)開(kāi)放性髖關(guān)節(jié)外科脫位研究和7項(xiàng)髖關(guān)節(jié)鏡檢查研究。開(kāi)放研究包括600例髖，平均隨訪57.6個(gè)月（4.8年；范圍6-144個(gè)月）。關(guān)節(jié)鏡檢查包括1484髖，平均隨訪50.8個(gè)月（4.2年；范圍12-97個(gè)月）。以THA為終點(diǎn)，開(kāi)放手術(shù)的總生存率為93％，關(guān)節(jié)鏡手術(shù)的總生存率為90.5％（P = .06）。兩種治療后，高齡和先前存在的軟骨損傷都是發(fā)展為T(mén)HA的危險(xiǎn)因素。兩種手術(shù)治療FAI在特殊疾病結(jié)果之間的直接比較參數(shù)受到結(jié)果指標(biāo)異質(zhì)性的限制。但是，兩種治療方法在各自的評(píng)分系統(tǒng)中均顯示出良好的效果。值得注意的是， SF-12簡(jiǎn)易生活質(zhì)量問(wèn)卷顯示髖關(guān)節(jié)鏡檢查與較高的一般健康相關(guān)生活質(zhì)量評(píng)分（HRQoL）相關(guān)（P <0.001）。

結(jié)論：在中期隨訪中，無(wú)論是髖關(guān)節(jié)鏡檢查還是開(kāi)放性髖關(guān)節(jié)外科脫位，采用特定的髖關(guān)節(jié)隨訪結(jié)果指標(biāo)，均顯示出極佳的且等同的髖關(guān)節(jié)存活率，證明了兩組之間的等效性。但是，與一般治療相比，髖關(guān)節(jié)鏡檢查在一般HRQoL方面顯示出更好的結(jié)果。仍然需要對(duì)FAI的自然病史進(jìn)行更深入的探索，以評(píng)估FAI患者的長(zhǎng)期療效。

開(kāi)放性髖關(guān)節(jié)外科脫位和髖關(guān)節(jié)鏡治療股骨髖臼撞擊癥的Kaplan-Meier生存分析，以進(jìn)展為全髖關(guān)節(jié)置換術(shù)為終點(diǎn)。

Arthroscopic Versus Open Treatment of Femoroacetabular Impingement: A Systematic Review of Medium- to Long-Term Outcomes

Background: Surgical treatment of symptomatic femoroacetabular impingement (FAI) aims to improve symptoms and potentially delay initiation of hip osteoarthritis and prevent progression to end-stage hip osteoarthritis and possible total hip arthroplasty (THA). Hip arthroscopy and open surgical hip dislocations are the 2 most common surgical approaches used for this condition.

Purpose: To perform a comparative systematic review to determine whether there is a significant difference in clinical outcomes and progression to THA between hip arthroscopy and open surgical hip dislocation treatment for FAI at minimum medium-term follow-up.

Study design: Systematic review and meta-analysis.

Methods: A systematic review of the MEDLINE database by use of the PubMed interface was performed. Minimum mean follow-up for included studies was set at 36 months. English-language studies with a minimum mean medium-term time frame evaluating outcome after arthroscopic or open treatment of FAI were included. Independent t tests, Kaplan-Meier survival analysis, and weighted mean pooled cohort statistics were performed.

Results: A total of 16 studies met inclusion criteria. There were 9 open surgical hip dislocation studies and 7 hip arthroscopy studies. Open studies included 600 hips at a mean follow-up of 57.6 months (4.8 years; range, 6-144 months). Arthroscopic studies included 1484 hips at a mean follow-up of 50.8 months (4.2 years; range, 12-97 months). With THA as an outcome endpoint, there was an overall survival rate of 93% for open and 90.5% for arthroscopic procedures (P = .06). Advanced age and preexisting chondral injury were risk factors for progression to THA after both treatments. Direct comparison among disease-specific outcome instruments between the 2 procedures was limited by outcome measure heterogeneity; however, both treatments demonstrated good outcomes in their respective scoring systems. Notably, hip arthroscopy was associated with a higher general health-related quality of life (HRQoL) score on the 12-Item Short-Form Survey physical component score (P < .001).

Conclusion: Both hip arthroscopy and open surgical hip dislocation showed excellent and equivalent hip survival rates at medium-term follow-up with hip-specific outcome measures, demonstrating equivalence between groups. However, hip arthroscopy was shown to have superior results regarding general HRQoL in comparison to open treatment. An increased understanding of the natural history of FAI remains warranted, with further studies needed to assess long-term outcomes for patients with FAI.

文獻(xiàn)出處：Benedict U Nwachukwu, Brian J Rebolledo, Frank McCormick, Samuel Rosas, Joshua D Harris, Bryan T Kelly. Arthroscopic Versus Open Treatment of Femoroacetabular Impingement: A Systematic Review of Medium- to Long-Term Outcomes. Am J Sports Med. 2016 Apr;44(4):1062-8.