文獻(xiàn)1

活動平臺假體全膝置換術(shù)后膝過伸的

危險因素及與臨床效果的關(guān)系

譯者：張軼超

介紹：評估活動平臺假體全膝置換術(shù)（TKA）后膝過伸的發(fā)生率及危險因素，以及其臨床預(yù)后。

材料和方法：本研究為回顧性病例對照研究，共納入了387例初次全膝置換患者，平均隨訪5年。評估了術(shù)后的臨床效果及影像學(xué)指標(biāo)（包括后髁的偏心距 PCO，股骨和脛骨的后傾角以及兩者間的夾角）。所有病例被分為兩組：第1組術(shù)后無膝過伸；第二組術(shù)后有膝過伸。當(dāng)在末次隨訪時用量角器測量存在5°以上的過伸就被認(rèn)為是存在術(shù)后過伸。采用邏輯和線性回歸分析來對數(shù)據(jù)進(jìn)行處理。

結(jié)果：有43膝（11.1%）在末次隨訪時存在膝關(guān)節(jié)過伸。盡管第二組膝關(guān)節(jié)功能評分比第一組差，但總體的臨床效果兩組間卻沒有明顯差異。術(shù)后影像學(xué)中PCO (第一組比第二組；? 0.2 mm ± 3.8 比 ? 2.4 mm ± 3.0, p = 0.003)、股骨遠(yuǎn)端截骨面的后傾角(? 9.1° ± 2.1比? 12.1° ± 1.7, p < 0.000)及股骨-脛骨后傾角間的夾角(0.3° ± 4.5比? 3.6° ± 3.9, p < 0.000)有統(tǒng)計(jì)學(xué)差異，其它的指標(biāo)均無明顯差異。PCO [優(yōu)勢比(OR) 0.86, p = 0.012]、后傾角夾角(OR 0.8136, p = 0.000)及術(shù)前股骨-脛骨機(jī)械軸夾角(OR 1.09, p = 0.003)的差異與術(shù)后膝關(guān)節(jié)過伸存在相關(guān)性。

結(jié)論：盡管沒有嚴(yán)重的并發(fā)癥發(fā)生，但在中期隨訪時發(fā)現(xiàn)活動平臺假體的TKA出現(xiàn)超過5°的膝關(guān)節(jié)過伸時，功能預(yù)后較差。我們術(shù)中要盡量保持后髁的偏心距，同時避免股骨和脛骨截骨面不平行造成的術(shù)后膝關(guān)節(jié)過伸與功能欠佳。

A、在影像學(xué)上測量股骨后髁偏心距（PCO）。即股骨后髁最高點(diǎn)到股骨后皮質(zhì)延長線的垂直距離。B、脛骨后傾角（a）即脛骨假體下表面和脛骨解剖軸線垂線之間的夾角；股骨后傾角（b）股骨假體遠(yuǎn)端內(nèi)側(cè)面與股骨解剖軸垂線間的夾角。

Risk factors of hyperextension and its relationship with the clinical outcomes following mobile-bearing total knee arthroplasty

INTRODUCTION: To evaluate the incidence and risk factors of postoperative hyperextension after mobile-bearing total knee arthroplasty (TKA) and its clinical outcomes.

MATERIALS AND METHODS: This retrospective case-control study included 387 knees of primary TKA patients after a 5-year follow-up. The clinical outcomes and radiographs including posterior condylar offset (PCO), femur and tibial slope angle and its discrepancy were evaluated. The patients were divided into two groups (group 1: non-hyperextension, group 2: hyperextension). An extension greater than 5° measured using a goniometer at the final follow-up was defined as hyperextension. Logistic and linear regression analyses were performed.

RESULTS: Overall, 43 knees (11.1%) with hyperextension were observed at the last follow-up. There was no significant difference between groups in terms of the clinical outcomes although the functional scores were worse in group 2. There was no significant difference in the postoperative radiologic evaluation except for a change in PCO (group 1 vs. group 2; - 0.2 mm?±?3.8 vs. - 2.4 mm?±?3.0, p?=?0.003), distal femoral resection slope angle (- 9.1°?±?2.1 vs. - 12.1°?±?1.7, p?<?0.000) and discrepancy of the slope angle (0.3°?±?4.5 vs. - 3.6°?±?3.9, p?<?0.000). The change in PCO [odds ratio (OR) 0.86, p?=?0.012], discrepancy of the slope angle (OR 0.8136, p?=?0.000) and the preoperative mechanical femorotibial angle (OR 1.09, p?=?0.003) were associated with hyperextension.

CONCLUSION: Mobile-bearing TKA with hyperextension over 5° showed worse functional outcomes at the mid-term follow-up, even though no serious complications were observed. Care should be taken to maintain the posterior condylar offset and to match the resection angles in femur and tibia due to the risk of hyperextension and worse functional outcomes.

文獻(xiàn)出處：Lee HJ, Park YB, Lee DH, Kim KH, Ham DW, Kim SH. Risk factors of hyperextension and its relationship with the clinical outcomes following mobile-bearing total knee arthroplasty. Arch Orthop Trauma Surg. 2019 Sep;139(9):1293-1305. doi: 10.1007/s00402-019-03231-6. Epub 2019 Jul 12.

文獻(xiàn)2

更好的證據(jù)證明髖臼側(cè)發(fā)育不良會導(dǎo)致骨關(guān)節(jié)炎

譯者：馬云青

背景:骨科文獻(xiàn)中一個常見的說法是髖臼中心邊緣角（CE角）小于20°診斷為髖臼發(fā)育不良（AD），而AD會導(dǎo)致骨關(guān)節(jié)炎(OA)。文章的目的是評估AD和OA的關(guān)聯(lián)性。

方法:對AD與OA有關(guān)聯(lián)的現(xiàn)實(shí)證據(jù)和相關(guān)理論進(jìn)行評價和討論。此外，測試已有的理論，即認(rèn)為當(dāng)髖臼CE角小于20°時，患者65歲時會患上OA，并尋找這個理論的例外。

結(jié)果:Wiberg和Cooperman及其同事研究了30例理想的病例來評估AD與OA的關(guān)系。開始每例患者都無關(guān)節(jié)炎表現(xiàn)，AD穩(wěn)定，CE角<20°，無半脫位，所有病例都被長期隨訪且均發(fā)展為OA。在Stulberg及其同事，Jacobsen及其同事的研究中的每例患者也表現(xiàn)為骨關(guān)節(jié)炎，因此很難確定什么樣的髖關(guān)節(jié)會發(fā)展為OA。在Murphy的研究中，也有同樣的問題，很難確定患者在初次評估時是否已經(jīng)患有OA。原因是所有這些研究使用了不同的OA診斷方案，研究難度比較大。研究中大多數(shù)患者來自歐洲北方血統(tǒng)，使得結(jié)果很難延伸到其他人群。而且有4例患者CE角<20°在65歲時沒有患上嚴(yán)重的關(guān)節(jié)炎。

結(jié)論:現(xiàn)有的結(jié)論只適用于歐洲北方血統(tǒng)患者。只有少數(shù)患者AD穩(wěn)定，輕度CE角異常（15到19°)在65歲時沒有關(guān)節(jié)炎。幾乎所有的AD穩(wěn)定的患者在65歲時發(fā)生OA。不穩(wěn)定AD (CE角<20°，并有半脫位)在65.歲時常會發(fā)生OA。將這些結(jié)論擴(kuò)展到其他人群可能是合理的，但隨著更多數(shù)據(jù)積累，必須做好重新評價的準(zhǔn)備。

How Good is the Evidence Linking Acetabular Dysplasia to Osteoarthritis?

BACKGROUND: A common claim in the orthopaedic literature is that acetabular dysplasia (AD) exists when the center-edge angle of Wiberg (CE angle) is <20 degrees and that AD leads to osteoarthritis (OA). Our purpose is to evaluate the validity of the linkage between AD and OA.

METHODS: We assess and discuss the theories and the empirical evidence relating AD to OA. Moreover, we test the rule that hips with a CE angle <20 degrees will develop OA by 65 years of age, by looking for exceptions to this rule.

RESULTS: Wiberg and Cooperman and colleagues present 30 ideal patients for assessing the relationship between AD and OA. Each was arthritis free, with stable AD, CE angle <20 degrees, without signs of subluxation. They were all followed and all developed OA. In the studies by Stulberg and colleagues, and Jacobsen and colleagues, every patient presented with OA, making it difficult to be certain about the appearance of the hip before the onset of OA. In the study by Murphy and colleagues, we have the same problem, as an unknown number of patients already had OA at first assessment. All of these studies used different schemes for diagnosing OA, making the studies difficult to compare. Most of the patients in the studies were of Northern European ancestry, making the results difficult to generalize to other populations. Four patients had CE angles <20 degrees and did not develop severe arthritis by 65 years of age.

CONCLUSIONS: Our conclusions apply directly to patients of Northern European ancestry. A few patients with stable, mild AD (CE angle 15 to 19 degrees) will be arthritis free at 65 years of age. Almost all patients with stable AD develop OA by 65 years of age. Unstable AD (CE angle <20 degrees, with subluxation) always leads to OA by 65 years of age. It is probably reasonable to extend these conclusions to other populations, but the reader must be prepared to re-evaluate them, as more data accumulates.

文獻(xiàn)出處：Cooperman DR. How Good is the Evidence Linking Acetabular Dysplasia to Osteoarthritis? J Pediatr Orthop. 2019 Jul;39(Issue 6, Supplement 1 Suppl 1):S20-S22. doi: 10.1097/BPO.0000000000001360.

文獻(xiàn)3

開放楔形脛骨高位截骨術(shù)正常矯正與

過度矯正術(shù)后臨床和影像學(xué)結(jié)果的比較

譯者：張薔

目的：評估過度矯正的脛骨平臺內(nèi)側(cè)角（MPTA）是否影響開放楔形脛骨高位截骨術(shù)的臨床療效，并探究膝關(guān)節(jié)線傾斜角改變與髖、踝關(guān)節(jié)代償性變化的關(guān)系。

方法：入組2006年7月至2015年8月連續(xù)的開放楔形脛骨高位截骨術(shù)病例。排除標(biāo)準(zhǔn)為雙側(cè)開放楔形截骨術(shù)和隨訪不足兩年。我們回顧性的根據(jù)術(shù)后脛骨平臺內(nèi)側(cè)角（MPTA）將病例分為兩組，正常矯正組（MPTA <95°）和過度矯正組（MPTA≥95°）。比較術(shù)后組間臨床和影像學(xué)結(jié)果。臨床結(jié)果指標(biāo)包括日本骨科協(xié)會評分（JOA）、牛津膝關(guān)節(jié)評分（OKS）和膝關(guān)節(jié)損傷與骨關(guān)節(jié)炎評分（KOOS）。影像學(xué)指標(biāo)包括髖-膝-踝角（HKA）、關(guān)節(jié)線匯聚角（JLCA）、MPTA、膝關(guān)節(jié)線傾斜角（KJLO）、踝關(guān)節(jié)線傾斜角（AJLO）和髖關(guān)節(jié)外展角（HAA），分別在術(shù)后和末次隨訪時采集。

A． 膝關(guān)節(jié)線傾斜角（KJLO），踝關(guān)節(jié)線傾斜角（AJLO）；髖關(guān)節(jié)外展角（HAA）

關(guān)節(jié)線匯聚角（JLCA）

結(jié)果：共入組94例（正常矯正組52例，過度矯正組42例）。開放楔形脛骨高位截骨術(shù)后，HKA和MPTA分別平均增加11.0°±3.2°和10.4°±2.7°，膝關(guān)節(jié)線傾斜角變化為3.7°±2.9°，而術(shù)后踝關(guān)節(jié)線傾斜角(4.3±3.9 to -1.3±3.3, P < .001)和髖關(guān)節(jié)外展角(3.7±2.5 to -1.1±2.3, P < .001)顯著降低。過度矯正組術(shù)后平均MPTA為96.9°±1.5°，而術(shù)后平均膝關(guān)節(jié)線傾斜角（KJLO）變化為3.1°±2.0°。末次隨訪時兩組間所有臨床評分均無顯著性差異。

結(jié)論：由于髖關(guān)節(jié)和踝關(guān)節(jié)的代償性變化，一定程度的脛骨平臺內(nèi)側(cè)角（MPTA）過度矯正（≥95°）并不會改變開放楔形脛骨高位截骨術(shù)的臨床效果。

Comparison of Clinical and Radiologic Outcomes between Normal and Overcorrected Medial Proximal Tibial Angle Groups after Open-Wedge High Tibial Osteotomy

Purpose: To evaluate whether the overcorrected medial proximal tibial angle (MPTA) affects the clinical outcomes after open-wedge high tibial osteotomy (OWHTO) and to assess the correlation between knee joint line obliquity (KJLO) changes and the compensatory changes in the hip and ankle joints.

Methods: Consecutive patients who underwent OWHTO from July 2006 to August 2015 were included. Exclusion criteria were bilateral OWHTO and follow-up of <2 years. The patients were retrospectively divided into 2 groups according to postoperative MPTA; a normal group (MPTA <95°) and an overcorrected MPTA group (MPTA≥95°). The groups were compared with respect to the clinical and radiologic outcomes after OWHTO. Clinical parameters, including Japanese Orthopedic Association (JOA) score, Oxford Knee Score (OKS), and Knee Injury and Osteoarthritis Outcome Score (KOOS), were evaluated. Radiologic outcomes, including the hip-knee-ankle angle (HKA), joint line convergence angle (JLCA), MPTA, KJLO, ankle joint line obliquity (AJLO), and hip abduction angle (HAA), were evaluated preoperatively and at the final follow-up.

Results: Ninety-four patients (normal group; n=52, overcorrected group; n=42) were included in this study. After OWTHO, the mean increases in HKA and MPTA were 11.0°±3.2°and 10.4°±2.7°, respectively, whereas the change in KJLO was only 3.7°±2.9°. The mean AJLO (4.3±3.9 to -1.3±3.3, P < .001) and HAA (3.7±2.5 to -1.1±2.3, P < .001) significantly decreased after OWHTO. The mean postoperative MPTA in the overcorrected group was 96.9°±1.5°, whereas the mean postoperative KJLO was only 3.1°±2.0°. No significant differences were noted in all clinical scores between the groups at the final follow-up.

Conclusions: A certain degree of overcorrected MPTA (≥95°) did not affect the clinical outcomes after OWHTO because of compensatory changes in the hip and ankle joints.

文獻(xiàn)出處：Goshima K, Sawaguchi T, Shigemoto K, Iwai S, Fujita K, Yamamuro Y. Comparison of Clinical and Radiologic Outcomes Between Normal and Overcorrected Medial Proximal Tibial Angle Groups After Open-Wedge High Tibial Osteotomy. Arthroscopy. 2019 Oct;35(10):2898-2908.e1. doi: 10.1016/j.arthro.2019.04.030.

第二部分：保髖相關(guān)文獻(xiàn)

文獻(xiàn)1

髖關(guān)節(jié)動態(tài)超聲能否可準(zhǔn)確地評估股骨頭前移？

譯者：羅殿中

背景：髖關(guān)節(jié)微不穩(wěn)定性作為引起髖關(guān)節(jié)疼痛的潛在原因，最近已受到關(guān)注。該診斷目前仍缺乏循證客觀的診斷標(biāo)準(zhǔn)。之前的研究表明在髖關(guān)節(jié)處于極端位置時，股骨頭會發(fā)生移位。然而，目前仍缺乏對股骨頭移位的可靠標(biāo)準(zhǔn)。

問題/目的：（1）明確肌骨超聲在測量髖關(guān)節(jié)前方不穩(wěn)定試驗(yàn)時股骨頭移位的精度（2）明確動態(tài)超聲檢查在評估股骨頭前方移位時的組內(nèi)和組間一致性。

方法：我們招募了10名（共20髖）年齡在22至50歲的受試者，其中女性7名，男性3名，所有受試者均沒有髖關(guān)節(jié)疼痛或功能受限的病史。使用了重復(fù)測量方法。受試者平均年齡為27歲（標(biāo)準(zhǔn)差8.7歲）；平均體重指數(shù)為22.6 kg / m（標(biāo)準(zhǔn)差2.2 kg / m）。所有受試者均由三位不同的醫(yī)生在相隔1周的時間內(nèi)進(jìn)行了動態(tài)髖部超聲檢查。每個髖關(guān)節(jié)均處于兩個中立位置（中立位和對側(cè)髖關(guān)節(jié)屈曲中立位[NF]）和兩個動態(tài)位進(jìn)行超聲檢查，受試者對髖關(guān)節(jié)病理并不知情，因此檢查過程中不會分心。第一個動態(tài)檢查時(EER1)，使髖關(guān)節(jié)保持伸展外旋，且使其不靠近檢查床的側(cè)面；第二個動態(tài)檢查時(EER2)，保持髖部離開檢查床的尾端。共進(jìn)行了120次超聲掃描（480張圖像）。計(jì)算NF和EER1與NF和EER2之間的超聲測量值差（mm）的絕對值，進(jìn)一步計(jì)算平均值及標(biāo)準(zhǔn)差，對每位醫(yī)生的測量數(shù)據(jù)及三個人的平均值均進(jìn)行統(tǒng)計(jì)分析。應(yīng)用同類相關(guān)系數(shù)（ICC）檢查組內(nèi)及組間測量一致性。

結(jié)果：在第一次試驗(yàn)時，NF和EER1的平均絕對差為0.84 mm（SD 0.93 mm），而NF和EER2的平均絕對差為0.62 mm（SD 0.40 mm）。在第二次試驗(yàn)時，NF和EER1位置的平均絕對差為0.90mm（SD 0.74mm），NF和EER2平均絕對差1.03mm（SD 1.18mm）。ICC分析的累積值表明，在所有四個體位，觀測者組內(nèi)一致性都非常好：中立位0.794（95％置信區(qū)間[CI]，0.494-0.918），NF 0.927（95％CI，0.814-0.971），EER1 0.929（95％CI，0.825） -0.972）和EER2 0.945（95％CI，0.864-0.978）。同樣，ICC分析的累積值顯示組間 一致性在NF、EER1和EER2非常好，中立位較好：中立位0.725（95％CI，0.526-0.846），NF 0.846（95％CI，0.741-0.913），EER1 0.812（95％CI，0.674-0.895）和EER2 0.794（95％CI，0.652-0.884）。

結(jié)論：這項(xiàng)研究首次位我們提供了應(yīng)用超聲測量股骨頭向前移位的方法。當(dāng)評估復(fù)雜的髖部疼痛和可疑的微不穩(wěn)定時，髖關(guān)節(jié)動態(tài)超聲可以幫助提供精確客觀的基于臨床的診斷依據(jù)。肌骨超聲是一種可靠的測量股骨頭向前移位的方法，不同經(jīng)驗(yàn)水平的醫(yī)生均可以使用。后期需要進(jìn)一步評估性別、既往髖關(guān)節(jié)手術(shù)史、髖關(guān)節(jié)骨形態(tài)和韌帶松弛對股骨頭移位的影響。

A 平臥位、髖關(guān)節(jié)中立位進(jìn)行超聲檢查；B NF檢查，即對側(cè)髖關(guān)節(jié)屈曲

A EER1檢查，即髖關(guān)節(jié)保持伸展外旋，且使其不靠近檢查床的側(cè)面；B EER2檢查，即保持髖部離開檢查床的尾端

應(yīng)用超聲機(jī)內(nèi)部軟件測量股骨頭向前移位距離，移位距離即股骨頭硬化緣前方至髖臼水平的垂直距離

Can Dynamic Ultrasonography of the Hip Reliably Assess Anterior Femoral Head Translation?

BACKGROUND: Hip microinstability has gained attention recently as a potential cause of hip pain. Currently there is a lack of evidence-based objective diagnostic criteria surrounding this diagnosis. Previous studies have shown translation of the femoral head during extreme hip positions. However, reliable assessment of femoral head translation is lacking.

QUESTIONS/PURPOSES: (1) How precise is musculoskeletal ultrasound for measuring anterior femoral head translation during the hip anterior apprehension test? (2) What is the intra- and interrater reliability of dynamic ultrasonography in assessing anterior femoral head translation?

METHODS: We recruited 10 study participants (20 hips) between the ages of 22 and 50 years with no history of hip pain or functional limitations. Test-retest methodology was used. Seven females and three males were enrolled. The mean age of study participants was 27 years (SD 8.7 years); mean body mass index was 22.6 kg/m (SD 2.2 kg/m). All study participants underwent dynamic hip ultrasonography by three different physicians 1 week apart. Each hip was visualized in two neutral positions (neutral and neutral with the contralateral hip flexed [NF]) and two dynamic positions, which sought to replicate the apprehension test, although notably study participants had no known hip pathology and therefore no apprehension. The first maintained the hip in extension and external rotation off to the side of the examination table (EER1), and the second held the hip off of the bottom of the examination table (EER2). One hundred twenty ultrasound scans (480 images) were performed. Mean and SD were calculated using absolute values of the difference in ultrasound measurements (mm) between positions NF and EER1 and NF and EER2 calculated for each physician as well as an average of all three physicians. Intraclass correlation coefficient (ICC) analysis was used to examine intra- and interrater reliability.

RESULTS: The mean absolute difference for NF and EER1 was 0.84 mm (SD 0.93 mm) and for NF and EER2 0.62 mm (SD 0.40 mm) on Study Day 1. Similarly, on Study Day 2, the mean absolute difference for NF and EER1 position was 0.90 mm (SD 0.74 mm) and for NF and EER2 1.03 mm (SD 1.18 mm). Cumulative values of ICC analysis indicated excellent intrarater reliability in all four positions: neutral 0.794 (95% confidence interval [CI], 0.494-0.918), NF 0.927 (95% CI, 0.814-0.971), EER1 0.929 (95% CI, 0.825-0.972), and EER2 0.945 (95% CI, 0.864-0.978). Similarly, interrater ICC analysis cumulative values were excellent for NF, EER1, and EER2 and fair to good for the neutral position: neutral 0.725 (95% CI, 0.526-0.846), NF 0.846 (95% CI, 0.741-0.913), EER1 0.812 (95% CI, 0.674-0.895), and EER2 0.794 (95% CI, 0.652-0.884).

CONCLUSIONS: This study offers the first ultrasound protocol of which we are aware for measuring anterior femoral head translation. Hip dynamic ultrasound may assist in providing precise objective clinical-based diagnostic evidence when evaluating complex hip pain and suspected microinstability. Musculoskeletal ultrasound is a reliable office-based method of measuring anterior femoral head translation that can be utilized by physicians with varying experience levels. Future studies are needed to investigate ultrasound anterior femoral head translation taking into account sex, prior hip surgery, hip osseous morphology, and ligamentous laxity.

文獻(xiàn)出處：d'Hemecourt PA, Sugimoto D, McKee-Proctor M, Zwicker RL, Jackson SS, Novais EN, Kim YJ, Millis MB, Stracciolini A. Can Dynamic Ultrasonography of the Hip Reliably Assess Anterior Femoral Head Translation? Clin Orthop Relat Res. 2019 May;477(5):1086-1098. doi: 10.1097/CORR.0000000000000457.

文獻(xiàn)2

髖關(guān)節(jié)發(fā)育不良患者的骨盆前平面（APP）角與

解剖學(xué)骨盆傾斜度（PT）和髖臼形態(tài)的

相關(guān)性：橫斷面研究

譯者：程徽

背景：既往文獻(xiàn)報(bào)道，髖關(guān)節(jié)發(fā)育不良會導(dǎo)致骨盆前傾，代償性的增加股骨頭骨性覆蓋。本研究的目的是了解骨盆的解剖參數(shù)（如PI和PT）與脊柱-骨盆的功能參數(shù)（如骨盆前平面角）之間的相關(guān)性。

方法：對作者所在機(jī)構(gòu)的84名因雙側(cè)髖關(guān)節(jié)發(fā)育不良進(jìn)行髖臼周圍弧形截骨術(shù)的女性患者進(jìn)行觀察。脊柱-骨盆功能參數(shù)使用術(shù)前的站立位胸腰椎X線片和骨盆X線片進(jìn)行測量。髖臼的形態(tài)學(xué)參數(shù)，包括前CE角、后CE角、外側(cè)CE角和髖臼前角，均在術(shù)前CT三維重建出的骨盆模型上進(jìn)行測量。使用Pearson相關(guān)分析評估參數(shù)之間的相關(guān)性。

圖1 骨盆參數(shù)的測量方法

圖2 髖臼參數(shù)的測量（譯者注：不同于我們常用的測量方法，本文中的各向CE角均在CT上進(jìn)行測量）

結(jié)果：在功能參數(shù)中，SS值（r = 0.666）與PI相關(guān)性最高，而在解剖參數(shù)中，解剖學(xué)SS值（r = 0.789）與PI相關(guān)性最高。骨盆前平面角（APPA）與PT（r =-0.594）和解剖學(xué)PT（r = 0.646）均存在中度相關(guān)。關(guān)于脊柱-骨盆功能參數(shù)與髖臼的骨形態(tài)參數(shù)之間的相關(guān)性，PT與髖臼前傾角（AA）中度相關(guān)（r= 0.424）， APPA與前CE角（r =-0.478），后CE角（r = 0.432）和AA（r = 0.565）均中度相關(guān)。與AA相比，解剖PT與APPA的相關(guān)性強(qiáng)得多（r = 460.646）。

結(jié)論：與髖臼的參數(shù)（外側(cè)CE角，前CE角，后CE角和髖臼的骨覆蓋度）相比，骨盆的傾斜受骨盆的形態(tài)參數(shù)（解剖學(xué)PT）的影響更大。本研究是第一個脊柱-骨盆功能參數(shù)（除PI以外）與髖臼形態(tài)參數(shù)之間的相關(guān)性的研究。

譯者的話：最終的結(jié)論是，骨盆前后傾與髖關(guān)節(jié)旋轉(zhuǎn)中心在骨盆上的前后位置有關(guān)。

Correlation of tilt of the anterior pelvic plane angle with anatomical pelvic tilt and morphological configuration of the acetabulum in patients with developmental dysplasia of the hip: a cross-sectional study

BACKGROUND: It was previously reported that pelvises with developmental dysplasia of the hip are tilted anteriorly, which increases bony coverage of the femoral head. This study aimed to investigate the correlation between anatomical parameters of the pelvis such as pelvic incidence and anatomical pelvic tilt and functional parameters of the spine and pelvis such as tilt of the anterior pelvic plane.

METHODS: We examined 84 female patients with bilateral developmental dysplasia of the hip who had undergone curved periacetabular osteotomy at author's institution. Radiographs of the thoracic to lumbar spines and the pelvis were obtained in the standing position to measure spino-pelvic parameters before surgery. Morphological parameters of the acetabulum such as the anterior center-edge (CE) angle, posterior CE angle, lateral CE angle, and acetabular anteversion were measured using a preoperative three-dimensional pelvic model reconstructed from computed tomography images. Pearson's correlation analysis was conducted to evaluate the relationship of these parameters.

RESULTS: With regard to correlations between pelvic incidence (PI) and other parameters, the sacral slope (SS) value (r?=?0.666) was the highest among functional parameters and the anatomical-SS value (r?=?0.789) was the highest among morphological parameters. There were moderate correlations of the anterior pelvic plane angle (APPA) with pelvic tilt (PT) (r?=?-?0.594) and anatomical-PT (r?=?0.646). With regard to correlations between spino-pelvic parameters and bony morphological parameters of the acetabulum, there was a moderate correlation between anatomical-PT and acetabular anteversion (AA) (r?=?0.424). There were moderate correlations of APPA with the anterior CE angle (r?=?-?0.478), posterior CE angle (r?=?0.432), and AA (r?=?0.565). APPA had a stronger correlation with anatomical-PT (r?=?0.646) than with AA.

CONCLUSIONS: The tilt of the pelvis may be more dependent on anatomical-PT, a morphological parameter of the pelvis, than the lateral CE angle, anterior CE angle, posterior CE angle, and acetabular anteversion on bony coverage of the acetabulum. This study is the first to investigate the correlation between functional parameters of the pelvis and spine and morphological parameters of the pelvis and acetabulum besides PI.

文獻(xiàn)出處：Imai N, Suzuki H, Nozaki A, Hirano Y, Endo N. Correlation of tilt of the anterior pelvic plane angle with anatomical pelvic tilt and morphological configuration of the acetabulum in patients with developmental dysplasia of the hip: a cross-sectional study. J Orthop Surg Res. 2019 Oct 17;14(1):323. doi: 10.1186/s13018-019-1382-8.

文獻(xiàn)3

患有髂脛束綜合征的長跑運(yùn)動員的

髖關(guān)節(jié)外展肌無力

譯者：肖凱

目的：檢查患有髂脛束帶綜合征（ITBS）的長跑運(yùn)動員的髖關(guān)節(jié)外展肌力量，將他們的受傷肢體力量與未受影響的肢體和健康長跑運(yùn)動員（對照組）進(jìn)行比較；明確通過康復(fù)計(jì)劃改善患者髖外展肌力量是否可以使其成功返回跑步賽場。

設(shè)計(jì)：病例隊(duì)列研究。

設(shè)置：斯坦福大學(xué)運(yùn)動醫(yī)學(xué)診所。

參與者：自就診于我們跑步者傷病診所的患者中隨機(jī)選擇24名患有ITBS的長跑運(yùn)動員（14名女性，10名男性），患者均具有ITBS典型的病史和體格檢查結(jié)果。從斯坦福大學(xué)越野與田徑隊(duì)中隨機(jī)選擇30名長跑運(yùn)動員作為對照組（14名女性，16名男性）。

主要觀察指標(biāo)：分別測量病例組受傷側(cè)肢體、未受傷肢體及對照組的髖關(guān)節(jié)外展扭矩，用于評估髖外展肌力量，應(yīng)用t檢驗(yàn)比較各組間是否存在差異。經(jīng)過6周的康復(fù)計(jì)劃后，比較受傷運(yùn)動員康復(fù)前髖外展肌扭矩與康復(fù)后扭矩的差異。

結(jié)果：用尼古拉斯手動肌肉測試儀（kg）測量髖關(guān)節(jié)外展肌扭矩，并以體重百分比乘以身高（％BWh）的單位標(biāo)準(zhǔn)化受試者的身高和體重差異。受傷女性的平均康復(fù)前髖關(guān)節(jié)外展扭矩為7.82％BWh，而未受傷肢體的平均為9.82％BWh，對照組為10.19％BWh。受傷男性的平均康復(fù)前髖關(guān)節(jié)外展扭矩為6.86％BWh，未受傷肢體的平均水平為8.62％BWh，對照組為男性跑步者的9.73％BWh?？祻?fù)前各組的差異在p <0.05水平上均具有統(tǒng)計(jì)學(xué)意義。然后將受傷的跑步者納入為期6周的標(biāo)準(zhǔn)化康復(fù)方案，并特別注意加強(qiáng)臀中肌訓(xùn)練。康復(fù)后，女性受傷肢體的髖關(guān)節(jié)外展扭矩平均增加34.9％，男性平均增加51.4％?？祻?fù)6周后，24名運(yùn)動員中有22名無疼痛，并且能夠恢復(fù)奔跑，并且在6個月的隨訪中沒有復(fù)發(fā)的報(bào)道。

結(jié)論：與未受影響的肢體和未受影響的長跑運(yùn)動員相比，患有ITBS的長跑運(yùn)動員患側(cè)肢體的髖關(guān)節(jié)外展肌強(qiáng)度較弱。此外，髖關(guān)節(jié)外展肌的強(qiáng)化伴隨著患者癥狀的緩解，患者可以回到傷病前的正常訓(xùn)練。

Hip abductor weakness in distance runners with iliotibial band syndrome

OBJECTIVE: To examine hip abductor strength in long-distance runners with iliotibial band syndrome (ITBS), comparing their injured-limb strength to their nonaffected limb and to the limbs of a control group of healthy long-distance runners; and to determine whether correction of strength deficits in the hip abductors of the affected runners through a rehabilitation program correlates with a successful return to running.

DESIGN: Case series.

SETTING: Stanford University Sports Medicine Clinics.

PARTICIPANTS: 24 distance runners with ITBS (14 female, 10 male) were randomly selected from patients presenting to our Runners' Injury Clinic with history and physical examination findings typical for ITBS. The control group of 30 distance runners (14 females, 16 males) were randomly selected from the Stanford University Cross-Country and Track teams.

MAIN OUTCOME MEASURES: Group differences in hip abductor strength, as measured by torque generated, were analyzed using separate two-tailed t-tests between the injured limb, non-injured limb, and the noninjured limbs of the control group. Prerehabilitation hip abductor torque for the injured runners was then compared with postrehabilitation torque after a 6-week rehabilitation program.

RESULTS: Hip abductor torque was measured with the Nicholas Manual Muscle Tester (kg), and normalized for differences in height and weight among subjects to units of percent body weight times height (%BWh). Average prerehabilitation hip abductor torque of the injured females was 7.82%BWh versus 9.82%BWh for their noninjured limb and 10.19%BWh for the control group of female runners. Average prerehabilitation hip abductor torque of the injured males was 6.86%BWh versus 8.62%BWh for their noninjured limb and 9.73%BWh for the control group of male runners. All prerehabilitation group differences were statistically significant at the p < 0.05 level. The injured runners were then enrolled in a 6-week standardized rehabilitation protocol with special attention directed to strengthening the gluteus medius. After rehabilitation, the females demonstrated an average increase in hip abductor torque of 34.9% in the injured limb, and the males an average increase of 51.4%. After 6 weeks of rehabilitation, 22 of 24 athletes were pain free with all exercises and able to return to running, and at 6-months follow-up there were no reports of recurrence.

CONCLUSIONS: Long distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners. Additionally, symptom improvement with a successful return to the preinjury training program parallels improvement in hip abductor strength.

文獻(xiàn)出處：Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000 Jul;10(3):169-75.

文獻(xiàn)4

關(guān)于學(xué)步后DDH患兒髖臼和股骨頸前傾的研究

譯者：任寧濤

使用CT對27名（17名女孩，10名男孩；年齡分布：18-48個月）學(xué)步后的DDH患兒（17名為雙側(cè)，10名為單側(cè)）的髖臼和股骨頸前傾的關(guān)系進(jìn)行定量分析，包括54個髖關(guān)節(jié)，其中25例完全脫位、19例半脫位和10例正常，在標(biāo)準(zhǔn)的骨盆片上測量CE角和AI，2維CT上測量髖臼和股骨頸的前傾，采用Ishida分型標(biāo)準(zhǔn)進(jìn)行髖關(guān)節(jié)脫位程度的診斷。研究結(jié)果發(fā)現(xiàn)3組患兒CE角、AI和髖臼前傾有統(tǒng)計(jì)學(xué)差異，3組股骨頸前傾角無統(tǒng)計(jì)學(xué)差異。正常髖關(guān)節(jié)髖臼前傾角為13.4±2.8度（平均值±SD），半脫位組為16.7±1.9度，完全脫位組為19.8±2.5度，3組之間具有統(tǒng)計(jì)學(xué)差異，各組髖臼前傾角值范圍廣泛（9-26度），脫位側(cè)髖臼前傾角增加，未見髖臼后傾。各組之間股骨頸前傾角無差異。因此學(xué)步后早期年齡的DDH患兒治療計(jì)劃中需要通過二維計(jì)算機(jī)斷層掃描確定髖臼和股骨頸的前傾角。

表1  10例正常髖關(guān)節(jié)和44例受影響髖關(guān)節(jié)CE角、AI、髖臼和股骨頸前傾角

表2  使用post hoc Tukey’s test對各組CE角、AI、髖臼和股骨頸前傾角進(jìn)行比較

表3  CE角、AI、髖臼和股骨頸前傾角之間的Pearson相關(guān)系數(shù)

圖1 AI與髖臼前傾角的相關(guān)性。

Anteversion of the acetabulum and femoral neck in early walking age patients with developmental dysplasia of the hip

Computed tomography measurements were made to quantify the relationship between the anteversion of the acetabulum and femoral neck in 27 early walking age patients (age range; 18-48 months) with developmental dysplasia of the hip. The centre-edge angle and acetabular index were measured in standard pelvis radiographs, and anteversion of acetabulum and femoral neck were measured by use of two-dimensional computed tomography in 25 complete dislocated, 19 subluxated and 10 unaffected hips (a total of 54 hips). The diagnosis of dysplasia, subluxation and complete dislocation of developmental hip dysplasia were determined radiographically using Ishida's criteria. There were statistically significant differences between the three groups for the centre-edge angle, the acetabular index, and acetabulumanteversion. There was no statistically significant difference between the three groups for femoral neck anteversion. The acetabular anteversion was found to be 13.4 /-2.8 degrees (mean /-SD) in unaffected hips, 16.7 /-1.9 degrees in subluxated hips and 19.8 /-2.5 degrees in complete dislocated hips. There was statistically significant difference between the three groups, with a wide range of acetabular anteversion values noted in all groups (9-26 degrees ). The acetabular anteversion was increased on the dislocated side in each patient and we found no retroverted acetabulum. On the other hand there was no significant difference between the groups with regards to femoral neckanteversion. We conclude that confirming anteversion of the acetabulum and the femoral neck by two-dimensional computed tomography is needed in treatment planning of early walking age patients with developmental hip dysplasia.

文獻(xiàn)出處：Sarban S, Ozturk A, Tabur H, Isikan UE. Anteversion of the acetabulum and femoral neck in early walking age patients with developmental dysplasia of the hip. J Pediatr Orthop B. 2005 Nov;14(6):410-4.

文獻(xiàn)5

懸崖征：髖關(guān)節(jié)不穩(wěn)的一項(xiàng)新影像學(xué)特征

譯者：張利強(qiáng)

背景：髖關(guān)節(jié)微不穩(wěn)定的術(shù)前診斷是具有挑戰(zhàn)性的。雖然有與微不穩(wěn)定相關(guān)的臨床查體和磁共振的描述，但對X線的描述卻很少。在微不穩(wěn)定的患者中，我們發(fā)現(xiàn)在股骨頭的外側(cè)邊緣可見一個很高發(fā)生率的快速下降區(qū)域，我們稱之為“懸崖征”。

目的：1）確定懸崖征和術(shù)中微不穩(wěn)定相關(guān)測量值之間的關(guān)系；2）確定這些測量值在觀察者之間的可靠性。

方法：對115例髖關(guān)節(jié)鏡手術(shù)患者進(jìn)行回顧性分析。排除有髖關(guān)節(jié)手術(shù)史、Legg- Calve-Perthes病、骨折、色素沉著絨毛結(jié)節(jié)性滑膜炎或滑膜軟骨瘤病的患者，結(jié)果納入96例患者。骨盆前后位片顯示股骨頭輪廓呈完美的圓圈。如果股骨頭外側(cè)沒有完全填滿完美的圓圈，這被認(rèn)為是懸崖征陽性。同時計(jì)算了與懸崖征相關(guān)的五項(xiàng)額外測量值。術(shù)中根據(jù)（1）牽開髖關(guān)節(jié)所需的牽引力，（2）初始牽引力釋放關(guān)節(jié)松弛后髖關(guān)節(jié)復(fù)位不足，或（3）術(shù)中與髖關(guān)節(jié)微不穩(wěn)定相一致的發(fā)現(xiàn)來診斷微不穩(wěn)定。用非配對t檢驗(yàn)和離散變量Fisher精確檢驗(yàn)對連續(xù)變量進(jìn)行分析。確定每次測量觀察者間的可靠性（n =3）。

結(jié)果：總的來說，89%（39/44）的有微不穩(wěn)定患者有懸崖征，而27%（14/52）沒有不穩(wěn)定的患者中有懸崖征（p<0.0001）。相反，74%有懸崖征的患者有微不穩(wěn)定，而只有12%沒有懸崖征的患者有不穩(wěn)定（p<0.0001）。在32歲以下有懸崖征的女性中，100%（20/20）被診斷為不穩(wěn)定。在5個額外的測量中沒有發(fā)現(xiàn)任何差異。觀察者間對于懸崖征的存在和懸崖角度的測量具有極好的可靠性。

結(jié)論：我們發(fā)現(xiàn)了一個與術(shù)中髖關(guān)節(jié)微不穩(wěn)定診斷相關(guān)的影像學(xué)表現(xiàn)，即懸崖征。其具有良好的觀察者間可靠性。結(jié)果顯示，100%有懸崖征的年輕女性術(shù)中發(fā)現(xiàn)微不穩(wěn)定。懸崖征對髖關(guān)節(jié)微不穩(wěn)的術(shù)前診斷有一定價值。

圖1.懸崖征。上排骨盆前后位片顯示股骨頭輪廓呈完美的圓圈。如果股骨頭外側(cè)沒有完全填滿完美的圓圈，這被認(rèn)為是懸崖征陽性。下排顯示了股骨頭外側(cè)完全填滿了完美的圓圈，被認(rèn)為是懸崖征陰性。

圖2.另外五個測量值：（a）懸崖角；（b）反向α角；（c）懸崖/股骨頸cobb角；（d）懸崖/股骨干cobb角；（e）懸崖長度/股骨頭直徑比。

圖3.微不穩(wěn)定患者的術(shù)中透視圖像。手動牽引髖關(guān)節(jié)（左）。在關(guān)節(jié)空氣造影后（中間），髖關(guān)節(jié)在牽引力釋放后仍然半脫位（右側(cè)）。

The Cliff Sign: A New Radiographic Sign of Hip Instability

Background: The preoperative diagnosis of hip microinstability is challenging. Although physical examination maneuvers and magnetic resonance imaging findings associated with microinstability have been described, there are limited reports of radio- graphic features. In patients with microinstability, we observed a high incidence of a steep drop-off on the lateral edge of the femoral head, which we have named the “cliff sign.”

Purpose: (1) To determine the relationship of the cliff sign and associated measurements with intraoperative microinstability and (2) to determine the interobserver reliability of these measurements.

Methods: A total of 115 consecutive patients who underwent hip arthroscopy were identified. Patients with prior hip surgery, Legg- Calve-Perthes disease, fractures, pigmented villonodular synovitis, or synovial chondromatosis were excluded, resulting in the inclusion of 96 patients in the study. A perfect circle around the femoral head was created on anteroposterior pelvis radiographs. If the lateral femoral head did not completely fill the perfect circle, it was considered a positive cliff sign. Five additional measurements relating to the cliff sign were calculated. The diagnosis of microinstability was made intraoperatively by the (1) amount of traction required to distract the hip, (2) lack of hip reduction after initial traction release following joint venting, or (3) intraoperative findings consistent with hip microinstability. Continuous variables were analyzed through use of unpaired t tests and discrete variables with Fisher exact tests. Interobserver reliability (n=3) was determined for each measurement.

Results: Overall, 89%(39/44) of patients with microinstability had a cliff sign, compared with  27% of patients (14/52) without instability (P<.0001). Conversely, 74% of patients with a cliff sign had microinstability, while only 12% of patients without a cliff sign had instability (P < .0001). In women younger than 32 years with a cliff sign, 100% (20/20) were diagnosed with instability. No differences were found in any of the 5 additional measurements. Excellent interobserver reliability was found for the presence of a cliff sign and the cliff angle measurement.

Conclusion: We have identified a radiographic finding, the cliff sign, that is associated with the intraoperative diagnosis of hip microinstability and has excellent interobserver reliability. Results showed that 100% of young women with a cliff sign had intraoperative microinstability. The cliff sign may be useful in the preoperative diagnosis of hip microinstability.

文獻(xiàn)出處：Packer J D , Cowan J B , Rebolledo B J , et al. The Cliff Sign: A New Radiographic Sign of Hip Instability[J]. Orthopaedic Journal of Sports Medicine, 2018, 6(11).

文獻(xiàn)6

原發(fā)性甲狀旁腺功能亢進(jìn)表現(xiàn)為股骨頭骨骺滑脫

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

一個15歲的男孩出現(xiàn)隱匿性雙側(cè)大腿活動性疼痛6個月。髖部檢查顯示內(nèi)旋受限。骨盆X線照片（圖1）顯示雙側(cè)股骨頭骨骺滑脫（SCFE），右下恥骨和髂骨軟骨下骨吸收。手部X線照片（圖2）顯示在中指骨橈側(cè)的骨膜下骨吸收。

考慮到非典型的（SCFE）放射學(xué)結(jié)果，我們?yōu)榛颊咦隽斯趋罊z查，顯示血清鈣12.3 mg/dL（正常8.5-10.5），磷2.3 mg/dL（正常2.5-5.0），堿性磷酸酶（ALP）832 IU/L（正常35–140）和甲狀旁腺激素（PTH）2512 pg/mL（正常10–65）。放射性核素掃描證實(shí)為右下甲狀旁腺腺瘤（圖3）。

最終診斷為患有原發(fā)性甲狀旁腺功能亢進(jìn)引起的慢性穩(wěn)定行SCFE。該患者接受了伽馬探針引導(dǎo)的右甲狀旁腺切除術(shù)。術(shù)后他出現(xiàn)了饑餓性骨骼綜合癥，予以靜脈注射及口服鈣劑治療。一個月后，他的骨骼輪廓恢復(fù)正常（鈣8.7 mg/dL，磷2.6 mg/dL，ALP 200 IU/L，PTH 15 pg/mL）。
確診后，他順利地進(jìn)行了雙側(cè)原位固定骨骺滑脫治療（圖4）。

SCFE是青少年常見的髖部疾患（1：10000）。伴有原發(fā)性甲狀旁腺功能亢進(jìn)的SCFE非常罕見，文獻(xiàn)共報(bào)道11例。骨膜下骨吸收和小梁變粗等放射學(xué)發(fā)現(xiàn)提示了這一點(diǎn)。血清PTH和放射性核素掃描有助于確定診斷。

如果未能及時確診甲狀旁腺功能亢進(jìn)癥，從全身和髖關(guān)節(jié)角度來看，患者的預(yù)后可能很差。在SCFE中，有非典型的影像學(xué)表現(xiàn)時，臨床醫(yī)生應(yīng)保持警惕，以完善進(jìn)一步檢查，因?yàn)榧谞钆韵俟δ芸哼M(jìn)癥的治療應(yīng)優(yōu)先于SCFE。

圖1. 骨盆前后位顯示整個骨骺位于SCFE診斷線（Klein線）下方。在正常髖關(guān)節(jié)中，三分之一的骨骺應(yīng)該在這條線以上。骨盆中骨小梁普遍變粗，可見沿髂骨（黑色箭頭）和恥骨下支（白色箭頭）的骨膜下骨吸收。SCFE，股骨頭骨骺滑脫。

圖2. 在手第四指中指骨的橈側(cè)緣上存在骨膜下骨吸收。這是甲狀旁腺功能亢進(jìn)癥的病理學(xué)特征。

圖3. 右下甲狀旁腺的攝取延遲提示甲狀旁腺腺瘤。

圖4. 雙側(cè)原位螺釘固定后的骨盆前后位影像學(xué)檢查結(jié)果。

Primary hyperparathyroidism presenting as slipped capital femoral epiphysis

A 15-year-old boy presented with insidious onset bilateral thigh pain for 6 months. Examination of hips showed restricted internal rotation. Pelvis radiograph (figure 1) showed bilateral slipped capital femoral epiphysis (SCFE) with subchondral bone resorption in right inferior pubic rami and ilium . Hand radiograph (figure 2) showed subperiosteal bone resorption along the radial aspect of middle phalanges.

In view of the atypical radiology, a bone profile was done which revealed serum calcium 12.3 mg/dL (normal 8.5–10.5), phosphorus 2.3 mg/dL (normal 2.5–5.0), alkaline phosphatase (ALP) 832 IU/L (normal 35–140) and parathormone (PTH) 2512 pg/mL (normal 10–65). Sestamibi scan confirmed a right inferior parathyroid adenoma (figure 3).

The final diagnosis was chronic stable SCFE1 with primary hyperparathyroidism. The patient underwent gamma probe guided right parathyroidectomy. Postoperatively he had an episode of hungry bone syndrome managed with intravenous followed by oral calcium. A month later, his bone profile normalised (calcium 8.7 mg/dL, phosphorus 2.6 mg/dL, ALP 200 IU/L, PTH 15 pg/mL).

He underwent bilateral in situ pinning for physis (figure 4) uneventfully. SCFE is a common hip pathology (1:10 000) in adolescents.2 SCFE with primary hyperparathyroidism is very rare with 11 cases3 described. Radiological findings like subperiosteal bone resorption and coarsened trabeculae suggest this. Serum PTH and sestamibi scans help in confirming the diagnosis.

If hyperparathyroidism is missed, patient is likely to have a poor outcome from a systemic and also hip standpoint. In SCFE, with atypical radiological findings like this case, the clinician should be vigilant to get further tests as hyperparathyroidism management takes precedence4 over SCFE.

文獻(xiàn)出處：Kumar G, Mathew V, Kandathil JC, Theruvil B. Primary hyperparathyroidism presenting as slipped capital femoral epiphysis. Postgrad Med J. 2019 Oct 15. pii: postgradmedj-2019-136811. doi: 10.1136/postgradmedj-2019-136811.

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