髋膝关节文献精译荟萃（第147期）
本期目录：
1、带股骨远端的全膝关节置换的长期效果
2、应用高交联聚乙烯髋关节假体治疗髋关节坏死可以获得长期假体生存率
3、同一患者后稳定型和超匹配型全膝关节置换术后关节感知度的自身比较
4、血液和关节液钙卫蛋白作为生物标志物诊断慢性髋、膝关节假体周围感染
5、超重和肥胖患者进行全髋和和全膝关节翻修术时使用阿司匹林预防静脉血栓栓塞是安全有效的
6、全髋关节置换术中矢状位脊柱畸形对髋臼前倾角的影响
7、髋关节发育不良骨盆畸形影响髋臼方向及覆盖
8、前垂直中心角是否等同于髋关节的前覆盖?
9、髋臼周围截骨术后髋臼和股骨的旋转方向可预测手术预后和骨关节炎进展
10、单侧髋关节脱位对侧髋关节出现发育不良：关于48名患者50年随访研究
11、反向髋臼周围截骨术治疗有症状的髋关节过度覆盖的早期疗效如何？
12、髋关节外科脱位和髋臼周围截骨术能改善Perthes病样畸形和髋臼发育不良患者的（髋部）疼痛吗？
第一部分：关节置换及保膝相关文献
文献1
带股骨远端的全膝关节置换的长期效果
译者：张轶超
背景：带有股骨远端（DFR）的全膝关节置换（TKA）是在初次和翻修术中的一种无奈的挽救性选择。尽管术后即刻就可以使假体固定确实并能早期负重，但缺乏TKA结合DFR的长期效果数据。本研究是为了确定在一批患者中TKA结合DFR手术假体的生存率，临床效果和放射学结果。
方法：我们研究了从2000年到2015年间在一个大学研究所医院完成的144例非肿瘤病因而行TKA结合DFR手术的病例。这批病例中有66例(46%)是由于股骨周围骨折 (n = 11) 或股骨假体周围骨折(n = 55)而行DFR手术的，40例 (28%)是由于假体周围感染而行阶段性翻修治疗的，28例 (19%)是无菌性松动，还有10例 (7%)是由于其它原因。28例(19%)采用多孔金属锥形袖套来加强股骨假体固定强度，38例 (26%)采用多孔金属锥形袖套来加强胫骨假体固定强度。通过观察累积翻修和再手术发生率（采用一个竞争风险模型），膝关节协会评分及影像学结果来确定手术效果。DFR手术时平均年龄为72岁，65%为女性。有111名没有翻修、死亡和随访丢失的病例获得平均5年（范围从2到13年）的随访。
结果：10年累积无菌松动翻修率，全因翻修率和再手术率分别为17.0%，27.5%和46.3%。相对于由于股骨远端或假体周围骨折而行DFR手术的病例，由于TKA无菌性松动 (危险比 [HR], 2.30; p = 0.026) 或假体周围感染(HR, 2.18; p = 0.022)而行DFR手术的再手术风险会更高。但是，根据最初手术原因来观察，各组间的无菌松动翻修风险和全因翻修风险无差异。平均膝关节协会评分从术前的45分增加到最终随访时的71分。根据影像学观察，有8例(7%)没有翻修的DFR病例中存在松动表现。最后随访时有7例行了膝上截肢，均是由于难以处理的假体周围感染。
结论：TKA 结合DFR有较高的10年翻修和再手术累积发生率，这是作为最后一种挽救性重建手术的一个选择。大部分患者通过这一终极翻修手术获得了临床功能的改善。
Long-Term Results of Total Knee Arthroplasty with Contemporary Distal Femoral Replacement
Background: Distal femoral replacement (DFR) is a salvage option for complex primary and revision total knee arthroplasty (TKA). Although excellent immediate fixation and weight-bearing are achieved, there is a paucity of data on long-term outcomes of TKA with DFR. The purpose of the present study was to determine implant survivorship, clinical outcomes, and radiographic results of TKAs with contemporary DFR components in a large series.
Methods: We identified 144 consecutive TKAs performed with DFR for non-oncologic indications from 2000 to 2015 at a single academic institution. Indications for the index DFR included 66 (46%) for native (n = 11) or periprosthetic (n = 55) femoral fracture, 40 (28%) for staged treatment of periprosthetic joint infection, 28 (19%) for aseptic TKA loosening, and 10 (7%) for other indications. Porous metal cones were used to augment femoral fixation in 28 patients (19%) and tibial fixation in 38 patients (26%). Outcomes included cumulative incidence of revision and reoperation (utilizing a competing risk model), Knee Society scores, and radiographic results. The mean age at the time of index DFR was 72 years, and 65% of patients were female. The mean follow-up was 5 years (range, 2 to 13 years) for the 111 patients who did not undergo revision, had not died, and were not lost to follow-up.
Results: The 10-year cumulative incidences of revision for aseptic loosening, all-cause revision, and any reoperation were 17.0%, 27.5%, and 46.3%, respectively. There was an increased risk of reoperation in patients who underwent index DFR for aseptic TKA loosening (hazard ratio [HR], 2.30; p = 0.026) or periprosthetic joint infection (HR, 2.18; p = 0.022) compared with periprosthetic or native femoral fractures. However, there was no difference in risk of revision for aseptic loosening or all-cause revision based on the original operative indication. The mean Knee Society score increased from 45 preoperatively to 71 at the time of the latest follow-up (p < 0.001). Radiographic loosening was observed in 8 unrevised DFRs (7%). There were 7 above-the-knee amputations performed at the time of the final follow-up, all for intractable periprosthetic joint infection.
Conclusions: TKAs with contemporary DFR had high 10-year cumulative incidences of both revision and reoperation, underscoring the salvage nature of this procedure as a final reconstructive option. Most patients experienced substantial clinical improvements with this end-stage revision procedure.
文献出处：Wyles CC, Tibbo ME, Yuan BJ, Trousdale RT, Berry DJ, Abdel MP. Long-Term Results of Total Knee Arthroplasty with Contemporary Distal Femoral Replacement. J Bone Joint Surg Am. 2020 Jan 2;102(1):45-51. doi: 10.2106/JBJS.19.00489. PMID: 31596808.
文献2
应用高交联聚乙烯髋关节假体治疗
髋关节坏死可以获得长期假体生存率
译者：马云青
背景: 髋关节股骨头坏死占全髋关节置换术(THAs)病因的3%-12%。与接受全髋关节置换的骨关节炎患者相比，因股骨头坏死而接受全髋关节置换的患者通常更年轻，并伴有更多的基础病，临床结果和假体生存率也较低。本研究的目的是比较股骨头坏死患者和骨关节炎患者的长期假体生存率(中位数随访10年)、术后功能和影像学结果。
方法: 研究对象为1999年至2007年，在作者所在医院登记的应用高交联聚乙烯内衬的初次人工全髋关节置换术患者，根据年龄、性别和体重指数(BMI)，使诊断股骨头坏死的患者与骨关节炎的患者相匹配为1:1。最终461髋417例股骨头坏死患者和461髋427例骨关节炎患者纳入研究(平均年龄59岁，47%为女性，平均BMI29kg/m)。比较两组患者假体长期生存率、患者自述临床结果和术后影像学结果。此外，对股骨头坏死组进行了亚组分析，以观察某些潜在的病因是否预示了术后不良结果。
结果: 股骨头坏死组和骨关节炎组15年累计翻修率分别为6.6% 和4.5% (危险率[HR]=1.8，p=0.09)。股骨头坏死组和骨关节炎组15年累计再手术率分别为10.5%和6.4%(HR=2.2，p=0.008)。在整个队列中没有假体松动或骨溶解的影像学表现。尽管股骨头坏死患者术前Harris髋关节评分的中位数较低，但术后两组患者的评分都有明显改善，术后各时间点两组的评分相似。其中股骨头坏死组内术后15年再次手术率，放射导致骨坏死亚组为0%，酒精性骨坏死亚组为6.3%，创伤后骨坏死亚组为9.0%，激素性骨坏死亚组为12.1%，特发性骨坏死亚组为25% 。
结论: 全髋关节置换术中应用高交联聚乙内衬可以为股骨头坏死患者提供良好的长期假体存活率和术后功能，但与骨关节炎患者相比，再次手术的风险更高。
Long-Term Survivorship of Total Hip Arthroplasty with Highly Cross-Linked Polyethylene for Osteonecrosis
Background: Osteonecrosis of the hip is the underlying etiology for 3% to 12% of total hip arthroplasties (THAs). Compared with patients who undergo THA because of osteoarthritis, those who do so because of osteonecrosis typically are younger, have a greater number of underlying diagnoses, and have inferior clinical outcomes and implant survivorship. The purpose of this study was to compare the long-term implant survivorship (median follow-up, 10 years), functional outcomes, and radiographic results of contemporary THAs with a highly cross-linked polyethylene (HXLPE) liner between patients with osteonecrosis and those with osteoarthritis.
Methods: All patients who underwent primary THA with an HXLPE liner from 1999 to 2007 were identified from our institutional total joint registry. Patients with a primary diagnosis of osteonecrosis were matched 1:1, on the basis of age, sex, and body mass index (BMI), to patients with a diagnosis of osteoarthritis. This resulted in 461 hips in 413 patients with osteonecrosis matched to 461 hips in 427 patients with osteoarthritis (mean age, 59 years; 47% female; and mean BMI, 29 kg/m). Long-term implant survivorship, patient-reported outcomes, and radiographic findings were compared. In addition, a subgroup analysis of the osteonecrosis group was performed to see whether certain underlying etiologies portended poor outcomes. The median follow-up was 10 years.
Results: The 15-year cumulative rates of revision were 6.6% and 4.5% in the osteonecrosis and osteoarthritis groups, respectively (hazard ratio [HR] = 1.8, p = 0.09). The 15-year cumulative rates of any reoperation were 10.5% and 6.4% in the osteonecrosis and osteoarthritis groups, respectively (HR = 2.2, p = 0.008). There were no radiographic signs of component loosening or osteolysis in the entire cohort. Despite a lower median preoperative Harris hip score (HHS) for patients with osteonecrosis, both groups had marked improvements in their scores, which were similar at all time points after surgery. The cumulative rate of reoperations at 15 years was 0% for hips with radiation-induced osteonecrosis, 6.3% for those with alcohol-induced osteonecrosis, 9.0% for those with posttraumatic osteonecrosis, 12.1% for those with steroid-induced osteonecrosis, and 25% for those with idiopathic osteonecrosis.
Conclusions: Contemporary THA with an HXLPE liner offers excellent long-term implant survivorship and functional outcomes for patients with osteonecrosis; however, the risk of a reoperation is higher when compared with patients with osteoarthritis.
文献出处：Hart A, Janz V, Trousdale RT, Sierra RJ, Berry DJ, Abdel MP. Long-Term Survivorship of Total Hip Arthroplasty with Highly Cross-Linked Polyethylene for Osteonecrosis. J Bone Joint Surg Am. 2019 Sep 4;101(17):1563-1568. doi: 10.2106/JBJS.18.01218. PMID: 31483399.
文献3
同一患者后稳定型和超匹配型全膝关节置换术后
关节感知度的自身比较
译者：张蔷
背景：后稳定型和超匹配型是后交叉韧带替代型全膝关节置换（TKA）假体中最常见的两种类型。文献中缺乏比较超匹配型和后稳定型TKA术后关节感知度差异的相关资料。本篇文章的目的是比较同一患者后稳定型和超匹配型全膝关节置换术后关节稳定性、功能和关节感知度的差异，以明确假体设计产生的影响。
方法：这一项前瞻性、随机对照试验包含50例单日双侧全膝关节置换手术病例，一侧应用Persona（Zimmer Biomet）后稳定型假体（后稳定组），另一侧应用超匹配型假体（超匹配组）。在术后2年随访时，我们评估了患者膝关节稳定性、功能和关节感知度。关节稳定性检测包括静息状态下膝关节前后稳定性和股骨后滚。关节功能使用KSS评分和WOMAC评分评价。关节感知度则由关节异响、左右侧倾向、满意度和遗忘关节评分来评价。
后稳定型假体的冠状位松弛度（位移）
超匹配型假体的冠状位松弛度（位移）
后稳定型和超匹配型股骨假体后滚对比（极度屈曲侧位测量垫片最深处到股骨假体与垫片接触位点的垂直距离）
结果：超匹配组的膝关节前后稳定性较后稳定组更差（4.5mm VS. 1.8mm；p<0.001）而股骨后滚更小（4.2mm VS. 9.0mm；p<0.001）。KSS评分和WOMAC评分组间没有显著性差异（p>0.05）。尽管在关节异响方面，超匹配组明显表现更好（18% VS. 38%），但在左右侧倾向性、满意度或遗忘关节评分方面组间均无显著性差异（p>0.05）。
结论：两组在术后两年随访时关节感知度相似，差异在于超匹配假体在关节异响方面表现更佳，矢状位更为松弛且股骨后滚更少。
Comparison of Joint Perception Between Posterior-Stabilized and Ultracongruent Total Knee Arthroplasty in the Same Patient
Background: Posterior-stabilized and ultracongruent designs are 2 common examples of posterior cruciate ligament-substituting total knee arthroplasty (TKA) prostheses. There is a lack of evidence regarding joint perception differences between ultracongruent and posterior-stabilized TKA. The purpose of this study was to compare the postoperative knee stability, function, and joint perception between ultracongruent and posterior-stabilized TKA in the same patients in order to determine whether there was a difference based on design.
Methods: This prospective, randomized controlled trial included 50 patients who underwent same-day bilateral TKA utilizing Persona (Zimmer Biomet) posterior-stabilized implants in 1 knee (posterior-stabilized group) and ultracongruent implants in the other knee (ultracongruent group). At 2 years postoperatively, patients were evaluated for knee stability, function, and joint perception. Postoperative static knee anteroposterior stability and femoral rollback were compared. Knee function was evaluated with use of the Knee Society Score and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Joint perception was compared by evaluating noise generation, side preference, satisfaction, and the Forgotten Joint Score.
Results: The ultracongruent group had more knee anteroposterior laxity (4.5 mm compared with 1.8 mm in the posterior-stabilized group; p < 0.001) and less femoral rollback (4.2 mm compared with 9.0 mm in the posterior-stabilized group; p < 0.001). Knee Society Score and WOMAC scores were not significantly different between groups (all p > 0.05). Although the ultracongruent group showed less noise generation than the posterior-stabilized group (18% compared with 38%, respectively; p = 0.026), there were no differences in side preference, satisfaction, or Forgotten Joint Score (all p > 0.05).
Conclusions: Both groups had similar joint perception 2 years postoperatively, with obvious differences in noise generation and more sagittal laxity with less femoral rollback in the ultracongruent group.
文献出处：Kim MS, Koh IJ, Kim CK, Choi KY, Jeon JH, In Y. Comparison of Joint Perception Between Posterior-Stabilized and Ultracongruent Total Knee Arthroplasty in the Same Patient. J Bone Joint Surg Am. 2021 Jan 6;103(1):44-52. doi: 10.2106/JBJS.20.00279. PMID: 33259430.
文献4
血液和关节液钙卫蛋白作为生物标志物诊断
慢性髋、膝关节假体周围感染
译者：李睿
目的：钙卫蛋白（CLP）在中性粒细胞和单核细胞中产生，并由于炎症或感染而释放到体液中。这项研究的目的是评估血液和关节液CLP在慢性关节假体周围感染（PJI）诊断中的效能。
方法：前瞻性收集195例行髋、膝关节初次置换或翻修术患者的血液和关节液。患者分为五组：1）由于特发性骨关节炎（OA；n = 60）而进行的初次全髋和膝关节置换术；2）因植入物的无菌性失败而进行的髋、膝关节翻修术（AR-TJR；n = 40）；3）确诊为慢性PJI等待手术的患者（n = 45）；4）使用占位器完成了PJI第一阶段治疗的患者，并且准备进行假体再植入手术（SR-TJR；n = 25），以及5）类风湿性关节炎患者接受了初次全髋和膝关节置换术（ RA；n = 25）。使用免疫比浊法定量测定血液和关节液中的CLP浓度。此外，还检测了血液和关节液CRP，血液白介素6（IL-6）和ESR，以及白细胞酯酶（LE）试纸。
结果：在血液样本中，PJI患者的CLP浓度高于无菌翻修的患者。PJI中位数为2.14 mg / l（四分位间距（IQR）1.37至3.56），而AR-TJR为0.66 mg / l（IQR 0.3至0.83）；p < 0.001。在关节液中，PJI组中位数为20.46 mg / l（IQR 14.3至22.36），而AR-TJR组为0.7 mg / l（IQR 0.41至0.95）; p <0.001。对于血液样本，当阈值取1.0 mg / l时， CLP的敏感性，特异性，阳性预测值和阴性预测值分别为93.3％，87.5％，89.4％和92.1％。对于关节液，阈值取1.5 mg / l时，其分别为95.6％，95％，95.5％和95％。
结论：这项小型研究表明，关节液和血液CLP是慢性PJI诊断中有用的标志物，其敏感性和特异性与常规使用的标志物（例如CRP，ESR，IL-6和LE）相似或更高。然而CLP对于区分PJI患者和类风湿关节炎没有帮助。
Blood and synovial fluid calprotectin as biomarkers to diagnose chronic hip and knee periprosthetic joint infections
Aims: Calprotectin (CLP) is produced in neutrophils and monocytes and released into body fluids as a result of inflammation or infection. The aim of this study was to evaluate the utility of blood and synovial CLP in the diagnosis of chronic periprosthetic joint infection (PJI).
Methods: Blood and synovial fluid samples were collected prospectively from 195 patients undergoing primary or revision hip and knee arthroplasty. Patients were divided into five groups: 1) primary total hip and knee arthroplasty performed due to idiopathic osteoarthritis (OA; n = 60); 2) revision hip and knee arthroplasty performed due to aseptic failure of the implant (AR-TJR; n = 40); 3) patients with a confirmed diagnosis of chronic PJI awaiting surgery (n = 45); 4) patients who have finished the first stage of the PJI treatment with the use of cemented spacer and were qualified for replantation procedure (SR-TJR; n = 25), and 5) patients with rheumatoid arthritis undergoing primary total hip and knee arthroplasty (RA; n = 25). CLP concentrations were measured quantitatively in the blood and synovial fluid using an immunoturbidimetric assay. Additionally, blood and synovial CRP, blood interleukin-6 (IL-6), and ESR were measured, and a leucocyte esterase (LE) strip test was performed.
Results: Patients with PJI had higher CLP concentrations than those undergoing aseptic revision in blood (median PJI 2.14 mg/l (interquartile range (IQR) 1.37 to 3.56) vs AR-TJR 0.66 mg/l (IQR 0.3 to 0.83); p < 0.001) and synovial fluid samples (median PJI 20.46 mg/l (IQR 14.3 to 22.36) vs AR-TJR 0.7 mg/l (IQR 0.41 to 0.95); p < 0.001). With a cut-off value of 1.0 mg/l, blood CLP showed a sensitivity, specificity, positive predictive value, and negative predictive value of 93.3%, 87.5%, 89.4%, and 92.1%, respectively. For synovial fluid with a cut-off value of 1.5 mg/l, these were 95.6%, 95%, 95.5%, and 95%, respectively.
Conclusion: This small study suggests that synovial and blood CLP are useful markers in chronic PJI diagnosis with similar or higher sensitivity and specificity than routinely used markers such as CRP, ESR, IL-6, and LE. CLP was not useful to differentiate patients with PJI from those with rheumatoid arthritis.
文献出处：Grzelecki D, Walczak P, Szostek M, Grajek A, Rak S, Kowalczewski J. Blood and synovial fluid calprotectin as biomarkers to diagnose chronic hip and knee periprosthetic joint infections. Bone Joint J. 2021 Jan;103-B(1):46-55. doi: 10.1302/0301-620X.103B1.BJJ-2020-0953.R1. PMID: 33380202.
文献5
超重和肥胖患者进行全髋和和全膝关节翻修术时
使用阿司匹林预防静脉血栓栓塞是安全有效的
译者：沈松坡
背景: 静脉血栓栓塞(VTE)，定义为肺栓塞或深静脉血栓形成，是全髋关节翻修术(RTHA)和全膝关节翻修术(RTKA)后罕见但严重的并发症。先前的研究表明，肥胖可能与肺栓塞、伤口并发症和感染的风险增加有关。由于目前没有普遍的静脉血栓栓塞预防护理标准，我们试图确定应用阿司匹林(ASA)对接受RTHA/RTKA的肥胖患者是否安全有效。
方法: 回顾性分析1578例连续RTHA/RTKA病例(751例RTHA和827例RTKA)，确定患者使用325 mg ASA（2017年9月之前）或81 mg ASA（2017年9月之后）。收集术后90天的静脉血栓栓塞率、出血、伤口并发症、深部感染和死亡率。根据体重指数(BMI)对队列进行分层:正常(18-24.9 kg/m2)、超重(25-29.9 kg/m2)、肥胖(30-34.9 kg/m2)、重度肥胖(35-39.9 kg/m2)、病态肥胖(≥40 kg/m2)。
结果: 该队列包括335名BMI正常患者，511名超重患者，408名肥胖患者，232名重度肥胖患者，92名病态肥胖患者。总VTE率在BMI组之间无统计学差异(0.90% vs 0.78% vs 0.74% vs 0.43% vs 0%， P =0.89)。各组间出血 (0.90% vs 0% vs 0% vs 0.43%比0%,P =0.08),伤口并发症(0.30% vs 0.20% vs 0.25% vs 0%比0%,P =0.93)、感染(1.49% vs 1.57% vs 0.98% vs 1.29%比1.09%,P =0.66)或死亡率(0% vs 0.20% vs 0% vs 0%比0%,P =0.72)均无统计学差异
结论：ASA预防肥胖患者静脉血栓栓塞是安全有效的，且并发症发生率与非肥胖患者行RTHA/RTKA手术相似。
Aspirin Use for Venous Thromboembolism Prevention Is Safe and Effective in Overweight and Obese Patients Undergoing Revision Total Hip and Knee Arthroplasty
Background: Venous thromboembolism (VTE), defined as pulmonary embolism or deep venous thrombosis, is a rare but serious complication following revision total hip arthroplasty (RTHA) and revision total knee arthroplasty (RTKA). Previous studies show that obesity may be associated with an increased risk for pulmonary embolism, wound complications, and infection. With no current universal standard of care for VTE prophylaxis, we sought to determine whether aspirin prescribed (ASA) is safe and effective in obese patients undergoing RTHA/RTKA.
Methods: A retrospective review of 1578 consecutive RTHA/RTKA cases (751 RTHAs and 827 RTKAs) was conducted identifying patients prescribed 325 or 81 mg ASA. Ninety-day postoperative VTE rates, bleeding, wound complications, deep infections, and mortality were collected. Cohorts were stratified according to body mass index (BMI): normal (18-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2), severely obese (35-39.9 kg/m2), and morbidly obese (≥40 kg/m2).
Results: The cohort comprised of 335 patients with a normal BMI, 511 were overweight, 408 obese, 232 severely obese, and 92 morbidly obese. Total VTE rates were statistically similar between BMI groups (0.90% vs 0.78% vs 0.74% vs 0.43% vs 0%, P = .89). There were no differences in bleeding rates (0.90% vs 0% vs 0% vs 0.43% vs 0%, P = .08), wound complications (0.30% vs 0.20% vs 0.25% vs 0% vs 0%, P = .93), infection (1.49% vs 1.57% vs 0.98% vs 1.29% vs 1.09%, P = .66), or mortality (0% vs 0.20% vs 0% vs 0% vs 0%, P = .72).
Conclusion: ASA is safe and effective for VTE prevention in obese patients with similar complication rates to nonobese patients undergoing RTHA/RTKA.
文献出处：Tang A, Sicat CS, Singh V, Rozell JC, Schwarzkopf R, Long WJ. Aspirin Use for Venous Thromboembolism Prevention Is Safe and Effective in Overweight and Obese Patients Undergoing Revision Total Hip and Knee Arthroplasty. J Arthroplasty. 2020 Dec 11:S0883-5403(20)31245-6. doi: 10.1016/j.arth.2020.12.006. Epub ahead of print. PMID: 33376036.
文献6
全髋关节置换术中矢状位脊柱畸形对髋臼前倾角的影响
译者：张峻
腰骶椎和骨盆之间的相互作用与位置变化动态相关，并可能因并存的病理而复杂化。本文总结了目前文献中关于矢状位脊柱畸形对全髋关节置换术（THA）中骨盆和髋臼方向的影响，并为脊柱病理或长时间脊柱融合患者的髋臼假体放置提供了建议。根据脊柱的柔韧性和矢状面平衡，术前可将患者分为四类。以这些信息为指导，髋臼假体的放置可以根据脊柱畸形的类型和意义进行优化。
图1. a站立和b坐位时骨盆参数的图示。无论站位还是坐位，骨盆入射角（PI）保持不变，与体位的变化无关。在坐位时，骨盆倾斜角（PT）增加，相应地骶骨倾斜角（SS）减小，髋臼前倾角（AA）增加。
图2. a站立和b坐位时灵活/平衡脊柱状态下骨盆倾斜角（PT）和髋臼前倾角（AA）的图示。在坐位时PT和AA增加。由于弹性脊柱的代偿能力，髋关节屈曲和伸直时发生髋关节撞击的可能性很低
图3. a站立和b坐位时僵硬/平衡脊柱状态下骨盆倾斜角（PT）和髋臼前倾角（AA）的图示。站立时，AA与灵活/平衡脊柱状态下相似，髋关节屈曲和伸直时髋关节撞击的可能性很低。在坐位时，由于脊柱融合到骶骨，PT或AA没有代偿性变化；由于AA没有增加，因此极度髋关节屈曲时髋关节前部撞击的可能性增加（*坐位时髋关节屈曲时可能撞击）
图4. a站立和b坐位时灵活/不平衡的脊柱状态下骨盆倾斜角（PT）和髋臼前倾角（AA）的图示。站立位置，腰椎后凸度增加，与灵活/平衡的脊柱相比PT和AA代偿性增加，与弹性/平衡的脊柱相比，髋关节最大伸直时髋关节后撞击的可能性增加。根据脊柱的柔韧性和畸形程度，有不同的位置变化代偿（*站立时伸直髋关节，后方可能撞击）。
图5. a站立和b坐位时僵硬/不平衡的脊柱状态下骨盆倾斜（角PT）和髋臼前倾角（AA）的图示。在站立姿势下，随着腰椎后凸度的增加，与灵活/平衡的脊柱相比PT和AA代偿性增加。站立位髋关节最大伸直时髋关节后方撞击的可能性增加。因为脊柱融合到骶骨，坐位时PT或AA没有代偿性变化（*站立髋关节伸直时可能发生撞击）。
The influence of sagittal spinal deformity on anteversion of the acetabular component in total hip arthroplasty
The interaction between the lumbosacral spine and the pelvis is dynamically related to positional change, and may be complicated by co-existing pathology. This review summarises the current literature examining the effect of sagittal spinal deformity on pelvic and acetabular orientation during total hip arthroplasty (THA) and provides recommendations to aid in placement of the acetabular component for patients with co-existing spinal pathology or long spinal fusions. Pre-operatively, patients can be divided into four categories based on the flexibility and sagittal balance of the spine. Using this information as a guide, placement of the acetabular component can be optimal based on the type and significance of co-existing spinal deformity.
文献出处：Phan D, Bederman SS, Schwarzkopf R. The influence of sagittal spinal deformity on anteversion of the acetabular component in total hip arthroplasty. Bone Joint J. 2015 Aug;97-B(8):1017-23. doi: 10.1302/0301-620X.97B8.35700. PMID: 26224815.
第二部分：保髋相关文献
文献1
髋关节发育不良骨盆畸形影响髋臼方向及覆盖
翻译：罗殿中
背景：虽然已经有大量的关于DDH骨盆畸形的报告，但DDH骨盆测量指标尚不明确，且指标与髋臼之间的关系也不明了。
问题和目的：我们设想，骨盆的无名骨是否存在旋转畸形，是否与髋臼的前后倾角、髋臼覆盖率相关？
患者和方法：我们对50例（82髋）DDH患者进行CT扫描来测量骨盆形态的指标，另外40例正常人作为对照，在三个轴线方向测定无名骨的旋转程度。髋臼的切线角（ASA）作为髋臼覆盖股骨头的指标；我们计算出其与无名骨旋转角度、髋臼朝向、及其与髋臼覆盖率之间的关系。
结果：我们发现在DDH患者中，骨盆无名骨内旋程度较正常人更多。无名骨向内旋转程度与增大的髋臼前倾角、髋臼外展角密切相关。在髋臼后倾的病例中（82髋中9例，11.0%）均存在无名骨外旋。无名骨内旋也与髋臼前覆盖、髋臼外侧覆盖减少密切相关。
结论：我们观察到DDH骨盆存在整体的结构性畸形，髋臼形态异常不仅仅受髋关节局部发育不良的影响，也受到骨盆整体形态的影响。
图1. A-C 计算机重建后影像上显示无名骨旋转角度。参考点髂前上棘（ASIS）、髂前下棘（AIIS）分别位于髂骨嵴的最前端。（A）上部髂骨翼外展角（SIA）是由ASIS内缘至骶髂关节前缘连线、与轴位断层的水平线之间形成的夹角；（B）下部髂骨翼外展角（IIA）是由AIIS前端至髂骨后缘连线、与轴位断层的水平线之间形成的夹角；（C）坐骨耻骨角（IPA）是由耻骨联合的前上缘至坐骨棘连线、与轴位断层的矢状线之间形成的夹角，先将坐骨棘和耻骨联合从上到下投射到一个层面上。
图2. A-C （A）髋臼前倾角（AcAV）在经过股骨头中心的轴位断层上，髋臼前后缘连线与矢状线的夹角；（B）髋臼外展角（AI）在胫骨股骨头中心的冠状断层上，髋臼外上缘至髋臼内下缘连线与水平线之间的夹角；（C）髋臼上部前倾角（CA）在髋臼顶下方5mm的轴位断层上，髋臼前后缘连线与矢状线的夹角。
图3. 髋臼切线角（ASA）是指在三维立体空间中，股骨头中心到髋臼连线与水平线的夹角，该角度包括前部角、上部角、和后部角。
表2
表4.
Pelvic deformity influences acetabular version and coverage in hip dysplasia
Background: Although a wide variety of acetabular deformities in developmental dysplasia of the hip (DDH) have been reported, the morphologic features of the entire pelvis in DDH are not well characterized and their correlation with acetabular deformity is unknown.
Questions/purposes: We determined whether there was a rotational deformity of the entire innominate bone, and if so, whether it related to acetabular version and coverage.
Patients and methods: We examined the morphologic features of the pelvis using CT for 50 patients with DDH (82 hips). Forty normal hips were used as controls. The innominate rotation angle was determined at three levels in the axial plane. The acetabular sector angle served as an indicator of acetabular coverage of the femoral head. We evaluated the association between innominate rotation angles and acetabular version and coverage.
Results: We observed greater internal rotation of the innominate bone in patients with DDH than in the control subjects. Internal rotation of the innominate bone was associated with increased acetabular anteversion angle and acetabular inclination angle. In hips with acetabular retroversion (nine of 82 hips; 11.0 %), the entire innominate bone was externally rotated, compared with hips with acetabular anteversion. Internal rotation of the innominate bone also was associated with decreased anterior and superior acetabular coverage.
Conclusion: Our observations suggest structural abnormalities exist throughout the pelvis in DDH, and the morphologic abnormalities of the acetabulum are not caused solely by local dysplasia around the hip, but are influenced by the morphologic features of the entire pelvis.
文献出处：Fujii M, Nakashima Y, Sato T, Akiyama M, Iwamoto Y. Pelvic deformity influences acetabular version and coverage in hip dysplasia. Clin Orthop Relat Res. 2011 Jun;469(6):1735-42. doi: 10.1007/s11999-010-1746-1. Epub 2011 Jan 4. PMID: 21203874; PMCID: PMC3094603.
文献2
前垂直中心角是否等同于髋关节的前覆盖?
译者：程徽
本研究测量了没有骨关节炎改变的100个髋关节，观察髋关节假斜位片上测量的前垂直中心角(VCA) 是否能代表真正的髋关节前覆盖。
图1 真正的髋关节前覆盖（前CE角），由坐标系的Y轴和经过股骨头中点C点和髋臼边缘与矢状面交点的连线构成。A正常髋关节 B发育不良的髋关节
在骨盆坐标系矢状面前上测量真正的髋臼前覆盖角。用CT数据生成数码投射重建片，用两种方法测量VCA角：VCA-1角将前点定义为髋臼骨质的最前面侧；而VCA-2角将前点定义为髋臼软骨下骨的硬化硬化带的最前侧。
图2 在数码投射重建片上测量VCA角，A1点定义为髋臼骨质的最前面侧；A2点定义为髋臼软骨下骨的硬化硬化带的最前侧。
在正常髋关节中，VCA-1与前覆盖角基本一致(r = 0.88, Spearman rank检验)，而VCA-2往往小于前覆盖(r = 0.72)。在发育不良的髋关节中，VCA-1角远远大于前覆盖(r = 0.002)，而VCA-2角与前覆盖(r = 0.64)的一致性也不佳。
对于正常的髋关节，VCA-1角代表真正的前覆盖；而发育不良髋关节的VCA角并不能准确的代表真正髋臼前覆盖。所以在发育不良髋关节中使用VCA角应当谨慎。
Is vertical-center-anterior angle equivalent to anterior coverage of the hip?
We investigated whether the vertical-center-anterior (VCA) angle measured on the false-profile view of the hip represents true anterior coverage by computer simulation using three-dimensional (3-D) computed tomography (CT) in 100 hips without osteoarthritic changes. True anterior coverage angle on the sagittal plane was measured in the pelvic coordinate system. Two types of VCA angle were measured on the digital reconstructed radiographs: the anterior point of the VCA angle was defined as the foremost aspect of the acetabulum, denoted VCA-1, whereas the anterior edge of the dense shadow of the subchondral bone of the acetabulum was defined as VCA-2. In the normal hips, VCA-1 was consistent with anterior coverage angle (r = 0.88, Spearman rank test), whereas VCA-2 underestimated the anterior coverage (r = 0.72). In the dysplastic hips, VCA-2 did not always indicate true anterior coverage (r = 0.64), whereas VCA-1 overestimated the anterior coverage (r = 0.002). Although VCA-1 in normal hips shows true anterior coverage, the VCA angle does not indicate true anterior coverage in dysplastic hips, and VCA angle measurement in dysplastic hips should be used carefully.
文献出处：Takashi Sakai, Takashi Nishii, Kazuomi Sugamoto, Hideki Yoshikawa, Nobuhiko Sugano. Is vertical-center-anterior angle equivalent to anterior coverage of the hip? Comparative Study Clin Orthop Relat Res. 2009 Nov;467(11):2865-71. doi: 10.1007/s11999-009-0802-1. Epub 2009 Mar 26.
文献3
髋臼周围截骨术后髋臼和股骨的旋转方向
可预测手术预后和骨关节炎进展
译者：肖凯
背景：髋臼周围截骨术是治疗髋关节发育不良的有效方法。手术的预后受髋臼骨块的最佳位置、股骨头的形态、甚至股骨扭转角或联合前倾角的影响。为了明确髋臼骨块的最佳位置，我们在患者术后中期随访中评估了髋臼的旋转和股骨的形态，并分析了与术后功能预后及骨关节炎进展的关系。
方法：对49例接受髋臼周围截骨术的患者（66髋）进行了在62.2±18.6个月的随访。手术时患者的平均年龄为26.7±9.6岁，其中40名（82％）为女性。所有患者均进行了骨盆正位X线片和各序列的MRI检查，进而评估髋臼前倾角、股骨头覆盖、α角、股骨扭转角和联合前倾角。分别在股骨头中心、股骨头中心下方0.5 cm、股骨头中心上方0.5 cm和1 cm处测量髋臼前倾角，此外还测量了7个改良的髋臼扇形角。在股骨颈斜视序列上进行股骨扭转角的测量。同时我们也计算了联合前倾角。应用术前及术后WOMAC评分以及术后牛津髋关节评分和总体治疗预后评估患者的功能情况。
结果：髋臼周围截骨术后在股骨头中心层面髋臼前倾角（31.4±9.6°）增加，在髋臼前方3点位置股骨头前覆盖（34.7±15.4°）减少，并且两指标均与骨关节炎的进展显着相关，但与功能预后无关。髋臼和股骨联合前倾角对骨关节炎的进展或临床预后没有影响。
结论：髋臼周围截骨术后的长期结果取决于髋臼骨块在三个平面上的位置关系。预后良好的前提除了要有良好的外侧覆盖，还要保证水平面上力线良好且没有因髋臼后倾导致的医源性撞击，股骨头前部覆盖正常也是重要的因素。
Acetabular- and femoral orientation after periacetabular osteotomy as a predictor for outcome and osteoarthritis
Background: Periacetabular osteotomy is a successful treatment for hip dysplasia. The results are influenced, however, by optimal positioning of the acetabular fragment, femoral head morphology and maybe even femoral version as well as combined anteversion have an impact. In order to obtain better insight on fragment placement, postoperative acetabular orientation and femoral morphology were evaluated in a midterm follow-up in regard to functional outcome and osteoarthritis progression.
Methods: A follow-up examination with 49 prospectively documented patients (66 hips) after periacetabular osteotomy (PAO) was performed after 62.2 ± 18.6 months. Mean age of patients undergoing surgery was 26.7 ± 9.6 years, 40 (82%) of these patients were female. All patients were evaluated with an a.p. pelvic x-ray and an isotropic MRI in order to assess acetabular version, femoral head cover, alpha angle, femoral torsion and combined anteversion. The acetabular version was measured at the femoral head center as well as 0.5 cm below and 0.5 and 1 cm above the femoral head center and in addition seven modified acetabular sector angles were determined. Femoral torsion was assessed in an oblique view of the femoral neck. The combined acetabular and femoral version was calculated as well. To evaluate the clinical outcome the pre- and postoperative WOMAC score as well as postoperative Oxford Hip Score and Global Treatment Outcome were analyzed.
Results: After PAO acetabular version at the femoral head center (31.4 ± 9.6°) was increased, the anterior cover at the 15 o'clock position (34.7 ± 15.4°) was reduced and both correlated significantly with progression of osteoarthritis, although not with the functional outcome. Combined acetabular and femoral torsion had no influence on the progression of osteoarthritis or outcome scores.
Conclusion: Long-term results after PAO are dependent on good positioning of the acetabular fragment in all 3 planes. Next to a good lateral coverage a balanced horizontal alignment without iatrogenic pincer impingement due to acetabular retroversion, or insufficient coverage of the anterior femoral head is important.
文献出处：Goronzy J, Franken L, Hartmann A, Thielemann F, Blum S, Günther KP, Nowotny J, Postler A. Acetabular- and femoral orientation after periacetabular osteotomy as a predictor for outcome and osteoarthritis. BMC Musculoskelet Disord. 2020 Dec 26;21(1):846. doi: 10.1186/s12891-020-03878-y. PMID: 33357245; PMCID: PMC7764525.
文献4
单侧髋关节脱位对侧髋关节出现发育不良：
关于48名患者50年随访研究
译者：任宁涛
本文旨在研究单侧髋关节脱位，“健侧”出现发育不良的发生率，并对此类髋关节的远期预后进行评估。选取1958年-1962年之间就诊患儿，总共纳入48名（40名女孩，8名男孩）晚期单侧DDH患儿，早期进行皮肤牵引，闭合复位，早期治疗年龄平均为17.8个月（4-65个月），只有1例进行切开复位。25名患儿在复位后3年内需进行“健侧”股骨去旋转手术，10名患儿进行了再次骨盆手术治疗。对他们幼时和成年后的片子进行回顾，最后拍片子年龄平均为50.9岁（43-55岁），8名（17%）患者出现“健侧”髋关节发育不良，幼时或成年后CE角< 20°，其中6名进行了再次手术以改善股骨头覆盖，4名行股骨内翻截骨，2名行造盖手术，发育不良均改善。在后期随访，2名患者出现发育不良加重呈现半脱位（CE 角分别为 4° 和 5°），均发展成OA，其中1名在49岁时行全髋置换。总之，“健侧”髋关节的长期预后相对较好，因为平均随访50年，只有2例髋关节发生OA（4%）。“健侧”髋关节需定期复查，当出现半脱位趋势或半脱位时需进行手术治疗。
图1 女性，a 生后14个月时，b 13岁时，c 51岁时。
图2 女性，a 生后19个月时，b 22岁时行内翻去旋转手术，c 54岁时，行全髋置换。
Dysplasia of the contralateral hip in patients with unilateral late-detected congenital dislocation of the hip 50 years' follow-up of 48 patients
The aim of this study was to investigate the incidence of dysplasia in the 'normal' contralateral hip in patients with unilateral developmental dislocation of the hip (DDH) and to evaluate the long-term prognosis of such hips. A total of 48 patients (40 girls and eight boys) were treated for late-detected unilateral DDH between 1958 and 1962. After preliminary skin traction, closed reduction was achieved at a mean age of 17.8 months (4 to 65) in all except one patient who needed open reduction. In 25 patients early derotation femoral osteotomy of the contralateral hip had been undertaken within three years of reduction, and later surgery in ten patients. Radiographs taken during childhood and adulthood were reviewed. The mean age of the patients was 50.9 years (43 to 55) at the time of the latest radiological review. In all, eight patients (17%) developed dysplasia of the contralateral hip, defined as a centre-edge (CE) angle < 20° during childhood or at skeletal maturity. Six of these patients underwent surgery to improve cover of the femoral head; the dysplasia improved in two after varus femoral osteotomy and in two after an acetabular shelf operation. During long-term follow-up the dysplasia deteriorated to subluxation in two patients (CE angles 4° and 5°, respectively) who both developed osteoarthritis (OA), and one of these underwent total hip replacement at the age of 49 years. In conclusion, the long-term prognosis for the contralateral hip was relatively good, as OA occurred in only two hips (4%) at a mean follow-up of 50 years. Regular review of the 'normal' side is indicated, and corrective surgery should be undertaken in those who develop subluxation.
文献出处：T Terjesen. Dysplasia of the contralateral hip in patients with unilateral late-detected congenital dislocation of the hip 50 years' follow-up of 48 patients. Bone Joint J . 2014 Sep;96-B(9):1161-6.
文献5
反向髋臼周围截骨术治疗有症状的髋关节
过度覆盖的早期疗效如何？
译者：张利强
背景：髋臼过度覆盖与钳夹型股骨髋臼撞击（FAI）有关。髋臼过度覆盖的一种亚型是由髋臼顶呈负倾斜为表现的髋臼过深引起的。在这种情况下，髋臼重新旋转可能是一种更好的选择，而不是行髋臼边缘修整以减少股骨头覆盖。我们在2003年介绍了真正的反向髋臼周围截骨术（PAO），与正向的PAO相比，它也使髋臼相对于髂骨旋转和外移，以减少股骨头的前外侧覆盖，纠正髋臼顶的过度倾斜。据我们所知，未发现真正的反向PAO的临床结果评估的文献。
问题/目的：对于一组接受反向PAO的患者：（1）接受反向PAO的患者是否表现出疼痛、功能和髋关节活动度的短期改善，以及由外侧、前侧中心边缘角和Tönnis角所定义的髋臼覆盖率的下降，（2）是否有可识别的因素与再次手术、转为全髋关节置换术或患者报告的不良结局评分有关？（3） 是否有可识别的因素与早期并发症有关？
方法：2003年至2017年，两位术者对37例患者进行49髋反向PAO。25例为单侧反向PAO，12例为分次、双侧反向PAO。为了确保每个髋关节是一个独立的数据点进行统计分析，我们只选择包括在我们的系列中双侧患者的先行手术侧的髋关节。在研究期间，我们的手术适应证是有症状的髋臼外侧和前侧过度覆盖导致FAI，且对以前的保守治疗或手术治疗无效。回顾性研究包括37例患者的37髋，平均年龄18岁（12~41岁；四分位间距16~21岁），随访时间至少2年（平均6年；范围2~17年）。34例患者完成了问卷调查，24例患者有影像学评估，23例患者接受了髋关节活动度临床检查。然而，有7名患者在超过5年的时间里没有出现。回顾性研究了37名接受反向PAO治疗患者的37髋的术前和术后临床和放射学参数。不良结果为术后至少2年转为THA或WOMAC疼痛评分大于10分。使用配对t检验或McNemar检验（视情况而定）对术前和末次随访的患者报告结果、影像学测量和髋关节活动度进行评估。线性回归分析用于评估与临床结果相关的可识别因素。Logistic回归分析用于评估与不良结局和手术并发症相关的可识别因素。所有的检验都是双侧的，p<0.05认为是显著的。
结果：反向PAO术后至少2年的随访中，患者的WOMAC疼痛（-7 [95% CI -9至 -5]；p<0.001）、僵硬（-2 [95% CI -3至-1]；p<0.001）、功能评分（-18 [95% CI -24至-12]；p<0.001）和改良Harris髋关节评分（mHHS）（20 [95% CI 13至27]；p<0.001）均提高。术后髋关节活内旋平均增加8°（[95% CI 2°~14°]；p=0.007）。髋臼覆盖度，LCEA减少-8°（95% CI -12°-5°；p<0.001），ACEA减少-12°（95% CI -15°至-9°；p<0.001），Tönnis角较少9°（95% CI 6°至13°；p<0.001）。术后影像学关节炎的严重程度与WOMAC功能评分较差相关，平均每增加一个Tönnis分级，WOMAC功能评分增加12分（95% CI 2至22；p=0.03）。术后Tönnis分级越高，mHHS越差，平均每增加一个Tönnis分级，mHHS降低12分（95% CI -20至-4；p=0.008）。术后前撞击试验阳性与随访时mHHS评分下降相关，mHHS平均下降23分（95% CI -34至-12；p=0.001）。19%（7/37）的髋关节有手术相关的并发症。在末次随访中，有4髋出现了不良结果，其中两个患者随后接受了全髋关节置换术，两个患者的WOMAC疼痛评分大于10。我们没有发现与并发症或不良结果相关的因素。
结论：与其他手术治疗方法相比，反向PAO治疗钳夹型FAI早期临床和影像学结果良好，提示反向PAO治疗因髋臼过度覆盖引起的钳夹型FAI是一种有前途的治疗方法。然而，这是一项技术复杂的手术，需要熟悉标准PAO的外科医生进行大量培训和准备，并且必须仔细地向患者介绍，交代潜在的风险和益处。未来的研究需要进一步完善适应证和确定反向PAO的长期疗效。
插图显示了反向PAO的手术技术。（A） 坐骨、耻骨上支和髂骨的截骨是按常规方式进行的。（B） 后柱截骨呈弧形与前方的坐骨截骨相连。（C） 线5是在完整的髂骨上做的一个小截骨，用于后面截骨的稳定。线6是一种髂骨成形术，在向内侧凸起的髂前下棘和髂骨前缘进行，以减少对股神经血管的压力。（D） 撑开器放置在髂骨和后柱间以帮助髋臼的游离。（E） 利用Ganz骨刀向远端和外侧截断坐骨。（F） 骨盆内侧利用反向Hohmann牵开器的下钝尖向前外侧推压髋臼截骨块的前下缘，有助于完成坐骨截骨的移位。（G）使用Schanz钉、T柄和Weber持骨器控制髋臼骨块将其相对于髂骨进行屈曲、外展和内旋。（H）另一个视图显示髋臼骨块进行了内旋。（I） 对髂骨向内侧凸起的成形术可减少术后髂腰肌和股神经血管的压力。（J） 采用多枚螺钉固定。髂骨成形术中取出的骨可作为自体骨移植，以填补截骨术中的任何间隙。（K） 髋臼截骨块的最终位置显示髋臼相对于髂骨的内旋和外展。
What Are the Early Outcomes of True Reverse Periacetabular Osteotomy for Symptomatic Hip Overcoverage?
Background: Acetabular overcoverage is associated with pincer-type femoroacetabular impingement (FAI). A subtype of acetabular overcoverage is caused by a deep acetabulum with a negatively tilted acetabular roof, in which acetabular reorientation may be a preferable alternative to rim trimming to uncover the femoral head. We introduced the true reverse periacetabular osteotomy (PAO) in 2003, which in contrast to an anteverting PAO, also flexes and abducts the acetabulum relative to the intact ilium to decrease anterior and lateral femoral head coverage and correct negative tilt of the acetabular roof. To our knowledge, the clinical results of the true reverse PAO have not been evaluated.
Questions/purposes: For a group of patients who underwent reverse PAO, (1) Do patients undergoing reverse PAO demonstrate short-term improvement in pain, function, and hip ROM, and decreased acetabular coverage, as defined by lateral and anterior center-edge angle and Tönnis angle? (2) Are there identifiable factors associated with success or adverse outcomes of reverse PAO as defined by reoperation, conversion to THA, or poor patient- reported outcome scores? (3) Are there identifiable factors associated with early complications?
Methods: Between 2003 and 2017, two surgeons carried out 49 reverse PAOs in 37 patients. Twenty-five patients had unilateral reverse PAO and 12 patients had staged, bilateral reverse PAOs. To ensure that each hip was an independent data point for statistical analysis, we chose to include in our series only the first hip in the patients who had bilateral reverse PAOs. During the study period, our general indications for this operation were symptomatic lateral and anterior acetabular overcoverage causing FAI that had failed to respond to previous conservative or surgical treatment. Thirty-seven hips in 37 patients with a median (range) age of 18 years (12 to 41; interquartile range 16 to 21) were included in this retrospective study at a minimum follow-up of 2 years (median 6 years; range 2 to 17). Thirty-four patients completed questionnaires, 24 patients had radiographic evaluation, and 23 patients received hip ROM clinical examination. However, seven patients had not been seen in more than 5 years. The clinical and radiographic parameters of all 37 hips that underwent reverse PAO in 37 patients from a longitudinally maintained institutional database were retrospectively studied preoperatively and postoperatively. Adverse outcomes were considered conversion to THA or a WOMAC pain score greater than 10 at least 2 years postoperatively. Patient-reported outcomes, radiographic measurements, and hip ROM were evaluated preoperatively and at most recent follow-up using a paired t-test or McNemar test, as appropriate. Linear regression analysis was used to assess for identifiable factors associated with clinical outcomes. Logistic regression analysis was used to assess for identifiable factors associated with adverse outcomes and surgical complications. All tests were two-sided, and p values less than 0.05 were considered significant.
Results: At a minimum of 2 years after reverse PAO, patients experienced improvement in WOMAC pain (-7 [95% CI -9 to -5]; p < 0.001), stiffness (-2 [95% CI -3 to -1]; p < 0.001), and function scores (-18 [95% CI -24 to -12]; p < 0.001) and modified Harris Hip Score (mHHS) (20 [95% CI 13 to 27]; p < 0.001). The mean postoperative hip ROM improved in internal rotation (8° [95% CI 2° to 14°]; p = 0.007). Acetabular coverage, as defined by lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), and Tönnis angle, improved by -8° (95% CI -12° to -5°; p < 0.001) for LCEA, -12° (95% CI -15° to -9°; p < 0.001) for ACEA, and 9° (95% CI 6° to 13°; p < 0.001) for Tönnis angle. The postoperative severity of radiographic arthritis was associated with worse WOMAC function scores such that for each postoperative Tönnis grade, WOMAC function score increased by 12 points (95% CI 2 to 22; p = 0.03). A greater postoperative Tönnis grade was also correlated with worse mHHS, with an average decrease of 12 points (95% CI -20 to -4; p = 0.008) in mHHS for each additional Tönnis grade. Presence of a positive postoperative anterior impingement test was associated with a decrease in mHHS score at follow-up, with an average 23-point decrease in mHHS (95% CI -34 to -12; p = 0.001). Nineteen percent (7 of 37) of hips had surgery-related complications. Four hips experienced adverse outcomes at final follow-up, with two patients undergoing subsequent THA and two with a WOMAC pain score greater than 10. We found no factors associated with complications or adverse outcomes.
Conclusion: The early clinical and radiographic results of true reverse PAO compare favorably to other surgical treatments for pincer FAI, suggesting that reverse PAO is a promising treatment for cases of pincer FAI caused by global acetabular overcoverage. However, it is a technically complex procedure that requires substantial training and preparation by a surgeon who is already familiar with standard PAO, and it must be carefully presented to patients with discussion of the potential risks and benefits. Future studies are needed to further refine the indications and to determine the long-term outcomes of reverse PAO.
文献出处：Pun SY, Hosseinzadeh S, Dastjerdi R, Millis MB. What Are the Early Outcomes of True Reverse Periacetabular Osteotomy for Symptomatic Hip Overcoverage? Clin Orthop Relat Res. 2020 Dec 17;Publish Ahead of Print. doi: 10.1097/CORR. 0000000000001549. Epub ahead of print. PMID: 33296152.
文献6
髋关节外科脱位和髋臼周围截骨术能改善Perthes病样
畸形和髋臼发育不良患者的（髋部）疼痛吗？
译者：陶可（北京大学人民医院骨关节科）
背景：有症状的残留Perthes病样畸形的患者可能会出现结构异常，包括大的非球行形股骨头，股骨颈短而宽，大转子高位和髋臼发育不良。有时，并发症状性股骨髋臼撞击（FAI）综合征（股骨近端畸形）和结构不稳定（髋臼发育不良）会进一步影响髋关节（功能）。
问题/目的：因此，我们采用髋关节外科脱位和髋臼周围截骨术（PAO）联合治疗Perthes病样髋部畸形，试图探究：（1）术中发现；（2）影像学矫正；（3）早期患者报告的疗效、并发症和失败（病例）。
方法：我们在2006年11月至2010年8月之间进行了694例髋关节保髋手术。其中46例具有残留的Perthes病样髋关节畸形，定义为与残留的Perthes病一致的近端畸形，并且有Perthes病史或小儿髋关节发育不良的治疗史。在这些患者中，我们报告了16例患者（16髋）残留的Perthes病样髋关节畸形并伴有髋臼发育不良（结构不稳定，定义为髋臼发育不良的影像学证据，术中证实为不稳定）。对这16例患者进行了联合髋关节外科脱位治疗以全面解决关节内和关节外来源的FAI，同时，采用PAO以解决髋关节结构不稳定的问题，并在至少24个月的随访（中位数为40个月；范围为24-78个月）。该系列患者均无失访。10名患者的髋关节曾接受过外科手术治疗，其中6例曾接受过截骨术。术中发现是从标准化的预期收集的术中数据收集表中提取的。用既定的方法（外侧中心边缘角，前中心边缘角，髋臼倾斜度，股骨头旋转中心到大转子尖端间距）评估影像学矫正结果，并用改良的Harris髋关节评分（mHHS）及术前记录数据来评估患者并发症和随访数据（临床效果）。
结果：髋臼盂唇软骨异常包括所有患者的髋关节盂唇肥大，其中有13位患者的髋关节盂唇和/或关节软骨病变需要治疗，这也证实了影像学矫正分析一致的结果。在40个月的中位随访中，术前mHHS的中位数从64增至92（p <0.001）。14位患者（14髋）的临床效果良好或优异。根据mHHS小于70（n = 1）或转换为全髋关节置换术（n = 1），将2位患者（2髋）分类为（保髋治疗）失败。
结论：髋关节外科脱位和PAO联合手术可纠正伴有髋臼发育不良的Perthes样髋关节畸形。早期临床结果表明该技术是安全有效的。需要进行长期研究，以确定长期结果的改善是否与综合畸形矫正相关。
图A-D，显示了一位17岁持续性右髋症状的女孩的Perthes样髋关节畸形，采用髋臼周围截骨术联合外科脱位术进行矫正。术前AP为位骨盆X线片（裁剪图）（A）显示股骨近端呈Perthes样畸形，股骨头非球形，股骨颈宽大和大转子高位。继发性髋臼发育不良伴后倾。蛙式位相（B）强调了股骨头和宽的非球形股骨头。术后1年拍摄的术后X线片（AP位骨盆，裁剪图像[C]和蛙式位[D]）显示出优秀的骨骼畸形的矫正。我们采用了髋关节外科脱位，股骨头重塑，股骨颈相对延长，股骨大转子下移。在动态检查期间，在手术时髋关节被判断为不稳定，并接受了髋关节外科脱位和PAO的联合治疗。在最近2年的随访中，该患者的HHS为92，具有优秀的疗效。
Does surgical hip dislocation and periacetabular osteotomy improve pain in patients with Perthes-like deformities and acetabular dysplasia?
Background: Patients with symptomatic residual Perthes-like deformities may present with a combination of structural abnormalities including a large aspheric femoral head, short and wide femoral neck, high greater trochanter, and acetabular dysplasia. Sometimes, the hip is further compromised by concurrent symptomatic femoroacetabular impingement (FAI) (proximal femoral deformities) and structural instability (acetabular dysplasia).
Questions/purposes: We therefore sought to characterize (1) the intraoperative findings; (2) radiographic correction; and (3) early patient-reported outcomes, complications, and failures of treating complex Perthes-like hip deformities with combined surgical dislocation and periacetabular osteotomy (PAO).
Methods: We performed 694 hip preservation procedures between November 2006 and August 2010. Of these, 46 had residual Perthes-like hip deformities, defined as proximal deformity consistent with residual Perthes and a history of Perthes disease or treatment of pediatric hip dysplasia. Of these, we report on 16 patients (16 hips) with residual Perthes-like hip deformities and associated acetabular dysplasia (structural instability, defined as radiographic evidence of acetabular dysplasia with intraoperative confirmation of instability). These 16 patients were treated with a combined surgical hip dislocation to comprehensively address intraarticular and extraarticular sources of FAI and PAO to address structural instability and were analyzed at a minimum 24-month followup (median, 40 months; range, 24-78 months). No patients in this series were lost to followup. Ten patients' hips had previous surgical treatment, including six with previous osteotomy. Operative findings were extracted from standardized prospectively collected intraoperative data collection forms. Radiographic correction was evaluated with established methods (lateral center-edge angle, anterior center-edge angle, acetabular inclination, center-to-trochanter distance) and clinical outcomes were measured with the modified Harris hip score (mHHS) as well as by prospectively recorded data on patient complications and followup.
Results: Acetabular labrochondral abnormalities included labral hypertrophy in all hips and labral and/or articular cartilage lesions requiring treatment in 13 hips. Radiographic analysis demonstrated consistent radiographic correction. The median preoperative mHHS improved from 64 to 92 at a median followup of 40 months (p < 0.001). Fourteen patients (14 hips) had a good or excellent clinical result. Two patients (two hips) were classified as failures based on mHHS less than 70 (n = 1) or conversion to total hip arthroplasty (n = 1).
Conclusions: Combined surgical hip dislocation and PAO provides major deformity correction in Perthes-like hip deformities with associated acetabular dysplasia. Early clinical results suggest this technique is safe and effective. Long-term studies are needed to determine if improved long-term outcomes are associated with comprehensive deformity correction.
文献出处：John C Clohisy, Jeffrey J Nepple, James R Ross, Gail Pashos, Perry L Schoenecker. Does surgical hip dislocation and periacetabular osteotomy improve pain in patients with Perthes-like deformities and acetabular dysplasia? Clin Orthop Relat Res. 2015 Apr;473(4):1370-7.
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