髋膝关节文献精译荟萃（第181期）
本期目录：
1、TKA是否行髌骨置换：来自澳大利亚骨科学会关节置换登记系统长达17年的效果评价
2、站立位骨盆X线片上骨盆旋转和倾斜对判断髋臼杯角度的影响
3、糖尿病与非糖尿病患者关节置换术后血糖升高的对照研究：血糖管理计划的影响
4、全关节初次置换和翻修术后哪些患者仍在接受输血?
5、CT在膝关节炎和置换术治疗中的作用
6、注射性臀肌挛缩反Ober征及其外科处理
7、计算机导航引导髋臼偏心旋转截骨术治疗髋臼髋关节发育不良合并骶髂融合和髋臼后倾导致的股骨髋臼撞击：1例病例报告
8、Kinesio肌效贴布治疗男性自体腘绳肌或同种异体前交叉韧带重建术后早期髋部肌肉无力的短期疗效
9、单侧股骨骨骺滑脱后对侧滑脱与髋臼后倾有关，与深髋臼及股骨头过度覆盖无关
10、髋关节发育不良生物力学缺陷
11、骨盆倾斜对髋臼应力分布的影响：有限元分析
12、2018年美国华盛顿大学：分类简述：股骨头骨折的Pipkin分类
13、髋关节:纤维胶原蛋白与兔的发育和衰老有关
14、用客观的肢体表现评估髋关节发育不良相关的失能情况
第一部分：关节置换及保膝相关文献
文献1
TKA是否行髌骨置换：来自澳大利亚骨科学会
关节置换登记系统长达17年的效果评价
译者：张轶超
背景：近40多年全膝置换术（TKA）是否需要做髌骨置换的问题一直都存在着争议。尽管登记数据显示出了越来越多的证据，但是否置换还是要看医生的偏好和曾经接受的训练来决定。本研究的目的是提供给大家一个TKA手术中髌骨置换与否的长期效果。
方法：研究数据来源于澳大利亚骨科学会关节置换登记系统（1999-2017年）。纳入了570，735例因膝关节骨关节炎行初次TKA手术的患者。采用危害比和17年的累积翻修率来对比4组的翻修率：低稳定型假体（MS）伴髌骨置换组、后稳定型假体（PS）伴髌骨置换组、低稳定型假体不伴髌骨置换组、后稳定型假体不伴髌骨置换组。另外还分析了嵌入型和覆盖型两种不同髌骨假体类型的效果。
结果：对于所有的初次TKA，相比行了髌骨置换的患者，未置换髌骨组的翻修率高 (HR, 1.31; 可信区间, 1.28- 1.35; P << span=''>0 .001)。17年时PS髌骨未置换组具有最高的累积翻修率(11.1%)，顺次为MS髌骨未置换组（8.8%），PS髌骨置换组（7.9%）和MS髌骨置换组（7.1%）。嵌入型髌骨假体的翻修率较覆盖型髌骨假体高(HR, 1.27;可信区间, 1.17-1.37; P << span=''>0 .001)。
结论：无论时MS型还是PS型假体，髌骨置换均可以降低其翻修率。覆盖型髌骨的翻修率低于嵌入型髌骨假体。
The Outcome of Total Knee Arthroplasty With and Without Patellar Resurfacing up to 17 Years: A Report From the Australian Orthopaedic Association National Joint Replacement Registry
Background: Patellar resurfacing in total knee arthroplasty (TKA) remains a controversial issue after more than 4 decades of TKA. Despite a growing body of evidence from registry data, resurfacing is still based largely on a surgeon’s preference and training. The purpose of this study is to provide long-term outcomes for patellar resurfaced compared to when the patella is not resurfaced.
Methods: Data from the Australian Orthopaedic Association National Joint Replacement Registry (1999- 2017) were used for this study. The analysis included 570,735 primary TKAs undertaken for osteoarthritis. Hazard ratios (HRs) and 17-year cumulative percent revision rates were used to compare revision rates between 4 subgroups: minimally stabilized (MS) patellar resurfacing, posterior stabilized (PS) patellar resurfacing, MS unresurfaced, and PS unresurfaced patella. Additional analyses of the patellar implant type and a comparison of inlay and onlay patellar resurfacing were also performed.
Results: For all primary TKA, procedures where the patella was not resurfaced have a higher rate of revision compared to procedures where the patella was resurfaced (HR, 1.31; confifidence interval, 1.28- 1.35; P < .001). Unresurfaced PS knees have the highest cumulative percent revision at 17 years (11.1%), followed by MS unresurfaced (8.8%), PS resurfaced (7.9%), and MS resurfaced (7.1%). Inlay patellar resurfacing has a higher rate of revision compared to onlay patellar resurfacing (HR, 1.27; confifidence interval, 1.17-1.37; P < .001).
Conclusion: Resurfacing the patella reduces the rate of revision for both MS and PS knees. MS knees with patellar resurfacing have the lowest rate of revision. Onlay patella designs are associated with a lower revision rate compared to inlay patella designs.
文献出处：Coory JA, Tan KG, Whitehouse SL, Hatton A, Graves SE, Crawford RW. The Outcome of Total Knee Arthroplasty With and Without Patellar Resurfacing up to 17 Years: A Report From the Australian Orthopaedic Association National Joint Replacement Registry. J Arthroplasty. 2020 Jan;35(1):132-138. doi: 10.1016/j.arth.2019.08.007. Epub 2019 Aug 12. PMID: 31477541.
文献2
站立位骨盆X线片上骨盆旋转和倾斜
对判断髋臼杯角度的影响
译者：马云青
背景: 不同患者骨盆正位X线片(AP)上的骨盆倾斜和旋转有很大的可变性，这可能影响髋臼假体方向的测量。本研究的目的是分析骨盆倾斜和旋转对髋臼杯角度影像学测量的影响。
方法: 本研究共纳入53例(63髋)患者。这些患者在术前和术后大约3个月进行了骨盆站立正位X线片和CT检查。作者使用二维/三维匹配的方法测量骨盆倾斜和旋转，以及非标准化和标准化（经APP平面矫正过）的髋臼假体角度。
结果: 患者骨盆倾斜度和旋转度在术前和术后影像学资料上比较无差异。只有在34/63(54%)的髋关节的非标准化前倾角与标准化前倾角之间出现了5 °以内的差异。骨盆倾斜与非标准化和标准化前倾角的差异相关，但这种差异与骨盆旋转不相关。当63例髋关节被分为左右两侧时，骨盆旋转对骨盆倾斜导致的非标准化和标准化的髋臼前倾角的差异在右侧髋臼假体前倾角呈反相关，而与左侧假体前倾角呈正相关。
结论: 骨盆倾斜和骨盆旋转对站立位AP片的髋臼前倾角测量有显著影响。对骨盆定位的进一步了解可能最终允许对特定患者安放所需位置的杯位，从而尽可能减少与臼杯位置不良相关的并发症。
Effect of pelvic tilt and rotation on cup orientation in standing anteroposterior radiographs
Background: Individual pelvic tilt and rotation have wide variability that can affect the measurement of cup orientation in anteroposterior (AP) radiographs. The purpose of this study was to analyse the effect of pelvic tilt and rotation on radiographic measurements of cup orientation.
Methods: A total of 53 patients (63 hips) were included in this study. The patients underwent a computed tomography study with standing AP pelvis radiographs taken both preoperatively and approximately 3 months postoperatively. We used 2-dimensional/3-dimensional matching to measure the pelvic tilt and rotation, and the non-standardised and standardised cup orientation.
Results: There was no difference in the pelvic tilt and rotation between the preoperative and postoperative radiographs. The distribution of the differences between the non-standardised and standardised cup anteversion exhibited a change within 5° in only 34/63 (54%) hips. The pelvic tilt correlated with the difference between the non-standardised and standardised cup anteversion, but the pelvic rotation did not. When all 63 hips were separated into the right and left sides, the pelvic rotation inversely correlated with the pelvic tilt-adjusted difference between the non-standardised and standardised cup anteversion of the right side but directly correlated with that of the left side.
Conclusions: The current study demonstrated that the measurement of cup anteversion in standing AP radiographs is significantly affected by both the pelvic tilt and pelvic rotation. An improved understanding of the pelvic orientation may eventually allow for desired cup positioning on a patient-specific basis to potentially reduce complications associated with the malposition of the cup.
文献出处：Yun HH, Murphy WS, Ward DM, Zheng G, Hayden B, Murphy SB. Effect of pelvic tilt and rotation on cup orientation in standing anteroposterior radiographs. Hip Int. 2020 Jan;30(1):48-55. doi: 10.1177/1120700019831665. Epub 2019 Mar 5. PMID: 30834795.
文献3
糖尿病与非糖尿病患者关节置换术后
血糖升高的对照研究：血糖管理计划的影响
译者：张蔷
背景：与糖尿病患者相比，术后血糖升高对非糖尿病患者术后疗效的影响更大，而对非糖尿病患者的降糖治疗是否安全有效目前并没有明确定论。我们假设：对关节置换术后非糖尿病患者出现术后血糖升高（血糖≥180mg/dL）时应用按比例增减的胰岛素治疗可以降低术后平均血糖水平，并将术后早期并发症风险降到最低。
方法：在这项前瞻性研究中，入组的1398例伴或不伴糖尿病的关节置换连续病例均在术后因血糖升高而接受治疗，而对照组为886例血糖监测并不频繁的回顾性病例。首要研究指标是术后48小时内的评价血糖水平。两项次要研究指标只能在前瞻性研究组记录，而前瞻性研究组比回顾性对照组的血糖监测明显更加频繁。第一项次要研究指标为应用多元回归方程研究合并症和手术因素对非糖尿病患者关节置换术后血糖升高的影响。第二项次要研究指标为胰岛素治疗是否能够降低非糖尿病患者关节置换术后的并发症风险。
结果：与886例回顾性对照组相比，对非糖尿病患者应用血糖管理计划后平均血糖水平（和标准差）从129±28mg/dL显著降低至123±23mg/dL（p=0.041）。应用多元回归方程显示与非糖尿病患者术后平均血糖水平升高相关的因素包括：术前快速血糖值（p<0.001< span=''>），围术期应用激素（p<0.001< span=''>），全麻（p<0.001< span=''>），手术时间（p=0.003）和输血（p=0.008）。968例非糖尿病患者中，203例术后出现血糖升高。血糖管理计划中的标准胰岛素治疗被应用于129例患者，另外的74例由于各种原因并未接受标准的胰岛素治疗。与未接受胰岛素治疗的患者相比，接受胰岛素治疗的患者任意部位培养阳性的概率和出现阳性培养并再入院的概率显著更低。接受胰岛素治疗的非糖尿病患者术后均未出现血糖轻度或显著升高的情况。
结论：非糖尿病患者在关节置换术后出现血糖升高较为常见，应用改进的血糖管理计划可以降低术后平均血糖水平。对非糖尿病患者关节置换术后应用标准胰岛素治疗可以降低早期并发症率，并减少相关不良反应。
Postoperative Hyperglycemia in Patients with and without Diabetes After Major Joint Replacement: The Impact of an Enhanced Glucose Management Program
Background: Perioperative hyperglycemia can have an even more detrimental effect on postoperative outcomes in patients without diabetes than in patients with diabetes, but it has not been established if the treatment of patients without diabetes is safe and effective. We hypothesized that sliding-scale insulin for severe postoperative hyperglycemia (glucose ≥180 mg/dL) could lower mean postoperative glucose levels and minimize short-term complications in patients without diabetes undergoing major joint replacement.
Methods: In a prospective study group, 1,398 consecutive patients, with and without diabetes, undergoing joint replacement were monitored and treated for hyperglycemia and were compared with 886 historical, less frequently monitored controls. The primary outcome was the mean glucose level in patients with and without diabetes within 48 hours after the surgical procedure. Two secondary outcomes could be examined only in the prospective study group, which, by design, had much more frequent glucose sampling and insulin use than the historical controls. First, the contribution of comorbidities and procedural factors to postoperative hyperglycemia in patients without diabetes was assessed with multivariable linear regression. Second, the ability of insulin treatment to reduce complications in patients without diabetes who developed hyperglycemia was evaluated.
Results: In comparison with 886 historical controls, enhanced glucose management lowered the mean glucose (and standard deviation) from 129 ± 28 mg/dL to 123 ± 23 mg/dL for patients without diabetes (p = 0.041). Multivariable linear regression revealed factors that contributed to elevated mean glucose in patients without diabetes: preoperative fasting glucose (p < 0.001), perioperative steroid use (p < 0.001), general anesthesia (p < 0.001), procedure duration (p = 0.003), and transfusion (p 0.008). Of 968 patients without diabetes, 203 developed severe hyperglycemia. The recommended insulin coverage was given to 129 of these patients, and 74 patients did not receive it for various clinical reasons. Insulin treatment reduced the frequency of positive cultures from any site (p = 0.025) and a composite of positive cultures and readmissions (p = 0.006) in comparison with no insulin treatment. No patient without diabetes who received insulin experienced mild or severe hypoglycemia.
Conclusions: Postoperative hyperglycemia is frequent in patients without diabetes after orthopaedic surgery, but an enhanced glucose management program can lower mean postoperative glucose levels. The treatment of hyperglycemia in patients without diabetes reduced short-term complications and was associated with minimal side effects.
文献出处：Mannion JD, Rather A, Manifold S, Gardner K, McEvilly M, Yaeger J, Siegelman G. Postoperative Hyperglycemia in Patients with and without Diabetes After Major Joint Replacement: The Impact of an Enhanced Glucose Management Program. JB JS Open Access. 2021 Aug 16;6(3):e20.00172. doi: 10.2106/JBJS.OA.20.00172. PMID: 34414343; PMCID: PMC8367068.
文献4
全关节初次置换和翻修术后哪些患者仍在接受输血?
译者：沈松坡
背景：由于多种原因，初次和翻修全髋、全膝关节置换术(全髋关节初次置换术[pTHA]、全髋关节翻修术[rTHA]、全膝关节初次置换术[pTKA]和全膝关节翻修术[rTKA])后的输血率一直在下降。本研究的目的是评估输血率是否持续下降，并评估与输血相关的患者因素。
方法：根据美国外科医师学会国家手术质量改进计划(American College of Surgeons National Surgical Quality Improvement Program)，确定2011年至2019年间接受pTHA、pTKA、rTHA和rTKA手术的患者。排除了接受双侧手术的患者，及因骨折、感染或肿瘤而接受关节置换的患者。评估了输血的趋势。使用2018年和2019年的数据评估了患者因素与输血的相关性。
结果：pTHA的输血率从2011年的21.4%降至2019年的2.5% (P < .0001)。对于pTKA，输血率从17.6%下降到0.7% (P < .0001)。在rTHA中，输血率从2011年的33.5%下降到2019年的12.0% (P < .0001)。在研究期间，rTKA的输血率从19.4%下降到2.6% (P < .0001)。输血更常发生在高龄、女性、合并症多、红细胞压积低、接受非脊髓麻醉和手术时间较长的患者。多因素分析表明，较低的术前红细胞压积、出血疾病史和术前输血与术后输血的较高几率相关。
结论：全关节初次置换和翻修术后输血持续减少。在评估总体并发症发生率时，关节置换术并发症的研究应考虑减少输血。未来的研究应考虑采取干预措施，进一步减少关节置换术后的输血。
Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?
Background: Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions.
Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data.
Results: Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative trans- fusion were associated with greater odds for postoperative transfusion after multivariate analysis.
Conclusion: Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.
文献出处：DeMik DE, Carender CN, Glass NA, Brown TS, Callaghan JJ, Bedard NA. Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty? J Arthroplasty. 2021 Aug 25:S0883-5403(21)00670-7. doi: 10.1016/j.arth.2021.08.018. Epub ahead of print. PMID: 34511282.
文献5
CT在膝关节炎和置换术治疗中的作用
译者：张峻
本综述研究CT在膝关节炎和置换术评估和治疗中的潜在价值。特别是以下几点：（1）评价膝关节间室关节炎，（2）评价髌股关节，（3）预测假体大小，（4）假体力线，（5）保护软组织，（6）辐射暴露的潜在顾虑。为了对比CT和X线那个更精确并且有临床相关性，使用布尔搜索运算符和术语进行搜索：“CT”、“X线”、“关节力线”、“膝关节”和“关节置换术”，得到661个结果。基于以下几点评价文献（1）评价膝关节间室关节炎，（2）评价髌股关节，（3）预测假体大小，（4）假体力线，（5）保护软组织，（6）放射暴露的潜在顾虑。纳入63项关于术前，术中，术后临床影像和病人相关因素的相关性和对比分析。CT扫描可以更好地检测内侧和外侧关节变化，骨性畸形，软骨下骨囊肿和骨缺失。CT术前预测假体大小准确性为99%。CT有助于更好地判断关节周围结构，例如后交叉韧带，因此，在全膝关节成置换术中有助于更好地保护软组织。虽然辐射是一个潜在的顾虑，但较新的影像协议与普通平片的曝光量相当。与平片相比，CT扫描更准确，提供更多临床相关数据。因此，作者建议使用CT对某些关节炎患者进行评估，并对膝关节置换术进行术前规划。
Benefits of CT Scanning for the Management of Knee Arthritis and Arthroplasty
This review investigated the potential value of computed tomography (CT) scans for the evaluation and management of knee arthritis and arthroplasty. Specifically, we evaluated the following: (1) assessment of arthritis within knee compartments, (2) patellofemoral joint assessment, (3) implant sizing prediction, (4) component alignment, (5) soft-tissue protection, and (6) potential concerns with radiation exposure. To compare if CT or X-ray imaging is more accurate and clinically relevant, a search was performed using Boolean search operators and terms: 'CT,' 'radiograph,' 'joint alignment,' 'knee,' and 'arthroplasty,' which yielded 661 results. Studies were evaluated based on (1) assessment of arthritis within knee compartments, (2) patellofemoral joint assessment, (3) implant sizing prediction, (4) component alignment, (5) soft-tissue protection, and (6) potential concerns with radiation exposure. Correlative and comparative analyses of imaging modalities to pre-, intra-, and postoperative clinical and patient-related factors were performed for the 63 included studies. CT scans were found to better detect medial and lateral arthritic changes, bony deformities, subchondral cysts, and cartilage losses. CT scans were shown to 99% accurately predict prosthetic sizes preoperatively. CT scans can also help better visualize surrounding anatomy, such as the posterior cruciate ligament, and have therefore been linked to better soft tissue protection during total knee arthroplasty. Although radiation is a potential concern, newer imaging protocols have comparable exposure to plain radiographs. Compared with plain radiographs, CT scans were found to be more accurate and provide more clinically relevant data. Therefore, the authors recommend the use of CT for the evaluation of certain patients with arthritis and for preoperative planning for knee arthroplasty.
文献出处：Sodhi N, Jacofsky DJ, Chee A, Mont MA. Benefits of CT Scanning for the Management of Knee Arthritis and Arthroplasty. J Knee Surg. 2020 Apr 8. doi: 10.1055/s-0040-1708041. Epub ahead of print. PMID: 32268407.
第二部分：保髋相关文献
文献1
注射性臀肌挛缩反Ober征及其外科处理
译者：罗殿中
背景：目前美国和其它发达国家的收养现象越来越多，一些被收养的孩子发现存在未告知的疾患，也包括一些骨科疾患。一种肌肉注射引起的臀大肌挛缩症，此前有几篇文献进行了描述，如果对这种疾病不熟悉，就会诊断困难。通过对这种疾病的病因、病理研究，同时结合典型的体征，包括几乎特异性的“反Ober征”阳性，医者可更好识别、并提供适当的治疗措施。
方法：本文回顾性研究了在我们研究所的4位注射性臀肌挛缩症患者，记录患者病史、物理检查、治疗结果，所有4位患者均沿髂胫束后缘做纵向切口，切除肥厚、挛缩的臀肌组织，直达坐骨结节。
结果：所有的四位患者都从发展中国家的孤儿院收养，患儿主诉多样，物理检查确非常相近。其中3例因在诊断注射性臀肌挛缩症之前，因股骨后倾而行股骨转子下增旋转截骨手术。所有患者均有臀部凹陷、肌肉萎缩，臀部大量针眼状瘢痕。所有患者走路均为外旋步态，提示股骨明显后倾。所有患者均发现，当伸髋时可以充分髋内收，当屈髋时髋关节外展挛缩。当患者髋关节由伸髋内收、到屈髋90°，患肢明显自动外展，描述为“反Ober征（ ）”。手术治疗后，所有患者从完全伸髋到完全屈髋，患肢均可内收到中立位。
结论：注射性臀大肌挛缩症虽然在俄国和中国很常见，但在美国和其它发达国家较少见。这种情况的诊断困难，或可导致不当治疗。掌握臀肌挛缩的典型临床表现，和特异性的“反Ober征”体征，顺利找到有效的手术方法，来矫正相关的功能异常。
图1. 一个7岁男孩臀部情况，臀部凹陷、多个针头注射疤痕。A)双侧臀部；B)左臀部近景。
图2. “反Ober试验”提示臀大肌挛缩。A)屈膝90度，伸髋位，髋内收至中立位；B)屈膝屈髋各90度，挛缩的臀大肌越过大转子时导致自主外展，引起髋关节外展体位；C)站立位，伸髋，可内收至中立位；D)下蹲时，屈髋，髋关节外展位。
Injection-induced gluteus muscle contractures: diagnosis with the 'reverse Ober test' and surgical management
Background: Adoption rates are increasing in the United States and other developed countries. A large proportion of adopted children have been found to have unsuspected medical diagnoses, including orthopedic problems. One condition, termed injection-induced gluteus maximus contracture, has been previously described in several case series and can be difficult to diagnose if unfamiliar with this condition. By reviewing the etiology and pathoanatomy of this problem, as well as the typical examination findings, including the near-pathognomonic-positive 'reverse Ober test,' treating providers will be better prepared to recognize and properly treat this condition.
Methods: This is a retrospective review of 4 patients treated at our institution for injection-induced gluteus maximus contracture. Patient history, physical examination findings, and treatment outcomes were recorded. All had undergone surgical treatment through a longitudinal incision along the posterior margin of the iliotibial band, with division of thickened, contracted gluteus tissue down to the ischial tuberosity.
Results: All 4 of the patients were adopted from orphanages in developing countries. Chief complaints of the patients varied, but physical examination findings were very consistent. Three of the 4 patients had undergone rotational osteotomies for presumed femoral retroversion before their diagnosis and treatment for injection-induced gluteus maximus contracture. All patients had concave, atrophic buttock contours and numerous punctate buttock scars. All walked with an out-toed gait and had marked apparent femoral retroversion. Each patient was found to have full hip adduction when the hip was extended but a hip abduction contracture when the hip was flexed. This finding of increasing abduction as an extended/adducted hip is flexed to 90 degrees is described as a positive 'reverse Ober test.' After surgical treatment, all hips could adduct to neutral from full extension to full flexion.
Conclusions: Although common in some countries, such as Russia and China, injection-induced gluteus muscle contractures are seldom seen in the United States and other developed countries. Diagnosis of this condition can be difficult leading to inappropriate treatment. Knowledge of the clinical presentation typical of a gluteus contracture and of the pathognomonic finding of a 'reverse Ober test' can facilitate an effective surgical procedure to correct the associated functional impairment.
文献出处：Scully WF, White KK, Song KM, Mosca VS. Injection-induced gluteus muscle contractures: diagnosis with the 'reverse Ober test' and surgical management. J Pediatr Orthop. 2015 Mar;35(2):192-8. doi: 10.1097/BPO.0000000000000238. PMID: 24992345.
文献2
计算机导航引导髋臼偏心旋转截骨术治疗
髋臼髋关节发育不良合并骶髂融合和
髋臼后倾导致的股骨髋臼撞击：1例病例报告
译者：程徽
背景：髋关节发育不良(DDH)是导致继发性髋关节骨性关节炎(髋关节OA)的主要原因。髋臼后倾可导致钳夹型股骨髋臼撞击(FAI)，也可以导致继发性髋关节OA。然而，尚未见DDH合并髋臼后倾的病例报道。对于治疗方法的选择，意见也尚未统一。我们报告一例应用导航引导的偏心旋转截骨(ERAO)治疗罕见的DDH合并髋臼后倾导致的FAI和骶髂关节发育不全的病例。
图1 一名27岁的女性 A.股骨头颈部凸轮畸形和对侧骶髂关节发育不全B.髋臼后外侧覆盖不良C.髋臼后倾D.外上方盂唇损伤
病例描述：一名27岁的女性，诊断为DDH，髋臼后倾导致FAI和对侧骶髂关节发育不全。我们在计算机导航引导下进行ERAO手术，改善髋臼的覆盖和髋臼后倾。术后髋臼前倾角由1°后倾改善至9°前倾，CE角由18°改善至43°，髋臼指数由69%改善至93%，并将股骨凸轮病变切除。术后2年，Harris髋关节评分从55.7分提高至100分。
图2 术后 A.右髋前后位片髋臼外侧覆盖改善；B.股骨凸轮畸形已切除C.髋臼后倾已纠正
结论：在这一罕见的DDH和FAI病例中，ERAO应用计算机导航精确地改善了髋臼的覆盖，消除了后倾。
Eccentric Rotational Acetabular Osteotomy Using Computed Navigation Guidance for Developmental Dysplasia of the Hip, Sacroiliac Fusion, and Femoroacetabular Impingement Owing to Acetabular Retroversion: A Case Report
Background: Developmental dysplasia of the hip (DDH) is the main factor that causes secondary osteoarthritis of the hip (hip OA). Acetabular retroversion results in pincer-type femoroacetabular impingement (FAI), and this is also known to cause secondary hip OA. However, few cases of DDH with acetabular retroversion have been reported, and there is no definite opinion on the optimal treatment. We report a rare case of DDH and FAI owing to acetabular retroversion and dysostosis of the sacroiliac joint that was treated with eccentric acetabular rotational osteotomy (ERAO) using navigation guidance.
Case presentation: A 27-year-old woman presented with DDH and acetabular retroversion with FAI and dysostosis of the sacroiliac joint on the contralateral side. We performed ERAO using computed navigation guidance and improved the coverage and retroversion of the acetabulum. The acetabular anteversion angle improved from 1° retroversion to 9° anteversion after surgery, the center edge angle improved from 18° to 43°, and the acetabular head index improved from 69% to 93%. The cam lesion of the femur was resected. The Harris Hip Score improved from 55.7 to 100 points at the final examination 2 years after surgery.
Conclusions: In this rare case of DDH and FAI, ERAO using computed navigation guidance accurately improved the coverage and retroversion of the acetabulum.
文献出处：Shimamura M, Iwata K, Fujiki T, Mashiba T, Yamamoto T. Eccentric Rotational Acetabular Osteotomy Using Computed Navigation Guidance for Developmental Dysplasia of the Hip, Sacroiliac Fusion, and Femoroacetabular Impingement Owing to Acetabular Retroversion: A Case Report. Orthop Surg. 2021 Sep 22. doi: 10.1111/os.12919. Epub ahead of print. PMID: 34549883.
文献3
Kinesio肌效贴布治疗男性自体腘绳肌或同种异体
前交叉韧带重建术后早期髋部肌肉无力的短期疗效
译者：肖凯
目的：Kinesio肌效贴布（KT）是一种广泛用于肌肉骨骼康复的治疗方法。对前交叉韧带重建（ACLR）患者的进行KT治疗和髋部力量的报道较少。本研究的目的是明确KT治疗对ACLR术后早期髋关节周围肌肉无力的治疗效果，并明确导致ACLR术后髋关节肌肉力量不足 (HSD) 的因素。
设计：双盲假对照研究。
地点：康复科。
患者：本研究共纳入26名男性患者，他们在4天前接受腘绳肌自体移植或同种异体肌腱移植的单侧ACLR手术。
干预措施：患者随机接受膝关节KT治疗（n = 13）、淋巴矫正联合肌肉（二头肌/股直肌）锻炼，对照组为假KT组（n = 13），所有的治疗持续10天。此外，所有患者均采用相同的 ACLR 康复计划。
主要预后指标：基线数据包括人口统计学数据、临床特征、术后肿胀情况、膝关节运动丧失和膝关节疼痛情况，同时测量双侧膝关节和髋关节肌群的力量（髋旋转肌群除外）。计算髋部HSD和膝关节力量肢体对称指数的百分比值。在KT治疗的第5天至第10天重复进行ACLR手术侧的髋关节力量测量。
结果：两组患者中所有髋关节力量均随时间的变化均显着改善（P < .01）。在第5天和第10天的组间分析中，KT组手术侧屈髋肌（仅第 10天）、伸髋肌和髋内收肌力量的改善更好（P < .05）。此外，术后大腿肿胀和膝关节力量肢体对称指数值与基线水平的HSD结果相关（P < .05）。
结论：ACLR术后HSD可能是术后肿胀加重和膝关节力量降低所致。KT治疗联合淋巴矫正及肌肉训练可用于ACLR术后髋关节肌力下降的治疗。
Short-Term Effects of the Kinesio Taping on Early Postoperative Hip Muscle Weakness in Male Patients With Hamstring Autograft or Allograft Anterior Cruciate Ligament Reconstruction
Objective: Kinesio taping (KT) is a widely used treatment method in musculoskeletal rehabilitation. Little is known about the KT treatment and hip strength in patients with anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to investigate the effectiveness of the KT treatment on hip muscle weakness in early rehabilitation of ACLR and the possible determinants of the ACLR-hip strength deficit (HSD).
Design: Double-blind sham-controlled study.
Setting: Rehabilitation department.
Patients: A total of 26 male patients who underwent unilateral ACLR using hamstring autograft or allograft 4 days before.
Interventions: The patients were randomized to receive the knee KT treatment (n = 13) with lymphatic correction plus muscle (biceps/rectus femoris) facilitation or sham KT (n = 13) for 10 days. In addition, the same ACLR rehabilitation program was applied to all the patients.
Main Outcome Measures: The baseline data included demographic and clinical characteristics, postoperative swelling, knee motion loss and knee pain, and bilateral strength of the knee and hip muscle groups, except for rotator. Then, percentage values of hip HSD and knee strength limb symmetry index were calculated. The hip strength measurements in ACLR-operated leg were repeated on the 5th to 10th days of KT.
Results: Changes in all hip strength values over time were significant in both groups (P < .01). In intergroup analysis of 5th and 10th days, improvements in the flexor (only 10th day), extensor, and adductor hip strength on operated leg were in favor of KT group (P < .05). In addition, the postoperative thigh swelling and knee strength limb symmetry index values were correlated with the HSD outcomes in baseline data (P < .05).
Conclusions: ACLR-HSD can be caused by postoperative increased swelling and reduced knee strength. The KT treatment with lymphatic correction and muscle facilitation can be used in the treatment of postoperative hip muscle weakness after ACLR.
文献出处：Balki S, Göktas HE. Short-Term Effects of the Kinesio Taping® on Early Postoperative Hip Muscle Weakness in Male Patients With Hamstring Autograft or Allograft Anterior Cruciate Ligament Reconstruction. J Sport Rehabil. 2019 May 1;28(4):311-317. doi: 10.1123/jsr.2017-0219. Epub 2018 Dec 12. PMID: 29252113.
文献4
单侧股骨骨骺滑脱后对侧滑脱与髋臼后倾有关，
与深髋臼及股骨头过度覆盖无关
译者：张振东
既往研究表明，股骨头过度覆盖、髋臼深度增加及髋臼后倾与股骨头骨骺滑脱(slipped capital femoral epiphysis，SCFE)有关。然而，关于髋臼形态对单侧SCFE术后发生对侧滑脱的影响如何尚无足够证据。因此本文旨在探究髋臼形态（包括股骨头过度覆盖、髋臼深度增加以及髋臼后倾）是否与对侧股骨头骨骺滑脱相关。
通过外侧中心边缘角(lateral center-edge angle，LCEA)以及Tönnis臼顶倾斜角来评估髋臼覆盖；通过髋臼深度-宽度比值(acetabular depth-width ratio，ADR)和是否存在髋臼过深来评估髋臼深度; 通过交叉征评估是否存在髋臼后倾。
本研究共评估了250例诊断为单侧SCFE的患者(平均年龄，12.5±1.7岁)，所有患者对侧髋关节均没有进行预防性内固定，中位随访时间为49个月(四分位数范围:25-76个月)。研究终点是对侧发生滑脱(70例，28%)或通过股骨近端生长板完全闭合评估达到骨性成熟(180例，72%)。分别在骨盆正位X线片上测量LCEA、Tönnis角、ADR和髋臼过深情况。
结果表明，LCEA每增加一度，对侧滑移的几率降低8%[比值比= 0.92; 95%置信区间(CI): 0.87-0.98; P = 0.009)。Tönnis角(P = 0.11)、ADR(P = 0.20)和髋臼过深(P = 0.37)与对侧滑脱的发生无相关性。交叉征阳性者对侧发生股骨头骨骺滑脱的几率增加了2.5倍(比值比= 2.5; 95% CI= 1.12-5.64; P = 0.03)。因此，在单侧SCFE患者中，髋臼后倾与对侧SCFE发生有关，而髋臼过度覆盖或髋臼深度增加与对侧SCFE发生无关。
Contralateral slip after unilateral slipped capital femoral epiphysis is associated with acetabular retroversion but not increased acetabular depth and overcoverage
Overcoverage of the femoral head by the acetabulum, increased acetabular depth and retroversion have been associated with the etiology of slipped capital femoral epiphysis (SCFE). However, limited evidence exists about the impact of the acetabular morphology on the development of a contralateral slip following an initial presentation of unilateral SCFE.
We aimed to investigate whether acetabular overcoverage as assessed by an increased lateral center-edge angle (LCEA) and low Tönnis angle, increased acetabular depth assessed by the acetabular depth-width ratio (ADR) and the presence of coxa profunda; and acetabular retroversion assessed by the presence of the crossover sign were associated with a contralateral slip in patients presenting with unilateral SCFE.
We evaluated 250 patients with initial diagnosis of unilateral SCFE (average age, 12.5 ± 1.7 years), who had not undergone prophylactic fixation on the contralateral hip for a median follow-up of 49 months (interquartile range: 25-76 months). Endpoints were the development of a contralateral slip (70 patients, 28%) or skeletal maturity assessed by complete closure of the proximal femoral growth plate (180 patients, 72%). We measured the LCEA, Tönnis angle, ADR, and the coxa profunda sign on an anteroposterior pelvic radiograph. The crossover sign was assessed in 208 hips who had a secondary ossification center in the posterior acetabular rim.
For each additional degree of LCEA, the odds of contralateral slip decreased 8% [odds ratio = 0.92; 95% confidence interval (CI), 0.87-0.98; P = 0.009]. Tönnis angle (P = 0.11), ADR (P = 0.20) and coxa profunda (p = 0.37) had no association with a contralateral slip. The presence of crossover sign increased two and half times the odds for a contralateral slip (odds ratio = 2.5; 95% CI = 1.12-5.64; P = 0.03). Acetabular retroversion, but not acetabular overcoverage or increased acetabular depth, was associated with contralateral SCFE development in patients with unilateral SCFE.
文献出处：Maranho DA, Miller P, Kim YJ, Novais EN. Contralateral slip after unilateral slipped capital femoral epiphysis is associated with acetabular retroversion but not increased acetabular depth and overcoverage. J Pediatr Orthop B. 2020 May;29(3):275-282. doi: 10.1097/BPB.0000000000000643. PMID: 31305365.
文献5
髋关节发育不良生物力学缺陷
译者：任宁涛
DDH可增加骨关节炎的风险，DDH骨骼异常可导致不利的生物力学负荷，但骨骼异常不能解释DDH患者所有损伤类型和症状，髋关节周围肌肉的几何形态和功能是进一步研究DDH异常生物力学的目标。在这项研究中，我们比较了 DDH 患者（N = 20）与健康对照（N = 15）的骨骼几何形状、肌肉体积、肌肉内脂肪浸润、力臂和等长肌力。与健康组相比，DDH患者的股骨覆盖率显着降低（p < 0.001，Cohen's d 效应值 = 2.2），股骨颈干角度较大（p = 0.001，d = 1.3），髋关节中心 (HJCs) 更向外移（p = 0.001，d = 1.3）。这些骨骼异常与 DDH 患者较小的外展肌力臂有关（例如，臀中肌 [GMED]：p = 0.001，d = 1.2）。与健康组相比，DDH 患者的 GMED 体积也更大（p = 0.02，d = 0.83），但脂肪浸润没有差异。患者髋外展肌、伸肌和屈肌的等长肌力较低，但与健康组无显着差异。异常的骨骼几何形状、HJC外移 和力臂减小可引起 DDH 患者的慢性持续性的生物力学劣势。这种现象导致对外展肌的需求增加，并导致向内侧和向上的关节反作用力高，这可以解释为何患者股骨上内侧软骨更加容易损伤。在骨骼结构异常的情况下，异常的肌肉几何形状和功能可能是 DDH 中破坏性负荷的重要因素，但此仍未被充分认识。
图1 等长肌力测试体位，对于测试的每个肌肉群，允许受试者练习收缩，然后完成两次最大努力收缩，每次收缩之间休息 5 秒，并记录最大值。
图2 左图：来自代表性受试者的磁共振图像以及骨骼和肌肉重建，具有特定的骨骼解剖结构、肌肉和髋关节中心 (HJC) 的肌肉骨骼模型。右图：骨盆大小和HJC的关系，外移情况根据B/A比值来定，前后移情况根据D/C比值来定。
图3 用于分析臀中肌 (GMED) 和臀大肌 (GMAX) 肌肉内脂肪浸润，近端、中间和远端切片位置。 插图显示为GMAX 的中间切片。
The biomechanical disadvantage of dysplastic hips
Developmental dysplasia of the hip (DDH) is strongly associated with an increased risk for hip osteoarthritis. Skeletal deformities undeniably contribute to detrimental biomechanical loading in dysplastic hips, but cannot explain all types of damage and symptoms that patients with DDH experience. Characterizing the geometry and function of the muscles spanning the hip is a logical next step in our progression of knowledge about DDH pathomechanics. In this study, we compared skeletal geometry, muscle volumes, intramuscular fatty infiltration, moment arms, and isometric strength in patients with DDH (N = 20) to healthy controls (N = 15). Femoral coverage was significantly less in patients (p < 0.001, Cohen's d effect size = 2.2), femoral neck-shaft angles were larger (p = 0.001, d = 1.3), and hip joint centers (HJCs) were more lateral (p = 0.001, d = 1.3). These skeletal abnormalities were associated with smaller abductor muscle moment arms in patients with DDH (e.g., gluteus medius [GMED]: p = 0.001, d = 1.2). Patients with DDH also had larger GMED volumes (p = 0.02, d = 0.83), but no differences in fatty infiltration, compared to controls. Isometric strength of the hip abductors, extensors, and flexors was lower in patients, but not significantly different from controls. The abnormal skeletal geometry, lateralized HJC, and reduced muscle moment arms represent a chronic biomechanical disadvantage under which patients with DDH operate. This phenomenon causes increased demand on the abductor muscles and results in high medially and superiorly directed joint reaction forces, which can explain reports of superomedial femoral cartilage damage in patients. The abnormal muscle geometry and function, in context with abnormal skeletal structure, are likely strong, but underappreciated, contributors to damaging loads in DDH.
文献出处：Michael D Harris , Molly C Shepherd , Ke Song , Brecca M M Gaffney , Travis J Hillen , Marcie Harris-Hayes , John C Clohisy . The biomechanical disadvantage of dysplastic hips. J Orthop Res . 2021 Aug 20. doi: 10.1002/jor.25165.
文献6
骨盆倾斜对髋臼应力分布的影响：有限元分析
译者：张利强
背景：有限元分析（FEA）已被应用于髋臼发育不良和截骨术的生物力学分析。然而，到目前为止很少有关于使用有限元分析来评估骨盆倾斜对髋臼应力分布的影响的报道。
方法：根据患者的3D-CT数据采用Mechanical Finder Ver 7.0软件（RCCM，Inc.，日本）构建有限元模型，并设计发育不良、临界和正常骨盆模型。为了进行分析，将体重放在骶骨上，将髋关节屈肌的负荷放在髂骨上。骨盆倾斜以骨盆前平面为基础，骨盆倾斜角度分别为-20°、0°和20°。使用力矩臂方程计算髋关节屈肌的负荷。
结果：三种模型的von Mises应力值在-20°骨盆倾斜角时最高，在20°骨盆倾斜角时最低。应力分布集中在承载区。临界发育不良骨盆倾斜角度为-20°时von Mises应力的最大值为3.5Mpa，骨盆倾斜角度为0°时von Mises应力的最大值为3.1Mpa。
结论：骨盆倾斜角为-20°的临界发育不良模型与骨盆倾斜角为0°的发育不良模型相比显示出相同的von Mises应力最大值，表明临界发育不良的骨盆后倾角为-20°是髋关节骨关节炎的危险因素类似于发育不良。
图1。3位实验对象的骨盆正位片。a，35岁女性正常髋臼（CE角30°）；b，39岁女性临界发育不良（CE角20°）；c，33岁女性髋臼发育不良（CE角0°）。
图2。骨盆示意图。a，骨盆前倾；b，骨盆中立位；c，骨盆后倾
图3。FEA示意图。A，正常髋臼模型；b，临界髋臼发育不良模型；c，发育不良模型。
图4。ab，FEA模型，髋臼和股骨头表面软骨均匀厚度为1.5mm。c，测量髋臼表面软骨的应力分布
图5。FEA模型示体重加载于骶骨上方，髋关节屈肌负荷加载于髂骨上。A，FEA模型的前后视图。B，骨盆前倾20°模型的侧位图。使用力矩臂方程计算髋关节的屈肌负荷100N。C，骨盆前倾0°模型的侧位图。使用力矩臂方程计算髋关节的屈肌负荷500N。D，骨盆后倾20°模型的侧位图。使用力矩臂方程计算髋关节的屈肌负荷950N。
图6示每例股骨头的覆盖率
图7，髋臼软骨的应力分布示意图。A-C，正常髋关节骨盆倾斜20°、0°、-20°。D-F，临界发育不良骨盆倾斜20°、0°、-20°。G-I，发育不良骨盆倾斜20°、0°、-20°。
图8，FEA模拟髋臼软骨的von Mises应力值
The influence of pelvic tilt on stress distribution in the acetabulum: finite element analysis
Background: Finite element analysis (FEA) has been previously applied for the biomechanical analysis of acetabular dysplasia and osteotomy. However, until now, there have been little reports on the use of FEA to evaluate the effects of pelvic tilt on stress distribution in the acetabulum.
Methods: We used the Mechanical Finder Ver. 7.0 (RCCM, Inc., Japan) to construct finite element models based on 3D-CT data of patients, and designed dysplasia, borderline, and normal pelvic models. For analysis, body weight was placed on the sacrum and the load of the flexor muscles of the hip joint was placed on the ilium. The pelvic tilt was based on the anterior pelvic plane, and the pelvic tilt angles were -20°, 0°, and 20°. The load of the flexor muscle of the hip joint was calculated using the moment arm equation.
Results: All three models showed the highest values of von Mises stress in the -20° pelvic tilt angle, and the lowest in the 20° angle. Stress distribution concentrated in the load-bearing area. The maximum values of von Mises stress in the borderline at pelvic tilt angles of -20° was 3.5Mpa, and in the dysplasia at pelvic tilt angles of 0° was 3.1Mpa.
Conclusions: The pelvic tilt angle of -20° of the borderline model showed equal maximum values of von Mises stress than the dysplasia model of pelvic tilt angle of 0°, indicating that pelvic retroversion of -20° in borderline is a risk factor for osteoarthritis of the hip joints, similar to dysplasia.
文献出处：Hasegawa K, Kabata T, Kajino Y, Inoue D, Sakamoto J, Tsuchiya H. The influence of pelvic tilt on stress distribution in the acetabulum: finite element analysis. BMC Musculoskelet Disord. 2021 Sep 6;22(1):764. doi: 10.1186/s12891-021-04500-5. PMID: 34488684; PMCID: PMC8422778.
文献7
2018年美国华盛顿大学：
分类简述：股骨头骨折的Pipkin分类
译者：陶可（北京大学人民医院骨关节科）
历史：Birkett 是 1869 年第一个在进行尸检时发现和记录股骨头骨折的人 [1]。这些高能量损伤并不常见，并且在所有髋关节后脱位中占 5% 至 15% [3, 5, 11]。股骨头骨折带来治疗挑战；且在技术上很难解决。
1954 年，Stewart 和 Milford 描述了四级髋关节脱位；伴有股骨近端头部或颈部骨折的脱位被归类为 IV 级 [14]。 1957 年，来自密苏里州堪萨斯城的矫形外科医生加勒特·皮普金 (Garrett Pipkin) 进一步细分了Stewart和Milford的 IV 级损伤。这种股骨头骨折分类系统后来被称为 Pipkin 分类系统 [10]。Pipkin 根据他对 24 名患者（25 处骨折）的观察结果开发了这个分类系统。25 处骨折中有 22 处归因于机动车碰撞[10]。
目的：如上所述，Pipkin 分类系统发展的基本原理是将 Stewart 和 Milford [14] 分类的髋关节 IV 级骨折脱位进行细分。
Pipkin希望他的分类系统能够进一步阐明 IV 级损伤，因为关于这些损伤的结果和后遗症的报道很少。突出的后遗症包括创伤后关节炎、骨坏死、异位骨化和坐骨神经损伤。此外，虽然不是主要目的，但他能够使用他的分类为这些伤害提供治疗方案。
描述：Pipkin 将这些损伤归类为四种类型之一 [10]： I 型定义为髋关节脱位，股骨头骨折限于股骨头中央凹（以下）（图 1）； II 型定义为髋关节脱位，股骨头骨折位于股骨头中央凹（以近部分）（图 2）； III 型骨折是 I 型（图 3）或 II 型（图 4）股骨头骨折并伴有相关的股骨颈骨折； IV 型骨折定义为 I 型或 II 型伴有髋臼缘骨折（图 5）。
Pipkin 使用股骨头中央凹作为 I 型和 II 型骨折划分的基础是，圆韧带在 II 型损伤中仍然附着在下部骨折块上，通常会导致该骨折块大量旋转。附有韧带的股骨头的旋转以下部分可以防止股骨头部分的同心复位。此外，他提出的理论认为，附有韧带的以下部分旋转难以通过闭合方式矫正，为适合手术的II型损伤患者考虑切开复位内固定提供了依据；相比之下，仅通过闭合方式可能更频繁地成功治疗 I 型骨折。结果是根据 Thompson 和 Epstein 标准 [15] 报告的，该标准结合使用放射学和临床信息来提供差到优的结果。 Pipkin 表示，他的系列中没有患者符合被归类为“优秀”结果的标准，因为所有患者都有一定程度的放射学退行性变化。
Pipkin 更喜欢对这些损伤进行封闭治疗，因为在他的系列中接受封闭治疗的患者比接受切开复位的患者有更好的结果。他将需要手术治疗的患者的较差结果归因于反复尝试闭合复位、治疗延迟和手术创伤。 Pipkin 报告说，当通过闭合措施无法复位脱位和/或骨折、存在阻塞性碎片或骨折碎片粉碎时，需要进行手术 [10]。
对于 I型和 II 型损伤以及 IV 型损伤的股骨头部分，他建议尝试将闭合复位作为主要治疗手段。此外，他建议通过复位和固定来管理 4 型损伤的髋臼边缘部分。对于 III 型损伤，Pipkin 表示封闭式治疗可能是可能的，但至少对颈部骨折部分的开放治疗更实用，因为大量的力量会阻止头颈部组件的闭合复位与脱位[10] ]。
验证：从放射学的角度来看，Pipkin 分类相对简单，但据我们所知，没有研究报告他的分类系统的观察者间和观察者内的可靠性。这可能是因为大多数关于股骨头骨折的现有研究仅限于小系列，因为这种损伤不常见。
然而，一些研究评估了使用 Pipkin 分类对骨折进行分级的患者在手术和非手术治疗后的预后。总的来说，它们对 Pipkin I 型和 II 型骨折的结果比对Pipkin III 型或 IV 型骨折的结果更好，这为分类方案提供了一些表面有效性。然而，结果有些好坏参半。
Marchetti等[7] 发现 Pipkin I 型和 II 型骨折患者在平均随访 49 个月后的 Thompson 和 Epstein 量表 [15] 上的结果得分高于Pipkin III 型或 IV 型骨折患者（分别为76% 对 56% 的良好结果）。
在一项平均随访近 7 年的研究中，根据 Thompson 和 Epstein 量表 [15] 评估时，76% 的 Pipkin I、II 和IV型骨折具有优异或良好的临床结果。 Pipkin I 型和 II型骨折患者的临床表现优于 IV型骨折患者 [9,15]。 Oransky 等人的系列研究中无 III 型骨折患者。 [9]，从而限制了该研究对 Pipkin 系统与结果相关的评估。
对 11 项研究中的 155 名股骨头骨折患者的系统评价发现，单独使用 Thompson 和 Epstein 标准时，Pipkin 类型之间的结果没有统计学差异[4]。
与使用 Thomas 和 Epstein 量表的上述结果相反，Stannard 等人[13] 使用 Short Form Heath Survey-12 (SF-12) 评估结果。他们发现，与 I型或 IV 型骨折患者相比，Pipkin II 型骨折患者的体检成分评分较低。
局限性：Pipkin 分类的主要限制是缺乏观察者间和观察者内的验证。据我们所知，此验证尚未执行。这种缺乏验证可能是由于这些伤害发生频率低，数据仅限于小系列病例。
我们认为，Pipkin 分类系统不能作为股骨头骨折手术治疗的充分指南。在确定手术治疗时，必须考虑未包含在该分类系统中的几个因素。这些因素包括获得和保持同心复位的能力、股骨头骨折的大小、股骨头骨折的位移以及 IV 型损伤中相关髋臼骨折的特征。
对股骨头骨折的系统评价发现，Pipkin I 型骨折最有可能采用非手术治疗，其中 21.1% 的骨折接受了非手术治疗，这与 Pipkin 认为 IV 型骨折可以通过闭合方式更频繁地治疗的观点一致 [4]。此外，发现 III 型骨折是最常见的关节置换术类型，其中 38.9% 的损伤以这种方式治疗 [4]。虽然II 型和 III 型损伤更可能采用切开复位内固定或关节置换术治疗，但 I 型和 IV 型骨折的治疗存在差异[4]，上述因素在决策中发挥作用。
这些损伤的后遗症，包括创伤后关节炎、骨坏死、异位骨化和坐骨神经损伤，已在多个系列中报道过 [4, 7, 12]。然而，Pipkin 类型与发生这些后遗症的风险之间没有相关性 [4, 7, 12]。正如 Letournel 和 Judet [6] 所提到的，导致髋臼骨折所需的力的大小会对股骨头软骨和股骨头的血管造成很大程度的损伤。这种程度的损伤很难单独从放射学上评估。因此，这解释了为什么仅基于 Pipkin 分类系统难以预测外伤后关节炎和股骨头坏死的发展。
股骨头骨折的替代分类系统已经开发出来，包括 Brumback 等人描述的那些[2]，Yoon等人[16]，以及 Marsh 等人报告的 AO/OTA 分类系统[8]。Brumback 等人的分类系统[2]比Pipkin分类系统更全面，考虑了脱位方向和关节稳定性（表1）。该系统似乎提供了预后价值，3B 型和 5 型损伤的患者表现最差，2B 型骨折患者的预后最好 [13]。由于 Brumback 系统强调了关节不稳定、脱位方向和髋臼骨折严重程度在预测较差结果方面的重要性 [2]，因此一些人认为它可能是一个更准确的分类系统 [4]。然而，在 Brumback 分类的观察者内和观察者间可靠性得到可靠验证之前，我们建议读者谨慎使用它。
Yoon等人[16] 对Pipkin的分类系统进行了修改，以帮助指导治疗。 I 型骨折是股骨头中央凹远端的小骨折，太小或太碎而无法用螺钉固定。 II型是中央凹远端的较大头部骨折。 III型是中央凹近端的头部大骨折，IV型是头部粉碎性骨折。他们得出的结论是，I 型骨折最好采用碎片切除治疗，II 型和 III 型采用复位和固定，IV 型采用关节成形术，特别是半关节成形术 [16]。然而，他们的分类系统是有限的，因为它是主观的，也没有得到验证；因此我们建议读者谨慎使用该系统。
结论：虽然Pipkin系统是最常用的股骨头骨折分类系统[4]，但它并不全面；它没有考虑骨折碎片的粉碎程度或头部骨折的大小、髋臼骨折的大小或 4 型损伤中的关节稳定性。因此，该分类系统缺乏作为手术干预指南的能力。然而，评估股骨头骨折患者预后的中长期研究发现，Pipkin 分类对预后有用，因为 Thompson 和 Epstein 定义的 1 型和 2 型骨折患者具有更好的预后[15] , 而不是 3 型和 4 型骨折患者 [4, 7]。最后，由于 Pipkin 分类的观察者间和观察者内可靠性未知，因此它作为可靠分类系统的能力受到很大限制。
图 1 Pipkin I 型骨折发生在头中央凹的以下部分。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）
图 2 此图显示股骨头头端至股骨头中心凹的 Pipkin II 型骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）
图 3 显示了位于中央凹下方的 Pipkin III 型股骨头骨折和股骨颈骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）
图 4 如图所示Pipkin III 型股骨头骨折高于中央凹和股骨颈骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）
图 5 图示显示了 Pipkin IV 型股骨头骨折和髋臼骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）
表 1 髋关节脱位和股骨头骨折的 Brumback 分类系统
Classifications in Brief: The Pipkin Classification of Femoral Head Fractures
文献出处：Nicholas M Romeo, Reza Firoozabadi. Classifications in Brief: The Pipkin Classification of Femoral Head Fractures. Clin Orthop Relat Res. 2018 May;476(5):1114-1119. doi: 10.1007/s11999.0000000000000045.
文献8
髋关节:纤维胶原蛋白与兔的发育和衰老有关
译者：李勇
摘要：应用免疫组化方法，对从胎儿17d至2岁成年兔髋关节的关节软骨、关节囊和圆韧带相关纤维胶原进行了鉴定。最初假定的关节软骨含有I型、Ⅲ型和V型胶原，但在胎儿25 d时空化完全，Ⅱ型胶原出现。17d胎儿软骨层细胞表达I型胶原mRNA，但不表达Ⅱ型胶原mRNA。Ⅲ型和V型胶原存在于整个生命过程中，特别是细胞周围。I型胶原蛋白丢失。在各方面，髋关节的关节软骨与膝关节的关节软骨相似。关节囊含有I型、Ⅲ型和V型胶原。胎儿圆韧带含有I型和V型胶原，细胞表达I型胶原mRNA; Ⅲ型胶原主要局限于其表面和插入部分。出生后，同样的分布保持不变。但在韧带中有更多的Ⅲ型胶原蛋白。在股骨头软骨的附着处仅发现标记的穿过软骨的I型胶原纤维;在附着处没有识别出标记的III型和V型胶原定位。髋臼盂唇与骨的附着处是通过I型和V型胶原纤维，Ⅲ型很少出现。韧带被IIl和V型胶原鞘覆盖。Ⅱ型胶原不位于大圆韧带的任何部位。圆韧带中胶原的分布与膝关节副韧带相似。它的插入是独特的，因为没有发现纤维软骨。
The hip joint: the fibrillar collagens associated with development and ageing in the rabbit
The fibrillar collagens associated with the articular cartilages, joint capsule and ligamentum teres of the rabbit hip joint were characterised from the 17 d fetus to the 2-y-old adult by immunohistochemica methods. Initially the putative articular cartilage contains types I, III and V collagens, but when cavitation is complete in the 25 d fetus, type II collagen appears. In the 17 d fetus, the cells of the chondrogenous layers express type I collagen mRNA, but not that of type II collagen. Types IIl and V collagens are present throughout life, particularly pericellularly. Type I collagen is lost. In all respects, the articular cartilage of the hip joint is similar to that of the knee. The joint capsule contains types I, III and V collagens. In the fetus the ligamentum teres contains types I and V collagens and the cells express type I collagen mRNA;type III collagen is confined mainly to its surface and insertions. After birth, the same distribution remains. but there is more type III collagen in the ligament, proper. The attachment to the cartilage of the head of the femur is marked only by fibres of type I collagen traversing the cartilage; the attachment cannot be distinguished in preparations localising types III and V collagens. The attachment to the bone at the lip of the acetabulum is via fibres of types I and V collagens and little type III is present. The ligament is covered by a sheath of types IIl and V collagens. Type II collagen was not located in any part of the ligamentum teres. The distribution of collagens in the ligamentum teres is similar to that in the collateral ligaments of the knee. Its insertions are unusual because no fibrocartilage was detected.
文献出处：YVETTE S. BLAND; DOREEN E. ASHHURST (2001). The hip joint: the fibrillar collagens associated with development and ageing in the rabbit., 198(1), 17–27. doi:10.1046/j.1469-7580.2001.19810017.x
文献9
用客观的肢体表现评估髋关节发育不良相关的失能情况
译者：王一昕
背景：下肢肢体表现评估（PPMs）可以客观量化的评估患者功能，是进行患者报告结局（PRO）评估的有价值的辅助工具。然而，很少有人将其应用于髋关节不稳的患者，测试其有效性。
目的：应用4种不同的PPM对有髋臼周围截骨（PAO）术手术指征的青壮年髋关节发育不良患者和无症状对照组进行评估，测试其鉴别诊断能力，测量者间和测量者内差异以及PPM与常用髋关节 PRO工具间的相关性。
研究设计：队列研究（诊断）；证据等级，2级。
方法：共有24名患者被纳入研究，年龄在15至39岁（100%女性），有髋关节发育不良（外侧中心边缘角<25°）< span=''>相关症状，有PAO手术指征。所有患者需完成疼痛视觉模拟量表（VAS）、髋关节残疾和骨关节炎结果（HOOS）疼痛评分、HOOS简表（HOOS PS），简明国际髋关节评分（iHOT-12）、改良Harris髋关节评分（mHHS）、患者报告结局评估信息系统（PROMIS）的肢体功能（PF）和疼痛干预情况（PI）评估，并进行4项肢体表现测试：（1）自选步行速度（SSWS），（2）反复坐下起立5次（STS5），（3）4象限步行测试（FSST）和（4）计时爬楼梯测试（TSA）。21名18至39岁的无症状青壮年（91%为女性）作为对照组，也接受了检测。组间比较采用Bonferroni-Holm校正的非配对t检验。通过在第二次就诊时重复进行PPM评估和使用2名评分员，对38名参与者进行测量者间和测量者内差异评价。应用Spearman等级相关系数，确定PPMs和PRO工具之间的相关性。
结果：髋关节发育不良患者与对照组之间的所有PRO工具均有显著差异（HOOS疼痛：47.8 vs 99.2；HOOS简表：61.9 vs 99.2；iHOT-12：32.2 vs 99.2；mHHS：54.5 vs 90.6；PROMIS肢体功能：41.4 vs 65.6；PROMIS疼痛干预情况：62.0 vs 39.1，所有P<0.001）< span=''>，试验组与对照组PPM检查均有显著差异（SSWS：1.21 vs 1.53 m/s；STS5：10.85 vs 5.95 s；FSST：6.59 vs 4.03 s，P<0.001；tsa< span=''>：4.58 vs 3.29 s，P=0.002）。所有4种PPM均表现出良好的测量者间和测量者内可靠性（组内相关系数，0.83-0.99）。STS5、FSST和TSA与评估肢体功能的PRO工具，包括PROMIS PF、mHHS和iHOT-12，高度相关（r>0.5）。
结论：与无症状对照组相比，有症状的髋关节发育不良患者进行功能评估时存在明显异常，而肢体表现评估有很好的可靠性。尤其是计时爬楼梯测试和反复坐立测试与身体功能PRO工具有很好的相关性。PPM评估在非关节炎性髋关节疾病患者中，可能是PRO工具的补充。后续进行PPM评估判断髋关节发育不良手术预后的研究也很有必要。
Assessment of Disability Related to Hip Dysplasia Using Objective Measures of Physical Performance
Background: Lower extremity physical performance measures (PPMs), which can objectively quantify functional ability, are an attractive adjuvant to patient-reported outcome (PRO) instruments. However, few tests have been validated for use in hip instability.
Purpose: To evaluate 4 different PPMs for their ability to differentiate between young adults with hip dysplasia indicated for treatment with periacetabular osteotomy (PAO) and asymptomatic controls and to test inter- and intratest reliability and relationship with popular hip PRO instruments.
Study design: Cohort study (diagnosis); Level of evidence, 2.
Methods: A total of 24 symptomatic patients aged 15 to 39 years (100% female) with hip dysplasia (lateral center-edge angle<25°) indicated for treatment with PAO completed the visual analog scale (VAS) for pain, Hip disability and Osteoarthritis Outcome (HOOS) Pain subscale, HOOS Short Version (HOOS PS), International Hip Outcome Tool Short Version (iHOT-12), modified Harris Hip Score (mHHS), Patient Reported Outcome Measurement Information System (PROMIS) physical function (PF) and pain interference (PI), and 4 physical function tests: (1) self-selected walking speed (SSWS), sit-to-stand 5 times (STS5), (3) 4-square step test (FSST), and (4) timed stair ascent (TSA). A further 21 young, asymptomatic adults aged 18 to 39 years (91% female) also underwent testing. Between-group comparisons were made with unpaired t test with Bonferroni-Holm correction. Inter- and intrarater reliability was assessed in 38 participants by repeating PPMs at a second visit and using 2 raters. Spearman rank correlation coefficients were used to determine associations between PPMs and PRO instruments.
Results: Significant differences between patients with hip dysplasia and controls were observed for all PRO instruments (HOOS Pain, 47.8 vs 99.2; HOOS PS, 61.9 vs 99.2; iHOT-12, 32.2 vs 99.2; mHHS, 54.5 vs 90.6; PROMIS PF, 41.4 vs 65.6; and PROMIS PI, 62.0 vs 39.1 [all P < .001]), and all PPMs (SSWS, 1.21 vs 1.53 m/s; STS5, 10.85 vs 5.95 s; FSST, 6.59 vs 4.03 s [all P < .001]; and TSA, 4.58 vs 3.29 s [P = .002]). All 4 PPMs demonstrated excellent intra- and intertest reliability (intraclass correlation coefficient, 0.83-0.99). STS5, FSST, and TSA were correlated highly (r > 0.5) with physical function PRO instruments, including PROMIS PF, mHHS, and iHOT-12.
Conclusion: Patients with symptomatic hip dysplasia demonstrated significant impairment on functional testing compared with asymptomatic controls, and performance measure testing demonstrated excellent test-retest reliability. Timed stair ascent and sit-to-stand testing in particular were correlated strongly with physical function PRO instruments. PPMs may be a viable and well-received adjuvant to PRO instrument administration for patients with nonarthritic hip conditions, and investigation of the ability of PPMs to assess surgical outcomes for hip dysplasia is warranted.
文献出处：Elizabeth J Scott, Michael C Willey, Arthur Mercado, John Davison, Jason M Wilken. Assessment of Disability Related to Hip Dysplasia Using Objective Measures of Physical Performance. Orthop J Sports Med. 2020 Feb 27;8(2):2325967120903290. PMID: 33283014 PMCID: PMC7686645 DOI: 10.1177/2325967120903290