本期目录：
1、复杂初次全膝关节置换术的长期效果
2、全膝关节假体周围感染的1.5期翻修术
3、血液微生物游离DNA测序可以确定假体周围感染中的致病原
4、一种对于不可再次重建的全膝关节翻修术改良人工融合技术
5、骨盆前/后倾导致髋臼杯导航不准确
6、肉毒素A治疗不同原因的痉挛医生和患者都很满意：来自多中心成人痉挛国际登记系统（ASPIRE）的报告
7、3D超声量化脑性瘫痪儿童髋关节外侧移位：一项验证性研究
8、髋关节镜下盂唇修复及髋臼缘成形术中期预后与髋臼缘成形术的深度或术后外侧中心边缘角无关
9、T1加权MRI像上低信号带的深度有助于区分软骨下不全骨折和股骨头坏死塌陷
10、早产臀位婴儿DDH发病情况
11、髋臼周围截骨术后发育不良髋关节的接触应力改善，但仍高于正常髋关节
12、保髋手术联合自体骨髓穿刺移植治疗无症状股骨头坏死：术后 6 年临床和影像学结果的回顾性研究
13、合并痉挛性脑瘫的骨成熟型髋关节重度发育不良患者:综合手术矫正（包括Bernese髋臼周围截骨术）的技术和早期疗效
背景：对于严重的畸形、韧带失稳和/或大量的骨缺损病例，我们偶尔可能需要使用髁限制性假体或旋转铰链假体来完成全膝关节置换手术（TKA）。本研究目的是比较采用髁限制性假体和非限制性假体完成TKA手术患者的人口学特征、长期生存率及再手术和翻修的原因。方法：我们选择了从1979年到2013年间再我院完成的28667例初次TKA手术。有427例采用髁限制性假体，有246例采用旋转铰链假体。根据使用的假体类型分组进行分析研究。采用多变量分析统计了患者的年龄、性别和体重指数（BMI）。采用Kaplan-Meier生存率来比较了在10年和20年时的由于并发症导致的再手术和假体翻修的情况。采用矫正风险率比较了复杂TKA和普通TKA两组间的再手术及翻修的常见原因。结果：各组间患者在年龄、性别和BMI上存在显著性差异 (p < 0.05)。与采用非限制性假体组比较，采用髁限制性假体和旋转铰链膝组在10年和20年时的全因再手术率高，髁限制性假体组的风险率为1.74(95% 可信区间 [95% CI], 1.36- 2.23)，旋转铰链膝的风险率为2.07 (95% CI, 1.58 - 2.70)。相比非限制性假体组，髁限制性假体组的全因翻修矫正风险率明显高，为1.65(p = 0.007)；而旋转铰链膝组却没有那么明显，为1.48(p = 0.054)。各组常见的翻修原因都为磨损及骨溶解、感染和骨折。结论：我们发现采用限制性假体是导致复杂TKA再手术和翻修率增高的相关因素。10年时限制性假体翻修的比率是非限制性假体的2倍多。到术后20年增加到了3倍多。Complex Primary Total Knee Arthroplasty: Long-Term OutcomesBackground: Total knee arthroplasty in patients with severe preoperative deformity, ligamentous instability, and/or marked bone loss occasionally requires a varus and valgus constrained or rotating-hinge design prosthesis. The purpose of this study was to compare patient populations that underwent primary total knee arthroplasty with constrained or unconstrained total knee arthroplasty implants to determine patient demographic characteristics, long-term survival, andreasons for reoperation and revision for each group.Methods: We identifified 28,667 primary total knee arthroplasties performed from 1979 to 2013 at our institution. A total of 427 knees had a varus and valgus constrained design and 246 knees underwent rotating-hinge total knee arthroplasties. Patient demographic information and preoperative diagnoses were analyzed by implant type. A multivariate analysis was performed to account for age, sex, and body mass index (BMI). Kaplan-Meier survival rates for each complication leading to reoperation or component revision were determined at 10 and 20 years. Adjusted hazard ratios were determined for the most common causes for reoperation and revision compared with a routine total knee arthroplasty control group.Results: Patient demographic characteristics were signifificantly different (p < 0.05) between all groups for age, sex, and BMI. The varus and valgus constrained and rotating-hinge groups had decreased survival free of all-cause reoperation at 10 and 20 years compared with the unconstrained total knee arthroplasty group, with a hazard ratio of 1.74 (95% confifidence interval [95% CI], 1.36 to 2.23) for the valgus and varus constrained group and 2.07 (95% CI, 1.58 to 2.70) for the rotating-hinge group. The adjusted hazard ratio for all-cause revision was signifificantly higher for the varus and valgus constrained group at 1.65 (p = 0.007) but not for the rotating-hinge group at 1.48 (p = 0.054) compared with the unconstrained total knee arthroplastygroup. Wear and osteolysis, infection, and fracture were the most common reasons for component revision in both groups.Conclusions: We found increased reoperation and revision rates associated with the use of constrained implants at the time of index total knee arthroplasty. The rate of component revision for any reason at 10 years was >2 times higher in the constrained total knee arthroplasty groups compared with the unconstrained total knee arthroplasty group. At 20 yearspostoperatively, the component revision rate was >3 times higher.文献出处：Martin JR, Beahrs TR, Stuhlman CR, Trousdale RT. Complex Primary Total Knee Arthroplasty: Long-Term Outcomes. J Bone Joint Surg Am. 2016 Sep 7;98(17):1459-70. doi: 10.2106/JBJS.15.01173. PMID: 27605690.背景: 全膝关节置换术(TKA)假体周围感染是一个具有挑战性的问题。本研究旨在探讨一种治疗膝关节假体周围感染方法。我们将1.5期关节翻修术定义为放置一个带关节面的占位器，以延长其使用时间。方法: 回顾性分析2007-2019年采用1.5期人工关节翻修术治疗膝关节PJI患者的临床资料。纳入标准包括: 膝关节占位器在关节内存留12个月以上，患者因可以接受目前占位器功能(28膝)或目前状态无手术适应证(3膝)而推迟二期再次翻修术。31例患者平均年龄63岁，平均 BMI 34.4 kg/m2,12例为女性，术后平均随访2.7年。采用钴铬合金股骨假体和聚乙烯胫骨假体。作者对第二次翻修情况、再感染和影像学结果进行了研究。结果: 平均随访2.7年，仍有25个占位器在体内继续使用(81%)。5例在初次翻修1年后期间(平均1.5年)接受二期翻修，再次的假体植入，其中1例出现发展性的放射透亮线，但还没有到完全松动的程度。3例(10%)出现PJI复发。其中4个膝关节有渐进性透亮线，但是没有任何膝关节假体松动取出的程度。结论: 1.5期人工关节翻修术是治疗膝关节PJI的合理有效方法。术后平均随访2.7年，感染复发率和关节型占位器生存率都是可以接受的。1.5-Stage Exchange Arthroplasty for Total Knee Arthroplasty Periprosthetic Joint InfectionsBackground: Periprosthetic joint infection (PJI) in total knee arthroplasty (TKA) is a challenging problem. The purpose of this study was to outline a novel technique to treat TKA PJI. We define 1.5-stage exchange arthroplasty as placing an articulating spacer with the intent to last for a prolonged time.Methods: A retrospective review was performed from 2007 to 2019 to evaluate patients treated with 1.5-stage exchange arthroplasty for TKA PJI. Inclusion criteria included: articulating knee spacer(s) remaining in situ for 12 months and the patient deferring a second-stage reimplantation because the patient had acceptable function with the spacer (28 knees) or not being a surgical candidate (three knees). Thirty-one knees were included with a mean age of 63 years, mean BMI 34.4 kg/m2, 12 were female, with a mean clinical follow-up of 2.7 years. Cobalt-chrome femoral and polyethylene tibial components were used. We evaluated progression to second-stage reimplantation, reinfection, and radiographic outcomes.Results: At a mean follow-up of 2.7 years, 25 initial spacers were in situ (81%). Five knees retained their spacer(s) for some time (mean 1.5 years) and then underwent a second-stage reimplantation; one of the five had progressive radiolucent lines but no evidence of component migration. Three knees (10%) had PJI reoccurrence. Four had progressive radiolucent lines, but there was no evidence of component migration in any knees.Conclusions: 1.5-stage exchange arthroplasty may be a reasonable method to treat TKA PJI. At a mean follow-up of 2.7 years, there was an acceptable rate of infection recurrence and implant durability.文献出处：Hernandez NM, Buchanan MW, Seyler TM, Wellman SS, Seidelman J, Jiranek WA. 1.5-Stage Exchange Arthroplasty for Total Knee Arthroplasty Periprosthetic Joint Infections. J Arthroplasty. 2021 Mar;36(3):1114-1119. doi: 10.1016/j.arth.2020.09.048. Epub 2020 Oct 9. PMID: 33162276.背景：每年有超过1百万美国人接受关节置换手术，而这其中大约有1/75的病例会遭遇假体周围感染。有效治疗的前提是可以确定致病微生物，而目前的诊断金标准培养需要有创取样，此外，有10%-20%的假体周围感染病例即使进行了培养也无法发现致病微生物。本研究的设想是假体周围感染病例的血液样本中可以发现致病微生物的碎片，而游离DNA测序技术可以准确的辨识这些感染。方法：本研究病例选自美国一家骨科专科医院的一项前瞻性观察研究，我们总共入组了53例髋或膝关节假体周围感染病例。所有入组病例均在术前进行了抽血采样。我们对离心血浆进行了微生物游离DNA测序，并将结果与拥有超过1000种微生物样本的基因组库数据进行了对比。后续我们还按照假体周围感染诊疗常规进行了术中组织与关节液采样培养。最终我们将测序结果与组织培养结果进行了比对。结果：术中与术前穿刺培养在46例（87%）中发现了致病微生物。微生物游离DNA测序技术在35例中发现了致病微生物，包括7例培养阴性病例中的4例（57%）。因此，如果作为培养结果的补充，游离DNA测序技术将筛查效率从87%提升至94%，而且与标准流程相比，这项技术还将感染检测的中位时间缩短了3天。此外，血液游离DNA测序技术在14例样本中发现了未在培养中发现的额外致病微生物。在术后测试中，游离DNA测序技术的结果为阴性或致病微生物显著减少。结论：假体周围感染患者的外周血液样本中可以发现致病微生物的游离DNA碎片。我们通过无创的静脉穿刺就可以采集这些血液循环中的生物标记物并对其测序，为寻找关节感染的致病原提供了全新的途径。作为组织培养的有效补充，这项技术可以增加鉴别感染源的准确性，并缩短检测时间。此外，这项技术还可以作为治疗期间监测感染清除情况的新方法。Sequencing of Circulating Microbial Cell-Free DNA Can Identify Pathogens in Periprosthetic Joint InfectionsBackground: Over 1 million Americans undergo joint replacement each year, and approximately 1 in 75 will incur a periprosthetic joint infection. Effective treatment necessitates pathogen identification, yet standard-of-care cultures fail to detect organisms in 10% to 20% of cases and require invasive sampling. We hypothesized that cell-free DNA (cfDNA) fragments from microorganisms in a periprosthetic joint infection can be found in the bloodstream and utilized to accurately identify pathogens via next-generation sequencing.Methods: In this prospective observational study performed at a musculoskeletal specialty hospital in the U.S., we enrolled 53 adults with validated hip or knee periprosthetic joint infections. Participants had peripheral blood drawn immediately prior to surgical treatment. Microbial cfDNA from plasma was sequenced and aligned to a genome database with >1,000 microbial species. Intraoperative tissue and synovial fluid cultures were performed per the standard of care. The primary outcome was accuracy in organism identification with use of blood cfDNA sequencing, as measured by agreement with tissue-culture results.Results: Intraoperative and preoperative joint cultures identified an organism in 46 (87%) of 53 patients. Microbial cfDNA sequencing identified the joint pathogen in 35 cases, including 4 of 7 culture-negative cases (57%). Thus, as an adjunct to cultures, cfDNA sequencing increased pathogen detection from 87% to 94%. The median time to species identification for cases with genus-only culture results was 3 days less than standard-of-care methods. Circulating cfDNA sequencing in 14 cases detected additional microorganisms not grown in cultures. At postoperative encounters, cfDNA sequencing demonstrated no detection or reduced levels of the infectious pathogen.Conclusions: Microbial cfDNA from pathogens causing local periprosthetic joint infections can be detected in peripheral blood. These circulating biomarkers can be sequenced from non-invasive venipuncture, providing a novel source for joint pathogen identification. Further development as an adjunct to tissue cultures holds promise to increase the number of cases with accurate pathogen identification and improve time-to-speciation. This test may also offer a novel method to monitor infection clearance during the treatment period.文献出处：Echeverria AP, Cohn IS, Danko DC, Shanaj S, Blair L, Hollemon D, Carli AV, Sculco PK, Ho C, Meshulam-Simon G, Mironenko C, Ivashkiv LB, Goodman SM, Grizas A, Westrich GH, Padgett DE, Figgie MP, Bostrom MP, Sculco TP, Hong DK, Hepinstall MS, Bauer TW, Blauwkamp TA, Brause BD, Miller AO, Henry MW, Ahmed AA, Cross MB, Mason CE, Donlin LT. Sequencing of Circulating Microbial Cell-Free DNA Can Identify Pathogens in Periprosthetic Joint Infections. J Bone Joint Surg Am. 2021 Jul 22. doi: 10.2106/JBJS.20.02229. Epub ahead of print. PMID: 34293751.膝关节融合术是一种可接受的治疗方法，可使关节稳定，假体周围感染的复发率较低。在一些翻修病例中，主要问题之一是骨缺损会影响骨愈合；因此，有研究认为人工关节融合术不需要骨愈合。目前的描述性回顾性研究是通过回顾假体周围关节感染并发症患者的医疗记录进行的。采用可视化模拟评分（VAS）和牛津膝关节评分（OKS）评价人工关节融合术后患者满意度。平均牛津膝关节评分为28分，平均肢体长度差异为11 mm。在这种新方法中，几乎所有患者的住院时间和腿长差异都减少了，肢体对线和旋转都是可调节的，几乎所有患者的关节假体周围感染都得到了控制。患者按标准TKA取仰卧位，在旧疤痕处行皮肤中线前切口。手术步骤包括清创、移除股骨和胫骨假体以及骨水泥。采集标本进行微生物培养和病理检查。积极彻底清除所有残留的骨水泥、肉芽组织和坏死组织，包括髌上囊、内、外侧沟以及膝关节后关节囊。使用高速磨钻将原股骨和胫骨假体区域的硬化骨打磨至正常骨。用7-9升生理盐水脉冲喷射灌洗股骨和胫骨髓腔。完全清创后，止血带放气1分钟，观察软组织和剩余骨床的渗血情况，确定组织活力。然后在胫骨和股骨髓腔内置入20cm长的用于外固定架的碳纤维或钢棒。这些棒子里周围填满骨水泥。在插入这些棒之前，使用2个可吸收泡沫封闭胫骨和股骨髓腔以利骨水泥加压，然后将骨水泥注射到髓腔中并植入外固定架的棒。胫骨和股骨棒通过外固定架的连接接头相互连接。恢复肢体长度和对线，外翻5度，膝关节屈曲5-10度，旋转中立;然后用骨水泥填充关节间隙(图3)。手术后，患者可以在耐受范围内承受重量。此外，根据微生物培养和感染疾病专家的建议，静脉注射抗生素。译者体会：本文作者来自伊朗首都德黑兰的伊玛目-侯赛因医学中心，文章发表于最近一期的美国髋膝外科协会（AAHKS）的期刊Arthroplasty Today。文中介绍的膝关节融合技术，只是为某些偏远贫困地区的特定病例提供一种相对可行的治疗方案，仅供参考，译者并不常规推荐使用。图1 膝关节术后正侧位X线片。患者诊断为类风湿性关节炎和骨质疏松。图2膝关节术后正侧位X线片。患者有严重的胫骨内侧平台骨缺损。A Modified Technique for Artificial Fusion in Unreconstructable Revision Total Knee ArthroplastyKnee arthrodesis is an acceptable treatment that leads to a stable joint with a lower rate of recurrence of infection in periprosthetic joint infections. One of the major problems in some revision cases is the bone loss that interferes with the bony union; therefore, some studies suggest artificial arthrodesis, which does not require bony union. The present descriptive retrospective study was conducted by reviewing the medical records of patients with periprosthetic joint infection complications. Patient satisfaction was evaluated after artificial arthrodesis, based on the visualized analog scale score and Oxford Knee Score. The mean Oxford Knee Score was 28, and the mean limb length discrepancy was 11 mm. In this new method, the length of hospitalization and leg length discrepancy was reduced, limb alignment and rotation was adjustable, and periprosthetic joint infection was controlled in nearly all patients.The patient was set in a supine position as for standard TKA, and an anterior midline skin incision was performed through the old scar. The operation included surgical debridement, removal of femoral and tibial components, and the bone cement. Samples were collected for microbiological culture and pathological assessment. Aggressive cutting was used to eliminate all residual cement, granulation and necrotic tissues, including in the supra- patellar pouch, medial and lateral gutter, and posterior section of the knee.The sclerotic bony surfaces, which were located by femoral and tibial components, were cut back to the normal bone by using a high-speed tip burr. Irrigation of femoral and tibial canals was performed using 7-9 liters of normal saline with pulsed jet lavage. After complete debridement, tissue viability was specified by observing blood oozing from the soft tissue and remaining bone stock using 1-minute deflation of the tourniquet.Then, a 20-cm carbon fiber or steel rod of external fixator was inserted in tibial and femoral canals. These rods were filled with cement. Before inserting these rods, tibial and femoral canals were closed using 2 absorbable foams for pressurizing the cement, which would be injected into the canals in the next step. Tibial and femoral rods were connected to each other through connection clamps. Limb length and alignment, 5 degrees of valgus, 5-10 de- grees of knee flexion, and neutral rotation were applied provi- sionally; then joint space was filled with cement (Fig. 3). After the operation, patients were permitted to bear weight as tolerated. Also, intravenous antibiotics were used based on microbiological culture and infection disease specialist suggestions.文献出处：Sarzaeem MM, Bonakdar M, Ramezani K, Omrani FA, Omidian M, Mortazavi SMJ. A Modified Technique for Artificial Fusion in Unreconstructable Revision Total Knee Arthroplasty. Arthroplast Today. 2021 Jul 26;10:128-132. doi: 10.1016/j.artd.2021.06.003. PMID: 34381855; PMCID: PMC8332371.背景：现代导航技术允许髋臼杯相对于骨盆前平面精确定位。骨盆前/后倾的变化将影响最终臼杯的空间方向。方法：我们用倾斜仪结合超声体位测量系统测量了30名志愿者的骨盆前/后倾程度。开发了一种数学算法，根据骨盆前/后倾计算标准X线照片上测量的臼杯位置。结果：休息时，平均骨盆倾前/后倾在仰卧位为-4°站立位为-8°，范围为-27°-3°。骨盆前/后倾1°将导致臼杯功能性前倾改变约0.7°。解释：骨盆前/后倾使导航系统参考骨盆前平面不准确。Pelvic tilt makes acetabular cup navigation inaccurateBackground: Modern navigation techniques allow precise positioning of the acetabular cup relative to the anterior pelvic plane. Variations in pelvic tilt will affect the resulting spatial orientation of the cup.Methods: We measured pelvic tilt in 30 volunteers with an inclinometer combined with an ultrasonographic position measurement system. A mathematical algorithm was developed to calculate the resulting cup position measured on standard radiographs, depending on pelvic tilt.Results: Average pelvic tilt at rest was -4 degrees in the lying position and -8 degrees in the standing position, and ranged from -27 degrees to 3 degrees. Pelvic reclination of 1 degree will lead to functional anteversion of the cup of approximately 0.7 degree.Interpretation: Pelvic tilt makes navigation systems referring to the anterior plane inaccurate.文献出处：Lembeck B, Mueller O, Reize P, Wuelker N. Pelvic tilt makes acetabular cup navigation inaccurate. Acta Orthop. 2005 Aug;76(4):517-23. doi: 10.1080/17453670510041501. PMID: 16195068.肉毒素A治疗不同原因的痉挛整体疗效未知；通过1年的短期临床分析，我们通过成人痉挛国际登记系统（ASPIRE）对肉毒素A治疗不同原因的痉挛、真实情况和临床疗效进行研究。ASPIRE是多中心、前瞻性、观察登记系统（NTC01930786），在医生指导下谨慎使用肉毒素A治疗不同原因导致的痉挛，包括卒中、多发性硬化（MS）、脑瘫（CP）、创伤性脑损伤（TBI）、脊髓损伤（SCI）等。对肉毒素A治疗期间，医生和患者的满意度（治疗后5±1周）、治疗后残障评分（DAS）。730人经过超过一个疗程的肉毒素A治疗，37%单侧使用肉毒素治疗痉挛。最常见的病因是卒中（411例，56%），此后顺序为多发性硬化MS（119例，16%）、脑瘫CP（77例，11%）、创伤性脑损伤TBI（45例，6%）、脊髓损伤SCI（42例，6%）。肉毒素A每个疗程平均累计剂量由CP的296±145U到TBI的406±152U。上肢治疗最常应用于握拳（卒中、MS、SCI）、屈腕（CP）、屈肘（TBI）；所有因素中下肢治疗最常应用于马蹄内翻足。卒中患者在四肢几乎所有的DAS评分中均有改善，提示整体功能得到改善。在所有病因中，下肢活动能力的DAS评分均得到提高。在所有治疗阶段中，84.7%（SCI）～94.2%（CP）的医生、和67.6%（TBI）～89.7%（SCI）的患者报告肉毒素A对控制痉挛的效果非常满意/满意；94.6%（TBI）～98.8%（CP）的医生、和88.4%（卒中）～91.2%（TBI）的患者表示确定/可能继续该方案治疗。治疗相关的并发症（TRAEs）和治疗相关的严重并发症（TRSAEs）如下：卒中TRAEs 10例（2.2%）、TRSAEs 3例（0.5%）；多发性硬化MS中TRAEs 5例（4.2%）、TRSAEs 0例；脑瘫CP中TRAEs 0例、TRSAEs 0例；创伤后脑损伤TBI中TRAEs 1例（2.2%）、TRSAEs 0例；脊髓损伤SCI中TRAEs 0例、TRSAEs 0例。没有发现新的安全警示信号。观察显示，肉毒素A治疗不同原因的痉挛医生和患者的满意度均很高，对整体功能的改善也很好。从ASPIRE的短期观察揭示了临床治疗不同病因痉挛的共性和差异。High clinician- and patient-reported satisfaction with individualized onabotulinumtoxinA treatment for spasticity across several etiologies from the ASPIRE studyEtiology-specific onabotulinumtoxinA utilization to manage spasticity is largely unknown. In this 1-year interim analysis, we evaluated real-world onabotulinumtoxinA utilization and effectiveness across several etiologies from the Adult Spasticity International Registry (ASPIRE) study. ASPIRE is a multicenter, prospective, observational registry (NCT01930786) examining stroke, multiple sclerosis [MS], cerebral palsy [CP], traumatic brain injury [TBI], and spinal cord injury [SCI] patients with spasticity treated with onabotulinumtoxinA at the clinician's discretion. Assessments included onabotulinumtoxinA utilization (each session), clinician (subsequent session)/patient (5±1 weeks post-treatment) satisfaction, and the Disability Assessment Scale (DAS; subsequent session). 730 patients received ≥1 onabotulinumtoxinA treatment, with 37% naïve to botulinum toxin(s) for spasticity. The most common etiology was stroke (n=411, 56%), followed by MS (N=119, 16%), CP (N=77, 11%), TBI (N=45, 6%), and SCI (N=42, 6%). The total body mean cumulative dose (±SD) of onabotulinumtoxinA per session ranged from 296 U (±145) in CP to 406 U (±152) in TBI. The most commonly treated upper limb presentations were clenched fist (stroke, MS, and SCI), flexed wrist (CP), and flexed elbow (TBI). Equinovarus foot was the most commonly treated lower limb presentation in all etiologies. Stroke patients showed improved DAS scores for nearly all subscales in both limbs, indicative of improved global function. All etiologies showed improved lower limb mobility DAS scores. Across all sessions, clinicians (range: 87.4% [SCI]-94.2% [CP]) and patients (range: 67.6% [TBI]-89.7% [SCI]) reported extreme satisfaction/satisfaction that onabotulinumtoxinA helped manage spasticity, and clinicians (range: 94.6% [TBI]-98.8% [CP]) and patients (range: 88.4% [stroke]-91.2% [TBI]) would definitely/probably continue treatment. Treatment-related adverse events (TRAEs) and treatment-related serious adverse events (TRSAEs) were reported as follows: stroke: 10 TRAEs (2.2% patients), 3 TRSAEs (0.5%); MS: 5 TRAEs (4.2%), 0 TRSAEs; CP: 0 TRAEs, 0 TRSAEs; TBI: 1 TRAEs (2.2%), 0 TRSAEs; SCI: 0 TRAEs, 0 TRSAEs. No new safety signals were identified. High clinician- and patient-reported satisfaction were observed following individualized onabotulinumtoxinA treatment, as well as improved global function. Interim results from ASPIRE demonstrate etiology-specific similarities and differences in clinical approaches to manage spasticity.文献出处：Francisco GE, Bandari DS, Bavikatte G, Jost WH, McCusker E, Largent J, Zuzek A, Esquenazi A. High clinician- and patient-reported satisfaction with individualized onabotulinumtoxinA treatment for spasticity across several etiologies from the ASPIRE study. Toxicon X. 2020 Jun 6;7:100040. doi: 10.1016/j.toxcx.2020.100040. PMID: 32875289; PMCID: PMC7452133.目的：评估外侧覆盖(LHC)这一新的指标用于描述脑性瘫痪(CP)儿童髋关节发育不良的有效性。方法：LHC获取自三维超声图像。22名接受常规髋关节监测的儿童CP患者被前瞻性纳入研究(15名男性，7名女性；年龄4 - 15岁)。作为治疗常规，每个参与者都有平面X线片，在他们拍平面X线片前后2周内采集3D超声。同一观测者采集一组数据的Reimer外移指数和LHC，使用Pearson相关计算它们之间的相关性。由三位观测者对10幅图像分别前后进行了三次测量，以了解LHC的重复性。观测者间和观测者内的变异使用ICC进行量化。图1 以上所有图像都来自一个四岁男孩的左髋。在所有的图像中，图像的上方定义为解剖学的上方，外侧定义为左侧，内侧定义为右侧。(a)股骨最大横截面积的二维冠状面切片。(b)叠加表面绘制的二维冠状面切片。(c)二维冠状切片，三维表面绘制。(d) 3D表面渲染的冠状视图，将“最佳匹配”的球体叠加在股骨头上。结果：LHC与Reimer外移指数具有很强的相关性(Spearman相关指数=−0.86，p<0.001)< span=''>。LHC的观测者间相关系数=0.97，观测者内相关系数=0.98，可靠性与文献报道的RMP类似。解释：这是3D超声用于监测CP患儿髋关节发育的初步验证。LHC与Reimer外移指数在评估髋关节发育不良方面具有可比性，RMP的可靠性水平类似。3D ultrasound to quantify lateral hip displacement in children with cerebral palsy: a validation studyAim: To assess the validity of a new index, lateral head coverage (LHC), for describing hip dysplasia in a population of children with cerebral palsy (CP).Method: LHC is derived from 3D ultrasound assessment. Twenty-two children (15 males, seven females; age 4–15y) with CP undergoing routine hip surveillance were recruited prospectively for the study. Each participant had both a planar radiograph acquired as part of their routine care and a 3D ultrasound assessment within 2 months. Reimer's migration percentage (RMP) and LHC were measured by the same assessor, and the correlation between them calculated using Pearson’s correlation coefficient. The repeatability of LHC was investigated with three assessors, analyzing each of 10 images three times. Inter- and intra-assessor variation was quantified using intraclass correlation coefficients.Results: LHC was strongly correlated with RMP (Spearman's rank correlation coefficient=−0.86, p<0.001). LHC had similar inter-assessor reliability to that reported for RMP (intraclass correlation coefficient=0.97 and intra-assessor intraclass correlation coefficient=0.98).Interpretation: This is an initial validation of the use of 3D ultrasound in monitoring hip development in children with CP. LHC is comparable with RMP in estimating hip dysplasia with similar levels of reliability that are reported for RMP.文献出处：Kay RH, Noble JJ, Johnston L, Keevil SF, Kokkinakis M, Reed D, Gough M, Shortland AP. 3D ultrasound to quantify lateral hip displacement in children with cerebral palsy: a validation study. Developmental Medicine & Child Neurology. 2020 Dec;62(12):1389-95.背景：髋关节镜治疗钳形髋关节撞击征仍存在争议，一些作者认为过度切除髋臼缘可能会导致早期关节退变。髋臼缘切除深度和术后髋臼形态对术后预后的影响尚未确定。目的/假设：本研究的数据为同一外科医生前瞻性收集，通过测量髋臼缘切除深度和术后外侧中心边缘角 (LCEA) 对术后至少5年患者自我评分 (PRO)、翻修率和转换为全髋关节置换术的影响。我们假设，根据LCEA测量髋臼缘切除大于10°的患者，或术后LCEA超出25°至35°范围的患者，其PRO较低，翻修率较高，并在中期随访中转为全髋关节置换术的比例更高。方法：本研究共纳入192名接受了初次关节镜下髋臼成形和盂唇修复术的患者，均由同一名外科医生完成，且进行了至少5年的随访。在平卧位正位片上测量术前和术后LCEA，并根据 LCEA 和髋臼缘切除深度将患者分组。其中根据术后LCEA分为：<20°< span=''>组（发育不良组）、20°至25°组（临界发育不良组）、25°至35°组（正常组）和>35°组（临界过度覆盖）。根据从术前到术后LCEA的变化，将髋臼缘切除深度分为<5°< span=''>组、5°至10°组和 >10°组。临床预后的评估包括：WOMAC评分、SF-12评分、改良Harris评分、髋关节预后评分、满意度评分、翻修率和转为关节置换术的比例。结果：患者在末次随访时的所有预后评分指标均显着改善。术后根据LCEA分组的任意两组之间，PRO或转为全髋关节置换术的比例均无显著统计学差异。LCEA 25°至35°组中翻修术比例与其他组存在差异（P = .02）。髋臼缘切除5-10°组术后WOMAC评分更高 (P = .03)，但其余评分、翻修率或转为全髋关节置换术比例与其他组无显著统计学差异。结论：术后LCEA在正常参考范围之外且髋臼缘切除量较大的患者在术后至少5年的随访中与术后LCEA正常及髋臼缘切除量较小的患者预后相似。No Correlation Between Depth of Acetabuloplasty or Postoperative Lateral Center-Edge Angle on Midterm Outcomes of Hip Arthroscopy With Acetabuloplasty and Labral RepairBackground: The treatment of pincer deformity in hip arthroscopy remains controversial, with some authors advocating that over resection may risk early joint deterioration. The role of acetabular resection depth and postoperative acetabular morphology on postoperative outcomes has yet to be defined.Purpose/hypothesis: This study measures the influence of acetabular resection depth and postoperative lateral center-edge angle (LCEA) on minimum 5-year patient-reported outcomes (PROs), revision rates, and conversion to total hip arthroplasty using a single surgeon's prospective database. We hypothesized that patients with acetabular resections >10°, as measured by LCEA, or patients with postoperative LCEA outside the normal range of 25° to 35° would have lower PROs, higher revision rates, and higher conversion to total hip arthroplasty at midterm follow-up.Methods: A total of 192 patients who underwent primary hip arthroscopy with acetabuloplasty and labral repair by a single surgeon with a minimum 5-year follow-up met the inclusion criteria. Preoperative and postoperative LCEAs were measured on supine anteroposterior radiographs, and patients were divided into cohorts based on LCEA and acetabular resection depth. Cohorts for postoperative LCEA were<20° to='' borderline='' and=''>35° (borderline overcoverage). Cohorts for acetabular resection depth were<5°, to='' and=''>10° difference from preoperative to postoperative LCEA. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-Item Short Form Health Survey, modified Harris Hip Score, Hip Outcome Score, satisfaction scores, revision rates, and conversion to arthroplasty rates.Results: Patients significantly improved in all outcome score measures at final follow-up. There were no statistically significant differences in PRO scores or conversion to total hip arthroplasty between any cohorts in the postoperative LCEA group. There were more revisions in the 25° to 35° cohort than the other cohorts (P = .02). The 5-10° resection depth cohort demonstrated a higher postoperative WOMAC score (P = .03), but otherwise no statistically significant differences were seen between resection depth cohorts in the remaining postoperative outcomes scores, revision rates, or conversion to total hip arthroplasty rates.Conclusion: Patients with postoperative LCEA values outside the normal reference range and with large resections perform similar to those with normal postoperative LCEA values and smaller resections at a minimum 5-year follow-up.文献出处：Johannsen AM, Ruzbarsky JJ, Pierpoint LA, Soares RW, Briggs KK, Philippon MJ. No Correlation Between Depth of Acetabuloplasty or Postoperative Lateral Center-Edge Angle on Midterm Outcomes of Hip Arthroscopy With Acetabuloplasty and Labral Repair. Am J Sports Med. 2021 Jan;49(1):49-54. doi: 10.1177/0363546520972998. Epub 2020 Nov 25. PMID: 33237820.股骨头软骨下不全骨折 (subchondral insufficiency fracture，SIF)多发生于老年骨质疏松女性，与股骨头坏死 (osteonecrosis of femoral head，ON)有着较多类似的临床特点及影像学表现，因此需注重两者的鉴别。既往有研究报道总结了股骨头软骨下不全骨折的影像学特点，主要为T1 加权 MRI 像上存在凸向关节面、不连续的低信号带，而股骨头坏死的低信号带通常是光滑的、和关节面走形相反。然而亦有两者低信号带走形一致的报道，因此鉴别仍存在困难。本文作者对低密度带的深度进行对比，拟分析其在两者鉴别中的临床价值。文章回顾分析了2013年5月至2016年1月间35例有股骨头软骨下塌陷影像学表现的患者，所有患者MRI和病理学资料完整。股骨头关节面至低密度带的距离代表低密度带的深度，分别计算中位冠状面该深度与股骨头直径之比(band depth ratio: BDR)以及冠状面BDR的最大值（图：b/a)。结果表明，SIF组的平均年龄显著高于ON组(SIF: 68岁；ON: 49岁，P =0.0017)。SIF组的激素使用史或饮酒者比例明显低于ON组(P=0.0022, P=0.0408)。SIF组中位冠状面BDR及最大BDR均值分别为0.16、0.23，均低于ON组（分别为0.42，0.59；P< 0.0001)。鉴别SIF与ON的临界值分别为中位冠状面BDR为0.22、最大BDR为0.38。因此，在股骨头塌陷的病例中，T1加权MR低强度带的深度有助于区分SIF和ON。The depth of the low-intensity band on the T1-weighted MR image is useful for distinguishing subchondral insufficiency fracture from osteonecrosis of the collapsed femoral headPurpose: To verify the hypothesis that depth of the low-intensity band on T1-weighted MR image is useful for distinguishing subchondral insufficiency fracture (SIF) from osteonecrosis of the collapsed femoral head (ON).Patients and methods: We reviewed 35 consecutive hips in 35 patients with radiological evidence of subchondral collapse of the femoral head and available MR images and histology between May 2013 and January 2016. Both clinical and radiological appearances were investigated. The ratios of distance from articular surface of the femoral head to the T1 low-intensity band to femoral head diameter (band depth ratio: BDR) on (1) mid-coronal slice of MR images and that on (2) coronal slice of MR images in which the highest BDR was observed, were calculated.Results: The mean age in SIF group was significantly higher than that in ON group (SIF: 68 years, ON: 49 years, P = 0.0017). The rates of history of steroid intake or alcohol consumption in SIF group were significantly lower than those in ON group (P = 0.0022 and P = 0.0408, respectively). The mean BDRs in SIF group were (1) 0.16 and (2) 0.23, which were significantly lower than those in ON group [(1) 0.42 and (2) 0.59] (P < 0.0001 for both). The cut-off BDR values to differentiate SIF from ON were (1) 0.22 and (2) 0.38, respectively.Conclusion: The results of the study suggest that depth of the low-intensity band on T1-weighted MR image is useful for distinguishing SIF from ON in cases with collapsed femoral heads.文献出处：Ikemura S, Mawatari T, Matsui G, Iguchi T, Mitsuyasu H. The depth of the low-intensity band on the T1-weighted MR image is useful for distinguishing subchondral insufficiency fracture from osteonecrosis of the collapsed femoral head. Arch Orthop Trauma Surg. 2018 Aug;138(8):1053-1058.背景：关于早产臀位婴儿和足月臀位婴儿的DDH发病率是否一致未有研究，但此信息对于DDH筛查指南至关重要。方法：对臀位出生的婴儿进行回顾性研究，以比较以下胎龄出生组的DDH发病率：23-27周、28-31周、32-36周和≥37周。结果：共纳入1144名婴儿，各组DDH发病率没有差异（p=0.40），分别为11.6%（23-27周）, 9.4%（28-31周）, 13.6%（32-36周） 和11.5%（≥37周）。60名婴儿因DDH需要治疗，校正潜在混杂因素后的多元逻辑回归显示，胎龄不影响DDH的发生率和治疗。结论：早产臀位婴儿的DDH发生率与足月臀位婴儿相似。Developmental dysplasia of the hip in preterm breech infantsBackground: Whether preterm infants born with breech presentation are at similar risk of developmental dysplasia of the hip (DDH) as the term breech infants is not known. The information will be vital for DDH screening guidelines.Methods: A retrospective audit of infants born in the breech position was performed to compare the incidence of DDH in the following gestational age groups: 23-27, 28-31, 32-36 and ≥37 weeks.Results: A total of 1144 neonates were included in the study. The incidence of DDH did not differ between the groups (11.6%, 9.4%, 13.6% and 11.5%, in 23-27, 28-31, 32-36 and ≥37 weeks, respectively, p=0.40). Sixty infants required intervention for DDH. Multiple logistic regression after correcting for potential confounders showed that gestational age group did not influence the risk of DDH, and requirement of therapy.Conclusion: Preterm infants born with breech presentation appear to have a similar incidence of DDH to term breech infants.文献出处：Deeparaj Hegde , Neil Powers , Elizabeth A Nathan , Abhijeet Anant Rakshasbhuvankar. Developmental dysplasia of the hip in preterm breech infants. Arch Dis Child Fetal Neonatal Ed . 2020 Sep;105(5):556-558.目的：本研究的目的是使用数字模型来确定髋关节发育不良的手术矫正是否能将髋关节接触力学恢复到无症状、影像学正常的髋关节。方法：采用离散元分析（DEA）对10例影像学正常无症状髋关节的对照组和10例年龄和体重匹配行髋臼周围截骨术（PAO）治疗的髋臼发育不良患者计算正常步态周期站立阶段的关节接触应力。结果：发育不良髋部的平均接触应力和峰值接触应力高于匹配的正常髋关节（分别为p<0.001和p=0.036）。< span=''>PAO能纠正影像学测量参数，并能调整关节内的接触应力。在步态的整个站立阶段计算的发育不良髋关节的平均接触应力（中位数5.5MPa，[IQR 3.9-6.1MPa]）在行PAO后没有显著降低（3.7MPa，[IQR 3.2-4.8]；p=0.109），与X线正常髋关节（2.4MPa，[IQR 2.2-2.8MPa]）相比，仍然显著升高（p<0.001）。< span=''>峰值接触应力表现出类似的趋势。PAO后，发育不良髋关节步态站立阶段的关节接触面积从395mm2（IQR 378-496mm2）显著增加（p=0.036）至595mm2（IQR 474-660mm2），但仍显著小于X线正常髋关节（中位数1120mm2，IQR 853-1444mm2）。结论：虽然发育不良髋关节行PAO后的接触力学与正常髋关节的接触力学更为相似，但PAO后接触应力升高和接触面积减小表明，即使影像学提示矫正成功后，仍应注意存在应力异常。正常髋关节的接触应力图（左）和匹配发育不良髋关节行PAO前（图中）后（图右）的相关图。Joint contact stress improves in dysplastic hips after periacetabular osteotomy but remains higher than in normal hipsAim: The purpose of this study was to use computational modeling to determine if surgical correction of hip dysplasia restores hip contact mechanics to those of asymptomatic, radiographically normal hips.Methods: Discrete element analysis (DEA) was used to compute joint contact stresses during the stance phase of normal walking gait for 10 individuals with radiographically normal, asymptomatic hips and 10 age- and weight-matched patients with acetabular dysplasia who underwent periacetabular osteotomy (PAO).Results: Mean and peak contact stresses were higher (p<0.001 and p=0.036, respectively) in the dysplastic hips than in the matched normal hips. PAO normalised standard radiographic measurements and medialised the location of computed contact stress within the joint. Mean contact stress computed in dysplastic hips throughout the stance phase of gait (median 5.5MPa, [IQR 3.9-6.1MPa]) did not significantly decrease after PAO (3.7MPa, [IQR 3.2-4.8]; p=0.109) and remained significantly (p<0.001) elevated compared to radiographically normal hips (2.4MPa, [IQR 2.2-2.8MPa]). Peak contact stress demonstrated a similar trend. Joint contact area during the stance phase of gait in the dysplastic hips increased significantly (p=0.036) after PAO from 395mm2(IQR 378-496mm2) to 595mm2 (IQR 474-660mm2), but remained significantly smaller (p=0.001) than that for radiographically normal hips (median 1120mm2, IQR 853-1444 mm2).Conclusions: While contact mechanics in dysplastic hips more closely resembled those of normal hips after PAO, the elevated contact stresses and smaller contact areas remaining after PAO indicate ongoing mechanical abnormalities should be expected even after radiographically successful surgical correction.文献出处：Goetz JE, Thomas-Aitken HD, Sitton SE, Westermann RW, Willey MC. Joint contact stress improves in dysplastic hips after periacetabular osteotomy but remains higher than in normal hips. Hip Int. 2021 Aug 5:11207000211036414. doi: 10.1177/11207000211036414. Epub ahead of print. PMID: 34348517.背景：我们之前已经建立了浓缩自体骨髓穿刺移植（CABMAT），这是一种用于治疗股骨头坏死（ONFH）的一步式、低侵入性、保留关节的手术技术。本研究旨在评估 CABMAT 作为保髋手术方法的效果，防止无症状 ONFH 股骨头塌陷。方法： 2003 年 4 月至 2013 年 3 月，共有 222 名 ONFH 患者（341 髋）接受了 CABMAT疗法。基于核磁共振成像，我们确定这些患者中有 119 名患有双侧无症状 ONFH（238 髋），另外 38 名患者有单侧无症状 ONFH（38 髋）。在本系列中，我们回顾性检查了 2003 年至 2012 年间接受手术治疗并随访 2 年以上的 31 名单侧无症状 ONFH 患者的 31 髋。在手术前即刻和最后一次随访时进行临床和影像学评估。单侧 ONFH 患者的两年随访率为 82%（31/38）。因此，本研究包括 31 名患者（19 名男性和 12 名女性），平均年龄和随访时间分别为 40 和 5.8 年。在 31 名无症状髋关节中，分别有 5、6、10 和 10 名患有 A、B、C1 和 C2 型骨坏死。ONFH 的诊断、分类和分期基于 2001 年日本骨科协会 (JOA) 分类。结果：分别在6/10 C1型髋和5/10 C2型股骨头坏死中观察到继发性股骨头塌陷。9.6% 的患者（3/31 髋）进行了全髋关节置换术，平均术后 33 个月。手术后临床症状有所改善，CABMAT 术后平均 5.8 年的继发性塌陷率低于先前关于无症状 ONFH 自然病程的几项研究报告的结果。结论：ONFH 的早期诊断（即在股骨头塌陷之前）和 CABMAT 的早期干预可以改善皮质类固醇和酒精诱导的 ONFH 的临床结果。译者体会：本文作者来自日本筑波大学医学院，文章发表于BMC Musculoskeletal Disorders (2017)。本文介绍了保髋手术联合自体骨髓穿刺移植治疗无症状股骨头坏死的术后 6 年临床和影像学结果的回顾性研究结果，但研究有一定的局限性：1. 因为这是一项回顾性研究，并且因为 ONFH 是一种临床状态（分期、类型、病因）差异很大的疾病，所以很难确定对照组，缺乏对照组是这项研究的最大局限性；2. 作者基本较小的样本量（31 名患者），得出目前的结论，统计学意义有限，但为了验证 CABMAT 的疗效，有必要进行前瞻性研究，最好采用多中心、随机临床试验的形式，将 CABMAT 结果与 ONFH 的自然病程和髓心减压的结果进行比较；3. 缺乏基于 ONFH 分期、ONFH 类型、性别和年龄的充分随机化和匹配，这些都应该在未来（以及我们的研究设计之初）的调查中（前）加以综合考虑。图 1 股骨头塌陷的测量。塌陷程度定义为覆盖圈与塌陷股骨头（白色箭头）之间的距离。a前后位图像。b 侧位图像（Sugioka 位视图）。a’ a 的放大图 b’ b 的放大图。图 2 根据日本骨科协会 (JOA) 髋关节评分评估髋关节功能。JOA 髋关节评分采用 100 分制，包括疼痛（40 分）、运动范围（ROM；20 分）、步行能力（步态；20 分）和日常生活活动（ADL；20分），得分越高表示髋关节功能越好。在最近的随访检查中，步行的 JOA 评分和 ADL 分（在术后较术前）显著改善。图 3 ONFH 中无股骨头塌陷的存活率：CABMAT 与自然过程。曲线描述了浓缩自体骨髓穿刺移植（CABMAT；本研究）后的结果和疾病自然病程的结果（取自参考文献 [14]）。ONFH，股骨头坏死。图 4 C1 型和 C2 型 ONFH 股骨头塌陷率比较。数据描述了自体骨髓穿刺浓缩移植（CABMAT；本研究）后的结果和疾病自然病程的结果（取自参考文献 [14, 15]）。ONFH，股骨头坏死。图 5 ONFH 中没有股骨头塌陷的生存：CABMAT 与髓心减压。曲线描述了浓缩自体骨髓穿刺移植 (CABMAT) 后的结果和髓心减压后的结果。ONFH，股骨头坏死。Hip preserving surgery with concentrated autologous bone marrow aspirate transplantation for the treatment of asymptomatic osteonecrosis of the femoral head: retrospective review of clinical and radiological outcomes at 6 years postoperatively.Background: We had previously established concentrated autologous bone marrow aspirate transplantation (CABMAT), a one-step, low-invasive, joint-preserving surgical technique for treating osteonecrosis of the femoral head (ONFH). The present study aimed to evaluate the effects of CABMAT as a hip preserving surgical approach, preventing femoral head collapse in asymptomatic ONFH.Methods: In total, 222 patients (341 hips) with ONFH were treated with CABMAT between April 2003 and March 2013. Based on magnetic resonance imaging, we determined that 119 of these patients had bilateral asymptomatic ONFH (238 hips), and 38 further patients had unilateral asymptomatic ONFH (38 hips). In this series, we retrospectively examined 31 hips in 31 patients with unilateral asymptomatic ONFH treated surgically between 2003 and 2012 and followed up for more than 2 years. Clinical and radiological evaluation were performed immediately before the procedure and at the final follow-up. The two-year follow-up rate among patients with unilateral ONFH was 82% (31/38). Therefore, the present study included 31 patients (19 males and 12 females), with a mean age and follow-up period of 40 and 5.8 years, respectively. Of the 31 asymptomatic hips, 5, 6, 10, and 10 had osteonecrosis of types A, B, C1, and C2, respectively. The diagnosis, classification, and staging of ONFH were based on the 2001 Japanese Orthopaedic Association (JOA) classification.Results: Secondary collapse of the femoral head was observed in 6/10 hips and 5/10 hips with osteonecrosis of types C1 and C2, respectively. Total hip arthroplasty was performed in 9.6% of patients (3/31 hips), at an average of 33 months after surgery. Clinical symptoms improved after surgery, and the secondary collapse rate at a mean of 5.8 years after CABMAT was lower than that reported in several previous studies on the natural course of asymptomatic ONFH.Conclusions: Early diagnosis of ONFH (i.e., before femoral head collapse) and early intervention with CABMAT could improve the clinical outcome of corticosteroid and alcohol-induced ONFH.文献出处：Yohei Tomaru, Tomokazu Yoshioka, Hisashi Sugaya, Katsuya Aoto, Hiroshi Wada, Hiroshi Akaogi, Masashi Yamazaki, Hajime Mishima. Hip preserving surgery with concentrated autologous bone marrow aspirate transplantation for the treatment of asymptomatic osteonecrosis of the femoral head: retrospective review of clinical and radiological outcomes at 6 years postoperatively. BMC Musculoskelet Disord. 2017 Jul 6;18(1):292.doi: 10.1186/s12891-017-1652-8.背景:治疗合并痉挛性脑瘫(CP)的骨成熟型的有症状性髋关节发育不良患者仍具有挑战性。本研究探讨了我们用Bernese髋臼周围截骨术(PAO)联合辅助手术治疗这种复杂髋关节畸形的技术经验。方法:回顾性分析16例(18髋)有症状的CP髋关节发育不良患者，采用PAO结合辅助手术治疗。2例患者(2髋)因随访不足而被排除。手术时的平均年龄为17.7岁(范围:13-28岁)。我们比较了术前和术后影像学参数的变化，以及使用改良Harris髋关节评分(mHHS)评估患者髋关节疼痛和功能的早期结果。结果:平均随访时间为3.3年(范围:2.0～6.3年)，Tonnis角从术前中位30度(范围:18～45度)下降到术后中位6度(范围:-9～21度)。外侧中心边缘角从中位数-8度(范围:-28到15度)增加到中位数32度(范围:19到38度)。前中心边缘角的中位数从2度(范围:-22到39度)增加到35度(范围:22到47度)。脱出指数从术前的中位数57%(范围:35%至73%)降至术后的中位数21%(范围:11%至36%)。mHHS中位数术前为62(范围:37 ~ 81)，术后为85(范围:65 ~ 100)。值得注意的是，mHHS的疼痛成分从20(范围:0 - 44)改善到42(范围:30 - 44)。Tonnis骨关节炎术前分级为0级(11髋)或1级(5髋)，11髋保持不变，5髋增加1级。结论:根据我们的经验，Bernese PAO结合适当的辅助治疗为CP髋关节发育不良提供了一个非常满意的手术方法。在患有痉挛性脑瘫的青少年和年轻成人中，利用Bernese髋臼周围截骨术技术使非常严重的髋臼发育不良的重新定向成为可能。辅助软组织手术和股骨近端截骨术经常是必要的，以保持术后稳定。在早期随访中发现，患者的生活质量和功能的显著改善可直接归因于我们对其先前存在问题的髋关节发育不良的手术治疗。Severe Hip Dysplasia in Skeletally Mature Patients With Spastic Cerebral Palsy: The Technique and Early Outcome of Comprehensive Surgical Correction (Including the Bernese PAO)Background: Treatment of symptomatic hip dysplasia in skeletally mature patients with spastic cerebral palsy (CP) can be challenging. This study examines our technical experience with the Bernese periacetabular osteotomy (PAO) in combination with adjunctive procedures in the treatment of this complex hip deformity. Methods: Sixteen consecutive patients (18 hips) with symptomatic CP hip dysplasia were treated with a PAO and variable adjunctive procedures and retrospectively reviewed. Two patient (2 hips) were excluded due to insufficient follow-up. The average age at the time of surgery was 17.7 years (range: 13 to 28 y). We compared the preoperative to postoperative changes in radiographic parameters as well as early outcomes as measured by patient assessment of hip pain and function using the modified Harris Hip Score (mHHS). Results: The average time of follow-up was 3.3 years (range: 2.0 to 6.3 y). Tonnis angles decreased from a median of 30 degrees (range: 18 to 45 degrees) preoperatively to a median of 6 degrees (range: -9 to 21 degrees) postoperatively. Lateral center-edge angles increased from a median of -8 degrees (range: -28 to 15 degrees) to a median of 32 degrees (range: 19 to 38 degrees). Anterior center-edge angles increased from a median of 2 degrees (range: -22 to 39 degrees) to a median of 35 degrees (range: 22 to 47 degrees). The extrusion index decreased from a median of 57% preoperatively (range: 35% to 73%) to a median of 21% (range: 11% to 36%) postoperatively. The median mHHS was 62 (range: 37 to 81) preoperatively and 85 (range: 65 to 100) postoperatively. Notably, the pain component of the mHHS improved from 20 (range: 0 to 44) to 42 (range: 30 to 44). Tonnis osteoarthritis grade preoperatively was either 0 (11 hips) or 1 (5 hips) and remained unchanged in 11 hips and increased by 1 grade in 5 hips. Conclusions: It has been our experience that the Bernese PAO in combination with appropriate adjunctive treatments has provided a very satisfactory surgical approach in the treatment of CP hip dysplasia. In the adolescent and young adult with spastic CP, utilizing the Bernese PAO technique makes it possible to obtain redirection of often a very severe acetabular dysplasia. Adjunctive soft tissue procedures and a proximal femoral osteotomy are frequently necessary to maintain postoperative stability. A notable improvement in the quality of life and function directly attributable to our surgical treatment of their pre-existing problematic hip dysplasia has been consistently noted in early follow-up for our patients.文献出处：Miller, M. L., Clohisy, J. C., Pashos, G. E., Berglund, L. M& Schoenecker, P. L. (2020).Severe Hip Dysplasia in Skeletally Mature Patients With Spastic Cerebral Palsy. Journal of Pediatric Orthopaedics, Publish Ahead of Print.doi: 10, 1097/bpo. 0000000000001635
