髋膝关节文献精译荟萃（第159期）
本期目录：
1、不能自主活动的年青脑瘫患者全髋置换报告
2、膝关节囊的感觉神经分布及对于关节神经阻滞和射频消融的意义：解剖学研究
3、术前内翻角度大于15°全膝关节置换术髌骨骨折发生率增加: 病例对照研究
4、与住院关节置换相比，现代的门诊关节置换同样安全：一项包含了574375例匹配后手术病例的队列研究
5、确定髋臼三维定向的新方法：基于200例病例的研究结果
6、髋臼周围截骨术后迟发坐骨神经损伤报告一例
7、肌效贴是否可以矫正过度的动态膝外翻？一项随机双盲对照试验
8、大转子阻滞结合软组织松解治疗LCPD
9、计算机辅助髋臼周围截骨术与常规截骨术治疗髋关节发育不良的疗效比较
10、股骨髋臼撞击征（FAI）的前期手术是否会影响髋关节置换术的结果？
第一部分：关节置换及保膝相关文献
文献1
不能自主活动的年青脑瘫患者全髋置换报告
翻译：罗殿中
背景：不能自主活动的青少年和年青成人脑瘫患者，由于髋关节疼痛或僵硬，造成日常生活受到严重影响。传统的手术治疗方法，如股骨近端切除术（PFR）一方面是毁损手术，另一方面疼痛缓解效果不很满意。
假设：本文通过回顾性研究，假定对这类患者行全髋关节置换（THA）较股骨近端切除术（PFR）在不加重活动受限的情况下，疼痛缓解更彻底、更有效。
病人与方法：本组病例采用双动髋关节假体、非骨水泥髋臼、骨水泥股骨柄、股骨近端短缩、术后石膏固定等措施，共33例40髋置换，其中31例患者合并多项功能障碍。主要对关节功能、疼痛、活动度三方面进行随访。
结果：平均随访5年，疼痛几乎完全缓解。活动度改善不明显，功能无明显改善。有2例普通并发症、2例感染、10例机械并发症，6例需要再次手术去除假体。
结论：在不能自主活动的年青脑瘫患者中，全髋关节置换（THA）在缓解疼痛方面较股骨近端切除手术（PFR）更为彻底。对于这类能够承受较长时间手术、能够植入较小股骨假体的严重脑瘫患者，全髋关节置换可以作为备选方案。
图1. 双动髋关节假体：骨水泥股骨柄、26mm股骨头、压配进入聚乙烯双动股骨头内。
图2. 一位单侧脱位、严重痉挛性疼痛、不能自主活动的脑瘫患者，手术后12年随访。
图3. （a）脑瘫患者多次手术髋关节严重疼痛，第二次髋关节置换后发生呼吸抑制，住重症监护，肺部培养出假单胞菌。（b）术后9年复查摄片，无疼痛，可轻松坐起来。25岁去世。
图4. 双动头与股骨柄装配失效，需要手术复位。
图5. 患者清醒无肌肉痉挛时小转子撕脱骨折，非手术牵引治疗后愈合。
图6. 非骨水泥假体，进行性股骨外侧壁吸收、无症状。
Total hip replacement in young non-ambulatory cerebral palsy patients
Introduction: The everyday life of a non-ambulatory adolescent or young adult with cerebral palsy can be severely impaired by a painful or stiff hip. The usual surgical solutions such as proximal femoral resection (PFR) are not entirely satisfactory for pain relief, and are mutilating.
Hypothesis: A retrospective study assessed the impact of total hip replacement (THR) on such impairment, on the hypothesis that it is more effective than PFR in relieving pain, without aggravating disability.
Patients and methods: The surgical technique consisted in implanting a dual-mobility prosthesis with uncemented acetabular component and cemented femur, after upper femoral shaft shortening and short hip-spica cast immobilization. Forty THRs were performed in 33 patients, including 31 with multiple disability. Follow-up assessment focused on change in functional status, pain, and range of motion.
Results: Mean follow-up was 5 years. Pain was more or less entirely resolved. Improvement in range of motion was less striking, and there was no significant change in functional status. There were 2 general, 2 septic and 10 mechanical complications, 6 of which required surgical revision.
Discussion: In non-ambulatory cerebral palsy, THR provided much better alleviation of pain than found with PFR treatment. It should be reserved for patients able to withstand fairly long surgery and with femur size compatible with implantation of a femoral component, however small.
文献出处：C. Morin, C. Ursu, C. Delecourt, Total hip replacement in young non-ambulatory cerebral palsy patients, Orthopaedics & Traumatology: Surgery & Research, Volume 102, Issue 7, 2016, Pages 845-849,
文献2
膝关节囊的感觉神经分布及对于关节神经阻滞和
射频消融的意义：解剖学研究
译者：张轶超
背景：尽管显现出治疗上的效果，但是对于人类膝关节囊的关节神经支配在解剖描述和术语应用上还是存在很多差异。出于治疗的目的，本尸体研究是为了确定神经的起点、走行、相关性和定位。
方法：我们解剖了21具尸体的21个下肢以评估膝关节囊上的关节神经的解剖分布。我们根据解剖标识来找出关节神经进入膝关节囊的恒定位置，用克氏针穿过神经钉到其下的骨骼上作为目标点。进行测量及拍摄前后位和侧位X片。
结果：支配骨内侧肌的神经、隐神经、闭孔神经前支、和坐骨神经的一支提供了内侧关节囊和支持带的主要神经支配。坐骨神经和支配股外侧肌的感觉神经提供了膝关节上外侧部分的神经支配而腓神经则提供了外下部的神经支配。胫神经和闭孔神经后支提供后关节囊的神经支配。根据我们的研究，有5个恒定准确的关节神经定位标识可以被用于治疗时使用。
结论：支配膝关节囊的感觉神经分布图可以为准确、安全的治疗提供恒定的5个关节神经的位置。本能研究为关节神经阻滞和射频消融治疗提供了稳妥的解剖学基础研究。
Distribution of sensory nerves supplying the knee joint capsule and implications for genicular blockade and radiofrequency ablation: an anatomical study
Background: Despite their emerging therapeutic relevance, there are many discrepancies in anatomical description and terminology of the articular nerves supplying the human knee capsule. This cadaveric study aimed to determine their origin, trajectory, relationship and landmarks for therapeutic purpose.
Methods: We dissected 21 lower limbs from 21 cadavers, to investigate the anatomical distribution of all the articular nerves supplying the knee joint capsule. We identified constant genicular nerves according to their anatomical landmarks at their entering point to knee capsule and inserted Kirschner wires through the nerves in underlying bone at those target points. Measurements were taken, and both antero-posterior and lateral radiographs were obtained.
Results: The nerve to vastus medialis, saphenous nerve, anterior branch of obturator nerve and a branch from sciatic nerve provide substantial innervation to the medial knee capsule and retinaculum. The sciatic nerve and the nerve to the vastus lateralis supply sensory innervation to the supero-lateral aspect of the knee joint while the fibular nerve supplies its infero-lateral quadrant. Tibial nerve and posterior branch of obturator nerve supply posterior aspect of knee capsule. According to our findings, five constant genicular nerves with accurate landmarks could be targeted for therapeutic purpose.
Conclusion: The pattern of distribution of sensitive nerves supplying the knee joint capsule allows accurate and safe targeting of five constant genicular nerves for therapeutic purpose. This study provides robust anatomical foundations for genicular nerve blockade and radiofrequency ablation.
文献出处：Fonkoué L, Behets C, Kouassi JK, Coyette M, Detrembleur C, Thienpont E, Cornu O. Distribution of sensory nerves supplying the knee joint capsule and implications for genicular blockade and radiofrequency ablation: an anatomical study. Surg Radiol Anat. 2019 Dec;41(12):1461-1471. doi: 10.1007/s00276-019-02291-y. Epub 2019 Jul 23. PMID: 31338537.
文献3
术前内翻角度大于15°全膝关节置换术
髌骨骨折发生率增加: 病例对照研究
译者：马云青
背景: 处理严重的膝关节内翻畸形需要软组织平衡才能植入低限制型膝关节假体。髌骨并发症在这个特殊群体中很少被研究。本研究的假设是严重膝内翻(>15 °)会增加髌骨并发症的发生率。
方法: 采用前瞻性队列研究方法，对1987年开始在同一中心的4216例人工膝关节置换病例进行分析，对280例术前膝关节内翻角度大于15 ° 的患者与673例术前髋-膝-踝为180 ° ± 2 ° 的全膝关节患者进行比较。比较两组术前和术后的临床和影像学特征，特别注意比较髌骨并发症。
结果: 平均随访时间为40.2个月(24-239)。术前正常力线组(髋-膝-踝180 ° ± 2)平均膝关节社会评分(KSS)明显较高(62.65 vs 37.47，p = . 001)。最后一次随访，两组术后 KSS 无显著性差异(内翻组87.5，正常力线组87.3，p = . 87)。两组患者满意率相同(85.3% vs 88.8% ，p = . 49)。而中期随访内翻组髌骨骨折病例较多(2.9% vs 0.9% ，p = . 005)。内翻组和髌骨骨折组患者髌骨高度明显降低(p < 0.001)。
结论: 严重内翻膝关节行TKA术后的KSS 评分与力线正常膝关节TKA术后相当。内翻畸形患者髌骨骨折的风险可能会导致术中髌骨置换的患者比例下降，特别是在术前存在髌骨低位的患者。
Increased Patellar Fracture Rate in Total Knee Arthroplasty With Preoperative Varus Greater Than 15°: A Case-Control Study
Background: Management of severe varus deformity requires soft tissue balancing for implantation of low-constraint knee prosthesis. Patellar complications have been rarely studied in this specific group. Our hypothesis was that severe genu varum (>15°) would increase the rate of patellar complications.
Methods: Using a prospective cohort of 4216 prostheses performed at a single center beginning in 1987, we analyzed 280 prostheses having preoperative varus greater than 15°, compared to 673 total knee arthroplasties (TKAs) with a preoperative hip-knee-ankle angle of 180° ± 2°. Preoperative and postoperative clinical and radiological characteristics were compared between the 2 groups, with particular attention paid to patellar complications.
Results: Average follow-up was 40.2 months (24-239). The mean preoperative Knee Society Score (KSS) was statistically higher in the normal (hip-knee-ankle angle 180° ± 2) axis group (62.65 vs 37.47, P = .001). At the last follow-up, no significant difference was found between the 2 groups in terms of postoperative KSS (87.5 in the varus group vs 87.3 in the normal axis group, P = .87). The rate of satisfied patients was identical between the 2 groups (85.3% vs 88.8%, P = .49). However, at mid-term, there were more patellar fractures in the varus group (2.9% vs 0.9%, P = .005). A significantly lower patellar height in both the varus group and the group of patella fractures (P < .001) was also found.
Conclusion: TKA in severe varus knees produces a KSS equivalent to TKA in knees with a mechanical axis of 0 ± 2. The risk of patellar fracture could initiate a decline in patella resurfacing in patients with major varus deformation, especially in case of a preoperative patella baja.
文献出处：Mouton J, Gaillard R, Bankhead C, Batailler C, Servien E, Lustig S. Increased Patellar Fracture Rate in Total Knee Arthroplasty With Preoperative Varus Greater Than 15°: A Case-Control Study. J Arthroplasty. 2018 Dec;33(12):3685-3693. doi: 10.1016/j.arth.2018.08.001. Epub 2018 Aug 7. PMID: 30197216.
文献4
与住院关节置换相比，现代的门诊关节置换同样安全：
一项包含了574375例匹配后手术病例的队列研究
译者：张蔷
背景：门诊关节置换是解决目前病例增多的方案之一，其需求正在快速增长。然而我们发现，最近七年，既往文献中并没有比较门诊关节置换与匹配后住院关节置换病例的相关研究。本篇文章的目的就是比较匹配后的门诊或住院关节置换病例的术后30天内并发症以及再住院率。
方法：我们从国家外科质量改进计划数据库中选取了2009年至2018年间所有初次全髋关节置换（THA）、初次全膝关节置换（TKA）和初次单髁置换（UKA）的病例。我们根据十项围手术期相关指标，按照1:4的比例，匹配了门诊关节置换与住院关节置换病例。我们使用McNemar试验比较了两组间的术后30天内并发症和再住院率，并应用多因素回归分析明确了并发症和再住院的危险因素。
结果：在所有入选的574375例病例中，21506例（3.74%）接受了门诊关节置换手术。进行匹配的组间比较后，我们发现门诊关节置换的病例术后并发症更少（3.18% VS. 7.45%；p < 0.001）。而当门诊TKA、THA和UKA置换病例分别与住院相应病例亚组进行比较时，我们发现所有门诊置换亚组的并发症率均低于对照组，而再住院率并无显著性差异。门诊关节置换是并发症率更低的独立影响因素（概率比OR，0.407，95%置信区间，0.369-0.449；p < 0.001），而并不会增加再住院率（OR, 1.004 [95%置信区间, 0.878-1.148]; p = 0.951）。
结论：与匹配后的住院关节置换相比，门诊关节置换在本研究中展现出了并发症率更低而并不增加30天内再住院率的优势。尽管康复地点的选择应该在多因素分析后决定，门诊关节置换仍不失为住院关节置换的一种安全有效的替代治疗方法。
Contemporary Outpatient Arthroplasty Is Safe Compared with Inpatient Surgery: A Propensity Score-Matched Analysis of 574,375 Procedures
Background: Outpatient joint arthroplasty is a potential modality for increased case throughput and is rising in demand. However, we are aware of no study that has compared outcomes between risk-matched outpatient and inpatient procedures within the last 7 years. The aims of this study were to compare matched patient cohorts who underwent outpatient or inpatient joint arthroplasty in terms of 30-day adverse events and readmission rates.
Methods: From the National Surgical Quality Improvement Program database, we identified patients who underwent primary total hip arthroplasty (THA), primary total knee arthroplasty (TKA), and primary unicompartmental knee arthroplasty (UKA) from 2009 to 2018. Using 10 perioperative variables, patients who underwent an outpatient procedure were 1:4 propensity score-matched with patients who underwent an inpatient procedure. The rates of 30-day adverse events and readmission were compared using the McNemar test. The risk factors for adverse events and readmissions were identified using multivariate regression.
Results: Of 574,375 patients identified, 21,506 (3.74%) underwent an outpatient procedure. After propensity score matching, an outpatient joint arthroplasty was associated with a lower rate of adverse events (3.18% compared with 7.45%; p < 0.001). When assessed individually, outpatient TKA (3.15% compared with 8.11%; p < 0.001), THA (4.94% compared with 10.05%; p < 0.001), and UKA (1.78% compared with 3.39%; p < 0.001) were all associated with fewer adverse events overall and there was no difference in the rate of 30-day readmission, when compared with inpatient analogs. Outpatient joint arthroplasty was an independent factor for lower adverse events (odds ratio [OR], 0.407 [95% confidence interval (CI), 0.369 to 0.449]; p < 0.001), with no increase in the risk of readmission (OR, 1.004 [95% CI, 0.878 to 1.148]; p = 0.951).
Conclusions: Contemporary outpatient joint arthroplasty demonstrated lower rates of adverse events with no increased rate of 30-day readmission when compared with risk-matched inpatient counterparts. Although multiple factors should guide the decision for the site of care, outpatient arthroplasty may be a safe alternative to inpatient arthroplasty.
文献出处：Lan RH, Samuel LT, Grits D, Kamath AF. Contemporary Outpatient Arthroplasty Is Safe Compared with Inpatient Surgery: A Propensity Score-Matched Analysis of 574,375 Procedures. J Bone Joint Surg Am. 2021 Apr 7;103(7):593-600. doi: 10.2106/JBJS.20.01307. PMID: 33646984.
文献5
确定髋臼三维定向的新方法：
基于200例病例的研究结果
译者：张峻
背景：由于骨盆和髋臼固有的复杂三维形态造成难以准确地判断髋臼的定向。本研究目的是寻找一种可靠的和准确的确定臼三维定向的方法，并且能够描述没有明显髋关节病变的大样本人群的相关特征。
方法：从本单位数据库中选择接受高分辨率CT扫描的200名患者，这些患者起初接受骨盆扫描的适应症与骨科方面无关。生成每个骨性骨盆的三维模型以提取特定的解剖数据集。研究一种新的计算方法以便明确在自动识别的前骨盆平面内参考框架内臼三维定向的标准测量值。在髋臼骨性边缘自动选择点来产生描述髋臼定向的最佳拟合平面。
结果：我们的方法表明良好的观察者间和观察者内一致性（组内相关系数>0.999），并获得了较高的准确性。观察到男性和女性在前倾角（平均3.5°；95%置信区间[CI]，所有角度定义1.9°至5.1°；p<0.0001）和外展角（1.4°；95%CI，解剖角度定义0.6°至2.3°；p<0.002）方面存在显著差异。解剖测量的患者内部不对称性显示双侧前倾角（最大12.1°）和外展角（最大10.9°）存在差异。
结论：只有对整个髋臼精确地测量才能发现髋臼定向在性别之间的差别。虽然观察到患者间髋臼定向角度变异较大，但大多数个体的髋臼的外展角和前倾角相对对称。
临床相关性：一种高精准度和可重复性强的测量髋臼孔定向的方法会使医生和患者受益，进一步细化正常髋关节和异常髋关节特征的区别。深入理解髋臼有助于髋关节疾病的诊断，计划和手术的实施，以及优化新假体的设计。
A novel approach for determining three-dimensional acetabular orientation: results from two hundred subjects
Background: The inherently complex three-dimensional morphology of both the pelvis and acetabulum create difficulties in accurately determining acetabular orientation. Our objectives were to develop a reliable and accurate methodology for determining three-dimensional acetabular orientation and to utilize it to describe relevant characteristics of a large population of subjects without apparent hip pathology.
Methods: High-resolution computed tomography studies of 200 patients previously receiving pelvic scans for indications not related to orthopaedic conditions were selected from our institution's database. Three-dimensional models of each osseous pelvis were generated to extract specific anatomical data sets. A novel computational method was developed to determine standard measures of three-dimensional acetabular orientation within an automatically identified anterior pelvic plane reference frame. Automatically selected points on the osseous ridge of the acetabulum were used to generate a best-fit plane for describing acetabular orientation.
Results: Our method showed excellent interobserver and intraobserver agreement (an intraclass correlation coefficient [ICC] of >0.999) and achieved high levels of accuracy. A significant difference between males and females in both anteversion (average, 3.5°; 95% confidence interval [CI], 1.9° to 5.1° across all angular definitions; p < 0.0001) and inclination (1.4°; 95% CI, 0.6° to 2.3° for anatomic angular definition; p < 0.002) was observed. Intrapatient asymmetry in anatomic measures showed bilateral differences in anteversion (maximum, 12.1°) and in inclination (maximum, 10.9°).
Conclusions: Significant differences in acetabular orientation between the sexes can be detected only with accurate measurements that account for the entire acetabulum. While a wide range of interpatient acetabular orientations was observed, the majority of subjects had acetabula that were relatively symmetrical in both inclination and anteversion.
Clinical relevance: A highly accurate and reproducible method for determining the orientation of the acetabulum's aperture will benefit both surgeons and patients, by further refining the distinctions between normal and abnormal hip characteristics. Enhanced understanding of the acetabulum could be useful in the diagnostic, planning, and execution stages for surgical procedures of the hip or in advancing the design of new implant systems.
文献出处：Higgins SW, Spratley EM, Boe RA, Hayes CW, Jiranek WA, Wayne JS. A novel approach for determining three-dimensional acetabular orientation: results from two hundred subjects. J Bone Joint Surg Am. 2014 Nov 5;96(21):1776-84. doi: 10.2106/JBJS.L.01141. PMID: 25378504.
第二部分：保髋相关文献
文献1
髋臼周围截骨术后迟发坐骨神经损伤报告一例
译者：程徽
1984年Ganz教授发明了伯尔尼髋臼周围截骨术(PAO)，目前是最常用的青少年和成人髋臼畸形矫形技术。尽管广泛应用，髋臼周围截骨术对手术技术要求很高，学习曲线较长，并发症发生率从6%到37%不等。总的来说，坐骨神经麻痹在发生率为15%。在手术量比较大中心，大神经损伤的发生率为2.1%。
本文描述了由髋臼骨块旋转角度较大引起的迟发性坐骨神经麻痹。类似情况伤及股神经已有报告，但坐骨神经损伤的报告尚无。
有关该病例的资料的提交发表已告知患者及其父母，他们表示理解并同意。
病例报告
术前评估：一名12岁女性患者于2009年出现双髋疼痛。疼痛集中于腹股沟和大转子区域，主要出现在长时间步行或体力活动后。体检见，患者身高157厘米(处于90百分位)，体重69公斤(处于97百分位)。右髋臀中肌试验阳性；双髋屈曲90度时内旋85度，外旋20度，临床检查股骨提示股骨前倾50度角。术前骨盆前后位线片显示严重的髋关节发育不良(图1)。外展位X线片显示双股骨头无外移，与髋臼匹配好。按本中心的要求并未常规进行磁共振成像(MRI)。
图1 术前骨盆前后位片
手术：计划行双侧截骨手术，手术间隔6个月；症状较重的右侧先行手术。2009年11月，患者行右侧PAO手术，无任何并发症发生。她经历了治疗过程平稳和临床恢复满意，臀中肌肌力也恢复正常。
2010年5月，即右髋PAO治疗6个月后，患者接受左髋PAO治疗。与第一次手术一样，手术是全透视手术台上进行的，患者取仰卧位。采用Ganz等所描述的标准方法。所有的截骨手术都顺利进行，髋臼骨块的旋转过程也遇到任何困难。
坐骨截骨术中，背伸外展髋关节，屈曲膝关节以减轻坐骨神经张力，避免损伤坐骨神经。由于髋臼复位后髋臼骨块内旋角度（60°）和股骨前倾角较大，未进行前囊切开术和头颈骨软骨成形。本中心不常规使用术中透视和神经监测。用术中骨盆正位片评估髋臼矫形情况，影像显示截骨髋臼对位对线良好。与对侧相同，使用3颗螺钉固定 (图2-A)。校正结果与右侧一致。尽管术后臼顶倾斜角略倾斜，但处于可接受的范围内，且双侧对称。术中判断不需要进行股骨侧截骨术。术后3年，截骨完全愈合，临床效果良好(图2-B)。
图2 术后骨盆前后位片 A左侧术中 B术后3年
术后病情变化：左髋术后在恢复室进行第一次术后评估，3条主要神经均反应良好，患者否认左肢麻木。
术后第一天开始康复，患肢不负重点地。在被动屈髋时，出现髋后坐骨神经痛和足背内侧感觉部分丧失。踝关节背屈和外翻的力量与对侧相比略有下降。超声检查发现左髋关节周围有少量积液。术后第2天，疼痛加重，从髋关节向足踝放射。直腿抬高测试加剧疼痛。
CT显示髋臼骨块向外突出(图3-A和3-B)，这可能压迫坐骨神经。我们推测截骨碎片和髋臼骨块旋转角度较大可能压迫和刺穿神经，因此，有必要进行翻修手术。
图3 向外突出的髋臼骨块
遂决定进行翻修。我们采用侧卧，后外侧Gibson入路。分离臀大肌牵向后方，可以看到髋关节的小外旋转肌。沿坐骨神经探查，在股方肌的近端神经周围脂肪中发现一个小血肿。神经本身连续性好，没有肉眼可见的损伤。髋臼骨块旋转后，在其后缘可扪及突起。打开梨状肌和上孖肌之间的间隙后，发现该骨突的皮质形成一个尖刺，压迫坐骨神经(图4-A)。屈曲髋关节时，神经压迫加重。切除部分高突的骨皮质，坐骨神经完全减压，髋屈曲时也无压迫(图4-B)。
术后放射疼痛虽有所改善，但在住院期间并没有完全消失。患者持续感到踝关节背屈和外翻无力，因此使用了踝足矫形器。术后2个月，疼痛完全消失。此时，术后X线片显示骨位良好，耻骨支和坐骨已经愈合。随后12个月的多次复查中发现足背屈和外翻力量逐渐改善。术后1年，在足跟行走时，可见踝关节背屈残余轻微的无力。在术后3年影像学随访中，双侧截骨愈合；股骨头在位，Shenton线完整(右侧LCE角36°，左侧30°；臼顶倾斜角右侧2°，左侧0°)。
患者否认有任何虚弱或功能限制。然而，神经学检查发现，左侧脚趾与对侧相比背屈轻微力弱。
讨论：PAO是治疗年轻人有症状的髋臼发育不良的首选保髋手术。据报道，高达90%的患者治疗结果良好，疼痛得以缓解，患者恢复日常活动。股骨神经、坐骨神经或股外侧皮神经的损伤都可能在手术中发生；尚未见闭孔神经的损伤的报道。目前的文献只报道了由于过度的软组织牵拉和截骨时直接破坏造成的坐骨神经损伤。在所有先前报道的病例中，患者要么是在手术后立即出现症状，要么是神经监测发现。Matheney等人报道了1例与我们类似的病例，在复位髋臼的时候发生神经损伤；然而，该研究只提供了有限的资料。在我们的病例中，神经损伤症状在术后第一次活动时，患者坐在床上时被动屈曲髋关节就得以发现。术后第2天CT诊断为骨碎片直接刺激神经。
完整的后柱可以保护坐骨神经。在PAO过程中，髋臼碎片的内旋与前旋导致其后下角部分抬高；然而，这个移位较小。髋臼骨块的内移可能与髂骨边缘产生的效果相似，两者都不能造成坐骨神经损伤。当髋臼碎片的后上缘有皮质骨刺，髋臼矫正后骨突尖向坐骨神经附近摆动时，可能伤及神经。这种类型的骨刺可能由于髋臼上截骨不完全造成，也有可能出现于反髋臼周围截骨术。
通常，PAO中使用透视评估截骨的准确性、髋臼矫形和内固定的位置。对于我们的患者而言，术中透视只能产生质量较差的后前位二维小视野图像，不能辨识压迫坐骨神经的骨块。尽管如此，透视检查与术后X光片有良好相关性，尤其当外科医生在学习曲线中时，可辅助手术。
一些中心使用术中神经监测，尽管术中信号与神经损伤的术后诊断有关，但尚未发现它们有助于预防此类损伤。我们的患者在术伸髋屈膝，一定程度上降低了神经的张力。如果我们的病人也使用神经监测，在伸膝时，我们可以早期发现问题。我们认为，避免这类并发症的最好方法是在复位时认真观察髋臼骨块后上外缘的移动。
Delayed-Onset Sciatic Nerve Palsy After Periacetabular Osteotomy: A Case Report
Case: A large surgical correction was required for severe hip dysplasia, which was associated with a delayed-onset sciatic nerve injury in an adolescent patient. A cortical bone spur on the outside of the acetabular fragment produced an indirect injury that became symptomatic during mobilization of the patient.
Conclusion: The risk of direct injury to the sciatic nerve during a periacetabular osteotomy is quite low when the osteotomy is executed in extension with abduction of the hip and flexion of the knee to reduce tension on the sciatic nerve. Reported injuries have been attributed to direct damage from excessive soft-tissue retraction or during osseous ischial, supra-acetabular, and/or retroacetabular osteotomies.
文献出处：Michael Leunig, Jonathan M Vigdorchik, Aidin Eslam Pour, Silvia Willi-Dähn, Reinhold Ganz. Delayed-Onset Sciatic Nerve Palsy After Periacetabular Osteotomy: A Case Report. Case Reports JBJS Case Connect. Jan-Mar 2017;7(1):e9. doi: 10.2106/JBJS.CC.16.00084.
文献2
肌效贴是否可以矫正过度的动态膝外翻？
一项随机双盲对照试验
译者：肖凯
背景：髋关节周围神经肌肉控制能力不足会导致过大的动态膝外翻（DKV），这会影响膝关节甚至导致膝盖受伤，尤其易导致ACL运动损伤。尽管肌效贴（KT）可以改善功能、稳定性和本体感觉，但有关其对运动员有效性的证据尚无定论。我们假设，肌效贴可以通过增强对髋关节周围的神经肌肉控制来降低DKV。
目的/目的：与对照组相比，确定臀中肌肌效贴是否可以矫正过度的动态膝外翻，并提高髋关节外展肌力量。
方法：本研究招募了40名年龄在18至28岁之间的大学水平的运动员，他们都存在动态膝外翻（男性> 8°，女性> 13°）。排除标准包括：在过去一年中有下腰痛史、外伤史或手术史。符合入选标准的受试者被随机分为肌效贴组和对照组。在对他们进行肌效贴固定之后的第三天，进行跳跃测试和外展肌力测试，并记录数据。
结果：在使用肌效贴即刻，男性[4.0°（95％CI 3.5-4.5）；p <0.001]和女性[4.3°（95％CI 3.5-5.2）；p <0.002] 的DKV显着降低。但在使用后第三天效果消失。肌效贴组在使用肌效贴即刻及三天内的肌力均显著提高于对照组。
结论：应用肌效贴后，DKV立刻减少。然而，使用第三天两组间DKV没有显着差异。在使用肌效贴后，臀中肌力量也显示出明显的改善，而且保持到了第三天。
肌效贴使用示意图
动态膝关节外翻测量示意图
Does Kinesio taping correct exaggerated dynamic knee valgus? A randomized double blinded sham-controlled trial
Background: Deficiency in hip girdle neuromuscular control can cause exaggerated Dynamic Knee Valgus (DKV) which afflicts the knee joint and lead to knee injuries especially ACL injury in sports. Though Kinesio taping (KT) is known to improve function, stability and proprioception, the evidence is inconclusive on its effectiveness in athletes. We hypothesized that kinesio taping could enhance neuromuscular control of the hip girdle there by causing a reduction in DKV.
Aim/objective: To determine whether KT on Gluteus medius can correct exaggerated dynamic knee valgus and improves hip abductor strength when compared to sham KT.
Method: 40 collegiate level athletes, aged between 18 and 28 years, of both genders with presence of dynamic knee valgus (>8° for men and >13° for women) were recruited in the study. Athletes were excluded if they had history of lower back pain, history of any injury or surgery to the lower extremities during the past year. Subjects who met the inclusion criteria were randomized into kinesio taping (KT) group and sham taping (ST) group. The Drop Jump test and the Donnatelli Drop Leg Test (DDT) were performed before, and on the third day, immediately after the application of KT on them and documented.
Results: There was a significant reduction in DKV among male [4.0° (95% CI 3.5-4.5); p < 0.001] and female [4.3° (95% CI 3.5-5.2); p < 0.002] immediately after application of taping but not on the third day after application of KT. There was a significant rise in DDT immediately and on the third day after application of KT between KT group and SC group.
Conclusion: There was a reduction in DKV immediately after the application of KT. However, there was no significant difference between KT group and SC group on the third day. Meanwhile, gluteus medius strength also showed significant improvement immediately after taping and it was maintained even on the third day.
文献出处：Rajasekar S, Kumar A, Patel J, Ramprasad M, Samuel AJ. Does Kinesio taping correct exaggerated dynamic knee valgus? A randomized double blinded sham-controlled trial. J Bodyw Mov Ther. 2018 Jul;22(3):727-732. doi: 10.1016/j.jbmt.2017.09.003. Epub 2017 Sep 8. PMID: 30100304.
文献3
大转子阻滞结合软组织松解治疗LCPD
译者：任宁涛
Perthes病碎裂早期的治疗目的主要集中在增加股骨头的覆盖，无论是采用支具、外展石膏、髋臼和/或股骨近端截骨，其目的均是最大限度的获得好的头臼匹配和关节活动度，避免出现铰链和FAI的形成。Perthes病可导致股骨颈生长障碍，我们的治疗方法是大转子阻滞加内侧软组织松解，除了可以增加股骨头覆盖，还可以解决后期下肢长度和外展问题，并可避免截骨引起来的医源性内翻畸形。
本研究采用回顾性研究，选取12名Perthes病患者，其中9名男孩，3名女孩，平均年龄7.3岁（5.3-9.7），均采用非手术治疗。采用八字板进行大转子阻滞，同时行内收肌和髂腰肌松解，Petrie石膏固定。对平均术后49个月（14-78）的临床和影像学资料进行比较。6块八字板在术后平均43.7个月（28-69）时因为内固定刺激被取出，其余的未取出，在最终随访时，11名患者疼痛、跛行和Trendelenburg征改善，大多数患者的髋关节活动范围得到改善或维持，外展接近正常，未出现大转子撞击。颈干角、Shenton's线、骨骺突出指数、CE角和大转子高度无明显变化。1名患者后期行大转子下移，所有患者后期无行髋臼和股骨近端截骨治疗。4名患者出现严重的下肢不等长，后行对侧骨骺阻滞治疗。术后双下肢不等长无明显改变，无围手术期并发症出现。
我们采用内收肌和髂腰肌肌腱松解和Petrie石膏，大转子阻滞以此来重新引导股骨近端骨骺软骨的生长。采用此方法可避免医源性内翻和外展肌肌力减弱，此方法目的是保持外展肌力量，避免大转子下移或股骨近端截骨。
图1 a 该患者观察6个月后出现半脱位的趋势，Shenton's线不连续，内侧间隙增宽，外侧柱覆盖不佳；b 造影可见外展25度时覆盖改善，但是大转子高位；c 采用大转子阻滞，内收肌和髂腰肌肌腱松解和Petrie石膏固定4周；d 9岁时片子，可见螺钉成角，证明大转子阻滞起效，Shenton's线恢复，外展肌力量好；e 可能是由于外展肌力量好，髋臼发育不良有所改善；f 10岁时，髋关节活动良好，每年复查。
Guided growth of the trochanteric apophysis combined with soft tissue release for Legg-Calve-Perthes disease
During the initial fragmentation stage of Perthes disease, the principle focus is to achieve containment of the femoral head within the acetabulum. Whether by bracing, abduction casts, femoral and/or pelvic osteotomy, the goals are to maximize the range of hip motion and to avoid incongruity, hoping to avert subsequent femoro-acetabular impingement or hinge abduction. A more subtle and insidious manifestation of the disease relates to growth disturbance involving the femoral neck. We have chosen to tether the greater trochanteric physis, combined with a medial soft tissue release, as part of our non-osteotomy management strategy for select children with progressive symptomatology and related radiographic changes. In addition to providing containment, we feel that this strategy addresses potential long-range issues pertaining to limb length and abductor mechanics, while avoiding iatrogenic varus deformity caused by osteotomy. This is a retrospective review of 12 patients (nine boys, three girls), average age 7.3 years old (range 5.3-9.7), who underwent non-osteotomy surgery for Perthes disease. An eight-plate was applied to the greater trochanteric apophysis at the time of arthrogram, open adductor and iliopsoas tenotomy, and Petrie cast application. We compared clinical and radiographic findings at the outset to those at an average follow-up of 49 months (range 14-78 months). Six plates were subsequently removed; the others remain in situ. Eleven of twelve patients experienced improvement in pain, and alleviation of limp and Trendelenburg sign at latest follow-up.The majority had improved or maintained range of motion and prevention of trochanteric impingement demonstrated by near normalization of abduction. Neck-shaft angles, Shenton's line, extrusion index, center edge angles and trochanteric height did not change significantly. One patient underwent subsequent trochanteric distalization and no other patients have undergone subsequent femoral or periacetabular osteotomies. Leg length discrepancy worsened in four patients and was treated with contralateral eight-plate distal femoral epiphysiodesis. As a group the mean leg length discrepancy did not change significantly. There were no perioperative complications. six trochanteric plates were subsequently removed after an average of 43.7 months (range 28-69) due to irritation of hardware; the others remain in situ, pending further growth. We employed open adductor and iliopsoas tenotomy and Petrie cast application and guided growth of the greater trochanter as a means of redirecting the growth of the common proximal femoral chondroepiphysis. The accrued benefits of preventing relative trochanteric overgrowth with a flexible tether are the avoidance of iatrogenic varus and weakening of the hip abductors. The goals are to preserve abductor strength and avoid trochanteric transfer or intertrochanteric osteotomy.
文献出处：Peter M Stevens , Lucas A Anderson, Jeremy M Gililland, Eduardo Novais. Guided growth of the trochanteric apophysis combined with soft tissue release for Legg-Calve-Perthes disease. Strategies Trauma Limb Reconstr . 2014 Apr;9(1):37-43.
文献4
计算机辅助髋臼周围截骨术与常规截骨术
治疗髋关节发育不良的疗效比较
译者：张利强
目的：比较计算机辅助髋臼周围截骨术（PAO）与常规PAO治疗髋关节发育不良（DDH）的疗效。
方法：91名患者（98髋）纳入本研究。在每一个DDH病例中，采用常规PAO治疗，其截骨的角度和方向由术中X线检查确定，采用计算机辅助PAO治疗，则使用3D导航系统。40髋接受常规PAO治疗，58髋接受计算机辅助PAO治疗。
结果：常规PAO患者的日本骨科协会髋关节评分中从术前的70.0分显著提高到术后的90.7分，在计算机辅助PAO患者中则从术前的74.5分显著提高到术后的94.2分。所有计算机辅助PAO患者术后AHI和VCA角均在影像学可接受范围。部分常规PAO患者术后AHI和VCA角度未达影像学可接受范围。平均随访5.4年后，我们对98例行PAO治疗髋关节中的5例（5.1%）进行了全髋关节置换术（THA）。计算机辅助PAO治疗的58个髋关节（0%）中没有一例。
讨论：计算机辅助PAO可实现术中截骨部位的确认，并可实时确定截骨块的位置。与常规PAO相比，计算机辅助PAO患者股骨头的前、外侧覆盖充分无需早期转为THA。
结论：计算机辅助PAO不仅提高了手术的准确性和安全性，而且是股骨头获得了足够的前侧和外侧覆盖，从而防止DDH的进展。
a-c使用规划软件将术前三维图像转换为标准模格式。d 将数据导入导航软件和基于CT的髋关节导航系统
a-b 49岁女性，右DDH，术前LCEA 1°，VCA 12°。c-d 利用跟踪探头检测PAO术后截骨块位置，确定前侧及外侧覆盖是否足够。e-f 术后ACEA为38°，VCA为42°。g 术后5年无骨关节炎
Outcomes of computer-assisted peri-acetabular osteotomy compared with conventional osteotomy in hip dysplasia
Aim of the study: To compare the outcomes after computer-assisted peri-acetabular osteotomy (PAO) and conventional PAO performed for hip dysplasia (DDH).
Methods: Ninety-one patients (98 hips) were enrolled in this study. In each case, DDH was treated with either conventional PAO, in which the angle and direction of the osteotomy was determined by intra-operative X-ray examination, or with computer- assisted PAO, which used the 3D navigation system. Forty hips underwent conventional PAO and 58 hips underwent computer- assisted PAO.
Results: Japanese Orthopaedic Association hip scores improved significantly from 70.0 points pre-operatively to 90.7 points post-operatively in patients with conventional PAO, and from 74.5 points pre-operatively to 94.2 points post-operatively in patients with computer-assisted PAO. In all patients with computer-assisted PAO, the post-operative AHI and VCA angle were within the radiographic target zone. Some patients with conventional PAO had post-operative AHI and VCA angle outside of the target zone. We performed total hip arthroplasty (THA) on five of the 98 PAO hips (5.1%) after an average follow-up period of 5.4 years. None of 58 hips (0%) with computer-assisted PAO was revised.
Discussion: Computer-assisted PAO enabled intra-operative confirmation of osteotomy sites, and the position of the osteotomized bone fragment could be confirmed in real time. Adequate anterior and lateral coverage of the femoral head in patients with computer-assisted PAO resulted in no need for early conversion to THA, in contrast to conventional PAO.
Conclusion: Computer-assisted PAO not only improved accuracy and safety but also achieved sufficient anterior and lateral displacement to prevent the progression of DDH.
文献出处：Imai H, Kamada T, Miyawaki J, Maruishi A, Mashima N, Miura H. Outcomes of computer-assisted peri-acetabular osteotomy compared with conventional osteotomy in hip dysplasia. Int Orthop. 2020 Jun;44(6):1055-1061. doi: 10.1007/s00264-020-04578-x. Epub 2020 Apr 28. PMID: 32342143; PMCID: PMC7260271.
文献5
股骨髋臼撞击征（FAI）的前期手术是否会
影响髋关节置换术的结果？
译者：陶可（北京大学人民医院骨关节科）
背景：开放和关节镜下手术已被报道用来解决股骨髋臼撞击征（FAI）。尽管效果良好，但仍有一部分患者随后需要进行全髋关节置换术（THA）。但是，关于FAI手术后THA结局的研究数据很少。该项研究的目的是确定THA的临床结局是否受到前期开放或关节镜下（手术治疗）FAI的影响。
方法：本项病例匹配的回顾性研究共纳入了23例（24髋）患者，这些患者在FAI前期手术（14例关节镜和10例开放）后接受了THA治疗，并将他们与24例没有（THA）术前髋关节手术史的匹配对照（病例）进行了比较。对照患者的年龄、性别、手术方式、所用植入物以及术前改良的Harris髋关节评分（mHHS）在两组之间没有差异。主要结果指标是mHHS。两组之间还比较了手术时间、失血量和THA后异位骨化的存在。
结果：在进行33（24-70）个月的THA平均随访后，FAI治疗组的平均mHHS 92.9±12.7与对照组的平均mHHS 95.2±6.6（P = 0.43）之间无显著差异。与对照组相比，髋关节外科脱位（SHD；平均109.3±29.8）后，THA的手术时间增加了（平均88.0±24.2；P <0.05）。两组之间的失血量无显着差异。与对照相比，SHD后异位骨化的发生率显著更高（P <0.05）。
结论：THA后的临床结局不受前期开放或关节镜治疗FAI的影响。但是，SHD后（THA的）手术时间增加、异位骨化风险增加。
图1.（A）对照组和FAI治疗组（在THA之前接受了HA或髋关节外科脱位治疗）之间在THA之后的平均mHHS的箱形图（P¼.4）。（B）THA后平均mHHS的亚分析，比较有HA、髋关节外科脱位病史和对照组患者。两组之间无显着差异（P¼.4）。FAI，股骨髋臼撞击征；HA，髋关节镜；mHHS，改良的Harris髋关节评分；THA，全髋关节置换术。
Does Prior Surgery for Femoroacetabular Impingement Compromise Hip Arthroplasty Outcomes?
Background: Open and arthroscopic approaches have been described to address femoroacetabular impingement (FAI). Despite good outcomes, there is a subset of patients who subsequently require total hip arthroplasty (THA). However, there is a paucity of data on the outcomes of THA after surgery for FAI. The purpose of this study was to determine whether clinical outcomes of THA are affected by prior open or arthroscopic treatment of FAI.
Methods: This case-matched retrospective review included 23 patients (24 hips) that underwent THA after previous surgery for FAI (14 arthroscopic and 10 open) and compared them to 24 matched controls with no history of prior surgery on the operative hip. The controls were matched for age, sex, surgical approach, implants used, and preoperative modified Harris hip score (mHHS) did not differ between groups. The primary outcome measure was the mHHS. Operative time, blood loss, and the presence of heterotopic ossification after THA were also compared between groups.
Results: There was no significant difference in mean mHHS between the FAI treatment group 92.9 ± 12.7 and controls 95.2 ± 6.6 (P = .43) at a mean follow-up after THA of 33 (24-70) months. Increased operative times were noted for THA after surgical hip dislocation (SHD; mean 109.3 ± 29.8) compared to controls (mean 88.0 ± 24.2; P < .05). There was no significant difference in blood loss between groups. The occurrence of heterotopic ossification was significantly higher after SHD compared to controls (P < .05).
Conclusions: Clinical outcomes after THA are not affected by prior open or arthroscopic procedures for FAI. However, increased operative times and an increased risk of heterotopic ossification were noted after SHD.
文献出处：Luke S Spencer-Gardner, Christopher L Camp, J Ryan Martin, Rafael J Sierra, Robert T Trousdale, Aaron J Krych. Does Prior Surgery for Femoroacetabular Impingement Compromise Hip Arthroplasty Outcomes? J Arthroplasty. 2016 Sep;31(9):1899-903.
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