本期目錄：

1、外側閉合楔形脛骨高位截骨后全膝關節置換術與初次全膝關節置換術比較

2、初次全膝關節置換術后恢復駕車的影響因素分析

3、膝關節內側單髁置換術后的臨床結局評分：MAKO機器人輔助手術與牛津傳統手術方法的比較

4、旋轉生長引導技術：兒童應用初步報告

5、DDH患兒髖關節重建術后早期活動

6、人工智能輔助成像對髖關節發育不良的診斷價值

7、髖臼周圍截骨術中骨盆后傾-如何避免系統誤差導致髖臼后傾和可能的股骨髖臼撞擊

8、髖臼前傾角測量：面積法測量髖臼前傾角

9、髖關節發育不良解剖結構改變步態中肌肉力矩臂長度、作用線及其對關節反作用力的貢獻

10、髖臼深度、髖臼發育的早期預測因素：切開復位后髖關節發育不良患者MRI觀察

第一部分：關節置換及保膝相關文獻

文獻1

外側閉合楔形脛骨高位截骨后全膝關節置換術與初次全膝關節置換術比較：傾向性評分匹配研究

譯者 張軼超

背景：患者報告的脛骨高位截骨術（HTO）后全膝關節置換術（TKA）與初次全膝關節置換術（TKA）預后的差異尚未被完全了解。本研究旨在比較HTO后TKA與初次TKA患者報告的預后、影像學參數和并發癥發生率。

方法：在術后6個月和1年時，對65例外側閉合楔形HTO術后行TKA的患者和相匹配的初次TKA患者進行比較。年齡、性別、吸煙狀況、體重指數、術前休息時的疼痛數字評定量表（NRS）、膝關節損傷和骨關節炎效果評分-身體功能簡表（KOOS-PS）、EuroQol五維（EQ-5D）總體健康評分和牛津膝關節評分（OKS）中的組間混雜因素通過傾向性評分匹配進行平衡。患者報告的效果通過NRS休息疼痛、KOOS-PS、EQ-5D總體健康評分和OKS來評測。影像學參數為股脛角、脛骨內側近端角、股骨遠端外側解剖角、脛骨后傾角和髕骨高度（install - salvati 比率）。比較兩組TKA的并發癥發生率。通過HTO術后行TKA患者的取釘時間是在TKA前還是同時進行來評估HTO生存時間，還有評估髕骨表面置換率。經Bonferroni校正，p值<0.0125表示有統計學意義。

結果：傾向性評分匹配后，在患者報告的效果、影像學參數和并發癥發生率方面，組間無顯著差異（p > 0.0125）。在HTO后TKA組中，平均HTO生存時間為8.7年，TKA前有46例（71%）和TKA期間有19例（19例）患者拆除了固定釘，11例（17%）患者進行了髕骨表面置換。在原發性TKA組，15例（23%）患者進行了髕骨置換。

結論：HTO術后TKA的短期評估結果與初次TKA相似。既往的HTO不會影響后續TKA的早期結果，這表明既往的HTO對TKA結果的影響很小。

Total knee arthroplasty following lateral closing-wedge high tibial osteotomy versus primary total knee arthroplasty: a propensity score matching study

Background：The disparity in patient-reported outcomes between total knee arthroplasty (TKA) following high tibial osteotomy (HTO) and primary TKA has yet to be fully comprehended. This study aims to compare the patientreported outcomes, radiological parameters and complication rates between TKA following HTO and primary TKA.

Methods：Sixty-fve patients who underwent TKA following lateral closing-wedge HTO were compared to a matched group of primary TKA at postoperative 6-months and 1-year. Between-group confounders of age, gender, smoking status, Body Mass index, preoperative Numeric Rating Scale (NRS) pain in rest, Knee injury and Osteoarthritis Outcome Score-Physical function Shortform (KOOS-PS), EuroQol fve-dimensional (EQ-5D) overall health score, and Oxford Knee Score (OKS) were balanced by propensity score matching. Patient-reported outcome measures were NRS pain in rest, KOOS-PS, EQ-5D overall health score, and OKS. Radiological parameters were femorotibial angle, medial proximal tibial angle, anatomical lateral distal femoral angle, posterior tibial slope, and patellar height assessed by Insall-Salvati ratio. The complication rates of TKA were compared between the two groups. The HTO survival time, the choice of staple removal before or during TKA in patients who underwent TKA following HTO patients, and the rate of patellar resurfacing were assessed. The p value<0.0125 indicates statistical signifcance after Bonferroni correction.

Results：After propensity score matching, no signifcant between-group diferences in the patient-reported outcome measures, radiographical parameters and complication rates were found (p>0.0125). In the TKA following HTO group, with an average HTO survival time of 8.7 years, staples were removed before TKA in 46 patients (71%) and during TKA in 19 patients, and 11 cases (17%) had patella resurfacing. In the primary TKA group, 15 cases (23%) had patella resurfacing.

Conclusion：The short-term assessment of TKA following HTO indicates outcomes similar to primary TKA. A previous HTO does not impact the early results of subsequent TKA, suggesting that the previous HTO has minimal infuence on TKA outcomes.

文獻出處：Xie T, de Vries AJ, van der Veen HC, Brouwer RW. Total knee arthroplasty following lateral closing-wedge high tibial osteotomy versus primary total knee arthroplasty: a propensity score matching study. J Orthop Surg Res. 2024 May 7;19(1):283. doi: 10.1186/s13018-024-04760-6. PMID: 38715064; PMCID: PMC11077886.

文獻2

初次全膝關節置換術后恢復駕車的影響因素分析

譯者 張薔

背景：全膝關節置換（TKA）術后患者何時可以恢復駕車目前并不明確。盡管患者間年齡、一般健康狀況和運動能力存在較大差異，絕大多數術者普遍限制患者TKA術后駕車的時間為4-6周。本研究的主要目的是創造全膝的臨床預測工具來評估初次TKA術后恢復駕車的時間。

方法：本前瞻性研究共入組了167例患者。受試者術后每三天接受一次短信調查隨訪以決定恢復駕車的時間。受試者還需在術后2周、6周和12周的門診隨訪時需要完成8項運動評測。最后，受試者需要完成所有的恢復駕車調查和固定的回訪。我們收集了一般信息、手術相關信息、患者自評療效和患者相關因素。最后，我們應用Cox比例風險模型和參數化生存模型來創造兩種全新的預測恢復駕車時間的計算工具。

結果：共有156名患者（平均年齡67.7歲[39-83歲]）完成了所有研究項目。恢復駕車的中位時間為18天（四分位數[IQR]，12-27天）。單因素分析顯示男性患者（18天）恢復駕車時間早于女性患者（25.3天）（p < 0.001），且左膝手術的患者（20.1天）恢復駕車的時間早于右膝手術的患者（24.4天）（p = 0.021）。術前因素中，年齡、性別、術側和術前膝關節損傷與骨關節炎評分（KOOS）對恢復駕車時間有影響，因此被列入術前臨床預測工具中。術后因素中，年齡、性別、術側、術前KOOS評分和6項運動評測項目對恢復駕車時間有影響，因此被列入術后基于運動水平的計算工具中。

結論：最終我們發現，接受初次TKA手術的患者術后恢復駕車的時間比之前普遍預想的要早很多。患者相關因素和術后運動能力顯著影響恢復駕車的時間。應用全新的術前臨床預測工具，我們可以給每位患者關于恢復駕車時間的個體化建議。而在術后，我們應用全新的基于運動水平的計算工具，可以在患者具備恢復駕車的條件時及時告知患者。

掃描二維碼可查看兩種計算工具。

Factors That Influence Returning to Driving Following Primary Total Knee Arthroplasty

A Prospective Investigation

Background: It is unclear when a patient can return to driving after total knee arthroplasty (TKA). Currently, most surgeons simply restrict all patients from driving for 4 to 6 weeks after TKA despite variability in patient age, general health, and physical capabilities. The primary objective of this study was to create novel clinical prediction calculators to estimate the return-to-driving time following primary TKA.

Methods: In this study, 167 patients who were undergoing a primary TKA were prospectively enrolled. Subjects received text message surveys every third day postoperatively to determine when they returned to driving. Subjects completed 8 physical performance maneuvers at their 2, 6, and 12-week postoperative clinical appointments. Additionally, subjects completed return-to-driving surveys and a structured interview. Data on demographic characteristics, operative factors, patient-reported outcomes, and patient factors were collected. Cox proportional hazard and parametric survival models were utilized to create 2 novel calculators for predicting return-to-driving time.

Results: There were 156 patients (mean age, 67.7 years [range, 39 to 83 years]) who completed the study. The median return-to-driving time was 18 days (interquartile range [IQR], 12 to 27 days). Univariate analysis demonstrated that male patients returned to driving sooner (18 days) than female patients (25.3 days) (p < 0.001) and that patients who underwent left-sided surgery returned to driving sooner (20.1 days) than patients who underwent right-sided surgery (24.4 days) (p = 0.021). For preoperative factors, age, sex, laterality, and preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) had an effect on return-to-driving time and therefore were included in the novel preoperative clinical prediction calculator. For postoperative factors, age, sex, laterality, preoperative KOOS, and 6 metrics from the physical performance maneuvers had an effect on return-to-driving time and therefore were included in the novel postoperative physical performance-based instrument.

Conclusions: Overall, patients undergoing primary TKA returned to driving considerably earlier than previously reported. Patient-related factors and postoperative physical performance significantly affect return-to-driving time. Using the novel preoperative clinical prediction tool, individual patients can be advised when to expect to return to driving. After surgery, the novel postoperative physical performance-based instrument can inform patients when they may be ready to return to driving.

文獻3

膝關節內側單髁置換術后的臨床結局評分：MAKO機器人輔助手術與牛津傳統手術方法的比較

譯者 沈松坡

背景：內側單髁膝關節置換術（UKA）是一種治療膝關節內側間室骨關節炎的可行手術方案。由于在假體定位和對線方面的精確性，機器人輔助手術UKA逐漸普及。本研究比較了MAKO機器人輔助手術UKA與傳統牛津UKA的臨床結局。

方法：本回顧性研究納入了2019年1月至2020年12月期間接受內側UKA的患者。MAKO組（n=47）與牛津組（n=60）分別比較了術前和術后患者報告的結局指標（PROMs），包括牛津膝關節評分（OKS）、遺忘關節評分-12（FJS-12）及患者滿意度評分。

結果：兩組術后OKS和FJS-12評分均顯著改善。與牛津組相比，MAKO組的術后平均OKS評分（43.3 vs 41.0，p=0.048）和FJS-12評分（75.1 vs 68.6，p=0.042）更高。患者滿意度在MAKO組也顯著更高（p=0.039）。

結論：在功能評分和患者滿意度方面，MAKO機器人輔助手術UKA較傳統牛津UKA可獲得更優越的短期臨床結局。

圖 (a) 術前規劃的股骨截骨與假體定位。(b) 術前規劃的脛骨截骨與假體定位。

Clinical Outcome Scores Post Medial Unicompartmental Knee Arthroplasty: A Comparison of the MAKO Robotic Arm versus the Oxford Conventional Approach

Introduction: Unicompartmental knee arthroplasty (UKA) has significant advantages over total knee arthroplasty (TKA). However, due to its need for precise positioning and soft tissue balancing, UKA failures and revision rates may be higher than that of TKA. Robotic-assisted UKA offers more accurate implant positioning, soft tissue balancing, improved lower limb alignment, and a reduction in surgical error. There are few studies studying functional outcomes post robotic-assisted UKA. The aim of this study was to compare the functional outcomes between robotic-assisted and conventional medial UKA.

Material and methods: A retrospective review was done of 159 patients; 110 patients underwent conventional UKA while 49 patients underwent robotic-assisted UKA. Outcome measures included the Oxford Knee Score (OKS), Knee Society Score (KSS), Visual Analogue Score (VAS) for pain, and range of motion (ROM) at three months, one-year and two years post-UKA.

Results: Pre-operative patient demographics and outcome scores were not significantly different between both groups. ROM was significantly greater in the MAKO compared to the Oxford group at 3 months (p=0.039), 1 year (0.053) and 2 years (0.001) post-operation. While OKS, KSS and VAS scores improved for both groups, there were no significant differences in the final outcome measures. None of the patients experienced a mechanical failure, infection, or revision post-surgery. One patient each in the Oxford and MAKO group suffered a periprosthetic fracture.

Conclusion: Both robotic-assisted MAKO UKA and conventional Oxford UKA showed good clinical outcomes. Robotic-assisted MAKO UKA had superior ROM outcomes compared to conventional Oxford UKA up to two years post-surgery.

第二部分：保髖相關文獻

文獻1

旋轉生長引導技術：兒童應用初步報告

譯者 羅殿中

兒童下肢扭轉異常較為常見，很難自我塑形，或需要手術治療。一般來說需要開放截骨來矯正。微創角度調整的生長引導技術已經成為（內外翻矯形的）金標準；并開始用于對扭轉畸形的調整探索。

該研究展示了我們的研究結果，采用脛骨或股骨外周彈力帶新技術。5個患者8處骨骼，采用合頁板（加拿大）彈力帶技術進行治療。荷葉板呈45°角分別固定于骺端和干骺端，然后用纖維束帶（美國）進行固定。內植物分別固定于內側和外側，45°相反方向，取決于希望矯正的方向。平均治療時間為12個月，在臨床評估中，所有患者的扭轉畸形均得到矯正。平均矯正角度股骨為30°、脛骨為9.5°。而且，在平均18個月的隨訪中，扭轉畸形無復發。在雙側均矯形的患者，縱向生長未受影響。

采用彈力帶進行扭轉畸形生長引導，是一項新的技術，可以在無需截骨的情況下，成功治療扭轉畸形。

圖1. 俯臥位檢查足股軸線（左圖）；俯臥位檢查髖關節內旋（中圖）；俯臥位檢查髖關節外旋（右圖）。

圖2. 旋轉生長引導內植物示意圖。采用一對對稱合頁鋼板；通過纖維束帶環繞聯接；鋼板采用螺釘固定于骨骼。示意圖版權歸屬Paley基金會，刊印已獲授權。

圖3. 一組鋼板傾斜置于股骨髁內側，另一組鋼板傾斜置于股骨髁外側，交叉角度盡可能接近90°。示意圖版權歸屬Paley基金會，刊印已獲授權。

圖4. 旋轉生長引導術前術后膝關節前面觀、后面觀、外側觀、內側觀示意圖。示意圖版權歸屬Paley基金會，刊印已獲授權。

圖5. 雙側股骨遠端旋轉生長引導術后髖關節內旋（左圖）、外旋（右圖）；同一患者與圖1術前情況進行比較。

圖6. 圖1、圖5同一患者雙下肢站立位全長正位片。旋轉生長引導裝置植入時片（左上圖）；旋轉生長引導完成后片（中上圖）；采用內側固定行內側半骺融合術矯正膝外翻（右上圖）。左下圖可以看到旋轉生長引導鋼板植入時交叉角度，與右下圖矯正完成時交叉角度進行比較，可以看到交叉角度的變化。

圖7. 旋轉生長引導技術在脛骨的應用。左圖為矯正開始時側位片，右圖為矯正結束時側位片，可以看出交叉角度的變化。該病例矯正角度為17°。

文獻出處：Paley D, Shannon C. Rotational Guided Growth: A Preliminary Study of Its Use in Children. Children (Basel). 2022 Dec 29;10(1):70. doi: 10.3390/children10010070. PMID: 36670621; PMCID: PMC9856838.

文獻2

DDH患兒髖關節重建術后早期活動

譯者 任寧濤

背景

針對DDH患兒髖關節重建術后，絕大多數小兒骨科醫生喜歡石膏制動4-12周，石膏制動可引起石膏固定相關并發癥，對DDH患兒髖關節重建術后不選擇石膏制動，選擇早期活動的研究甚少。

方法

對行髖關節重建手術（Dega、股骨近端截骨、切開復位）的患兒進行回顧性研究，共納入27名患兒（3.4±2.0歲），包括33例髖關節，涵蓋發育不良和脫位（T?nnis1-4），術后患兒放置在泡沫殼內，保持髖關節中立位屈曲外展30度，手術后幾天內進行早期被動活動，術后3-4周完全負重，記錄患兒術前和術后查體和影像學評估情況，隨訪時間12.3±2.9月。

結果

術后AI從36.9°降低到21.7°，CE角從9.9°增加到28.6°，終末隨訪時所有的髖關節復位達到了T?nnis 1，未發現骨塊移位、股骨頭或髖臼缺血壞死、不愈合和神經損傷。

結論

此隊列研究發現，髖關節重建術后早期活動不影響臨床和影像學效果，DDH髖關節重建術后可進行早期活動。

圖 泡沫殼，保持髖關節中立位屈曲外展。

Outcome after early mobilization following hip reconstruction in children with developmental hip dysplasia and luxation

Background: Most orthopedic surgeons prefer spica cast immobilization in children for 4 to 12 weeks after surgical hip reconstruction in children with developmental hip dysplasia. This challenging treatment may be associated with complications. Studies are lacking that focus on early mobilization without casting for postoperative care after hip reconstruction.

Methods: Twenty-seven children (3.4±2.0 years), including 33 hips with developmental hip dysplasia (DDH) and dislocation of the hip (T?nnis grade 1 to 4), who underwent hip reconstruction (Dega acetabuloplasty, varisation-derotation osteotomy and facultative open reduction) were retrospectively included in this study. Postoperatively the patients were placed in an individual foam shell with 30 degrees of hip abduction, hip extension, and neutral rotation. Early mobilization physiotherapy was performed within the first few days after the surgery under epidural anaesthesia. Full weight bearing was allowed after 3-4 weeks. All children received a clinical examination and radiographic evaluation before and after surgical intervention. The follow-up period was 12.3±2.9 months.

Results: On average, the postoperative acetabular index decreased significantly from 36.9 to 21.7 degrees and the center-edge angle increased from 9.9 to 28.6 degrees. All hips had reached T?nnis grade 1 at the time of the last follow-up. No complications such as dislocation of the bone wedge, avascular necrosis of the acetabulum or femur, lack of non-union, or nerve injury, were reported.

Conclusions: In this cohort study, hip reconstruction was successful according to clinical and radiographic outcome parameters after early mobilization without cast therapy. Early mobilization may be used as an alternative treatment option after hip reconstruction in DDH.

文獻出處：Katharina Susanne Gather, Eva von Stillfried, Sebastien Hagmann Sebastian Müller, Thomas Dreher. Outcome after early mobilization following hip reconstruction in children with developmental hip dysplasia and luxation. World J Pediatr. 2018 Apr;14(2):176-183.

文獻3

人工智能輔助成像對髖關節發育不良的診斷價值：系統綜述與薈萃分析

譯者 李勇

目的 通過薈萃分析，闡明人工智能（AI）輔助成像對髖關節發育不良（developmental dysplasia， DDH）的診斷價值。

方法 截止2024年4月4日，檢索PubMed、Web of Science、Embase、The Cochrane Library數據庫中有關人工智能早期診斷DDH的相關文獻。使用診斷準確性研究質量評估工具評估納入研究的質量。采用Revman5.4和StataSE-64軟件計算AI輔助成像診斷DDH的綜合靈敏度、特異度、AUC值和DOC值。

結果 meta分析納入13項研究（6項前瞻性研究，7項回顧性研究），28個人工智能模型，共10,673個樣本。總結靈敏度、特異度、AUC值、DOC值分別為99.0% （95% Cl: 97.0 ~ 100.0%）、94.0% （95% Cl: 89.0 ~ 96.0%）、99.0% （95% Cl: 98.0 ~ 100.0%）、1342 （95% Cl: 469 ~ 3842）。

結論 AI輔助成像對DDH有較高的診斷效能，提高了DDH早期影像學檢查的準確性。需要更多的前瞻性研究來進一步證實AI輔助成像在DDH早期診斷中的價值。

The diagnostic value of artificial intelligenceassisted imaging for developmental dysplasia of the hip: a systematic review and metaanalysis

Objective To clarify the efficacy of artificial intelligence (Al)-assisted imaging in the diagnosis of developmental dysplasia of the hip (DDH) through a meta-analysis. Methods Relevant literature on Al for early DDH diagnosis was searched in PubMed, Web of Science, Embase, and The Cochrane Library databases until April 4, 2024. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess the quality of included studies. Revman5.4 and StataSE-64 software were used to calculate the combined sensitivity, specificity, AUC value, and DOC value of Al-assisted imaging for DDH diagnosis. Results The meta-analysis included 13 studies (6 prospective and 7 retrospective) with 28 Al models and a total of 10,673 samples. The summary sensitivity, specificity, AUC value, and DOC value were 99.0% (95% Cl: 97.0-100.0%),94.0% (95% Cl: 89.0-96.0%), 99.0% (95% Cl: 98.0-100.0%), and 1342 (95% Cl: 469-3842), respectively. Conclusion Al-assisted imaging demonstrates high diagnostic efficacy for DDH detection, improving the accuracy of early DDH imaging examination. More prospective studies are needed to further confirm the value of Al-assisted imaging for early DDH diagnosis. Keywords Artificial intelligence, Diagnostic value, Developmental dysplasia of the hip, Meta-analysis

文獻出處：Chen M, Cai R, Zhang A, Chi X, Qian J. The diagnostic value of artificial intelligence-assisted imaging for developmental dysplasia of the hip: a systematic review and meta-analysis. J Orthop Surg Res. 2024 Aug 29;19(1):522. doi: 10.1186/s13018-024-05003-4. PMID: 39210407; PMCID: PMC11360681.

文獻4

髖臼周圍截骨術中骨盆后傾-如何避免系統誤差導致髖臼后傾和可能的股骨髖臼撞擊

譯者 張利強

背景：骨盆傾斜直接影響X線片上髖臼扭轉角度。骨盆傾斜度的改變可能影響髖臼周圍截骨術（periacetabular osteotomy, PAO）后的髖臼再定位。

目的：(1)比較髖關節發育不良和髖臼后傾、單側和雙側PAO、男性和女性患者的恥骨聯合高度與骶髂寬度的比值（PS-SI）。(2)通過追蹤PAO術后患者術前、術中、術后及中短期隨訪的骨盆傾斜度（PS-SI比值量化）來評估PAO術后患者的骨盆傾斜度。

研究設計：病例系列；證據等級，4級。

方法：回顧性分析2005年1月至2019年12月接受PAO治療的124例（139髖）髖關節發育不良患者和46例（57髖）髖臼后傾患者的臨床資料。排除標準包括影像學資料不足、既往或同期有髖關節手術、創傷后或兒童畸形，或者發育不良合并后傾（90例患者，95髖）。發育不良定義為外側中心邊緣角<23°；后傾定義為同時出現后傾指數30%和坐骨棘陽性和后壁征。分別于術前、PAO時、術后及短期和中期隨訪時拍攝仰臥位骨盆正位X線片(均值± SD[范圍]；9 ± 3周[5-23周]和21 ± 21周[6-125個月])。在5個觀察期（術前至中期隨訪）計算不同亞組（發育不良與后傾、單側手術與雙側手術、男性與女性）的PS-SI比值，并進行組內和組間一致性檢驗[組內相關系數（ICC）分別為0.984 （95%CI, 0.976 ~ 0.989）和0.991 (95%CI, 0.987 ~ 0.994)]。

結果：在所有觀察期內，發育不良與后傾的PS-SI比值均有差異（P = .041至P<.001）。男性發育不良髖關節PS-SI比值在各觀察時間段均低于女性（P< 0.05）。001至P = .005)。在髖臼后傾患者中，男性的PS-SI比值在短期和中期隨訪時均低于女性（P = .024和.003）。在單側和雙側手術之間沒有差異（P = .306到P = .905），除了短期隨訪的發育不良組（P = .040）。術前、術中和術后各亞組PS-SI比值均較術前降低（P< 0.05）。P = 0.031)。術后近、中期隨訪時PS-SI比值較術中升高（P< 0.05）。從0.001到P = .044)，所有亞組與術前相比無差異（P = .370到P = .795）。

結論：男性和發育不良髖關節的PS-SI比值較低。所有亞組術中PS-SI比值均降低，提示骨盆后傾。術中正確的骨盆定向對髖臼精確再定位至關重要。術中后傾導致低估了髖臼骨塊的旋轉角度和隨訪時髖臼醫源性后傾，使骨盆處于正確且更前傾的方向。PAO術中不考慮后傾可能導致股骨髖臼撞擊。因此，我們改變了我們的術中設置，通過調整透視角度來補償骨盆后傾。

關鍵詞：髖臼后傾；髖臼的發育不良;骨盆傾斜;髖臼周圍截骨術

（a）PS-SI比在截骨術之前，期中和之后量化骨盆傾斜度。 PS-SI比定義為恥骨聯合（PS）高度與sacroiliac（SI）寬度的比率。 從（b）術前到（c）術后，PS-SI比降低，表明骨盆傾斜降低

Retrotilt of the Pelvis During Periacetabular Osteotomy

How to Avoid a Systematic Error Resulting in Acetabular Retroversion and Possible Femoroacetabular Impingement

Background: Pelvic tilt directly influences acetabular version on radiographs. Changes of pelvic tilt potentially affect acetabular reorientation after periacetabular osteotomy (PAO).

Purpose: (1) To compare the ratio of the pubic symphysis height to the sacroiliac width (PS-SI) between hips with dysplasia and acetabular retroversion, uni- and bilateral PAO, and male and female patients. (2) To evaluate pelvic tilt (quantified using the PS-SI ratio) in patients after PAO by tracking it from preoperative to intra- and postoperative and short- and middle-term follow-up.

Study Design: Case series; Level of evidence, 4.

Methods: A retrospective and radiographic study was conducted evaluating pelvic tilt in 124 patients (139 hips) with dysplasia and 46 patients (57 hips) with acetabular retroversion who were undergoing PAO (January 2005–December 2019). Patients were excluded if they had insufficient radiographic data, previous or concomitant hip surgery, posttraumatic or pediatric deformities, or combined dysplasia and retroversion (90 patients, 95 hips). Dysplasia was defined as a lateral center-edge angle < 23°; retroversion was defined by simultaneous appearance of a retroversion index 30% and positive ischial spine and posterior wall signs. Anteroposterior pelvic radiographs were taken in the supine position preoperatively, during PAO, postoperatively, and at shortand middle-term follow-up (mean ± SD [range]; 9 ± 3 weeks [5-23 weeks] and 21 ± 21 weeks [6-125 months]). The PS-SI ratio was calculated at 5 observation periods (preoperatively to middle-term follow-up) for different subgroups (dysplasia vs retroversion, uni- vs bilateral surgery, male vs female) and validated with intra- and interobserver agreement (intraclass correlation coefficients, 0.984 (95%CI, 0.976-0.989) and 0.991 (95% CI, 0.987-0.994), respectively).

Results: The PS-SI ratio differed between dysplasia and retroversion at all observation periods (P = .041 to P<.001). Male dysplastic hips had a lower PS-SI ratio when compared with female dysplastic hips at all observation periods (P<.001 to P = .005). In hips with acetabular retroversion, the PS-SI ratio was lower in men than women at short- and middle-term follow-up (P = .024 and .003). No difference was found between uni- and bilateral surgery (P = .306 to P = .905) except for short-term follow-up in dysplasia (P = .040). The PS-SI ratio decreased in all subgroups preoperatively to intra- or postoperatively (P<.001 to P = .031). At short- and middle-term follow-up, the PS-SI ratio increased as compared with intraoperatively (P<.001 to P = .044) and did not differ from preoperatively in all subgroups (P = .370 to P = .795).

Conclusion: A lower PS-SI ratio was found for male or dysplastic hips. In all subgroups, the PS-SI ratio decreased during surgery, indicating retrotilt of the pelvis. Correct pelvic orientation during surgery is crucial for accurate acetabular reorientation. Retrotilt during surgery results in underestimation of acetabular version and iatrogenic retroversion of the acetabulum at follow-up, with the pelvis in the correct and more forward-tilted orientation. Not taking into account retrotilt during PAO potentially results in femoroacetabular impingement. Therefore, we changed our intraoperative setting with adjustment of the central beam to compensate for retrotilt of the pelvis.

文獻出處：Vuillemin N, Meier MK, Moosmann AM, Siebenrock KA, Steppacher SD. Retrotilt of the Pelvis During Periacetabular Osteotomy: How to Avoid a Systematic Error Resulting in Acetabular Retroversion and Possible Femoroacetabular Impingement. Am J Sports Med. 2023 Apr;51(5):1224-1233. doi: 10.1177/03635465231155201. Epub 2023 Mar 6. PMID: 36876866.

文獻5

髖臼前傾角測量：面積法測量髖臼前傾角

譯者 陶可

目前已描述了幾種用于測量全髖關節置換術后髖臼杯假體前傾角的放射學方法，這些方法均耗時且重復性各異。本研究旨在將近期提出的面積法與真實髖臼前傾角進行比較。

本研究進一步以編程方式應用該方法，使用兩個計算機程序自主確定髖臼的放射學方向，然后將這些結果與手動測量和加速度計測量結果進行比較。對裝有全髖關節置換系統的標準假骨骨盆拍攝了160張前后位骨盆X線片。在每次拍攝之間重新調整髖臼杯的方向，使其前傾角范圍為0°至90°。在髖臼上安裝一個加速度計來測量真實的髖臼前傾角。通過三種方法獨立測量髖臼影像學方向：手動測量、線性圖像處理和機器學習。將測量結果與三軸加速度計記錄進行比較。手動測量、機器學習和線性圖像處理的判定系數(R2)分別為0.997、0.991和0.989。機器學習程序和手動測量分別高估了前傾0.70°和0.02°。使用線性技術的程序低估了前傾5.02°。機器學習和線性圖像處理程序的平均運行時間分別為0.03和0.59秒。當真正的髖臼前傾小于51°時，機器學習程序的平均杯形方向誤差在1°以內，當前傾小于85°時，機器學習程序的平均杯形方向誤差在2°以內。與真實前傾相比，面積法通過手動測量顯示出很高的準確性和可靠性。本研究結果支持使用機器學習準確、及時、自主地評估髖臼杯方向。

圖1 測量者徒手測量（綠色圓圈）、使用線性圖像處理技術的程序（橙色方塊）和機器學習程序（灰色三角形）的前傾角測量值與髖臼杯加速度計獲得的前傾角的對比。

圖2 (a)線性圖像處理技術顯示像素強度閾值大于0.2（綠色）、0.4（紅色）、0.6（藍色）和0.8（青色）。髖臼后部不成比例地被股骨頭遮擋。(b)線性圖像處理技術顯示像素強度閾值大于0.40（綠色）、0.60（紅色）、0.80（藍色）和0.86（青色）。閾值的增加表明閾值的增加趨勢向中心方向和髖臼杯被遮擋的部分發展。

The area method for measuring acetabular cup anteversion: An accurate and autonomous solution

Several radiological methods of measuring anteversion of the acetabular component after total hip arthroplasty have been described, all time-consuming and with varying reproducibility. This study aimed to compare the recently proposed Area method to true cup anteversion as determined by an accelerometer. This study further applied this method programmatically to autonomously determine radiographic cup orientation using two computer programs, then compared these results to hand and accelerometer measurements. 160 anteroposterior pelvis radiographs were taken of a standard Sawbones? pelvis fitted with a total hip arthroplasty system. The acetabular cup was re-oriented between each radiograph, with anteversion ranging from 0° to 90°. An accelerometer was mounted to the cup to measure true cup anteversion. Radiographic anteversion was independently measured via three methods: by hand, linear image processing, and machine learning. Measurements were compared to triaxial accelerometer recordings. Coefficient of determination (R2) was found to be 0.997, 0.991, and 0.989 for hand measurements, the machine learning, and linear image processing, respectively. The machine learning program and hand measurements overestimated anteversion by 0.70° and 0.02° respectively. The program using linear techniques underestimated anteversion by 5.02°. Average runtime was 0.03 and 0.59 s for the machine learning and linear image processing program, respectively. The machine learning program averaged within 1° of cup orientation given a true cup anteversion less than 51°, and within 2° given an anteversion less than 85°. The Area method showed great accuracy and reliability with hand measurements compared to true anteversion. The results of this study support the use of machine learning for accurate, timely, autonomous assessment of cup orientation.

文獻出處：Michael P Murphy, Cameron J Killen, Steven J Ralles, Nicholas M Brown, Albert J Song, Karen Wu. The area method for measuring acetabular cup anteversion: An accurate and autonomous solution. J Clin Orthop Trauma. 2021 Apr 14:18:61-65. doi: 10.1016/j.jcot.2021.04.002. eCollection 2021 Jul.

文獻6

髖關節發育不良解剖結構改變步態中肌肉力矩臂長度、作用線及其對關節反作用力的貢獻

譯者 邱興

髖關節發育不良（developmental dysplasia of the hip, DDH）以異常骨性解剖結構為特征，可導致有害的髖關節負荷并引發繼發性骨關節炎。髖關節負荷部分取決于肌肉誘發的關節反作用力（joint reaction forces, JRFs），因此受髖部肌肉力矩臂長度（moment arm lengths, MALs）和作用線（lines of action, LoAs）的影響。本研究采用個體化肌肉骨骼模型和體內運動分析技術，量化DDH骨性解剖結構對步態早期支撐相（約17%）和晚期支撐相（約52%）動態肌肉MALs、LoAs及其對JRF峰值貢獻的影響。與健康髖關節（N=15，16-39歲）相比，未經治療的DDH患者（N=15，16-39歲）的外展肌具有更小的外展MALs（例如臀中肌前部：早期支撐相35.3 vs. 41.6 mm，晚期支撐相45.4 vs. 52.6 mm，p≤0.01）和更偏向內側的LoAs。主要髖屈肌（如股直肌和髂肌）的外展-內收及旋轉MALs也存在差異。DDH患者的異常MALs對應更高的髖外展肌力、內側JRFs（早期支撐相1.26 vs. 0.87×體重（body weight, BW），p=0.03）及合成JRFs（晚期支撐相5.71 vs. 4.97×BW，p=0.05）。DDH解剖結構不僅影響髖部肌肉在主要功能平面的力量生成，還改變其跨平面力學特性，共同導致JRFs升高。總體而言，DDH骨性解剖顯著改變了髖部肌肉MALs及其對JRFs的貢獻。因此，為深入理解關節退變機制并優化DDH治療策略，需綜合考量動態解剖-力學關系和髖周肌群的多平面功能。

圖1.（A）示例模型展示個體化骨盆與股骨幾何形態、髖關節中心（hip joint center, HJC）定位及肌肉路徑（muscle paths）。（B）髖部肌肉力矩臂（muscle moment arm, MAL）示例（臀中肌前部“GMedAnt”，紅色箭頭示意）。在完整步態周期中提取髖關節屈曲、外展及旋轉方向的MALs。（C）髖部肌肉作用線（lines of action, LoAs）示例。各肌肉LoA在骨盆坐標系中的前后（anteroposterior, AP）、上下（superoinferior, SI）及內外側（mediolateral, ML）分量，表示其凈力在特定方向上的百分比分布。

圖2. 主要髖部外展肌、屈肌及外旋肌的平均肌肉力矩臂（左側、中部）與作用線（右側）。陰影區域表示±1個標準差（standard deviation, SD）。垂直突出顯示區域標記步態早期支撐相（JRF1）和晚期支撐相（JRF2）的關節反作用力（joint reaction forces, JRFs）峰值時間。“*”表示組間統計學顯著性差異。肌肉縮寫：臀中肌前部（anterior gluteus medius, GMedAnt）；闊筋膜張肌（tensor fasciae latae, TFL）；股直肌（rectus femoris, RF）；髂肌（iliacus, IL）；臀大肌前部（anterior gluteus maximus, GMaxAnt）。

圖3. 髖關節平均關節反作用力（joint reaction forces, JRFs）分量與外展肌及外旋肌肌力的疊加顯示。內旋肌肌力（未顯示）與外展肌呈現相似的變化模式。陰影區域表示±1個標準差（standard deviation, SD）。垂直突出區域標記髖關節JRF峰值出現的時間點。“*”表示組間統計學顯著性差異。

圖4. 臀中肌（gluteus medius, GMed）與闊筋膜張肌（tensor fasciae latae, TFL）的平均肌力。DDH組與健康組存在肌力差異的三塊肌肉為：臀中肌、闊筋膜張肌（僅合成分力與上部分力）及臀小肌（變化模式與臀中肌相似）。陰影區域表示±1個標準差（standard deviation, SD）。垂直高亮區域標記髖關節關節反作用力（joint reaction forces, JRFs）峰值出現的時間點。“*”表示組間統計學顯著性差異。

Dysplastic hip anatomy alters muscle moment arm lengths, lines of action, and contributions to joint reaction forces during gait

Developmental dysplasia of the hip (DDH) is characterized by abnormal bony anatomy, which causes detrimental hip joint loading and leads to secondary osteoarthritis. Hip joint loading depends, in part, on muscle-induced joint reaction forces (JRFs), and therefore, is influenced by hip muscle moment arm lengths (MALs) and lines of action (LoAs). The current study used subject-specific musculoskeletal models and in-vivo motion analysis to quantify the effects of DDH bony anatomy on dynamic muscle MALs, LoAs, and their contributions to JRF peaks during early (~17%) and late-stance (~52%) of gait. Compared to healthy hips (N = 15, 16-39 y/o), the abductor muscles in patients with untreated DDH (N = 15, 16-39 y/o) had smaller abduction MALs (e.g. anterior gluteus medius, 35.3 vs. 41.6 mm in early stance, 45.4 vs. 52.6 mm late stance, p ≤ 0.01) and more medially-directed LoAs. Abduction-adduction and rotation MALs also differed for major hip flexors such as rectus femoris and iliacus. The altered MALs in DDH corresponded to higher hip abductor forces, medial JRFs (1.26 vs. 0.87 × BW early stance, p = 0.03), and resultant JRFs (5.71 vs. 4.97 × BW late stance, p = 0.05). DDH anatomy not only affected hip muscle force generation in the primary plane of function, but also their out-of-plane mechanics, which collectively elevated JRFs. Overall, hip muscle MALs and their contributions to JRFs were significantly altered by DDH bony anatomy. Therefore, to better understand the mechanisms of joint degeneration and improve the efficacy of treatments for DDH, the dynamic anatomy-force relationships and multi-planar functions of the whole hip musculature must be collectively considered.

文獻出處： Song K, Gaffney B M M, Shelburne K B, et al. Dysplastic hip anatomy alters muscle moment arm lengths, lines of action, and contributions to joint reaction forces during gait[J]. Journal of biomechanics, 2020, 110: 109968.

文獻7

髖臼深度，髖臼發育的早期預測因素：切開復位后髖關節發育不良患者的 MRI

譯者 徐子茵

早期預測未來髖臼發育對于確定髖關節發育不良 （DDH） 是否手術干預很重要。本研究的目的是使用 MRI 調查髖臼發育的預測因素。

本研究回顧性調查了 37 例 DDH 兒科患者 （9 例男性和 28 例女性） 的 40 個髖關節脫位和 34 個正常髖關節，這些患者在行走年齡后接受了切開復位。我們在 5 歲時使用冠狀 MRI T2加權圖像評估了患者的軟骨髖臼和盂唇。手術時的平均年齡為 22 個月，末次隨訪平均年齡為 19 歲。在最終隨訪時，我們根據 Severin 分類將患者分為兩組。使用每側的 MRI 參數比較預后良好 （患側26 個髖關節和對側27 個髖關節） 和預后不良 （分別為14 個髖關節和 7 個髖關節） 的組。使用logistic 回歸分析確定髖臼發育的預測因素。結果顯示，5 歲時髖臼頂深度和盂唇-髖關節中心間距是患側切開復位后的預測因素 （比值比 0.27，P = 0.035;比值比 3.4，P = 0.028），骨性髖關節中心距離為患側的預測因素 （比值比 2.6，P = 0.049）。健側的髖臼發育可以通過骨性指標評估來預測，而患側的髖臼發育必須通過使用 MRI 的盂唇進行評估。

Acetabular depth, an early predictive factor of acetabular development: MRI in patients with developmental dysplasia of the hip after open reduction

Early prediction of future acetabular development is important to determine an additional surgery for developmental dysplasia of the hip (DDH). The purpose of this study was to investigate the predictive factors of acetabular development using MRI. We retrospectively investigated dislocated 40 hips and 34 normal hips in 37 pediatric patients (9 males and 28 females) with DDH who underwent open reduction after walking age. We evaluated the cartilaginous acetabulum and labrum of the patients using coronal MRI T2*-weighted images at 5 years of age. The mean age at the time of surgery was 22 months, and the mean age at the final survey was 19 years. We divided patients into two groups in accordance with the Severin classification at the final follow-up. Groups with good outcomes (affected 26 hips and unaffected 27 hips) and poor outcomes (14 hips and 7 hips) were compared using the MRI parameters on each side. Predictive factors of acetabular development were identified using univariate and multiple logistic regression analyses. Using multiple logistic regression analysis, labral acetabular roof depth and labral hip center distance at 5 years of age represented predictors after open reduction (odds ratio 0.27, P = 0.035; odds ratio 3.4, P = 0.028, respectively) on the affected side, and bony hip center distance represented a predictor on the unaffected side (odds ratio 2.6, P = 0.049). Acetabular development in the unaffected side could be predicted by bony assessment, while acetabular development in the affected side had to be assessed by labrum using MRI.

文獻來源：Kawamura, Yoshi et al. “Acetabular depth, an early predictive factor of acetabular development: MRI in patients with developmental dysplasia of the hip after open reduction.” Journal of pediatric orthopedics. Part B vol. 30,6 (2021): 509-514. doi:10.1097/BPB.0000000000000799

來源：304關節學術

作者：304關節團隊

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