本期目錄：

1、機器人輔助膝關節重建的有效性和安全性

2、經典適應證以外的內側單間室膝關節置換病例獲得近似療效

3、全膝關節置換術后膝關節對線判斷的機器學習模型開發

4、基于CT三維統計建模的骨盆環不對稱性評估

5、Perthes病患者限制負重和運動與生活質量的關系

6、機器人輔助增強現實（AR）引導的髖臼周圍截骨手術導航

7、切開復位治療攣縮型髖關節是否會導致關節僵硬

8、股骨前傾角增大導致內八字步態受試者行走時的關節接觸力研究

9、盂唇內翻是DDH患兒行挽具治療失敗的預測因素

第一部分：關節置換及保膝相關文獻

文獻1

機器人輔助膝關節重建的有效性和安全性：系統回顧和薈萃分析

譯者 張軼超

目的：機器人輔助手術越來越多地應用于髖關節和膝關節重建。然而，與傳統手術相比，機器人輔助全膝關節置換術（RATKR）的相對療效和安全性仍不確定。本研究旨在系統回顧當前文獻，比較RATKR與傳統手術的效果。

材料與方法：在主要數據庫中進行全面的文獻檢索，找出比較RATKR與傳統手術的研究。主要比較結果是功能評分和術后并發癥。采用隨機效應模型計算95%置信區間（CIs）的合并平均差（MDs）。

結果：共納入12項研究。兩組間的西安大略和麥克馬斯特大學骨關節炎指數（WOMAC）、膝關節協會評分（KSS）、特種外科醫院 （HSS）評分、疼痛視覺模擬評分(VAS) 的合并功能評分差異無統計學意義（MD = -0.99, 95% CI -2.32 ~ 0.34， p值= 0.14）。髖關節和膝關節重建的亞組分析也顯示在功能評分方面沒有顯著差異。然而，對于術后并發癥，雖然兩組在失血量方面無顯著差異（MD = -1.62, 95% CI -4.42 ~ 1.17， p值= 0.25），但RATKR組的再入院率明顯高（MD = 0.94, 95% CI 0.77 ~ 1.11， p值< 0.00001）?？傮w異質性非常高（I2= 93%），特別是在術后并發癥的分析中。

結論：研究結果表明，與傳統手術相比，機器人輔助膝關節重建并沒有顯著改善功能預后。除了RATKR后再入院率更高外，安全性大體相似?？紤]到高度的異質性，需要進一步的大規模、精心設計的隨機對照試驗來最終確定機器人輔助髖關節和膝關節重建的有效性和安全性。

Efficacy and safety of robotic-assisted knee reconstruction: a systematic review and meta-analysis

OBJECTIVE: Robotic-assisted surgery is increasingly being utilized in hip and knee reconstruction. However, the relative efficacy and safety of robotic-assisted total knee replacement (RATKR) compared to traditional surgery remained uncertain. This study aimed to systematically review the current literature comparing the outcomes of RATKR to traditional procedures.

MATERIALS AND METHODS: Comprehensive literature searches were conducted in major databases to identify studies comparing RATKR with traditional surgeries. The primary outcomes were functional scores and post-operative complications. Pooled mean differences (MDs) with 95% confidence intervals (CIs) were calculated using a random effects model.

RESULTS: A total of 12 studies were considered for inclusion. The pooled functional scores of The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Society Score (KSS), hospital for Special Surgery (HSS) score, visual analogue score (VAS) pain score showed no significant differences between the two groups (MD = -0.99, 95% CI -2.32 to 0.34, p-value = 0.14). The subgroup analysis for hip and knee reconstructions also revealed no significant difference in terms of functional scores. However, for post-operative complications, while there was no significant difference in terms of blood loss (MD = -1.62, 95% CI -4.42 to 1.17, p-value = 0.25), the readmission rates were significantly higher in the RATKR group (MD = 0.94, 95% CI 0.77 to 1.11, p-value < 0.00001). The overall heterogeneity was extremely high (I2 = 93%), particularly in the analyses of post-operative complications.

CONCLUSIONS: The findings suggested that robotic-assisted knee reconstruction did not significantly improve functional outcomes compared to traditional surgery. The safety profile was similar except for a higher readmission rate following RATKR. Given the high heterogeneity, further large-scale, well-designed, randomized controlled trials are needed to conclusively determine the efficacy and safety of robotic-assisted hip and knee reconstruction.

文獻出處：Alshahrani AH. Efficacy and safety of robotic-assisted knee reconstruction: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2024 Mar;28(6):2250-2262. doi: 10.26355/eurrev_202403_35729. PMID: 38567588.

文獻2

經典適應證以外的內側單間室膝關節置換病例獲得近似療效

譯者 張薔

背景：單間室膝關節置換（UKA）手術的適應證有多條。本研究的目的是探究經典UKA適應證以外病例UKA術后的療效。

方法：本研究納入了197例2017年-2020年間因內側間室骨關節炎而接受UKA手術治療的病例。病例分兩組進行比較：一組為滿足經典適應證的病例，另外一組為至少有一條禁忌證的病例（如年齡≥75歲，BMI≥30kg/m2或內翻畸形>8°）。所有病例均采用了同一款現代固定平臺假體。最短隨訪3年。首要研究指標為關節功能，包括膝關節協會評分（KSS），次要研究指標為并發癥情況及翻修率。

結果：最終經典適應證組有100例，適應證以外組有97例。兩組間的身高、性別比例、術側或骨關節炎階段均無顯著性差異（p > 0.05）。兩組間的KSS評分也沒有顯著性差異（p = 0.96）。在3年隨訪時，經典適應證組的生存率為100%，而適應證以外組為95.38%（p = 0.57）。經典適應證組的并發癥率為12.9%而適應證以外組為8.96%（p = 0.47）。

結論：至少包含一項禁忌證（BMI≥30kg/m2，年齡≥75歲或內翻畸形>8°）的內側間室膝骨關節炎病例在UKA術后獲得了與經典適應證病例近似的關節功能，且術后3年隨訪時的并發癥率或翻修率也沒有顯著性變化。

Similar Functional Results in Patients outside the Classical Criteria for Medial Unicompartmental Knee Arthroplasty

Background: The indications for unicompartmental knee arthroplasty (UKA) are restricted by multiple criteria. The aim of this study was to explore the functional results of UKA in a population of patients outside the classical criteria.

Methods: This study included a population of 197 patients who underwent UKA for medial osteoarthritis between 2017 and 2020. Two groups of patients were compared: those meeting the classical criteria and those presenting with ≥1 contraindication (e.g., age of ≥75 years, body mass index [BMI] of ≥30 kg/m2, or coronal limb deformity of >8°). The implant that was used was a modern fixed-bearing primary medial UKA component. The minimal follow-up was 3 years. The primary outcome was the functional results, including the Knee Society Score (KSS), and the secondary outcomes were the complication and revision rates.

Results: There were 100 patients in the indication group and 97 in the off-indication group. No significant differences were observed between the 2 groups for height, sex ratio, operated side, or osteoarthritis stage (p > 0.05). There was no significant difference in the KSS between the 2 groups (p = 0.96). At 3 years of follow-up, the survival rate without revision was 100% in the indication group and 95.38% in the off-indication group (p = 0.57). The rate of complications was 12.9% in the indication group and 8.96% in the off-indication group (p = 0.47).

Conclusions: UKA for medial osteoarthritis yielded the same functional results for patients presenting with ≥1 theoretical contraindication, including a BMI of ≥30 kg/m2, age of ≥75 years, and coronal limb deformity of >8°, without altering the complication or revision rates at 3 years of follow-up.

文獻3

全膝關節置換術后膝關節對線判斷的機器學習模型開發

譯者 沈松坡

引言：對線異常仍然是全膝關節置換術（TKA）后植入物失敗的主要原因之一。大規模手動圖像分析不可行，而機器學習（ML）模型或許是判斷TKA術后對線的有用工具，并能幫助識別有失敗風險的患者。我們旨在開發一款能從全長髖-膝-踝影像中準確判斷TKA對線的ML模型。

方法：收集了550位接受初次TKA的患者的長腿X線片（LLR），其中440例用于訓練ML模型以識別用于測量對線的標志點。包括股骨頭、轉子間區域、股骨干中段、股骨假體內外側髁遠端、脛骨托板上緣內側1/3與外側1/3、脛骨干中段、脛骨平臺底面等位置?；谶@些標志點計算力線膝角（mHKA）、股骨遠端外側角（LDFA）、脛骨平臺近端內側角（MPTA）與關節線傾斜度（JLO）。另外110例LLR用于測試模型的準確性。

結果：ML模型可在小于0.1秒內分析一張影像。ML模型與人工測量的平均角度誤差為：mHKA誤差0.08o（標準差SD = 0.8），LDFA誤差0.7o（SD = 0.9），MPTA誤差0.4o（SD = 0.3），JLO誤差0.7o（SD = 0.8）。

結論：我們開發的ML模型在TKA術后對線判斷中展現出高度準確性，顯示出人工智能技術在提升關節置換術臨床工作流程和科研效率方面的巨大潛力。

Development of a Machine Learning Model for Determining Alignment in Knees Following Total Knee Arthroplasty

Introduction: Malalignment remains a major reason for implant failure following total knee arthroplasty (TKA). Manual analysis of images at a large scale is untenable, and machine learning (ML) models may be a useful tool for determining alignment following TKA and can help identify patients who are at risk for failure. We aimed to develop an ML model that can accurately determine TKA alignment from full-length hip-to-ankle films.

Methods: Long-leg radiographs (LLR) from 550 patients who had undergone primary TKA were collected, of which 440 were utilized to train an ML model to identify landmarks used for alignment measurement. These landmarks included the femoral head, the intertrochanteric region, the femoral midshaft, the distal aspects of the medial and lateral implant femoral condyle, the medial third and lateral third of the superior border of the tibial base plate, the tibial midshaft, and the tibial plafond. Following identification of these landmarks, mechanical hip-knee-ankle angle (mHKA), lateral distal femoral angle (LDFA), medial tibial plateau angle (MPTA), and joint line obliquity (JLO) were calculated. A separate random sample of 110 LLR was utilized to test the accuracy of the ML model.

Results: The ML model was effective in analyzing one image in less than 0.1 seconds. The mean angle error between human-measured and ML model-measured mHKA was 0.08o (standard deviation [SD = 0.8), the mean error for LDFA was 0.7o (SD = 0.9), the mean error for MPTA was 0.4o (SD = 0.3), and the mean error for JLO was 0.7o (SD = 0.8).

Conclusions: We describe an ML model that demonstrates high accuracy in determining alignment following TKA and demonstrates the vast potential of applying artificial intelligence technology to improving clinical workflow and increasing research productivity in total joint arthroplasty.

第二部分：保髖相關文獻

文獻1

基于CT三維統計建模的骨盆環不對稱性評估

譯者 羅殿中

人類骨盆是由無名骨、骶骨和尾骨組成的復雜解剖結構，共同構成骨盆環。盡管通常被視為對稱實體，但骨盆環不對稱（APR）可能改變其解剖結構、功能或生物力學特性，并影響臨床病例的評估與治療。由于骨盆環解剖結構復雜，APR及其評估具有挑戰性。目前對APR的認知有限，且缺乏標準化評估方法。本研究旨在采用基于CT的三維統計建模與分析技術，在骨盆環復雜解剖結構內評估APR，以期深化對APR的理解，并將相關知識與應用轉化至人體解剖學、研發課題及臨床實踐。研究對150例歐亞男女患者（64±15歲（20-90歲）的常規盆腔CT影像進行后處理，構建了基于性別和種族的骨盆環三維統計模型。通過主成分分析（PCA）評估尺寸、形態及不對稱模式變異，最終建立四個不同族群與性別的骨盆環三維統計模型。PCA主要呈現尺寸與形態變異，而擴展模式分析識別出六種典型不對稱區域：骶骨、髂嵴、骨盆界線、恥骨聯合、恥骨下支及髖臼鄰近區。研究表明骨盆環并非完全對稱，其不對稱性評估極具挑戰。基于CT三維統計建模與PCA，我們確定了分布于不同解剖區域的六種APR類型，這些區域更易發生不對稱。需區分輕微不對稱模式與典型APR，并考慮尺寸、形態和/或位置的側別差異。APR可能源于脊柱或下肢傳遞的負荷機制，亦或是局部負荷作用。當前亟需開發更簡便高效且可靠的方法，并常規應用于人體解剖學、相關研發課題及臨床實踐。

圖1. 典型歐洲女性（上面一排）和男性（下面一排）CT 3D統計學模型。中間灰色為平均模型，左側黃色為-3.0SD模型，右側黃色為+3.0SD模型。

圖2. 典型亞洲女性（上面一排）和男性（下面一排）CT 3D統計學模型。中間灰色為平均模型，左側黃色為-3.0SD模型，右側黃色為+3.0SD模型。

圖3. 典型歐洲女性（上面一排）CT 3D統計學模型，及六種不對稱情形和位置?；疑珵槠骄Ｐ?，黃色為-3.0SD模型，紅色為+3.0SD模型。(a) -3.0SD模型前后觀，紅色箭頭顯示骶骨不對稱；(b) +3.0SD模型前后觀，紅色箭頭顯示髂骨嵴不對稱；(c) -3.0SD模型入盆觀，紅色箭頭顯示骨盆內緣不對稱；(d) +3.0SD模型出盆觀，紅色箭頭顯示髖臼不對稱；(e) -3.0SD模型入盆觀，紅色箭頭顯示恥骨聯合不對稱；(f) +3.0SD模型入盆觀，紅色箭頭顯示恥骨下支不對稱。

圖4. 6種不同類型骨盆不對稱示例：(a) 一位88歲亞洲女性，骶骨不對稱；(b) 一位27歲亞洲男性，髂骨嵴不對稱；(c) 一位54歲歐洲女性，骨盆入口邊緣不對稱；(d) 一位65歲歐洲女性骨盆側面半透明透視觀，髖臼不對稱；(e) 一位86歲歐洲女性骨盆出口位觀，恥骨聯合不對稱；(f) 一位62歲亞洲女性骨盆入口觀，恥骨下肢不對稱。

文獻出處：Handrich K, Kamer L, Mayo K, Sawaguchi T, Noser H, Arand C, Wagner D, Rommens PM. Asymmetry of the pelvic ring evaluated by CT-based 3D statistical modeling. J Anat. 2021 May;238(5):1225-1232. doi: 10.1111/joa.13379. Epub 2020 Dec 31. PMID: 33382451; PMCID: PMC8053576.

文獻2

Perthes病患者限制負重和運動與生活質量的關系

譯者 任寧濤

背景:在Perthes病的活動期通常采用限制負重和運動。這些限制，從免負重的石膏或支架治療，到完全負重的運動限制，都可能對兒童的身體、心理和社會健康產生重大影響。然而，它們對患者生活質量的影響尚未得到很好的研究。

問題/目的:在控制混雜變量后，我們提出以下問題:(1)負重和運動的限制是否與Perthes病活動期兒童的身體健康指標(通過患者報告的結局測量信息系統[Patient-Reported Outcome Measurement Information System, PROMIS]的活動能力、PROMIS疼痛干擾和PROMIS疲勞表示)相關?(2)這些限制是否與較差的心理健康測量分數(PROMIS抑郁癥狀和PROMIS焦慮)有關?(3)這些限制是否與較差的社會健康指標(PROMIS同伴關系)分數有關?

方法:2013年至2020年，對某一機構的211名Perthes患者進行了6項PROMIS分析，以評估其身體、心理和社會健康狀況。對符合以下入選標準的患者進行分析:年齡8 - 14歲，完成了6項PROMIS測量，會說英語，Perthes病處于活躍期(Waldenstrom期I、II或III)。在Perthes病的初始到早期骨化階段，當患者出現疼痛加重、髖關節活動差或受限、股骨頭畸形進展、髖關節滑膜炎加重時，臨床推薦患者限制負重和運動時，以及MRI顯示股骨頭受累或有無手術史。根據負重和運動限制情況將患者分為4個干預組。我們排除了111例不符合納入標準的患者。評估了以下六種PROMIS分析:活動能力、疼痛干擾、疲勞、抑郁癥狀、焦慮和同伴關系。100例患者中，其中無限制負重和運動者36例，輕度限制者27例，中度限制者25例，重度限制者12例，診斷時的中位年齡(范圍)為8歲(范圍2至13歲)。其中，男85例，女15例;11例患者的髖關節處于Waldenstrom I期，10例處于II期，79例處于III期。外側柱B型44例，外側柱C型47例。9例未達到碎裂中期，無法進行合適的外側柱分型。方差分析用于比較這些負重/運動方案的平均PROMIS t評分之間的差異。結果以p < 0.05 有顯著性差異;采用多因素回歸分析Waldenstrom分期、性別、診斷年齡和手術史之間的關系。

結果:在控制混雜變量后，輕度- β回歸系數為-15 [95% CI為-19 ~ -10];p < 0.001)，中度- (β -19 [95% CI -24 ~ -14];p < 0.001)，重度的- (β -25 [95% CI -30 ~ 19];p < 0.001)與無限制組相比，限制組的活動能力t評分較差，但未發現疼痛干擾或疲勞的關聯。負重和活動限制與心理健康指標(抑郁癥狀和焦慮)無關。負重和活動限制與社會健康指標(同伴關系)無關。Waldenstrom分期與疼痛干擾 (β 10 [95% CI 2~17];p = 0.01)和同伴關系評分(β -8 [95% CI -15~-1];P = 0.03)有關;女性與更嚴重的抑郁癥狀 (β 7 [95% CI 2 ~ 12];p = 0.005)和更差的同伴關系評分(β -6 [95% CI -12 ~ 0];P = 0.04) 相關;診斷年齡越早與同伴關系評分越差相關(β 1 [95% CI 0 ~ 2];P = 0.03)。大手術史與6項PROMIS指標均無關聯。

結論:我們發現，在控制Waldenstrom分期、性別、診斷年齡和手術史后，負重和運動限制治療與Perthes病活動期患者報告的較差的活動能力相關。然而，負重/運動限制與疼痛干擾、疲勞、抑郁癥狀、焦慮和同伴關系無關。了解這些治療如何與Perthes疾病患者的生活質量相關聯，可以幫助醫生做出決策，幫助為患者及其父母設定期望，并提供更好的教育和準備機會。由于Perthes病為慢性病，未來的研究可能關注患者報告結局的縱向趨勢，以更好地了解該病及其治療的總體影響。

Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease

Background: Weightbearing and activity restrictions are commonly prescribed during the active stages of Perthes disease. These restrictions, ranging from cast or brace treatment with nonweightbearing to full weightbearing with activity restrictions, may have a substantial influence on the physical, mental, and social health of a child. However, their impact on the patient's quality of life is not well-described.

Questions/purposes: After controlling for confounding variables, we asked (1) are restrictions on weightbearing and activity associated with physical health measures (as expressed by the Patient-Reported Outcome Measurement Information System [PROMIS] mobility, PROMIS pain interference, and PROMIS fatigue) of children in the active stages of Perthes disease? (2) Are these restrictions associated with poorer scores for mental health measures (PROMIS depressive symptoms and PROMIS anxiety)? (3) Are these restrictions associated with poorer scores for social health measures (PROMIS peer relationships)?

Methods: Between 2013 and 2020, 211 patients with Perthes disease at a single institution were assigned six PROMIS measures to assess physical, mental, and social health. Patients who met the following eligibility criteria were analyzed: age 8 to 14 years old, completion of six PROMIS measures, English-speaking, and active stage of Perthes disease (Waldenstrom Stage I, II, or III). Weightbearing and activity restrictions were clinically recommended to patients in the initial through early reossification stages of Perthes disease when patients had increasing pain, loss of hip motion, loss of hip containment, progression of femoral head deformity, increased hip synovitis, and femoral head involvement on MRI or as a postoperative regimen. Patients were categorized into four intervention groups based on weightbearing and activity regimen. We excluded 111 patients who did not meet the inclusion criteria. The following six pediatric self-report PROMIS measures were assessed: mobility, pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Of the 100 patients, 36 were categorized into the no-restriction regimen, 27 into the mild-restriction regimen, 25 into the moderate-restriction regimen, and 12 into the severe-restriction regimen at the time of PROMIS administration. The median (range) age at diagnosis was 8 years old (range 2 to 13 years). There were 85 boys and 15 girls. Eleven patients had hips in Waldenstrom Stage I, 10 were in Stage II, and 79 were in Stage III. Forty-four patients had hips classified as lateral pillar B and 47 patients as lateral pillar C. Nine patients had not reached the mid-fragmentation stage for appropriate lateral pillar classification by the time they took the PROMIS survey. ANOVA was used to compare differences between the mean PROMIS T-scores of these weightbearing/activity regimens. Results were assessed with a significance of p < 0.05 and adjusted for Waldenstrom stage, gender, age at diagnosis, and history of major surgery using multivariate regression analysis.

Results: After controlling for confounding variables, the mild- (β regression coefficient -15 [95% CI -19 to -10]; p < 0.001), moderate- (β -19 [95% CI -24 to -14]; p < 0.001), and severe- (β -25 [95% CI -30 to -19]; p < 0.001) restriction groups were associated with worse mobility T-scores compared with the no-restriction group, but no association was detected for the pain interference or fatigue measures. Weightbearing and activity restrictions were not associated with mental health measures (depressive symptoms and anxiety). Weightbearing and activity restrictions were not associated with social health measures (peer relationships). Earlier Waldenstrom stage was associated with worse pain interference (β 10 [95% CI 2 to 17]; p = 0.01) and peer relationships scores (β -8 [95% CI -15 to -1]; p = 0.03); female gender was linked with worse depressive symptoms (β 7 [95% CI 2 to 12]; p = 0.005) and peer relationships scores (β -6 [95% CI -12 to 0]; p = 0.04); and earlier age at diagnosis was associated with worse peer relationships scores (β 1 [95% CI 0 to 2]; p = 0.03). History of major surgery had no connection to any of the six PROMIS measures.

Conclusion: We found that weightbearing and activity restriction treatments are associated with poorer patient-reported mobility in the active stages of Perthes disease after controlling for Waldenstrom stage, gender, age at diagnosis, and history of surgery. Weightbearing/activity restrictions, however, are not associated with pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Understanding how these treatments are associated with quality of life in patients with Perthes disease can aid in decision-making for providers, help set expectations for patients and their parents, and provide opportunities for better education and preparation. Because of the chronic nature of Perthes disease, future studies may focus on longitudinal trends in patient-reported outcomes to better understand the overall impact of this disease and its treatment.

文獻出處：Do DH, McGuire MF, Jo CH, Kim HKW. Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease. Clin Orthop Relat Res. 2021 Jun 1;479(6):1360-1370. doi: 10.1097/CORR.0000000000001608. PMID: 33394755; PMCID: PMC8133300.

文獻3

機器人輔助增強現實（AR）引導的髖臼周圍截骨手術導航

譯者 李勇

髖臼周圍截骨術(PAO)是治療髖關節發育不良（DDH)的有效手術方法。然而,由于髖關節周圍解剖結構復雜且術中視野(FoV)受限,醫生實施PAO手術極具挑戰性。為此,我們提出一種用于PAO的機器人輔助增強現實(AR)引導手術導航系統。該系統主要由機械臂、光學追蹤器和微軟HoloLens 2頭顯(一種前沿的光學穿透式頭戴顯示器, OST HMD)組成。在AR引導方面,我們提出一種基于光學標記的AR配準方法,用于估算從光學追蹤器坐標系(COS)到虛擬空間坐標系的變換矩陣,從而實現虛擬模型與對應實體結構的精準疊加。此外,為引導截骨操作,系統可自動將骨鋸與術前影像規劃的截骨平面對齊,并為醫生提供雙重支持:一方面通過虛擬約束限制骨鋸移動范圍,另一方面通過AR引導提供無需視線轉移的視覺反饋,從而提高手術精度與安全性。通過綜合實驗評估了該導航系統的AR配準精度與截骨精度:所提出的AR配準方法實現了1.96 ± 0.43毫米的平均絕對距離誤差(mADE) ;機器人系統達到0.96 ±0.23毫米的平均中心平移誤差,1.31 ± 0.20毫米的平均最大距離誤差及 3.77 ± 0.85。的平均角度偏差。實驗結果驗證了該系統在AR配準與截骨操作上的精確性。

Robot-Assisted Augmented Reality (AR)-Guided Surgical Navigation for Periacetabular Osteotomy

Periacetabular osteotomy (PAO) is an effective approach for the surgical treatment of developmental dysplasia of the hip (DDH). However, due to the complex anatomical structure around the hip joint and the limited field of view (FoV) during the surgery, it is challenging for surgeons to perform a PAO surgery. To solve this challenge, we propose a robot-assisted, augmented reality (AR)-guided surgical navigation system for PAO. The system mainly consists of a robot arm, an optical tracker, and a Microsoft HoloLens 2 headset, which is a state-of-the-art (SOTA) optical see-through (OST) head-mounted display (HMD). For AR guidance, we propose an optical marker-based AR registration method to estimate a transformation from the optical tracker coordinate system (COS) to the virtual space COS such that the virtual models can be superimposed on the corresponding physical counterparts. Furthermore, to guide the osteotomy, the developed system automatically aligns a bone saw with osteotomy planes planned in preoperative images. Then, it provides surgeons with not only virtual constraints to restrict movement of the bone saw but also AR guidance for visual feedback without sight diversion, leading to higher surgical accuracy and improved surgical safety. Comprehensive experiments were conducted to evaluate both the AR registration accuracy and osteotomy accuracy of the developed navigation system. The proposed AR registration method achieved an average mean absolute distance error (mADE) of 1.96 ± 0.43 mm. The robotic system achieved an average center translation error of 0.96 ± 0.23 mm, an average maximum distance of 1.31 ± 0.20 mm, and an average angular deviation of 3.77 ± 0.85°. Experimental results demonstrated both the AR registration accuracy and the osteotomy accuracy of the developed system.

文獻出處：Ding H, Sun W, Zheng G. Robot-Assisted Augmented Reality (AR)-Guided Surgical Navigation for Periacetabular Osteotomy. Sensors (Basel). 2024 Jul 22;24(14):4754. doi: 10.3390/s24144754. PMID: 39066150; PMCID: PMC11280818.

文獻4

切開復位治療攣縮型髖關節是否會導致關節僵硬？

譯者 張利強

背景：盡管已有相關研究報道了切開復位治療先天性脫位髖關節的積極效果，但對于患有多關節攣縮癥的先天性髖關節脫位患者進行切開復位手術后是否會出現關節僵硬的問題仍存在擔憂。我們對52名患有多關節攣縮癥的患者進行了回顧性研究，這些患者接受了75次先天性髖關節脫位的切開復位手術，且術后隨訪時間至少為2年。我們比較了術前和術后的髖關節活動度，并評估了接受該手術患者的行走能力。

方法：在10年的時間里，52名患有多關節攣縮癥的患者進行了75次先天性髖關節脫位的切開復位手術，且術后隨訪時間至少為2年。手術時患者的平均年齡為23個月。術前、術后以及最后一次隨訪時均記錄了髖關節活動度數據，同時記錄了患者的行走能力。對髖關節狀態和缺血性壞死進行了X線評估。

結果：平均隨訪時間為68個月；59%的患者同時行股骨縮短。術前，34個髖關節的平均屈曲攣縮度為33度，隨訪時改善了22度；59個髖關節的蛙式外展角度小于45度，術前為11度和10度，分別改善了11度和10度（所有P≤ 0.001）。從術前到術后，關節的屈伸總活動范圍僅減少了1度（P=0.733）。單側脫位患者（n=29）在最終隨訪時，脫位側與未脫位側髖關節的總活動范圍無顯著差異。術前屈曲度小于90度的髖關節在復位后未見明顯改善。平均隨訪時間為68個月（24至152個月），31名患者能夠獨立行走，15名患者依靠輪椅但仍在改善，6 名患者仍無法行走。約一半的髖關節出現了缺血性壞死（AVN），但在隨訪時并未影響屈伸總活動范圍；AVN病例中55%為2型，僅為短期變化（延遲骨化）。

結論：對于關節攣縮型髖關節脫位的切開復位術能夠保持關節的活動性而不造成僵硬。雖然術前髖關節的總活動范圍略有惡化（約 1 至 5 度），但下肢位置得到了改善，尤其是在髖關節伸直和外展方面，從而增強了行走能力。大多數患者能夠實現獨立行走。

證據級別：IV 級 - 病例系列。

關鍵詞：先天性多關節攣縮癥、關節攣縮癥、先天性髖關節脫位、切開復位、行走能力

Does Open Reduction of Arthrogrypotic Hips Cause Stiffness?

Background: Concerns of potential hip stiffness following open reduction for congenitally dislocated hips in arthrogryposis multiplex congenita (arthrogryposis) persist, despite published accounts of positive outcomes. We retrospectively compared preoperative and postoperative hip motion and evaluated the ambulatory abilities of patients who underwent the procedure.

Methods: Over a 10-year period, 52 patients with arthrogryposis had 75 open reductions for congenitally dislocated hips with a minimum follow-up of 2 years. The mean patient age at surgery was 23 months. Hip range of motion data was recorded preoperatively, postoperatively, and at last follow-up, as was ambulatory ability. Radiographs were assessed for hip station and avascular necrosis.

Results: The average follow-up was 68 months; 59% had concurrent femoral shortenings. Preoperatively, 34 hips had a mean flexion contracture of 33 degrees, improving 22 degrees at follow up; 59 hips had <45 degree frogleg abduction and 39 hips had <30 degree abduction preoperatively, improving by 11 and 10 degrees, respectively (all P≤ 0.001). The flexion-extension total arc of motion decreased by only 1 degree from preoperative to follow-up (P= 0.733). Patients with unilateral dislocation (n = 29) had no significant difference in the total arc of motion between the dislocated and nondislocated hips at the final follow up. Hips with <90 degrees of flexion preoperatively showed no improvement following reduction. At a mean follow-up of 68 months (24 to 152 mo), 31 patients were independently ambulatory, 15 were walker-dependent but still progressing, and 6 remained nonambulatory. Avascular necrosis (AVN) was seen in approximately half the hips but without affecting flexion-extension total arc of motion at follow-up; 55% of AVN cases were type 2, with only transient changes (delayed ossification).

Conclusions: Open reduction for arthrogrypotic hip dislocations maintains mobility without causing stiffness. While pre-existing hip total arc of motion slightly worsened (～1 to 5 degree), lower limb positioning improved, especially in hip extension and abduction, enhancing ambulation. Most achieved independent ambulation.

Level of Evidence: Level IV—case series.

Key Words: arthrogryposis multiplex congenita, arthrogryposis, congenital hip dislocation, open reduction, ambulation

文獻出處：Teytelbaum DE, Bijanki V, Samuel SP, Silva S, Israel H, van Bosse HJP. Does Open Reduction of Arthrogrypotic Hips Cause Stiffness? J Pediatr Orthop. 2025 Jul 1;45(6):e581-e589. doi: 10.1097/BPO.0000000000002940. Epub 2025 Apr 30. PMID: 40304381.

文獻5

股骨前傾角增大導致內八字步態受試者行走時的關節接觸力研究
譯者 邱興

內八字步態是一種病理現象，表現為兒童行走時足部內旋（即呈“內八字”）而非指向前方。此病癥會改變下肢結構排列，增加膝髖關節骨關節炎發病率。本研究旨在探究內八字步態受試者的運動學特征與關節負荷。實驗選取兩組受試者：正常組與股骨前傾角增大導致內八字步態組（每組15人）。采用Qualisys運動分析系統和Kistler測力臺記錄行走時的下肢運動及受力數據，并通過OpenSim軟件（3.3版）分析兩組受試者的關節活動度、力矩、肌力及關節接觸力。

正常組步長均值（1.1±0.141米）與內八字步態組（0.94±0.183米）差異顯著。內八字步態組的地面反作用力內外側分量較正常組顯著降低（p值=0.05）。與正常組相比，內八字步態組大部分髖關節肌肉的峰值肌力顯著增加（p值<0.05）。研究結果表明：因股骨前傾角增大形成的內八字步態僅引起骨盆與髖關節的旋轉變化。兩組在步行速度及大部分地面反作用力分量上無顯著差異。由于內八字步態組髖關節多數肌肉的峰值肌力顯著升高，導致關節接觸力增大（尤以髖關節前后向分量與膝關節內外側分量為主），最終可能增加髖膝關節骨關節炎的發病風險。

Investigation of joint contact forces during walking in the subjects with toe in gait due to increasing in femoral head anteversion angle

Toe-in gait is a pathology in which the child walks and turns the foot inward instead of pointing straight ahead. The alignment of the lower limb structure changes in this disease, increasing the incidence of knee and hip osteoarthritis. This study aimed to determine the kinematic and joint loading in subjects walking with a toe-in gait pattern. This study selected two groups of subjects: normal subjects and those with toe-in gait due to an increased femoral head anteversion angle (each group consisted of 15 subjects). A Qualisys motion analysis system and a Kistler force plate were used to record the motions and forces applied to the leg while walking. OpenSim software (version 3.3) was used to analyze the range of motion, moments, muscle forces, and joint contact forces in both groups of subjects. The mean values of stride length for normal subjects (1.1?±?0.141?m) and those with toe-in gait (0.94?±?0.183?m) differed significantly. The mediolateral component of the ground reaction force decreased significantly in the toe-in gait group compared to normal subjects (p-value?=?0.05). The peak force of most of the hip joint muscles increased significantly in those with toe-in gait compared to normal subjects (p-value?<?0.05). The results of this study showed that those with toe-in gait, due to an increase in femoral head anteversion angle, only had a change in rotation of the pelvic and hip joint. There was no significant difference between walking speed and most ground reaction force components between normal subjects and those with toe-in gait. As the peaks of most of the hip joint muscles increased significantly in the toe-in gait group, this increased joint contact forces (especially the anteroposterior component of the hip joint and the mediolateral component of the knee joint), which may ultimately increase the incidence of hip and knee joint osteoarthritis.

文獻出處：Karimi, Mohammad Taghi, et al. "Investigation of joint contact forces during walking in the subjects with toe in gait due to increasing in femoral head anteversion angle." Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 238.7 (2024): 755-763.

文獻6

盂唇內翻是DDH患兒行挽具治療失敗的預測因素

譯者 張振東

背景：髖關節發育不良（DDH）行Pavlik挽具治療失敗率高達55%。本研究目的是明確盂唇內翻對該治療結果的影響。

方法：對一家三級兒科醫院 2004 年至 2016 年接受治療的 DDH 患兒進行回顧性研究。納入的DDH患兒均接受過Pavlik挽具治療，且隨訪至少12個月。對患兒的人口統計學、治療和結果進行了回顧性分析。比較了有內翻盂唇的患者和沒有內翻盂唇的患者的治療效果差異。

結果：共納入156例患者（229髖）診斷為髖關節發育不良。開始使用Pavlik治療的平均年齡為（1.9±1.4）個月，平均隨訪時間為（37.7±23.0）個月。46%的患者（73/156）被診斷為雙側DDH。共有37%（75/229）的髖關節未行Pavlik治療。Pavlik治療失敗的患者中，91%的患者（68/75）再采用硬質髖關節外展支架進行治療，5%的患者（4/75）再采用閉合復位治療，另外4%的患者（3/75）再采用切開復位治療。在所有髖關節中，10%（22/229）的髖關節存在內翻盂唇。內翻盂唇患者中Pavlik治療失敗率為91%（20/22），而對照組為27%（55/207）（P<0.001）。內翻盂唇患者中，86%（15/22）的髖關節需要二次手術，包括閉合或切開復位，而對照組僅為3%（7/207）（P<0.001）。此外，盂唇內翻的患者中，股骨頭壞死發生率為18%（4/22），而對照組為0.4%（1/207）（P<0.001）。

結論：在使用Pavlik 治療的 DDH 患兒中，盂唇內翻是治療失敗的重要預測指標。與無內翻盂唇的患兒相比，有內翻盂唇的DDH患兒需要閉合或切開復位、以及發生股骨頭缺血壞死的風險也明顯更高。

An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia

Introduction: The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH.

Methods: A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum.

Results: A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P<0.001). Closed or open reduction was required in 86% (15/22) of the inverted labrum group compared with 3% (7/207) of hips in the control group (P<0.001). The incidence of avascular necrosis was 18% (4/22) in hips with an inverted labrum compared with 0.4% (1/207) in the control group (P<0.001).

Conclusions: In children with DDH undergoing index treatment in a Pavlik harness, the presence of an inverted acetabular labrum is strongly predictive of treatment failure. Dysplastic hips with an inverted labrum also have a significantly higher risk of requiring closed or open reduction and developing avascular necrosis compared with those without an inverted labrum.

文獻出處：Lin AJ, Siddiqui AA, Lai LM, Goldstein RY. An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia. J Pediatr Orthop. 2021 Sep 1;41(8):479-482.

來源：304關節學術

作者：304關節團隊

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