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本期目录： 1、全膝关节置换术中内侧副韧带浅层松解的指征。比较拉花松解技术和骨膜下松解的效果：在尸体上的研究 2、全髋关节置换术中功能安全区优于Lewinnek安全区：为什么Lewinnek安全区并不总是能够预测的关节稳定性 3、延长全膝及全髋关节置换术后预防性口服抗生素治疗时间可以降低术后90天内感染率 4、带血管蒂骨移植治疗非创伤性股骨头坏死：5-11年随访 5、股骨头坏死保头手术成功的影响因素 6、股骨头缩小术联合髋臼周围截骨术治疗严重股骨头畸形 7、改良Dunn截骨术治疗不稳定性股骨头骨骺滑脱 8、发育性髋关节发育不良残留畸形于骨成熟后骨与软骨髋臼指数在MRI的差异 第一部分：关节置换相关文献 文献1 全膝关节置换术中内侧副韧带浅层松解的指征。比较拉花松解技术和骨膜下松解的效果：在尸体上的研究 译者：张轶超 目的：在做内翻膝的全膝关节置换术中经常需要松解内侧副韧带（sMCL）的浅层。本研究的目的是在尸体上比较拉花松解法（MNP）和骨膜下松解法（SE）对于松解关节间隙的效果及松解顺序的关系。 假说：对于松解屈曲位间隙时MNP的效果比SE的效果更加可靠。 方法：选择8具尸体，随机在每具尸体的一个膝关节上做MNP，另外一侧做SE。在MNP组，用18号注射器针头穿刺sMCL，以穿刺5针为一组。SE组，采用sMCL止点下的骨膜下松解，从近端向远端松解以松解5mm为一组。测量每组膝关节间隙在伸直位和屈曲90°位时的变化情况。 结果：在各自做4组松解后这两种技术在改变屈曲和伸直间隙的宽度效果上没有明显的差异，当做了6组松解后SE组的伸直间隙比MNP组有明显增大。对于两组间在各个松解次数时的效果（变化宽度的95%中位值）SE组都大于MNP组（伸直间隙每松解一组增宽0.5mm比0.24mm；屈曲间隙每松解一组增宽2.28mm比0.95mm；总体p < 0.001)。 结论：在松解膝关节的屈曲间隙时，sMCL的拉花松解技术是可以反复进行的。相对于SE技术，MNP技术的松解程度变化更小，可以一点一点的改善软组织的不平衡，因此是比较安全的方法。 MNP技术是采用18号针头穿刺绷紧的sMCL纤维（A），SE技术是采用1/4英寸的骨膜玻璃器松解sMCL的胫骨侧止点（B） Predictability of open superficial medial collateral ligament lengthening technique in total knee arthroplasty. Comparison of multiple needle puncturing and subperiosteal elevation: A cadaver study PURPOSE: Lengthening of superficial medial collateral ligament (sMCL) is often needed in total knee replacement for varus osteoarthritis knee. This study aimed to compare the relationship of multiple needle puncturing (MNP) and subperiosteal elevation (SE) for sMCL lengthening on the gap increment and sequential lengthening in cadaveric knees. HYPOTHESIS: MNP produces more reliable gap increment than SE technique for sMCL lengthening performed in knee flexion. METHODS: From 8 pairs of cadaveric knees, one knee from each pair was randomly assigned to undergo MNP and the others to SE. In the MNP group, an 18gauge needle was used to puncture through the sMCL, performing five punctures each time of release. For the SE group, a periosteal elevator was used to sequentially deepen distally beneath the sMCL insertion with an increment depth of 5mm each time of release. The primary outcome was the medial gap increment at knee extension and 90° knee flexion after every attempt in each group. RESULTS: At each level of lengthening, the widening of flexion and extension gap were not significantly different between the two techniques except for lengthening after 4 and 6 attempts of SE that gave greater widening in extension gap. Variability (width of mid 95% of values) was significantly greater for any given number of attempts using SE than MNP (0.5 vs. 0.24mm per attempt for extension and 2.28 vs. 0.95mm per attempt for flexion; both p<0.001). CONCLUSION: The MNP technique is a reproducible technique for lengthening the sMCL in knee flexion. It has less variability in gap widening compared to the SE technique. 文献出处：Iamthanaporn K, Geater A, Yuenyongviwat V. Predictability of open superficial medial collateral ligament lengthening technique in total knee arthroplasty. Comparison of multiple needle puncturing and subperiosteal elevation: A cadaver study. Orthop Traumatol Surg Res. 2018 Nov;104(7):977-982. doi: 10.1016/j.otsr.2018.08.004. Epub 2018 Sep 20. 文献2 全髋关节置换术中功能安全区优于Lewinnek安全区：为什么Lewinnek安全区并不总是能够预测的关节稳定性 译者：马云青 背景: Lewinnek“安全区”并不总是预测全髋关节置换术后的稳定性(THA)。最近的研究于集中于在脊柱-骨盆-髋侧位X线片上的髋部功能运动范围。本研究的目的是评估Lewinnek安全区与功能安全区基于髋部和盆腔矢状面上运动情况。 方法: 320髋(291例患者)采用计算机导航行全髋关节置换术。其中296例髋关节假体(92.5%)位于Lewinnek安全区范围外倾角40±10°和15±10°的前倾角。所有患者术前、术后随访均行站立位和坐位的骨盆脊柱侧位x光片。结合矢状面指数(CSI)，测量每位患者的矢状髋臼和股骨位置，并评估其功能安全区。对Lewinnek安全区范围内和范围外的髋关节进行了矢状面功能安全区的数据分析。确定了髋关节功能安全区外的预测不稳定因素。 结果: 在Lewinnek安全区的296例髋中，254例(85.8%)也处于功能性安全区。42例患者在CSI功能安全区外；19人站立位CSI增加，23人的坐位CSI降低，所有人都被认为有脱位风险。功能安全区外的预测因素包括股骨侧活动度增加(P < 0.632 r¼)，脊柱骨盆活动度下降(P < 0.455措施,r¼)和骨盆指数(P < 0.400措施,r¼)。 结论: 在本研究中，Lewinnek安全区内14.2%的髋关节在功能安全范围外，确定一个有“正常角度”的臼杯的潜在的脱位原因，最好的预测方法是测量术前和术后髋关节是否位于功能安全区，主要取决于股骨的活动度，而不是矢状面臼杯的位置。 股骨活动度就是图中PFA的变化角度，PFA AI（髋臼前倾角）=CSI（联合矢状面指数） CSI也就是功能安全区指数 Functional Safe Zone Is Superior to the Lewinnek Safe Zone for Total Hip Arthroplasty: Why the Lewinnek Safe Zone Is Not Always Predictive of Stability BACKGROUND: The Lewinnek 'safe zone' is not always predictive of stability after total hip arthroplasty (THA). Recent studies have focused on functional hip motion as observed on lateral spine-pelvis-hip x-rays. The purpose of this study was to assess the correlation between the Lewinnek safe zone and the functional safe zone based on hip and pelvic motion in the sagittal plane. METHODS: Three hundred twenty hips (291 patients) underwent primary THA using computer navigation. Two hundred ninety-six of these hips (92.5%) were within the Lewinnek safe zone as determined by inclination of 40° ± 10° and anteversion of 15° ± 10°. All patients had preoperative and postoperative standing and sitting lateral spinopelvic x-rays. The combined sagittal index (CSI), a combination of sagittal acetabular and femoral position, was measured for each patient and used to assess the functional safe zone. Data analysis was performed to identify hips in the Lewinnek safe zone inside and outside the sagittal functional safe zone. Predictive factors for hips outside the functionalsafe zone were identified. RESULTS: Of the 296 hips within the Lewinnek safe zone, 254 (85.8%) were also in the functional safe zone. Forty-two patients were outside the functional safe zone based on CSI; 19 had an increased standing CSI and 23 had a decreased sitting CSI, all were considered at risk for dislocation. Predictive factors for falling outside the functional safe zone were increased femoral mobility (P < .001, r = 0.632), decreased spinopelvic mobility (P < .001, r = 0.455), and pelvic incidence (P < .001, r = 0.400). CONCLUSION: In this study, 14.2% of hips within the Lewinnek safe zone were outside the functional safe zone, identifying a potential reason hips dislocate despite having 'normal' cup angles. The best predictor for falling outside the functional safe zone, both preoperatively and postoperatively, was femoral mobility, not the sagittal cup position (ie, cup anteinclination). 文献出处：Tezuka T, Heckmann ND, Bodner RJ, Dorr LD. Functional Safe Zone Is Superior to the Lewinnek Safe Zone for Total Hip Arthroplasty: Why the Lewinnek Safe Zone Is Not Always Predictive of Stability. J Arthroplasty. 2019 Jan;34(1):3-8. doi: 10.1016/j.arth.2018.10.034. Epub 2018 Nov 2. 文献3 延长全膝及全髋关节置换术后预防性口服抗生素治疗时间可以降低术后90天内感染率 译者：张蔷 背景：逐渐流行的关节置换费用模型分析定期向医生和医院回馈假体周围感染风险与支出的相关数据，导致一些医生故意回避高感染风险的患者。此外，既往文献中并没有关于优化患者术前相关因素以降低假体周围感染的相关文章，同时，有文献支持关节翻修术后延长口服抗生素治疗时间。这篇文章的目的是为了评估延长初次全膝及全髋关节置换术后预防性口服抗生素治疗时间能否降低高感染风险患者术后出现假体周围感染的几率。已被证实的感染高危因素被定义为：BMI≧40kg/m2，糖尿病，吸烟者。 方法：文章回顾了某市区教学医院2011年至2016年间共2181例初次全膝及全髋关节置换手术病例，该医院长久以来坚持运用现代化围术期管理措施，并遵循严格的感染预防原则。从2015年1月起，该医院将所有初次关节置换患者出院后口服抗生素治疗时间延长至7天（如果确定为高危患者，出院后连续应用7天的头孢羟氨苄胶囊，500mg Bid；如果对头孢过敏，连续应用7天的克林霉素 300mg Qd）。统计延长前与延长后患者术后90天内假体周围感染几率，p≦0.05提示显著性差异。 结果：全膝及全髋关节置换术后90天内感染率分别为1.0%和2.2%。未延长口服抗生素治疗时间的感染高危患者全膝及全髋关节置换术后出现感染的机会是延长治疗时间患者的4.9倍(p = 0.009)及4.0倍(p = 0.037)。 结论：延长关节置换术后感染高危患者的口服抗生素治疗时间可以明显降低术后90天内假体周围感染几率。但我们依然鼓励大家在改变目前术后预防性口服抗生素治疗时间之前进行更多更深入的研究，尽量在降低假体周围感染风险与增加细菌的抗生素耐药性之间进行权衡。 Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate Background: Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended anti-biotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients. Methods: A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p≦0.05 indicating significance. Results: The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis. Conclusions: Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance. 文献出处：Inabathula A, Dilley JE, Ziemba-Davis M, Warth LC, Azzam KA, Ireland PH, Meneghini RM. Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary TotalHip and Knee Arthroplasty 90-Day Infection Rate. J Bone Joint Surg Am. 2018 Dec 19;100(24):2103-2109. doi: 10.2106/JBJS.17.01485. 第二部分：保髋相关文献 文献1 带血管蒂骨移植治疗非创伤性股骨头坏死：5-11年随访 译者：罗殿中 我们对应用带血管蒂髂骨移植治疗的26例（31髋）股骨头坏死患者进行研究，其中包括非创伤性股骨头坏死20例及激素性股骨头坏死6例。患者手术时平均年龄38.3岁，包括3名女性及23名男性。术后平均随访时间为8年。患者Harris评分由术前平均62分提高至术后83分，1名患者因为术后股骨头塌陷而接受人工关节置换术。末次随访时，19髋（63%）临床结果优良，4髋一般，7髋较差。末次随访时，27髋II期中的15髋术后发生了股骨头进行性塌陷。在激素性股骨头坏死患者中，3名女性患者（4髋）中的2髋效果较差。本研究的结果仅轻微优于接受髓芯减压术的患者，不优于接受髓芯减压联合单纯打压植骨的患者。我们认为带血管蒂髂骨移植术适用于部分早期未发生股骨头塌陷的股骨头坏死患者。 手术示意图 A 植骨块取自髂骨翼，保留旋髂浅动静脉；B 将骨块自股骨近端制备的骨隧道植入。8例患者应用了旋髂深动静脉 35岁男性患者MRIA 术前冠状位；B 术后6个月冠状位；C 术后18个月冠状位 28岁双侧酒精性股骨头坏死 A 术前骨盆正位片，左侧为JIC分型I-C型，II期，右侧尚无症状；B 术前双髋蛙式位片；C 左髋术后11年，进展为III-A期，右髋术后9年，进展为III-B期；D 末次随访时双髋蛙式位片 Vascularized pedicle bone-grafting for nontraumatic avascular necrosis of the femoral head. A 5- to 11-year follow-up We investigated the results of 31 hips in 26 patients with nontraumatic (n = 20) and steroid-induced (n = 6) avascular necrosis of the femoralhead (ANFH) treated with vascularized iliac pedicle bone graft (PBG). The average age at operation was 38.3 years. Three were women and 23 men. The average follow-up was 8.0 years. The Harris hip score prior to operation and at latest follow-up improved from 62 to 83; one hip collapsed and was revised with a bipolar endoprosthesis. At the final follow-up, 19 hips (63%) were clinically rated as good to excellent, 4 fair, and 7 poor. At the final follow-up, 15 of 27 hips (56%) of stage II before operation showed progressive collapse after bone grafting. In steroid-induced ANFH, in three women, 2 of 4 hips showed poor results. These results are only slightly better than those of core decompression and no better than those obtained after decompression and simple nonvascularized grafts to provide support for the subchondral bone. We concluded that vascularized PBG is sometimes indicated for ANFH in an early stage before collapse of the femoral head. 文献出处：Hasegawa Y, Iwata H, Torii S, Iwase T, Kawamoto K, Iwasada S. Vascularized pedicle bone-grafting for nontraumatic avascular necrosis of the femoral head. A 5- to 11-year follow-up. Arch Orthop Trauma Surg. 1997;116(5):251-8. 文献2 股骨头坏死保头手术成功的影响因素 译者：程徽 目的：股骨头坏死的保头手术有多种，但是哪一种效果最好仍无共识。 问题/目的本研究旨在回答以下问题：（1）根据文献数据，是否有一种手术方式结果更好？（2）在股骨头塌陷前及塌陷后行保头手术，之后病变进展或再行THA的比率有多少？（3）坏死区域大小影响病变进展吗？（4）坏死累及负重区的大小是否影响保头手术结果？ 方法：在MEDLINE及Scopus数据库搜索1998-2010年的文献，文献限于股骨头坏死的保头手术，证据等级I –IV级，最后54篇文献入选。 结果：没有一种保头手术能证明优于其他方式。塌陷前手术有31%（264/864）、塌陷后手术有49%（419/850）术后出现病变继续进展。坏死区域小于股骨头15%、或坏死区角度小于200°（14%–25%）、以及坏死仅累及负重区内侧1/3（4.6%）时，保头成功率更高。 结论：根据有限的文献报道，股骨头坏死塌陷前的最佳治疗方法仍不明确，但数据显示当坏死面积较小、或有限累及负重区时，采用手术干预效果较好。一旦出现塌陷，保头手术失败率较高。 Which Factors Influence Preservation of the Osteonecrotic Femoral Head? Background Although surgeons use many procedures to preserve the femoral head in patients with hip osteonecrosis, there is no consensus regarding the best procedure. Questions/purposes We raised the following questions: (1) Is one surgical treatment preferred based on published data? (2) What are the rates of radiographic progression or conversion to THA after treatment of pre- and postcollapse hips? (3) Does lesion size in the femoral head influence progression? And (4) does the extent of involvement of the weightbearing surface of the femoral head influence outcome? Methods We searched MEDLINE and Scopus for articles published between 1998 and 2010. We included only articles assessing an operative intervention for hip osteonecrosis and having a level of evidence of I to IV. We included 54 of the 488 reviewed manuscripts. Results No procedure was superior to others. In pre- and postcollapse hips, 264 of 864 hips (31%) and 419 of 850 hips (49%), respectively, exhibited radiographic disease progression. There were lower failure rates when the lesion involved less than 15% of the femoral head or had a necrotic angle of less than 200°(14%–25%) and when the osteonecrotic lesion involved only the medial 1/3 of the weightbearing surface (4.6%). Conclusions The best treatment of precollapse lesions is difficult to determine due to the limitations of the available literature. However, the data suggest operative intervention prevents collapse of small lesions of the femoral head or when there is a limited amount of the weightbearing surface involved. Patients with head collapse have a high progression rate after a femoral head-saving procedure. 文献出处：Which factors influence preservation of the osteonecrotic femoral head?Lieberman JR, Engstrom SM, Meneghini RM, SooHoo NF.Clin Orthop Relat Res. 2012 Feb;470(2):525-34. doi: 10.1007/s11999-011-2050-4. 文献3 股骨头缩小术联合髋臼周围截骨术治疗严重股骨头畸形 译者：肖凯 目的：本研究的目的是回顾股骨头缩小术（FHRO）联合髋臼周围截骨术（PAO）手术技术，并报道其用于治疗严重股骨头畸形的临床与影像学短期预后。 方法：自2011年至2016年，共有6名女性患者接受FHRO联合PAO治疗，平均年龄13.6岁（12.6-15.7岁）。前瞻性收集患者人口统计学数据、患者自我评分。在患者影像学资料上测量臼顶倾斜角、外侧CE角、内测股骨头颈偏心距、股骨头非覆盖率、alpha角。 结果：术后平均随访时间为3.3年（2-4.6年）。改良Harris评分由术前平均53.5分提高到术后平均83.4分，P=0.003。西安大略麦克马斯特大学骨关节炎指数分数由术前平均62分提高到术后平均90分，P=0.029。所有的影像学指标均由明显改善。患者术后没有长时间关节功能障碍，没有患者需要进一步接受人工关节置换术治疗。 结论：FHEO联合PAO短期效果良好，临床及影像学指标均有改善，可将其用于治疗特定年轻股骨头严重畸形患者。 14岁女性患者，左髋关节发育不良，关节半脱位，股骨头增大（左）；中图为术前设计，通过PAO纠正髋臼畸形，FHRO缩小股骨头体积，改善关节对位关系，股骨转子下截骨纠正异常前倾角；术后23.4个月随访显示，患者关节对位良好，各项影响学指标改善，患者改良Harris评分89.1分（右） 术中图片显示股骨头不圆，中心区域坏死；用记号笔标记股骨头截骨区域；摆锯进行股骨头截骨；移除中心坏死区骨块 Concurrent femoral head reduction and periacetabular osteotomies for the treatment of severe femoral head deformities AIMS:The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities. PATIENTS AND METHODS:Between 2011 and 2016, six female patients were treated with a combined FHRO and PAO. The mean patient age was 13.6 years (12.6 to 15.7). Clinical data, including patient demographics and patient-reported outcome scores, were collected prospectively. Radiologicalally, hip morphology was assessed evaluating the Tönnis angle, the lateral centre to edge angle, the medial offset distance, the extrusion index, and the alpha angle. RESULTS: The mean follow-up was 3.3 years (2 to 4.6). The modified Harris Hip Score improved by 33.0 points from 53.5 preoperatively to 83.4 postoperatively (p = 0.03). The Western Ontario McMasters University Osteoarthritic Index score improved by 30 points from 62 preoperatively to 90 postoperatively (p = 0.029). All radiological parameters showed significant improvement. There were no long-term disabilities and none of the hips required early conversion to total hip arthroplasty. CONCLUSION: FHRO combined with a PAO resulted in clinical and radiological improvement at short-term follow-up, suggesting it may serve as an appropriate salvage treatment option for selected young patients with severe symptomatic hip deformities. 文献出处：Clohisy JC, Pascual-Garrido C, Duncan S, Pashos G, Schoenecker PL. Concurrent femoral head reduction and periacetabular osteotomies for the treatment of severe femoral head deformities. Bone Joint J. 2018 Dec;100-B(12):1551-1558. doi: 10.1302/0301-620X.100B12.BJJ-2018-0030.R3. 文献4 改良Dunn截骨术治疗不稳定性股骨头骨骺滑脱 译者：任宁涛 背景：采用改良Dunn截骨术治疗不稳定性股骨头骨骺滑脱（SCFE）已经被证实是一种安全有效的治疗方法。我们选择连续系列不稳定性SCFE患者，均同一名术者治疗，重点关注手术干预的时间、术后并发症、以及患者影像学效果。 方法：本研究共纳入31例连续的不稳定性SCFE患者。我们记录下患者的人口特征信息、从症状出现到手术的时间、手术时间以及并发症情况。在患者末次随访时，我们采用双侧髋关节影像学检查，来记录滑脱角度、α角、大转子高度和股骨颈长度。 结果：有30名患者总共31例髋关节纳入研究：男性15例（50%）女性15例（50%），平均年龄为12.37岁（范围，8.75至14.8岁）；左侧髋关节20例（65%）右髋关节11例（35%），平均随访时间为27.9个月（范围，1至82个月）；从症状出现到手术治疗的时间为13.9个小时（范围，2.17至23.4个小时）；其中有2名患者（6%）出现缺血性坏死，平均时间为术后19周；有3名患者（10%）出现轻度异位骨化，不需要进行治疗干预。有2名患者（6%）因内植物出现症状需要取出，有1名患者出现内植物固定失效。未发现不愈合、延迟愈合或者术后髋关节半脱位/脱位的情况。有3名患者（10%）表现为双侧稳定性SCFE，需要进行对侧钢钉原位固定。有5名患者（16%）相继出现SCFE且需要进行治疗，其中有1名患者在之前手术10个月后出现急性不稳定性SCFE表现。所有患者术后平均滑脱角度为2.5°（范围， 19°至-9.4°）（SD，7.2），α角为47.43°（范围， 34°至64°）（SD，7.49），大转子高度平均位于股骨头中心下方3.5mm（范围，-17.5至 25mm），股骨颈长度差异平均为-7.75mm（范围，-1.8至-18.6mm）。 结论：同一术者的研究病例显示，采用改良Dunn截骨术治疗不稳定性SCFE，术后出现缺血性坏死的发生率为6%，末次随访时并发症的发生率低。影像学检查显示滑脱角度、α角、股骨颈长度、以及大转子高度得到恢复。本系列研究表明在治疗不稳定性SCFE时，改良Dunn截骨术具有安全性和有效性。 图一：滑移角。我们采用患侧髋关节与健侧髋关节之间的差异来评估矫正度数。负值代表滑移角的过度矫正。 图二：大转子高度。从股骨头中心到大转子尖端的高度。我们对患侧与健侧髋关节的差异进行记录。对于双侧髋关节受累及的患者，采用其测量的平均值进行表示。 图三：股骨颈长度。从髋臼后壁边缘（X）骨骺中心处到转子间线的距离。我们采用患侧髋关节与健侧髋关节之间的差异来判断股骨颈长度的变化。对于双侧髋关节受累及的患者，采用其测量的平均值进行表示。
图四：（A）患者术前左髋关节前后位片显示急性不稳定性股骨头骨骺滑脱，（B）术后前后位片以及（C）蛙式位侧位片显示，在接受改良Dunn截骨术治疗后股骨近端力线恢复，截骨处愈合。 Treatment of Unstable Slipped Capital Epiphysis Via the Modified Dunn Procedure Background: The modified Dunn procedure has been shown to be safe and effective in treating unstable slipped capital femoral epiphysis (SCFE). We present a consecutive series of unstable SCFE managed by a single surgeon with a focus on timing of surgical intervention, postoperative complications, and radiographic results. Methods: Thirty-one consecutive unstable SCFEs were treated. Demographics, presentation time to time of operation, surgical times, and complications were recorded. Bilateral hip radiographs at latest follow-up were utilized to record slip angle, a angle, greater trochanteric height, and femoral neck length. Results: Thirty-one consecutive hips in 30 patients were reviewed: 15 males (50%) and 15 females (50%), average age 12.37 years (range, 8.75 to 14.8 y), 20 left hips (65%) and 11 right hips (35%). Mean follow-up was 27.9 months (range, 1 to 82 mo). Time from presentation to intervention averaged 13.9 hours (range, 2.17 to 23.4 h). Two patients (6%) developed avascular necrosis at average 19 weeks postoperative. Three patients (10%) developed mild heterotopic ossification requiring no treatment. Two patients (6%) required removal of symptomatic hardware. One patient had hardware failure and in no patients was nonunion, delayed union, or postoperative hip subluxation/dislocation seen. Three patients (10%) presented with bilateral, stable SCFE requiring contralateral in situ pinning. Five patients (16%) had sequential SCFE requiring treatment with 1 patient having an acute, unstable SCFE 10 months after the previous realignment. Mean postoperative slip angle measured 2.5 degrees (range, 19 to 9.4 degrees) (SD, 7.2), a angle 47.43 degrees (range, 34 to 64 degrees) (SD, 7.49), greater trochanteric height averaged 3.5mm below the center of femoral head (17.5 to 25 mm), and mean femoral neck length difference measured 7.75mm (range, 1.8 to 18.6 mm). Conclusions: A single surgeon series of unstable SCFEs treated by a modified Dunn procedure showed a 6% incidence of avascular necrosis and low complication rates at latest followup. Radiographs showed restoration of the slip angle, a angle, femoral neck length, and greater trochanteric height. This series reveals the safety and effectiveness of the modified Dunn procedure for unstable SCFE. 文献出处：'Treatment of Unstable Slipped Capital Epiphysis Via the Modified Dunn Procedure', F. Persinger, R. L. Davis, 2nd, W. P. Samora, and K. E. Klingele, J Pediatr Orthop (2016). 文献5 发育性髋关节发育不良残留畸形于骨成熟后骨与软骨髋臼指数在MRI的差异 译者：张利强 目前尚不能预测发育性髋关节发育不良（DDH）残留畸形自我改善的质量。在MRI上已建立了骨髋臼指数（OAI）、软骨髋臼指数和盂唇髋臼指数的正常年龄相关值。在这项研究中，我们评估了发育异常髋关节的MRI，并随访盆腔X片上髋臼随着时间的推移的进一步成熟变化，以发现MRI结果与放射学演变之间的相关性。这是一项单中心回顾性研究。包括2007年2月至2014年6月进行骨盆MRI检查的DDH患儿。在MRI上测量骨髋臼指数（OAI）、软骨髋臼指数和盂唇髋臼指数值。随后在随访期间记录下每张可用的X线片的OAI。 总共随访包括20髋。MRI诊断的平均年龄为3.55岁。共分为两种类型的DDH：一组为协调性发育不良即髋臼骨和软骨同时缺损（A组，n=14），另一组为差异性发育不良即髋臼存在骨性缺损，但软骨覆盖足够（B组，n=6）。最终放射学随访的平均年龄分别为7.6岁和8.3岁（p=0.7408）。A组中，4名（28.6%）6岁以上的儿童的OAI低于18°，而B组中只有2名（33.3%）6岁以上的儿童的OAI低于18°（p=0.0117）。这项研究表明，在三分之一的病例中，差异性髋臼发育不良会自行恢复。MRI应尽早用于准确诊断和随访DDH病例并帮助医生证明所需的外科治疗是合理的。
在MRI冠状面上测量骨髋臼指数（OAI）和软骨髋臼指数（CAI）
入组时的MRI和随访最后一次的X线。测量协调（a）和差异（b）髋臼发育不良（DDH，入组时和最后一次）的骨髋臼指数（OAI）。（a）女孩2.5岁入组时（OAI:33.87°）和4.55岁时（AI:22.55°）：髋臼覆盖未完成。（b）女孩2.25岁入组时（OAI:27.21°）和4.37岁时（AI:13.19°）：髋臼覆盖明显改善 Bone maturation of MRI residual developmental dysplasia of the hip with discrepancy between osseous and cartilaginous acetabular index Quality of spontaneous amelioration of residual developmental dysplasia of the hip (DDH) is nowadays not possible to predict. Normal age-related values of the osseous acetabular index (OAI), cartilaginous acetabular index and labral acetabular index have been established on MRI. In this study, MRI of dysplastic hips has been evaluated, and further osseous acetabular maturation was followed-up over time on pelvic radiography to find a correlation between MRI findings and radiological evolution. This is a retrospective single-centre study. Children with DDH who had a pelvic MRI between February 2007 and June 2014 were included. AI was measured for osseous (OAI), cartilaginous (cartilaginous acetabular index) and labral (labral acetabular index) values on MRI. OAI was thereafter recorded on each available radiograph during follow-up. A total of 20 hips were included. The mean age at MRI diagnosis was 3.55 years. Two types of DDH were observed: harmonious dysplasia, associated with an osseous and cartilaginous defect (group A, n = 14), and divergent dysplasia, associated with an osseous defect but with sufficient cartilaginous coverage (group B, n = 6). The mean age at final radiological follow-up was 7.6 and 8.3 years(P = 0.7408), respectively. In group A, four (28.6%) children older than 6 years had an OAI of less than 18°, whereas only two (33.3%) children older than 6 years had an OAI less than 18° in group B (P = 0.0117). This study shows that, in one-third of cases, divergent dysplasia leads to a spontaneous recovery. MRI should be used early to accurately diagnose and follow-up DDH cases and allow surgeons to justify the required surgical treatment. |
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