本期目錄：

1,、用于診斷慢性假體周圍感染的實(shí)驗(yàn)室檢查可以預(yù)測二期翻修術(shù)的效果

2,、初次髖關(guān)節(jié)置換術(shù)中股骨球頭的使用情況

3,、人工關(guān)節(jié)置換術(shù)后血糖值波動升高與負(fù)性反應(yīng)增多相關(guān)

4、帶血管蒂骨移植治療非創(chuàng)傷性股骨頭壞死：5-11年隨訪

5,、治療股髖撞擊手術(shù)中行軟骨游離瓣下鉆孔降低全髖關(guān)節(jié)置換的風(fēng)險——超過5年隨訪

6,、髖關(guān)節(jié)鏡下髂前下棘成形不會影響術(shù)后的肌肉力量

7、髖關(guān)節(jié)反復(fù)后脫位的手術(shù)治療

第一部分：關(guān)節(jié)置換相關(guān)文獻(xiàn)

文獻(xiàn)1

用于診斷慢性假體周圍感染的實(shí)驗(yàn)室檢查可以預(yù)測二期翻修術(shù)的效果

譯者：張軼超

背景：盡管二期翻修術(shù)對于治療慢性假體周圍感染（PJI）是個非常有效的方法,，但是成功率卻有很大差別,。本研究的目的是檢驗(yàn)診斷慢性假體周圍感染的指標(biāo)是否也能被用于預(yù)測二期翻修的失敗風(fēng)險。

方法：我們收集了來自于4個單位的205名由于全膝或髖置換術(shù)后假體周圍感染行二期翻修手術(shù)的患者,。通過醫(yī)學(xué)記錄收集了他們的一般情況,，手術(shù)情況和實(shí)驗(yàn)室檢查。實(shí)驗(yàn)室檢查值包括血沉（ESR）,，血清C反應(yīng)蛋白（CRP）,，關(guān)節(jié)液白細(xì)胞計數(shù)和中性粒細(xì)胞百分比，關(guān)節(jié)液和/或組織培養(yǎng),，以及革蘭氏染色,。對于因感染復(fù)發(fā)而再次行翻修手術(shù)的病例被認(rèn)為是二期翻修手術(shù)失敗。比較兩組間的一般情況,，手術(shù)情況和實(shí)驗(yàn)室檢查指標(biāo),。通過受試者工作特征曲線（ROC）來確定有意義的實(shí)驗(yàn)室指標(biāo)的閾值。

結(jié)果：總體看二期翻修的失敗率為27.3%。感染復(fù)發(fā)的病例的術(shù)前血沉(p=0.035),、關(guān)節(jié)液白細(xì)胞計數(shù)(p=0.008)及中性粒細(xì)胞百分比(p=0.041)都明顯高于二期翻修成功的病例,。ROC曲線分析結(jié)果顯示關(guān)節(jié)液白細(xì)胞計數(shù)的閾值為>60,000個/μL ，關(guān)節(jié)液中性粒細(xì)胞百分比>92%,，血沉>99mm/小時,。二期翻修失敗的病例術(shù)前關(guān)節(jié)液白細(xì)胞計數(shù)比成功的病例增高2.5倍，關(guān)節(jié)液中性粒細(xì)胞百分比高2倍,，血沉高1.8倍,。

結(jié)論：我們的結(jié)果證明了二期翻修失敗的病例術(shù)前的關(guān)節(jié)液白細(xì)胞計數(shù)>60,000個/μL ，關(guān)節(jié)液中性粒細(xì)胞百分比>92%,，血沉>99mm/小時,。實(shí)驗(yàn)室指標(biāo)比成功的高1.8到2.5倍。這個數(shù)據(jù)可以給臨床提供術(shù)前預(yù)測二期翻修手術(shù)失敗風(fēng)險,。

Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange

BACKGROUND: Although 2-stage exchange arthroplasty is the most effective treatment among available strategies for managing chronic periprosthetic joint infection (PJI), rates of its success vary greatly. The purpose of our study was to examine whether objective measurements collected at the time of the diagnosis of PJI could be used to identify patients at risk of failure of 2-stage exchange.

METHODS: We identified 205 patients across 4 institutions who underwent 2-stage exchange arthroplasty for the treatment of PJI following total hip or total knee arthroplasty. Demographic, surgical, and laboratory data were obtained for each patient from their medical chart. Laboratory values included serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) level, synovial fluid white blood-cell (WBC) count and neutrophil percentage, synovial fluid and/or tissue culture, and Gram stain. Patients who underwent revision surgery for recurrent infection were considered to have failed the 2-stage procedure. Demographic, surgical, and laboratory variables were compared between the 2 groups. Receiver operating characteristic (ROC) curves were constructed to determine threshold cutoffs for significant laboratory values. Risk ratios and 95% confidence intervals were calculated.

RESULTS: Overall, 2-stage exchange was unsuccessful for 27.3% of the patients. Preoperative serum ESR (p = 0.035) and synovial fluid WBC count (p = 0.008) and neutrophil percentage (p = 0.041) were greater in patients with recurrent infection. ROC curve analysis revealed a threshold of >60,000 cells/μL for synovial fluid WBC count, >92% for synovial fluid WBC neutrophil percentage, and >99 mm/hr for serum ESR. Failure of 2-stage exchange was 2.5 times more likely for patients with an elevated preoperative synovial fluid WBC count, 2.0 times more likely for those with an elevated preoperative synovial fluid WBC neutrophil percentage, and 1.8 times more likely for those with an elevated preoperative serum ESR.

CONCLUSIONS: Our results demonstrated that a greater number of patients in whom 2-stage exchange arthroplasty ultimately failed had a preoperative synovial fluid WBC count of >60,000 cells/μL, a synovial fluid WBC neutrophil percentage of >92%, or a serum ESR of >99 mm/hr. Patients with elevated laboratory values had 1.8 to 2.5 times the risk of treatment failure. These data can serve as a clinical guideline to identify patients most at risk for failure of 2-stage exchange.

文獻(xiàn)出處：Dwyer MK, Damsgaard C, Wadibia J, et al. Laboratory Tests for Diagnosis of Chronic Periprosthetic Joint Infection Can Help Predict Outcomes of Two-Stage Exchange. J Bone Joint Surg Am. 2018 Jun 20;100(12):1009-1015. 

文獻(xiàn)2

初次髖關(guān)節(jié)置換術(shù)中股骨球頭的使用情況

譯者：馬云青

1. 過去10年中,，大直徑球頭在全髖關(guān)節(jié)置換術(shù)(THA)中的使用有所增加；參考幾個較大的關(guān)節(jié)置換術(shù)登記處的報告,，32 mm和36 mm是最常用的股骨頭大小,。

2. 使用大直徑球頭是增加髖關(guān)節(jié)穩(wěn)定性和減少髖關(guān)節(jié)使用壽命（減少聚乙烯厚度）間的一種平衡。

3. 通過文獻(xiàn)回顧（主要集中在過去5年）,，確定了在THA中使用更大的球頭的好處和并發(fā)癥,。我們發(fā)現(xiàn)，當(dāng)使用>36 mm的球頭時,，髖關(guān)節(jié)活動范圍或髖關(guān)節(jié)功能沒有明顯提高,。

4. 36 mm或更大直徑球頭因脫位而導(dǎo)致翻修的風(fēng)險明顯低于28 mm或更小的球頭，甚至是32 mm球頭,。

5. 金屬對交聯(lián)聚乙烯(MoXLPE)THA中大于32mm球頭比32 mm或更小球頭的容積摩擦和摩擦扭矩更高,。而在陶瓷對交聯(lián)聚乙烯(CoXLPE)THA中并沒有這種現(xiàn)象。

6. 32mm球頭MoXLPE摩擦界面的THA長期假體生存率比較大和較小的球頭都高,。

7. 如果使用MoXLPE界面,，我們建議使用32mm的球頭。在使用較大球頭的髖關(guān)節(jié)病例上,，使用陶瓷頭更安全,。

不同國家地區(qū)髖關(guān)節(jié)假體股骨頭直徑分布

不同國家地區(qū)髖關(guān)節(jié)假體摩擦界面選擇分布

Head size in primary total hip arthroplasty

1．The use of larger femoral head size in total hip arthroplasty (THA) has increased during the past decade; 32 mm and 36 mm are the most commonly used femoral head sizes, as reported by several arthroplasty registries.

2．The use of large femoral heads seems to be a trade-off between increased stability and decreased THA survivorship.

3．We reviewed the literature, mainly focussing on the past 5 years, identifying benefits and complications associated with the trend of using larger femoral heads in THA.

4．We found that there is no benefit in hip range of movement or hip function when head sizes > 36 mm are used.

5．The risk of revision due to dislocation is lower for 36 mm or larger bearings compared with 28 mm or smaller and probably even with 32 mm.

6．Volumetric wear and frictional torque are increased in bearings bigger than 32 mm compared with 32 mm or smaller in metal-on-cross-linked polyethylene (MoXLPE) THA, but not in ceramic-on-XLPE (CoXLPE).

7. Long-term THA survivorship is improved for 32 mm MoXLPE bearings compared with both larger and smaller ones. We recommend a 32 mm femoral head if MoXLPE bearings are used. In hips operated on with larger bearings the use of ceramic heads on XLPE appears to be safer.

文獻(xiàn)出處：Tsikandylakis G, Mohaddes M, Cnudde P, Eskelinen A, K?rrholm J, Rolfson O. Head size in primary total hip arthroplasty. EFORT Open Rev. 2018 May 21;3(5):225-231. doi: 10.1302/2058-5241.3.170061. eCollection 2018 May.

文獻(xiàn)3

人工關(guān)節(jié)置換術(shù)后血糖值波動升高與負(fù)性反應(yīng)增多相關(guān)

譯者：張薔

背景：既往研究顯示：住院期間，非骨科手術(shù)后患者住院時間延長,、死亡率升高與血糖值波動升高相關(guān),。本研究的目的是調(diào)查人工關(guān)節(jié)置換術(shù)后患者血糖值波動與術(shù)后并發(fā)癥的相關(guān)性。

方法：2001年至2017年間,，單一醫(yī)療中心共21487例全膝,、全髖置換術(shù)病例入組,。入組標(biāo)準(zhǔn)為術(shù)后每天至少測2次血糖值或總共測3次以上血糖值。血糖值波動水平通過變異系數(shù)表示,。負(fù)性反應(yīng)包括住院時間延長,、90天死亡率、再手術(shù)率,、假體周圍感染和手術(shù)切口感染,。假體周圍感染的診斷通過肌骨感染協(xié)會標(biāo)準(zhǔn)（MSIS）確定。

結(jié)果：最終組里包括2360例全髖置換患者和2698例全膝置換患者,，其中1007人有糖尿病,。血糖值波動升高與住院時間延長、90天死亡率升高,、假體周圍感染和手術(shù)切口感染率升高相關(guān),。分析顯示：血糖值變異系數(shù)每增高10%，住院時間延長6.1% (95% confidence interval[CI], 5.1% to 7.2%; p < 0.001),，死亡率升高26% (odds ratio[OR] = 1.26, 95% CI = 0.98 to 1.61; p = 0.07),，假體周圍感染和手術(shù)切口感染風(fēng)險分別增高20% (OR = 1.20, 95% CI = 1.02 to 1.41; p = 0.03)和14% (OR = 1.14, 95% CI = 1.00 to 1.31; p = 0.06)。手術(shù)時間,、年齡,、BMI、Elixhauser合并癥指數(shù),、糖尿病診斷、住院期間應(yīng)用胰島素或激素和住院期間平均血糖水平并不影響本研究相關(guān)性,。

結(jié)論：術(shù)后血糖值波動升高與假體周圍感染和手術(shù)切口感染率升高相關(guān),，并可以作為全髖、全膝置換術(shù)后死亡率的預(yù)測因素,。因此,，我們應(yīng)盡力控制術(shù)后早期患者血糖值波動。在未來,，相關(guān)研究的重點(diǎn)應(yīng)放在對血糖值波動較大的患者進(jìn)行持續(xù)血糖監(jiān)測等方面,。

Increased Postoperative Glucose Variability Is Associated with Adverse Outcomes Following Total Joint Arthroplasty

Background: Increased glucose variability during hospitalization has been associated with a longer length of stay in the hospital and a higher mortality rate following non-orthopedic surgical procedures. Our aim was to investigate the association between glucose variability and postoperative complications following total joint arthroplasty.

Methods: We analyzed data on 21,487 patients who had undergone total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a single center from 2001 to 2017. Patients with a minimum of 2 postoperative glucose values per day or > 3 values overall were included in the study. Glucose variability was assessed using a coefficient of variation. Adverse outcomes included an increased length of stay in the hospital, 90-day mortality, reoperations, periprosthetic joint infection, and surgical site infection. Periprosthetic joint infection was defined using the Musculoskeletal Infection Society criteria.

Results: The final cohort included 2,360 patients who had undergone THA and 2,698 who had undergone TKA; 1,007 (19.9%) had diabetes. Higher glycemic variability was associated with an increased length of stay, 90-day mortality, periprosthetic joint infection, and surgical site infection. Adjusted analysis indicated that for every 10-percentage-point increase in the coefficient of variation, the length of stay increased by 6.1% (95% confidence interval [CI], 5.1% to 7.2%; p < 0.001), the risk of mortality increased by 26% (odds ratio [OR] = 1.26, 95% CI = 0.98 to 1.61; p = 0.07), and the risks of periprosthetic joint infection and surgical site infection increased by 20% (OR = 1.20, 95% CI = 1.02 to 1.41; p = 0.03) and 14% (OR = 1.14, 95% CI = 1.00 to 1.31; p = 0.06), respectively. These associations were independent of the year of surgery, age, body mass index, Elixhauser comorbidity index, diagnosis of diabetes, in-hospital use of insulin or steroids, and mean glucose values during hospitalization.

Conclusions: Higher glucose variability in the postoperative period is associated with increased rates of surgical site and Periprosthetic joint infections and may be a useful predictor of the risk of mortality following THA and TKA. Efforts should be made to control the glucose variability in the early postoperative period, and future studies should examine the role of continuous glucose monitoring in a subset of patients with high glucose fluctuations.

文獻(xiàn)出處：Noam Shohat, Camilo Restrepo, Arash Allierezaie, et al. Increased Postoperative Glucose Variability Is Associated with Adverse Outcomes Following Total Joint Arthroplasty. J Bone Joint Surg Am. 2018; 100:1110-7

第二部分：保髖相關(guān)文獻(xiàn)

文獻(xiàn)1

帶血管蒂骨移植治療非創(chuàng)傷性股骨頭壞死：5-11年隨訪

譯者：羅殿中

我們研究了26例（31髖）股骨頭壞死患者，其中非創(chuàng)傷性股骨頭壞死20例,，激素性股骨頭壞死6例,，所有患者均通過帶血管蒂髂骨移植術(shù)治療。所有患者平均手術(shù)年齡為38.3歲,。性別組成：女性3例,，男性23例。術(shù)后平均隨訪時間為8年,?；颊逪arris評分由術(shù)前平均62分提高到末次隨訪時平均83分,。1例患者因術(shù)后股骨頭塌陷行人工關(guān)節(jié)置換術(shù)。末次隨訪時,，19髖（63%）臨床預(yù)后被評定為好/非常好,，4髖評定為一般，7髖評定為較差,。末次隨訪時,，術(shù)前股骨頭壞死Inoue及Ono分期II期27髖中的15髖（56%）術(shù)后出現(xiàn)了股骨頭進(jìn)行性塌陷。在激素性股骨頭壞死患者中,，3位女患者4髖中的2髖術(shù)后臨床效果較差,。此研究中接受帶血管蒂骨移植患者的臨床預(yù)后僅輕微優(yōu)于接受髓芯減壓術(shù)的文獻(xiàn)報道，并不優(yōu)于那些接受骨減壓結(jié)合單純打壓植骨（用不帶血管的骨支撐軟骨下骨）的患者,。我們的結(jié)論是：帶血管蒂骨移植術(shù)適用于某些早期未發(fā)生股骨頭塌陷的非創(chuàng)傷性股骨頭壞死患者,。

A．髂骨取骨，保留旋髂淺動脈及靜脈,，有8髖應(yīng)用了旋髂深動脈及靜脈,；B. 做足夠大的骨隧道，植入髂骨骨塊,，血管蒂與股動靜脈吻合

35歲男性患者不同時期右髖關(guān)節(jié)冠狀位MRI  A. 術(shù)前 B. 術(shù)后6個月 C. 術(shù)后18個月

28歲男性酒精性雙側(cè)股骨頭壞死  A. 術(shù)前骨盆A-P位X線片,，左髖日本股骨頭壞死研究學(xué)會分型I-C型，Inoue及Ono分期II期,，右髖關(guān)節(jié)無癥狀 B.雙髖術(shù)前蛙式位 C. 左髖術(shù)后11年進(jìn)展為III-A型,，右髖術(shù)后9年進(jìn)展為III-B型 D. 末次隨訪時雙髖蛙式位

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 femoral head (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.

文獻(xiàn)出處：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.

文獻(xiàn)2

治療股髖撞擊手術(shù)中行軟骨游離瓣下鉆孔降低全髖關(guān)節(jié)置換的風(fēng)險——超過5年隨訪

譯者：程徽

介紹：股髖撞擊（FAI）手術(shù)中，如何很好的處理髖臼軟骨瓣目前尚不明確,。我們希望明確軟骨下鉆孔是否可以改善臨床和影像學(xué)結(jié)果,，以及是否存在可以預(yù)測手術(shù)失敗的因素。

方法：在2000年1月至2007年12月期間,，使用髖關(guān)節(jié)外科脫位技術(shù)治療了79例有癥狀的FAI伴有髖臼游離軟骨瓣的患者,。除外既往髖關(guān)節(jié)病史和創(chuàng)傷史，本研究納入62例患者（80髖）,。43例患者/ 51髖（對照組）中,，軟骨瓣僅僅進(jìn)行了輕微的修整。在28例患者/ 29髖（研究組）中,，術(shù)中同時進(jìn)行軟骨瓣下鉆孔,。失訪4例（5髖，6％）,。平均隨訪時間為9年（5-13年）,。兩組患者在人口統(tǒng)計學(xué)數(shù)據(jù)，放射學(xué)參數(shù)或隨訪情況方面無顯著差異,。使用Merle d'Aubigné評分,，改良Harris髖關(guān)節(jié)評分,，和加州大學(xué)洛杉磯分校活動評分評估臨床結(jié)果,；使用T?nnis分級評價骨關(guān)節(jié)炎進(jìn)展情況,。

結(jié)果：在隨訪中，對照組的7例患者（8髖,，16％）最終接受終行全髖關(guān)節(jié)置換術(shù)（THA）,，而鉆孔治療組沒有患者進(jìn)行置換（p = 0.005）。在未行置換的髖關(guān)節(jié)中,，兩組間臨床評分和T?nnis分級的進(jìn)展沒有差異,。過大的髖臼覆蓋率，年齡和體重指數(shù),，是導(dǎo)致關(guān)節(jié)置換的單變量預(yù)測因素,。沒有鉆孔，也是導(dǎo)致關(guān)節(jié)置換的獨(dú)立預(yù)測因素（風(fēng)險比58.07,，p = 0.009）,。

結(jié)論：在手術(shù)治療FAI中，髖臼軟骨瓣下的鉆孔可以降低后期行關(guān)節(jié)置換的概率,。

Subchondral drilling for chondral flaps reduces the risk of total hip arthroplasty in femoroacetabular impingement surgery at minimum five years follow-up

INTRODUCTION: The best treatment of acetabular chondral flaps during surgery for femoroacetabular impingement (FAI) is unknown. We asked if subchondral drilling improves clinical and radiographic outcome and if there are factors predicting failure.

METHODS: We treated 79 patients with symptomatic FAI and acetabular chondral flaps with surgical hip dislocation between January 2000 and December 2007. Exclusion of all patients with previous hip pathology or trauma resulted in 62 patients (80 hips). The chondral flap was slightly debrided in 43 patients/51 hips (control group). In 28 patients/29 hips (study group), additional osseous drilling was performed. 4 patients (5 hips, 6%) were lost to follow-up. Mean follow-up was 9 years (5-13 years). The groups did not differ in demographic data, radiographic parameters or follow-up. Clinical outcome was assessed with the Merle d'Aubigné score, modified Harris Hip Score and University of California Los Angeles activity score and progression of osteoarthritis with the T?nnis grade.

RESULTS: No patient underwent conversion to total hip arthroplasty (THA) in the drilling group compared to 7 patients (8 hips, 16%) in the control group (p = 0.005); in the remaining hips, clinical scores and progression of T?nnis grade did not differ. Increased acetabular coverage, age and body mass index were univariate predictive factors for conversion to THA. No drilling was as an independent predictive factor for conversion to THA (hazard ratio 58.07, p = 0.009).

CONCLUSION: Subchondral drilling under acetabular chondral flaps during surgical treatment of FAI is an effective procedure to reduce the rate of conversion to THA.

文獻(xiàn)出處：Haefeli PC, Tannast M, Beck M, Siebenrock KA, Büchler L. Subchondral drilling for chondral flaps reduces the risk of total hip arthroplasty in femoroacetabular impingement surgery at minimum five years follow-up. Hip Int. 2018 Jun 1:1120700018781807. 

文獻(xiàn)3

髖關(guān)節(jié)鏡下髂前下棘成形不會影響術(shù)后的肌肉力量

譯者：肖凱

目的：本研究的目的是評估髖關(guān)節(jié)鏡下髂前下棘（AIIS）成形術(shù)后是否會影響伸膝肌肉及屈髖肌肉力量,；比較進(jìn)行或不進(jìn)行髂前下棘成形術(shù)的FAI患者術(shù)后的功能情況。

方法：本研究納入60例接受髖關(guān)節(jié)鏡手術(shù)治療的FAI患者,，根據(jù)患者髂前下棘形態(tài)不同分為兩組,。其中31例（FAI組）單純進(jìn)行關(guān)節(jié)鏡下FAI處理，不進(jìn)行髂前下棘成形,，髂前下棘分型：I型5例,，II型26例，III型0例,。另外29例（AIIS組）除了進(jìn)行關(guān)節(jié)鏡下FAI處理，同時進(jìn)行髂前下棘成形,，髂前下棘分型：I型5例,，II型24例，III型0例,。術(shù)前及術(shù)后6個月對伸膝肌肉力量及屈髖肌肉力量進(jìn)行測試,。術(shù)前及術(shù)后6個月要求患者完成自我評分量表，包括改良Harris髖關(guān)節(jié)評分,、非骨關(guān)節(jié)炎髖關(guān)節(jié)評分,、iHOT-12評分。

結(jié)果：兩組患者間術(shù)前及術(shù)后6個月的伸膝肌肉力量間均無明顯差異,。AIIS組患者術(shù)后屈髖肌肉力量較術(shù)前明顯提高（p <0.05）,，而FAI組術(shù)后肌肉力量較術(shù)前無明顯改善,。兩組患者術(shù)前及術(shù)后改良Harris髖關(guān)節(jié)評分及非骨關(guān)節(jié)炎髖關(guān)節(jié)評分均無明顯差異。但是,，AIIS組患者術(shù)后iHOT評分較FAI組高（p <0.01）,。AIIS組患者再手術(shù)率明顯低于FAI組（p <0.05）。

左,、中,、右分別為術(shù)前、初次術(shù)后,、翻修術(shù)后髖關(guān)節(jié)CT三位重建影像,，初次手術(shù)未處理髂前下棘，翻修術(shù)后,，髂前下棘突出部分明顯變小

結(jié)論：髂前下棘成形術(shù)作為關(guān)節(jié)鏡下治療FAI的一部分,，可以降低再手術(shù)的概率，并且不會影響伸膝肌肉及屈髖肌肉力量,。相比FAI組,，AIIS組患者手術(shù)預(yù)后更好。對于FAI患者,，同時進(jìn)行髂前下棘成形術(shù)可以改善術(shù)后患者自我評分結(jié)果,，并且不影響屈髖及伸膝肌肉力量。

Arthroscopic anterior inferior iliac spine decompression does not alter postoperative muscle strength

PURPOSE: The purpose of this study was to assess the additional effect of anterior inferior iliac spine (AIIS) decompression on knee extensor and hip flexor strength and compare functional outcomes after arthroscopic FAI correction with and without AIIS decompression.

METHODS: Sixty patients who underwent arthroscopic FAI correction surgery were divided into two groups matched for AIIS morphology: 31 patients who underwent arthroscopic FAI surgery only (without AIIS decompression) (FAI group) (AIIS Type I; n?=?5, Type II; n?=?26, Type III; n?=?0) and 29 patients who underwent arthroscopic FAI surgery with AIIS decompression (AIIS group) (AIIS Type I; n?=?5, Type II; n?=?24, Type III; n?=?0). Knee extensor and hip flexor strength were evaluated preoperatively and at 6 months after surgery. Patient-reported outcome (PRO) scores using the modified Harris hip score (MHHS), the nonarthritic hip score (NAHS) and iHOT-12 were obtained preoperatively and at 6 months after surgery.

RESULTS: In the AIIS group, there was no significant difference between knee extensor strength pre- and postoperatively (n.s.). In the AIIS group, hip flexor strength was significantly improved postoperatively compared to preoperative measures (p?<?0.05). In the FAI group, there were no significant improvements regarding muscle strength (n.s.). While there were no significant differences of preoperative and postoperative MHHS and NAHS between both groups (MHHS; n.s., NAHS; n.s.), the mean postoperative iHOT-12 in the FAI group was inferior to that in the AIIS group. (p?<?0.01). The revision surgery rate for the AIIS group was significantly lower compared with that in the FAI group (p?<?0.05).

CONCLUSION: Anterior inferior iliac spine decompression, as a part of an arthroscopic FAI corrective procedure, had a lower revision surgery rate and did not compromise knee extensor and hip flexor strength, and it improved clinical outcomes comparable to FAI correction without AIIS decompression. AIIS decompression for FAI correction improved postoperative PRO scores without altering the muscle strength of hipflexor and knee extensor.

文獻(xiàn)出處：Tateishi S, Onishi Y, Suzuki H, et al. Arthroscopic anterior inferior iliac spine decompression does not alter postoperative muscle strength. Knee Surg Sports Traumatol Arthrosc. 2018 Jun 28. 

文獻(xiàn)4

髖關(guān)節(jié)反復(fù)后脫位的手術(shù)治療

譯者：張振東

阿基米德曾經(jīng)說過“給我一個支點(diǎn),，就可以撬動整個地球”,，同樣對于髖關(guān)節(jié)穩(wěn)定性來講，如果股骨近端與骨盆間存在支點(diǎn),，也可導(dǎo)致髖關(guān)節(jié)后脫位,。對于無既往手術(shù)史的髖關(guān)節(jié)反復(fù)發(fā)生脫位，曾經(jīng)被認(rèn)為與嚴(yán)重系統(tǒng)性疾病或神經(jīng)肌肉疾病有關(guān),，而忽視了髖關(guān)節(jié)結(jié)構(gòu)本身的問題（圖1）,。而近年來研究表明這類髖關(guān)節(jié)脫位與髖關(guān)節(jié)撞擊征和/或髖關(guān)節(jié)后傾相關(guān)。髖臼前壁高凸,、股骨頸凸輪畸形及股骨頸前傾角小或后傾,，均可以提供一個可以使髖關(guān)節(jié)后脫位的支點(diǎn)。

圖1 男性,，29歲,，反復(fù)髖關(guān)節(jié)后脫位，有癲癇病史,，但其每一次髖關(guān)節(jié)脫位均與癲癇無關(guān)

髖關(guān)節(jié)反復(fù)后脫位在臨床上較為罕見,，且對其治療的長期報道更是少見，因此對于其治療缺乏相關(guān)臨床建議,，Carlson BC等人總結(jié)了兩個中心（美國Mayo Clinic以及瑞士SchulthessClinic）共計9例髖關(guān)節(jié)反復(fù)后脫位的患者治療特點(diǎn),，對其手術(shù)療效及影像學(xué)結(jié)果進(jìn)行隨訪,，結(jié)果報道于最新一期的JBJSAm雜志上。

該研究回顧性分析了9例接受保髖手術(shù)治療的反復(fù)性髖關(guān)節(jié)后脫位的患者,，術(shù)前患者脫位次數(shù)平均為3.2次（范圍：1-7次）,。使用骨盆X線測量評估髖臼及股骨近端形態(tài)，影像學(xué)測量是否存在髖關(guān)節(jié)撞擊有助于選擇合適的手術(shù)方式,。手術(shù)方式包括股骨畸形糾正伴或不伴髖臼周圍截骨術(shù)（圖2）,。

圖2 反復(fù)髖關(guān)節(jié)后脫位患者的髖關(guān)節(jié)側(cè)位（A）及正位（B）x線片，可見右側(cè)髖臼后傾,，后壁征（ ）,、交叉征（ ），右側(cè)股骨頸alpha角60度,，存在凸輪畸形,。C、D示髖臼周圍截骨術(shù)糾正髖臼前傾角并結(jié)合股骨頭頸部骨軟骨成形術(shù)

結(jié)果顯示,，9例患者平均隨訪時間為73.8月（范圍：10-192月）,，截至末次隨訪未出現(xiàn)一例髖關(guān)節(jié)再次脫位情況。因此對于反復(fù)髖關(guān)節(jié)脫位的患者,，需明確是否存在解剖學(xué)異常造成的股骨近端與髖臼間的支點(diǎn),，據(jù)此可選擇合適的手術(shù)治療以避免再次脫位。

附 反復(fù)性髖關(guān)節(jié)后脫位的診治原則

Modern Surgical Treatment of Recurrent Posterior Dislocation of the Native Hip

BACKGROUND: Redislocation of the native hip is rare. An anterior fulcrum between the proximal part of the femur and the pelvis must be present for a posterior dislocation to occur. The purpose of this study is to describe the cases of 9 patients with posterior redislocation or recurrent subluxation of the native hip that was treated with hip preservation surgery.

METHODS: We retrospectively identified the cases of 9 patients, from 2 institutions, who had undergone hip preservation surgery for the management of posterior redislocation or recurrent subluxation of the native hip after a dislocation. The mean number of dislocations prior to surgery was 3.2 (range, 1 to 7). Pelvic radiographs were used to classify the acetabular morphology, sufficiency of acetabular containment, and structural anatomy of the proximal part of the femur. Radiographic identification of impinging structures was used to guide surgical treatment, which involved either femoral correction alone or the combination of femoral correction and an anteverting periacetabular osteotomy.

RESULTS: At a mean follow-up of 73.8 months (range, 10 to 192 months), there had been no subsequent episodes of dislocation or subluxation in any of the hips treated with correction of the anatomic pivot point. An algorithmic approach is presented.

CONCLUSIONS: In patients who have episodes of redislocation or recurrent subluxation of the native hip, the identification of anatomic abnormalities that create a fulcrum between the proximal part of the femur and the pelvis is critical for making appropriate treatment decisions.

文獻(xiàn)出處：Carlson BC, Desy NM, Johnson JD, Trousdale RT, Leunig M, Ganz R, Sierra RJ. Modern Surgical Treatment of Recurrent Posterior Dislocation of the Native Hip. J Bone Joint Surg Am. 2018 Jun 20;100(12):1056-1063. 

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