本期目录

1、骨发育不良患者全膝置换的技术挑战

2、锥形非骨水泥半髋关节置换术治疗股骨颈骨折后的股骨假体下沉和髋臼侧侵蚀的10-13年随访研究

3、旋转平台全膝关节置换术后功能性屈曲不稳定的工程力学研究

4、2020年Frank Stinchfield奖：谁会在保留假体清创治疗关节假体感染后失败：一种基于机器学习并经过验证的工具

5、再次探讨全膝关节置换术中单独更换聚乙烯衬在无菌性失败中的作用

6、梨状肌综合症的诊断、治疗及预后：一项为期10年的研究

7、股骨不同节段对股骨整体扭转的影响

8、手法触摸大转子试验测量股骨扭转角的可靠性和有效性

9、DDH早期超声筛查

10、髂囊肌与股直肌比值的增加提示临界髋关节发育不良不稳定

11、儿童髋关节疾病的十大成人表现：一份最新的给放射科医生的综述

第一部分：关节置换及保膝相关文献

文献1

骨发育不良患者全膝置换的技术挑战

译者：张轶超

背景：骨发育不良患者由于解剖变异和严重的骨骼畸形使得全膝关节置换术（TKA）具有很大的挑战性。但很少有文献介绍骨发育不良TKA的手术技术考量。

问题/目的：我们在此描述骨发育不良患者TKA手术的技术考量，包括假体选择和韧带平衡。

患者和方法：我们回顾分析了8名患者的12例TKA手术，其不同程度的畸形（范围从内翻30°到外翻45°）均继发于三种类型的骨发育不良：多发性遗传性外生骨疣，软骨发育不全和成骨不全。分析了临床记录、手术记录和影像学资料。最少随访时间为1年（平均4年；范围从1到10）。

结果：12例手术采用定制假体。5例采用胫骨限制性垫片。所有12膝均松解（软组织松解或髁上截骨）以达到间隙平衡和髌骨轨迹满意。平均膝关节协会评分从术前35.9分改善为术后82.9分，平均功能评分从术前47.9分改善到术后96.7分。有两例出现短期的腓总神经麻痹。

结论：对于不常见的解剖变异和畸形的骨发育不良患者的TKA手术，需要尤其注意其假体的选择和韧带的平衡。但短期的临床效果呈现疼痛和功能的改善。

Technical challenges of total knee arthroplasty in skeletal dysplasia

Background: Total knee arthroplasty (TKA) in patients with skeletal dysplasias is particularly challenging as a result of the anatomic variances and substantial bony deformities. Little has been written regarding technical considerations that should be made when performing TKA in skeletal dysplasia.

Questions/purposes: We describe special operative considerations that must be made when performing TKA on patients with skeletal dysplasia, including implant selection and ligamentous balancing.

Patients and methods: We retrospectively reviewed 12 TKAs in eight patients with varying degrees of deformity (ranging from 30° of varus to 45° of valgus) secondary to three types of skeletal dysplasias: multiple hereditary exostosis, achondroplasia, and osteogenesis imperfecta. Clinical notes, operative records, and radiographic data were reviewed. Minimum followup was 1 year (average, 4 years; range, 1-10 years).

Results: We used customized implants in three of the 12 knees. Constrained tibial inserts were used in five knees. All 12 knees underwent releases (soft tissue or epicondylar osteotomy) to address gap balancing or patellar tracking. Average Knee Society scores improved from 35.9 preoperatively to 82.9 postoperatively and average function scores improved from 47.9 preoperatively to 96.7 postoperatively. Complications included two transient peroneal nerve palsies.

Conclusions: Special considerations must be made with regard to implant selection and ligamentous balancing as a result of the unusual anatomy and deformities that accompany skeletal dysplasia, but the short-term clinical results reveal consistent improvements in pain and function.

文献出处：Kim RH, Scuderi GR, Dennis DA, Nakano SW. Technical challenges of total knee arthroplasty in skeletal dysplasia. Clin Orthop Relat Res. 2011;469(1):69-75. doi:10.1007/s11999-010-1516-0

文献2

锥形非骨水泥半髋关节置换术治疗股骨颈骨折后的股骨假体下沉和髋臼侧侵蚀的10-13年随访研究

译者：马云青

背景：现代生物型半髋关节假体置换术是治疗移位型股骨颈骨折的方法之一，但其功能和放射学结果仍然存在争议。本研究的目的是评估锥形生物股骨柄结合双极关节或双动半髋关节置换术后的至少随访10年的临床和放射学结果。

患者及方法：在2004年至2007年间，135例移位型股骨颈骨折患者接受了非骨水泥髋半关节置换术。患者的平均年龄为81.5岁（70至90岁）。对38例患者进行了至少10年的随访评估。我们根据Merle D´Aubigne和Postel量表分析并发症及术后临床结果。根据的股骨近端分型采用Dorr等分型方法，根据Baker等的研究，还评估了股骨髓腔填充和假体松解、假体下沉和髋臼侧侵蚀的表现。

结果：术后早期发生股骨假体周围骨折2例。术后平均临床评分15.8分（范围9-17分）。由于髋臼侧侵蚀，6髋接受全髋关节置换术翻修，3例股骨假体翻修：假体周围感染、晚期假体周围骨折和无菌松动各1例。全因假体存活率为85.4%(Cl 76-92.4%)。髋臼侧翻修术后10年生存率92.6%(Cl 85-100%)，股骨侧为97.6%(CI 94.4-100%)。14髋表现为非进展性放射性假体下沉和9髋臼表现为髋臼侵蚀。股骨下沉与股骨髓腔充填率小于80%有关(p=0.035)和髋臼侵蚀与应用圆柱形股骨髓腔形状的有关(p=0.024)。

结论：70岁以上股骨颈骨折患者行半关节置换术时，可采用现代非骨水泥型假体。术后10年随访，髋臼侵蚀常见，但翻修率低。

Radiological subsidence and acetabular erosion after tapered uncemented hemiarthroplasty in femoral neck fractures a 10- to 13- year follow-up study

Background: Contemporary uncemented hemiarthroplasties are being used after displaced femoral neck fractures, however, their functional and radiological results remain controversial. The aim of this study was to evaluate the clinical and radiological results of a tapered uncemented stem combined with a uni- or bipolar hemiarthroplasty after a minimum follow-up of ten years.

Patients and methods: 135 patients underwent uncemented hip hemiarthroplasty after a displaced femoral neck fracture between 2004 and 2007. Their mean age was 81.5 years old (range, 70 to 90). 38 patients were evaluated with a minimum follow-up of ten years. We analysed the complications and the postoperative clinical result according to the Merle D´Aubigné and Postel scale. Radiological femoral type according to Dorr et al., femoral canal filling and the appearance of stem loosening, subsidence and acetabular erosion according to Baker et al., were also assessed.

Results: There were two early periprosthetic femoral fractures. The mean clinical score was 15.8 (range, 9 to 17). Six hips were converted to a total hip arthroplasty due to acetabular erosion, and three stems were revised due to an infection, a late periprosthetic fracture and one aseptic loosening. The survival rate for any cause was 85.4% (Confidence interval (CI) 76 - 92.4%). The survival rate for revision surgery on the acetabular side at 10 years was 92.6% (CI 85 - 100%) and on the femoral side was 97.6% (CI 94.4 - 100%). 14 hips showed non-progressive radiological subsidence and 9 acetabular erosion. Stem subsidence was related to a femoral canal filling < 80% (p = 0.035) and acetabular erosion to a cylindrical femur (p = 0.024).

Conclusion: Bone fixation can be obtained with a contemporary uncemented stem in hemiarthroplasty for patients over 70 years old with a femoral neck fracture. Acetabular erosion was frequent after ten years, however, the rate of revision surgery was low.

文献出处：Rubio I, Bellostas L, García-Rey E. Radiological subsidence and acetabular erosion after tapered uncemented hemiarthroplasty in femoral neck fractures a 10- to 13- year follow-up study. Injury. 2020;51 Suppl 1:S37-S41. doi:10.1016/j.injury.2020.02.012

文献3

旋转平台全膝关节置换术后功能性屈曲不稳定的工程力学研究

译者：张蔷

背景：我们希望通过工程力学研究找出与旋转平台全膝关节置换（TKA-RP）假体过度负荷相关并可能会引起垫片半脱位和旋出的情况，并测量屈伸间隙不对称或松弛的耐受范围以期在未来能够规避这些不良事件。

方法：我们使用间隙平衡技术在六具尸膝上施行了旋转平台全膝关节置换手术，并应用生物力学设备对其进行测试，接着我们依次进行了股骨侧翻修换用不同厚度的聚乙烯垫片来模拟5种屈伸间隙不平衡与不对称的情况。每一种模拟情况下，我们都在0°、30°和60°屈曲位进行了生物力学负荷试验。然后我们使用电子卡尺分别测定了垫片在金属背托上的旋转位移、外侧间室分离与垫片凹陷深度。最后，我们还使用自定义的MATLAB代码计算了屈服扭矩，作为垫片旋转和股骨假体逃逸的替代指标。

定制的膝关节负荷仪器

结果：在每一种模拟情况下，屈膝角度增加会导致垫片设计的可旋转角度下降。同样的，在所有模拟情况下，屈服扭矩会随着屈膝角度增加而增加，并随关节松弛度增加而下降。我们在屈膝角度增加和屈曲间隙松弛度不对称的情况下复制出了垫片不稳定和股骨髁位移的情况。聚乙烯垫片外侧凹陷深度决定了股骨髁捕获的情况，并把引发垫片旋转不稳定的最小屈曲间隙不对称阈值确定在2mm以内。

不同屈曲角度下的垫片旋转和股骨髁抬起情况

结论：正如假体设计所示，股骨-胫骨关节面型合度下降、屈膝角度增加和屈曲间隙不对称都可能引发股骨假体在垫片上表面的反常运动。

临床相关性：旋转平台全膝关节置换手术是一种有技术难度的术式，特别需要平衡的屈曲间隙。最小2mm的外侧屈曲间隙松弛就可能引起型合度下降、股骨髁抬起和垫片半脱位。屈曲超过30°会减小关节负重面积，使得垫片旋转角度减少，并诱发力学异常。

Functional Flexion Instability After Rotating-Platform Total Knee Arthroplasty

Background: We sought to define “at risk” loading conditions associated with rotating-platform total knee arthroplasty (TKA-RP) implants that predispose to insert subluxation and spinout and to quantify tolerances for flexion-extension gap asymmetry and laxity in order to prevent these adverse events.

Methods: Biomechanical testing was performed on 6 fresh-frozen cadaveric limbs with a TKA-RP implant with use of a gap-balancing technique, followed by sequential femoral component revision with variable-thickness polyethylene inserts to systematically represent 5 flexion-extension mismatch and asymmetry conditions. Each configuration was subjected to mechanical loading at 0°, 30°, and 60°. Rotational displacement of the insert on the tibial baseplate, lateral compartment separation, and insert concavity depth were measured with use of a digital caliper. Yield torque, a surrogate for ease of insert rotation and escape of the femoral component, was calculated with use of custom MATLAB code.

Results: Design-intended insert rotation decreased with increasing knee flexion angles in each loading configuration. Likewise, yield torque increased with increasing joint flexion and decreased with increasing joint laxity in all testing configurations. Insert instability and femoral condyle displacement were reproduced in positions of increasing knee flexion and asymmetrical flexion gap laxity. The depth of lateral polyethylene insert concavity determined femoral condylar capture and defined a narrow tolerance of <2 mm in the smallest implant sizes for flexion gap asymmetry leading to rotational insert instability.

Conclusions: Decreased femoral-tibial articular surface conformity with increasing knee flexion and asymmetrical flexion gap laxity enable paradoxical motion of the femoral component on the upper insert surface rather than the undersurface, as designed.

Clinical Relevance: Mobile-bearing TKA-RP is a technically demanding procedure requiring a snug symmetrical flexion gap. As little as 2mm of asymmetrical lateral flexion laxity can result in decreased conformity, condyle liftoff, and insert subluxation. Flexion beyond 30° decreases bearing surface contact area and predisposes to reduced insert rotation and mechanical malfunction.

文献出处：Quinlan ND, Wu Y, Chiaramonti AM, et al. Functional Flexion Instability After Rotating-Platform Total Knee Arthroplasty [published online ahead of print, 2020 Jun 15]. J Bone Joint Surg Am. 2020;10.2106/JBJS.19.01403. doi:10.2106/JBJS.19.01403

文献4

2020年Frank Stinchfield奖：谁会在保留假体清创治疗关节假体感染后失败：一种基于机器学习并经过验证的工具

译者：李睿

目的：保留假体清创（I＆D）治疗关节假体感染（PJI）失败受多种宿主，手术和病原体相关因素的影响。我们旨在基于机器学习的方法，开发和验证一种实用且易于使用的工具。该工具可综合多种影响因素准确预测I＆D术后结果。

方法：这是一项国际多中心的回顾性研究。2005年1月至2017年12月，共有1,174例因PJI采用I＆D进行髋、膝关节翻修的病例。PJI是根据肌肉骨骼感染学会（MSIS）标准定义的。使用随机森林机器学习算法评估了共52个变量，包括人口学，合并症以及临床和实验室检查结果。然后通过交叉验证对算法进行验证。

结果：在纳入研究的1,174例患者中，有405例（34.5％）治疗失败。我们使用随机森林创建了一种算法，该算法可计算每个特定患者失败的可能性。按重要性排列，与I＆D失败相关的十个最重要的变量是血清CRP水平，血培养阳性，既往因骨关节炎以外的关节置换术，未更换假体组件，使用免疫抑制药物，晚期急性（血源性）感染，耐甲氧西林的金黄色葡萄球菌感染，皮肤感染，多菌种感染以及老年人。该算法具有良好的判别能力（曲线下面积= 0.74）。交叉验证显示，算法预测的失败和实际观察到的失败有相似的概率，表明模型的准确性很高。

结论：这是骨科文献中第一项利用机器学习方法预测I＆D手术结果的研究。开发的算法为医学界提供了可用于临床决策和改善患者护理的工具。未来的研究应在其他人群中对这一工具进行进一步验证。

2020 Frank Stinchfield Award: Identifying Who Will Fail Following Irrigation And Debridement For Prosthetic Joint Infection: A Machine Learning-Based Validated Tool

Aims: Failure of irrigation and debridement (I&D) for prosthetic joint infection (PJI) is influenced by numerous host, surgical, and pathogen-related factors. We aimed to develop and validate a practical, easy-to-use tool based on machine learning that may accurately predict outcome following I&D surgery taking into account the influence of numerous factors.

Methods: This was an international, multicentre retrospective study of 1,174 revision total hip (ThA) and knee arthroplasties (TKA) undergoing i&D for pJi between January 2005 and December 2017. PJI was defined using the Musculoskeletal Infection Society (MSIS) criteria. A total of 52 variables including demographics, comorbidities, and clinical and laboratory findings were evaluated using random forest machine learning analysis. The algorithm was then verified through cross-validation.

Results: of the 1,174 patients that were included in the study, 405 patients (34.5%) failed treatment. Using random forest analysis, an algorithm that provides the probability for failure for each specific patient was created. By order of importance, the ten most important variables associated with failure of i&D were serum CRP levels, positive blood cultures, indication for index arthroplasty other than osteoarthritis, not exchanging the modular components, use of immunosuppressive medication, late acute (haematogenous) infections, methicillin- resistant Staphylococcus aureus infection, overlying skin infection, polymicrobial infection, and older age. The algorithm had good discriminatory capability (area under the curve = 0.74). cross-validation showed similar probabilities comparing predicted and observed failures indicating high accuracy of the model.

Conclusion: This is the first study in the orthopaedic literature to use machine learning as a tool for predicting outcomes following i&D surgery. The developed algorithm provides the medical profession with a tool that can be employed in clinical decision-making and improve patient care. Future studies should aid in further validating this tool on additional cohorts.

文献出处：Shohat N, Goswami K, Tan TL, et al. 2020 Frank Stinchfield Award: Identifying who will fail following irrigation and debridement for prosthetic joint infection. Bone Joint J. 2020;102-B(7_Supple_B):11-19. doi:10.1302/0301-620X.102B7.BJJ-2019-1628.R1

文献5

再次探讨全膝关节置换术中单独更换聚乙烯衬在无菌性失败中的作用

译者：沈松坡

背景：关于全膝关节置换术后(TKA)无菌性失效后单独更换聚乙烯衬(IPE)是否合适的争议仍然存在。我们试图比较IPE术后无菌失败再手术累积发生率的差异，并评估导致失败的危险因素。

方法：我们对122例因无菌性失败的膝关节进行了回顾性队列研究。导致无菌性膝关节进行IPE的原因包括:不稳定、聚乙烯磨损、关节纤维化、髌骨骨折、髌骨表面置换、髌骨轨迹不良、伸膝装置失效、髌骨切除术和用于矫正外翻畸形的定制聚乙烯衬。相对较高的失败率需要一个竞争风险模型来评估累积的再手术发生率。随访时间以自IPE起到再次翻修手术或最后一次随访的年份为标准。采用广义估计方程进行比较。

结果：我们的分析显示，在5年内无再次手术的生存率为87% (95% CI, 78-92%)。再次翻修是继发于无菌失败、感染和髌骨对线不良。聚乙烯磨损后行IPE具有保护作用，不太可能需要再次手术(SHR 0.121 95% CI: 0.016-0.896, p = 0.039)。

结论：目前的研究表明，在精心选择适应症后，IPE可能是一种可接受的手术，尤其是在术前诊断为聚乙烯磨损的情况，是TKA无菌性失败翻修的有益选择。这与以前的报道形成对比，可能意味着需要重新审视单纯更换聚乙烯衬的作用。

Revisiting the role of isolated polyethylene exchange for aseptic failures in total knee arthroplasty

Background: Controversy continues to exist regarding the advisability of isolated polyethylene exchange (IPE) following total knee arthroplasty (TKA) for aseptic indications. We sought to compare the difference in the cumulative incidence of reoperation after IPE specifically for aseptic failure and to evaluate risk factors for failure.

Methods: We performed a retrospective cohort study of 122 knees revised for aseptic failure. Reasons for IPE in aseptic knees included: instability, polyethylene wear, arthrofibrosis, patella fracture, patellar resurfacing, patellar maltracking, extensor mechanism failure, patellectomy, and a custom polyethylene for correction of valgus deformity. The relatively high rate of mortality warranted a competing risk model to evaluate the cumulative incidence reoperation. Follow-up time was defined by years from IPE to date of reoperation or last follow-up. Generalized estimating equations were used for comparisons.

Results: Our analysis demonstrated an 87% (95% CI, 78–92%) survivorship free of reoperation at five years. Re-revision was secondary to aseptic failure, infection, and patellar malalignment. IPE for polyethylene wear was found to be protective and less likely to require reoperation (SHR 0.121 95% CI: 0.016–0.896, p = 0.039).

Conclusions: The current study suggests that when done for carefully selected indications, IPE may be an acceptable procedure and helpful alternative for aseptic TKA revisions, particularly when the pre-operative diagnosis is polyethylene wear. This is in contrast to prior reports and may represent a need to re-visit the role of isolated polyethylene exchange.

文献出处：Duensing I, Pelt CE, Anderson MB, Erickson J, Gililland J, Peters CL. Revisiting the role of isolated polyethylene exchange for aseptic failures in total knee arthroplasty. Knee. 2020;27(3):958-962. doi:10.1016/j.knee.2020.01.002

第二部分：保髋相关文献

文献1

梨状肌综合症的诊断、治疗及预后：项为期10年的研究

译者：罗殿中

目的：基于髋关节屈曲内收内旋试验（FAIR试验）的延长H反射，明确梨状肌综合征的实用性定义，并评估保守治疗和手术治疗对症状缓解和减少残疾的有效性。

设计：基于FAIR试验明确的患者组接受治疗前后的研究。

地点：门诊病人选自2家医院和4名医师办公室。手术在3家医院进行。

患者：连续的918名（1014髋）患者，随访了733名。

干预：对FAIR试验显著阳性（3个标准差）的患者进行局部注射、物理治疗，并连续记录疼痛和残疾情况。43名患者（6.47％）接受了手术治疗。

主要预后指标：Likert疼痛量表。日常生活中活动能力和工具性日常活动生活能力的主观评估。

结果：以3个标准差为标准，FAIR试验的敏感性和特异性分别为0.881和0.832。FAIR试验阳性（FTP）的患者中有99%（514/655）的在接受局部注射和物理治疗后缓解了50％或更多，平均随访时间为10.2个月，平均改善率为71.1％。在385名具有残疾数据的FTP患者中，平均残疾率从研究前的35.37％（SD = 0.2275）降至研究后的12.96％（SD = 0.1752），改善了62.8％。28名接受手术治疗的FTP患者（68.8％）术后平均16个月随访时显示改善50％或更多，平均改善率为68％。手术患者术后FAIR试验降低至1.35 +/- 2.17ms。经过保守治疗后，FTP患者通常比其他患者预后提高10％至15％。

结论：FAIR试验与梨状肌综合症的临床实用定义密切相关，并且能更好地预测物理疗法和手术的成功概率。FAIR试验结合局部注射、物理治疗和/或手术治疗是诊断和治疗梨状肌综合症的有效手段。

FAIR试验，在保持髋臼垂直、髋关节最大限度内收内旋屈曲状态下，向下压膝关节，同时将小腿向外上方移动。

Piriformis syndrome: diagnosis, treatment, and outcome--a 10-year study

Objectives: To validate an operational definition of piriformis syndrome based on prolongation of the H-reflex with hip flexion, adduction, and internal rotation (FAIR) and to assess efficacy of conservative therapy and surgery to relieve symptoms and reduce disability.

Design: Before-after trial of cohorts identified by operational definition.

Setting: Outpatient departments of 2 hospitals and 4 physicians' offices. Surgery performed at 3 hospitals.

Patients: Consecutive sample of 918 patients (1014 legs) with follow-up on 733.

Intervention: Patients with significant (3 standard deviations [SDs]) FAIR tests received injection, physical therapy, and serially reported pain and disability assessments. Forty-three patients (6.47%) had surgery.

Main outcome measures: Likert pain scale. Subjective estimates of disablement in activities of daily living and instrumental activities of daily living.

Results: At 3 SDs, the FAIR test had sensitivity and specificity of.881 and.832, respectively. Seventy-nine percent (514/655) of FAIR test positive (FTP) patients improved 50% or more from injection and physical therapy at a mean follow-up of 10.2 months. Average improvement was 71.1%. Of 385 FTP patients with disability data, mean disability fell from 35.37% prestudy (SD =.2275) to 12.96% poststudy (SD =.1752), a 62.8% improvement. Twenty-eight surgical FTP patients (68.8%) showed 50% or greater improvement; mean improvement was 68% at a mean follow-up of 16 months. Surgery reduced the mean FAIR test to 1.35 +/- 2.17 months postoperatively. FTP patients generally improved 10% to 15% more than others after conservative treatment.

Conclusions: The FAIR test correlates well with a working definition of piriformis syndrome and is a better predictor of successful physical therapy and surgery than the working definition. The FAIR test, coupled with injection and physical therapy and/or surgery, appears to be effective means to diagnose and treat piriformis syndrome.

文献出处：Fishman LM, Dombi GW, Michaelsen C, et al. Piriformis syndrome: diagnosis, treatment, and outcome--a 10-year study. Arch Phys Med Rehabil. 2002;83(3):295-301. doi:10.1053/apmr.2002.30622

文献2

股骨不同节段对股骨整体扭转的影响

译者：程徽

背景：股骨扭转是髋膝关节疾病的关键参数，假设股骨扭转只取决于股骨颈，但此假设未经证实。

目的：此研究旨在对患者组（股骨扭转大或小）和健康组的股骨不同节段的扭转进行测量比较，我们假设健康组和患者组股骨不同节段扭转不一样。

方法：纳入MRI检查有髌骨不稳和股骨扭转 ≥25°的患者（11个患者，16个股骨），股骨扭转≤0°（14个患者，22个股骨）， 对照组选择30个健康志愿者（60个股骨）。选择4条线进行股骨扭转的评估，第一条线为股骨头中心和股骨颈中心的连线（FN），第二条线为小转子顶点和股骨中心的连线（LT），第三条线为腓肠肌附着点正上方股骨远端后方相切的线（DF），第四条线为股骨后髁的切线（PCs）。三名观测者进行测量，均进行2次的测量。

结果：在高扭转组、低扭转组和对照组中，所有股骨不同节段显示出明显的不同扭转角，不同节段的扭转均可影响股骨整体扭转。在高扭转组，由于股骨干外旋小，颈部扭转角（FN和LT夹角）和股骨干扭转角（LT和PCs夹角）比值增大，低扭转组，由于股骨干内旋小外旋大，两者比值变小。

结论：通过重复测量进行颈部扭转角（FN和LT夹角），股骨中部扭转角（LT和DF夹角）和股骨远端扭转角（DF和PCs夹角）的差异比较，我们发现三个水平的扭转可影响股骨整体扭转，在高扭转和髌骨不稳的患者中会有不用的模式。

图1  4个不同水平面及4条连线，a 股骨颈（股骨头和股骨颈-小转子） b 小转子中点（小转子-股骨远端） c 股骨远端（股骨远端-后髁） d 股骨总扭转（股骨头和颈-后髁），A 左髋MRI，层厚增加，直至可显示出整个头和颈，白线通过股骨头和颈的中心 B 小转子水平，白线通过股骨中点和小转子中心 C 腓肠肌附着点水平，白线与股骨远端后部相切 D 后髁切线

表1 股骨不同节段扭转角度

图2 三组内不同节段对股骨整体扭转的影响

图3  三组股骨颈扭转与股骨干扭转的相关性（R）

图4 三组扭转分布情况，与对照组相比，高扭转组内旋略增加，外旋明显减少，低扭转组内外旋也有相似的变化。

表2  不同测量观察者间和观察者内可靠性

The Contribution of Different Femur Segments to Overall Femoral Torsion

BACKGROUND: Femoral torsion is a critical parameter in hip and knee disorders. The unproven assumption is that the femoral neck exclusively contributes to the overall torsion of the femur.

PURPOSE/HYPOTHESIS: The aim of this study was to measure femoral torsion at different levels in patients with abnormally high or low femoral torsion and to compare the results with healthy volunteers. Our hypothesis was that the pattern of torsion distribution among the different femoral levels varies between patients with abnormal torsion and healthy volunteers.

METHODS: Magnetic resonance images of patients with a history of patellar instability and torsion of the femur ≥25° (11 patients, 16 femurs) and ≤0° (14 patients, 22 femurs) were analyzed. Our controls were 30 healthy volunteers (60 femurs). To assess femoral torsion, 4 lines were drawn: a first line through the center of the femoral head and neck, a second line through the center of the femur at the top of the lesser trochanter, a third line tangent to the posterior aspect of the distal femur just above the attachment of the gastrocnemius, and a fourth line tangent to the posterior condyles. Three investigators performed the measurements; 1 performed the measurements twice.

RESULTS: All femur segments showed significantly different torsion among the high-torsion, low-torsion, and control groups. Regarding the pattern of torsion distribution, on average, all levels contributed to the torsion. The ratio between the average neck and shaft torsion shifted toward a higher value in the high-torsion group, mostly because of a lack of external torsion in the shaft, and toward a lower value in the low-torsion group, owing to both a lack of internal torsion of the neck and increased external torsion in the shaft.

CONCLUSION: We established a difference between neck, mid, and distal femoral torsion with reproducible measurements. Our data suggest that all 3 levels of the femur contribute to the total femoral torsion, with a different pattern among patients with high torsion and patellar instability.

文献出处：Seitlinger G, Moroder P, Scheurecker G, Hofmann S, Grelsamer RP. The Contribution of Different Femur Segments to Overall Femoral Torsion. Am J Sports Med. 2016 Jul;44(7):1796-800. doi: 10.1177/0363546516639945. Epub 2016 Apr 22.

文献3

手法触摸大转子试验测量股骨扭转角的可靠性和有效性

译者：肖凯

股骨扭转对股髋撞击和其他髋关节疾病的的影响尚未得到充分认识。在临床检查过程中未通常使用影像学方法对其进行测量。本研究的目的时明确体格检查是否可以可靠地测量股骨扭转角，或至少可以筛查出股骨扭转角大体异常的患者，或者明确是否应常规进行适当的影像学检查测量股骨扭转角。使用手法触摸大转子试验和磁共振成像对45名志愿者的股骨扭转角进行检查评估。手法测量的观察者之间和观察者内可信度范围从差到中等，手法测量结果与MRI结果的一致性较差。尽管股骨扭转角的数值与临床表现上有5°到10°的差异，但仍有一半的通过手法测量的结果与MRI测量结果差值与超过±10°。我们武断地将股骨扭转角的异常值分别定义为> 30°和 <0°，通过手法触摸大转子试验不能发现扭转角异常的病例。如果将扭转角异常值定义为> 20°和 <10°，通过手法触摸大转子试验明确患者扭转角异常的敏感度分别为18-75 ％，特异度仅为58％-98％。使用手法触摸大转子试验对股骨扭转进行物理评估并不准确，不能对大体异常的病例进行筛查。因此，临床中我们还是建议通过MRI测量股骨的扭转角。

Femoral torsion: reliability and validity of the trochanteric prominence angle test

Influence of femoral torsion on femoroacetabular impingement and other hip conditions is not well documented and its assessment by imaging methods during clinical work-up is not routinely performed. We studied whether physical examination could reliably measure or at least screen for gross anomalies of femoral torsion or if appropriate imaging should routinely be performed. Assessing femoral torsion of 45 volunteers using the "trochanteric prominence angle test" and magnetic resonance imaging (MRI), inter- and intra-observer reliability ranged from poor to moderate and agreement with MRI values was only fair. Considering a 5° to 10° difference of femoral torsion as clinically relevant, physical examination failed to match MRI values within ±10° in more than 50%. Arbitrarily defining thresholds for pathological femoral torsion, the "trochanteric prominence angle test" could not recognise torsions outside the >30°/<0° range and diagnosed torsions outside the >20°/<10° range with a sensitivity of 18%-75% and a specificity of 58%-98% only. Physical assessment of femoral torsion using the "trochanteric prominence angle test" does not allow reliable measurement or screening for gross anomalies. We therefore integrate an adapted MRI protocol allowing measurement of femoral torsion within our clinical work up.

文献出处：Maier C, Zingg P, Seifert B, Sutter R, Dora C. Femoral torsion: reliability and validity of the trochanteric prominence angle test. Hip Int. 2012;22(5):534-538. doi:10.5301/HIP.2012.9352

文献4

DDH早期超声筛查

译者：任宁涛

目的：评估DDH早期普遍性髋关节超声筛查的有效性。

方法：对Szeged大学妇产科2012年-2013年之间所有足月新生儿的普遍性髋关节超声筛查进行前瞻性研究，其中包括1636名新生儿，3272例髋关节，在生后3天行髋关节超声检查（Graf方法），对DDH发病率、风险因素以及临床检查的敏感性和特异性进行评估。

结果：第1次超声检查（生后3天），70例髋关节为阳性（2.14%），分别为21例髋关节（30.0%）为II C，24例髋关节（34.28%）为type D，24例髋关节（34.28%）为type III，1例髋关节为type IV。风险因素方面，女性、臀位和家族史是有意义的。55名新生儿临床查体阴性，除了女性之外无其他风险因素，其中28名新生儿（50.90%）有DDH。临床检查的敏感性为20%，特异性为98.34%。

结论：为期1年的研究发现50.9%的伴有DDH的新生儿既没有临床查体阳性体征，除了女性之外也无其他风险因素。相比之下，早期髋关节超声检查有助于DDH的诊断，也是避免手术干预的有效的方式，但是后期需多选择性和普遍性髋关节超声筛查的手术率进行比较。

表1  临床查体结果，包括假阳性和假阴性

表2 髋关节超声检查分型分布，临床查体阴性率和性别比例

Early detection of developmental dysplasia of hip by ultrasound

Objective: To assess the effectiveness of early universal ultrasound (US) screening of developmental dysplasia of the hip (DDH).

Study design: A prospective study of universal hip screening of all mature neonates was conducted from 2012 to 2013, at the Department of Obstetrics and Gynaecology, University of Szeged; 1636 newborns (3272 hips) had clinical examinations and hip ultrasound by the Graf method within the1st 3 days of life. Prevalence of DDH, risk factors, sensitivity and specificity of clinical examinations were evaluated.

Results: At the 1st US, 70 of the examined 3272 hips (2.14%) were found to be positive. According to Graf categories, the following distribution was observed: type II C, 21 hips (30.0%); D, 24 hips (34.28%); III, 24 hips (34.28%); IV, 1 hip (1.44%). Regarding the risk factors, female gender, breech presentation and positive family history proved to be significant. Interestingly, 28 (50.90%) of the 55 newborns with DDH had neither positive physical signs nor any risk factors, except being female. The physical examination was calculated for sensitivity (20.0%) and specificity (98.34%).

Conclusions: In our 1-year period study, 50.9% of the newborns with DDH had neither any positive physical signs nor any risk factors, except being a female. In contrast, early universal US screening of the hip facilitated to diagnose all cases with hip dysplasia. Hip sonography is an effective mode of prevention in orthopaedics, however further studies are needed to compare the rates of operative procedures in selective versus universal screening models.

文献出处：Zita Gyurkovits, Gellért Sohár, Anna Baricsa, Gábor Németh, Hajnalka Orvos, Beat Dubs.Early detection of developmental dysplasia of hip by ultrasound. Hip Int. 2019 Sep 30;1120700019879687.

文献5

髂囊肌与股直肌比值的增加提示临界髋关节发育不良不稳定

译者：张利强

背景：髂囊肌是一髋关节前方肌肉，在正常髋关节中起稳定关节的作用。先前的研究表明在发育性髋关节发育不良（DDH）中髂囊肌肥大。一项简单的基于磁共振的测量髂囊肌与邻近解剖结构（如股直肌）大小的比值的方法可能有助于日常临床应用。

问题/目的：我们提出（1）与过度覆盖或正常髋臼相比，DDH患者髂腰肌与股直肌的横截面积、厚度、宽度和周长的比值是否增加；以及（2）这些比率在区分发育不良和钳夹型髋关节方面的诊断性能如何？

方法：回顾性比较不同髋臼覆盖率的有症状的两个研究组和无症状髋关节对照组的髂囊肌解剖。研究组是从一系列门诊就诊的DDH或股骨髋臼撞击的患者中选择的。研究组的分配是基于常规的放射学检查：发育不良组定义为外侧中心边缘（LCE）角<25°，最小髋臼指数为14°，由45例患者（45髋）组成；钳夹型组的LCE角超过39°，由37名患者（40髋）组成。对照组为26例（30髋）因非骨科原因行MRI检查的无症状髋关节。应用髋关节磁共振成像和以下参数（横截面积、厚度、宽度和周长）评估髂囊肌和股直肌的解剖结构。比较研究组和对照组的髂腰肌与股直肌这四个解剖参数的比值。通过计算受试者操作特性（ROC）曲线和比值>1时的阳性预测值（PPV）来评估这些比率对区分发育不良和过度覆盖的诊断性能。使用前面提到的影像学参数，在平片上确定是否存在DDH。对X片和磁共振成像进行盲法评估。选择PPV是因为它表明如果髂囊肌与股直肌的比值大于1，髋关节发育不良的可能性有多大。

结果：X片显示DDH组的髂囊肌与股直肌的横截面积、厚度、宽度和周长的比值（比值1.31～1.35）明显高于钳夹型组（0.71～0.90，p<0.001），与对照组相比，其横截面积比、厚度比、宽度比、周长比均明显增加（比率范围为1.10至1.15；p范围为0.002至0.039）。ROC曲线下面积为0.781～0.852。对于一对一的髂囊肌股直肌比率，横截面积的PPV为89%（95%可信区间[CI]，73%-96%），厚度为77%（95%CI，61%-88%），宽度为83%（95%CI，67%-92%），周长为82%（95%CI，67%-91%）。

结论：髂囊肌与股直肌比值是DDH的一个有价值的次要指标。该指标可作为临界髋关节发育不良临床决策的辅助参数，对合并钳夹畸形的BDDH以确定主要的病理学特征。未来的研究需要证明这一发现有助于临床医生确定临界发育不良是否是患者出现髋部症状的原因。

证据水平III级，预后研究。

LCE角为穿过股骨头中心和髋臼顶最外侧部分的线和穿过股骨头中心的垂直线之间的夹角。髋臼指数（AI）是连接髋臼顶最内侧和最外侧部分的连线与穿过髋臼顶最内侧部分的水平线之间的夹角。DDH被定义为LCE角小于25°，AI大于14°。钳夹型髋关节定义为LCE角大于39°。对照组髋部LCE角为25°～39°，AI为0°～14°。

在股骨头中心高度的水平面MRI上评估髂囊肌和股直肌的解剖尺寸

在股骨头中心高度（F）的水平MRI切片上评估四个研究参数：髂囊肌（IC）和股直肌（RF）的横截面积、厚度、宽度和周长。沿穿过股骨头中心（F）的径向线测量厚度（a和b）。垂直于厚度测量宽度（c和d）。

两个髋臼（A-B）的X片显示髋臼覆盖范围相当，没有明显的主要病理生理问题。在相应的轴向MRI切片中，左髋（C）的髂囊肌（IC）与股直肌（RF）的横截面积比值增加，右髋（D）略有降低。这表明DDH是左髋关节的主要病理生理改变，而另一髋关节（F）的髋臼覆盖似乎并不充分。F=股骨头；AC=髋臼；L=盂唇；LT=圆韧带；MA=臀大肌；ME=臀中肌；MI=臀小肌；T=阔筋膜腱膜；S=缝匠肌；I=髂骨；PA=腰大肌；PI=腰小肌；PE=耻骨肌；OI=闭孔内肌；A=股动脉；V=股静脉；N=股神经；FS=浅筋膜；SC=皮下脂肪组织。

An Increased Iliocapsularis-to-rectus-femoris Ratio Is Suggestive for Instability in Borderline Hips

Background: The iliocapsularis muscle is an anterior hip structure that appears to function as a stabilizer in normal hips. Previous studies have shown that the iliocapsularis is hypertrophied in developmental dysplasia of the hip (DDH). An easy MR-based measurement of the ratio of the size of the iliocapsularis to that of adjacent anatomical structures such as the rectus femoris muscle might be helpful in everyday clinical use.

Questions/purposes: We asked (1) whether the iliocapsu-laris-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference is increased in DDH when compared with hips with acetabular overcoverage or normal hips; and (2) what is the diagnostic performance of these ratios to distinguish dysplastic from pincer hips?

Methods: We retrospectively compared the anatomy of the iliocapsularis muscle between two study groups with symptomatic hips with different acetabular coverage and a control group with asymptomatic hips. The study groups were selected from a series of patients seen at the outpatient clinic for DDH or femoroacetabular impingement. The allocation to a study group was based on conventional radiographs: the dysplasia group was defined by a lateral center-edge (LCE) angle of < 25° with a minimal acetabular index of 14° and consisted of 45 patients (45 hips); the pincer group was defined by an LCE angle exceeding 39° and consisted of 37 patients (40 hips). The control group consisted of 30 asymptomatic hips (26 patients) with MRIs performed for nonorthopaedic reasons. The anatomy of the iliocapsularis and rectus femoris muscle was evaluated using MR arthrography of the hip and the following parameters: cross-sectional area, thickness, width, and circumference. The iliocapsularis-to-rectus-femoris ratio of these four anatomical parameters was then compared between the two study groups and the control group. The diagnostic performance of these ratios to distinguish dysplasia from protrusio was evaluated by calculating receiver operating characteristic (ROC) curves and the positive predictive value (PPV) for a ratio > 1. Presence and absence of DDH (ground truth) were determined on plain radiographs using the previously mentioned radiographic parameters. Evaluation of radiographs and MRIs was performed in a blinded fashion. The PPV was chosen because it indicates how likely a hip is dysplastic if the iliocapsularis-to-rectus-femoris ratio was > 1.

Results: The iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference was increased in hips with radiographic evidence of DDH (ratios ranging from 1.31 to 1.35) compared with pincer (ratios ranging from 0.71 to 0.90; p < 0.001) and compared with the control group, the ratio of cross-sectional area, thickness, width, and circumference was increased (ratios ranging from 1.10 to 1.15; p ranging from 0.002 to 0.039). The area under the ROC curve ranged from 0.781 to 0.852. For a one-to-one iliocapsularis-to-rectus-femoris ratio, the PPV was 89% (95% confidence interval [CI], 73%–96%) for cross-sectional area, 77% (95% CI, 61%–88%) for thickness, 83% (95% CI, 67%–92%) for width, and 82% (95% CI, 67%–91%) for circumference.

Conclusions: The iliocapsularis-to-rectus-femoris ratio seems to be a valuable secondary sign of DDH. This parameter can be used as an adjunct for clinical decision-making in hips with borderline hip dysplasia and a concomitant cam-type deformity to identify the predominant pathology. Future studies will need to prove this finding can help clinicians determine whether the borderline dysplasia accounts for the hip symptoms with which the patient presents.

文献出处：Haefeli PC, Steppacher SD, Babst D, Siebenrock KA, Tannast M. An increased iliocapsularis-to-rectus-femoris ratio is suggestive for instability in borderline hips. Clin Orthop Relat Res. 2015;473(12):3725-3734. doi:10.1007/s11999-015-4382-y

文献6

儿童髋关节疾病的十大成人表现：份最新的给放射科医生的综述

译者：陶可（北京大学人民医院骨关节科）

小儿髋关节先天性、发育性和后天性疾病在成年人中经常会出现后遗症。这些病理状况的最终结果存在明显重叠，包括骨骼结构变化、软骨/盂唇损伤和过早的骨关节炎。这篇综述讨论了小儿髋关节的十大常见病因，并在一个说明性、多模式、基于病例模式基础上介绍成年人的相关畸形。定量成像指标和先进的成像技术作用也进行了评价。最终目标是增强普通放射科医师对儿童髋关节病理状况及其相关并发症预期发展的理解。

图1. 髋关节X线片投影：前后位AP（A），侧位（B），蛙式位（C），Dunn位（D）和假斜位（E）。

图2. AP骨盆正位X线片上的髋关节解剖学标志：髋臼后缘（紫罗兰色）；髋臼前缘（紫色）；泪滴（红色）；髂耻线（黄色）；髂坐线（绿色）；髋臼眉弓（边缘以淡蓝色和黄色圆圈标记）。

图3. 一名以左腹股沟痛为主要表现的23岁男性DDH患者（A）。左髋关节X线片显示股骨头偏扁，髋臼发育不良（倾斜度增加时浅）（B）。左髋关节轴向斜位T1加权造影MR显示，由于病理负荷以及韧带边缘肥大所致的前上盂唇撕裂（箭头）（C）。左髋关节X线片显示髋臼周围截骨术能改善股骨头覆盖率和髋臼方向。

图4. 正常髋关节的髋臼生理负荷示意图（左）与髋臼发育不良边缘和盂唇病理负荷示意图

图5. 髋臼周围截骨术（1-2）、然后髋臼部分旋转（3）和固定（4）的示意图，从而改善股骨头覆盖范围和形合度。

图6. 一个有早产和三胞胎出生史的3岁男孩出现股骨近端缺损（Proximal focal femoral deficiency, PFFD）（A）。右髋关节前位片显示畸形扁平的股骨头和髋关节（B）。左髋的冠状位非增强T2加权MR成像显示股骨头畸形（黑色箭头）和关节软骨（白色箭头）（C）。外翻截骨矫正术后右髋关节AP位片。

图7. 多例伴有髋关节发育不良的脑瘫病例。（A）一名21岁脑瘫男子的左髋关节X线片显示了髋关节外翻、股骨头偏扁、髋臼发育不良和病理性负荷导致的慢性髋臼缘骨折。（B）一名28岁脑瘫和脊柱侧弯患者的未增强骨窗CT轴位片显示右髋关节发育不良伴股骨头半脱位（短箭头）和髋臼窝浅平并伴有小转子假关节形成（箭头）。（C）病例（B）的右髋关节AP位X线片。

图8. 一名1型神经纤维瘤病的17岁男性青少年，整个右腿有股骨过度生长和丛状神经纤维瘤（A）。右股骨X线片显示髋内翻和扁平，髋关节半脱位（白色短箭头），髋臼发育不良（黑色短箭头）以及弥漫性骨和软组织肥大（B）。右髋部冠状位的带脂肪饱和技术的MR成像显示股骨和髋臼发育异常以及围绕髋部和整个下肢的广泛丛状神经纤维瘤（箭头）。

图9. 一名患有脊柱裂、Chiari畸形和截瘫病史的29岁男子的神经病理性髋关节。骨盆冠状位未增强骨窗扫描显示左髋扁平股骨头畸形、髋臼发育不良、异位骨形成和病理性脱位。右侧看到的病变较小。

图10. 患有慢性右髋痛的25岁LCPD女性患者（3年护理期间的序列图像显示了疾病后遗症和治疗进展）。（A）右髋部AP片显示髋关节扁平、髋臼发育不良、股骨颈短缩和关节外大转子撞击症。Perthes病可见“松弛绳”迹象（穿过股骨颈的硬化线）（白色箭头）（2016年）。（B）右髋关节矢状位T1加权MR关节造影显示前/上病理性有盂唇撕裂（箭头）（2016）。（C）右髋关节AP位片显示髋臼周围截骨，并有股骨转子截骨和向远侧移位。注意术后相对股骨颈延长和大转子外部撞击减少（2017）。（D）右髋关节AP位片显示随后的全髋关节置换术（2018）。

图11. 股骨头坏死的病理后遗症主要有股骨颈短缩、关节内和关节外撞击（A，B）；通过股骨转子截骨术进行矫正和大转子上移，后进行（股骨头颈交界处）凸轮畸形的骨软骨成形术，从而消除关节内和关节外撞击（C，D）。

图12. 一位右髋关节疼痛并有儿童期股骨头骨骺滑脱（SCFE）保守治疗失败史的25岁男性患者。该患者目前正在接受髋关节镜检查和干预治疗。（A，B）（16岁）右髋关节AP位和蛙式位X线片显示，股骨颈向前滑脱与SCFE损伤相符。（C）股骨头原位内固定治疗后的右髋关节蛙式位X线片。（D）右髋关节CT三维重建（25岁）显示股骨颈的前外侧凸轮畸形（箭头）。（E）右髋关节矢状位抑脂MR关节造影（25岁）显示软骨缺损（箭头），并伴邻近骨髓水肿（箭头）。

图13. 正常的髋关节解剖与钳夹形或凸轮形畸形的后遗症，会导致屈曲或内旋撞击症。

图14. 一名表现为右髋关节疼痛和伴青少年特发性关节炎（juvenile idiopathic arthritis, JIA）病史的41岁女性患者。右髋关节AP位X线片显示严重退行性改变，包括髋关节扁平、髋内翻畸形、骨硬化症、软骨下骨囊肿、骨赘和关节间隙变窄。患者最终接受了全髋关节置换术。

图15. 一位右耳感染史较轻的12岁男孩的化脓性关节炎。右髋关节冠状位未增强骨窗CT显示股骨头被侵蚀、变平和侧方移位，并伴有髋臼侧骨质侵蚀破坏。

图16. 一名患有髋关节特发性软骨病的16岁男性青少年，表现为慢性右髋关节疼痛和僵硬。患者对髋关节病理状况进行了广泛检查（A），结果均为阴性。骨盆AP位X线片显示左髋关节对称的关节间隙变窄（箭头）（B）。左髋关节轴位未增强骨窗CT显示关节间隙丢失和早期退行性改变（软骨下囊肿，箭头）。

图17. 一名AIIS撞击致右髋关节疼痛的28岁男性患者，病人之前参加多种运动。检查时，髋关节屈曲活动受限且疼痛。（A）右髋关节蛙式位X线片显示III型AIIS（箭头），股骨颈凸轮畸形（箭头）。（B）右髋关节CT三维重建可见突出的AIIS（黑箭头），股骨颈（短箭头）凸轮畸形，MR显示盂唇磨损。（C）关节镜下进行AIIS清理（绿色阴影）、股骨头颈骨软骨成形术（红色阴影）和盂唇清创术后右髋关节AP位X线片。

Top Ten Adult Manifestations of Childhood Hip Disorders: An Up-To-Date Review for General Radiologists

Congenital, developmental, and acquired conditions of the pediatric hip frequently present with sequelae in the adult. There is substantial overlap in the end-stage results of these pathologic conditions, including osseous changes, chondral/labral injuries, and premature osteoarthritis. This review discusses the top 10 etiopathogeneses of pediatric hip conditions and presents associated dysmorphisms in the adult on an illustrative, multimodality, case-based template. Quantitative imaging metrics and the role of advanced imaging techniques are reviewed. The ultimate goal is enhanced understanding of the expected evolution of childhood hip pathologic conditions and their associated complications for general radiologists.

文献出处：Jedidiah Schlung, Scott Schiffman, Apeksha Chaturvedi. Top Ten Adult Manifestations of Childhood Hip Disorders: An Up-To-Date Review for General Radiologists. Radiol Clin North Am, 2020, 58(3):529-548.