髖膝文獻精譯薈萃

本期目錄：

1、警惕單側髖關節完全脫位患者脫位側下肢的絕對長度超過對側

2、髕股關節骨關節炎相關人群及骨性力線特性的屍體研究

3、慢性假體周圍感染的化驗診斷可以幫助預測二期感染翻修手術的預後

4、1997-2011年日本初診非創傷性股骨頭壞死的動態趨勢特點研究

5、一種用於描述青少年特發性髖關節炎生長異常和結構變化的新影像學評分系統

6、磁共振成像診斷髖關節病變準確性的研究

7、切開複位內固定治療繼發兒童股骨頭壞死（Legg-Calvé-Perthes病）的剝脫性骨軟骨炎

第一部分：關節置換相關文獻

文獻1

警惕單側髖關節完全脫位患者脫位側下肢的絕對長度超過對側

譯者：張軼超

背景：在骨盆平片上有一些方法可以用來評估下肢長度的差異（LLD）。但是只通過骨盆平片我們是不能預測單側髖關節發育不良（DDH）患者下肢長度的變化以及LLD的準確值。在本研究中我們通過測量下肢站立位全長片分析了單側DDH患者LLD的特點。

方法：我們回顧了從2011年3月到2016年5月的符合入選標準的單側DDH患者的片子。測量數據包括股骨長度，脛骨長度，骨性肢體長度及從小粗隆到脛骨遠端關節面間的距離。我們還比較了HartofilakidisⅡ型和Ⅲ型之間LLD的特點。

結果：67名（男性12名，女性55名）患者入選。DDH側肢體的脛骨長度，骨性下肢長度及小粗隆到脛骨遠端關節面的長度較正常側長(分別為p 0.05)。

結論：在單側DDH患者中，無論是高脫位還是低脫位，LLD可能即來源於股骨側也來源於脛骨側。大多數雙側下肢不等長的DDH患者具有更長的脛骨長度，骨性肢體長度和小粗隆到脛骨遠端關節面的長度，而股骨長度可能有各種情況。在骨盆平片中通過比較兩側小粗隆的高度來評價下肢的LLD是不準確的。對於這種病人應該通過下肢站立位全長片來測量下肢的長度。

Unexpected Long Lower Limb in Patients with Unilateral Hip Dislocation

BACKGROUND:Several methods are commonly used to predict lower-limb-length discrepancy (LLD) on pelvic radiographs. It is not clear how the lower-limb length of patients with unilateral developmental dislocation of the hip (DDH) changes and whether a pelvic radiograph is reliable to predict LLD. In this study, we analyzed the characteristics of LLD in patients with unilateral DDH by measuring full-length standing anteroposterior radiographs.

METHODS:The radiographic data of all patients with unilateral DDH who met the inclusion criteria from March 2011 to May 2016 were retrospectively reviewed. These data included femoral length, tibial length, skeletal limb length, and distance from the lesser trochanter to the tibial plafond. We also compared LLD between patients with Hartofilakidis type-II DDH and those with type III.

RESULTS:Sixty-seven patients (12 male and 55 female) were included. The tibial length, skeletal limb length, and lesser trochanter-tibial plafond distance were significantly greater (p 0.05).

CONCLUSIONS:Patients with unilateral DDH, regardless of whether the hip dislocation is low or high, may present with LLD derived from both the femur and the tibia. This LLD includes a greater ipsilateral tibial length, skeletal limb length, and lesser trochanter-tibial plafond distance in most patients and an unpredictable femoral length. Using the lesser trochanter on pelvic radiographs to predict LLD is not reliable. The use of full-length standing anteroposterior radiographs for preoperative templating is advisable for this special group of patients.

文獻出處：Zhang Z1, Luo D, Cheng H, Xiao K, Zhang H. Unexpected Long Lower Limb in Patients with Unilateral Hip Dislocation. J Bone Joint Surg Am. 2018 Mar 7;100(5):388-395.

文獻2

髕股關節骨關節炎相關人群及骨性力線特性的屍體研究

譯者：馬雲青

背景：髕股關節骨關節炎比較普遍，但其演變和發病的病理環境仍不清楚。外科技術的進步使得患者長骨在冠狀面、矢狀面和軸面上力線得以調整。然而，據我們所知，關於最適合手術干預的解剖力線參數與髕骨關節炎之間的關係，還沒有明顯的長期數據研究。

方法：從Hamann–Todd骨科採集的標本中獲取的571具屍體骨骼。測量標本的股骨遠端機械外翻角、脛骨近端內翻角、脛骨後傾率、股骨前傾角、脛骨扭轉角、脛骨結節相對於脛骨平台寬度的位置、滑車深度和髕骨大小。已發表的髕股關節炎分級系統被用來量化評價退行性關節病的大體表現。

結果：相關因素中，年齡增加(SD β 0.532，p=0.001)，女性(SDβ 0.201，p=0.002)，股骨遠端機械外翻角減小(SDβ ?0.128，p=0.025)，作為獨立相關因素與髕股關節骨關節炎增加有關。一個相對外移的脛骨結節可預測髕股關節骨關節炎(SDβ 0.080，p=0.089)。

結論：這些發現證實了髕股關節骨關節炎與年齡增加和性別密切相關。而股骨遠端的外翻力線、脛骨結節的相對外移和較淺的滑車溝對髕股關節骨關節炎發展的影響相對不大。

A cadaveric investigation into the demographic and bony alignment properties associated with osteoarthritis of the patellofemoral joint

Background:Patellofemoral joint osteoarthritis is common, although circumstances dictating its evolution and pathogenesis remain unclear. Advances in surgical technique have improved the ability to modify long-bone alignment in the coronal, sagittal, and axial planes. However, to our knowledge, there is no significant longterm data available in regard to the relationship between anatomic alignment parameters most amenable to surgical modification and patellofemoral joint osteoarthritis.

Methods:Five-hundred and seventy-one cadaveric skeletons were obtained from the Hamann–Todd osteological collection. Mechanical lateral distal femoral angle, medial proximal tibial angle, tibial slope, femoral version, tibial torsion, the position of the tibial tubercle relative to the width of the tibial plateau, trochlear depth, and patellar size were measured using validated techniques. A previously published grading system for patellofemoral joint arthritis was used to quantify macroscopic signs of degenerative joint disease.

Results:Increasing age (standardized beta 0.532, p b 0.001), female gender (standardized beta 0.201, p = 0.002), and decreasing mechanical lateral distal femoral angle (standardized beta ?0.128, p = 0.025) were independent correlates of increased patellofemoral joint osteoarthritis. A relatively more laterally positioned tibial tubercle trended towards predicting patellofemoral joint osteoarthritis (standardized beta 0.080, p = 0.089).

Conclusions:These findings confirm that patellofemoral joint osteoarthritis is strongly associated with increasing age and female gender. Valgus alignment of the distal femur, a relatively more lateral location of the tibial tubercle, and a shallower trochlear grove appear to have modest effects on the development of patellofemoral joint osteoarthritis.

文獻出處：Weinberg DS, Tucker BJ, Drain JP, Wang DM, Gilmore A, Liu RW. A cadaveric investigation into the demographic and bony alignment properties associated with osteoarthritis of the patellofemoral joint. Knee. 2016 Jun;23(3):350-6.

文獻3

慢性假體周圍感染的化驗診斷可以幫助預測二期感染翻修手術的預後

譯者：張薔

背景：儘管二期感染翻修手術是目前慢性假體周圍感染所有處理方法中最有效的措施之一，不同醫生間的成功率卻有很大差異。本研究的目的是明確慢性假體周圍感染的化驗診斷數據能否篩選出二期翻修失敗的高危病例。

方法：來自4家醫院共205例全膝或全髖置換術後因假體周圍感染行二期翻修的病例。採集的資料包括基礎信息、外科及化驗數據。化驗數據包括CRP、血沉、關節液白細胞計數和中性粒百分比，關節液或組織培養，革蘭氏染色。感染複發再次行感染翻修手術的病例被記錄為二期翻修失敗病例。成功組與失敗組進行組間比較，模擬ROC曲線計算重要化驗數據的變化閾值。

結果：二期翻修的總體失敗率為27.3%。感染複發的病例中術前血沉(p= 0.035)，關節液白細胞計數(p= 0.008)和中性粒百分比(p=0.041)均較成功病例更高。ROC曲線分析得出關節液白細胞計數的閾值為大於60000個/ml，中性粒百分比的閾值為大於92%，血沉的閾值為大於99mm/小時。關節液白細胞計數高過閾值的病例二期翻修失敗率是低於閾值病例的2.5倍，中性粒百分比高過閾值是2倍，血沉高過閾值是1.8倍。

結論：我們得出結論：很大一部分二期感染翻修失敗的病例中，其術前關節液白細胞計數>60,000個/mL、中性粒百分比>92%、血沉>99mm/小時。升高的化驗數據預示二期翻修失敗率是一般情況的1.8-2.5倍。這些實驗結果可以作為臨床指南，幫助醫生預判二期翻修失敗風險較高的病人。

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/mL 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/mL, 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.

文獻出處：Maureen K. Dwyer, Christopher Damsgaard, Jason Wadibia, 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; 100:1009-15.

第二部分：保髖相關文獻

文獻1

1997-2011年日本初診非創傷性股骨頭壞死的動態趨勢特點研究

譯者：羅殿中

背景：非創傷性股骨頭壞死是由各種原因造成的股骨頭血供破壞所致。既往已有研究報道了股骨頭壞死發病趨勢，但對於該類患者詳細特點（如年齡、性別、致病因素等）的動態變化趨勢特點尚無相關報道。本研究擬通過收集基於多中心醫院的患者數據，分析日本股骨頭壞死患者特點的動態變化趨勢。

方法：研究共納入1997年至2011年34家醫院3041例初診股骨頭壞死患者，記錄患者初診年齡、可能致病因素、需激素治療的伴隨疾病等信息。按照每5年分析動態趨勢特點（1997–2001, 2002–2006, 2007–2011）。

結果：隨時間變化，股骨頭壞死患者中性別比例及致病因素分布沒有改變。至於需服用激素的基礎疾病患者：系統性紅斑狼瘡在男女股骨頭壞死患者中所佔的比例均有所減少，分別由10%減少至6.4%（男）、37%減少至29%（女）；腎移植患者所佔比例在男女股骨頭壞死患者中亦均持續減低，分別由3.8%減少至1.2%（男）、3.2%減少至0.8%（女）；而因肺部疾病（哮喘除外）需服用激素者，其比例則表現出增加的趨勢，分別由0.5%增加至5.5%（男）、0.5%增加至3.6%（女）。

結論：本研究基於多中心大數據，首次報道了股骨頭壞死患者特點的動態變化趨勢，為以後的進一步相關研究奠定了基礎。

附表：1997至2011年股骨頭壞死患者特點分布變化趨勢。

Temporal Trends in Characteristics of Newly Diagnosed Nontraumatic Osteonecrosis of the Femoral Head From 1997 to 2011: A Hospital-Based Sentinel Monitoring System in Japan

BACKGROUND:Nontraumatic osteonecrosis of the femoral head (ONFH) is a rare disorder caused by ischemic necrosis of unknown etiology. A few studies have demonstrated trends in the number of patients with ONFH. However, there are no data on temporal trends in characteristics such as age, gender, and causative factors. To investigate this, we examined data from a multicenter hospital-based sentinel monitoring system in Japan.

METHODS:A total of 3041 newly-diagnosed ONFH patients from 34 participating hospitals who were reported to the system from 1997-2011 were analyzed. We examined age at diagnosis, potential causative factors, and underlying diseases for which patients received systemic steroid administration. Their temporal trends were assessed according to date of diagnosis in 5-year intervals (1997-2001, 2002-2006, and 2007-2011).

RESULTS:The gender ratio and distribution of potential causative factors did not change. Regarding underlying diseases requiring steroid administration, the proportion of patients with systemic lupus erythematosus decreased in males (10% to 6.4%) and in females (37% to 29%). Proportion of patients with renal transplantation fell consistently across the study period in both males (3.8% to 1.2%) and females (3.2% to 0.8%). In contrast, the proportion of patients receiving steroids for pulmonary disease (except asthma) significantly increased in both males (0.5% to 5.5%) and females (0.5% to 3.6%).

CONCLUSIONS:This large descriptive study is the first to investigate temporal trends in the characteristics of ONFH, which provide useful information for future studies.

文獻出處：Takahashi S, Fukushima W, Yamamoto T, et al. Temporal Trends in Characteristics of Newly Diagnosed Nontraumatic Osteonecrosis of the Femoral Head From 1997 to 2011: A Hospital-Based Sentinel Monitoring System in Japan. J Epidemiol. 2015;25(6):437-44.

文獻2

一種用於描述青少年特發性髖關節炎生長異常和結構變化的新影像學評分系統

譯者：程徽

背景：大約20-50％的青少年特發性關節炎（JIA）患兒在診斷後6年內累及髖關節。目前尚缺乏與髖關節影像學變化相關的評分系統。

目的：檢驗影像學變化的準確度並提出新的評分系統。

材料和方法：我們回顧了自兩個歐洲中心的75名JIA患兒的75張骨盆X線片。根據預先定義的評分系統，我們評估了（1）骨破壞性和（2）生長異常的結果。所有射線照片由兩組放射科醫師獨立評分。一組進行了第二次X線片。我們使用kappa統計來評估觀察者間和觀察者內的差異。

射線照片的評分/測量

觀察基於骨盆前後位X線攝片，患兒取仰卧位，投射中心在恥骨聯合上方2-3厘米處，使用標準電子測量工具（角度和距離）進行評估。右髖和左髖進行分別評分。

破壞性的變化

我們按照評分系統描述了骨缺損，股骨頭扁平，關節間隙，馬蹄窩的大小，關節面的硬化。

圖1 骨缺損，根據病灶位置分別進行分類：股骨頭（所累及的表面比例：0度0％，1度1-25％，2度26- 50％，3度51-75％，4度76-100％）；股骨頸（是否存在病灶）；髖臼（所累及的髖臼表面的比例：0度0％，1度1-33％，2度34-66％，3度67-100％）。

圖2 股骨頭的扁平程度的判斷使用Mose模板作為參考進行主觀判斷（0-4度，0度0％，1度1-25％，2度26- 50％，3度51-75％，4度76-100％）。

馬蹄窩的擴大，分為0-2度，0度為正常，1度可能擴大，2度擴大。在股骨頭和髖臼分別評定硬化的存在（0-4度，0度0％，1度1-25％，2度26-50％，3度51-75％，4度76-100％）。

圖3 關節間隙：負重區和關節內側兩個位置分別測量。關節內側間隙從股骨頭量到髂坐線。

圖4 關節空間高度分為正常（≥4mm），輕度變窄（2-4mm）或變窄（≤2mm）。需要注意關節僵硬、軟骨下囊腫和髖臼內突。

生長異常

圖5 我們使用以下標準測量生長異常：（1）沿著股骨頸長軸測量的股骨頸長度，從大轉子外側到股骨頭表面（以毫米為單位）； （2）股骨頸寬度（以毫米為單位）； （3）內翻/外翻畸形（頸干角）（度），大轉子尖到股骨頭頂點的垂直高度（以毫米為單位）； （4）骨骺是否閉合，是否存在大股骨頭畸形，是否存在小股骨頭畸形。

從骨盆前後位X線片上隨著年齡的增長而減小，新生兒平均為145°過度到骨骼成熟後平均為135°。我們將髖內翻定義為頸軸角度小於120°，髖外翻定位為角度大於135°。

正常變異

圖6 以下特徵被認為是在正常範圍內：髖臼外側缺損，髖臼頂的承重部分的凹陷，以及髖臼負重區域的輕度硬化。

結果：在股骨頭，股骨頸和髖臼的破壞方面，觀察者內一致性為中至良（kappa為0.5-0.8）。但是，觀察者間的一致性很低（kappa為0.1-0.3）。對股骨頭扁平程度的評估一致性為中至良（同一觀察者內的kappa為0.6-0.7，觀察者間為0.3-0.7）。對關節間隙減小的評估，觀察者內部和觀察者之間一致性均為中至良（kappa為0.4-0.8）。對股骨頸長度和寬度、股骨頸干角，和大轉子尖到股骨頭的垂直距離相對精確，在觀察者內和觀察者間一致性的95％置信區間差異，均在10％-15％內。

結論：描述兒童髖關節JIA的破壞性和生長異常的影像學指標中有幾項具有較好的重複性。我們建議未來的臨床研究重點評估這些可重複性較好的影像學變化。

A novel radiographic scoring system for growth abnormalities and structural change in children with juvenile idiopathic arthritis of the hip

BACKGROUND:Approximately 20-50% of children with juvenile idiopathic arthritis (JIA) have hip involvement within 6 years of diagnosis. Scoring systems for hip-related radiographic changes are lacking.

OBJECTIVE:To examine precision of potential radiographic variables and to suggest a scoring system.

MATERIALS AND METHODS:We reviewed a set of 75 pelvic radiographs from 75 children with JIA hip involvement across two European centres. We assessed findings of (1) destructive change and (2) growth abnormality, according to a pre-defined scoring system. All radiographs were scored independently by two sets of radiologists. One set scored the radiographs a second time. We used kappa statistics to rate inter- and intra-observer variability.

RESULTS:Assessment of erosions of the femoral head, femoral neck and the acetabulum showed moderate to good agreement for the same reader (kappa of 0.5-0.8). The inter-reader agreement was, however, low (kappa of 0.1-0.3). There was moderate to high agreement for the assessment of femoral head flattening (kappa of 0.6-0.7 for the same reader, 0.3-0.7 between readers). Joint space narrowing showed moderate to high agreement both within and between observers (kappa of 0.4-0.8). Femoral neck length and width measurements, the centrum-collum-diaphysis angle, and trochanteric-femoral head lengths were relatively precise, with 95% limits of agreement within 10-15% of the observer average.

CONCLUSION:Several radiographic variables of destructive and growth abnormalities in children with hip JIA have reasonable reproducibility. We suggest that future studies on clinical validity focus on assessing only reproducible radiographic variables.

文獻出處：Shelmerdine SC , Di Paolo PL, Rieter JFMM, Malattia C, Tanturri de Horatio L, Rosendahl K. A novel radiographic scoring system for growth abnormalities and structural change in children with juvenile idiopathic arthritis of the hip. Pediatr Radiol. 2018 May 1.

文獻3

磁共振成像診斷髖關節病變準確性的研究

譯者：肖凱

背景：髖關節鏡技術的應用使得我們對髖關節內病變有了更深入的了解。非造影磁共振成像（MRI）是目前非侵入性診斷髖關節病變的金標準，其對髖關節盂唇損傷的診斷有著較高的敏感性，但是對韌帶損傷及軟骨缺損的診斷較為模糊。本研究的目的是評估非造影MRI診斷關節內病變的準確性，同時明確哪些影像學特徵可以提高診斷的準確性。

方法：本研究為前瞻性研究，共納入68例（71髖）接受髖關節鏡治療的患者，對比術前MRI與關節鏡術中所見。兩名肌肉骨骼方向影像學專家獨立對MRI進行閱讀分析。所有的髖關節鏡手術均由同一術者完成。納入患者的MRI均為關節鏡術前6個月內進行。評價指標包括對韌帶損傷、盂唇損傷及軟骨邊緣缺損的判斷的準確性。之後比較觀測者間觀測的一致性，並比較應用MRI比較韌帶損傷分期的準確性。

結果：MRI報道韌帶損傷、盂唇損傷及軟骨邊緣損傷的準確率為85.92%。MRI判斷盂唇損傷的主要徵象包括自關節面向盂唇內部延伸的線性高信號影、盂唇內部液體聚集影、盂唇失去三角形均質低信號。軟骨邊緣損傷的診斷比較困難，但是軟骨盂唇交界區的異常信號伴隨局部缺損應該是較準確的診斷依據。韌帶損傷通常可以被MRI發現，但是分期評判並不準確。韌帶增厚及信號增強提示滑膜炎，韌帶連續性中斷及磨損提示部分撕裂。

結論：非造影MRI提供了一種準確的非侵入性檢查方法，有助於篩選有癥狀的盂唇損傷、軟骨缺損、韌帶損傷/滑膜炎患者。這項研究表明，通過傳統的非造影MRI可以準確診斷韌帶撕裂和滑膜炎，這些病變也可能是髖關節疼痛的來源。但是，MRI具有較低的診斷的特異性及陰性預測值，因此對於MRI結果陰性的可能需要進一步研究。

Hip pathology: the diagnostic accuracy of magnetic resonance imaging

BACKGROUND:ip arthroscopy has led to a greater understanding of intra-articular hip pathology. Non-contrast magnetic resonance imaging (MRI) is currently the gold standard in non-invasive imaging diagnosis, with high sensitivity in identifying labral pathology but equivocal results for ligamentum teres damage and chondral defects. The aim of this study is to determine the accuracy of non-contrast MRI for diagnosis of intra-articular hip derangements and identify radiological features that could increase the accuracy of the diagnosis.

METHODS:A prospective study of 71 hips on 68 patients undergoing hip arthroscopy was conducted comparing pre-operative analysis of MRI imaging versus an arthroscopic examination. Two musculoskeletal radiologists reported the data independently. All hip arthroscopies were performed by a single surgeon. Patients with MRIs performed within 6 months before hip arthroscopy were included. Outcome measures included observer accuracy identifying ligamentum teres tears, labral lesions, and chondral rim damage. Secondary outcome measures included inter-observer variability and correctly staged ligamentum teres tears.

RESULTS:The accuracy of radiology reporting for, labral damage, and chondral rim lesions was 85.92% for each instance. The MRI findings most consistent with labral tears include the presence of linear high signal traversing the articular surface into the labrum, presence of intra-labral fluid signal, and loss of homogenous low signal triangular morphology. Chondral rim damage was difficult to diagnose, but abnormal signal at the chondrolabral junction with partial thickness defects would suggest damage. Ligamentum teres tears are commonly found but poorly graded. Thickening and increased signal suggests synovitis while discontinuity and fraying suggests partial tearing.

CONCLUSION:Conventional non-arthrographic MRI offers an accurate non-invasive method to screen patients with symptoms referable to the hip by revealing the presence of labral tears, chondral defects, and ligamentum teres tears/synovitis. This study demonstrates that tears and synovitis of the ligamentum teres as potential sources of hip pain can be accurately identified on conventional non-arthrographic MRI. However, MRI has poor specificity and negative predictive value, and thus, a negative MRI result may warrant further investigation.

文獻4

切開複位內固定治療繼發兒童股骨頭壞死（Legg-Calvé-Perthes病）的剝脫性骨軟骨炎

譯者：張振東

背景：Legg-Calvé-Perthes病（LCPD）患者中剝脫性骨軟骨炎發生率為2%至7%。不穩定的骨軟骨碎片可導致髖關節疼痛癥狀，需要手術治療。切開複位固定剝脫的骨軟骨碎片可獲得良好的臨床療效。本研究目的為報道切開複位內固定治療繼發LCPD的剝脫性骨軟骨炎的臨床及影像學結果。

方法：對接受切開複位內固定治療的LCPD繼發剝脫性骨軟骨炎患者進行隨訪，並記錄患者一般資料及隨訪結果。患者術前確診依據影像學檢查，術後定期隨訪並記錄影像學數據。切開複位內固定手術適應證為：髖關節疼痛、機械卡壓癥狀且核磁明確存在剝脫的骨軟骨碎片。術中直視下可明確骨軟骨碎片的穩定性。同時還對術前及術後髖關節查體情況進行記錄。

結果：在64例LCPD患者中，共7例因繼發剝脫性骨軟骨炎而接受髖關節外科脫位及內固定治療。骨軟骨剝脫的面積為200至625mm2。平均隨訪時間為4.6年（範圍：1.1年至7.4年）。所有患者髖關節癥狀術後顯著改善，末次隨訪時，所有剝脫的骨軟骨碎片均良好癒合（附圖）。髖關節內旋角度由術前5.0±5.0度改善至16.4±9.8度（P=0.02）；髖關節Harris評分由術前平均47.8分提高至隨訪時平均82.7分（P=0.002）。所有患者均無骨關節炎進展等併發症發生。

結論：本研究證實了LCPD後剝脫性骨軟骨炎患者經切開複位內固定治療的臨床療效。該手術藉助髖關節外科脫位技術，保留了局部剝脫的軟骨，可獲得良好臨床療效，骨癒合滿意及且無併發症發生，可作為該疾病的首選治療方法。

附：

圖19歲男孩，骨盆正位（A）及蛙式位（B）提示LCPD，分期為Stülberg 2期，可見股骨頭骨骺不規則、軟骨下骨硬化及股骨頭輕度扁平。髖關節核磁矢狀位（C）、冠狀位（D）可見股骨頭增寬扁平，骨骺中間部密度增高，軟骨分離形成不穩定的骨軟骨碎片。

圖2切開複位內固定治療剝脫性骨軟骨炎手術示意圖：A髖關節外科脫位後，確定骨軟骨剝脫的位置、程度及穩定性；B 使用雙爪探鉤小心分離剝脫的碎片並抬起，顯露其下方的粗糙面，刮匙修整後保證對合面解剖貼附；C複位後導線及克氏針臨時固定骨軟骨片；D 3枚無釘帽加壓螺釘固定，螺釘埋入軟骨內。

圖3術後影像學表現：術後1.9年，骨盆正位（A）、蛙式位（B）見3枚無釘帽加壓螺釘穿過骺線、2枚皮質骨螺釘固定大轉子截骨塊以及髖臼外上方修復盂唇的2枚錨釘。所有內固定位置良好，骨癒合滿意。

圖48歲女孩，A術前片示Stülberg2期LCPD繼發剝脫性骨軟骨炎；B 術前矢狀位及冠狀位核磁示不穩定的剝脫的骨軟骨碎片；C行髖關節外科脫位，固定剝脫的骨軟骨碎片，同時修復盂唇；D 術後3.2年，骨癒合好，無併發症發生。

Open Reduction and Internal Fixation for the Treatment of Symptomatic Osteochondritis Dissecans of the Femoral Head in Patients With Sequelae of Legg-Calvé-Perthes Disease

BACKGROUND:Osteochondritis dissecans (OCD) is estimated to occur in 2% to 7% of patients with Legg-Calvé-Perthes disease (LCPD). Unstable osteochondral fragments secondary to LCPD may produce mechanical symptoms requiring surgical intervention. Reattachment of the fragment with open reduction and internal fixation (ORIF) may provide good clinical outcomes. The purpose of this study is to report short-term clinical and radiographic results of ORIF for the treatment of symptomatic osteochondral lesions resulting from LCPD.

METHODS:Clinical data including patient demographics and patient-reported outcome scores were collected prospectively. All patients underwent preoperative radiographs and magnetic resonance imaging confirming an unstable OCD fragment as well as postoperative radiographs at regular intervals. Indications for ORIF of the OCD fragment were hip pain and mechanical symptoms with radiographic evidence of LCPD and a magnetic resonance imaging demonstrating an OCD fragment of the femoral head. Osteochondral fragment instability was confirmed intraoperatively. Preoperative and postoperative physical examination findings were documented. All patients failed a course of nonsurgical treatment (activity modification, anti-inflammatories, and physical therapy).

RESULTS:From a total of 64 consecutive patients treated with hip preservation surgery for LCPD, 7 patients with symptomatic OCD secondary to LCPD were treated with surgical hip dislocation and ORIF of the femoral head osteochondral fragment. OCD size lesion ranged from 200 to 625?mm. All patients reported marked clinical improvement, with resolution of both pain and mechanical symptoms. Radiographs at final follow-up demonstrated complete osteochondral fragment healing without implant failure. Mean follow-up was 4.6 years (range, 1.1 to 7.4?y). There was a significant postoperative improvement in measured internal rotation in flexion (5.0±5.0 to 16.4±9.8; P=0.02). Modified Harris Hip Score markedly improved from baseline to final follow-up (47.8 to 82.7; [INCREMENT]34.9; minimal clinically important difference, 11; P=0.002), with all patients meeting minimal clinically important difference for modified Harris Hip Score. There were no complications and no progression of osteoarthritis in all patients at final follow-up.

CONCLUSIONS:We have demonstrated both predictable radiographic healing and marked clinical improvement following ORIF of symptomatic post-Perthes OCD lesions. We advocate ORIF for symptomatic osteochondral lesions as a first-line surgical treatment for these patients due to the advantages of native osteochondral tissue preservation, predictable healing, and marked clinical improvement.

文獻出處：Lamplot JD, Schoenecker PL, Pascual-Garrido C, Nepple JJ, Clohisy JC. Open Reduction and Internal Fixation for the Treatment of Symptomatic Osteochondritis Dissecans of the Femoral Head in Patients With Sequelae of Legg-Calvé-Perthes Disease. J Pediatr Orthop. 2018 May 29.

張洪主任門診時間：周三上午

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