第一部分：关节置换相关文献

文献1

关节内注射会增加TKA术后感染的风险吗？

译者：张轶超

背景：全膝关节置换术（TKA）后感染会导致灾难性的后果。 以往关于关节注射和TKA手术感染风险的研究是存在争论的，并且这些研究通常是小样本的队列研究。

问题和目的：本研究的目的是评估TKA术前行关节内注射是否会增加TKA术后感染的风险，并明确关节内注射与TKA间隔时间的长短是否影响TKA感染的风险。

方法：Humana数据集来自2007年至2014年所有在TKA术前接受膝关节注射的患者。使用现行操作术语集（CPT）代码和偏侧调整策略来鉴定接受膝关节注射并行同侧TKA的患者。根据国际疾病分类第9修订版/CPT代码确定TKA术后6个月内的感染，它表现为两个感染性终点：任何术后手术部位感染（包括所有的严重感染）和因TKA感染而行手术干预（深部TKA感染处理）。注射组根据关节注射到TKA手术间隔的时间，按月进行分组，共12个亚组。比较注射组和非注射组术后感染的风险。总共有29603例TKA患者（35％）术前行同侧膝关节注射，54,081例TKA患者（65％）术前未行膝关节注射。PearlDiver数据库目前不支持逐行输出患者数据，因此我们无法执行多变量分析来确定研究组之间是否存在其他可能对感染风险产生不同影响的重要因素的变化。然而，Charlson合并症指数在注射组与非注射组之间没有差异（两者均为2.9）表明组间相似的合并症概况。

结果：术前接受关节注射的TKA患者发生任何术后感染的比例高于术前未接受关节注射的TKA患者（4.4％比3.6％；优势比[OR]，1.23；95％置信区间[CI]，1.15-1.33；p< 0.001）。同样，术前接受关节注射的TKA患者发生TKA术后感染返回手术室的比例也高于术前未接受关节注射的TKA患者（1.49％比1.04％；OR， 1.4；95％CI，1.3-1.63；p<0.001）。逐个的月分析关节注射与TKA间隔时间显示：关节注射与TKA间隔6月以内的发生任何术后感染的几率保持较高（注射与TKA间隔1-6个月，OR范围为1.23-1.46；所有P<0.05），而且关节注射与TKA间隔7月以内，因TKA术后感染需手术干预的几率也较高（注射与TKA间隔7个月，OR范围为1.38-1.88；所有P<0.05）。当关节注射和TKA间隔时间长于6或7个月时，到研究终点时的OR值均未再升高。

结论：TKA术前关节注射与TKA术后较高的感染风险有关，注射和TKA间隔时间较短时，感染几率较高。但仍需要进一步的研究来更好地评估TKA术前注射对引起TKA感染所占的比重，而且可以通过多变量分析控制其他已知的风险因素来研究建立其与TKA感染更确定的关系。

Do Intraarticular Injections Increase the Risk of Infection After TKA?

BACKGROUND: Infection after total knee arthroplasty (TKA) can result in disastrous consequences. Previous research regarding injectionsand risk of TKA infection have produced conflicting results and in general have been limited by small cohort size.

QUESTIONS/PURPOSES: The purpose of this study was to evaluate if intraarticular injection before TKA increases the risk of postoperative infection and to identify if time between injection and TKA affect the risk of TKA infection.

METHODS: The Humana data set was reviewed from 2007 to 2014 for all patients who received a knee injection before TKA. Current Procedural Terminology (CPT) codes and laterality modifiers were used to identify patients who underwent knee injection followed by ipsilateral TKA. Postoperative infection within 6 months of TKA was identified using International Classification of Diseases, 9th Revision/CPT codes that represent two infectious endpoints: any postoperative surgical site infection (encompasses all severities of infection) and operative intervention for TKA infection (surrogate for deep TKA infection). The injection cohort was stratified into 12 subgroups by monthly intervals out to 12 months corresponding to the number of months that had elapsed between injection and TKA. Risk of postoperative infection was compared between the injection and no injection cohorts. In total, 29,603 TKAs (35%) had an injection in the ipsilateral knee before the TKA procedure and 54,081 TKA cases (65%) did not. The PearlDiver database does not currently support line-by-line output of patient data, and so we were unable to perform a multivariate analysis to determine whether other important factors may have varied between the study groups that might have had a differential influence on the risk of infection between those groups. However, the Charlson Comorbidity index was no different between the injection and no injection cohorts (2.9 for both) suggesting similar comorbidity profiles between the groups.

RESULTS: The proportion of TKAs developing any postoperative infection was higher among TKAs that received an injection before TKA than in those that did not (4.4% versus 3.6%; odds ratio [OR], 1.23; 95% confidence interval [CI], 1.15-1.33; p < 0.001). Likewise, the proportion of TKAs developing infection resulting in return to the operating room after TKA was also higher among TKAs that received an injection before TKA than those that did not (1.49% versus 1.04%; OR, 1.4; 95% CI, 1.3-1.63; p < 0.001). Month-by-month analysis of time between injection and TKA revealed the odds of any postoperative infection remained higher for the injection cohort out to a duration of 6 months between injection and TKA (ORs ranged 1.23 to 1.46 when 1-6 months between injection and TKA; p < 0.05 for all) as did the odds of operative intervention for TKA infection when injection occurred within 7 months of TKA (OR ranged from 1.38 to 1.88 when 1-7 months between injection and TKA; p < 0.05 for all). When the duration between injection and TKA was longer than 6 or 7 months, the ORs were no longer elevated at these endpoints, respectively.

CONCLUSIONS: Injection before TKA was associated with a higher risk of postoperative infection and appears to be time-dependent with closer proximity between injection and TKA having increased odds of infection. Further research is needed to better evaluate the risk injection before TKA poses for TKA infection; a more definitive relationship could be established with a multivariate analysis to control for other known risk factors for TKA infection.

文献出处：Bedard NA, Pugely AJ, Elkins JM, et al. The John N. Insall Award: Do Intraarticular Injections Increase the Risk of Infection After TKA? Clin Orthop Relat Res. 2017 Jan;475(1):45-52.

文献2

膝前痛和有证据的髌股关节炎不应被视为膝关节活动平台单髁置换的手术禁忌

译者：马云青

目标：目前尚不清楚髌股关节（PFJ）骨关节炎（OA）和前膝疼痛是否是内侧单间室膝关节置换术(UKA)的禁忌证。本研究的目标是为了调查一系列连续性UKA患者的长期临床结果，而患者均伴有膝前疼痛伴或髌股关节骨关节炎。

患者与方法：作者评价了805例行接受内侧移动平台单髁关节置换的膝关节（677名患者）术后10年的功能结果和15年的假体生存率。髌股关节骨关节炎的情况均在术中有所记录，除了外侧有严重的骨缺损外，无论是否存在临床或影像学上的PFJ骨关节炎和膝前痛均不认为是手术禁忌。本研究同时对100膝（91名患者）的影像学资料与膝前痛情况进行了分析。

结果：术前存在膝前疼痛或术中记录在内侧髌骨或股骨滑车以及影像学表现出不同程度髌股关节炎的患者，术后10年的功能结果和15年假体生存率方面没有差异。有6%的患者髌骨外侧软骨全层磨损，即使在这种情况下，术后10年的功能和15年假体生存率与那些没有软骨损伤的患者相似，只是出现下楼困难的比例略高于无软骨损伤的患者。影像学上的髌股关节外侧骨关节炎表现，与术后功能和假体生存率无关。

结论：PFJ外侧严重损伤，如骨丢失和软骨严重损伤仍是活动平台UKA的禁忌证。PFJ外侧较轻的损伤和内侧的损伤，无论多么严重，都不会影响到术后功能或假体生存率，因此不应被视为手术禁忌。但是，如果患者在PFJ外侧有全层的软骨丢失，他们可能有轻微的下楼功能障碍。术前膝前疼痛既不影响术后功能也不影响术后假体生存率，不应被视为手术禁忌证。

Anterior knee pain and evidence of osteoarthritis of the patellofemoral joint should not be considered contraindications to mobile-bearing unicompartmental knee arthroplasty: a 15-year follow-up

AIMS: It is not clear whether anterior knee pain and osteoarthritis (OA) of the patellofemoral joint (PFJ) are contraindications to medial unicompartmental knee arthroplasty (UKA). Our aim was to investigate the long-term outcome of a consecutive series of patients, some of whom had anterior knee pain and PFJ OA managed with UKA.

PATIENTS AND METHODS: We assessed the ten-year functional outcomes and 15-year implant survival of 805 knees (677 patients) following medial mobile-bearing UKA. The intra-operative status of the PFJ was documented and, with the exception of bone loss with grooving to the lateral side, neither the clinical or radiological state of the PFJ nor the presence of anterior knee pain were considered a contraindication. The impact of radiographic findings and anterior knee pain was studied in a subgroup of 100 knees (91 patients).

RESULTS: There was no relationship between functional outcomes, at a mean of ten years, or 15-year implant survival, and pre-operative anterior knee pain, or the presence or degree of cartilage loss documented intra-operatively at the medial patella or trochlea, or radiographic evidence of OA in the medial side of the PFJ. In 6% of cases there was full thickness cartilage loss on the lateral side of the patella. In these cases, the overall ten-year function and 15-year survival was similar to those without cartilage loss; however they had slightly more difficulty with descending stairs. Radiographic signs of OA seen in the lateral part of the PFJ were not associated with a definite compromise in functional outcome or implant survival.

CONCLUSION: Severe damage to the lateral side of the PFJ with bone loss and grooving remains a contraindication to mobile-bearing UKA. Less severe damage to the lateral side of the PFJ and damage to the medial side, however severe, does not compromise the overall function or survival, so should not be considered to be a contraindication. However, if a patient does have full thickness cartilage loss on the lateral side of the PFJ they may have a slight compromise in their ability to descend stairs. Pre-operative anterior knee pain also does not compromise the functional outcome or survival and should not be considered to be a contraindication.

文献出处：

Hamilton TW1, Pandit HG2, Maurer DG1, et al. Anterior knee pain and evidence of osteoarthritis of the patellofemoral joint should not be considered contraindications to mobile-bearing unicompartmental knee arthroplasty: a 15-year follow-up. Bone Joint J. 2017 May;99-B(5):632-639.

文献3

全髋关节置换术后陶瓷对陶瓷摩擦界面的翻修原因与其它摩擦界面有差异吗？

译者：张蔷

背景：尽管陶对陶（CoC）摩擦界面已经在全髋关节置换手术中广泛应用近10年了，我们依然对此种摩擦界面的翻修原因知之甚少。

目的：本研究目的：（1）陶对陶摩擦界面的翻修原因与其他摩擦界面有不同吗？（2）陶对陶摩擦界面的初次至翻修时间与其他摩擦界面的有不同吗？（3）陶对陶摩擦界面有哪些独有的翻修原因？

方法：SoFCOT组织中所有年翻修例数超过30的成员均被邀请加入此多中心、前瞻性的观察研究。我们的数据涵盖了法国一年12%的翻修病例。2010年1月至2011年12月间共2107位患者，2107例髋翻修，其中1201例女患者（57%）、906例男患者（43%）；中位年龄为73岁，范围17岁-104岁。初次至翻修的中位时间为11年，范围0天-42年。有238例（11%）陶对陶CoC，148例（7%）金对金MoM，1721例（82%）金对聚乙烯MoP。

结果：各种摩擦界面的翻修原因并不相同：（1）金对聚乙烯：臼杯松动698例（41%）、假体周围骨折220例（13%）、骨溶解213例（12%）；（2）陶对陶：臼杯松动41例（17%）、感染39例（16%）、脱位23例（10%）；（3）金对金：臼杯松动28例（19%）、金属碎屑副反应26例（18%）、感染16例（11%）。与金对聚乙烯比较，陶对陶极少出现骨溶解导致翻修的情况（4例，2%），却容易出现髂腰肌激惹导致翻修（18例，8%）。初次至翻修时间随摩擦界面变化亦有不同：陶对陶的中位时间为3年（3天-28年），金对金的中位时间为4年（14天-37年），金对聚乙烯的中位时间为13年（0天-42年）。238例陶对陶翻修中有37例（16%）与陶瓷的应用直接相关（陶瓷碎裂23例，异响6例，撞击7例，陶瓷内衬安放错误1例）。并未发现与异响、髂腰肌激惹或撞击直接相关的因素，但假体安放位置并未评估。

结论：陶对陶与其他摩擦界面的翻修原因和初次至翻修时间不同。陶对陶初次全髋翻修时间更早，3%易出现机械问题，如撞击、异响以及陶瓷碎裂等，第三代陶瓷和大头的应用并未改善这些问题。陶对陶髋关节很少会因为骨溶解导致翻修，却有较高比例的髂腰肌激惹，需要进一步研究证实。

Do the Reasons for Ceramic-on-ceramic Revisions Differ From Other Bearings in Total Hip Arthroplasty?

BACKGROUND: Despite widespread use of ceramic-on-ceramic (CoC) in total hip arthroplasty (THA) during the past 10 years, little is known about why revisions are performed in hips with this bearing or the time elapsed before revision.

QUESTIONS/PURPOSES: The purposes of this study were: (1) Do the reasons for first revision differ between CoC bearings and other bearing couples? (2) Does the time to revision differ between CoC and other bearing couples? (3) Are there unique reasons for revisions of CoC bearings?

METHODS: All members of the Société Française de Chirurgie Orthopédique et Traumatologique (SoFCOT) who performed ≥ 30 revisions per year were invited to participate in this multicenter, prospective, observational study. Our data represent 12% of the revision procedures performed in France. A total of 2107 first revisions of THA (from January 2010 to December 2011) were done in 2107 patients (1201 females [57%] and 906 males [43%]; median age, 73 years; age range, 17-104 years) at the time of surgery after a median of 11 years (range, 0 day-42 years) after the primary THA. There were 238 of 2107 (11%) CoC, 148 of 2107 (7%) metal-on-metal (MoM), and 1721 of 2017 (82%) metal-on-polyethylene (MoP) bearings.

RESULTS: The reasons for reoperation differed according to the bearing component: (1) for the MoP reference bearing (odds ratio [OR]; 95% confidence interval), cup loosening occurred in 698 of 1721 hips (41%), periprosthetic fracture in 220 of 1721 hips (13%), and osteolysis in 213 of 1721 hips (12%); (2) for CoC, cup loosening occurred in 41 of 238 hips (17%) (OR, 0.31 [0.22-0.43; p < 0.001), infection in 39 of 238 hips (16%) (OR, 1.63 [1.12-2.37]; p = 0.01), and dislocation in 23 of 238 hips (10%) (OR, 0.9 [0.57-1.42]; p = 0.9); (3) for MoM, cup loosening occurred in 28 of 148 hips (19%) (OR, 0.34 [0.22-0.52]; p < 0.001), adverse reaction to metallic debris in 26 of 148 hips (18%) (OR, 18.12 [9.84-33.4]; p < 0.001), and infection in 16 of 148 hips (11%) (OR, 1 [0.59-1.73]; p = 0.9). In comparison with MoP, osteolysis was rarely the reason for revision in CoC (four of 238 hips [2%]; OR, 0.12 [0.05-0.33]; p < 0.001), but this bearing was frequently revised because of iliopsoas irritation (18 of 238 hips [8%]; OR, 4.9 [2.7-9]; p < 0.001). The time elapsed before revision differed between bearings: median of 3 years (range, 3 days to 28 years) for CoC and 4 years (range, 14 days to 37 years) for MoM versus a median 13 years (range, 0 day to 42 years) for MoP (p < 0.001). Thirty-seven of the 238 revisions (16%) were directly related to ceramic use (ceramic breakage [n = 23], squeaking [n = 6], impingement [n = 7], incorrect ceramic insert insertion [n = 1]). No factors were identified that contributed to breakage of the 12 bulk ceramic components (eight heads, four inserts, four of 12 Delta ceramic). No factors were associated with squeaking, iliopsoas irritation, or impingement, but component orientation was not assessed.

CONCLUSIONS: The reasons and time to first revision differed between CoC and other bearings. CoC THAs are revised earlier and3% are sensitive to mechanical problems such as impingement, squeaking, and ceramic rupture that did not disappear with introduction of Delta ceramics and large-diameter (≥ 36 mm) bearings. CoC was rarely revised for osteolysis, but a high rate of iliopsoas irritation requires further investigation.

文献出处：

Migaud H, Putman S, Kern G, et al. Do the Reasons for Ceramic-on-ceramic Revisions Differ From Other Bearings in Total Hip Arthroplasty? Clin Orthop Relat Res. 2016 Oct;474(10):2190-9.

文献4

初潮年龄与原发性骨关节炎膝关节置换有关

（来自HUNT研究和挪威关节置换登记中心的数据）

译者：程凌燕

目的：研究胎次、初潮年龄、绝经状态、绝经年龄、口服避孕药（OC）或使用激素替代疗法（HRT）是否与原发性骨关节炎全膝关节置换术（TKR）或全髋关节置换术（THR）有关。

方法：从Nord-Trøndelag健康研究的第二次和第三次调查中抽取30,289名妇女，进行前瞻性队列研究，数据与挪威关节置换术登记处（NAR）相关联，统计由原发性骨关节炎引起的TKR或THR。使用Cox比例风险模型来估计风险比（HR）。

结果：观察了430例TKR和675例THR，平均随访8.3年。月经初潮年龄升高与TKR风险呈负相关（P <0.001）。曾使用过HRT的人和现阶段使用系统性HRT疗法的人与未使用者相比风险更高（HR分别是 1.42（95％可信区间（CI）1.06-1.90）和 1.40（95％可信区间1.03-1.90）。胎次、初潮年龄、绝经状态、绝经年龄、使用口服避孕药或使用HRT与THR之间无关联。

结论：初潮年龄的增加降低了TKR的风险。过去曾使用HRT的人以及现阶段正在使用系统性HRT的人与未使用者相比，TKR风险更高。胎次并没有增加THR或TKR的风险。

Age of menarche is associated with knee joint replacement due to primary osteoarthritis (The HUNT Study and the Norwegian Arthroplasty Register)

OBJECTIVE: To investigate whether parity, age at menarche, menopausal status, age at menopause, use of oral contraceptives (OC) or use of hormone replacement therapy (HRT) were associated with total knee replacement (TKR) or total hip replacement (THR) due to primary osteoarthritis.

METHOD: In a prospective cohort study of 30,289 women from the second and third surveys of the Nord-Trøndelag Health Study, data were linked to the Norwegian Arthroplasty Register (NAR) in order to identify TKR or THR due to primary osteoarthritis. Cox proportional hazards models were used to estimate the hazard ratios (HRs).

RESULTS: We observed 430 TKRs and 675 THRs during a mean follow-up time of 8.3 years. Increasing age at menarche was inversely associated with the risk of TKR (P-trend < 0.001). Past users and users of systemic HRT were at higher risk of TKR compared to never users (HR 1.42 (95% confidence interval (CI) 1.06-1.90) and HR 1.40 (95% CI 1.03-1.90), respectively). No association was found between parity, age at menarche, menopausal status, age at menopause, oral contraceptive use or HRT use and THR.

CONCLUSION: We found that increasing age at menarche reduced the risk of TKR. Past users and users of systemic HRT were at higher risk of TKR compared to never users. Parity did not increase the risk of THR or TKR.

文献出处：

Hellevik AI, Nordsletten L, Johnsen MB, et al. Age of menarche is associated with knee joint replacement due to primary osteoarthritis (The HUNT Study and the Norwegian Arthroplasty Register). Osteoarthritis Cartilage. 2017 Oct;25(10):1654-1662.

第二部分：保髋换相关文献

文献1

进化对凸轮畸形的作用及其对人类髋关节生物力学的影响

译者：程徽

人类在长期直立行走中，形成了具有独特解剖学和生物力学特点的髋关节。生活环境和生物学行为均可以影响髋关节的形态，所以同科不同种属的动物间髋关节的形态也不尽相同。作用于髋关节的力主要是自身重力和髋周肌肉的拉力。髋臼和股骨的特殊解剖结构，确保髋关节既具稳定，又高度灵活。我们发现，第一个直立行走人类祖先的股骨头就是球形的（球形髋）。这种球形髋也见于人类的近亲——现代大型类人猿，和绝大多数的现代人类中。然而，如果在青春期，股骨头骺闭合之前，进行高强度的运动，就会激活人类基因中潜在的强化股骨颈的能力，引起骨骺延伸，在股骨颈前上方形成非球形的凸起（凸轮畸形）。凸轮畸形的形态，略似四足动物的非球形髋。其不同之处在于，四足动物的非球形隆起位于髋关节后侧。可以推测，这是因为人类在髋关节伸展时承重，而四足动物在屈髋90-100°时承重。关节非球形改变了髋关节的生物力学特性，如果强力屈髋使非球形部分进入髋臼，会导致髋关节软骨继发性损伤。这是髋关节骨关节炎形成和发展的一个重要的危险因素。活动范围受限，是这种畸形的典型临床表现。

The Influence of Evolution on Cam Deformity and its Impact on Biomechanics of the Human Hip Joint

Anatomy and biomechanics of the human hip joint are a consequence of the evolution of permanent bipedal gait. Habitat and behavior have an impact on hip morphology and significant differences are present even within the same biological family. The forces acting upon the hip joint are mainly a function of gravitation and strength of the muscles. Acetabular and femoral anatomy ensure an inherently stable hip with a wide range of motion. The femoral head in first human ancestors with upright gait was spherical (coxa rotunda). Coxa rotunda is also seen in close human relatives (great apes) and remains the predominant anatomy of present-day humans. High impact sport during adolescence with open physis however can activate an underlying genetic predisposition for reinforcement of the femoral neck, causing an epiphyseal extension and the formation of an osseous asphericity at the antero-superior femoral neck (cam deformity). The morphology of cam deformity is similar to the aspherical hips of quadrupeds (coxa recta), with the difference that in quadrupeds the asphericity is posterior. It has been postulated that this is due to the fact that humans bear weight on the extended leg, while quadrupeds bear weight at 90 - 100° flexion. The asphericity alters the biomechanical properties of the joint and as it is forced into the acetabulum leading to secondary cartilage damage. It is considered a risk factor for later development of osteoarthritis of the hip. Clinically this presents as reduced range of motion, which can be an indicator for the structural deformity of the hip. This article is protected by copyright. All rights reserved.

文献出处：

Anwander H1,2, Beck M1, Büchler L2. The Influence of Evolution on Cam Deformity and its Impact on Biomechanics of the Human Hip Joint. J Orthop Res. 2018 Feb 5.

文献2

双胞胎的髋关节发育不良：机械因素在DDH发病中的重要性分析

译者：肖凯

背景：发育性髋关节发育不良是由多种因素引起的一种形态学异常疾病。基因及子宫内异常的机械因素都会影响髋关节的发育，增加DDH的发病率。臀位分娩也是DDH发病的高位因素。本研究的目的是分析双胞胎是否也是一种像臀位、胎儿宫内活动受限、髋关节外展受限那样增加DDH发病率的宫内机械因素。

方法：本研究纳入了无DDH家族史及其他疾病的臀位或头位生产的双胞胎做研究对象。我们连续收集了2002年至2007年间出生的105对双胞胎（210新生儿，420髋），其中48对为1头位1臀位，35对为双头位，22对位双臀位。上述资料是由产检B超师及产科医生记录。产妇平均孕期为36.7周，新生儿平均出生体重2290g。对照组1纳入了274例单胎头位分娩的新生儿，平均孕期39.1周，平均体重3200g。对照组2纳入了48例单胎臀位分娩的新生儿，平均孕期36.8周，平均体重2870g。应用Graf超声技术对所有新生儿进行髋关节超声检查。应用X²检验进行数据分析。

结果：X²检验显示，双胞胎组与2个对照组比，髋关节发育异常的比例无统计学差异。对照组1和对照组2总体的DDH发病率比双胞胎组高了3.4%。

结论：通过大样本的双胞胎及对照组研究，我们发现没有家庭病史的双胞胎新生儿及单胎生产的胎儿之间，DDH发病率无明显差异。我们认为，当膝关节弯曲的情况下，即使双胞胎是臀位生产也不会增加DDH的发病风险。

Developmental Dysplasia of the Hip in Twins: The Importance of Mechanical Factors in the Etiology of DDH

Background: Developmental dysplasia of the hip (DDH) is a disease of multifactorial etiology. Genetic and intrauterine mechanical factors influence the development of the hip joint and the incidence of DDH. Breech position is a risk factor for DDH. The aim of this study is to analyze whether in twins, the intrauterine mechanical factors, such as a breech position, limitation of fetal mobility, limitation of hip abduction, and increase the incidence of DDH may, therefore, be considered as risk factors.

Methods: A pair of twins with either breech or cephalic presentation, and no family history of DDH or any other sicknesses were included in this study. During a 6-year period between 2002 and 2007, data were collected on 105 consecutively born twins (210 children with 420 hips) of whom 48 were a cephalic breech, 35 were a cephalic-cephalic, and 22 were a breech-breech presentation. The presentation was defined by regular prenatal ultrasounds and the obstetric records at birth. The average gestational age was 36.7 weeks and average weight at birth was 2290 g. Control group 1 consisted of 274 single gestation children, with a cephalic presentation at birth. The average gestational age was 39.1 weeks and average weight at birth was 3200 g. Control group 2 consisted of 48 single gestation children, with a breech presentation at birth. The average gestational age was 36.8 weeks and average weight at birth was 2870 g. Ultrasonography of the hips was done according to the Graf technique. Statistical analysis was done using a X² test.

Results: The X² test was used and it showed no significant association between the presence or absence of pathologic hip types in the twins group and in the 2 control groups. A higher incidence of DDH (3.4%) was present in groups 1 and 2.

Conclusions: This comparison of a large series of twins with matched controls shows that there is no increased incidence of DDH in twins when compared with single birth infants with no family history of DDH. This study supports the idea that breech presentation in twins is not a risk factor, when knees are flexed.

文献出处：

De Pellegrin M1, Moharamzadeh D. Developmental Dysplasia of the Hip in Twins: The Importance of Mechanical Factors in the Etiology of DDH. J Pediatr Orthop. 2010 Dec;30(8):774-8.

文献3

髋臼周围截骨术中期随访报告：华盛顿大学经验

译者：张振东

背景：髋臼周围截骨术（Bernese periacetabular osteotomy，PAO）可治疗髋关节发育不良患者，其中期随访报道较少。本研究总结并分析了PAO治疗髋关节发育不良患者的中期生存分析情况及病人报告结果（patient-reportedoutcomes）。

方法：自1994年7月至2008年8月，共206例患者（238髋）接受PAO治疗。其中62髋为非髋关节发育不良，另外22例（22髋）失访，其余129例（154髋）纳入本研究。术后平均随访10.3年。使用Kaplan-Meier方法行生存分析，记录终点为接受髋关节置换（THA）。髋关节功能使用UCLA（University of California at Los Angeles）活动评分、改良髋关节Harris评分（mHHS）以及WOMAC疼痛评分评估。WOMAC评分≥10和/或mHHS≤70可认为髋关节功能不良。

结果：K-M生存分析显示，术后15年PAO保髋生存率为92%（95%CI：82%-97%）。8髋（5%）在PAO术后6.8±5.2年行THA治疗。另外24髋（16%）被认为髋关节功能不良。其余122髋（79%）未接受THA并且髋关节功能良好（WOMAC评分<10和/或mHHS>70），在平均随访10.1年时，该122髋mHHS为92.4±8.4分，WOMAC疼痛评分为1.2±1.9分，UCLA活动评分为7.7±2.0分。PAO预后失败的因素包括术前关节头臼匹配中或差（OR：8.65；95%CI：1.18-63.55）以及术后外侧CE角大于38°（OR：8.04；95%CI：2.01-32.22）。而PAO术中同时行头颈处骨软骨成形可降低PAO失败的风险（OR：0.27；95%CI：0.09-0.78）。

结论：该研究明确了PAO治疗髋关节发育不良的可靠性，预后失败因素包括术前关节头臼匹配中或差以及术后外侧CE角大于38°，而术前髋关节活动度差的患者PAO术中同时行头颈处骨软骨成形可降低PAO失败的风险。

Intermediate-Term Hip Survivorship and Patient-Reported Outcomes of Periacetabular Osteotomy: The Washington University Experience

Background: The Bernese periacetabular osteotomy (PAO) is an alternative to arthroplasty for treating symptomatic acetabular dysplasia, but there have been few studies on the intermediate-term outcomes of this procedure. In the present study, we assessed intermediate-term hip survival and patient-reported outcomes of PAO used to treat symptomatic acetabular dysplasia.

Methods: From July 1994 to August 2008, 238 hips (206 patients) were treated with PAO. Sixty-two had a diagnosis other than classic acetabular dysplasia, and 22 were lost to follow-up. The remaining 154 hips (129 patients) were evaluated at an average of 10.3 years postoperatively. Kaplan-Meier analysis was used to assess survivorship with an end point of total hip arthroplasty (THA). Hips were evaluated using the University of California at Los Angeles (UCLA) Activity Score, modified Harris hip score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale score. A WOMAC pain subscale score of ≥10 and/or an mHHS of ≤70 were considered to indicate a clinically symptomatic hip.

Results: Kaplan-Meier analysis revealed a hip survival rate of 92% (95% confidence interval [CI]: 82% to 97%) at 15 years postoperatively. Eight hips (5%) underwent THA at a mean (and standard deviation) of 6.8 ± 5.2 years. Twenty-four additional hips (16%) were considered symptomatic based on a WOMAC pain score of ≥10 and/or an mHHS of ≤70. One hundred and twenty-two hips (79%) did not undergo THA and did not meet the criteria for symptoms, and these hips had a mean mHHS of 92.4 ± 8.4, WOMAC pain subscale score of 1.2 ± 1.9, and UCLA Activity Score of 7.7 ± 2.0 at a mean of 10.1 years. A higher risk of failure was associated with fair or poor preoperative joint congruency (odds ratio [OR]: 8.65; 95% CI: 1.18 to 63.55; p = 0.034) and with a postoperative lateral center-edge angle of >38° (OR: 8.04; 95% CI: 2.01 to 32.22). A concurrent head-neck osteochondroplasty was associated with a decreased risk of failure (OR: 0.27; 95% CI: 0.09 to 0.78; p = 0.016).

Conclusions: This study demonstrates the durability of the Bernese PAO. Fair or poor preoperative joint congruency and excessive postoperative femoral head coverage were found to be predictors of failure, while concurrent head-neck osteochondroplasty in patients with an inadequate range of motion after PAO was associated with a decreased risk of failure.

文献出处：Wells, Joel; Schoenecker, Perry; Duncan, Stephen et al. Intermediate-Term Hip Survivorship and Patient-Reported Outcomes of Periacetabular Osteotomy: The Washington University Experience. JBJS. 100(3):218-225, February 7, 2018.

文献4

临床指南：DDH的早期筛查

译者：杨金鑫

摘要：描述股骨头和髋臼异常关系的首选术语是髋关节发育不良。髋关节发育不良包括：完全脱位、半脱位、髋关节不稳定和影像学反映出来的髋臼形态异常。因为这些畸形不一定在婴儿出生时表现出来，比起“先天性”，“发育性”更能准确的反映DDH的生物学特征。DDH是种少见病。脱位关节越早发现，治疗越简单，而且越有效。尽管存在新生儿DDH筛查，婴幼儿期的髋关节脱位仍不能被及时的诊断，在一些情况下，诊断的不及时不仅会延误适当的治疗时机，而且会导致大量的医疗事故索赔。本指南的目的在于减少婴幼儿期的髋关节脱位的延迟诊断率。目标受众为基层医疗机构。目标患者为出生到18个月的健康婴幼儿，不适用于神经肌肉障碍、脊髓发育不良或者关节挛缩的婴幼儿。

Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip

ABSTRACT: Developmental dysplasia of the hip is the preferred term to describe the condition in which the femoral head has an abnormal relationship to the acetabulum. Developmental dysplasia of the hip includes frank dislocation (luxation), partial dislocation (subluxation), instability wherein the femoral head comes in and out of the socket, and an array of radiographic abnormalities that reflect inadequate formation of the acetabulum. Because many of these findings may not be present at birth, the term developmental more accurately reflects the biologic features than does the term congenital. The disorder is uncommon. The earlier a dislocated hip is detected, the simpler and more effective is the treatment. Despite newborn screening programs, dislocated hips continue to be diagnosed later in infancy and childhood,1-11 in some instances delaying appropriate therapy and leading to a substantial number of malpractice claims. The objective of this guideline is to reduce the number of dislocated hips detected later in infancy and childhood. The target audience is the primary care provider. The target patient is the healthy newborn up to 18 months of age, excluding those with neuromuscular disorders, myelodysplasia, or arthrogryposis.

文献出处：

Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip. Pediatrics. 2000 Apr;105(4 Pt 1):896-905.