髖膝關節文獻精譯薈萃（第381期)

本期目錄：

1、全膝關節置換術中髕骨軌跡的機器人評估

2、既往髖臼周圍截骨術對發育性髖關節發育不良患者全髖關節置換術療效的影響

3、膝關節置換術前低認知功能和軀體心理癥狀與術后譫妄高風險相關

4、機器人輔助全膝關節置換術（TKA）與患者滿意度增加無關

5、兒童和青少年股骨頸骨折后股骨頭壞死:危險因素分析

6、青少年群體髖臼周圍截骨術后坐骨-恥骨結合部骨折

7、股神經和坐骨神經在髖臼周圍不同位置的CT研究

8、基于德爾菲法的股骨頭壞死塌陷預后模型

第一部分：關節置換及保膝相關文獻

文獻1

全膝關節置換術中髕骨軌跡的機器人評估

譯者 張軼超

目的：機器人作為一種工具已被開發用于改進全膝關節置換術（TKA）的計劃、準確性和效果。本研究的目的是描述和闡明一種使用無圖像機器人平臺評估TKA中髕骨股骨關節（PFJ）的新技術。

方法：由一名外科醫生采用上述技術連續做了30例R-TKA。開發了一種在術中，在植入假體前和植入假體后動態評估PFJ的技術。然后收集了9個病例的全套數據并進行了回顧性分析。本文介紹了術中在植入假體前、后收集的一系列動態PFJ軌跡。此外，通過對90度活動范圍內的PFJ過度填充和填充不足進行了全面評估。最后，確定并測量了PFJ安裝假體前后的旋轉中心。

結果：所描述的技術是根據使用上述的機器人平臺完成的一系列30 R-TKA而定義的。對9個案例進行了分析，以確定使用機器人平臺可以測量哪些數據。通過術中實時數據可以對假體植入前后膝關節0 - 90屈曲運動范圍內的PFJ軌跡進行視覺評估。在術中還對0 -90 度屈曲活動范圍內PFJ的過度填充和不足進行了評估。術后可以進行更詳細的研究，包括確定植入假體前后髕骨旋轉中心（COR）。確定了髕骨平面的定義。此外，測量了膝關節完全伸展到極度屈曲過程中髕骨內外側移位的情況。

結論：TKA術中對PFJ的評估是很困難的。機器人工具已經開發出來，以提高TKA手術中的測量方法和準確性。這些工具可以以新的方式來評估PFJ，這可能會導致TKA技術的進一步改進。

Robotic assessment of patella tracking in total knee arthroplasty

Objectives: Robotic tools have been developed to improve planning, accuracy and outcomes in total knee arthroplasty (TKA). The purpose of this study was to describe and illustrate a novel technique for assessing the patellofemoral (PFJ) in TKA using an imageless robotic platform.

Methods: A consecutive series of 30 R-TKA was undertaken by a single surgeon utilising the described technique. A technique to dynamically assess the PFJ intra-operatively, pre- and post-implantation was developed. A full set of data from 9 cases was then collected and reviewed for analysis. A series of dynamic PFJ tracks collected intra-operatively pre- and post-implantation are presented. Furthermore, a full assessment of PFJ over and under-stuffing through a 90arc of flexion is illustrated. Finally, a pre- and post-centre of rotation for the PFJ was defined and measured.

Results: The described technique was defined over a series of 30 R-TKA using the described robotic platform. Nine cases were analysed to determine what data could be measured using the robotic platform. Intra-operative real time data allowed a visual assessment of PFJ tracking through a range of motion of 0 –90 flexion pre- and postimplantation. PFJ over and under-stuffing was also assessed intra-operatively through a range of motion of 0 –90flexion. Post-operative analysis allowed a more detailed study to be performed, including defining a pre- and postimplantation centre of rotation (COR) for the patella. Defining the COR allowed the definition of a patella plane. Furthermore, patella mediolateral shift in full extension, and end flexion could be measured.

Conclusion: Intra-operative assessment of the PFJ in TKA is challenging. Robotic tools have been developed to improve measurement, accuracy of delivery and outcomes in TKA. These tools can be adapted in novel ways to assess the PFJ, which may lead to further refinements in TKA techniques.

文獻出處：Shatrov J, Khasian M, Lording T, Monk AP, Parker D, Lustig S. Robotic assessment of patella tracking in total knee arthroplasty. J ISAKOS. 2024 Oct;9(5):100287. doi: 10.1016/j.jisako.2024.06.006. Epub 2024 Jun 21. PMID: 38909904.

文獻2

既往髖臼周圍截骨術對發育性髖關節發育不良患者全髖關節置換術療效的影響

譯者 馬云青

研究背景：本研究旨在闡述臨床醫師在為因髖關節發育不良繼發骨關節炎的患者行全髖關節置換術（THA）時可能面臨的治療難點。本研究對比了伴有/不伴有既往髖臼周圍截骨術（PAO）史、因發育性髖關節發育不良（DDH）繼發骨關節炎而行全髖關節置換術的患者的臨床結果。

研究方法：患者分為兩組。A組為青少年期曾行髖臼周圍截骨術、后續在本骨科中心接受全髖關節置換術的患者（共29髖）；B組為患有發育性髖關節發育不良、僅行全髖關節置換術而無既往髖臼周圍截骨術史的青少年患者（共24髖）。觀測指標包括：術中失血量、髖臼假體尺寸、假體位置、髖臼覆蓋情況、髖臼杯傾斜角與前傾角、手術時長、臨床評分、住院時長及異位骨化發生情況。

研究結果：改良哈里斯髖關節評分（mHHS）存在顯著統計學差異（A組：89分 vs B組：91分；P=0.03）。以術前與術后第3天血紅蛋白濃度差值評估失血量，A組差值較B組高0.85 mg/dL（A組：4.4 mg/dL vs B組：3.55 mg/dL；P=0.004）；同時A組術后第3天紅細胞壓積顯著更低（A組：27% vs B組：29.5%；P=0.02）。影像學測量顯示兩組Brooker分級差異具有統計學意義（P=0.005）。A組13例患者全髖關節置換術后出現Ⅰ級及以上異位骨化，B組僅2例患者出現Ⅰ～Ⅱ級異位骨化。此外，既往行PAO的患者術后旋轉中心下移距離顯著更大（79 mm，73–83 mm vs 74.5 mm，69–77 mm；P=0.004）。

研究結論：與無既往截骨術史的患者相比，既往行髖臼周圍截骨術的患者在接受全髖關節置換術后，改良哈里斯髖關節評分更低，圍手術期失血量更多，異位骨化發生風險及旋轉中心下移程度均更高。

文獻出處：Moses MJ, Novikov D, Luthringer T, Poultsides L, Vigdorchik JM. Clinical Outcomes of Total Hip Arthroplasty in Patients with Prior Periacetabular Osteotomy. Bull Hosp Jt Dis (2013). 2022 Dec;80(4):216-220. PMID: 36403948.

文獻3

全膝關節置換術前低認知功能和軀體心理癥狀與術后譫妄高風險相關

譯者 張薔

背景：譫妄（POD）是接受全膝關節置換（TKA）的高齡患者術后一項嚴重的并發癥，它可能導致住院時間延長，病死率增加和醫療開銷增加等問題。盡管認知障礙是一項已知的導致術后譫妄的危險因素，TKA患者術前的綜合認知和心理評估依然被顯著低估。本研究的目標是評估TKA患者術前認知功能和心理狀態評估與術后譫妄的關系。

方法：本前瞻性隊列研究選擇了1-2家地區性醫療中心所有60歲及以上接受初次TKA手術的574名患者。我們選擇評估術前認知功能的工具包括簡易精神狀態檢查（MMSE）、建立阿爾茨海默病登記聯盟（CERAD）、主觀記憶抱怨問卷（SMCQ）和首爾癡呆知情人報告問卷（SIRQD）。用于心理評估的工具包括匹茲堡睡眠質量指數（PSQI）、患者健康問卷-15項 （PHQ-15）和醫院焦慮抑郁量表（HADS）。我們在術后1-5天應用4A試驗（4AT）和混淆評估法（CAM）評價患者的POD情況。最后，我們應用多因素邏輯回歸分析法來確認術后譫妄的獨立危險因素。

結果：共有24例（4.2%）病例出現了術后譫妄。多元分析顯示術后譫妄與低MMSE評分（p < 0.001）、高PHQ-15評分（p = 0.014）、高PSQI評分（p = 0.014）、高Charlson合并癥指數（p = 0.010）、術前應用鎮靜劑（p = 0.044）和抗抑郁藥（p = 0.027）以及患者所在病房的平均噪音水平（p = 0.002）呈強相關性。在受試者工作特征曲線分析中，我們得出預測術后譫妄的MMSE最佳閾值為≤25分，敏感度為74.5%而特異度為78.3%（曲線下面積，0.834；p = 0.001）。多因素邏輯回歸分析顯示低MMSE評分（概率比[OR], 0.771; p = 0.002）和高PHQ-15評分（OR, 1.187; p = 0.028）是術后譫妄的獨立預測指標。

結論：本研究全面的評估了TKA手術患者術前認知功能和心理狀態。我們發現亞臨床認知障礙和軀體癥狀也與術后譫妄相關，突顯出對高風險患者施行術前評估鑒別的重要性。

Low?Cognitive?Function?and?Somatic Psychological?Symptoms?Are?Correlated?with Greater?Risk?of?Delirium?After?Total?Knee Arthroplasty

Background: Postoperative delirium (POD) is a clinically important complication in elderly patients undergoing total knee arthroplasty (TKA) that is associated with prolonged hospitalization, increased morbidity, and higher health-care costs. Although cognitive impairment is a known risk factor for POD, the role of comprehensive cognitive and psychological evaluation remains underexplored in patients undergoing TKA. This study aimed to evaluate the correlation of preoperative cognitive and psychological factors with POD after TKA.

Methods: This prospective cohort study included 574 patients who were ≥60 years of age and underwent primary TKA at 1 of 2 major tertiary care hospitals. We assessed preoperative cognitive function using the Mini-Mental State Examination (MMSE), the full Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) battery, the Subjective Memory Complaints Questionnaire (SMCQ), and the Seoul Informant Report Questionnaire for Dementia (SIRQD). Psychological assessments were conducted with the Pittsburgh Sleep Quality Index (PSQI), the Patient Health Questionnaire-15 (PHQ-15), and the Hospital Anxiety and Depression Scale (HADS). POD was evaluated daily from postoperative days 1 to 5 using the 4 A’s Test (4AT) and the Confusion Assessment Method (CAM). A multivariable logistic regression analysis was performed to identify independent risk factors for POD.

Results: POD occurred in 24 (4.2%) of 574 patients. Univariate analysis revealed that POD was significantly correlated with lower MMSE (p < 0.001), higher PHQ-15 (p = 0.014), higher PSQI (p = 0.014), and higher Charlson Comorbidity Index (p = 0.010) scores; preoperative use of sedatives (p = 0.044) and antidepressants (p = 0.027); and lower mean noise levels in the patient’s hospital room (p = 0.002). In the receiver operating characteristic curve analysis, the optimal cutoff value for predicting POD was an MMSE score of ≤25, with a sensitivity of 74.5% and a specificity of 78.3% (area under the curve, 0.834; p = 0.001). Multivariable logistic regression analysis identified lower MMSE scores (odds ratio [OR], 0.771; p = 0.002) and higher PHQ-15 scores (OR, 1.187; p = 0.028) as significant independent predictors of POD.

Conclusions: This study comprehensively evaluated preoperative cognitive function and psychological symptoms in patients undergoing TKA. Even subclinical cognitive and somatic symptoms were linked to POD, emphasizing the need for preoperative identification of high-risk patients.

文獻4

機器人輔助全膝關節置換術（TKA）與患者滿意度增加無關

譯者 沈松坡

目的 全膝關節置換術（TKA）是一種常見的骨科手術，但術后約20%的病例仍存在不滿意。機器人全膝關節置換術（rTKA）有望提高精準性，但與傳統全膝關節置換術（cTKA）相比，其對患者滿意度的影響仍存在爭議。本系統評價旨在評估rTKA術后患者滿意度，并比較其與cTKA的結局。

方法 檢索并審閱以下數據庫中的文獻：PubMed、Scopus、Web of Science和Cochrane Online Library，使用的關鍵詞包括“Knee replacement”“Total knee arthroplasty”“Robotic”和“Patient satisfaction”。提取的數據包括患者滿意度測量、Knee Society Score、Oxford Knee Score、Forgotten Joint Score、SF-36、HSS和KOOS。采用R軟件進行統計分析，包括比值比及95%置信區間。采用Cochrane的Q檢驗評估異質性。

結果 本系統評價納入17篇文章，共涉及1148例患者（rTKA組571例，cTKA組577例），評估了rTKA后的患者滿意度。比例分析顯示，rTKA滿意率為95%，而cTKA為91%。比較rTKA與cTKA的Meta分析發現，患者滿意度方面無統計學顯著差異。此外，還評估了多種患者報告結局指標（PROMs），結果顯示在不同研究及不同隨訪時間點上結論不一。

結論 本研究結果發現，在短期至中期隨訪中，rTKA與傳統方法相比，在患者滿意度結局方面無差異。本研究并未斷言機器人輔助手術方式具有優越性，這提示在膝關節置換術中，應審慎考慮影響結局的多種因素。

文獻出處：Hoveidaei AH, Esmaeili S, Ghaseminejad-Raeini A, Pirahesh K, Fallahi MS, Sandiford NA, Citak M. Robotic assisted Total Knee Arthroplasty (TKA) is not associated with increased patient satisfaction: a systematic review and meta-analysis. Int Orthop. 2024 Jul;48(7):1771-1784. doi: 10.1007/s00264-024-06206-4. Epub 2024 May 6. PMID: 38705892.

第二部分：保髖相關文獻

文獻1

兒童和青少年股骨頸骨折后股骨頭壞死:危險因素分析

譯者 任寧濤

背景:兒童和青少年股骨頸骨折最嚴重的并發癥是股骨頭壞死。雖然許多因素都涉及到股骨頭壞死的發生和發展，但沒有確定具體的因果關系。本研究的主要目的是確定兒童和青少年股骨頸骨折后股骨頭壞死的發生率，并確定其發生的危險因素。

方法:本回顧性研究確定了2000年至2011年在一個一級兒童創傷中心治療的70例年齡在1.3 - 18.1歲的股骨頸骨折患者，隨訪至臨床和影像學愈合。通過病歷和影像學檢查記錄人口統計學信息、受傷細節、手術治療類型、合并損傷、受傷至治療時間和術后復位。主要統計結局是存在股骨頭壞死的，股骨頭壞死是通過復查現有影像學確定。多變量logistic回歸分析檢驗了年齡、治療時間、固定類型、損傷機制、術后復位和關節囊減壓是否是發生股骨頭壞死的可能危險因素。

結果:70例患者中有20例(29%)發生股骨頭壞死，診斷股骨頭壞死的中位時間為7.8個月。股骨頭壞死的多因素預測因素包括骨折移位(P=0.01)和骨折位置(P=0.02)。患者年齡、固定類型、損傷機制、關節囊減壓、術后復位和復位效果不能預測股骨頸骨折后股骨頭壞死的發生情況。最后，治療時間也被發現是股骨頭壞死的積極預測因素(P=0.004)，傷后24小時內治療的患者更有可能發生股骨頭壞死，但這一發現可能是由于混淆，因為損傷的嚴重程度與治療時間密切相關。

結論:無論采用何種治療方法，股骨頸骨折后股骨頭壞死的發生率仍然很高。識別預測股骨頭壞死發展的因素可以幫助外科醫生就這種并發癥的風險向患者和家屬提供適當的咨詢。

Osteonecrosis After Femoral Neck Fractures in Children and Adolescents Analysis of Risk Factors

Background: The most serious complication of femoral neck fractures in children and adolescents is osteonecrosis. Although a number of factors have been implicated in the development of osteonecrosis, no specific cause-and-effect relationship has been determined. The primary purpose of this study was to determine the prevalence of osteonecrosis in children and adolescents after femoral neck fractures and to identify risk factors for its development.

Methods: This retrospective review identified 70 patients between the ages of 1.3 and 18.1 years who were treated for a femoral neck fracture between 2000 and 2011 at a single level I pediatric trauma center and followed until clinical and radiographic union. Demographic information, injury event details, type of surgical treatment, associated injuries, time from injury to treatment, and postoperative alignment were recorded from chart and radiographic review. The primary outcome was the presence of osteonecrosis, which was determined by review of available imaging. Multivariable logistic regression analysis tested age, time to treatment, type of fixation, mechanism of injury, postoperative alignment, and capsular decompression as possible risk factors for the development of osteonecrosis.

Results: Osteonecrosis occurred in 20 (29%) of the 70 patients. The median time to diagnosis of osteonecrosis was 7.8 months. Multivariable predictors of osteonecrosis included fracture displacement (P=0.01) and fracture location (P=0.02). Patient age, type of fixation, mechanism of injury, capsular decompression, postoperative alignment, and performance of reduction were not predictive of osteonecrosis after femoral neck fracture. Finally, time to treatment also was found to be a positive predictor of osteonecrosis (P=0.004), with osteonecrosis more likely in patients treated in less than 24 hours, but this finding is likely due to confounding because injury severity was closely linked to time to treatment.

Conclusions: Regardless of the treatment, the prevalence of osteonecrosis after femoral neck fractures remains high. Recognizing factors that are predictive of the development of osteonecrosis can help surgeons counsel patients and families appropriately about the risk of this complication.

文獻出處：Spence D, DiMauro JP, Miller PE, Glotzbecker MP, Hedequist DJ, Shore BJ. Osteonecrosis After Femoral Neck Fractures in Children and Adolescents: Analysis of Risk Factors. J Pediatr Orthop. 2016 Mar;36(2):111-6. doi: 10.1097/BPO.0000000000000424. PMID: 25730381.

文獻2

青少年群體髖臼周圍截骨術后坐骨-恥骨結合部骨折

譯者 李勇

引言： Ganz 髖臼周圍截骨術（PAO）是一種廣泛接受的髖關節發育不良手術干預方式。在青少年人群中，該手術適用于骨骼已成熟且伴有髖臼發育不良相關癥狀的患者。PAO 術后半骨盆應力重新分布可能導致坐骨-恥骨結合部（IPJ）發生骨折。

方法： 本研究為一項經倫理委員會批準的回顧性分析，納入 1999 年至 2012 年在一家醫療機構接受 PAO 治療髖臼發育不良的青少年患者。進行影像學測量，包括外側中心邊緣角、Sharp 髖臼指數和負重區髖臼指數。這些指標在術前、術后 6 周和術后 1 年通過站立位骨盆前后位 X 線片進行測量。同時分析術后改良 Harris 髖關節評分（mHHS）。排除手術時年齡超過 21 歲及隨訪不足 2 年的患者。

結果： 共納入 166 例患者（187 例手術髖），平均年齡為 15.6 ± 2.5 歲。12 例患者（6.4%）出現 IPJ 應力性骨折。其中 7 例在術后初次影像學檢查中發現，5 例在術后 6 周復查后發現。7 例（58.3%）應力性骨折伴有上后支骨不連。6 例（50%）在術后 2 年內愈合，其余 6 例（50%）發展為骨不連。與無應力性骨折的患者相比，兩組在術前、術后 6 周及末次隨訪時的中心邊緣角（P = 0.94、0.29、0.27）、Sharp 髖臼指數（P = 0.95、0.38、0.16）及負重區髖臼指數（P = 0.37、0.21、0.54）方面均無顯著差異。術后平均改良 Harris 髖關節評分亦無顯著差異（P = 0.63）。易感因素分析顯示，患有腓骨肌萎縮癥（CMT）的患者更易發生 IPJ 骨折（P = 0.001）。發生 IPJ 骨折的患者年齡更大（17.1 歲 vs. 15.5 歲，P = 0.05）。不同性別之間無顯著差異（P = 0.22）。

討論與結論： 青少年人群 PAO 術后 IPJ 骨折的發生率為 6.4%，部分骨折發生在手術過程中。這些骨折還與上后支截骨處骨不連及腓骨肌萎縮癥基礎診斷相關。此類骨折在臨床上無顯著影響，在本研究系列中，發現后均未需進一步干預。

Fracture at the Ischio-Pubic Junction After Periacetabular Osteotomy in the Adolescent Population

Introduction: The Ganz periacetabular osteotomy (PAO) is a well-accepted surgical intervention for hip dysplasia. In the adolescent population it is performed in patients who are skeletally mature with symptoms related to acetabular dysplasia. Redistribution of stresses through the hemipelvis after PAO can lead to a fracture at the ischio-pubic junction (IPJ).

Methods: This is an IRB-approved, retrospective analysis of adolescent patients treated with a PAO for acetabular dysplasia from 1999 to 2012 at a single institution. Radiographic measurements were performed to include the lateral center-edge angle, Sharp acetabular index, and acetabular index of the weight-bearing zone. These were measured preoperatively and at 6-weeks and 1 year postoperatively from a standing anterior posterior pelvis radiograph. Postoperative modified Harris hip scores (mHHS) were also analyzed. Patients over the age of 21 at time of surgery and those with <2 years of follow-up were excluded.

Results: One hundred sixty-six patients (187 operated hips) at an average age of 15.6 ± 2.5 were included. Twelve (6.4%) stress fractures at the IPJ were identified in 12 patients. Seven were identified on the initial postoperative films, whereas 5 were identified after the 6-week visit. Seven (58.3%) stress fractures had an associated superior posterior ramus nonunion. Six (50%) healed by 2 years after surgery; the remaining 6 (50%) went on to non-union. Compared with those without a stress fracture, there was no significant difference in preoperative, 6 weeks postoperative, and final center-edge angle (P = 0.94, 0.29, 0.27), Sharp acetabular index (P = 0.95, 0.38, 0.16), or AIBWZ (P = 0.37, 0.21, 0.54). There was no difference in postoperative mean modified Harris hip scores (P = 0.63). Analysis of predisposing factors demonstrated that patients with Charcot-Marie-Tooth (CMT) disease were more likely to develop an IPJ fracture (P = 0.001). Patients with an IPJ fracture were older (17.1 vs. 15.5, P = 0.05). There was no difference based on patient sex (P = 0.22).

Discussion and Conclusions: The incidence of fracture at the IPJ after PAO in the adolescent population is 6.4% with some occurring at the time of surgery. These fractures are also associated with a nonunion at the superior posterior ramus cut and an underlying diagnosis of Charcot-Marie-Tooth. These fractures are not clinically significant and in this series did not merit further intervention when identified.

文獻出處： Swann M, Sucato DJ, Romero J, Podeszwa DA. Fracture at the Ischio-Pubic Junction After Periacetabular Osteotomy in the Adolescent Population. J Pediatr Orthop. 2017 Mar;37(2):127-132. doi: 10.1097/BPO.0000000000000742. PMID: 27137904.

文獻3

股神經和坐骨神經在髖臼周圍不同位置的CT研究

譯者 陶可

背景：股神經和坐骨神經在髖臼周圍截骨術的各個階段都可能受到損傷。改變髖關節位置可能是預防神經損傷最有效的方法。本研究旨在探討健康成年人骨盆計算機掃描圖像中，不同髖關節位置下神經與各骨性標志點之間的距離。

材料與方法：納入15名健康成年男性（30個髖關節）（年齡30±6歲）。使用量角器測量髖關節在三個不同位置（中立位“N”、屈曲（30-45°）+外展（30-45°）+外旋（20°）“F”（體位）和中立位+外展（30-45°）+外旋（20°）（Nabext））（體位）進行掃描，掃描位置分別為：髖臼眉弓“1”、股骨頭中央“2”和Y型軟骨下緣“3”。

結果：在髖臼眉弓水平，與屈曲位或中立位+外展+外旋位相比，中立位時股神經與髖臼前緣的距離最遠（p < 0.001）。對于坐骨神經，在股骨頭中央水平2，髖關節屈曲時坐骨神經與髖臼前緣的距離大于中立位（p = 0.001）。在Y型軟骨下緣水平3，與中立位（N 或 Nabex 位）相比，髖關節屈曲導致坐骨神經與髖臼前緣的距離減小（p = 0.001）。

結論：在恥骨截骨術中，股神經在髖關節屈曲或外展加外旋時更靠近髖臼前壁。在坐骨截骨術中，坐骨神經在髖關節屈曲時更靠近坐骨，而在髖臼向后截骨術中則遠離骨骼。

圖1. a中立位/仰臥位計算機斷層掃描圖像。b外展（30-45°）+外旋（20°）位計算機斷層掃描圖像。c外展（30-45°）+外旋（20°）+外展（30-45°）位計算機斷層掃描圖像。

圖2. 骨盆X線片測量平面示意圖。

圖3. 股神經和坐骨神經在1、2水平的測量示意圖。

圖4. 坐骨神經在3水平的測量示意圖。

A CT study of the femoral and sciatic nerve periacetabular moving in different hip positions

Background: Femoral and sciatic nerves could be damaged during various stages of the periacetabular osteotomy. Changing the position of the hip could be the most effective way of preventing nerve injuries. The purpose of the present study was to investigate the distances of the nerves to various bony landmarks with different hip positions in computerized pelvic scanograms of healthy adults.

Materials and methods: Fifteen healthy male adults (30 hips) (age 30 ± 6) were included. Scans were performed at three different hip positions measured by goniometer (neutral "N," flexion (30-45°) + abduction (30-45°) + external rotation (20°) "F" and neutral+ abduction (30-45°) + external rotation (20°) (Nabext) at three different levels (sourcil "1," the middle of the femoral head "2," and lower border of triradiate cartilage "3."

Results: At the sourcil level, the femoral nerve was found to be the furthest distance from the anterior acetabulum in the neutral position compared to flexion or neutral plus abduction, external rotation (p < 0.001). For the sciatic nerve, at level 2, hip flexion resulted in a greater distance than in the neutral position (p = 0.001). For level 3, hip flexion caused a decrease in the distance of the sciatic nerve to the acetabulum compared to both neutral positions (N or Nabex) (p = 0.001).

Conclusions: During a pubic cut of the osteotomy, the femoral nerve moves closer to the anterior acetabulum wall with hip flexion or abduction plus external rotation. During an ischial cut, the sciatic nerve gets closer to the ischium with hip flexion while it moves away from the bone during retroacetabular cut. Level-III Study.

文獻出處：Yagmur Isin, Onur Hapa, Yavuz Selim Kara, Ali Ihsan Kilic, Ali Balc?. A CT study of the femoral and sciatic nerve periacetabular moving in different hip positions. J Orthop Surg Res. 2020 Sep 11;15(1):404. doi: 10.1186/s13018-020-01937-7.

文獻4

基于德爾菲法的股骨頭壞死塌陷預后模型：一種多因素分析方法

譯者 邱興

股骨頭壞死（ONFH） 是一種呈進行性發展且可導致功能嚴重受損的疾病，其特征為血供不足引發的骨組織壞死。盡管診斷影像學與治療策略不斷取得進展，預測股骨頭塌陷風險仍然是臨床上面臨的一項重大挑戰。本研究旨在通過整合臨床、影像學及實驗室數據，構建一個穩健的預后模型，從而彌補這一不足，以提升早期診斷水平并指導治療決策。

方法
本研究采用定性系統評價，并結合德爾菲法，從臨床資料、影像學表現及實驗室指標中篩選關鍵預后因素。研究納入2014年1月至2021年12月期間接受治療的股骨頭壞死患者。通過單因素與多因素Cox回歸分析，構建了預測股骨頭塌陷風險的列線圖。模型效能通過一致性指數（C-index）、校準曲線及決策曲線分析（DCA）進行評價。

結果
研究共納入297例患者（454髖）。確定的關鍵預后因素包括：存在疼痛（p < 0.001，RR = 0.185，95%置信區間：0.11–0.31）、JIC分型（C1型：p < 0.001，RR = 0.096，95%置信區間：0.054–0.171；C2型：p < 0.001，RR = 0.323，95%置信區間：0.215–0.487）、壞死面積（3 < MNAI < 6：p < 0.001，RR = 0.107，95%置信區間：0.061–0.190；MNAI ≥ 6：p < 0.001，RR = 0.466，95%置信區間：0.314–0.692）、承重減輕狀態（p < 0.001，RR = 0.466，95%置信區間：0.323–0.672）、前外側柱保留（p < 0.001，RR = 0.223，95%置信區間：0.223–0.473）以及CT顯示軟骨下骨折（p < 0.001，RR = 0.32，95%置信區間：0.217–0.472）。所構建的列線圖顯示出較高的一致性指數（0.88），表明其具有卓越的預測準確性。校準曲線顯示預測結果與實際觀測結果具有良好的一致性，決策曲線分析則驗證了該模型的臨床實用性。

結論
本研究構建的預后模型為預測股骨頭壞死患者股骨頭塌陷風險提供了可靠的工具。該模型有助于早期識別高危患者，進而指導個體化治療策略的制定，以改善患者預后，并減少侵入性手術干預的需求。

A delphi-based model for prognosis of femoral head collapse in osteonecrosis: a multi-factorial approach

Background: Osteonecrosis of the femoral head (ONFH) is a progressive and debilitating condition characterized by the death of bone tissue due to inadequate blood supply. Despite advances in diagnostic imaging and treatment strategies, predicting the risk of femoral head collapse remains a significant clinical challenge. This study seeks to address this gap by developing a robust prognostic model that integrates clinical, imaging, and laboratory data to improve early diagnosis and guide therapeutic decision-making.

Methods: We conducted a qualitative systematic review and employed the Delphi method to select key prognostic factors from clinical data, imaging findings, and laboratory indicators. The study included ONFH patients treated from January 2014 to December 2021. We used univariate and multivariate Cox regression analyses to develop a nomogram for predicting the risk of femoral head collapse. The model's performance was evaluated using the concordance index (C-index), calibration plots, and decision curve analysis (DCA).

Results: The study included 297 patients (454 hips) with ONFH. Key prognostic factors identified included pain presence (p < 0.001, RR = 0.185, 95% CI: 0.11-0.31), JIC classification (C1: p < 0.001, RR = 0.096, 95% CI: 0.054-0.171; C2: p < 0.001, RR = 0.323, 95% CI: 0.215-0.487), necrotic area (3 < MNAI < 6: p < 0.001, RR = 0.107, 95% CI: 0.061-0.190; MNAI ≥ 6: p < 0.001, RR = 0.466, 95% CI: 0.314-0.692), weight-bearing reduction (p < 0.001, RR = 0.466, 95% CI: 0.323-0.672), preservation of the anterolateral pillar (p < 0.001, RR = 0.223, 95% CI: 0.223-0.473), and subchondral bone fracture on CT (p < 0.001, RR = 0.32, 95% CI: 0.217-0.472). The nomogram demonstrated a high C-index of 0.88, indicating excellent predictive accuracy. Calibration plots showed good agreement between predicted and observed outcomes, and DCA confirmed the model's clinical utility.

Conclusions: The prognostic model developed in this study provides a reliable tool for predicting femoral head collapse in ONFH patients. It allows for early identification of high-risk patients, guiding personalized treatment strategies to improve patient outcomes and reduce the need for invasive surgical procedures.

文獻出處：Yang TJ, Sun SY, Zhang L, Zhang XP, He HJ. A delphi-based model for prognosis of femoral head collapse in osteonecrosis: a multi-factorial approach. Journal of Orthopaedic Surgery & Research. 2024;19(1).

來源：304關節學術

作者：304關節團隊

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