陶可医生的科普号

PAO截骨术后1双脚踝泵训练2股四头肌锻炼-平卧位3股四头肌锻炼-坐位4蚌式运动5侧卧位-侧抬大腿6侧卧位-侧抬大腿-2,加强锻炼（5公斤弹力带）7大腿绷紧后方抬起锻炼8单腿后伸9单腿后伸-加强锻炼（5公斤弹力带）10单屈髋-双屈髋11仰卧位-足踝部滚动锻炼12非负重蹲起锻炼13站立位,大腿伸直向侧方抬起锻炼（外展肌群：臀中肌、臀小肌、阔筋膜张肌）14大腿侧后伸直抬起锻炼（后伸肌群：臀大肌）15双下肢前后交叉锻炼（内收肌群：长收肌、大收肌、耻骨肌等）16核心肌群训练模块-1：靠墙蹲起锻炼16核心肌群训练模块-2：靠墙蹲起锻炼17核心肌群训练模块-1——太极式蹲起锻炼18改良平板支撑训练19核心肌群训练模块-3——站立伸腿、屈髋屈膝20核心肌群训练模块-4——弓步箭步蹲式训练

2018年美国华盛顿大学：分类简述：股骨头骨折的Pipkin分类译者：陶可（北京大学人民医院骨关节科） 文献出处：Nicholas M Romeo, Reza Firoozabadi. Classifications in Brief: The Pipkin Classification of Femoral Head Fractures. Clin Orthop Relat Res. 2018 May;476(5):1114-1119. doi: 10.1007/s11999.0000000000000045.Review. Classifications in Brief: The Pipkin Classification of Femoral Head Fractures. HistoryBirkett was the first to discover and document femoral head fractures in 1869 while performing a postmortem dissection [1]. These high-energy injuries are infrequent and occur in conjunction with 5% to 15% of all posterior hip dislocations [3, 5, 11]. Femoral head fractures pose a management challenge; these can be technically difficult to address.In 1954 Stewart and Milford described four grades of dislocations of the hip; dislocations with a fracture of the head or neck of the proximal femur were classified as Grade IV [14]. In 1957, Garrett Pipkin, an orthopaedic surgeon from Kansas City, Missouri, further subclassified Stewart and Milford Grade IV injuries. This classification system of femoral head fractures came to be known as the Pipkin classification system [10]. Pipkin developed this classification system based on his observations of 24 patients (25 fractures). Twenty-two of the 25 fractures were attributable to motor vehicle collisions[10].历史Birkett 是 1869 年第一个在进行尸检时发现和记录股骨头骨折的人 [1]。这些高能量损伤并不常见，并且在所有髋关节后脱位中占 5% 至 15% [3, 5, 11]。股骨头骨折带来治疗挑战；且在技术上很难解决。1954 年，Stewart 和 Milford 描述了四级髋关节脱位；伴有股骨近端头部或颈部骨折的脱位被归类为 IV 级 [14]。 1957 年，来自密苏里州堪萨斯城的矫形外科医生加勒特·皮普金 (Garrett Pipkin) 进一步细分了Stewart和Milford的 IV 级损伤。这种股骨头骨折分类系统后来被称为 Pipkin 分类系统 [10]。Pipkin 根据他对 24 名患者（25 处骨折）的观察结果开发了这个分类系统。25 处骨折中有 22 处归因于机动车碰撞[10]。PurposeAs noted above, the rationale for development of Pipkin’s classification system was to subclassify Grade IV fracture-dislocations of the hip as classified by Stewart and Milford [14].Pipkin was hopeful that his classification system would shine further light on Grade IV injuries, as there had been little published regarding the outcomes and sequelae of these injuries. Highlighted sequelae include posttraumatic arthritis, osteonecrosis, heterotopic ossification, and sciatic nerve injury. Additionally, although not the primary purpose, he was able to provide a management scheme for these injuries with the use of his classification.目的如上所述，Pipkin 分类系统发展的基本原理是将 Stewart 和 Milford [14] 分类的髋关节 IV 级骨折脱位进行细分。Pipkin希望他的分类系统能够进一步阐明 IV 级损伤，因为关于这些损伤的结果和后遗症的报道很少。突出的后遗症包括创伤后关节炎、骨坏死、异位骨化和坐骨神经损伤。此外，虽然不是主要目的，但他能够使用他的分类为这些伤害提供治疗方案。DescriptionPipkin classified these injuries as one of four types [10]: Type 1 is defined as a hip dislocation with a femoral head fracture caudad to the fovea capitis femoris (Fig. 1); Type 2 is defined as a hip dislocation with a femoral head fracture cephalad to the fovea capitis femoris (Fig. 2); Type 3 fractures are a Type I (Fig. 3) or Type II (Fig. 4) femoral head fracture with an associated femoral neck fracture; and Type 4 fractures are defined as a Type 1 or 2 with an associated acetabular rim fracture (Fig. 5).Pipkin’s basis for using the fovea capitis as a division between Types 1 and 2 fractures is that the ligamentum teres remains attached to the inferior fragment in a Type 2 injury, often resulting in substantial rotation of this fragment. The rotated caudal segment of the femoral head with the ligamentum attached could prevent a concentric reduction of the cranial head segment. Furthermore, he theorized that rotation of the caudal segment with the ligamentum attached is difficult to correct by closed means, providing a basis to consider open reduction and internal fixation for patientswith Type 2 injuries and who are fit for surgery; by contrast, Type 1 fractures may be successfully treated more frequently by closed means alone. Outcomes were reported in relation to the Thompson and Epstein criteria [15], which uses a combination of radiographic and clinical information to provide an outcome of poor to excellent. Pipkin stated that no patients in his series fulfilled criteria to be classified as having an ‘excellent’ outcome as all patients had some degree of radiographic degenerative changes.Pipkin preferred closed treatment for these injuries, as the patients in his series who received closed treatment had better outcomes that those who underwent open reduction. He attributed inferior outcomes in those who required surgical treatment to a combination of repeated attempts at closed reduction, delay in treatment, and the trauma of surgery. Pipkin reported that surgery was indicated when reduction of the dislocation and/or fracture was not achievable by closed measure, if an obstructive fragment was present, or if there was comminution of the fracture fragment [10].For Types 1 and 2 injuries and the femoral head component of Type 4 injuries, he recommended attempting closed reduction as the primarymeans of management. Additionally, he recommended that the acetabular rim component of Type 4 injuries be managed with reduction and fixation. For Type 3 injuries, Pipkin stated that closed management may be possible, but that open treatment of at least the neck fracture component is more practical owing to the substantial forces that would prevent closed reduction of the head and neck components in combination with dislocation[10].描述Pipkin 将这些损伤归类为四种类型之一 [10]： I 型定义为髋关节脱位，股骨头骨折限于股骨头中央凹（以下）（图 1）； II 型定义为髋关节脱位，股骨头骨折位于股骨头中央凹（以近部分）（图 2）； III 型骨折是 I 型（图 3）或 II 型（图 4）股骨头骨折并伴有相关的股骨颈骨折； IV 型骨折定义为 I 型或 II 型伴有髋臼缘骨折（图 5）。Pipkin 使用股骨头中央凹作为 I 型和 II 型骨折划分的基础是，圆韧带在 II 型损伤中仍然附着在下部骨折块上，通常会导致该骨折块大量旋转。附有韧带的股骨头的旋转以下部分可以防止股骨头部分的同心复位。此外，他提出的理论认为，附有韧带的以下部分旋转难以通过闭合方式矫正，为适合手术的II型损伤患者考虑切开复位内固定提供了依据；相比之下，仅通过闭合方式可能更频繁地成功治疗 I 型骨折。结果是根据 Thompson 和 Epstein 标准 [15] 报告的，该标准结合使用放射学和临床信息来提供差到优的结果。 Pipkin 表示，他的系列中没有患者符合被归类为“优秀”结果的标准，因为所有患者都有一定程度的放射学退行性变化。Pipkin 更喜欢对这些损伤进行封闭治疗，因为在他的系列中接受封闭治疗的患者比接受切开复位的患者有更好的结果。他将需要手术治疗的患者的较差结果归因于反复尝试闭合复位、治疗延迟和手术创伤。 Pipkin 报告说，当通过闭合措施无法复位脱位和/或骨折、存在阻塞性碎片或骨折碎片粉碎时，需要进行手术 [10]。对于 I型和 II 型损伤以及 IV 型损伤的股骨头部分，他建议尝试将闭合复位作为主要治疗手段。此外，他建议通过复位和固定来管理 4 型损伤的髋臼边缘部分。对于 III 型损伤，Pipkin 表示封闭式治疗可能是可能的，但至少对颈部骨折部分的开放治疗更实用，因为大量的力量会阻止头颈部组件的闭合复位与脱位[10] ]。ValidationThe Pipkin classification is relatively simple from a radiographic standpoint, but to our knowledge, no studies have reported on the interobserver and intraobserver reliability of his classification system. This likely is because the majority of the available studies regarding femoral head fractures are limited to small series owing to the infrequency of this injury.However, several studies have evaluated prognosis after surgical and nonsurgical treatment of patients whose fractures were graded using the Pipkin classification. In general, they show better results with Pipkin Types 1 and 2 fractures than with Pipkin Types 3 or 4 fractures, which provides some face validity to the classification scheme. However, results are somewhat mixed.Marchetti et al. [7] found that patients with Pipkin Types 1 and 2 fractures had better outcome scores on the Thompson and Epstein scale [15] after a mean followup of 49 months than did patients with Types 3 or 4 fractures (76% versus 56% good results, respectively).In a study with a mean followup of nearly 7 years, 76% of the patients who sustained Pipkin Types 1, 2, and 4 fractures had excellent or good clinical outcomes when evaluated according to Thompson and Epstein scale [15]. Patients with Pipkin Types 1 and 2 fractures did better clinically than those with Type 4 fractures [9,15]. There were no patients with Type 3 fractures in the series of Oransky et al. [9], thus limiting the study’s evaluation of the Pipkin system in relation to outcomes.A systematic review of 155 patients with femoral head fractures in 11 studies found no statistical difference in outcomes among Pipkin types when using Thompson and Epstein criteria alone. [4].In contrast to the above outcomes using the Thomas and Epstein scale, Stannard et al. [13] evaluated outcomes using the Short Form Heath Survey-12 (SF-12). They found that the physical component scores were lower in patients with Pipkin Type 2 fractures compared with those with Type 1 or Type 4 fractures.验证从放射学的角度来看，Pipkin 分类相对简单，但据我们所知，没有研究报告他的分类系统的观察者间和观察者内的可靠性。这可能是因为大多数关于股骨头骨折的现有研究仅限于小系列，因为这种损伤不常见。然而，一些研究评估了使用 Pipkin 分类对骨折进行分级的患者在手术和非手术治疗后的预后。总的来说，它们对 Pipkin I 型和 II 型骨折的结果比对Pipkin III 型或 IV 型骨折的结果更好，这为分类方案提供了一些表面有效性。然而，结果有些好坏参半。Marchetti等[7] 发现 Pipkin I 型和 II 型骨折患者在平均随访 49 个月后的 Thompson 和 Epstein 量表 [15] 上的结果得分高于Pipkin III 型或 IV 型骨折患者（分别为76% 对 56% 的良好结果）。在一项平均随访近 7 年的研究中，根据 Thompson 和 Epstein 量表 [15] 评估时，76% 的 Pipkin I、II 和IV型骨折具有优异或良好的临床结果。 Pipkin I 型和 II型骨折患者的临床表现优于 IV型骨折患者 [9,15]。 Oransky 等人的系列研究中无 III 型骨折患者。 [9]，从而限制了该研究对 Pipkin 系统与结果相关的评估。对 11 项研究中的 155 名股骨头骨折患者的系统评价发现，单独使用 Thompson 和 Epstein 标准时，Pipkin 类型之间的结果没有统计学差异[4]。与使用 Thomas 和 Epstein 量表的上述结果相反，Stannard 等人[13] 使用 Short Form Heath Survey-12 (SF-12) 评估结果。他们发现，与 I型或 IV 型骨折患者相比，Pipkin II 型骨折患者的体检成分评分较低。LimitationsThe primary limitation of the Pipkin classification is the lack of interobserver and intraobserver validation. To our knowledge, this validation has yet to be performed. Without this validation the classification is very limited to serve as a trustworthy classification system. This lack of validation may be attributable to the infrequency of these injuries, with data limited to small series.In our opinion, the Pipkin classification system does not serve as a sufficient guide for surgical treatment of femoral head fractures. Several factors not included in this classification system must be considered when determining surgical treatment. These factors include the ability to obtain and maintain a concentric reduction, size of the femoral head fracture, displacement of the femoral head fracture, and the characteristics of the associated acetabular fracture in Type 4 injuries.A systematic review of femoral head fractures found that Pipkin Type 1 fractures were the most likely treated nonoperatively, with 21.1% of these fractures undergoing nonoperative treatment, consistent with Pipkin’s belief that Type 1 fractures are able to be treated more frequently by closed means [4]. Additionally, Type 3 fractures were found to be the mostfrequent type to be treated with arthroplasty, with 38.9% of these injuries treated in this manner [4]. Although Types 2 and 3 injuries are more likely to be treated with open reduction and internal fixation or arthroplasty, there is variability in the management of Types 1 and 4 fractures [4], with the aforementioned factors playing a role in decision making.The sequelae of these injuries, including posttraumatic arthritis, osteonecrosis, heterotopic ossification, and sciatic nerve injury have been reported in several series [4, 7, 12]. However, no correlation has been shown betweenPipkin type and risk of development of these sequelae [4, 7, 12]. As mentioned by Letournel and Judet [6], the magnitude of force required to cause fracture of the acetabulum can cause a substantial degree of injury to the femoral head cartilage and to vascularity of the femoral head. This degree of injury is difficult to appreciate radiographically alone. Thus this lends to why the development of posttraumatic arthritis and osteonecrosis of the femoral head are difficult to predict based on the Pipkin classification system alone.Alternative classification systems for femoral head fractures have since been developed, including those described by Brumback et al. [2], Yoon et al. [16], and the AO/OTA classification system as reported by Marsh et al. [8]. The classification system of Brumback et al. [2] is more comprehensive than the Pipkin classification system, taking into account the direction of dislocation and joint stability (Table 1). This system appears to provide prognostic value, with patients sustaining Type 3B and Type 5 injuries faring the worst, and patients with Type 2B fractures having the best physical outcomes [13]. As the Brumback system highlights the importance of joint instability, direction of dislocation, and acetabular fracture severity in the prediction of a poorer outcome [2], some consider that it may be a more-accurate classification system [4]. However, until intraobserver and interobserver reliability of the Brumback classification are validated in a robust way, we recommend readers use it only with caution.Yoon et al. [16] developed a modification of Pipkin’s classification system to help guide treatment. A Type I fracture is a small fracture of the femoral head distal to the fovea centralis, too small or too fragmented to be fixed with screws. Type II is a larger fracture of the head distal to the fovea centralis. Type III is a large fracture of the head proximal to the fovea centralis, and Type IV is a comminuted fracture of the head. They concluded that Type I fractures were best treated with fragment excision, Types II and III by reduction and fixation, and Type IV by arthroplasty, specifically hemiarthroplasty [16]. However, their classification system is limited as it is subjective and also has not been validated; therefore we recommend readers use this system only with caution.局限性Pipkin 分类的主要限制是缺乏观察者间和观察者内的验证。据我们所知，此验证尚未执行。如果没有这种验证，分类非常仅限于作为一个值得信赖的分类系统。这种缺乏验证可能是由于这些伤害发生频率低，数据仅限于小系列病例。我们认为，Pipkin 分类系统不能作为股骨头骨折手术治疗的充分指南。在确定手术治疗时，必须考虑未包含在该分类系统中的几个因素。这些因素包括获得和保持同心复位的能力、股骨头骨折的大小、股骨头骨折的位移以及 IV 型损伤中相关髋臼骨折的特征。对股骨头骨折的系统评价发现，Pipkin I 型骨折最有可能采用非手术治疗，其中 21.1% 的骨折接受了非手术治疗，这与 Pipkin 认为 IV 型骨折可以通过闭合方式更频繁地治疗的观点一致 [4]。此外，发现 III 型骨折是最常见的关节置换术类型，其中 38.9% 的损伤以这种方式治疗 [4]。虽然II 型和 III 型损伤更可能采用切开复位内固定或关节置换术治疗，但 I 型和 IV 型骨折的治疗存在差异[4]，上述因素在决策中发挥作用。这些损伤的后遗症，包括创伤后关节炎、骨坏死、异位骨化和坐骨神经损伤，已在多个系列中报道过 [4, 7, 12]。然而，Pipkin 类型与发生这些后遗症的风险之间没有相关性 [4, 7, 12]。正如 Letournel 和 Judet [6] 所提到的，导致髋臼骨折所需的力的大小会对股骨头软骨和股骨头的血管造成很大程度的损伤。这种程度的损伤很难单独从放射学上评估。因此，这解释了为什么仅基于 Pipkin 分类系统难以预测外伤后关节炎和股骨头坏死的发展。股骨头骨折的替代分类系统已经开发出来，包括 Brumback 等人描述的那些[2]，Yoon等人[16]，以及 Marsh 等人报告的 AO/OTA 分类系统[8]。Brumback 等人的分类系统[2]比Pipkin分类系统更全面，考虑了脱位方向和关节稳定性（表1）。该系统似乎提供了预后价值，3B 型和 5 型损伤的患者表现最差，2B 型骨折患者的身体预后最好 [13]。由于 Brumback 系统强调了关节不稳定、脱位方向和髋臼骨折严重程度在预测较差结果方面的重要性 [2]，因此一些人认为它可能是一个更准确的分类系统 [4]。然而，在 Brumback 分类的观察者内和观察者间可靠性得到可靠验证之前，我们建议读者谨慎使用它。Yoon等人[16] 对Pipkin的分类系统进行了修改，以帮助指导治疗。 I 型骨折是股骨头中央凹远端的小骨折，太小或太碎而无法用螺钉固定。 II型是中央凹远端的较大头部骨折。 III型是中央凹近端的头部大骨折，IV型是头部粉碎性骨折。他们得出的结论是，I 型骨折最好采用碎片切除治疗，II 型和 III 型采用复位和固定，IV 型采用关节成形术，特别是半关节成形术 [16]。然而，他们的分类系统是有限的，因为它是主观的，也没有得到验证；因此我们建议读者谨慎使用该系统。ConclusionAlthough the Pipkin system is the most-frequently used system for classification of femoral head fractures [4], it is not comprehensive; it does not take into account the degree of comminution of the fractured fragments or the size of the head fracture, size of the acetabular fracture, or joint stability in Type 4 injuries. Thus this classification system is lacking in its abilities to serve as a guide for operative intervention. However, mid- and long-term studies that have evaluated the prognosis of patients with femoral head fractures found that Pipkin’s classification is prognostically useful, in that patients with Types 1 and 2 fractures have better outcomes, as defined by Thompson and Epstein [15], than patients with Types 3 and 4 fractures [4, 7]. Finally, as the interobserver and intraobserver reliability of the Pipkin classification are unknown, it is substantially limited in its abilities as a reliable classification system.AcknowledgementsWe thank Jason Black, Web Media Specialist (Department of Orthopaedics and Sports Medicine, University of Washington) for creation of the figures contained in this article.结论虽然Pipkin系统是最常用的股骨头骨折分类系统[4]，但它并不全面；它没有考虑骨折碎片的粉碎程度或头部骨折的大小、髋臼骨折的大小或 4 型损伤中的关节稳定性。因此，该分类系统缺乏作为手术干预指南的能力。然而，评估股骨头骨折患者预后的中长期研究发现，Pipkin 分类对预后有用，因为 Thompson 和 Epstein 定义的 1 型和 2 型骨折患者具有更好的预后[15] , 而不是 3 型和 4 型骨折患者 [4, 7]。最后，由于 Pipkin 分类的观察者间和观察者内可靠性未知，因此它作为可靠分类系统的能力受到很大限制。致谢我们感谢网络媒体专家 Jason Black（华盛顿大学骨科和运动医学系）创建了本文中的数字。References1. Birkett J. Description of a dislocation of the head of the femur, complicated with its fracture; with remarks by John Birkett (1815–1904). 1869. Clin Orthop Relat Res. 2000;377:4–6.2. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the femoral head. Proceedings of the Hip Society, 1986. St Louis, MO: CV Mosby; 1987:181–206.3. Epstein HC, Wiss DA, Cozen L Posterior fracture-dislocation of the hip with fractures of the femoral head. Clin Orthop Relat Res. 1985;201:9–17.4. Giannoudis PV, Kontakis G, Christoforakis Z, Akula M, Tosounidis T, Koutras C. Management, complications and clinical results of femoral head fractures. Injury. 2009;40:1245–1251.5. Hougaard K, Thomsen PB. Traumatic posterior fracture dislocation of the hip with fracture of the femoral head or neck, or both. J Bone Joint Surg Am.1988;70:233–239.6. Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Germany Berlin: Springer-Verlag; 1993.7. Marchetti ME, Steinberg GG, Coumas JM. Intermediate-term experience of Pipkin fracture-dislocations of the hip. J Orthop Trauma. 1996;10:455–461.8. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audige L. Fracture and dislocation classification compendium -2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21 (suppl):S1–133.9. Oransky M, Martinelli N, Sanzarello I, Papapietro N. Fractures of the femoral head: a long-term follow-up study. Musculoskelet Surg. 2012;96:95–99.10. Pipkin G. Treatment of grade IV fracture dislocation of the hip. J Bone Joint Surg Am. 1957;39:1027–1042. 11. Sahin V, Karakas ES, Aksu S, Atlihan D, Turk CY, Halici M. Traumatic dislocation and fracture-dislocation of the hip: a long-term follow-up study. J Trauma. 2003;54:520–529.12. Scolaro JA, Marecek G, Firoozabadi R, Krieg JC, Routt ML. Management and radiographic outcomes of femoral head fractures. J Orthop Traumatol. 2017 Feb 10. [Epub ahead of print] doi:10.1007/s10195-017-0445-z.13. Stannard JP, Harris HW, Volgas DA, Alonso JE. Functional outcome of patients with femoral head fractures associated with hip dislocations. Clin Orthop Relat Res. 2000; 377:44–56.14. Stewart MJ, Milford LW. Fracturedislocation of the hip: an end-result study. J Bone Joint Surg Am. 1954;36: 315–342.15. Thompson VP, Epstein HC. Traumatic dislocation of the hip: a survey of two hundred and four cases covering a period of twenty-one years. J Bone Joint Surg Am. 1951;33:746–778.16. Yoon TR, Rowe SM, Chung JY, Song EK, Jung ST, Anwar IB. Clinical and radiographic outcome of femoral head fractures: 30 patients followed for 3–10 years. Acta Orthop Scand 2001;72:348–353.Fig. 1 A Pipkin Type I fracture occurs caudal to the fovea capitis. (Published with permission from Jason Black, Web Media Specialist, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.)图 1 Pipkin I 型骨折发生在头中央凹的以下部分。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）Fig. 2 This illustration shows a Pipkin Type II fracture of the femoral head cephalad to the fovea capitis. (Published with permission from Jason Black, Web Media Specialist, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.)图 2 此图显示股骨头头端至股骨头中心凹的 Pipkin II 型骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）Fig. 3 A Pipkin Type III femoral head fracture inferior to the fovea centralis and femoral neck fracture is shown. (Published with permission from Jason Black, Web Media Specialist, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.)图 3 显示了位于中央凹下方的 Pipkin III 型股骨头骨折和股骨颈骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）Fig. 4 A Pipkin Type III femoral head fracture superior to the fovea centralis and femoral neck fracture is shown in this illustration. (Published with permission from Jason Black, Web Media Specialist, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.)图 4 如图所示Pipkin III 型股骨头骨折高于中央凹和股骨颈骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）Fig. 5 The illustration shows a Pipkin Type IV femoral head fracture in addition to an acetabular fracture. (Published with permission from Jason Black, Web Media Specialist, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA.图 5 图示显示了 Pipkin IV 型股骨头骨折和髋臼骨折。（经美国华盛顿州西雅图市华盛顿大学骨科和运动医学系网络媒体专家 Jason Black 许可发布。）Table 1. The Brumback classification system of hip dislocations and femoral head fractures表 1 髋关节脱位和股骨头骨折的 Brumback 分类系统

2014年意大利米兰大学与英国利兹大学：使用（骨）诱导小室技术和基于生物学方法治疗股骨头坏死：适应症和临床结果译者：陶可（北京大学人民医院骨关节科）摘要：目的：确定髓心减压（CD）技术联合重组骨形态发生蛋白、自体间充质干细胞（MSCs）和异体骨替代物进入股骨头坏死病灶对临床症状和股骨头坏死进展的疗效。患者和方法：对 38 名早期股骨头坏死患者（40 髋）进行了为期 4 年的研究。结果：CD 技术结合重组形态发生蛋白、自体 MSCs 和异体骨移植替代物与疼痛和关节症状的显着减少相关，并降低了骨折分期的发生率。在 36 个月时，33 名患者实现了临床和放射学愈合。结论：本长期随访研究证实，CD技术联合重组骨形态发生蛋白、自体MSCs和异体移植骨替代物可能是治疗早期股骨头坏死患者的有效方法。关键词：股骨头坏死AVN；自体植入；缺血性坏死；生物室；髓心减压；早期；股骨头；间充质干细胞；骨坏死；重组骨形态发生蛋白rhBMP。文献出处：G M Calori, E Mazza, M Colombo, S Mazzola, G V Mineo, P V Giannoudis. Treatment of AVN using the induction chamber technique and a biological-based approach: indications and clinical results. Injury. 2014 Feb;45(2):369-73.doi: 10.1016/j.injury.2013.09.014. Epub 2013 Sep 19.Treatment of AVN using the induction chamber technique and a biological-based approach: indications and clinical results.AbstractObjective: To determine the efficacy of core decompression (CD) technique combined with recombinant morphogenetic proteins, autologous mesenchymal stem cells (MSCs) and xenograft bone substitute into the necrotic lesion of the femoral head on clinical symptoms and on the progression of osteonecrosis of the femoral head.Patients and methods: A total of 38 patients (40 hips) with early stage osteonecrosis of the femoral head were studied over a 4-year period.Results: CD technique combined with recombinant morphogenetic proteins, autologous MSCs and xenograft bone substitute was associated with a significant reduction in both pain and joint symptoms and reduced the incidence of fractural stages. At 36 months, 33 patients achieved clinical and radiographic healing.Conclusion: This long-term follow-up study confirmed that CD technique combined with recombinant morphogenetic proteins, autologous MSCs and xenograft bone substitute may be an effective treatment for patients with early stage osteonecrosis of the femoral head.Keywords: AVN; Autologous implantation; Avascular necrosis; Biological chamber; Core decompression; Early stage; Femoral head; Mesenchymal stem cells; Osteonecrosis; rhBMP.Fig. 1. Two cases of AVN of the femoral head treated with our technique. (a–c) First patient, 33-year-old man. (a) MRI image showing the lesion; (b) MRI image of the femoral head 1 year after the procedure showing the implanted biotechnologies and the conserved shape of the femoral head; (c) CT scan after 3 years, good ossification of the subcondral bone, no trabecular collapse, shape of the femoral head still conserved. (d–f) second patient, 54-year-old woman. (d) MRI image showing the lesion; (e) X-ray at 2 years after the treatment, good integration of the biotechnologies implanted, no collapse; (f) CT scan after 3 years, no collapse, shape of the head conserved.图 1. 使用我们的技术治疗的两例股骨头 AVN。 (a-c) 第一位患者，33 岁男性。 (a) 显示病变的 MRI 图像； (b) 手术后 1 年的股骨头 MRI 图像，显示植入的生物技术和股骨头的保留形状； (c) 3年后CT扫描，软骨下骨骨化良好，无小梁塌陷，股骨头形态尚存。 (d-f) 第二位患者，54 岁女性。 (d) 显示病变的 MRI 图像； (e) 治疗后2年X线片，植入的生物技术整合良好，无塌陷； (f) 3年后CT扫描，无塌陷，股骨头形状保存。注：（骨）诱导小室技术Giorgio M Calori, Peter V Giannoudis. Enhancement of fracture healing with the diamond concept: the role of the biological chamber. Injury. 2011 Nov;42(11):1191-3.doi: 10.1016/j.injury.2011.04.016. Epub 2011 May 18.Fig. 1. Diamond concept and the biological chamber. V = vascularity, H = host, MS = mechanical stability, MSC = osteoprogenitor cells, S = scaffold, GF = growth factor. 1. Closed chamber; 2. Open chamber; 3. Partially closed chamber.图 1. 菱形概念和生物小室。 V = 血管分布，H = 宿主，MS = 机械稳定性，MSC = 骨祖细胞，S = 生物支架，GF = 生长因子。 1.密闭室； 2.开放室； 3. 部分封闭的腔室。

系统性红斑狼疮皮质类固醇（治疗）相关股骨头坏死的自体骨髓穿刺浓缩移植中期结果译者：陶可（北京大学人民医院骨关节科）摘要：目的：我们之前已经建立了浓缩自体骨髓穿刺移植（CABMAT），这是一种用于治疗股骨头坏死（ONFH）的一步式、微创、保留髋关节的手术技术。本研究旨在评估 CABMAT 作为保留髋关节手术方法的效果，防止系统性红斑狼疮 (SLE) 患者转为全髋关节置换术 (THA) 和股骨头塌陷。方法：自2003年以来，52例SLE患者（男8例，女44例，92髋，平均年龄35.3（16-77）（岁））接受CABMAT治疗，平均随访5.5（0.7-14）年。对THA的发生率及其预测因素进行了分析。结果：THA 的总体转化率为 29% (27/92)。在 A、B、C1 和 C2 型中，THA 的转化率分别为 0% (0/3)、0% (0/4)、22% (9/41) 和 41% (18/44)。在第 1、2、3A、3B 和4阶段，向 THA 的转化率分别为 26% (5/19)、26% (6/23)、28% (11/39)、44% (4/9) 和 50% (1/2)。在多元逻辑回归分析中，性别、体重指数（BMI）、术前ONFH类型和术前分期与转换为 THA 显著相关。结论：THA的转化率低于自然疗程髓心减压术，但高于其他骨髓移植和截骨术。由于性别、术前疾病类型和术前分期与转换为 THA 显著相关，因此推测女性、晚期（3A 期或以上）和晚期（C 型或以上）比例较高影响了这项研究的THA 转化率。关键词：浓缩自体骨髓穿刺移植；生长因子；髋关节保留手术；间充质干细胞；股骨头坏死；系统性红斑狼疮文献出处：Yohei Tomaru, Tomokazu Yoshioka, Hisashi Sugaya, Yukiyo Shimizu, Katsuya Aoto, Hiroshi Wada, Hiroshi Akaogi, Masashi Yamazaki, Hajime Mishima. Mid-term results of concentrated autologous bone marrow aspirate transplantation for corticosteroid-associated osteonecrosis of the femoral head in systemic lupus erythematosus. Int Orthop. 2018 Jul;42(7):1623-1630.doi: 10.1007/s00264-018-3959-y. Epub 2018 Apr 28.Mid-term results of concentrated autologous bone marrow aspirate transplantation for corticosteroid-associated osteonecrosis of the femoral head in systemic lupus erythematosus.AbstractPurpose: We had previously established concentrated autologous bone marrow aspirate transplantation (CABMAT), a one-step, low-invasive, joint-preserving surgical technique for treating osteonecrosis of the femoral head (ONFH). This study aimed to evaluate the effects of CABMAT as a hip-preserving surgical approach, preventing conversion to total hip arthroplasty (THA) and femoral head collapse in patients with systemic lupus erythematosus (SLE).Methods: Since 2003, 52 SLE patients (8 male, 44 female, 92 hips, mean age 35.3 (16-77) (years) were treated with CABMAT. The mean follow-up period was 5.5 (0.7-14) years. Conversion rate to THA and its predicting factors were analyzed.Results: The overall conversion rate to THA was 29% (27/92). Conversion rate to THA was 0% (0/3), 0% (0/4), 22% (9/41), and 41% (18/44) in types A, B, C1, and C2, respectively. Conversion rate to THA was 26% (5/19), 26% (6/23), 28% (11/39), 44% (4/9), and 50% (1/2) in stages 1, 2, 3A, 3B, and 4, respectively. In multivariate logistic regression analysis, sex, body mass index (BMI), pre-operative type, and pre-operative stage were significantly correlated with conversion to THA.Conclusion: The conversion rate to THA was lower than that in the natural course and core decompression, but was higher than that seen in other bone marrow transplantation and osteotomy. Since sex, pre-operative type, and pre-operative stage were significantly correlated with conversion to THA, it is suggested that the higher proportion of women, advanced stage (stage 3A or above), and advanced type (type C or above) in this study affected the THA conversion rate.Keywords: Concentrated autologous bone marrow aspirate transplantation; Growth factors; Joint preserving surgery; Mesenchymal stem cells; Osteonecrosis of the femoral head; Systemic lupus erythematosus.Fig. 1 A 58-year-old woman, SLE, no collapse progression after 5 years. Pre-operative plane radiograph: AP view (a), frog leg lateral view (b). Five years after operation: AP view (c), frog leg lateral view (d). Preoperative MRI (T1WI): coronal view (e), oblique axial view (f). Five years after operation: coronal view (g), oblique axial view (h).图 1 一名 58 岁女性，SLE，5 年后无塌陷进展。术前平片：前后AP位 视图 (a)，蛙式位视图 (b)。术后五年：前后AP位视图 (c)，蛙式位视图 (d)。术前 MRI (T1WI)：冠状位视图 (e)，斜轴位视图 (f)。术后五年：冠状位（g），斜轴位（h）。Fig. 2 Prognosis of stage 1 and 2 hips. (a) THA conversion rate to THA in stage 1 and 2. (b) Stage at most recent follow-up in the THA nonconversion group. Definition of stage is as follows. Stage 1: No abnormality is detected on radiographs. Abnormality can be detected only on MRI or scintigraphy. Stage 2: Sclerotic change without collapse is detected on radiographs. Stage 3A: collapse of femoral head less than 3 mm, without osteoarthritic change. Stage 3B: collapse of femoral head more than 3 mm, without osteoarthritic change. Stage 4: Osteoarthritic change is detected. MRI magnetic resonance imaging, THA total hip arthroplasty.图 2 1 期和 2 期髋关节的预后。 (a) 第 1 阶段和第 2 阶段的 THA 转换率。 (b) THA 未转换组最近一次随访时的阶段。阶段的定义如下。第一阶段：X光片未发现异常。异常只能在 MRI 或闪烁扫描中检测到。阶段 2：在 X 光片上检测到没有塌陷的硬化变化。 3A 期：股骨头塌陷小于 3 毫米，无骨关节炎改变。 3B 期：股骨头塌陷超过 3 毫米，无骨关节炎改变。第 4 阶段：检测到骨关节炎变化。 MRI 磁共振成像，THA 全髋关节置换术。

浓缩自体骨髓穿刺移植治疗股骨头坏死的10年（随访）结果：一项回顾性研究译者：陶可（北京大学人民医院骨关节科）摘要：背景：特发性股骨头坏死 (ONFH) 发生在相对年轻的患者。因此，在这些患者中防止由此产生的股骨头塌陷和全髋关节置换术是很重要的。2003 年，我们在筑波大学医学院启动了自体骨髓穿刺浓缩移植 (CABMAT)，这是一种保留髋关节的 ONFH 治疗方法。在这里，我们报告了 CABMAT 治疗的长期结果。方法：我们回顾性整理和分析了 2003 年 4 月至 2008 年 4 月间接受 CABMAT 治疗的 69 例特发性 ONFH 患者（109 髋）的人口统计学和治疗数据。结果：共44例（男21例，女23例，80髋）完成10年随访。随访率为 73.4%，平均随访时间为 12.0（范围，10.0-15.4）年。患者的平均年龄为 42.2（范围，16.3-70.5）岁。使用骨循环研究协会(ARCO) 分类系统进行术前分析，分别将 12、31、32 和 5 个髋关节分为 1、2、3 和 4 期。全髋关节置换术 (THA) 的总转换率为 34%（27/80 髋）。在多元回归分析中，发现 ONFH 的术前分期和体重指数与转换为 THA 显著相关。总共有 43 个髋关节（共 80 个）被归类为塌陷前阶段（即第 1 或第 2 阶段）。这些髋关节的整体塌陷率和 THA 转换率估计分别为 49% (21/43) 和 14% (6/43)。结论：根据我们的长期研究结果，微创可行的CABMAT治疗可作为ONFH的一种保髋治疗方法。关键词：骨髓穿刺浓缩液；保髋手术；股骨头坏死文献出处：Yohei Tomaru, Tomokazu Yoshioka, Hisashi Sugaya, Hiroshi Kumagai, Kojiro Hyodo, Katsuya Aoto, Hiroshi Wada, Hiroshi Akaogi, Masashi Yamazaki, Hajime Mishima. Ten-year results of concentrated autologous bone marrow aspirate transplantation for osteonecrosis of the femoral head: a retrospective study. BMC Musculoskelet Disord. 2019 Sep 5;20(1):410.doi: 10.1186/s12891-019-2797-4.Ten-year results of concentrated autologous bone marrow aspirate transplantation for osteonecrosis of the femoral head: a retrospective study.AbstractBackground: Idiopathic osteonecrosis of the femoral head (ONFH) occurs at a relatively younger age. It is therefore important to prevent the resultant femoral head collapse and requirement of total hip arthroplasty in these patients. In 2003, we initiated concentrated autologous bone marrow aspirate transplantation (CABMAT), a joint-preserving treatment for ONFH, at our institution. Here, we report the long-term results of CABMAT treatment.Methods: We retrospectively collated and analyzed the demographic and treatment data of 69 patients (109 hips) with idiopathic ONFH treated with CABMAT between April 2003 and April 2008.Results: Totally, 44 patients (21 men, 23 women, 80 hips) completed the 10-year follow-up. The follow-up rate was 73.4%, and the mean follow-up period was 12.0 (range, 10.0-15.4) years. The mean age of the patients was 42.2 (range, 16.3-70.5) years. Using the Association Research Circulation Osseous (ARCO) classification system for preoperative analysis, 12, 31, 32, and 5 hips were classified as stages 1, 2, 3, and 4, respectively. The overall rate of conversion to total hip arthroplasty (THA) was 34% (27/80 hips). In a multivariate regression analysis, the preoperative stage of ONFH and the body mass index were found to correlate significantly with conversion to THA. Totally, 43 hips (of 80) were classified as belonging to the pre-collapse stage (i.e., stages 1 or 2). The overall collapse rate and the THA-conversion rate of these hips were estimated to be 49% (21/43) and 14% (6/43), respectively.Conclusions: On the basis of our long-term findings, the minimally invasive and feasible CABMAT therapy can be utilized as one of a joint-preserving treatment for ONFH.Keywords: Bone marrow aspirate concentrate; Hip preserving surgery; Osteonecrosis of the femoral head.Fig. 1 Survival curve (end point: conversion to total hip arthroplasty).图 1 生存曲线（终点：转换为全髋关节置换术）。

股骨头坏死：病理生理学和当前治疗概念译者：陶可（北京大学人民医院骨关节科）北京大学人民医院骨关节科陶可摘要：股骨头坏死是一种导致年轻人群（治疗时的平均年龄为 33 至 38 岁）残疾的病理因素，并且是该人群中全髋关节置换术的最重要原因。它反映了导致股骨头血流量减少的各种疾病过程的终点。病理生理学反映了灌注股骨头前部和上部的细血管的血管化的改变。（股骨头前部和上部）坏死区是导致髋关节过早磨损且髋关节形合度丧失的根源。已经开发了几种不同类型的药物来逆转（股骨头）缺血过程和/或恢复股骨头的血管化。对于特定的治疗方法还没有达成共识。手术治疗的目的是在出现坏死区和髋关节形合度丧失之前尽可能地保留关节。它们包括骨髓减压术、髋关节周围截骨术、血管或非血管移植物。未来的疗法包括使用生物活性分子以及用生物活性组织浸泡过的植入物。文献出处：Daniel Petek, Didier Hannouche, Domizio Suva. Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. Review EFORT Open Rev. 2019 Mar 15;4(3):85-97.doi: 10.1302/2058-5241.4.180036. eCollection 2019 Mar.Osteonecrosis of the femoral head: pathophysiology and current concepts of treatmentAbstractOsteonecrosis of the femoral head is a disabling pathology affecting a young population (average age at treatment, 33 to 38 years) and is the most important cause of total hip arthroplasty in this population. It reflects the endpoint of various disease processes that result in a decrease of the femoral head blood flow. The physiopathology reflects an alteration of the vascularization of the fine blood vessels irrigating the anterior and superior part of the femoral head. This zone of necrosis is the source of the loss of joint congruence that leads to premature wear of the hip. Several different types of medication have been developed to reverse the process of ischemia and/or restore the vascularization of the femoral head. There is no consensus yet on a particular treatment.The surgical treatments aim to preserve the joint as far as the diagnosis could be made before the appearance of a zone of necrosis and the loss of joint congruence. They consist of bone marrow decompressions, osteotomies around the hip, vascular or non-vascular grafts.Future therapies include the use of biologically active molecules as well as implants impregnated with biologically active tissue.Fig. 1 Different pathways participating in ONFH.图 1 ONFH 的不同成因。Fig. 2 Radiological aspects according to modality.图 2 股骨头坏死的影响学检查及所见。Fig. 3 Grade I ONFH on a) plain radiograph, b) T1 and c) T2.图 3 a) 平片，b) T1 相和 c) T2 相上的 I 级 ONFH。Fig. 4 Crescent sign on a) MRI T2, b) CT scan c) radiograph.图 4 a) MRI T2相, b) CT 扫描 c) X线片上的新月征。Fig. 5 Involvement of the acetabulum. 图 5 髋臼受累。Fig. 6 Total hip replacement in advanced femoral head collapse after ONFH.图 6 ONFH 后晚期股骨头塌陷中的全髋关节置换。Fig. 7 Conservative surgery consisting of hip dislocation and non-vascular bone grafting.图 7 由髋关节（外科）脱位和非血管植骨组成的保髋手术。Fig. 8 a) Necrotic head portion, b) osteochondral transfer, c) CT scanner at one-year follow-up. 图 8 a) 坏死的股骨头，b) 骨软骨转移，c) 一年随访时的 CT 扫描结果。Fig. 9 a) Debridement of the femoral head and PMMA filling of the defect, b) radiograph at five-year follow-up, c) aspect of the femoral head at time of arthroplasty, at 12 years of follow-up.图 9 a) 股骨头（坏死组织）清创和缺损的骨水泥 PMMA 填充，b) 5 年随访时的 X 线片，c) 随访 12 年时进行髋关节置换术时，股骨头的大体拍照。

非创伤性股骨头坏死：我们今天的立场(研究进展)？：5 年更新译者：陶可（北京大学人民医院骨关节科）摘要： 临床医生应高度警惕高危患者（使用皮质类固醇、过量饮酒、患有镰状细胞病等），以便及早诊断出股骨头坏死。 非手术治疗方式在阻止（股骨头坏死）进展方面通常是无效的。因此，当人们试图保留天然（髋）关节时，非手术治疗在早期是不合适的，除非在极少数情况下，小尺寸、位于内侧的病变可能无需手术即可愈合。 早期病变应尝试保髋手术，以保留住股骨头。 基于细胞疗法的（髋）关节保留手术继续显示出有希望的结果，因此应被视为可能改善临床结果的辅助治疗方法。 在骨坏死的情况下全髋关节置换术的结果非常好，结果与潜在诊断为骨关节炎的患者的结果相似。文献出处：Michael A Mont, Hytham S Salem, Nicolas S Piuzzi, Stuart B Goodman, Lynne C Jones. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year Update. Review, J Bone Joint Surg Am. 2020 Jun 17;102(12):1084-1099.doi: 10.2106/JBJS.19.01271.Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today?: A 5-Year UpdateAbstract Clinicians should exercise a high level of suspicion in at-risk patients (those who use corticosteroids, consume excessive alcohol, have sickle cell disease, etc.) in order to diagnose osteonecrosis of the femoral head in its earliest stage. Nonoperative treatment modalities have generally been ineffective at halting progression. Thus, nonoperative treatment is not appropriate in early stages when one is attempting to preserve the native joint, except potentially on rare occasions for small-sized, medially located lesions, which may heal without surgery. Joint-preserving procedures should be attempted in early-stage lesions to save the femoral head. Cell-based augmentation of joint-preserving procedures continues to show promising results, and thus should be considered as an ancillary treatment method that may improve clinical outcomes. The outcomes of total hip arthroplasty in the setting of osteonecrosis are excellent, with results similar to those in patients who have an underlying diagnosis of osteoarthritis.Figs. 1-A and 1-B Small-diameter CD for ONFH. A trocar is introduced into the necrotic lesion using light mallet blows (Fig. 1-A) under fluoroscopic guidance (Fig. 1-B).图1 用于股骨头坏死 ONFH 的 1-A 和 1-B 小直径髓心减压CD术。在透视引导下（图 1-B）使用轻槌敲击（图 1-A）将套管针引入坏死病变区域。Fig. 2 Aspiration of bone marrow from the iliac crest for subsequent processing and implantation following femoral head CD.图 2 从髂嵴抽吸骨髓，用于股骨头髓心减压CD术后的后续处理和植入。Fig. 3 The lightbulb technique—creation of a cortical window at the femoral head-neck junction for evacuation of necrotic tissue and replacement with a bone graft.图 3 灯泡技术——在股骨头颈交界处创建一个皮质窗口，用于清除坏死组织并用骨移植物替代。

与髋臼盂唇切除相比，股骨髋臼撞击术中行盂唇再锚定术可增加（髋关节）10年生存率译者：陶可（北京大学人民医院骨关节科）摘要：背景：由于已经显示了完整的盂唇对于正常髋关节功能的重要性，因此，盂唇再锚定术已成为开放性或关节镜下治疗股骨髋臼撞击征（FAI）的标准方法。但是，没有长期的临床结果评估盂唇再锚定术的效果。之前在我们医学中心进行了为期2年的随访，比较FAI开放性外科手术治疗中盂唇切除术与再锚定术的优劣。这项研究的目的是报告对这些患者至少10年的随访结果。问题/目的：我们询问接受手术性髋关节脱位治疗混合型FAI并进行人工复位的患者与人工切除相比，患者（1）是否基于Merle d'Aubigné-Postel评分改善了髋关节疼痛和功能；（2）改善了10年随访的生存率。方法：1999年6月至2002年7月，我们对52例混合型FAI患者（60髋）在髋关节外科脱位下进行了股骨颈骨成形术和髋臼缘修剪术。到2001年6月，在最早的20例患者（25髋）中，切除了髋臼缘切除区域的盂唇撕裂或脱垂。在接下来的32例患者（35髋）中，进行了唇唇的重新锚定。在上述期间，两种手术均使用相同的适应症。在第一组的20例患者（25髋）中，有19例患者（95%）（24髋 [96％]）可在（术后）至少10年得到临床和/或影像学随访（平均13年；范围12-14年）。第二组的32例患者（35髋）中，有29例患者（91%）（32髋 [91％]）可在（术后）至少10年得到临床和/或影像学随访（平均12年；范围10-13年）。我们使用前撞击试验来评估疼痛。使用Merle d'Aubigné-Postel评分和ROM评估功能。使用Kaplan-Meier方法进行生存率计算，失败的定义为转化为THA、骨关节炎的进展（Tnnis评分为一级或更高级）以及Merle d'Aubigné-Postel评分<15。结果：在10年的随访中，髋关节盂唇在锚定组的术后Merle d'Aubigné-Postel髋关节疼痛评分轻度改善（5.0±1.0分对比3.9±1.7分；p = 0.017）。在已有的（两组）病例中，使用前撞击试验评估的髋关节疼痛并未发现患病率有差异（切除组52％[11/21髋]与再锚定组27％[8/30髋]；比值比，3.03；95％的置信度区间[CI]，0.93-9.83；p = 0.062）。再锚定组的Merle d'Aubigné-Postel总体评分较（切除组）轻度改善（16.7±1.5 [13-18]对比15.3±2.4 [9-18]；p = 0.028），且髋关节外展亦有所改善（45°±13°）[范围，30°-70°]与38°±8°[范围，25°-45°]；p = 0.001）。将转为THA（治疗）、骨关节炎进展及Merle d'Aubigné-Postel得分<15定义为终点，与盂唇切除组髋关节相比，经盂唇再锚定的髋关节在10年时的存活率更高（78％；95％CI，64％-92％对比46％，95％CI，26％-66％；p = 0.009）。通过单独的终点判断，盂唇再锚定组10年生存率在（采用）Merle d'Aubigné得分<15（判断）时提高了（83％，95％CI，70％-97％对比48％，95％CI，28％-69％；p = 0.009），但骨关节炎的进展（83％，95％CI，68％-97％相对于81％，95％CI，63％-98％；p = 0.957）或转化为THA（94％，95％CI，86％-100％与87％，95％CI，74％-100％；p = 0.366）（在上述两组）无差异。结论：目前的结果表明保持盂唇的重要性，并表明切除术可能使髋关节处于早期退变风险中。在10年的随访中，盂唇再锚定较少地降低髋关节的Merle d'Aubigné评分，但未显示出对骨关节炎进展或转化为THA有益。文献出处：Helen Anwander, Klaus A Siebenrock, Moritz Tannast, Simon D Steppacher. Labral Reattachment in Femoroacetabular Impingement Surgery Results in Increased 10-year Survivorship Compared With Resection. Clin Orthop Relat Res. 2017 Apr;475(4):1178-1188.Labral Reattachment in Femoroacetabular Impingement Surgery Results in Increased 10-year Survivorship Compared With Resection AbstractBackground: Since the importance of an intact labrum for normal hip function has been shown, labral reattachment has become the standard method for open or arthroscopic treatment of hips with femoroacetabular impingement (FAI). However, no long-term clinical results exist evaluating the effect of labral reattachment. A 2-year followup comparing open surgical treatment of FAI with labral resection versus reattachment was previously performed at our clinic. The goal of this study was to report a concise followup of these patients at a minimum of 10 years.Questions/purposes: We asked if patients undergoing surgical hip dislocation for the treatment of mixed-type FAI with labral reattachment compared with labral resection had (1) improved hip pain and function based on the Merle d'Aubigné-Postel score; and (2) improved survival at 10-year followup.Methods: Between June 1999 and July 2002, we performed surgical hip dislocation with femoral neck osteoplasty and acetabular rim trimming in 52 patients (60 hips) with mixed-type FAI. In the first 20 patients (25 hips) until June 2001, a torn labrum or a detached labrum in the area of acetabular rim resection was resected. In the next 32 patients (35 hips), reattachment of the labrum was performed. The same indications were used to perform both procedures during the periods in question. Of the 20 patients (25 hips) in the first group, 19 patients (95%) (24 hips [96%]) were available for clinical and/or radiographic followup at a minimum of 10 years (mean, 13 years; range, 12-14 years). Of the 32 patients (35 hips) in the second group, 29 patients (91%) (32 hips [91%]) were available for clinical and/or radiographic followup at a minimum of 10 years (mean, 12 years; range, 10-13 years). We used the anterior impingement test to assess pain. Function was assessed using the Merle d'Aubigné- Postel score and ROM. Survivorship calculation was performed using the method of Kaplan-Meier with failure defined as conversion to THA, progression of osteoarthritis (of one grade or more on the Tnnis score), and a Merle d'Aubigné-Postel score < 15.Results: At the 10-year followup, hip pain in hips with labral reattachment was slightly improved for the postoperative Merle d'Aubigné-Postel pain subscore (5.0 ± 1.0 [3-6] versus 3.9 ± 1.7 [0-6]; p = 0.017). No difference existed for the prevalence of hip pain assessed using the anterior impingement test with the numbers available (resection group 52% [11 of 21 hips] versus reattachment group 27% [eight of 30 hips]; odds ratio, 3.03; 95% confidence interval [CI], 0.93-9.83; p = 0.062). Function was slightly better in the reattachment group for the overall Merle d'Aubigné-Postel score (16.7 ± 1.5 [13-18] versus 15.3 ± 2.4 [9-18]; p = 0.028) and hip abduction (45° ± 13° [range, 30°-70°] versus 38° ± 8° [range, 25°-45°]; p = 0.001). Hips with labral reattachment showed a better survival rate at 10 years than did hips that underwent labral resection (78%; 95% CI, 64%-92% versus 46%, 95% CI, 26%-66%; p = 0.009) with the endpoints defined as conversion to THA, progression of osteoarthritis, and a Merle d'Aubigné-Postel score < 15. With isolated endpoints, survival at 10 years was increased for labral reattachment and the endpoint Merle d'Aubigné score < 15 (83%, 95% CI, 70%-97% versus 48%, 95% CI, 28%-69%; p = 0.009) but did not differ for progression of osteoarthritis (83%, 95% CI, 68%-97% versus 81%, 95% CI, 63%-98%; p = 0.957) or conversion to THA (94%, 95% CI, 86%-100% versus 87%, 95% CI, 74%-100%; p = 0.366).Conclusions: The current results suggest the importance of preserving the labrum and show that resection may put the hip at risk for early deterioration. At 10-year followup, hips with labral reattachment less frequently had a decreased Merle d'Aubigné score but no effect on progression of osteoarthritis or conversion to THA could be shown.Fig. 1 Hips with labral reattachment (continuous line) showed an increased mean survival rate at 10 years of 78% (95% CI, 64%–92%) compared with hips with labral resection (broken line; mean survival rate of 46% [95% CI, 26%–66%; p = 0.009]).图1. 与有盂唇切除术的髋关节（虚线；髋关节生存率46％[95％CI，26％–66％）相比，有盂唇再锚定术的髋关节（实线）显示10年的平均存活率增加了78％（95％CI，64％–92％），p = 0.009。Fig. 2A–F (A) A 27-year-old male patient presented with mixed-type FAI, a Merle d’Aubigne -Postel score of 14, and radiologic osteoarthritis Grade 1 according to Tonnis. (B) The preoperative alpha angle was 63. (C) He underwent surgical hip dislocation with acetabular rim trimming, reattachment of the labrum using four titanium bone anchors, and (D) osteochondroplasty of the neck. (E) At 11 years follow-up, the patient did not show progression of osteoarthritis (F) and had an excellent clinical result (Merle d’Aubigne-Postel score of 18).图2A–F（A）根据Tonnis分级，一名27岁的男性患者表现为混合型FAI，Merle d'Aubigne-Postel评分为14，影像学（髋）骨关节炎为1级。（B）术前α角为63°。（C）他接受了髋关节外科脱位下的盂唇修复，使用四枚钛制骨锚钉重新固定了盂唇，以及（D）股骨颈骨软骨成形术。（E）在11年的随访中，该患者未显示出骨关节炎的进展（F），并且具有出色的临床效果（Merle d’Aubigne-Postel评分为18）。Fig. 3A–F (A) A 33-year-old male patient presented with mixed-type FAI, a Merle d’Aubigne -Postel score of 13, and radiologic osteoarthritis Grade 1 according to Tonnis. (B) The preoperative alpha angle was 60°. (C) He underwent surgical hip dislocation with trimming of the excessive part of the acetabular rim, resection of the labrum in the area of rim resection, and (D) osteochondroplasty of the neck. (E) At 5 years follow-up, the patient did show progression of osteoarthritis, increased pain, and impaired mobility and, therefore, (F) the hip had to be converted to THA at 5.5-year follow-up.图3A–F（A）根据Tonnis分级，一名33岁的男性患者表现为混合型FAI，Merle d'Aubigne-Postel评分为13，影像学（髋）骨关节炎为1级。（B）术前α角为60°。（C）他接受了髋关节外科脱位，修剪了髋臼缘的多余部分，切除了髋臼缘切除区的盂唇，以及（D）股骨颈骨软骨成形术。（E）在5年的随访中，患者确实显示出骨关节炎进展，疼痛加剧和（髋关节）活动能力受损，因此（F）在5.5年的随访中，髋关节必须转化为THA。Fig. 4 Bubble chart showing follow-up, survival rate (with THA as the endpoint), size of the patient series (size of bubble), and the color-coded treatment of the labrum. Studies with 100% of labral reattachment are represented in black, labral resection in white, and percentage of labral reattachment in corresponding gray scales.图4 气泡图显示了随访情况，存活率（以THA为终点），患者系对列的大小（气泡的大小）以及用彩色编码的盂唇治疗方法。黑色表示有100％的盂唇再锚定研究，白色表示了盂唇切除，相应的灰度表示了盂唇再锚定的百分比。

超声引导下的髋关节注射———北京大学人民医院多学科诊治经验：2019年超声技术学ArthroscTech杂志：超声引导下的髋关节内穿刺注射：Nashville声像作者；ElizabethABardow

股骨头坏死译者：陶可（北京大学人民医院骨关节科）摘要：股骨头坏死最常由外伤或皮质类固醇和饮酒引起，但也与血液恶液质以及代谢和凝血功能障碍有关。初步评估包括病史和体格检查以及 X 线片。早期股骨头坏死最好通过 MRI 评估。 Ficat 和 Arlet 分类系统是最广泛使用的分类系统。双膦酸盐、抗凝剂、血管扩张剂、他汀类药物和生物物理方式等非手术治疗已经用于临床。手术治疗包括使用或不使用自体骨髓等辅助药物的髓心减压，而全髋关节置换术仅用于老年患者或关节保护治疗失败的晚期股骨头坏死。关键词：核心解压；皮质类固醇;股骨头坏死;干细胞;全髋关节置换术文献出处：Anna Cohen-Rosenblum, Quanjun Cui. Osteonecrosis of the Femoral Head. Orthop Clin North Am. 2019 Apr;50(2):139-149.doi: 10.1016/j.ocl.2018.10.001.Osteonecrosis of the Femoral Head.AbstractOsteonecrosis of the femoral head most commonly arises from trauma or corticosteroid and alcohol use but is also associated with blood dyscrasias and metabolic and coagulation disorders. Initial evaluation includes a history and physical examination and plain radiographs. Early-stage osteonecrosis is best evaluated by MRI. The Ficat and Arlet classification system is the most widely used. Nonoperative treatment has been studied using bisphosphonates, anticoagulants, vasodilators, statins, and biophysical modalities. Operative treatment includes core decompression with or without adjuvants, such as autologous bone marrow, whereas total hip arthroplasty is reserved for advanced-stage osteonecrosis in older patients or those who have failed joint-preserving treatment.Keywords: Core decompression; Corticosteroid; Femoral head osteonecrosis; Stem cell; Total hip arthroplasty.Fig. 1. A 50 year-old male heavy drinker presented with bilateral groin pain and radiographic findings of femoral head sclerosis on AP (A) and frog lateral (B) views. MRI showed (C) T1 hypointense and (D) T2 hyperintense signal of the necrotic lesions of the femoral heads bilaterally.图 1. 一名 50 岁男性酗酒者出现双侧腹股沟疼痛和股骨头硬化的影像学表现，前后AP位 (A) 和蛙式位 (B) X线片。MRI显示双侧股骨头坏死病变（C）T1低信号和（D）T2高信号。Fig. 2. The crescent sign describes an area of subchondral lucency in the femoral head (arrows) that indicates subchondral fracture.图 2. 新月征描述了股骨头中的软骨下透明区域（箭头），表明软骨下骨骨折。Fig. 3. AP pelvis view shows a collapsed left femoral head with arthritic changes of the hip joint.图 3. 前后AP位 骨盆X线片显示左侧股骨头塌陷，髋关节发生骨关节炎变化。Fig. 4. Core decompression can be performed (A) using a trephine to remove an 8-mm to 10-mm core from the osteonecrotic lesion in the femoral head or (B) using small guide wires to pass multiple times through the lesion.图 4. 可以进行髓心减压 (A) 使用环钻从股骨头坏死病灶中取出 8 毫米至 10 毫米的髓心，或 (B) 使用小导丝多次穿过病灶。Fig. 5. (A) Autologous bone marrow aspirated from the anterior iliac crest is concentrated and then (B) delivered to the necrotic lesion site through the core decompression tract.图5.（A）从髂前上棘抽取的自体骨髓经浓缩，然后（B）通过髓心减压通道输送到股骨头坏死病变部位。