2026年4月 保髋进展 JCR Q3+Q4

PURPOSE: Pediatric femoral neck fractures (PFNFs) are rare (≈1% of pediatric fractures), and avascular necrosis (AVN) is a devastating complication without a universally accepted management. High-degree posterior rotational osteotomy (HDPRO) with three-dimensional (3D) navigation is a novel joint-preserving technique with the potential to improve outcomes.

METHODS: A retrospective case series was conducted with three pediatric patients (2 boys, 1 girl; aged 9-15 years at injury) diagnosed with AVN secondary to PFNF. All underwent HDPRO using Stryker OrthoMap 3D navigation to reposition the viable anteromedial femoral head. Preoperative and postoperative outcomes were assessed using radiographic analysis, functional scoring (Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ)), and sports participation. Follow-up ranged from 24 to 36 months.

RESULTS: All patients showed pain relief, functional improvement, stable femoral head morphology, and revascularization. JHEQ improved to 79-84 points; hip motion normalized without impingement. All patients returned to sports (track, volleyball, cycling).

CONCLUSIONS: HDPRO with 3D navigation is a promising joint-preserving option for AVN following PFNF. Preliminary results are favorable; however, the small cohort and limited follow-up warrant larger studies.

SIGNIFICANCE OF STUDY: To the best of our knowledge, this is the first report demonstrating that navigation-guided HDPRO reliably relocates the viable anteromedial head to the load-bearing zone.

LEVEL OF EVIDENCE: Level IV.

BACKGROUND: Developmental dysplasia of the hip (DDH) with complete dislocation (grade ≥III) in older patients often requires open reduction. However, achieving long-term stability remains challenging. This study introduces and evaluates a novel surgical technique, intraosseous tunneling and ligamentodesis of the ligamentum teres (LT), conceived to enhance postoperative hip stability while preserving the ligament's anatomic course.

METHODS: Pediatric patients with grade ≥III DDH, as classified by the International Hip Dysplasia Institute (IHDI), underwent open reduction using a novel ligamentum teres ligamentodesis technique to enhance joint stability. The ligament was detached, sutured, and tunneled intraosseously from the fovea to the greater trochanter, then anchored to the periosteum. Postoperative evaluation included gait status, pain, hip range of motion, reluxation, residual dysplasia, avascular necrosis (AVN), physeal bars, growth arrest, complications, and need for reintervention.

RESULTS: Nineteen hips in 16 patients (14 females, 2 males) with a median age of 24 months underwent LT intraosseous ligamentodesis combined with femoral and pelvic osteotomies. At a median follow-up of 23 months, all patients were pain-free, had normal gait, and no functional limitations, except for one case of persistent limping and one hip with mild limitation of abduction. Radiographically, all hips achieved satisfactory outcomes with IHDI type I, and severing grades I (80%) and II (20%). No cases of redislocation, dysplasia, infection, physeal bars, or growth arrest were observed. Two hips (10.5%) developed asymptomatic AVN.

CONCLUSIONS: The ligamentum teres intraosseous ligamentodesis ("Teretization") is a safe and technically feasible adjunct to open reduction in severe DDH, demonstrating favorable mid-term outcomes with no redislocations and low complication rates. These findings support its potential role in enhancing hip stability without jeopardizing femoral head physis and vascularity.

LEVEL OF EVIDENCE: Level IV-therapeutic case series.

BACKGROUND: The purpose of this study is to compare acetabular remodeling rates in age and severity matched, idiopathic DDH patients undergoing closed reduction (CR) versus open reduction alone (OR) versus open reduction supplemented by ligamentum teres reconstruction (LTR) utilizing a suture button device.

METHODS: Prospectively obtained data of patients who underwent open reduction with LTR were compared with historic cohorts of children 2.5 years or younger who underwent CR or OR. Acetabular index (AI) was measured on radiographs taken prior to reduction and on serial postoperative follow-ups. Monthly and yearly rates of AI change were calculated. Subgroup analysis of the prospective LTR cohort was performed to characterize how the rate of acetabular remodeling changes with increasing time after surgery.

RESULTS: Sixty-three patients with 71 hips underwent surgical reduction: 28 patients (29 hips) with CR, 19 patients (24 hips) with OR, and 16 patients (18 hips) with LTR. The average follow-up was 33.6 months. An annual acetabular index (AI) improvement of 7.9° was identified in the LTR cohort compared with 4.7° for OR and 4.0° for CR (P≤0.001). No patients within the LTR cohort have undergone subsequent pelvic osteotomy for residual dysplasia, versus 12.5% and 34.5% of the OR and CR groups, respectively. LTR patients demonstrated their greatest remodeling during the first year after surgery (1.0° per month). Rates decreased during the second year postoperatively (0.4° per month) and beyond (0.3° per month) (P=0.007).

CONCLUSIONS: Short-term results suggest that enhanced stability provided by LTR may permit more robust acetabular remodeling and lead to less residual dysplasia in patients with idiopathic DDH.

LEVEL OF EVIDENCE: Level II.

BACKGROUND: This paper describes a pelvic procedure that is technically simpler, quicker to perform, and equally effective as all existing pelvic osteotomies. It is used alongside hip open reduction for the treatment of the associated acetabular dysplasia. It is a minimal additional procedure that is intended to ignite the growth of the dysplastic acetabulum.

METHODS: A total of 167 hips (in 154 infants) treated with open reduction and growth-stimulating minimal acetabuloplasty, all with follow-up between 4 and 16 years postoperatively, are reported. The surgical technique is described. Sequential radiographs were analyzed through to final follow-up, which for 21% is to skeletal maturity. Patient demographics, preoperative and sequential postoperative indices, and outcomes are recorded.

RESULTS: Preoperative IHDI position was grade IV dislocation in 77% and grade III in 33%. Mean starting acetabular index (AI) was 41.3 degrees (range 30 to 54 degrees) and median age at operation was 13 months (range from 1 to 2.5years). At final follow-up, 98.2% of hips have a Severin 1 (excellent) or 2 (good) outcome, with the AI normalized. These are all IHDI grade 1 and have a mean center-edge-angle of 35.7 degrees. Only 6 of these (3.6%) have warranted a subsequent pelvic osteotomy for residual acetabular dysplasia.

CONCLUSIONS: The growth-stimulating minimal acetabular procedure is technically straightforward. It is simpler than standard existing pelvic osteotomies, yet it is shown to be at least as effective. With up to 16 years follow-up, we can highly commend its routine use alongside hip open reduction in infants aged 1 to 2.5 years old.

LEVEL OF EVIDENCE: Level III-case-control study.

INTRODUCTION: Periacetabular osteotomy, commonly performed for prearthritic hip dysplasia, was identified as a procedure that could benefit from an enhanced recovery after surgery pathway due to wide variation in multimodal pain management and regional anesthesia practices at our institution. The global aim of this project was to implement an enhanced recovery after surgery pathway for patients undergoing periacetabular osteotomy. Our SMART aim was to achieve greater than 70% compliance for the intraoperative medication bundle elements during the first PDSA cycle.

METHODS: A multidisciplinary pathway was designed and implemented with key stakeholders from the Departments of Evidence Based Practice, Anesthesiology, Orthopedic Surgery, and Perioperative Nursing. Patient data from all patients undergoing periacetabular osteotomy from 2018 to the present were analyzed, which included the baseline cohort as well as outcomes from two Plan-Do-Study-Act cycles.

RESULTS: After ERAS implementation and two subsequent Plan-Do-Study-Act cycles, we observed a decrease in hospital length of stay from 3.34 days (95% CI [2.95, 3.72]) to 2.37 days (95% CI [2.00, 2.74]) and an intraoperative medication bundle compliance of 90%. These gains occurred with minimal change in average postoperative pain scores and no hospital readmissions within 30 days of surgery.

CONCLUSIONS: Multidisciplinary enhanced recovery after surgery pathways continue to play a critical role in standardizing perioperative care, reducing unwarranted variation, and promoting faster recovery across paediatric populations.

INTRODUCTION: The purpose of this study was to conduct an analysis of the cross-sectional area (CSA) of hip musculature before and after hip arthroscopy (HA) for femoroacetabular impingement (FAI). The hypothesis was that there will be a significant increase in the CSA of analysed hip muscles that will correlate with increases in PROs following surgery.

METHODS: This is a single-centre, single-surgeon, retrospective analysis performed between August 2011 and February 2022. All hips that had a preoperative MRI within 1 year of their date of surgery and ≥1 postoperative MRI >2 months after surgery were included. Cross-sectional areas of the gluteus maximus, gluteus medius, gluteus minimus, iliopsoas, pectineus, sartorius, rectus femoris and tensor fascia lata muscles were measured by 1 blinded researcher and results were checked for reliability by a musculoskeletal radiologist.

RESULTS: 89 hips met criteria to be included in the analysis. The cohort had an average age of 35.8 ± 15.7 years, was 66.3% female, and had an average BMI of 23.3 ± 8.1 kg/m

CONCLUSIONS: Gluteus maximus and minimus muscles demonstrated significantly increased CSA after HA for FAI patients. Change in CSA was positively correlated with PROs for the gluteus maximus at 1-year follow-up. These findings underscore the clinical significance of muscle adaptations following hip arthroscopy for FAI.

OBJECTIVE: To describe and compare arthroscopy-assisted (AA) with fluoroscopy-assisted (FA) minimally invasive plate osteosynthesis (MIPO) for simple transverse acetabular fractures.

STUDY DESIGN: Ex vivo cadaveric study.

SAMPLE POPULATION: A total of 10 canine cadavers (>20 kg) without coxofemoral joint disease.

METHODS: Pelvic computed tomography (CT) images were mirrored and three-dimensional (3D) printed to create models for precontouring 2.7-mm locking compression plates (LCP). Acetabula were randomly assigned to AA or FA MIPO groups and pelvis were prepared for stabilization by standardized osteotomies of the pubic, ischial and acetabular bones. In the AA group, fracture reduction was arthroscopically confirmed, and precontoured plates were applied via small approaches to the ilium and ischium. In the FA group, reduction was guided fluoroscopically. Surgical time, incision length, procedural complications, and feasibility were recorded. Postprocedural CT scans measured fracture gap, step formation, medio-lateral displacement and pelvic angulation. Necropsy assessed iatrogenic injuries.

RESULTS: MIPO was successful for all 20 acetabula. Mean procedure time and incision length were not significantly different between groups. Mean fracture gaps and step defects were <1 mm in both groups. Medio-lateral displacement exceeded 1 mm in the FA group (median 1.08 mm) compared to 0.74 mm in the AA group. Low coronal angles (<5°) were consistent across procedures. Sciatic nerve injury occurred in one case per group. Minor superficial cartilage damage was common.

CONCLUSION: Arthroscopy-assisted MIPO was feasible for simple acetabular fractures, resulting in anatomic (6/10) or near-anatomic (4/10) reductions.

CLINICAL SIGNIFICANCE: Further studies and clinical experience are necessary before recommending AA as an alternative for open approaches.

BACKGROUND: Neurogenic hip dysplasia (NHD) is a clinically significant musculoskeletal complication in children with neurological disorders, particularly infantile cerebral palsy (CP). It contributes substantially to pain, functional limitations, and reduced quality of life. Muscle imbalance and impaired dynamic hip stability lead to progressive deformity of the femoral head and acetabulum, increasing the risk of subluxation and dislocation. Risk strongly correlates with GMFCS level and is highest in non-ambulatory children (levels IV-V).

DIAGNOSTICS: Diagnosis and monitoring rely on radiographic parameters such as the Reimers migration index, Rutz classification and other classification systems, although some measures have limitations in CP. Management requires long-term, interdisciplinary care. GMFCS-based hip surveillance enables early detection and timely intervention before irreversible damage occurs.

THERAPY: Treatment decisions must be individualized, as not all dysplasia is symptomatic. Options range from conservative measures with limited long-term efficacy to soft-tissue procedures and reconstructive surgery (e.g., VDRO with or without pelvic osteotomy), while salvage procedures are reserved for severe cases.

CONCLUSION: Overall, NHD is a multifactorial, complex disease that requires structured diagnostics, continuous monitoring, and early, patient-specific therapy with the active involvement of families, with the aim of improving function and quality of life.

Slipped capital femoral epiphysis (SCFE) occurs in preadolescent and adolescent children. The exact pathomechanism of the slip is not known. Several risk factors have been identified including hormonal derangement. Of the classification systems, stability and severity classification systems are most relevant to everyday practice. There is a strong agreement regarding the management of a mild slip. Controversies exist in the treatment of moderate and severe slips and also regarding the prophylactic pinning of the opposite side. Discrepancies exist amongst countries and surgeons as to the number of screws to be used for pinning. Increasing evidence of femoroacetabular impingement as a cause of osteoarthritis of the hip may change the treatment of moderate and severe slips in the future. The modified Dunn procedure may become a standard procedure in the future to treat moderate and severe slips; however, experience and accurate knowledge of surgical anatomy is required for good outcomes following this procedure.

Pelvic and femoral osteotomies, including soft-tissue balancing of the pediatric hip joint, aim to restore as physiological a geometry and biomechanics as possible in order to improve function and prevent wear. The main indications are developmental (DDH) and neurogenic dysplasia (NDH), Perthes disease (LCP), and femoral head slippage (ECF/SCFE). In childhood, acetabular roof plasty (PDP) and the Salter osteotomy (SIO) are the primary options; after growth is complete, triple pelvic osteotomy (TPO) and periacetabular osteotomy (PAO) are available, with the former potentially being performed even before skeletal maturity. If incongruity is present, shelf and Chiari osteotomies may be considered as salvage procedures. The outcome depends on correct indication, selection of the appropriate procedure, adequate consideration of soft tissue conditions, and structured follow-up care.

Osteoarthritis of the ankle joint affects a younger and often occupational and sport-active patient group than hip and knee arthritis and in the majority of cases has a secondary or posttraumatic origin. Corrective osteotomy is a biological and functionally attractive option for these young and active patients with asymmetric arthritis and correctable malalignment as the native joint is preserved and subsequent arthrosis can be potentially prevented or delayed by arthrodesis. Decisive for the success are consistent 3-dimensional diagnostics, precise planning, correct interpretation of the indications as well as completely addressing the fibular, hindfoot and instability components.

Hip arthroscopy has grown exponentially over the past decade, with a parallel rise in revisions, underscoring the importance of refined patient selection and diagnostic accuracy. This review outlines the most common causes of failure after primary hip arthroscopy and provides a framework for evaluation, imaging, and management. Notably, differentiating between impingement and instability is crucial, as misclassification can worsen outcomes. Revision procedures may provide clinically meaningful improvement in patient-reported outcomes and delay total hip arthroplasty in well-selected patients. However, recognizing when to shift from preservation to replacement is key to optimizing outcomes.