特殊类型全髋关节置换术的疗效分析

目的探讨成人髋臼发育不良致股骨头坏死和股骨上端骨肿瘤患者行全髋关节置换术的疗效。方法对10例16侧成人髋臼发育不良并股骨头坏死者(双侧6例,单侧4例)行全髋关节置换术,另对8例股骨近端肿瘤者(3例复发性骨巨细胞瘤,5例骨转移瘤)作瘤段切除全髋关节置换术。结果术后所有患者均获随访。股骨头坏死16侧Harris评分由术前的平均36.6分恢复到术后的89分;8例股骨近端肿瘤经假体置换后,Harris评分平均为93.5分。结论全髋关节置换术治疗成人髋臼发育不良致股骨头坏死及股骨近端肿瘤疗效确切,用以治疗股骨近端肿瘤具有肿瘤切除彻底、负重早、功能恢复快及生活质量高的优点。     

保留股骨颈型人工全髋关节置换术

目的探讨保留股骨颈型人工全髋关节置换的疗效。方法2000年9月～2005年1月,采用保留股骨颈型人工全髋关节置换治疗髋关节骨关节病16例(20侧),男5例,女11例；年龄32～56岁,平均48岁。其中股骨头坏死致髋关节骨关节病8例(4例为双侧),股骨头坏死4例(2例股骨颈骨折愈合后股骨头坏死),髋臼发育不良股骨头坏死2例,股骨颈头下型骨折不愈合2例。病程2～8年,平均4年。结果全部患者获得0．5～4年的随访,20侧人工髋关节临床效果良好。人工髋关节的活动及功能良好,影像学检查显示人工髋关节位置良好,假体无松动和下沉。结论保留股骨颈型人工全髋关节置换符合股骨近端生理顺应性,使假体适应应力分布,防止股骨近端骨质疏松引起假体松动和下沉。同时为今后假体翻修提供骨结构基础。     

股骨头缺血坏死患者的股骨近端骨改变

有研究显示 ,骨与假体界面或骨水泥与骨界面的松质骨不正常而引起固定失败[1 ] 。我们通过观察了解固定假体的股骨近端的骨质情况。1 .资料和方法 :股骨头坏死患者 1 8例 ,按照文献 [2 ]的标准分为Ⅲ～Ⅳ级 ,其中男性 1 2例 ,女 6例 ,平均年龄 50岁 ,其中酒精引起的 6例 ,激素引起的 5例 ,其他为原因不明 ,全部行全髋关节置换术。对照组为 1 8个骨性关节炎的患者 ,其中男性 1 0例 ,女性 8例 ,平均 62岁 ,均没有股骨头坏死的X线依据 ,也全部行全髋关节置换术。术中每个患者的股骨头切除后放在1 0 %的福尔马林缓冲液中浸泡。并从下列 4个部位…     

髋臼骨折合并股骨近端骨折初期治疗失败后的全髋关节置换术中期随访结果

背景:高能量髋臼骨折合并股骨头缺血性坏死和创伤性关节炎的发生率较高,既往关于髋臼骨折合并股骨近端骨折,特别是后期采用全髋关节置换术(THA)假体重建的的临床报告并不多见。目的:评价THA治疗初期治疗失败的髋臼骨折合并股骨近端骨的中期随访结果。方法:回顾性分析2002年1月至2017年12月初期发生髋臼骨折合并股骨近端骨折(股骨头骨折4例、股骨颈骨折7例、股骨粗隆间骨折7例以及股骨粗隆下骨折4例)的22例患者(22髋)。经治疗后继发严重创伤性关节炎或股骨头缺血性坏死而在二期接受全髋关节置换术重建。临床结果采用Harris髋关节评分系统对患者疼痛程度、髋关节功能及活动度进行评分。影像学结果依据髋关节X线检查进行评估。结果:所有患者随访26~205个月,平均(118.3±60.5)个月。术前Harris髋关节评分45.5(38.0,62.3)分;术后92.5(89.8,100.0)分,较术前显著提高(Z=5.670,P<0.001)。17例优,2例良,2例一般,1例较差。术后发生坐骨神经损伤1例,未出现关节脱位、假体周围感染和严重异位骨化等并发症。随访时均未出现明确的假体松动或下沉征象。无一病例翻修。结论:对于髋臼骨折合并股骨近端骨折病例经初次治疗后继发严重创伤性关节炎或股骨头缺血性坏死者,尽管采用全髋关节置换术重建的过程复杂,但中期临床和影像学结果满意,具有较高的患者满意度和较低的并发症发生率。     

SPECT断层骨显像对早期股骨头缺血坏死的诊断价值

作者对26例X线片检查无异常表现的股骨头缺血坏死患者的双髋关节SPECT断层显像进行了研究。结果显示,受累的32个股骨头均有骨坏死征象。认为SPECT断层显像对早期股骨头缺血坏死的诊断具有重要意义。     

SPECT断层骨显像对早期股骨头缺血坏死的诊断价值

作者对２６例Ｘ线片检查无异常表现的股骨头缺血坏死患者的双髋关节ＳＰＥＣＴ断层显像进行了研究。结果显示,受累的３２个股骨头均有骨坏死征象。认为ＳＰＥＣＴ断层显像对早期股骨头缺血坏死的诊断具有重要意义。     

股骨头骨坏死范围对髋关节表面置换术后股骨近端力学分布的影响

目的探讨髋关节表面置换术后股骨头骨坏死范围对股骨近端与假体松动或股骨颈骨折相关的应力分布的影响。方法依据基于连续CT断层图像构建的股骨三维图形和髋关节表面置换假体，采用计算机辅助技术，建立股骨头部无坏死和前后位坏死角分别为60°、80°、100°、120°、140°的表面置换三维有限元模型，单腿负重条件下，模拟坏死骨未清除及清除后填充骨水泥的情形进行受力分析。结果骨坏死范围对股骨颈部的应力分布影响微小。股骨头近端骨质出现明显的应力遮挡。当坏死角≤80°时，骨水泥界面和头颈交界骨质中的Von Mises等效应力峰值变化较小；当坏死角≥100°时，应力峰值变化明显，其中水泥层外上缘的峰值增幅为22．3％和27．3％（坏死角120°和140°），头颈交界外上缘骨质的峰值增幅为13．2％、28．3％和53．3％（坏死角100°、120°和140°）。填充骨水泥后，主要应力集中区的等效应力峰值逐渐减小或变化不明显。结论髋关节表面置换术改变了股骨头内应力分布；股骨头近端出现明显的应力遮挡，允许股骨头负重区出现小的骨坏死（坏死角≤80°）；坏死角≥100°的骨坏死，是否适于髋关节表面置换术还需深入研究。     

股骨颈骨折全髋关节置换术后股骨近端形态变化

目的:观察全髋关节置换(THA)治疗股骨颈骨折及股骨头坏死术后股骨近端形态改变,分析是否存在差异及其表现形式.方法:2014年1月至12月同一手术组连续股骨颈骨折和股骨头坏死行THA治疗的病例进行对比分析,其中股骨颈骨折患者22例,男11例,女11例,年龄44~83岁,平均(66.18±11.47)岁;股骨头坏死患者23例,男12例,女11例,年龄19~68岁,平均(51.91±11.76)岁.测量THA术后股骨高度,Offset,截骨位置和调整方式,进行统计分析.结果:全部患者获得测量,行THA治疗后,股骨颈骨折病例较股骨头坏死病例有更低的股骨高度,更小的Offset,更低的截骨位置,并发现了3种低位截骨后的调整方式.结论:股骨颈骨折行THA手术,有产生低截骨、较小Offset的可能,因低位截骨而进行的调整可能会对近远期疗效产生不良影响.     

金属对金属全髋关节表面置换术治疗股骨头骨坏死

背景：近来，随着改进型金属对金属关节假体的出现，全髋关节表面置换术发展成为一种可行的关节成形术式。然而，这种术式是否适用于股骨头坏死患者尚存争议，因为这类患者股骨侧假体是用骨水泥固定于坏死的股骨头表面。本研究的目的是分析股骨头坏死患者应用金属对金属全髋关节表面置换术后的临床和影像学结果，并将本组结果与诊断为骨关节炎的患者进行比较。 方法：对42个股骨头骨坏死的髋关节行金属对金属全髋关节表面置换术。根据年龄、性别、术者和手术入路，选择42个同样进行金属对金属全髋关节表面置换术的骨关节炎性髋作为对照。在骨坏死组，男25例，女11例；在骨关节炎组，男28例，女13例。手术时平均年龄42岁。对患者进行临床和影像学随访，平均随访41个月。 结果：两组临床结果相似，骨坏死组，效果优或良39髋（93％）；骨关节炎组，效果优或良41髋（98％）。两组各有2例失败而行标准的全髋关节成形术。两组患者生存曲线相似。 结论：对于活动量大的骨坏死患者进行金属对金属全髋关节表面置换术，短期随访可获得与骨关节炎患者相似的优良效果。我们期待长期随访是否也能得到类似的结果。 可信水平：治疗性研究，Ⅱ级。进一步可信度参见作者介绍。     

成人股骨头缺血性坏死骨髓内压变化规律及减压术的改进

目的 测定健康人股骨近端不同区域骨髓腔内压力正常值。探索成人股骨头缺血坏死不同期、不同部位骨髓腔内压力变化规律,改进传统骨髓内减压术。方法 选用26例健康人,52个股骨;117例患者,169个股骨。分股骨大粗隆、股骨颈、股骨头中心及股骨头负重区进行骨髓腔内压力测定。测压后,对117例患者股骨大粗隆、股骨颈、股骨头中心及股骨头负重区进行分区减压术。结果 健康人股骨近端骨髓腔内压力,股骨大粗隆〈股骨颈〈股骨头中心〈股骨头负重区。非创伤性股骨头缺血性坏死各期各区的骨髓内压均高于创伤性股骨头坏死。Ⅰ、Ⅱ期股骨头缺血性坏死股骨头中心、股骨头负重区压力明显高于大粗隆及股骨颈;Ⅲ、Ⅳ期股骨头中心及其股骨头负重区压力呈下降趋势,而股骨大粗隆及股骨颈反而升高。99例随访2～5年2个月,根据修订后的’82北京髋关节疗效评定标准评价：优45例,良42例,可7例,差5例。结论 股骨近端分区钻孔减压术可缓解疼痛,对于保护性关节活动受限也可很快得以改善,同时可以刺激血管再生,是一种行之有效的治疗方法。     

The extent of osteocyte death in the proximal femur of patients with osteonecrosis of the femoral head

Our aim was to assess the local extent of osteocyte death in the proximal femur of 16 patients with osteonecrosis of the femoral head. We performed histological examination of the femoral heads and cancellous bone biopsies from four regions of the proximal femur in patients undergoing total hip arthroplasty. A control group consisted of 19 patients with osteoarthritis. All histological specimens were examined in a blinded fashion. Extensive osteonecrosis was shown in the proximal femur up to 4 cm below the lesser trochanter in the group with osteonecrosis. There was an overall statistically significant difference in the extent of osteocyte death distal to the femoral head between the two groups (p < 0.001). We discuss the implications of these findings as possible contributing factors in regard to the early failure of total hip arthroplasty reported in patients with osteonecrosis of the femoral head.     

Histologic analysis of acetabular and proximal femoral bone in patients with osteonecrosis of the femoral head

BACKGROUND: The purpose of this study was to investigate the hypothesis that osteonecrosis of the femoral head may also involve the acetabulum and the proximal part of the femur. METHODS: Twenty-five patients who underwent simultaneous bilateral total hip arthroplasty and thirty-eight patients who had a unilateral total hip arthroplasty for treatment of symptomatic osteonecrosis of the femoral head were included in the study. There were fifty-five men and eight women. The etiology of the osteonecrosis was idiopathic in forty patients (fifty-six hips, 64%), associated with ethanol abuse in eighteen patients (twenty-five hips, 28%), and associated with steroid use in five patients (seven hips, 8%). The mean age of the patients at the time of arthroplasty was 47.1 years. We performed cancellous bone biopsies in the acetabulum, the proximal part of the femur, and the femoral head intraoperatively and then examined the specimens histologically. RESULTS: Of the eighty-one hips with idiopathic or ethanol-associated osteonecrosis, seventy-six (94%) had normal or stage-1 bone in the acetabulum and the proximal part of the femur according to the system of Arlet and Ficat, and seventy-eight (97%) of the eighty-one had a grade of 0 or 1 according to the system of Humphreys et al. Of the seven hips with steroid-associated osteonecrosis, four had normal or stage-1 bone and a grade of 0 or 1 and three had stage-2 or 3 disease and a grade of 2 or 3. Therefore, the vast majority of hips with idiopathic or ethanol-associated osteonecrosis had normal or nearly normal bone in the acetabulum and the proximal part of the femur. Three of the seven hips with steroid-associated osteonecrosis had abnormal bone in the proximal part of the femur only. CONCLUSIONS: One can expect to find normal or nearly normal cancellous bone in the acetabulum and the proximal part of the femur of patients with either idiopathic or ethanol-associated osteonecrosis of the hip. More extensive osteonecrosis may accompany steroid-associated osteonecrosis of the hip.     

Decreased osteogenic differentiation of mesenchymal stem cells in alcohol-induced osteonecrosis

We postulated that osteogenic and adipogenic differentiation ability of the mesenchymal stem cells isolated from the bone marrow could be altered in patients with alcohol-induced osteonecrosis of the femoral head. To examine this hypothesis, we investigated the differentiation ability of the mesenchymal stem cells isolated from the bone marrow from the proximal end of the femur during hip replacements in patients with alcohol-induced osteonecrosis of the femoral head and compared it with the differentiation ability of patients with femoral neck fractures. Marrow was collected from the proximal femurs of 33 patients having hip replacement for either alcohol-induced osteonecrosis of the femoral head or femoral neck fractures. The mesenchymal stem cells were isolated and the culture was expanded from the marrow. The cell populations were compared in terms of the doubling time and the differentiation ability to the osteoblasts and adipocytes. The cells obtained from the patients with alcohol-induced osteonecrosis of the femoral head showed a reduced ability to differentiate the osteogenic lineages compared with the cells obtained from the patients with femoral neck fractures. Such changes may play a role in the development of alcohol-induced osteonecrosis of the femoral head. The altered function of mesenchymal stem cells can be responsible for the pathogenesis of osteonecrosis.     

Avascular necrosis of the femoral head after intertrochanteric fractures

OBJECTIVE: To determine factors that may influence the appearance of avascular necrosis after intertrochanteric fractures. DESIGN: Retrospective. SETTING: University hospital. PATIENTS: Twelve patients between the ages of fifty-nine and eighty-eight who had developed avascular necrosis of the femoral head after treatment of an intertrochanteric femur fracture at our institution between 1976 and 1995. Fractures were classified according to Kyle and Gustilo. There were three Type I, two Type II, six Type III, and one Type IV fractures. MAIN OUTCOME MEASURES: Risk factors for osteonecrosis, fracture pattern, surgical influence, location of the nail within the femoral head, and valgus malalignment. RESULTS: All fractures healed. Five patients had risk factors for osteonecrosis. Intertrochanteric fractures with a proximal fracture line appeared in five patients. The nail tip was situated in every quadrant of the femoral head. Valgus malalignment occurred in three cases. CONCLUSIONS: Avascular necrosis of the femoral head is an uncommon complication after intertrochanteric fractures. The pathogenesis is unknown, but in patients developing pain who have had intertrochanteric fractures, osteonecrosis should be included in the differential diagnosis, especially in cases with risk factors for osteonecrosis or a proximal intertrochanteric fracture line that perhaps disrupts the vascular anastomotic ring at the base of the femoral neck.     

The relationship between osteonecrosis of the proximal femur identified by MRI and lesions proven by histological examination

Total hip replacement in patients with advanced osteonecrosis of the femoral head is often complicated by early loosening of the femoral component. Recent evidence has suggested that abnormal bone extending into the proximal femur may be responsible for the early failure of the femoral component. We aimed to identify which patients were at high risk of early failure by evaluating gadolinium-enhanced MR images of histologically-confirmed osteonecrotic lesions beyond the femoral head. Although the MR signal intensity has been shown to correlate well with osteonecrosis in the femoral head, it was found to be relatively insensitive at identifying lesions below the head, with a sensitivity of only 51% and a predictive value of a negative result of only 48%. However, the specificity was 90%, with the predictive value of a positive MRI finding being 86%. Only those patients with osteonecrosis of the femoral head secondary to sickle-cell disease, who are known to be at high risk of early loosening, had changes in the MR signal in the greater trochanter and the femoral shaft. This observation suggests that changes in the MR signal beyond the femoral head may represent osteonecrotic lesions in areas essential for the fixation of the femoral component. Pre-operative identification of such lesions in the neck of the femur may be important when considering hip resurfacing for osteonecrosis of the femoral head, following which early loosening of the femoral component and fracture of the neck are possible complications.     

Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children

BACKGROUND: Recent reports have described osteonecrosis of the femoral head after intramedullary nailing of the femur through the piriformis fossa in children. Other reports have raised concerns about the development of femoral neck narrowing and valgus deformity of the proximal part of the femur after intramedullary nailing through the tip of the greater trochanter. We evaluated the radiographic changes in the proximal part of the femur following intramedullary nailing through the lateral trochanteric area at a minimum of two years postoperatively in twenty-five affected extremities. The mean age of the patients at the time of the index procedure was ten years and six months. METHODS: A retrospective radiographic review was performed to look for proximal femoral changes. Specifically, the radiographs were examined for evidence of osteonecrosis. The articulotrochanteric distance, femoral neck diameter, and neck-shaft angle were measured on the initial and final radiographs. RESULTS: No patient had evidence of osteonecrosis of the femoral head. The articulotrochanteric distance decreased by a mean of 0.4 mm, the femoral neck diameter increased by a mean of 4.9 mm, and the neck-shaft angle decreased by a mean of 1.4 degrees. Compared with a group of seventeen patients with adequate initial and final radiographs of the contralateral side, the final mean articulotrochanteric distance was 4.5 mm less on the involved side than on the uninvolved side, the mean femoral neck diameter was 0.7 mm less on the involved side than on the uninvolved side, and the mean neck-shaft angle was 3.2 degrees less on the involved side than on the uninvolved side. No patient had development of clinically important femoral neck narrowing or valgus deformity. Statistically, the likelihood that these data represent a group with a mean 3-mm increase in the articulotrochanteric distance is <1%. The likelihood that these data represent a group with a mean 3.2-mm decrease in the ultimate femoral neck diameter is <1%. The likelihood that these data represent a group with a mean 5 degrees increase in the neck-shaft angle is <1%. CONCLUSIONS: Lateral transtrochanteric intramedullary nailing in children who are nine years of age or older does not produce clinically important femoral neck valgus deformity or narrowing, and we did not observe osteonecrosis of the femoral head after this procedure.     

Decrease in the mesenchymal stem-cell pool in the proximal femur in corticosteroid-induced osteonecrosis

We have evaluated bone-marrow activity in the proximal femur of patients with corticosteroid-induced osteonecrosis and compared it with that of patients with osteonecrosis related to sickle-cell disease and with a control group without osteonecrosis. Bone marrow was obtained by puncture of the femoral head outside the area of necrosis and in the intertrochanteric region. The activity of stromal cells was assessed by culturing fibroblast colony-forming units (FCFUs). We found a decrease in the number of FCFUs outside the area of osteonecrosis in the upper end of the femur of patients with corticosteroid-induced osteonecrosis compared with the other groups. We suggest that glucocorticosteroids may also have an adverse effect on bone by decreasing the number of progenitors. The possible relevance of this finding to osteonecrosis is discussed.     

Preservation of bone mineral density of the proximal femur following hemisurface arthroplasty

Bone mineral density of the proximal femur was measured in six patients who underwent hemisurface replacement for osteonecrosis of the femoral head. Bone mineral density values in operated and contralateral nonoperated hips were compared. In four patients who had sequential examinations, bone mineral density was compared over time. Average patient age was 34.6 years, average follow-up was 9.1 years, and mean follow-up of bone mineral density measurements was 6.6 years. Average bone mineral density variation was 0.0048 to -0.0264 g/cm2 per year in all five regions in nonoperated hips and -0.012 to -0.0300 g/cm2 in operated hips. These results support bone conservation and preservation with hemiresurfacing arthroplasty in young patients with osteonecrosis of the femoral head.     

Optimizing free fibular grafting in femoral head osteonecrosis: the Ioannina aiming device

The extracapsular placement of a vascularized fibular graft in the subchondral region of the femoral head now is a widely accepted method for treating patients with osteonecrosis of the femoral head. The effectiveness of the fibular graft seems to be dependent on precise placement in a biologically and anatomically relevant site within the femoral head. The current authors present the Ioannina technique for application of a new computer-aided design and computer-aided manufacturing process in the treatment of osteonecrosis of the femoral head using free vascularized fibular transplantation. The objective was to develop a computer-assisted design and manufacturing system for an accurate and easier approach to the necrotic area in the femoral head. The Ioannina technique uses serial computed tomography scans of the proximal femur to identify the configuration of the proximal femur, and the size, location, and configuration of the lesion using a computer-aided design and computer-aided manufacturing process. Optimal graft placement is determined and a guide wire canal is drilled into an patient-specific aiming device. In this process, identification of the optimal graft location is related to achieving that location surgically. The more arbitrary placement of the graft during conventional fibular graft surgery leads to accurate graft placement in only 55% of the patients, whereas the use of the patient-specific Ioannina aiming device resulted in optimal graft placement in 89% of the patients.