股骨头坏死的关节镜下表现及分析

目的关节镜下观察股骨头坏死的病理表现并对其进行分析。方法对27例（38髋）股骨头坏死施行髋关节镜手术，其中男19例，女8例。FicatⅠ期8髋，Ⅱ期21髋，Ⅲ期7髋，Ⅳ期2髋。关节镜下探查股骨头、髋臼和滑膜组织的外观及质地，同时镜下行关节清理及股骨头微钻孔髓心减压术。结果镜下见Ⅰ期：股骨头表面关节软骨完整无破坏。外观及触探质地正常。滑膜组织充血肿胀。Ⅱ期：股骨头表面大部分区域正常，负重区软骨软化，有裂隙，触探有凹陷，软骨下骨坏死区域有裂隙形成，但软骨钙化层与软骨尚未分离。坏死骨表面硬化，如沙砾样粗糙。滑膜组织增生。Ⅲ期：软骨大面积剥脱，与软骨下骨分离。软骨下骨塌陷、碎裂，内有无效修复的肉芽组织。Ⅳ期：呈骨性关节炎样改变，关节间隙变窄，股骨头表面软骨缺损，软骨下骨外露、坏死、塌陷，髋臼软骨退变。结论关节软骨的损害是股骨头坏死病程中的重要环节。关节镜技术对股骨头坏死的价值主要在于评估关节软骨的受累程度，对治疗方法的选择具有重要的参考价值。     

髓芯减压、空心钛钉植入治疗股骨头坏死

目的研究自体红骨髓组织工程复合物联合髓芯减压、空心钛钉植入治疗早期股骨头坏死临床应用的疗效。方法本组12例,男性9例,女性3例,双侧股骨头3例,右单侧7例,左单侧2例。术前均行X线摄片、CT、MRI检查,ARCO分期,Ⅰ期4髋,Ⅱ期11髋;C型臂X线透视下行股骨头坏死区和囊性变区定位、髓芯减压,关节镜监视下刮除坏死骨,送病理;植入由自体红骨髓与骨诱导活性材料复合成的非细胞型组织工程骨,空心钛钉支撑股骨头软骨下骨质。结果本组12例均获得随访,随访时间12～24个月,平均18个月。采用12分法评分系统评定,优8髋,良5髋,可2髋,差0髋,优良率为86．66％。结论髓芯减压、自体红骨髓非细胞型组织工程骨植入、空心钛钉支撑治疗早期股骨头坏死在减轻疼痛、改善关节功能、防止股骨头塌陷方面具有较好的作用。     

暂时性骨质疏松症与股骨头坏死继发骨髓水肿临床分析

目的 探讨暂时性骨质疏松症(transient osteoporosis of the hip,TOH)与股骨头坏死继发骨髓水肿在临床症状及影像学上的差异. 方法 对2006年1月-2008年2月收治的5例(5髋)TOH及63例(67髋)股骨头坏死继发骨髓水肿患者分析其病因、发病诱因、疼痛程度、持续时间及病情转归等方面的差异,并分析X线片、MRI和ECT改变的异同点.5例TOH患者,男1例,女4例;年龄29～42岁.63例(67髋)股骨头坏死继发骨髓水肿患者,男53例,女10例:年龄18～70岁;根据ARGO分期标准,Ⅱ期23髋,Ⅲ期43髋,Ⅳ期1髋. 结果 TOH与股骨头坏死继发骨髓水肿患者在发病诱因、疼痛程度、关节积液和ECT改变上无差异.TOH患者发病前无股骨头坏死相关病因;发病前无不适症状;2髋X线片表现为密度降低;MRI水肿信号改变在股骨头颈的上方或整个股骨头;治疗后5～11个月疼痛消失后无残留症状.65髋股骨头坏死继发骨髓水肿患者有股骨头坏死的相关诱因:10髋表现为疼痛加重;59髋X线片上有硬化改变;MRI水肿信号改变在股骨头坏死灶的外侧,水肿信号消退后仍有轻度疼痛. 结论 TOH与股骨头坏死继发骨髓水肿在临床表现、X线片及MRI图像改变上存在差异.     

SARS后双侧股骨头坏死进展前瞻性分析

目的通过对SARS患者随访,了解应用激素后双侧股骨头坏死的发生发展状况,观察股骨头坏死的影象学变化。方法自2003年7月～2008年7月对北京市的使用激素治疗的539例SARS患者进行了随访,全部患者在开始使用激素后2～6个月行双髋MRI检查、X线摄片以及体格检查等,检出后定期行坏死关节的X线摄片及CT扫描,如出现关节疼痛等则及时摄片观察。股骨头坏死按照ARCO国际骨循环协会分期,III期作为观察终点。结果 539例应用激素者检出骨坏死176例(32.7%),其中累及股骨头为130例,双侧股骨头骨坏死86例;病例占股骨头坏死的66.2%。73例得到连续随访。目前进入III期为6～46个月,73例146髋中塌陷27髋,23髋为IIC期进展,4髋为IIB期进展;双侧塌陷4例。负重面外侧型(49髋)塌陷23髋,负重面中央型(61髋)塌陷4髋,负重面内侧型(36髋)无塌陷。早期MRIT1中低信号带的形态:开放型-开放型27例,塌陷12例16髋;开放型-包含型25例,开放型塌陷9例9髋,包含型塌陷2例2髋;包含型-包含型21例,无塌陷髋。开放型塌陷比例为25/79;包含型塌陷比例为2/67。结论坏死灶的大小位置影响双侧股骨头坏死的预后;坏死灶上负重面外侧型更易早塌陷;对于双侧股骨头坏死的病例,MRI显示相似的面积,T1低信号带包含型者,预后相对较好;CT显示软骨下骨均匀增厚或明显的"焊接"现象是延迟塌陷的因素;但是软骨下骨没有或有不均匀(不连续)硬化是危险因素。     

早中期股骨头坏死疼痛与坏死面积及关节积液分级相关性分析

目的探讨早中期股骨头坏死疼痛与坏死面积及关节积液分级的相关性。方法 76例(116髋)患者进行研究。其中男47例,女29例;平均年龄39岁(21~62岁);左侧55髋,右侧61髋。其中Ⅰ期5髋,Ⅱ期44髋,Ⅲ期67髋。所有患者均行标准正位和蛙式位X线片、轴位CT扫描及冠状位、矢状面重建等检查,所有患者均接受MRI检查判断早期坏死范围及关节积液等级。根据MRI、CT及X线片表现确定ARCO分期,参考Liu等关节积液分级作为关节积液量评判标准,以语言模拟评分法(verbal rating scale,VRS)作为描述性疼痛的程度分级法,以Kruskal-Wallis秩和检验作为检验方法。结果随着股骨头坏死的进展,疼痛也逐渐加重;Ⅱ期和Ⅲ期中坏死范围越大,疼痛症状加重;关节积液分级与疼痛呈正相关。结论早中期股骨头坏死疼痛与坏死范围及关节积液均有密切联系,坏死范围大,积液多则疼痛重。     

X线、MRI在膝关节退行性骨关节病中的诊断价值

目的:分析X线片、MRI在膝关节退行性骨关节病变中的诊断价值。方法:分析96例101个膝关节退行性骨关节病的X线片、MRI表现,并与手术结果进行对照。结果:X线片能对膝关节骨皮质的连续性、松质骨的疏密、关节间隙的宽窄及关节的稳定性进行客观的反映,且对软骨下增殖骨的显示优于MRI,而对骨质吸收、游离体的显示略逊色于MRI,对显示关节软骨、半月板及滑膜的一系列改变明显不及MRI。结论:对膝关节退行性病,X线片仍是必不可少的基础检查,MRI是最佳检查方法,可为临床诊治提供确切的依据。     

X线平片、CT和MRI诊断滑膜骨软骨瘤病

目的比较X线、CT和MRI对滑膜骨软骨瘤病的诊断价值。方法回顾性分析20例经手术病理证实的滑膜骨软骨瘤病患者的X线平片（n=18）、CT（n=20）和MRI（n=10）表现。结果 X线平片正确诊断15例,CT正确诊断18例,MRI正确诊断8例。X线平片、CT和MRI均能显示关节周围及关节内形态多样、大小不一、数量不等的游离体;X线平片和CT均可显示游离体的钙化;MRI可显示早期软骨游离体;CT和MRI可发现关节腔积液。结论 X线平片、CT及MRI均能诊断本病,CT和MR检查能发现X线平片不能检出的病灶和征象。     

激素治疗SARS患者中期随访的髋部MRI表现

目的 对应用激素治疗的严重急性呼吸综合征(severe acute respiratory syndrome,SARS)患者进行中期髋部MRI随访,探讨早期股骨头坏死和未发生股骨头坏死即正常股骨头的MRI特征.方法 2003年6月至2004年1月对539例(1078髋)应用激素治疗的SARS患者行MR及X线榆查,诊断股骨头坏死210髋,无股骨头坏死868髋.2007年2至11月对510例(1020髋)SARS患者再行MR及X线复查.观察早期股骨头坏死和未发生股骨头坏死股骨头的MRI表现及其变化.结果 末次随访时无新发股骨头坏死病例,应用激素冲击治疗的SARS患者MRI影像上的股骨头坏死均出现在激素治疗后的6个月内.股骨头塌陷或手术后,股骨头坏死的信号类型发生改变,表现为T1加权像低信号,对应STIR序列上高信号.3髋出现坏死范围减小.正常股骨头在T1加权像上有四种MRI影像类型.24髋初次诊断无股骨头坏死者T1加权像出现异常表现,但STIR序列均无异常高信号.这些信号类型在随访的MRI上发生了改变.结论 应用激素冲击治疗的SARS患者,MRI影像上出现股骨头坏死均发生在激素治疗后的6个月内,少数早期坏死股骨头的坏死范围会减小.正常股骨头的MRI影像存在变异.T1加权像上低信号带、对应STIR序列上高信号可作为股骨头坏死的诊断标准.     

不典型非创伤性股骨头坏死的诊断

目的探讨不典型非创伤性股骨头坏死的影像表现及诊断方法。方法回顾性分析8例(8髋)非创伤性股骨头坏死的不典型影像表现,并按照年龄、性别、病灶大小与典型非创伤性股骨头坏死对照比较临床表现及影像特点。结果8例(8髋)病理结果与非创伤性股骨头坏死相符。8例(8髋)不典型非创伤性股骨头坏死MRI均无典型T1WI的带样征,无明显T2WI双线征;X线平片及CT无典型硬化带,仅有针尖样钙化。临床表现与典型非创伤性股骨头坏死无明显差异。结论少数非创伤性股骨头坏死出现不典型影像特点,诊断应结合病理。     

股骨头髓心减压加异体腓骨移植术治疗股骨头坏死

目的探讨股骨头髓心减压加异体腓骨移植术治疗早期股骨头缺血性坏死的疗效。方法1998年6月～2004年8月，采用股骨头髓心减压加异体腓骨移植术治疗Ⅰ～Ⅲ期股骨头缺血性坏死22例39髋，其中男17例，女5例。年龄22～60岁。术前疼痛时间2～12个月，平均6、5个月。所有患者于术前及术后15d，3个月和6个月行双髋关节功能、常规X线片、ECT、CT和MRI检查。结果患者均获随访3～74个月，平均31．4个月。17例临床症状缓解明显，Harris评分从术前平均78分升至术后91．6分。18例X线片显示髋关节形态基本保持完好，无明显坏死进展。ECT、CT和MRI检查均见植骨成骨征象。有2例4髋于1年半后改行人工全髋关节置换术。另有3例4髋症状有所加重，但未行人工关节置换术。结论股骨头髓心减压加异体腓骨移植术治疗早期股骨头缺血性坏死，手术损伤小，术后关节功能2～4周即可恢复或超过术前水平，临床症状改善。其短期疗效肯定，中长期疗效仍需进一步观察。     

Degeneration of the acetabular cartilage in osteonecrosis of the femoral head: Histopathologic examination of 15 hips

Acetabular cartilage with subchondral bone was taken from the superior dome from 15 hips of 13 patients undergoing total hip arthroplasty due to osteonecrosis of the femoral head. The mean age of the patients was 40 years. There were 10 hips ARCO stage IIIA, and 5 hips stage IIIB. 3 of the cases were mild, 12 moderate, and 1 had severe arthrosis. The degree of collapse of the femoral head was significantly related to the degeneration of the acetabular cartilage on histological examination. Our observations support the view that patients with an ARCO Stage III hip do not benefit from head-preserving procedures. They may also explain why bipolar prosthesis gives poorer results than total hip arthroplasty, in cases of osteonecrosis of the femoral head.     

Degeneration of the acetabular cartilage in osteonecrosis of the femoral head: Histopathologic examination of 15 hips

Acetabular cartilage with subchondral bone was taken from the superior dome from 15 hips of 13 patients undergoing total hip arthroplasty due to osteonecrosis of the femoral head. The mean age of the patients was 40 years. There were 10 hips ARCO stage IIIA, and 5 hips stage IIIB. 3 of the cases were mild, 12 moderate, and 1 had severe arthrosis. The degree of collapse of the femoral head was significantly related to the degeneration of the acetabular cartilage on histological examination. Our observations support the view that patients with an ARCO Stage III hip do not benefit from head-preserving procedures. They may also explain why bipolar prosthesis gives poorer results than total hip arthroplasty, in cases of osteonecrosis of the femoral head.     

Degeneration of the acetabular cartilage in osteonecrosis of the femoral head: histopathologic examination of 15 hips

Acetabular cartilage with subchondral bone was taken from the superior dome from 15 hips of 13 patients undergoing total hip arthroplasty due to osteonecrosis of the femoral head. The mean age of the patients was 40 years. There were 10 hips ARCO stage IIIA, and 5 hips stage IIIB. 3 of the cases were mild, 12 moderate, and 1 had severe arthrosis. The degree of collapse of the femoral head was significantly related to the degeneration of the acetabular cartilage on histological examination. Our observations support the view that patients with an ARCO Stage III hip do not benefit from head-preserving procedures. They may also explain why bipolar prosthesis gives poorer results than total hip arthroplasty, in cases of osteonecrosis of the femoral head.     

Resection arthroplasty for septic arthritis of the hip in ambulatory and nonambulatory adult patients

Twenty-three patients who required resection arthroplasty because of pyogenic infection of a hip joint were reviewed. Nine of the patients were ambulatory, and the others were either paraplegic or bed-ridden because of chronic neurologic disease. The average duration of symptoms was more than two months. The only consistently abnormal laboratory test was the erythrocyte sedimentation rate (ESR). Joint-space narrowing and bone erosion due to osteomyelitis were the most common roentgenographic findings. Different microorganisms were isolated from the different cases, but Staphylococcus aureus was documented in eight hips. Femoral head dislocation of subluxation was documented in 11 of 24 hips. Osteoarthrosis or osteonecrosis was a preexisting condition in only four hips, all in ambulatory patients. Pathologic findings included loss of articular cartilage by surface erosion and by subchondral bone resorption, resulting in the separation of the cartilage from the underlying bone, bone erosion, osteomyelitis, and segmental osteonecrosis.     

Signal variability in magnetic resonance imaging of femoral head osteonecrosis

The present study was designed to document the pattern and extent of magnetic resonance imaging (MRI) changes in femoral head osteonecrosis and also to correlate MRI findings with technetium bone scans and computed tomograms. Over a three-year period, MRI was performed on 26 patients who had clinical and roentgenographic evidence of femoral head necrosis in one or both hips. MRI abnormalities were present in all 41 hips with osteonecrosis, even when symptoms were absent and roentgenographic findings were nonspecific or not yet apparent. A single possible false-positive MRI was noted in a hip with mild degenerative change. There was considerable variation in the pattern and extent of MRI abnormalities. The most common findings were irregularity of the subchondral cortical outline (82.9%), an inhomogeneous pattern of signal loss (50%), focal increases in signal intensity with T2 weighting (35.5%), and effusion (33.3%). Regions of dense cancellous bone on computed tomograms correlated with bands of low-intensity MRI signal. In the diagnosis of asymptomatic hips, MRI was clearly more sensitive than technetium bone imaging. The role of MRI in defining prognosis and treatment selection remains to be established.     

Pathology of femoral head collapse following transtrochanteric rotational osteotomy for osteonecrosis

We investigated the pathology of femoral head collapse following transtrochanteric anterior rotational osteotomy. Six femoral heads were obtained during total hip arthroplasty some 2–12 years after osteotomy. In all cases, the preoperatively necrotic lesions exhibited mostly osteonecrosis with accumulation of bone marrow cell debris and trabecular bone with empty lacunae, although repair tissue such as granulation tissue and appositional bone formation were observed in limited areas in some cases. In the transposed intact articular surface of the femoral head, osteoarthritic changes such as fissure penetration to the subchondral bone and osteophyte formation were commonly observed. In newly created subchondral areas at weight-bearing sites, trabecular thickness and the number of trabecular bones had decreased, with few osteoblasts, osteoclasts, and osteocytes being present, resulting in a coarse lamellar structure of the trabecular bone. These findings suggest that transposed areas in cases of failure consist mostly of low-turnover osteoporotic lesions which could cause collapse of the femoral head. Received: 5 October 1999     

Effect of hip hemiarthroplasty on articular cartilage and bone in a canine model

The purpose of this study was to determine if acetabular articular cartilage damage occurs in the presence or absence of changes in subchondral plate thickness or porosity and trabecular bone architecture after hip hemiarthroplasty. Eight canines were sacrificed 6 months after receiving unilateral hemiarthroplasties in which a cobalt chrome alloy femoral head was used. The acetabular cartilage, subchondral plate, and trabecular bone were quantitatively evaluated. Although the articular cartilage in the treated hip showed gross and histologic degenerative changes, there were no differences in the treated and contralateral hips in any of the trabecular bone parameters or subchondral plate thickness. However, the subchondral plate porosity was increased 2.6-fold in the treated hip. Therefore, degradation of cartilage can occur in the absence of thickening of the subchondral plate or alterations in the supporting trabecular bone architecture. These observations provide a better understanding of the role that periarticular bone has in the degenerative process after hemiarthoplasty.     

Scanning electron microscopic study of subchondral bone tissues in osteoarthritic femoral head]

In total hip replacement for 12 aged women with advanced osteoarthritis of the hip joint, three types of lesioned articular cartilage with various degrees of severity and ivory bone were obtained together with their subchondral bone tissues. These specimens were processed and studied under scanning electron microscope and were compared with sex and age-matched non-osteoarthritic femoral head articular cartilage specimens. In osteoarthritic femoral heads, with deepening of the articular lesion, the articular cartilage gradually became thinned out and eventually lost. The subchondral bone plate became markedly thickened in most of the specimens. The epiphyseal trabeculae were also thickened and turned rough so that the meshwork pattern gradually disappeared. The thickened trabeculae finally fused into a large piece of dense bone tissues without microfracture. These changes could be accounted for by the increased stress imposed on the subchondral bone tissues as a result of incompetence of the diseased articular cartilage. Consequently, the changes on the part of subchondral bone tissues of the osteoarthritic femoral heads were the sequent, rather than the cause, of the articular lesions.     

Biophysical stimulation in osteonecrosis of the femoral head

Osteonecrosis of the femoral head is the endpoint of a disease process that results from insufficient blood flow and bone-tissue necrosis, leading to joint instability, collapse of the femoral head, arthritis of the joint, and total hip replacement. Pain is the most frequent clinical symptom. Both bone tissue and cartilage suffer when osteonecrosis of the femoral head develops. Stimulation with pulsed electromagnetic fields (PEMFs) has been shown to be useful for enhancing bone repair and for exerting a chondroprotective effect on articular cartilage. Two Italian studies on the treatment of avascular necrosis of the femoral head with PEMFs were presented in this review. In the first study, 68 patients suffering from avascular necrosis of the femoral head were treated with PEMFs in combination with core decompression and autologous bone grafts. The second one is a retrospective analysis of the results of treatment with PEMFs of 76 hips in 66 patients with osteonecrosis of the femoral head. In both studies clinical information and diagnostic imaging were collected at the beginning of the treatment and at the time of follow up. Statistical analysis was performed using chi-square test. Both authors hypothesize that the short-term effect of PEMF stimulation may be to protect the articular cartilage from the catabolic effect of inflammation and subchondral bone-marrow edema. The long-term effect of PEMF stimulation may be to promote osteogenic activity at the necrotic area and prevent trabecular fracture and subchondral bone collapse. PEMF stimulation represents an important therapeutic opportunity to resolve the Ficat stage-I or II disease or at least to delay the time until joint replacement becomes necessary.     

Subchondral screw fixation of cervical hip fractures: joint congruence studied with combined arthrography and tomography

This study was done to determine whether fixation with the Uppsala internal fixation technique into the subchondral bone of the femoral head in the treatment of cervical hip fractures could lead to elevation of the femoral head cartilage. Combined arthrography and frontal tomography of the hip joint in the plane of the screws was performed. The series consisted of 16 patients. In two of the patients, the tips of the screws had penetrated into the cartilage of the femoral head. In the other 14, the internal fixation was technically correct with the tips of the screws in the subchondral bone. In the two hips with the screws penetrating into the cartilage, the cartilage was slightly elevated. In the hips where the screws were in the correct position, no incongruities or deformity in the cartilage could be detected. Combined arthrography and frontal tomography can, therefore, detect elevation of the cartilage of the femoral head. By placing the screws in the immediate subchondral bone, no elevation of the cartilage of the femoral head surface should occur.