保留股骨头手术治疗股骨头缺血性坏死1005例临床分析

目的探讨股骨头缺血性坏死保留股骨头的外科治疗方法。方法对采用带旋股外侧血管升支髂骨瓣、带旋股外侧血管横支大转子骨瓣、带旋股外侧血管降支骨膜支骨膜瓣及旋髂深血管蒂髂骨瓣及联合骨瓣方法治疗并获得临床随访的1005例患者（1226髋）进行回顾分析。其中男性579例（695髋）,女性426例（53l髋）;年龄17～65岁,平均年龄37.4岁;Ficat Ⅱ期485髋,Ⅲ期473髋,Ⅳ期268髋;Harris髋关节功能评分平均56.2分;术后随访1.5～15年,平均随访5.1年。根据Harris髋关节功能评分标准进行临床评价,根据手术前后Ficat分期改变进行影像学评价。结果57例61髋于术后1～6年改行人工全髋关节置换术。股骨头得到重建的病例,术后Harris髋关节功能评分提高至平均85.8分,其中临床成功率为89.4％（104l髋）,影像学成功率为75.4％（878髋）。Ficat Ⅱ期优良率为95.3％,Ⅲ期为87.9％,Ⅳ期为60.8％。结论应用显微外科技术,针对不同程度的股骨头缺血性坏死采用单纯或联合带血管蒂骨（膜）瓣转移,是青壮年股骨头缺血性坏死患者保留股骨头的有效治疗方法。     

带血管蒂髂骨膜瓣移植术治疗股骨头缺血性坏死

带血管蒂髂骨膜瓣移植术治疗股骨头缺血性坏死王成琪，范启申，王剑利，王增涛，张树明股骨头缺血性坏死发病原因尚不太清楚，但是不论是成人还是小儿，造成股骨头坏死的原因是血供不良，因此在病程的各个时期如何改善股骨头血供是治疗该病的主要措施。￣［１，４］我们自...     

带旋髂深血管髂骨膜瓣植入治疗股骨头缺血性坏死

股骨头缺血性坏死是骨科常见且病残较高的一种疾病。从１９９２年２月至１９９７年６月，我们应用带旋髂深血管蒂的髂骨膜植入的方法，治疗股骨头缺血性坏死１６例１９髋，经观察疗效尚满意。报道如下。临床资料本组１６例１９髋，其中男１４例１６髋，女２例３髋。年龄最...     

带旋髂深血管髂骨瓣移植治疗股骨头缺血性坏死

目的 探讨带旋髂深血管髂骨瓣移植治疗股骨头缺血性坏死(ischemic necrosis of the femoral head，INFH)的方法及疗效。方法 1996年2月～2003年9月对46例58髋INFH，其中采用带旋髂深血管的髂骨瓣移植治疗44例56髋，2例2髋采用缝匠肌骨瓣治疗。左侧34髋，右侧24髋；Ⅱ期16髋，Ⅲ期39髋，Ⅳ期3髋。结果 术后37例40髋获随访6个月～10年，平均3.1年。根据范启申的评定方法：优19例21髋；良11例12髋；中5例5髋；差2例2髋，优良率81％。结论 带旋髂深血管的髂骨瓣手术治疗INFH具有重建股骨头血运、髓腔减压、清除坏死骨和支撑股骨头软骨的特点。带旋髂深血管的髂骨瓣手术是治疗INFH的有效方法。     

股骨头坏死的外科治疗

股骨头坏死(osteonecrosis 0fthe femoral head,0NFH)由于病因、发病机制不明,给临床治疗带来困难,目前为止尚无一种方法能到满意的临床治疗效果.普遍认为外科治疗是ONFH主要的治疗方法,积极的外科治疗效果要优于保守治疗.外科治疗能够治愈ONFH或延缓ONFH疾病进展,缓解疼痛,恢复关节功能.外科治疗包括ONFH早、中期(Ficat Ⅰ～Ⅲ期)保留股骨头的各种手术治疗方法,和ONFH晚期(FicatⅢ～Ⅳ期)各种人工关节置换治疗方法.本文就近年来ONFH外科治疗研究进展作一综述.     

Trapdoor手术治疗股骨头缺血性坏死

目的　报道成人非创伤性股骨头坏死的手术治疗。方法　非创伤性股骨头坏死 10例 ,平均年龄 39岁 ,Ficat分期Ⅱ～Ⅲ期。其中Ⅱa 3例 ,Ⅱb5例 ,Ⅲ期 2例。采用经股骨头负重区开瓣死骨清除 ,取髂骨植骨术 ,结果　平均随访 32个月。根据Harris临床评分 ,Ⅱb 以前 8例效果满意 ,优良率达 85 5 %。结论　该手术对于Ⅱb 以前软骨面完好的病人效果优良     

肌骨瓣治疗股骨头缺血性坏死32例

1　临床资料1 1　一般资料本组 3 2例 41髋 ,男 2 7例 ,女 5例 ,最大年龄 65岁 ,最小年龄 2 0岁 ,平均 3 9 5岁 ;左侧 10例 ,右侧 13例 ,双侧 9例 ;病史 :有长期饮酒史 11例 ,用激素史 7例 ,创伤性 4例 ,原因不明 10例。按Ficat病变分期属Ⅱ期 9髋 ,Ⅲ期 19髋 ,Ⅳ期 13髋。1     

带双血管蒂大转子骨瓣转移治疗股骨头缺血性坏死

目的 探讨应用旋股外侧血管横支及升支、臀中肌支双血管蒂大转子骨瓣转移的方法治疗股骨头缺血性坏死的临床效果。方法应用带旋股外侧血管横支及升支、臀中肌支双血管蒂大转子骨瓣转移术治疗股骨头缺血性坏死32例（32髋），其中男18例，女14例；Ficat Ⅱ期15侧，Ⅲ期17例。术后平均随访25个月（15-38个月），根据Harris髋关节功能评分标准进行临床评价，根据手术前后Ficat分期改变进行影像学评价，对其中的9例进行手术前后数字减影血管造影（DSA）检查以明确坏死股骨头血运重建状况。结果术后两髋改行人工全髋关节置换。股骨头得到重建的病例，术后Harris髋关节功能评分明显提高（术前平均55分，术后88．6分），本组临床成功率为90．6％，影像学成功率为87．5％。9例重建股骨头手术前后DSA评估提示血管蒂充盈好，骨瓣血运丰富。结论旋股外侧血管横支及升支、臀中肌支双血管蒂大转子骨瓣转移的方法治疗股骨头缺血性坏死骨瓣血供确切，股骨头血运重建良好，早期疗效满意。     

带旋骼深血管蒂髂骨瓣移植结合早期功能锻炼治疗股骨头缺血性坏死32例

股骨头缺血坏死是骨科常见病,随着近年对其病理学的研究,产生了各种改善股骨头血液供应的方法,诸如带血管蒂或肌肉蒂的骨瓣或骨膜瓣移植术[1、2]、血管束植入术[3],以及吻合血管的腓骨移植术[4]等.自1988年,我们运用带旋髂深血管蒂髂骨瓣移植,结合早期功能锻炼,推迟负重时间的方法治疗该病32例,取得较为满意结果,现予以报告.     

股骨头缺血性坏死显微外科手术治疗

目的：报道显微手术改善股骨头血液循环、促进病灶修复的疗效。方法：根据病损程度，对Ⅱ期以上者可采取带血管蒂骼骨块植入术，单纯血管束植入术，或两者并用，或再加带血运的骨膜包颈术等治疗２２６例。结果：有效率为８８．６％。结论：显微手术是当前治疗此症较好的方法。     

A diagnostic algorithm for osteonecrosis of the femoral head

For patients considered at risk for osteonecrosis (ON) of the femoral head, an algorithm for the efficient and appropriate use of diagnostic tests can be developed. Such an algorithm requires a clear idea of the evolution of the disease process and an understanding of the limitations of each of the modalities by which the disease process can be identified. The role of each of the diagnostic tests available for the diagnosis of ON and the results of prospective evaluations to assess their sensitivity, specificity, and predictive values are reviewed. No single diagnostic test is 100% accurate in the diagnosis of the disease. Thus, one must consider an algorithm that accounts for the variable nature of the disease presentation. The goal of such an algorithm is the accurate identification and staging of the disease. For disease not roentgenographically apparent, an approach using magnetic resonance imaging and bone scanning is recommended. For disease that is apparent roentgenographically, tomography is used to define the extent of the disease and the presence or absence of subchondral fracture. The accuracy of diagnosis is critical to understanding the role of the various treatment modalities prescribed for ON. For this purpose, it is necessary to reach a consensus as to what constitutes a successful outcome of treatment. Once diagnosis of the disease is accepted, clinical success of treatment outcomes should be reported in three ways: by a standard hip rating system, by ability to prevent roentgenographic deterioration, and by survival of the femoral head (the absence of further treatment intervention).(ABSTRACT TRUNCATED AT 250 WORDS)     

Hemiresurfacing for femoral head osteonecrosis

A modified THARIES femoral resurfacing component was used as a hemiarthroplasty in 11 young adult patients (12 hips) with osteonecrosis. The mean follow-up period was 39 months (range, 24-62 months). In all of the hips, the necrosis had advanced to the stage of subchondral femoral head fracture and segmental depression, but there was a relatively normal acetabulum. Ten hips have maintained satisfactory improvement of UCLA pain, walking, and function hip scores. One hip was revised to an uncemented total replacement, and one has some residual pain. No case failed because of component loosening. The modified femoral THARIES component was used as a preferable alternative to unipolar or bipolar hemiarthroplasty, and the results appear to be comparable in this difficult group of patients. Hemiresurfacing was conceived not as a definitive procedure but rather as a time-buying measure to improve symptoms and function and to allow the performance of a technically uncompromised total hip arthroplasty at a future date.     

Endoprostheses for osteonecrosis of the femoral head

Summary Eighty-eight hip arthroplasties were carried out in 75 patients, all aged 50 years or less, with osteonecrosis. All the operations were carried out by one surgeon. Four different methods were used: a standard cemented arthroplasty; a cemented THARIES surface replacement; an uncemented surface replacement; a cemented titanium femoral surface hemiarthroplasty. Comparable clinical improvement occurred in all 4 groups initially. Aseptic loosening, with intersurface degradation and osteolytic lesions, was the most common cause of failure in the 3 types which had a polythene bearing. Polyethylene is the major contributor to bone loss around the endoprosthesis and loosening. Fixation of the surface hemiarthroplasty remained intact in every patient and failure was secondary to wear of the acetabular cartilage. We recommend surface hemiarthroplasty as an interim solution for young patients with stage III or early stage IV osteonecrosis because this procedure conserves bone stock, there is little osteolysis and it can easily be revised.

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Résumé Quatre-vingt-huit prothèses de hanche chez 75 patients atteints d'ostéonécrose et âgés de 50 ans ou moins ont été faites par un seul chirurgien. Vingt patients (24 hanches) ont été traités par une prothèse conventionelle cimentée. Il y eut 6 révisions, en moyenne à 87 mois. Trente et un patients (35 hanches) furent traités par une cupule couplée cimentée THARIES. Vingt deux révisions furent nécessaires, en moyenne à 84 mois. Un remplacement de surface sans ciment a été utilisé chez 19 patients, dont 10 furent réopérés à 60 mois en moyenne. Neuf patients (10 hanches) furent traités avec une hémi-arthroplastie fémorale de surface en titane, cimentée. 5 d'entre-eux ont dû être réopérés à un délai moyen de 89 mois. L'amélioration fonctionnelle a été comparable dans les 4 groupes. Dans les 3 groupes ayant une surface de frottement en polyéthylène, le descellement aseptique avec lésions d'ostéolyse fut la cause la plus fréquente d'échec. La fixation de l'hémi-arthroplastic fémorale ne s'est pas dégradée, et les échecs survinrent secondairement à cause de l'usure du cartilage acétabulaire. Ceci suggère que le polyéthylène est le facteur principal de l'ostéolyse péri-prothétique et du descellement. Avec l'avantage de la conservation osseuse, de l'absence d'ostéolyse et la facilité de la reprise, nous recommandons l'hémiarthroplastie de surface comme solution temporaire chez le jeune patient atteint d'une ostéonécrose au stade III ou IV précoce.

     

Cyclosporin A and osteonecrosis of the femoral head

A vascular osteonecrosis has occurred in 5 to 40 per cent of patients who have undergone transplantation of a kidney and generally has been considered to be a complication of the use of corticosteroids. Currently cyclosporin A is in general use for its immunosuppressive property, so that a lower dose of corticosteroids is needed. We analyzed the cases of a series of our patients who underwent transplantation of a kidney in order to find out if our present regimen, using cyclosporin A, influenced the prevalence of osteonecrosis of the femoral head. Of a total of 270 patients, osteonecrosis of the femoral head developed in fifteen of 174 who received conventional immunosuppressive therapy and in only one of ninety-six who received cyclosporin A (p less than 0.05). During the first two months after transplantation, the mean dose of prednisone was approximately 2.5 milligrams per kilogram of body weight per day in the group that received conventional immunosuppressive therapy and approximately 1.1 milligrams per kilogram of body weight per day in the group that received cyclosporin A (p less than 0.001). We concluded that the pathogenesis of the osteonecrosis in patients who underwent transplantation of a kidney was probably related to the higher doses of corticosteroids that were administered.     

非创伤性股骨头坏死的国外研究进展

非创伤性股骨头坏死在国内外均被列为尚未解决的难治性疾病之一,本文中作者综合近几年的研究对非创伤性股骨头坏死的病因及手术和非手术治疗方法进行最新的阐述.非创伤性股骨头坏死的发病有遗传学基础,各种危险因素及遗传易感性的相互作用将决定病情的转归.早期诊断及在股骨头出现塌陷之前进行干预是关节保留治疗能否得到良好结果的关键.关节是否保留取决于放射影像学表现.对于股骨头已经塌陷的患者,行关节置换术的满意度优于关节保留治疗.最新的药物治疗方法如生长分化因子可能会改变作者目前的治疗方法,但是有待于临床研究结果及长期的随访.     

Aseptic osteonecrosis of the femoral head in thalassemia minor: a case report

We report a case of aseptic necrosis of the femoral head in a 14-year-old black adolescent with thalassemia minor disclosed by physical examination and blood tests. No other anomaly could be identified. Despite the very probably secondary nature of the aseptic osteonecrosis of the femoral head and the absence of any other etiology, it is highly difficult to demonstrate the causal effect of thalassemia minor. We reviewed the literature and discuss the pathogenesis of this association.     

Intertrochanteric osteotomy for osteonecrosis of the femoral head

We studied 32 hips (in 27 patients) treated by intertrochanteric osteotomy for osteonecrosis of the femoral head. Average follow-up was 17 (range 9-26) years. There were 22 men and 5 women with an average age of 39 (range 25-55) years. Eleven hips were classified as Ficat stage II, 19 as stage III and two as early stage IV. Nine hips showed collapse of the femoral head within 3 years after operation and in six hips collapse occurred after 3-8 years. In 13 hips slow progression with incipient signs of arthrosis was noted 8 years after surgery. Four hips with a moderate degree of necrosis at the time of surgery showed no radiological progression 9-26 years after operation. We recommend intertrochanteric osteotomy for patients with Ficat stage II and early stage III, provided that they still have a good range of motion in the hip.     

晚期股骨头坏死的人工关节置换术

[目的]探讨晚期股骨头坏死患者髋关节置换术的选择方法及其临床结果。[方法]对本科于1985年5月～2003年12门行髋关节置换术的119例（138髋）股骨头坏死患者进行了随访。使用人工双极股骨头置换术及THA治疗晚期股骨头坏死者分别为29例（31髋），90例（107髋）。所有手术均采用后外侧人路。[结果]早期使用的国产骨水泥人工双极股骨头假体，86．7％的股骨柄假体出现松动。全骨水泥THA，50％髋出现了髋臼杯似体松动，62．5％髋股骨柄似体松动，25％髋行全髋人工关节翻修术：混合型（Hybrid）THA，未出现髋臼杯及股骨柄似体的松动，非骨水泥THA，除1例外无髋臼杯及股骨柄假体松动或下沉。[结论]使用人工双极股骨头置换术治疗晚期股骨头坏死应慎重选择，可适用于老年、日常活动量小的患者；而对于年轻患者，非骨水泥型THA为最佳选择；对于股骨侧出现骨质疏松或不适合使用生物固定型股骨柄假体的患者，混合型（Hybrid）THA同样可以获得满意疗效；全骨水泥犁THA应很少使用。     

Core decompression of the femoral head for osteonecrosis

The results of forty core-decompression procedures that were performed for ischemic necrosis of the femoral head in thirty-one patients over a four-year period were retrospectively reviewed to ascertain the effectiveness of the procedure. The data did not support the published rates of success of the procedure for Stage-1 and Stage-2 lesions. With a mean length of follow-up of eighteen months, 60 per cent of the hips that had a decompression prior to collapse of the femoral head demonstrated progression of the lesion and were judged to be a failure by clinical or radiographic criteria. Computerized tomographic scans and magnetic resonance imaging proved to be 100 per cent sensitive for diagnosis in preoperative testing; isotopic bone-scanning was less sensitive (80 per cent). Functional intraoperative testing by the method of Ficat did not provide added sensitivity or specificity to the results of the preoperative bone scan. A postoperative or intraoperative fracture occurred in four hips, for an incidence that exceeded any in previously published reports. We concluded that core decompression should be considered a relatively ineffective procedure with significant morbidity.