股骨颈骨折后股骨头坏死

简要叙述股骨颈骨折后股骨头坏死的早期诊断和坏死预测等的最新进展。为使骨折后骨坏死尽量减少，早期手术和关节穿刺减压，避免髋关节放置在伸直及内旋位是必要的，建议屈曲位牵引。应用Gd-DTPA增强MRI T1脂肪浸润扫描，可预测股骨头坏死的可能性。建议将股骨头坏死分为静息型骨坏死和临床型骨坏死．     

Osteonecrosis of the femoral head caused by bone marrow blockage: a case report

Interruption of the blood flow may occur in intra-osseous arteries within the femoral head. We report a 72-year-old woman who developed osteonecrosis of the femoral head 11 months after surgery involving massive cementing of a segmental distal femoral rotating hinge prosthesis to treat nonunion of the distal femur. The bone cement filled the cavity up to the femoral neck and the superolateral portion of the femoral head, blocking the bone marrow.     

Obstructive lung disease after allogeneic bone marrow transplantation

We report the cases of 3 patients with marked dyspnea and an obstructive ventilation disorder associated with chronic graft-versus-host disease after allogeneic bone marrow transplantation. This disorder was characterized by recurrent pulmonary infections and colonization of the lower respiratory tract by Pseudomonas aeruginosa. Two patients have shown rapidly progressive deterioration with death following due to respiratory failure. Intensive therapy with antibiotics, bronchodilators, high-dose steroids, and azathioprine was not effective in arresting the malignant course of this disorder.     

Osteonecrosis of the femoral head after solid organ transplantation: a prospective study

BACKGROUND: The reported prevalence of osteonecrosis of the femoral head in patients who have undergone a solid organ transplant has ranged from 3% to 41%. The wide variation is due to the retrospective nature of most studies and the inability to capture data on asymptomatic patients. The primary goals of this study were to determine the true prevalence of osteonecrosis of the femoral head following solid organ transplantation, the time to the development of the osteonecrosis, and whether findings on magnetic resonance imaging precede the onset of symptoms. METHODS: Beginning in 1997, patients who had undergone a solid organ transplant were asked to participate in a prospective study in which they would be screened for osteonecrosis of the femoral head. Inclusion criteria included an age of greater than fourteen years, a first-time transplant, and magnetic resonance imaging performed within six months after the transplant. Exclusion criteria were pre-existing osteonecrosis of the femoral head in the hip included in the study, a history of inflammatory arthritis, previous hip surgery, any contraindication to magnetic resonance imaging, a prior organ transplant, prior systemic corticosteroid treatment, and mental health issues preventing adequate follow-up. Screening magnetic resonance imaging was performed every four months. Survivorship analysis was used to determine the prevalence of osteonecrosis of the femoral head. RESULTS: Fifty-two patients (103 hips) were enrolled in the study. Their ages ranged from twenty-four to sixty-five years (mean, forty-three years). Sixteen patients were dropped from the study, but the data collected on them before they were dropped were included in the analysis. Osteonecrosis of the femoral head was diagnosed in eight of the 103 hips. Survivorship analysis revealed that, at one year after the transplant, 89% +/- 7% of the hips and 80% +/- 13% of the patients were free of osteonecrosis of the femoral head; thus the prevalence of osteonecrosis one year after transplantation was 11% or 20%, respectively. The mean duration of follow-up of the remaining hips was 2.3 years. In two hips the osteonecrosis of the femoral head was seen on the initial screening magnetic resonance imaging, and in the other six it developed after the initial magnetic resonance imaging revealed negative findings. All cases of osteonecrosis of the femoral head developed within ten months after the transplant. Seven of the eight hips were asymptomatic at the time of diagnosis. There was a significant difference in the one-year osteonecrosis-free survival rate between the patients who were less than forty years old (78%) and those who were at least forty years old (97%) (p = 0.011). Diabetes, smoking, and rejection episodes were not risk factors for osteonecrosis of the femoral head. CONCLUSIONS: Our study of patients who had had a solid organ transplant revealed that the true prevalence of osteonecrosis of the femoral head in such patients is lower than that reported in most previous studies, osteonecrosis of the femoral head develops prior to the onset of symptoms, an age of less than forty years is a risk factor for osteonecrosis of the femoral head, and osteonecrosis of the femoral head develops within one year after transplantation. We recommend that magnetic resonance imaging be used to screen for osteonecrosis of the femoral head within one year after transplantation. The utility of additional magnetic resonance imaging after one year has not been established.     

Cementless total hip arthroplasty for osteonecrosis of the femoral head after allogenic bone marrow transplantation

From 1998 until 2004, we performed 26 consecutive cementless total hip arthoplasties in 15 patients who had developed advanced avascular necrosis of the femoral head after allogenic bone marrow transplantation. The average age at transplantation was 31.1 years, and the mean age at implantation was 33.6 years. Follow-up period ranged from 2 to 8 years with an average of 56.4 months. The mean D'Aubigne-Postel score improved from 7.5 points preoperatively to 17 points postoperatively. The overall result was excellent in 92.3%, good in 3.8%, and fair in 3.8% of cases. There were no radiological signs of components loosening and no severe complications. Cementless total hip arthroplasty appears as a favorable alternative for the treatment of avascular necrosis of the femoral heads after allogenic bone marrow transplantation.     

Adult respiratory distress syndrome-like disorders after allogeneic bone marrow transplantation

BACKGROUND: Adult respiratory distress syndrome-like respiratory disorders are a serious, but uncommon, complication of bone marrow transplantation. METHODS: We measured various cytokines in 2 patients with respiratory disorders and 11 patients without respiratory problems after allogeneic bone marrow transplantation. RESULTS: The patients with respiratory disorders had elevated levels of interferon-gamma and interleukin-2 in the aplastic phase, and elevation of tumor necrosis factor-alpha, intercellular adhesion molecule-1, and interleukin-8 at the time of leukocyte recovery. Both patients with respiratory disorders developed fever during the aplastic phase, whereas none of the patients without fever had respiratory disorders. Among patients who had fever during the aplastic phase but no respiratory disorders, there was no elevation of cytokines from the aplastic phase to the recovery phase. CONCLUSIONS: Respiratory disorders may occur after bone marrow transplantation when an inflammatory response during the aplastic phase stimulates cytokines that cause vascular endothelial damage and increases the levels of chemokines and adhesive molecules along with elevation of the leukocyte count.     

A boy with membranous nephropathy after allogeneic bone marrow transplantation

A 6-year-old boy developed bronchiolitis obliterans organizing pneumonia and nephrotic syndrome 5 months after allogeneic bone marrow transplantation from an unrelated donor for acute lymphoblastic leukemia. His renal biopsy showed membranous nephropathy. He was treated with prednisolone and cyclosporine A. Proteinuria disappeared 3 months after the onset of nephrotic syndrome. To our knowledge, this patient is the youngest case with nephrotic syndrome due to membranous nephropathy after hematopoietic stem cell transplantation.     

Osteonecrosis of the femoral head in Japanese adults after liver transplantation: a preliminary report

Patients who are treated with high-dose corticosteroids as an immunosuppressive therapy are at high risk of developing osteonecrosis, especially in the femoral head. We examined whether symptomatic osteonecrosis of the femoral head (ONFH) would be a clinical problem after liver transplantation. From June 1990 to December 2001, a total of 169 patients underwent liver transplantation at the Shinshu University Hospital. Within this group, 65 patients were more than 18 years old at the time of surgery, and all were enrolled in the present study. All patients were referred to the Orthopaedic Department of Shinshu University Hospital when they experienced musculoskeletal symptoms, including hip or groin pain. In addition, they were informed of the potential risk of osteonecrosis associated with immunosuppressive therapy after the liver transplant. As result, the patients were advised to have a magnetic resonance imaging (MRI) check for osteonecrosis after transplant surgery. In terms of outcomes, none of the patients presented with symptomatic hip difficulties due to osteonecrosis. Additional clinical investigation revealed that of the 18 patients who underwent MRI screening, only one was found to have asymptomatic unilateral ONFH. In conclusion, ONFH after liver transplantation has not been a clinical problem for our patients.     

Streptococcus pneumoniae mycotic aortic aneurysm after allogeneic bone marrow transplantation

BACKGROUND: Streptococcus pneumoniae (SP) is a common cause of community-acquired pneumonia and accounts for up to 30% of all cases of pneumonia. Patients with chronic graft-versus-host-disease (GvHD) after allogeneic bone marrow transplantation (BMT) have a high susceptibility to SP infections. So far, mycotic aneurysm resulting from SP has not been reported after BMT. METHODS: We report on a patient with extensive, chronic GvHD who developed low back pain 22 months after allogeneic BMT. RESULTS: Computed tomography of the abdomen displayed mycotic, saccular aneurysmatic enlargement of the infrarenal aorta, with leakage of contrast medium into the aneurysm. The aneurysm was resected, and the defect was closed with an autologous patch from the internal iliac artery. Bacteriologic samples from the abscess grew SP. The patient recovered uneventfully. CONCLUSIONS: This observation confirms the importance of pneumococcal prophylaxis after BMT and suggests that an aggressive diagnostic approach should always be considered in patients with chronic GvHD, even if they present with nonspecific symptoms.     

Osteonecrosis of the femoral head.

New cases of osteonecrosis of the femoral head in the United States number between 10,000 and 20,000 per year. This disease usually affects patients in their late 30s and early 40s. Although a number of authors have related specific risk factors to this disease, its etiology, pathogenesis, and treatment remain a source of considerable controversy. This disorder has been associated with corticosteroid use, substance abuse, and various systemic medical conditions. Either direct damage to osteocytes (e.g., by toxin production) or indirect damage (e.g., due to disorders in fat metabolism or hypoxia) may lead to osteonecrosis. Patients at increased risk for osteonecrosis should be monitored closely. Unfortunately, most cases are diagnosed in an advanced stage of disease, when minimally invasive surgical procedures are no longer helpful. Furthermore, patients in the advanced stage of the disease must undergo total hip replacement at a young age, which carries a poor long-term prognosis.     

Immune reconstitution after allogeneic bone marrow transplantation depleted of T cells

BACKGROUND: Immune reconstitution following transplantation in individuals who had received T-cell-depleted marrow from HLA identical siblings was serially documented and correlated with the clinical recovery. METHODS: Patients were preconditioned with radiation containing programs. GvHD prophylaxis was by T-cell depletion with CAMPATH 1G (ex vivo; median dose 20 mg). After transplantation lymphoid development was studied by flow cytometry and serum Ig concentrations were determined. Charts were reviewed to determine the effects of the immune reconstitution on the clinical performance. RESULTS: The mean donor mononuclear cell number infused was 0.89x10(8)/kg. Within 6 months all the patients recovered their blood parameters and only one required therapy for GvHD. However, despite normal blood counts, 15 suffered life-threatening opportunistic infections, developing at a median of 24 weeks post grafting, but occurring even after 11 months. At 8 weeks from marrow infusion when leukocyte values had normalized in 15/20, compared to normal, immunophenotyping of blood cells from BMT revealed a significantly reduced mean lymphocyte count (1.06, SD 0.83x10(9)/l; P = 0.01), cells expressing CD3 (0.7x10(9)/l, SD 0.68; P = 0.05), CD4 (0.13x10(9)/l, SD 0.21; P = 0.0001) and CD19 (0.04x10(9)/l, SD 0.05; P = 0.001). Populations expressing CD8 and CD56 remained within normal range throughout the study. Normalization of cell numbers displaying CD2, CD3 and CD19 was delayed until 52, 52 and 24 weeks respectively, while CD4 counts persisted subnormal even at 72 weeks. Serum IgA levels were significantly decreased for the entire study period. CONCLUSIONS: T-cell depletion with CAMPATH 1G while effectively preventing GvHD, also causes clinically significant and prolonged immunosuppression with apparently important clinical implications.     

Graft-versus-host disease in the absence of the spleen after allogeneic bone marrow transplantation

BACKGROUND: The spleen is considered to be an important secondary lymphoid organ where acute graft-versus-host disease (GVHD) is initiated by donor T cells that recognize host alloantigens after allogeneic bone-marrow transplantation (BMT). The influence of splenectomy on the development of GVHD prior to BMT has yet to be determined. METHODS: The mortality and severity of murine GVHD of unsplenectomized, splenectomized, and sham-operated recipients of allogeneic BMT were compared in a blinded fashion. Serum levels of interferon (IFN)-gamma were measured 7 days after BMT, as an index of systemic donor T-cell responses. RESULTS: Mortality and morbidity of acute GVHD were not significantly affected by splenectomy in a major histocompatibility complex (MHC)-mismatched, CD4-driven murine GVHD model and a minor histocompatibility antigen (MiHA)-mismatched, CD8-driven GVHD model. Serum levels of IFN-gamma also were not different between the groups. CONCLUSION: GVHD can readily develop after allogeneic BMT, even in the absence of the spleen, in these mouse models.     

Bone marrow repopulation capacity after transplantation of lymphocyte-depleted allogeneic bone marrow using counterflow centrifugation

Bone marrow from six allogeneic HLA-matched and MCL nonreactive siblings was fractionated by means of isopycnic flotation centrifugation and subsequent counterflow centrifugation. The low density fraction (d less than or equal to 1.070 g/ml) obtained by IFC contained 20% of the nucleated cells and more than 90% of the myeloid and erythroid progenitors. The putative stem cell fraction obtained by CC showed a satisfactory recovery (88%) of the CFU-GM and BFU-E and only 3.5% of the original number of T lymphocytes. Bone marrow repopulation capacity was not impaired in comparison with a comparable group of patients. Despite the average high age of this group (29.6 years), only one of the four evaluable patients developed graft-versus-host disease.     

Repetitive DNA polymorphisms in following chimerism after allogeneic bone marrow transplantation

Information about the chimeric status of patients is of great importance in comparison of different conditioning and prophylactic regimens as well as for the post-bone marrow transplantation (BMT) therapies. In some cases, mixed chimerism (MC) can also be predictive of relapse. Analysis of the short tandem repeats (STR) loci by polymerase chain reaction (PCR) is a choice method for this purpose. In this study, we monitored 15 patients after BMT. Twelve of them underwent classical-conditioning regimen while the remaining three patients were subjected to non-myeloablative conditioning (minitransplantation). Evaluation of chimerism was performed using five STR and one variable number of tandem repeats (VNTR) locus. Four additional loci were PCR-amplified in cases of minitransplantation. Samples were analyzed by electrophoresis in an ALFexpress sequencer. MC was detected in seven cases of which it was predictive of relapse for two patients, who suffered from acute lymphocytic leukemia (ALL). The PCR-STR method proved to be a fast and relatively simple method, while the tested STR loci showed a high level of informativeness.     

Immune recovery following allogeneic bone marrow transplantation

A total of 144 evaluations of cell surface markers and cellular immune functions were carried out in 57 patients undergoing allogeneic bone marrow transplantation for acute leukemia in remission and relapse and for aplastic anemia. The periods tested were pretransplant, and 1-3, 4-6, 7-12 and more than 12 months posttransplant. The determination consisted of lymphocyte counts; lymphocyte surface marking using OKT3, OKT4, and OKT8 antibodies; and determination of adherent cells, lysozymes and antibody dependent cellular cytotoxicity (ADCC) against chicken red blood cells, human red blood cells, and CEM cells. Natural killer cells were determined against K562 target cells. Lymphoblastic responses were tested after stimulation with pokeweed mitogen (PWM), concanavalin-A (Con-A), and phytohemagglutinin (PHA). We found that the progression in the leukemic state (first remission, second remission, and relapse), prior to transplantation was paralleled by a decrease in T4 lymphocytes (976/microliter +/- 462; 411/microliter +/- 222; 372/microliter +/- 419; P = .04). There was a lack of helper cells and an inverted T4:T8 ratio beyond one year posttransplant independent of graft-versus-host disease status. Lymphocyte functions persisted to be depressed for more than one year. We found a direct correlation of T4 helper cells and an inverse correlation of T8 suppressor cells with lymphoblastic responses to mitogens. It is hoped that the longitudinal evaluations of immune functions after allogeneic bone marrow transplantation, and the characterization of the immune defects seen may lead to better immunorestorative treatments.