An injectable self-adaptive polymer as a drug carrier for the treatment of nontraumatic early-stage osteonecrosis of the femoral head

Core decompression(CD) with the elimination of osteonecrotic bone is the most common strategy for treating early-stage nontraumatic osteonecrosis of the femoral head(ONFH). Adjuvant treatments are widely used in combination with CD as suitable methods of therapy. Existing augmentations have to be fabricated in advance. Here, we report a novel injectable glycerin-modified polycaprolactone(GPCL) that can adapt to the shape of the CD cavity. GPCL shows great flowability at 52.6 °C. After solidifica...     

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.     

股骨头坏死保头治疗研究进展

股骨头坏死病程长,自然进展较快,若不采取及时有效的保头治疗,晚期行关节置换比例很高.保头治疗是年轻患者的首选方式,日趋多样化且各具特色.随着研究的深入,保头治疗已不单纯行股骨头髓芯减压,而是针对股骨头坏死成骨与成血管修复的病理过程,采取植骨或其他内置物结合各种生长因子的综合治疗.该文就股骨头坏死保头治疗研究进展作一综述...     

股骨头骨坏死塌陷机制研究进展

股骨头骨坏死是骨科临床常见的难治性疾病,多种原因可以引起该疾病,然而目前其病理机制还不是很明确。股骨头骨坏死后发生股骨头塌陷,是该病进展过程中的一个重要节点,特别是对于活动量大的年轻患者。作者回顾文献发现骨坏死修复过程中成骨和破骨活动的不平衡会导致股骨头内骨小梁力学性能及结构的改变,从而在正常力学载荷的情况下导致股骨头发生塌陷。所以作者认为防治股骨头骨坏死塌陷不但要为股骨头提供有效的力学支撑,更重要的是要调节股骨头局部的成骨和破骨活动。     

Posterior rotational osteotomy for the treatment of femoral head osteonecrosis

Posterior rotational osteotomy in 46 hips of 39 patients with femoral head osteonecrosis was reviewed radiographically and clinically after 2-12 years of follow-up (mean 5 years). The age of the patients at the time of surgery ranged from 18 to 60 years, with a mean of 35 years. There were 18 women and 21 men. The cause of the osteonecrosis was steroid administration in 14, alcohol abuse in 5, trauma in 16, and no apparent risk factor in 4. According to the Ficat staging system, 2 hips were stage II, 30 hips III, and 14 hips stage IV. All hips had an extensive lesion. Forty-one hips showed less than 1/3 noncollapsed posterior living area, which was a contraindication for traditional anterior rotational osteotomy. The posterior rotational angle was 60-180 deg with an mean of 127 deg. Recollapse of the final follow-up anteroposterior radiograph was prevented in 36 hips (78%). Progressive joint space narrowing was found in 12 hips (26%). Of these hips, 9 suffered recollapse, while the remaining 3 hips did not. Clinically, 32 hips (70%) showed excellent or good results (both hips in stage II, 23 of 30 hips in stage III, 7 of 14 hips in stage IV. A fair or poor result was seen in 14 hips (30%)). These results suggest that posterior rotational osteotomy is effective in delaying the progression of degeneration for large necrotic lesions, especially in young patients. Extent of rotation is limited to 150 deg because of limitations of bone quality. The indications should be refined further, and longer term follow-up is necessary.     

Granuloma debridement and the use of an injectable calcium phosphate bone cement in the treatment of osteolysis in an uncemented total knee replacement

Polyethylene particulate debris-induced periprosthetic osteolysis is a known complication of knee arthroplasty surgery, and may result in the need for revision surgery. The management of these bony defects can be surgically challenging, and full revisions of well-fixed total knee components can lead to substantial bone loss. We present the case of a 71 year old man who developed knee pain and osteolysis around an uncemented total knee replacement. Due to significant medical comorbidies he was treated by percutaneous cyst granuloma debridement and grafting using an injectable calcium phosphate bone substitute. There were no wound complications, and the patient was allowed to fully weight-bear post-operatively. Histopathology and microbiology of the cyst material confirmed polyethylene granulomata without any evidence of infection. At 6 weeks post-operatively the patient's previous knee pain had resolved, he was able to comfortably fully weight-bear. Preoperative scores (Knee Society Score (KSS) 41, WOMAC score 46.2, and Oxford Knee Score 39) had all improved at the 12-month post-operative review KSS 76, WOMAC 81.7 and Oxford Knee score 21). This is a safe and effective technique with minimal morbidity and may be an appropriate treatment modality when more extensive revision surgery is not possible. The case is discussed with reference to the literature.     

全髋表面置换术治疗股骨头坏死

目的:探讨全髋表面置换术治疗股骨头缺血性坏死的疗效和适应证.方法:回顾性分析17例(21髋)股骨头缺血性坏死患者的临床资料.其中男10例,女7例;年龄25～51岁,平均36岁.其中Ficat Ⅲ期8髋,Ficat Ⅳ期13髋.均行金属全髋表面置换术.取Gibson后外侧切口,采用非骨水泥型假体.处理股骨头时,以颈干角通过股骨头中心打入1根导针,用空心钻头钻孔后插入导引杆,再用圆柱形的股骨头切割器锉去股骨头的多余部分,在股骨头上钻孔,将骨水泥涂抹在股骨头和假体上,将假体柄插入股骨颈中心轴骨孔内,冲紧到位,等待骨水泥固化.术后Harris评分分析,并进性统计学分析(t检验),定期复查X线片.结果:全部病例均获得随访,随访时间18～42个月,平均32个月.髋关节功能Harris评分由术前的平均(35.30±5.23)分提高到术后(90.47±3.14)分,优良率90.5％,手术前后Harris评分差异有统计学意义(P＜0.01).X线摄片发现2例髋臼假体周围出现透亮线,而无松动迹象.结论:全髋表面置换术是治疗中晚期股骨头缺血性坏死的理想方法,它能恢复正常的关节生物力学及负载传递,提高了关节的稳定性,延缓了全髋关节置换,不影响日后的翻修效果,且创伤小、操作简便、感染率低.适用于FicatⅢ期及部分FicatⅣ期的股骨头坏死,股骨颈破坏少,特别是活动量大的年轻患者.     

Umbrella-shaped, memory alloy femoral head support device for treatment of avascular osteonecrosis of the femoral head

Purpose

Avascular necrosis (AVN) of the femoral head is a common orthopaedic disease that is difficult to treat. The purpose of this study was to explore the preliminary efficacy of a self-designed umbrella-shaped memory alloy femoral head support device in the treatment of adult patients with avascular osteonecrosis of the femoral head.

Methods

The minimally-invasive approach involved curettage of the necrotic tissue of the femoral head, and a self-designed umbrella-shaped, memory alloy femoral head support device was implanted into the collapsed necrotic area to support the collapsed femoral head. Autologous iliac bone and artificial bone were implanted into the support device for the treatment of adult patients with avascular osteonecrosis of the femoral head.

Results

The clinical device was used in ten patients and 18 hip joints. The support device failed in one hip joint, which subsequently underwent joint replacement surgery, and the remaining 17 implanted devices were followed up for four to 19 months. The 17 postoperative hip joints were evaluated using the percent-efficacy evaluation method for avascular osteonecrosis of the femoral head in adult patients, and the efficacy rate was 82.35 %.

Conclusion

The umbrella-shaped femoral head support device can be used in Ficat stage I, stage II, and stage III adult patients with avascular osteonecrosis of the femoral head.     

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.

     

可注射型硫酸钙动物实验研究

目的研究观察可注射型硫酸钙(ICSC)植入家兔体内后组织学及与可注射型磷酸钙(ICPC)影像学和组织学相比较。方法24只家兔分为ICSC植入组(12只)和ICPC植入组(12只),在左股骨髁上钻孔后填入ICSC或ICPC,于术后即刻,24小时,1、2、4、8、12周分批处死动物后取出标本,进行一般观察、X线观察、CT值测定及标本不脱钙病理切片光镜观察。结果组织学观察显示,2周时ICSC中可见骨小梁长入且ICSC开始被吸收;4周时开始被较多的吸收;12周时大量新骨生成,ICSC大量吸收,骨孔愈合良好。X线片显示ICSC自4周开始在骨缺损区有较明显的吸收,12周时骨孔愈合,骨孔内ICSC基本吸收完全;CT值测定结果显示ICSC自4周开始吸收率大幅增加。结论ICSC在体内比ICPC降解速度快,且有骨传导作用。     

Studies of nontraumatic osteonecrosis. The role of core decompression in the treatment of nontraumatic osteonecrosis of the femoral head

This study reports a five-year experience with core decompression for treatment of nontraumatic osteonecrosis of the femoral head. There were 25 patients (39 hips) with predominantly steroid-associated osteonecrosis followed postoperatively for a minimum of two years. All patients were evaluated functionally, roentgenographically, histologically, and hemodynamically. At latest follow-up examination, two of 12 hips (17%) with Stage I disease, seven of 12 hips (58%) with Stage IIA disease, four of four hips with Stage IIB disease, and nine of 11 hips (82%) with Stage III disease have progressed roentgenographically and/or clinically. A lack of correlation between pressure manometrics, venography, and clinical outcome in this study suggests that mechanisms other than progressive ischemia may be involved. Current indications for core decompression are Ficat Stage 0, I, and IIA (sclerotic predominant) disease.     

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.     

酒精性晚期股骨头缺血性坏死

[目的]探讨酒精性晚期股骨头坏死与长期、过量饮酒的关系。[方法]回顾本院165例人工全髋关节置换病例。分析其中27例酒精性晚期股骨头坏死的l临床资料，结合文献复习，探讨酒精性股骨头坏死的发病机理。长期大量饮酒与股骨头缺血性坏死、血液生化学和凝血功能等之间的关系。比较文献报道的实验结果有何异同。[结果]大量长期饮酒可导致股骨头坏死，是多方面因素综合的结果；日均饮酒750ml以上者，有发生晚期双侧或单侧股骨头坏死的危险；血液生化观察指标无明显改变，但与凝血功能降低有关；股骨头坏死与髋关节的骨性关节炎可同时发生。[结论]长期大量饮酒，日均饮酒量大于750ml以上者，有导致股骨头坏死的可能；血液生化的改变无特异性的意义；坏死的严重程度与酒量多少、时间长短有关；酒精性股骨头缺血性坏死的晚期患者，行人工全髋关节置换应是最佳选择，但这类患者术中术后有渗血较多的倾向。．     

The natural history of asymptomatic osteonecrosis of the femoral head

Purpose

To observe the natural history of asymptomatic osteonecrosis of the femoral head, and to analyse the associations between the subsequent development of symptoms, epidemiological risk factors and the character of the lesions.

Methods

Sixty-eight patients were diagnosed with asymptomatic osteonecrosis of the femoral head. The patients were classified based on the development of symptoms. Relations were sought between symptom development and epidemiological risk factors, and the size and location of the necrotic lesions.

Results

Thirty-eight patients developed symptoms (55.9 %) at a mean 2.27 years after diagnosis. Symptoms developed in 18 of 28 patients with alcohol-related necrosis (64.3 %), in eight of 14 patients with steroid-related necrosis (57.1 %), and in 12 of 26 patients with idiopathic necrosis (46.2 %). None of the following: gender, age, body mass index (BMI), smoking status, or cholesterol level, was found to be significantly associated with the development of symtoms in asymptomatic osteonecrosis of femoral head (ONFH). Duration and amount of exposure to steroid were not significantly associated with symptom development. In the groups of heavy alcohol drinkers, large necrotic lesions and laterally located lesions showed a higher prevalence of symptom development.

Conclusion

Symptoms developed in 55.9 % of asymptomatic osteonecrosis of the femoral head. Prevalence of symptom development was significantly higher in heavy alcohol drinkers and large-sized lateral lesions.     

股骨头骨折后并发股骨头缺血性坏死的治疗

目的 探讨股骨头骨折内固定术后并发股骨头缺血性坏死的治疗.方法 对单侧股骨头骨折内固定术后股骨头缺血性坏死采用带血运骨瓣转移术治疗的26例临床资料进行回顾分析.21例数字减影血管造影(DSA)检查明确股骨头及其周围骨的血供后行内固定物取出、带血运骨瓣转移术.1例内固定物取出后行全髋置换术.结果 施行带血运骨瓣转移术的术后平均随访23个月(12～38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15例进行术后DSA检查以明确坏死股骨头血运重建情况.术后2髋改行人工全髋关节置换.股骨头得到重建的病例,术后Harris髋关节功能评分提高至平均86.2分(术前平均54分),其中临床成功率为92.0%,影像学成功率为84.0%.15例重建股骨头手术后DSA评估提示血管蒂充盈好,骨瓣血运丰富.结论 股骨头骨折内固定术后股骨头坏死发生率较高(可达40%).在取出内固定物同时行带血运骨瓣转移治疗股骨头缺血性坏死、股骨头血运重建良好,早期疗效满意.     

Extracorporeal shockwave treatment of osteonecrosis of the femoral head in systemic lupus erythematosis

This article reported a case of systemic lupus erythematosis (SLE) with osteonecrosis of the femoral heads (ONFH-3) successfully treated with a novel extracorporeal shockwave treatment (ESWT). The follow-up at 3 years showed that both hips had no pain on activities for daily living. Magnetic resonance image (MRI) showed substantial reduction in bone marrow edema and no further collapse of the lesions. Radiographs and MRIs showed no change in the staging of the disease. ESWT provided beneficial effects for hips affected by ONFH in patients with SLE. This novel treatment modality resulted in significant pain relief and functional improvement of the hip and reduction in bone marrow edema in our patient. It appeared that ESWT might have the potential to curtail the progression of the disease and to delay the need for total hip arthroplasty in the very young patients contracted with SLE.