Ischemic necrosis of the entire femoral head and rapidly destructive hip disease: potential causative relationship

 Objective. Rapidly destructive hip disease (RDHD) is an uncommon disorder of the hip that has been considered a disease of unknown cause and distinct from ischemic necrosis of the femoral head. The objective of this study was to investigate ischemic necrosis of the femoral head as one potential cause of RDHD. Design and patients. In 600 patients who underwent MR imaging of the hip, 20 cases of ischemic necrosis involving the entire femoral head in 18 patients (3%) were retrospectively studied with routine radiography and MR imaging. All patients had surgically confirmed ischemic necrosis of the femoral head. Results and conclusions. All patients showed rapid destruction of the femoral head on routine radiography and MR imaging as compared with the gradual onset of clinical symptoms. Plain radiographs showed several bone fragments at the inferomedial aspect of the femoral head (75%), acetabular erosions (55%), eccentric depression at the lateral articular surface of the femoral head conforming to the adjacent acetabulum (35%), and mild osteoarthritis (15%). Bone sclerosis was often present at sites of impaction between the femoral head and the acetabulum. MR imaging showed marked distention of the joint capsule in all cases. In 14 of 20 cases, the contents of the joint space showed predominantly low or intermediate signal intensity on T1- and T2-weighted images. Ischemic necrosis involving the entire femoral head may represent one of the causes of RDHD.     

Quantitative T2 mapping of femoral head cartilage in systemic lupus erythematosus patients with noncollapsed osteonecrosis of the femoral head associated with corticosteroid therapy

Purpose:

To evaluate articular cartilage degeneration with transverse relaxation time (T2) mapping in systemic lupus erythematosus (SLE) patients with noncollapsed and asymptomatic osteonecrosis of the femoral head associated with corticosteroids.

Materials and Methods:

T2 mapping with a 1.5‐T magnetic resonance imaging system was prospectively performed for 28 normal hips from 14 healthy volunteers (control group) and 15 hips from 10 SLE patients that met the inclusion criteria of noncollapsed and asymptomatic osteonecrosis of the femoral head (osteonecrosis group). Exclusion criteria were past experience of pain, trauma, infection, or prior hip joint surgery. Distribution of T2 values of the femoral head cartilage were compared between the control group and the osteonecrosis group with respect to acetabular dysplasia by center‐edge angle (CEA).

Results:

T2 values of the femoral head cartilage were significantly higher in the osteonecrosis group than in the control group (34.4 msec vs. 30.8 msec, P = 0.001). Multiple regression analysis revealed that the osteonecrosis group and decreased CEA was significantly associated with high T2 values (T2 value = 34.6 + 3.6 × [osteonecrosis] ? 0.14 × CEA, R² = 0.52, P = 0.003).

Conclusion:

Degeneration of articular cartilage was associated with osteonecrosis of the femoral head in SLE patients and acetabular dysplasia. J. Magn. Reson. Imaging 2011;. © 2011 Wiley Periodicals, Inc.

     

Hip Chondrolysis and Femoral Head Osteonecrosis: A Complication of Periacetabular Cryoablation

PurposeTo describe a new complication and retrospectively identify the incidence and risk factors for hip chondrolysis and femoral head osteonecrosis associated with percutaneous cryoablation of periacetabular malignancies.Materials and MethodsIn this retrospective study, 45 patients with a total of 113 musculoskeletal lesions were treated by percutaneous image-guided cryoablation between May 2008 and June 2013. Included in the treated population were 10 patients with a total of 12 periacetabular lesions. Clinical and imaging follow-up of at least 2 months was reviewed for evidence of femoral head osteonecrosis or hip chondrolysis. Parametric and nonparametric statistical methods were used to assess patient demographics and treatment technique and parameters on the development of hip chondrolysis/femoral head osteonecrosis.ResultsHip chondrolysis/femoral head osteonecrosis developed in 40% of patients (four of 10) and in 33% of treated periacetabular lesions (four of 12). All patients in whom chondrolysis/osteonecrosis developed were women. Needle proximity to the acetabulum (< 5 mm) was a significant predictor of chondrolysis/osteonecrosis development (P = .01). Three of the four patients in whom chondrolysis/osteonecrosis developed have undergone total joint replacement.ConclusionsPeriacetabular cryoablation can result in transarticular extension of the ablation zone, which may result in the development of hip chondrolysis and femoral head osteonecrosis. The proximity of the cryoablation probe to the acetabulum is a significant risk factor in the development of this complication.     

Digital subtraction arthrography in preoperative evaluation of painful total hip arthroplasty

 Objective. The objective of this clinical study was to define the diagnostic value of plain radiography, digital subtraction arthrography and two-phase bone scintigraphy in patients with clinically loose or infected hip prostheses. Design. Digital subtraction arthrograms, scintigrams and plain radiographs of 70 consecutive patients who underwent revision hip arthroplasty were scored individually and in masked fashion for the presence or absence of features indicating loosening of femoral and/or acetabular components. The operative findings acted as the gold standard. Results. Digital subtraction arthrography was best (P<0.001) for predicting a loose acetabular component, while no significant additional predictive value was found for plain radiographs (P=0.24) and scintigraphy (P=0.27). Digital subtraction arthrography was also the most important modality for predicting a loose femoral component (P=0.001), while the plain radiograph was of significant (P=0.04) additional value and scintigraphy was of no additional value (P=0.13) on multivariate analysis. Conclusion. Digital subtraction arthrography gives the best results in the prediction of loosening of acetabular and femoral components. Plain radiographs give additional information on loosening of the femoral component, but scintigraphy offers no additional advantage.     

成人髋臼结构不良CT应用价值

目的　探讨CT对成人髋臼结构不良的诊断价值。方法　对 2 8例髋臼结构不良患者的 5 6个髋关节CT资料进行回顾性分析。结果　成人髋臼结构不良的CT影像中 ,75 .0 %髋臼表现有前部发育不良 ,而髋臼前后部均发育不良 ( 14 .4% )和臼窝形态异常 ( 14 .9% )者少见 ,5 7.1%髋臼顶部有发育不良。此外 ,CT发现继发性骨关节病和股骨头缺血坏死分别为 91.1%和 16 .1% ,均高于平片所见。结论　CT有助于全面了解髋臼发育状况及其与股骨头相互适应情况 ;确定髋臼结构不良的基本类型 ;早期发现继发性骨关节病和股骨头缺血坏死及评估髋关节病变的严重程度。     

非创伤性股骨头坏死0期临床诊断标准的建立及相关临床研究

目的 探讨股骨头坏死0期临床诊断标准的建立,并通过临床应用验证其准确性和临床价值.方法 回顾性分析临床非创伤性股骨头坏死患者258例,建立非创伤性股骨头坏死0期临床诊断标准,并根据该标准进行临床对照研究.结果 所建立标准的灵敏度、特异度、准确度分别为93.7%、86.4%、89.7%.临床应用研究显示给予预防性治疗(干预组)的患者,其股骨头坏死发生率明显低于无干预组(34.2% vs 84.9%,P＜0.01).结论 确立了非创伤性股骨头坏死0期临床诊断标准,有助于早期发现股骨头坏死,具有重大的临床应用价值;同时发现对0期非创伤性股骨头坏死应用多种预防性综合措施进行干预,治愈率较高,能有效降低股骨头坏死的发病率.     

Ⅰ期全髋置换术治疗合并股骨头或股骨颈骨折的髋臼骨折

目的 探讨全髋关节置换术(total hip arthroplasty,THA)治疗合并股骨头或股骨颈骨折的髋臼骨折方法、手术特点和疗效.方法 对7例合并股骨头或股骨颈骨折的髋臼骨折行Ⅰ期THA.髋臼骨折按AO分型:A型1例,B型3例,C型3例.股骨头骨折1例,股骨颈骨折6例.伤后7～21 d接受THA,5例行髋臼复位内固定后采用生物型髋臼,2例金属加强环配合骨水泥固定髋臼,股骨侧均采用生物型固定.结果 6例得到随访,平均随访时间3年9个月(2年3个月～6年5个月),出现脱位1例,经手法复位后未再脱位,1例出现异位骨化.所有随访患者髋关节功能均有明显改善,Harris评分术前平均48分,术后提高到91分.随访期内未发现假体松动.结论 THA是治疗合并同侧股骨头或股骨颈骨折髋臼骨折的有效方法,能显著改善关节功能,避免多次手术.     

不同入路与髋关节置换术后并发症的相关性分析

目的探讨采用前外侧、外侧、后外侧3种不同手术入路实施人工髋关节置换术治疗不同髋关节疾病的术后深静脉血栓及脱位的发生率。方法回顾分析我院960例人工髋关节置换术病例,采用不同手术入路治疗不同髋关节病种术后发生深静脉血栓及脱位的情况,总结术后并发症类型与入路选择的相关性。结果股骨颈骨折组536例,术后发生下肢深静脉血栓5例,后脱位3例。5例发生下肢深静脉血栓均为前外侧入路,后脱位3例均为后外侧入路。股骨头无菌性坏死组280例,发生后脱位1例,术后深静脉血栓1例。髋臼骨折术后骨性关节炎组50例,发生后脱位1例。髋关节发育不良组22例,术后发生脱位1例。发育性髋关节脱位组38例,术后发生深静脉血栓1例。髋关节置换术后翻修组34例,发生后脱位1例。结论采用前外侧入路更适合老年股骨颈骨折患者。外侧入路更适合单纯股骨头无菌性坏死病例。后外侧入路更适合髋臼骨折术后骨性关节炎、髋关节发育不良、发育性髋关节脱位、晚期强直性脊柱炎及髋关节置换术后翻修病例。个体化的入路选择可以减少术后深静脉血栓与脱位的发生率。     

Computed tomography of the femur head. Normal aspects and appearance in aseptic necrosis

The diagnostic value of Computed Tomography (CT) in the diagnosis of the aseptic necrosis of the femoral head is discussed. The CT findings in the different evolutive stages are reported and the respective diagnostic value of Conventional Radiology and CT are discussed. The CT findings of femoral head necrosis in the early phases are emphasized. The capability of CT to demonstrate structural changes in femoral heads with regular morphology allows to consider this technique when there exists a clinical doubt of osteonecrosis of the femoral head and in risk patients.     

Arthrography of painful hips following arthroplasty: digital versus plain film subtraction

Digital and manual subtraction images obtained during the arthrographic evaluation of 78 painful hip prostheses were reviewed retrospectively. Revision arthroplasty was performed in 53 of these cases, and the arthrographic and surgical findings were correlated. The digital and manual subtraction images were evaluated without knowledge of the surgical results using established criteria for component loosening. Digital subtraction arthrography of the femoral component demonstrated a 96% sensitivity and 100% specificity for the diagnosis of component loosening. Sensitivity and specificity for acetabular component loosening were 83% and 80%, respectively. Plain film subtraction of the femoral component demonstrated a 79% sensitivity and 100% specificity; the sensitivity and specificity for the acetabular component were 75% and 80%, respectively. The difference between detection of femoral component loosening on digital as opposed to manual subtraction images was statistically significant (P<0.05). This study demonstrates that digital subtraction improves the evaluation of femoral component loosening in painful hip prostheses.     

Ⅰ期全髋关节置换治疗髋臼骨折

目的 探讨髋臼骨折后Ⅰ期全髋关节置换(total hip arthroplasty,THA)的手术适应证和手术方法,观察其临床疗效.方法 对11例髋臼骨折患者行Ⅰ期THA.其中前柱骨折3例,后壁骨折1例,后柱骨折2例,后柱合并后壁骨折2例,横形骨折1例,横形合并后壁骨折1例,两柱骨折1例.伤后8～37 d(平均24 d)接受THA.对新鲜髋臼骨折患者,先用重建钢板或螺钉固定骨折以恢复髋臼肇的形态,将切下的股骨头制成颗粒状或块状植于髋臼内后安置臼杯.陈旧性髋臼骨折有节段性髋臼骨缺损者,将切下的股骨头制成大块状进行髋臼内结构性植骨后再安置臼杯.结果 术后3个月完全负重,无人工关节脱位.随访时间6～45个月,平均28个月.Harris评分平均78分.髋关节屈伸平均活动度为95°.X线片示1例出现髋臼松动及骨溶解征象.结论 髋臼骨折移位明显,关节软骨面损伤严重,错过了手术复位时机,可以Ⅰ期行THA.如能创造稳定的髋臼杯结构,近期临床效果满意.     

Avascular necrosis of the femoral head as a complication of chronic myelogenous leukaemia

 A 17-year-old male patient complaining of intense pain in his right hip was found to be suffering from chronic myelogenous leukaemia. Preliminary X-rays and bone scintigraphy did not suggest avascular necrosis of the femoral head. Magnetic resonance imaging (MRI) did, however, reveal leukaemic infiltration of the femoral neck and generalised ischeamia in the femoral head. Further, MRI carried out 4 months later disclosed typical signs of osteonecrosis, despite previous indications of an improvement under chemotherapy. Flattening of the head of the femur appeared in radiographs taken in the 9th month. In the 12th month, recurrence of pain made it necessary to perform a total hip arthroplasty. Anatomo-pathological investigation confirmed both the necrosis and the leukaemic invasion.     

Association of femoral head and acetabular fractures on computerized tomography: correlation with the Judet-Letournel classification

Purpose

Tha aims of this study were to identify the incidence of femoral head fractures in the setting of acetabular fractures and to determine the relationship between acetabular fracture pattern, the degree of acetabular fracture displacement, and the incidence of femoral head fractures.

Materials and methods

This is a retrospective cross-sectional study of 274 patients with 300 acetabular fractures diagnosed on pelvic CT. Acetabular fractures were categorized using the Judet-Letournel classification system.

Results

Femoral head fractures were present in 18.0% of acetabular fractures. Fracture patterns with a posterior wall component had a very high (56.3%) incidence of femoral head fracture. Anterior column and anterior column with posterior hemitransverse fractures have a very low (3.4%) incidence of femoral head fracture. Anterior hip dislocation had a 66.7% incidence of femoral head fracture, while posterior dislocation had a 71.9% incidence. Acetabular fractures displaced by more than 5 mm had a 26.9% incidence of femoral head fracture, while acetabular fracture displaced less than 5 mm had only 4.2% incidence of femoral head fracture.

Conclusion

Femoral head fractures are a very common associated finding in patients presenting with acetabular fractures. In patients with a posterior wall component of the fracture or associated hip dislocation, a femoral head fracture is more likely than not present. Conversely, in acetabular fractures with less than 5 mm displacement or anterior column fractures without posterior acetabular involvement, femoral head fractures are very unlikely in the absence of a dislocation event.

     

股骨侧骨水泥假体翻修术

目的 探讨非感染性股骨侧骨水泥假体翻修术的手术指征及手术技巧。方法 回顾性分析1998年1月－2001年12月接受股骨侧骨水泥假体翻修术患者45例，其中男19例，女26例；年龄59－67岁，平均64岁。翻修原因中，人工股骨头置换术后柄松动9例，髋臼磨损7例，全髋置换术后柄松动17例，柄断裂2例，髋臼松动或臼松动或臼柄松动10例。所有病例均I期翻修，采用骨水泥假体，有骨质缺损者同时植骨。结果 术后无一例发生伤口感染、脱位和神经血管并发症，术后6个月，患者可弃拐行走。随访6－40个月，平均23个月，患者髋关节功能良好，Harris评分由术前35．0分提高至术后88．5分。结论 假体松动是人工关节翻修术的主要原因。在翻修假体的选择上，骨水泥假体主要适用于老年骨质疏松患者、需长段异体骨复合人工假体患者、非骨水泥假体翻修失败患者及关节感染需在翻修术中使用抗生素骨水泥患者。翻修手术对手术技巧和手术设备要求较高，术前计划必不可少。     

Avascular bone necrosis in an untreated case of chronic myelogenous leukemia

Hip pain due to aseptic necrosis of the femoral head was the first clinical manifestation of chronic myelogenous leukemia in a 9-year-old white female. An erroneous diagnosis of rheumatoid arthritis was first entertained. Physical examination showed splenomegaly, complete blood count revealed leucocytosis of 359 000. the initial radiograph of the involved hip was negative. Biopsy revealed aseptic necrosis of the femoral head. Chronic myelogenous leukemia (CML) was diagnosed on the basis of the peripheral blood smear and bone marrow biopsy. Two months later, radiograph, radionuclide bone scan, and magnetic resonance imaging (MR) of the involved hip were positive for aseptic necrosis of the femoral head.     

骨水泥股骨柄和非骨水泥臼杯在首次全髋关节置换术中的应用

目的 随访一组采用同一类型骨水泥型股骨假体和非骨水泥型髋臼假体组合在首次人工全髋关节置换术中的应用，并探讨该种混合型假体对于全身健康情况和骨质质量一般较差的老年患者的适用情况。方法 共有75例患者84髋得到临床和影像学随访，平均年龄为67．9岁。其中老龄股骨颈骨折患者41例41髋，平均年龄72．1岁。随访时间为4．1年。随访内容包括患者的健康状况、手术方法、术后恢复情况以及对于骨形态、骨水泥固定质量和假体稳定性的判断。结果 2例股骨假体发生无菌性松动，臼杯则未见骨溶解或松动征象。未出现骨水泥相关的术中或术后死亡，各类全身性疾病在围手术期无加重表现。41例股骨颈骨折患者术后Harris评分为81.1分。股骨近端骨形态A型17髋（20％），B型47髋（56％），C型20髋（24％）。骨水泥固定质量分别为A级31髋（37％），B级40髋（48％），C级13髋（15％）。结论 混合型人工关节置换术的短期随访结果良好；混合型人工关节的术后即时稳定性有利于老年患者的康复；在手术中必须应用现代骨水泥技术。     

Bone SPECT is more sensitive than MRI in the detection of early osteonecrosis of the femoral head after renal transplantation.

We compared the diagnostic sensitivity of (99m)Tc-methylene diphosphonate bone SPECT and MRI in the early detection of femoral head osteonecrosis after renal transplantation. METHODS: The patients were 24 renal allograft recipients who underwent both bone SPECT and MRI within 1 mo of each other because of hip pain but normal findings on plain radiography. SPECT was considered positive for osteonecrosis when a cold defect was detected in the femoral head, and the defect was further classified according to the presence of adjacent increased uptake: type 1 = a cold defect with no adjacent increased uptake; type 2 = a cold defect with adjacent increased uptake. MRI was considered positive for osteonecrosis when a focal region with low signal intensity on T1 images was detected in the femoral head. Final diagnoses were made by surgical pathology or clinical and radiologic follow-up of >1 y. RESULTS: A total of 32 femoral heads, including 24 of 29 painful hips and 8 of 19 asymptomatic contralateral hips, were confirmed as having osteonecrosis. SPECT detected osteonecrosis in all 32 of the femoral heads, resulting in a sensitivity of 100% (32/32), whereas MRI detected osteonecrosis in 21 femoral heads, for a sensitivity of 66% (21/32, P < 0.005). SPECT showed the type 1 pattern in 13 and the type 2 in 19. Ten of the 13 femoral heads with the type 1 pattern were false-negative on MRI, whereas only 1 of 19 with the type 2 pattern was normal on MRI (P < 0.001). There were 6 femoral heads with normal MRI findings and abnormal SPECT findings (type 1 pattern) in 3 patients, for whom hip pain decreased and radiographic findings were normal during follow-up. Follow-up bone SPECT showed a decreasing area of cold defect in 4 femoral heads. CONCLUSION: (99m)Tc-methylene diphosphonate SPECT is more sensitive than MRI for the detection of femoral head osteonecrosis in renal transplant recipients. Bone scintigraphy with SPECT is needed to diagnose osteonecrosis in patients with hip pain despite normal radiography results after renal transplantation. The significance of a transient SPECT abnormality needs to be clarified by further natural history studies.     

早期股骨头无菌坏死80例的影像学对比研究

目的探讨成人股骨头无菌坏死的早期X射线、CT表现并进行对比研究。方法收集具有典型X射线平片、CT表现并经病理或随访证实的80例成人股骨头无菌坏死患者的X射线平片和CT片,分组对比分析其征象及变化。结果CT表现：股骨头完整组40例,62个关节,出现高密度硬化股骨头49个,在高密度周围出现囊性变伴低密度区者26个,12个股骨头内出现气体密度影;股骨头塌陷组40例,71个关节,其中8个股骨头显示单纯高密度硬化,63个在硬化区周围还伴有低密度区,有22个股骨头内出现气体密度影。结论股骨头内出现单纯高密度硬化、气体密度影及囊性变为本病的早期影像征象,其特殊的CT表现比X射线平片具有更重要的临床诊断价值。     

人工关节置换治疗老年骨质疏松性髋部骨折

目的探讨人工关节置换治疗老年骨质疏松性髋部骨折的疗效。方法对42例老年骨质疏松性髋部骨折行全髋或人工股骨头置换术,获得1.5～5年随访(平均3年2个月)。结果全髋关节置换15例,人工股骨头置换27例。按Harris评分,优良率为88.1%,无假体松动、关节脱位、假体周围骨折。结论采用人工关节置换治疗老年骨质疏松性髋部骨折,临床效果好,可以尽快恢复患者下地活动、减少并发症。     

人工关节置换治疗晚期股骨头缺血性坏死合并严重股骨颈前倾角畸形

目的 探讨晚期股骨头缺血性坏死合并严重股骨颈前倾角畸形患者采用普通假体髋关节置换的手术方法及临床疗效.方法 本组男9例,女6例;年龄30～42岁,平均37岁.前倾角40°～50°,术前Harris评分(59±8)分,术中通过将股骨假体缩小前倾角20°～30°,同时将髋臼杯前倾角增大10°～15°,使其基本恢复正常对合关系,防止关节前脱位.术后定期影像学检查和临床疗效Harris髋评分.结果 术后15例患者均获得随访2.5～3.7年(平均2.9年),关节假体稳定性良好,关节活动度基本正常.术后2年Harris评分为(88±6)分,与术前相比,疗效显著(P<0.01).结论 晚期股骨头缺血性坏死合并严重股骨颈前倾角畸形患者手术中通过对普通的股骨假体及髋臼杯安放的角度的联合调整,使关节置换术后人工假体与髋臼的对合基本恢复正常,疗效显著,同时避免了使用小柄股骨假体、转子下截骨或使用特殊前倾角股骨假体等治疗方法.