手术配合生骨饮Ⅱ号方治疗塌陷前期非创伤性股骨头坏死的临床研究

目的:探讨髓芯减压打压支撑植骨术配合生骨饮Ⅱ号方治疗塌陷前期非创伤性股骨头坏死的疗效。方法:非创伤性股骨头坏死患者19例(23髋),采用髓芯减压打压支撑植骨术配合术后生骨饮Ⅱ号方口服治疗,随访8个月～5年,从X线片的股骨头塌陷程度和髋关节功能Harris评分两方面对疗效进行评价。结果:未发生塌陷的20髋,2髋塌陷加重不超过2mm,1髋塌陷2～4mm,Harris评分,术后(88.62±4.80)分。优19髋,良3髋,可1髋。结论:髓芯减压打压支撑植骨术配合生骨饮Ⅱ号方治疗非创伤性股骨头坏死有利于骨坏死修复,能够预防股骨头坏死塌陷。     

微创开窗打压植骨联合细针钻孔减压治疗塌陷前期股骨头坏死

目的 探讨微创下开窗坏死病灶清除打压植骨联合细针多孔钻孔减压治疗塌陷前期股骨头坏死的临床疗效.方法 2009年1月至2011年12月收治的43例(64髋)塌陷前期股骨头坏死患者,均采用微创股骨头坏死病灶清除打压植骨联合细针多孔钻孔减压的手术方式治疗.收集患者术前及术后24个月的Harris髋关节功能评分,以评价手术疗效.结果 本组随访时间24.0～60.0个月,平均(32.0±3.5)个月,失访2例(2髋).术后24个月,Harris髋关节功能评分为(81.2±5.6)分,优良率达77.42％,与术前的(62.2±4.2)分相比,差异有统计学意义(P＜0.05).结论 微创开窗坏死病灶清除打压植骨联合细针多孔钻孔减压治疗塌陷前期股骨头坏死疗效显著,是一种简单有效的治疗方法.     

微创减压自体骨打压植骨治疗早期股骨头坏死的近期疗效

目的 探讨微创减压自体骨打压植骨治疗早期股骨头坏死的近期疗效。方法 借助天玑骨科手术机器人定位,采用微创减压自体骨打压植骨联合唑来膦酸、富血小板血浆注射治疗15例早期股骨头坏死患者。手术前后采用疼痛VAS评分评估髋疼痛程度,末次随访时采用Harris评分评估髋关节功能。结果 切口均一期愈合。患者均获得随访,时间12～20(13. 51±2. 43)个月。术后均无感染、神经损伤、深静脉血栓等并发症发生。末次随访时,髋关节Harris评分和VAS评分均较术前改善,差异均有统计学意义(P 0. 05)。末次随访时,患髋股骨头形态稳定,未发生明显塌陷,无一例患者因股骨头塌陷而接受全髋关节置换。结论 借助天玑骨科手术机器人的精准定位,微创减压自体骨打压植骨治疗早期股骨头坏死具有创伤小、定位减压精准、植骨成活率高等优点。     

微创减压打压植骨治疗早中期股骨头坏死

目的观察微创减压刮除病灶后打压植骨治疗早中期股骨头缺血性坏死的临床疗效。方法自2010年1月至2015年1月,采用透视下微创钻孔减压刮除病灶植入优质自体松质骨并压实,同时活血抗凝治疗早中期股骨头缺血性坏死,共36例(44髋),男22例(28髋),女14例(16髋);年龄22~58岁,平均36岁。按国际骨循环研究会(the assciation research circulation osseuse,ARCO)骨坏死分期标准分类,Ⅰa 2髋,Ⅰb 8髋,Ⅰc 10髋,Ⅱa 10髋,Ⅱb 4髋,Ⅱc 6髋,Ⅲa 4髋。观察术前及末次随访时Harris评分和股骨头的X线片影像结果。结果本组均获随访,随访时间12~36个月,平均24个月。术前Harris评分(53.10±6.12)分,末次随访时Harris评分(81.10±10.90)分,比术前明显提高,差异有统计学意义(P0.05)。影像学显示,多数植骨愈合,关节间隙增宽。结论微创减压刮除病灶后打压植骨治疗早中期股骨头缺血性坏死有较好的疗效,能有效改善髋关节功能。     

经髋关节外科脱位入路自体髂骨瓣打压植骨治疗中青年ARCO Ⅱ、Ⅲ期股骨头缺血性坏死

目的探讨经髋关节外科脱位入路自体髂骨瓣打压植骨治疗中青年ARCOⅡ、Ⅲ期股骨头缺血性坏死的临床疗效。方法回顾性分析自2015-02—2017-08诊治的52例(53髋)中青年ARCOⅡ、Ⅲ期股骨头缺血性坏死,经髋关节外科脱位入路行股骨大粗隆截骨,彻底清除股骨头内坏死骨肌硬化带,将松质骨打压植骨,将游离髂骨块修整后打压植入股骨后外侧柱或前外侧柱进行支撑。结果 52例均获得随访,随访时间平均20(8~38)个月。2例(2髋)术后1年因髋关节严重塌陷行全髋关节置换术。末次随访时髋关节功能Harris评分为(83.2±5.8)分,较术前明显提高。总体稳定情况:好转29髋,稳定14髋,加重8髋。结论经髋关节外科脱位入路自体髂骨瓣打压植骨治疗中青年ARCOⅡ、Ⅲ期股骨头缺血性坏死的短期疗效满意,术中在不破坏股骨头血供的基础上直视下对坏死骨、硬化骨清除,可利用股骨大粗隆处松质骨及髂骨瓣重建股骨头外侧及前外侧生物学及生物力学稳定,但远期疗效有待进一步观察。     

病灶清除后打压植骨联合多孔钽金属棒植入治疗早期股骨头缺血性坏死

目的探讨病灶清除后打压植骨联合多孔钽金属棒植入治疗早期股骨头缺血性坏死的临床疗效。方法 2008年3月-2010年5月,收治14例16髋股骨头缺血性坏死患者。男13例15髋,女1例1髋;年龄18～73岁,中位年龄42.2岁。外伤性1例1髋,酒精性4例4髋,激素性9例11髋。股骨头缺血性坏死根据国际骨循环研究会(ARCO)分期:Ⅰ期3髋,Ⅱ期13髋。Harris评分为(51.89±12.42)分,采用中华医学会骨科学分会百分比评价法中的X线评价方法评分为(31.88±4.03)分。病程6个月～7年,中位病程2.5年。采用经股骨头颈部开窗、病灶清除、自体髂骨打压植骨联合多孔钽金属棒植入治疗。术后患肢避免负重3个月,部分负重3个月。结果术后切口均Ⅰ期愈合,无感染等早期并发症发生。患者均获随访,随访时间13～36个月,平均24个月。2例2髋因关节疼痛加重、股骨头塌陷,于术后4个月及2年行人工全髋关节置换;其余患者术后关节疼痛症状均明显缓解,股骨头生存率为87.5%(14/16)。髋关节功能行Harris评分为(84.89±17.96)分,与术前比较差异有统计学意义(t=—8.038,P=0.001)。X线片检查示植骨区域成骨化明显,骨密度增高,骨小梁排列整齐规则,股骨头无明显塌陷。末次随访时X线片评分为(32.19±6.57)分,与术前比较差异无统计学意义(t=—2.237,P=0.819)。结论病灶彻底清除后打压植骨联合多孔钽金属棒植入治疗早期股骨头缺血性坏死能有效缓解疼痛、改善髋关节功能、防止股骨头塌陷,延缓甚至避免人工全髋关节置换。     

髓芯减压打压植骨腓骨支撑术与头颈部开窗打压植骨术治疗早中期股骨头坏死疗效比较

目的比较微创髓芯减压死骨清理打压植骨腓骨支撑术与头颈部开窗打压植骨术治疗早中期股骨头坏死的临床疗效。方法选取自2009-11—2013-11诊治的30例(40髋)ARCOⅡB~ⅢA期股骨头坏死,随机分成A、B组,A组采用微创髓芯减压打压植骨腓骨支撑术,B组采用股骨头颈部开窗打压植骨术。比较2组术后1周VAS疼痛评分及末次随访时髋关节功能Harris评分。结果术后1周VAS疼痛评分:A组(2.40±1.20)分,B组(4.30±1.50)分,A组VAS评分低于B组,差异有统计学意义(t=-3.81,P0.05)。30例(40髋)均获得随访8~40个月,平均24个月。末次随访时A组髋关节功能Harris评分总分、疼痛评分、关节活动度评分均高于B组,差异有统计学意义(P0.05)。A组ARCO分期中ⅡB期患者髋关节功能Harris评分高于B组,差异有统计学意义(P0.05);而ⅡC、ⅢA期患者由于样本数量较少,2组差异无统计学意义(P0.05)。结论微创髓芯减压死骨清理打压植骨腓骨支撑术治疗早中期股骨头缺血性坏死的疗效较股骨头颈部开窗打压植骨术好,可有效改善髋关节功能。     

灯泡状病灶清除打压植骨术治疗股骨头坏死的疗效

目的探讨股骨头颈交界开窗灯泡状病灶清除打压植骨术治疗早中期股骨头坏死的初步疗效。方法自2011年5月至2012年9月在潍坊市中医院治疗股骨头坏死患者32例(39髋),随访2年。其中ARCO分期:Ⅱ期29髋、Ⅲa期10髋,行股骨头颈交界开窗灯泡状病灶清除打压植骨术,采用Harris评分系统评估术后患髋关节的功能改善情况,并于3、6、9个月及每年定期予以X线检查,进行影像学评估。结果参考Harris评分系统:优21髋,良9髋,可6髋,差3髋,患者治疗前的Harris评分平均为(70.21±7.36)分,治疗后平均为(85.50±9.87)分,平均提高15.29分(P0.01)。影像学检查表现稳定,绝大部分病例未出现进一步塌陷,股骨头内成骨明显。结论股骨头颈交界开窗灯泡状病灶清除打压植骨术手术操作微创,不破坏股骨头本身的血液供应,死骨清除彻底,减压充分,植入成骨活性较好的骨质及磷酸三钙多孔生物陶瓷,成骨作用强,并增加了股骨头坏死区软骨下骨的机械支撑,对早中期股骨头坏死有很好的临床疗效。     

髓芯减压打压植骨腓骨支撑术对改善早中期股骨头坏死患者髋关节功能的效果

目的探讨髓芯减压打压植骨腓骨支撑术治疗早中期股骨头坏死的效果。方法选择2016-01—2018-01间在西华县人民医院治疗的56例早中期股骨头坏死患者。随机分为2组,各28例。对照组行股骨头颈部开窗打压植骨术,观察组采取髓芯减压打压植骨腓骨支撑术。比较2组术前与术后6个月VAS疼痛评分、髋关节功能及股骨头塌陷程度。结果观察组治疗后VAS评分低于对照组,Harris评分高于对照组,差异有统计学意义(P0.05)。2组股骨头塌陷程度差异无统计学意义(P0.05)。结论髓芯减压打压植骨腓骨支撑术治疗早中期股骨头坏死,可缓解患者疼痛,改善髋关节功能,降低股骨头塌陷程度。     

髋关节外科脱位打压植骨术与髓芯减压支撑植骨术治疗ARCO Ⅲ期股骨头缺血性坏死疗效比较

目的比较经髋关节外科脱位打压植骨术与髓芯减压支撑植骨术治疗国际骨循环研究会(ARCO Ⅲ期股骨头缺血性坏死(avascular necrosis of the femoral head,ANFH)的疗效。方法回顾性分析2013年10月—2016年4月收治并符合选择标准的60例(69髋)ARCO Ⅲ期非创伤性ANFH患者临床资料。其中,24例(28髋)行经髋关节外科脱位打压植骨支撑术治疗(A组),36例(41髋)行髓芯减压、坏死病灶清除,并打压植骨、同种异体腓骨支撑术治疗(B组)。两组患者性别构成、年龄、侧别、ANFH类型及分期、病程以及术前髋关节Harris评分、疼痛视觉模拟评分(VAS)等一般资料比较,差异均无统计学意义(P0.05)。术后采用Harris评分评价髋关节功能,X线片复查观察股骨头形态改变情况,评价患者保髋临床是否成功。结果术后两组切口均Ⅰ期愈合。两组患者均获随访,A组随访时间为12～48个月,平均25.8个月;B组为12～54个月,平均26.4个月。A组5髋保髋临床失败,股骨头生存率为82.1%,中位生存时间为43个月;B组19髋保髋临床失败,股骨头生存率为53.7%,中位生存时间为42个月;两组生存曲线分布差异有统计学意义(χ~2=4.123,P=0.042),A组优于B组。末次随访时A、B组保髋成功患者髋关节Harris评分明显高于术前,VAS评分明显低于术前(P0.05),两组间各评分比较差异无统计学意义(P0.05)。X线片复查示,两组植骨均融合,融合时间组间比较差异无统计学意义(t=0.752,P=0.456)。A组大转子截骨处均愈合良好,1例髋关节周围出现异位骨化。结论对于股骨头轻度塌陷的ARCO ⅢA期患者,两种术式疗效确切;对于股骨头塌陷较严重的ARCO ⅢB期患者,经髋关节外科脱位打压植骨术后股骨头生存率优于髓芯减压支撑植骨术。     

Development of flattening and apparent fragmentation following ischemic necrosis of the capital femoral epiphysis in a piglet model

BACKGROUND: The repair response that follows ischemic necrosis of the immature femoral head and the biological processes that are responsible for the development of femoral head deformity and fragmentation have not been clearly defined. A piglet model was used to study the radiographic and histopathologic changes that occur prior to and during the development of femoral head deformity and fragmentation following ischemic necrosis. METHODS: Twenty-five male piglets were studied. A nonabsorbable ligature was placed tightly around the femoral neck to disrupt the blood supply to the capital femoral epiphysis. The animals were killed three days to eight weeks following the induction of ischemia. Radiographs of whole and sectioned femoral heads were made, and the radiographic findings were correlated with the histopathologic changes observed in the specimens. RESULTS: Mild femoral head flattening was observed by four weeks after the induction of ischemia, and severe flattening and fragmentation were observed by eight weeks. The predominant repair response observed following revascularization was osteoclastic bone resorption. Prior to the development of flattening, a large area of osteoclastic bone resorption was observed in the central region of the femoral head. Many osteoclasts were present along the revascularization front, which we believe were responsible for active resorption of the necrotic trabecular bone. Appositional new-bone formation, the hallmark of the repair response in adult ischemic necrosis, was not observed in the area of bone resorption. Instead, the areas of resorbed bone were replaced with a fibrovascular tissue that persisted for up to eight weeks. Appositional new-bone formation was observed, but it was limited to small areas in which revascularization was not followed by osteoclastic bone resorption and in which necrotic trabecular bone was still present. The simultaneous presence of the areas of bone resorption and new-bone formation contributed to the fragmented radiographic appearance of the femoral head. CONCLUSIONS: The predominant repair response observed in the piglet model of ischemic necrosis was osteoclastic bone resorption. The early bone loss, the lack of new-bone formation, and the persistence of fibrovascular tissue in the areas of bone resorption compromised the structural integrity of the femoral head and produced progressive femoral head flattening over time. The repair response was different from that observed in femoral heads removed from adult patients with ischemic necrosis and from that observed in the adult rabbit model of ischemic necrosis. Clinical Relevance: The piglet model of ischemic necrosis may be useful for the investigation of the biological processes that lead to the development of femoral head deformity following ischemic necrosis of the immature femoral head.     

应用显微外科技术预防青壮年股骨颈骨折后股骨头坏死

目的 探讨应用显微外科技术治疗青壮年股骨颈骨折，预防股骨头坏死的可行性。方法自1995年1月至2004年12月，临床应用74例，年龄23-50岁，其中新鲜骨折6l例，陈旧性骨折13例，均采用切开复位内固定加带血管蒂骨瓣移植的治疗方法，平均随访3．2年，观察股骨头缺血性坏死的发生情况。结果依据主要临床症状和X线片诊断发生股骨头缺血性坏死共19例，占病例总数的25．68％，其中男性13例，女性6例，年龄37～49岁，平均42．35岁，发现时间为伤后10～78个月，平均28．5个月。髋关节Harris评分优良率为74．32％。结论采用显微外科技术治疗青壮年股骨颈骨折，能降低股骨头缺血性坏死的发生率。     

Effect of methylprednisolone on reperfusion after femoral head ischemia

An episode of ischemia and reperfusion of the femoral head is thought to be the common pathway in the pathogenesis of femoral head necrosis. The influence of short-term high-dose steroid treatment on femoral head reperfusion after ischemia was investigated in a porcine model. Twenty-two pigs were randomized to receive methylprednisolone 20 mg/day/kg bodyweight intramuscularly for 3 days followed by methylprednisolone 10 mg/day/kg bodyweight for 11 days (n = 11), whereas the control group (n = 11) received no treatment. Femoral head ischemia was achieved by 6 hours of unilateral intraarticular hip pressure increase to 250 mm Hg. Femoral head blood flow was estimated using radiolabeled microspheres (15 microm in diameter) before ischemia, during hip tamponade, and 4 hours after tamponade release. Femoral head blood flow was lower in the corticosteroid treated pigs. Subtotal femoral head ischemia was documented in both groups during joint tamponade. Apart from two femoral head epiphyses in either group, reperfusion after tamponade release on the average occurred to a blood flow level similar to that before ischemia. Short-term high-dose methylprednisolone treatment depressed bone perfusion in general, but had no effect on reperfusion after femoral head ischemia in the porcine model.     

股直肌直头肌骨瓣移位治疗股骨头缺血性坏死

目的 观察应用带肌直肌直头肌骨瓣移位治疗成人股骨头缺血性坏死的疗效。方法 选择８例股骨头缺血性坏死患者,按Ｆｉｃａｔ分期Ⅱ期５例,Ⅲ期３例,采用Ｓｍｉｔｈ－Ｐｅｔｅｒｓｏｎ切口进入关节囊。游离股直肌直头,其起点附着部位保持联系,截取包括髂骨两层骨皮质和骨膜的骨瓣,在Ｘ线控制下,用刮匙将坏有组织刮除后,将肌蒂骨瓣紧密嵌入骨洞内,同时进行标准的髓蕊减压术。结果 术后患髋疼痛均消失,５例Ⅱ期患者１年后跛     

干细胞移植改善股骨头坏死缺血状态122例临床观察

目的探讨经动脉自体骨髓干细胞（BMSC）和外周血干细胞（PBSC）移植改善股骨头坏死缺血状态的临床疗效。方法2004年7月至2006年12月对122例（211髋）成人缺血性股骨头坏死（ANFH）患者施行自体BMSC或PBSC移植治疗,按国际分期标准（ARCO）分期,设自身前后对照方法进行疗效观察。BMSC组90例和PBSC组32例在DSA下行股骨头供血动脉干细胞移植术,移植后第3、6、12、24个月进行髋关节Harris评分做疗效评价,6个月复查股骨头供血动脉造影观察血管新生情况。每间隔6个月复查影像学变化。结果122例患者随访3～24个月（平均10．2个月）,髋关节疼痛缓解104例（85．1％）,关节功能改善76例（62．0％）,90例（73．9％）行走间距延长。干细胞移植术后6个月,15例患者股骨头供血动脉造影检查见供血动脉较移植前明显增多、增粗,血流速度增快;12～24个月20例股骨头区可见骨质病变获得改善。结论经动脉自体BMSC和PBSC移植方法简便,安全有效,对缺血性股骨头无再次损伤,患者依从性好,是治疗缺血性股骨头坏死的一种新途径。     

带阔筋膜张肌髂骨瓣移植治疗股骨头缺血性坏死

目的:探讨带阔筋膜张肌骨瓣移植结合软骨下微骨折技术在促进修复、治疗股骨头缺血性坏死的疗效。方法:股骨头缺血性坏死患者37例,男24例,女13例;年龄17~51岁,平均37岁。FicatⅠ期13例,Ⅱ期15例,Ⅲ期9例。5例为双侧发病。均经非手术治疗6~49个月后采用股骨颈开槽并去除硬化及囊性变之股骨头软骨下骨后嵌入带阔筋膜张肌骨瓣,清理坏死区域,使用2mm克氏针作锥入孔,直至有血液及脂滴自孔中溢出。术后使用CPM机康复训练,3个月内禁负重,3个月后先后经双拐、单拐、手杖辅助行走,1年后正常行走。结果:所有病例随访1~10年,平均3.4年。髋关节Harris评分,优24例,患髋无疼痛;良8例,患髋活动时疼痛明显减轻,偶服用止痛药;可3例,症状有所缓解,但仍需服用止痛药,后期行人工关节置换术后恢复正常活动。结论:应用带阔筋膜张肌骨瓣移植结合软骨下微骨折技术治疗能有效地改善股骨头的血供,促使坏死软骨面的再生修复。     

Follow-up results of osteosynthesis of medial femoral neck fractures with the dynamic hip screw

The operative treatment of subcapital femoral neck fractures of stages Garden III and IV in the young patient is still a problem. The current methods of osteosynthesis show a high rate of avascular necrosis of the femoral head. We controlled 24 patients with subcapital femoral neck fracture, who were treated with a dynamic hip screw (DHS). The average age of these patients is 55 years. They were examined after 30-89 months from the operation. All patients were assessed regarding clinical and radiological parameters. All of the six patients with femoral neck fractures of stages Garden I and II had no pain, their clinical results were good. In one of these patients we found a partial avascular necrosis of the femoral head. Four out of the 18 patients with femoral neck fractures of stages Garden III and IV had painful complications, 3 of them needed a reoperation. Fourteen patients of the group with femoral neck fractures of stages Garden III and IV had no pain and wer satisfied with the result. But in this group we found 7 patients with partial avascular necrosis of the femoral head. These results are discussed and compared with data published elsewhere.     

股骨头髓心减压加异体腓骨移植术治疗股骨头缺血性坏死

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临床疗效。方法：2004年1月至2008年11月治疗Ⅰa-Ⅲb期股骨头缺血性坏死25例32髋,其中男17例,女8例,年龄20～55岁,平均39．1岁。采用股骨头髓心减压加异体腓骨移植、空心拉力螺钉内固定治疗。术前疼痛时间2-14个月,平均5．5个月。所有患者于术前术后行常规X线片、MRI检查、Harris评分。结果：25例均获随访,时间24-48个月,平均36-4个月。X线片显示18例21髋改善,4例6髋不变,关节面未塌陷,2例3髋恶化,1例2髋失败,总有效率84_4％。Harris评分术前（77．0±8．0）分,术后（90．6±2．5）分,差异有统计学意义（t=1．67,P〈0．05）。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,创伤小,关节功能影响小,术后卧床时间短,恢复快,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。     

复元散对激素性股骨头坏死微循环影响的实验研究

目的 探讨验方复元散对激素性股骨头坏死微循环的影响。方法 40只成年雄性新西兰大白兔随机分为模型组（15只），复元散组（15只）和对照组（10只）。模型组采用臀肌注射醋酸氢化泼尼松（简称激素）建立股骨头骨细胞坏死模型。复元散组按上法注射激素并每日灌服复元散。每隔2周各组分别进行全血粘度、甘油三酯、血清总胆固醇及骨内压测定。结果 模型组全血粘度、甘油三酯、血清总胆固醇及骨内压均明显升高，而复元散组各项指标无明显升高（P＜0．01）。结论 复元散能够改善股骨头微循环，扭转股骨头缺血状态，抑制本病的发生发展。     

Closed reduction of developmental dislocation of the hip by prolonged traction

The efficacy of traction before an attempted closed reduction for patients with developmental dislocation of the hip remains controversial. We treated 55 children (62 dislocations of the hip) by preliminary, prolonged traction for a mean of eight weeks. All were followed up for at least two years in order to observe the development of any avascular changes within the femoral head. Of the 55 children, 27 (31 dislocations) were followed up until they were over six years of age. Fifty-seven of the 62 hips (92%) showed a successful closed reduction. Only one had radiological evidence of avascular necrosis of the femoral head. Of the 31 hips which were followed up to over six years of age, 15 (48%) showed residual subluxation. Our method of prolonged preliminary traction leads to a high rate of successful closed reduction, a low incidence of avascular necrosis and a reduced need for secondary operations.