空心螺钉治疗股骨颈骨折术后并发症的分析

目的探讨影响空心螺钉治疗股骨颈骨折术后早期并发症及中晚期股骨头缺血性坏死的因素。方法对1994年1月～2004年1月间应用空心螺钉治疗的116例股骨颈骨折患者进行回顾性总结,将患者性别、年龄、骨折类型、骨折复位情况、外伤至手术时间与骨折术后早期并发症及中晚期股骨头缺血性坏死间的关系进行统计学分析。结果116例患者获平均(3．2±2．5)年(1～11年)随访。术后早期并发症包括：骨折内固定失败6例,骨折周围再骨折2例,感染2例,下肢深静脉血栓6例。年龄是引起骨折术后早期并发症的主要因素之一；骨折术后早期并发症还与骨质情况及内固定技术有关。本组16例出现股骨头缺血性坏死,其坏死率为13．8%。造成股骨头缺血性坏死的因素主要是骨折类型,其次为骨折复位情况。结论①年龄大于60岁的患者股骨颈骨折术后早期并发症相对多。②对于骨折移位严重的高龄患者,建议行人工关节置换术。③内固定术应尽可能解剖复位、坚强牢靠,以减少术后股骨头缺血性坏死的发生。     

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.     

Bisphosphonate-induced Osteonecrosis of the Jaws: Review, Clinical Implications and Case Report

The introduction of bisphosphonates has increased in the last decade following their indication for metastatic bone diseases, osteoporosis, hypercalcaemia of malignancy and Paget’s disease. Although bisphosphonates have been used clinically for more than three decades there have been no documented long-term complications of their effects on the jaws until recently, where there is now growing evidence of the influence of bisphosphonates on osteonecrosis of the jaws. The aim of this paper is to report a case of this newly described complication, to review this phenomenon, including the clinical implications and to reiterate current clinical guidelines for management of patients in which bisphosphonate therapy is indicated. To the best of our knowledge this is the first reported case of bisphosphonate-induced necrosis of the jaw in South Africa.     

Bisphosphonate-related Osteonecrosis of the Jaws: An Update on Clinical, Pathological and Management Aspects

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is mainly observed in patients with multiple myeloma and bone metastasis from solid tumors receiving iv bisphosphonate therapy. The reported incidence of BRONJ is significantly higher with the iv preparations zoledronic acid and pamidronate while the risk appears to be minimal for patients receiving oral bisphosphonates. Currently available published incidence data for BRONJ are based on retrospective studies and estimates of cumulative incidence range from 0.8 to 12%. The mandible is more commonly affected than the maxilla (2:1 ratio), and 60–70% of cases are preceded by a dental surgical procedure. The signs and symptoms that may occur before the appearance of clinical evident osteonecrosis include changes in the health of periodontal tissues, non-healing mucosal ulcers, loose teeth and unexplained soft-tissue infection. Although the definitive role of bisphosphonates remains to be elucidated, the inhibition of physiologic bone remodeling and angiogenesis by these potent drugs impairs the regenerative capacity of the bone causing the development of BRONJ. Tooth extraction as a precipitating event is a common observation. The significant benefits that bisphosphonates offer to patients clearly surpass the risk of potential side effects; however, any patient for whom prolonged bisphosphonate therapy is indicated, should be provided with preventive dental care in order to minimize the risk of developing this severe condition. This article provides an update review of current knowledge about clinical, pathological and management aspects of BRONJ.     

Avascular necrosis of the femoral head in long-term follow-up of systemic sclerosis: report of two cases

Summary A long-term follow-up of two patients with scleroderma (SS) who developed a polyarthritis with bilateral femoral head osteonecrosis is reported. The severe parallel evolution of the small and large joint lesions and the late appearance of osteonecrotic changes in our patients suggest that avascular osteonecrosis is related to the osteoarticular progression of the longstanding SS.     

Pyogenic granuloma-like reaction in the necrotic, vessels-deprived femoral head of the rat

Osteonecrosis of the femoral head was produced in rats by cutting the ligamentum teres and incising the cervical periosteum. As of the second postoperative week, fibrous tissue pervaded the necrotic epiphyses, macrophages and osteoclasts removed the debris, osteoblasts deposited lamellar-fibred and woven-fibred intramembranous bone, and remodeling began. In 16% of the rats killed during the 2nd postoperative week, the epiphyses contained big fragments of necrotic bone enclosed by densely packed, capillary-sized vessels. Ingrowth of this hypervascularized, pyogenic granuloma-like tissue is presumably due to the presence of excessive growth factors, reflecting an exaggerated pathophysiological reaction within the framework of organization of the necrotic epiphyses.     

Hip preserving procedures for osteonecrosis of the femoral head after collapse

Osteonecrosis of the femoral head (ONFH) affects mainly young patients and causes secondary hip osteoarthritis if remains untreated. Several operative treatments have been introduced with successful outcomes in the early stages. However, in late stages of ONFH treatment may be challenging due to the progressive nature of disease and many surgeons prefer arthroplasty option after collapse. Considering the size, age and etiology an effort should be made to preserve hip joint selected patients with early collapse or minimal arthritic changes. The purpose of the current review is to discuss the results of joint preserving procedures for late stages of ONFH.     

Culture-Expanded Autologous Adipose-Derived Mesenchymal Stem Cell Treatment for Osteonecrosis of the Femoral Head

BackgroudOutcomes of traditional treatment for osteonecrosis of the femoral head (ONFH) are not always satisfactory. Hence, cell-supplementation therapy has been attempted to facilitate necrotic-tissue regeneration. Adipose-derived mesenchymal stem cell (ADMSC) transplantation is potentially advantageous over bone marrow-derived MSC implantation, but its outcomes for ONFH remain unclear. The aim of this study was to determine 2-year radiological and clinical outcomes of culture-expanded autologous ADMSC implantation for ONFH.MethodsEighteen hips with necrotic lesions involving ≥ 30% of the femoral head were included. ADMSCs were harvested by liposuction and culture expanded for 3 passages over 3 weeks. With a 6-mm single drilling, ADMSCs were implanted into the necrotic zone. All patients underwent magnetic resonance imaging (MRI), single-photon emission computed tomography/computed tomography (SPECT/CT) at screening and 6 months, 12 months, and 24 months postoperatively. The primary outcome was the change in the size of necrotic area on MRI. Secondary outcomes were changes in clinical scores and radioisotope uptake on SPECT/CT. Conversion total hip arthroplasty (THA) was defined as the endpoint.ResultsPreoperatively, the necrotic lesion extent was 63.0% (38.4%–96.7%) of the femoral head. The mean Harris hip score was 89.2, the University of California at Los Angeles (UCLA) score was 5.6, and Western Ontario and McMaster Universities Arthritis index (WOMAC) was 79.4. Three patients underwent THA and 1 patient died in an accident. Finally, 11 patients (14 hips) were available for ≥ 2-year follow-up. At the last follow-up, no surgery-related complications occurred, and 14 of 17 hips (82%) were able to perform daily activities without THA requirement. There was no significant decrease in lesion size between any 2 intervals on MRI. However, widening of high signal intensity bands on T2-weighted images inside the necrotic lesion was observed in 9 of 14 hips (64%); 11 of 14 hips (79%) showed increased vascularity on SPECT/CT at 2 years postoperatively. No significant differences were observed between preoperative and 24-month mean Harris hip score (89.2 vs. 88.6), WOMAC (79.4 vs. 75.7), and UCLA score (5.6 vs. 6.2).ConclusionsOur outcomes suggest that culture-expanded ADMSC implantation is a viable option for ONFH treatment without adverse events.     

钻孔减压结合自体松质骨及同种异体骨植骨治疗股骨头坏死的短期疗效观察

目的 对ARCO Ⅱa期至Ⅲa期股骨头坏死（osteonecrosis of the femoral head, ONFH）且接受大通道钻孔减压、病灶清除,并经减压通道行股骨头内自体松质骨、同种异体颗粒骨打压植骨、同种异体腓骨条植骨治疗的患者进行短期临床疗效分析。方法 2018年1月至2020年12月,四川省骨科医院纳入47例（59髋）股骨头坏死患者。其中,男39例,女8例;年龄29 ～ 51岁,平均37.2岁;ARCO Ⅱa期16髋,ARCO Ⅱb期21髋,ARCO Ⅱc期13髋,ARCO Ⅲa期9髋;酒精性ONFH 46髋（酒精组）,激素性ONFH 13髋（激素组）。术后门诊随访,复查X线片（双髋正位及蛙式位片）,观察股骨头形态及骨整合情况,记录患髋Harris评分。结果 本组47例（59髋）随访24 ～ 36个月,平均随访30个月。术后所有患者疼痛明显缓解,部分患者疼痛消失（包括Ⅱa期14髋,Ⅱb期13髋,Ⅱc期4髋）。6例（9髋）患者病情进展股骨头发生塌陷,其中Ⅱb期1髋,Ⅱc期3髋,Ⅲa期5髋。按病因分,酒精性坏死塌陷6髋,塌陷率13%;激素性坏死塌陷3髋,塌陷率23.1%。酒精组和激素组末次随访时Harris评分与术前比较,差异均有统计学意义（P＜0.05）;酒精组术后Harris评分（82.7±5.6）分显著高于激素组（78.3±8.3）分,差异具有统计学意义（P＜0.05）。不同ARCO分期患者术后髋关节功能均得到一定程度改善,其中Ⅱa及Ⅱb期优良率78.4%,Ⅱc、Ⅲa期优良率50%（P＜0.05）。结论 针对ARCO Ⅱa期至Ⅲa期股骨头坏死的患者,采用大直径通道减压、清除死骨,同时植入自体松质骨和同种异体颗粒骨混合物,最后配合同种异体腓骨条加强支撑,短期可有效防止坏死股骨头的塌陷并减轻疼痛、改善患功能。