月骨无菌性缺血坏死(Kienbock病)的发病机制及临床治疗进展

文题释义： Kienbock病：月骨无菌性缺血坏死又称Kienbock病，好发于20-30岁的年青人，主要表现为腕关节慢性疼痛、乏力，后期疼痛加重并出现活动受限、手握持力降低，伴随不同程度的关节僵硬等症状。具体发病机制不明，早期慢性疼痛，多在骨扫描或MRI上可鉴别，晚期结合症状和X射线多可诊断。目前Kienbock病无绝对理想治疗方案，临床效果主要取决于主刀医生资历、患者期望度和依从性、术后锻炼等。 舟骨-大-小多角骨间关节融合(scaphoid-trapezium-trapezoid，STT)：舟骨-大-小多角骨间关节融合可局限腕骨关节活动，使腕关节轴向负荷传导途径改变，从而减小月骨负荷，进而达到促进组织修复、血供重建的目的。 背景：Kienbock病是由于各种原因导致的月骨无菌性坏死，其发病机制不明，由于腕骨关节面周围软组织少，所致血供差，进行性坏死多不可逆。早期特异性差，临床诊断率低，晚期致畸致残率高。临床诊疗复杂，报道术式繁多，暂无相关指南推荐较好治疗方案。 目的：综述Kienbock病的相关发生机制、分期及临床诊断研究现状，总结国内外近年来Kienbock病的临床治疗方案，探讨各种方案的临床疗效，为临床诊治提供指导。 方法：应用计算机检索1970年至2019年发表在PubMed数据库、中国知网数据库的相关文章。中文检索词为“Kienbock病，月骨，坏死”，英文检索词为“Kienbock’s disease，lunate bone，necrosis，mechanism，treatment”。共检索到900余篇文献，通过纳入标准和排除标准摘选52篇文献进行综述。 结果与结论：①Kienbock病的致病机制不明，病因学复杂，学术界多认为解剖学和生物力学及个体因素引起，需进一步研究；②Kienbock病的分期临床广泛使用Lichtman分期，最新在关节镜上有部分突破，可望形成新的分期标准，其通过X射线、CT或MRI结合“三联征”多可诊断，早期特异性差，漏诊率高，需注意与腕部疾病鉴别；③早期保守治疗，晚期术式有带蒂血管骨移植、肌腱填塞、桡骨截骨、舟骨-大-小多角骨间关节融合、近排腕骨切除、骨水泥假体置换等，随访疗效差异大，无绝对完美方案。 ORCID: 0000-0002-7044-4892(屈晓龙) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Pathogenesis and clinical treatment progress of Kienbock’s disease

BACKGROUND: Kienbock’s disease is aseptic necrosis of the lunate bone due to various causes, and its pathogenesis is unknown. Because the soft tissue around the wrist articular surface is small, so it leads to poor blood supply, and the progressive necrosis is irreversible. Early specificity is poor, clinical diagnosis rate is low, and late teratogenicity and disability rate is high. The clinical diagnosis and treatment are complicated, and there are many procedures, but there is no accurate guidance. OBJECTIVE: To review the current research status of mechanism, stage and clinical diagnosis of Kienbock’s disease, to summarize the clinical treatment of Kienbock’s disease in recent years, so as to discuss the clinical efficacy of various programs and provide guidance for clinical diagnosis and treatment. METHODS: A computer-based online search of PubMed and CNKI databases from 1970 to 2019 was conducted. Key words were "Kienbock’s disease, lunate bone, necrosis, mechanism, treatment" in English and Chinese, respectively. About 900 articles were retrieved, and 52 articles eligible for the inclusion and exclusion criteria were included for review. RESULTS AND CONCLUSION:(1) The pathogenesis of Kienbock’s disease is unknown, its etiology is complex, and researchers believe that anatomy and biomechanics, and individual factors are main causes, which still need further research.(2) The Lichtman stage is widely used in Kienbock’s disease classification. The latest breakthrough in arthroscopy is expected to form a new classification standard, which can be diagnosed by X-ray, CT or MRI combined with "triple sign". It has poor early specificity, so the rate of misdiagnosis is high, and it should be identified with wrist diseases.(3) Early-stage Kienbock’s disease usually receive conservative treatment, and advanced stage tends to undergo surgical programs, including free vascularized bone graft, the lumate resection + tendon tamponade, radial wedge and shortening osteotomy, scaphotrapeziotrapezoid fusion, proximal row carpectomy, and bone cement prosthesis replacement, and the follow-up outcomes are different, so there is still no perfect treatment program.