成人股骨头坏死保髋手术治疗的策略及探讨
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摘要
股骨头坏死(osteonecrosis of the femoral head,ONFH)是骨科常见病,好发于中青年人。因人工关节假体有一定的使用寿命,且髋关节翻修术难度较高、风险较大、并发症较多,所以保留髋关节手术越来越受到重视。目前临床上应用的保髋手术方法较多,但疗效不确切。关于如何在恰当的时机选择恰当的手术方式的认识也在不断更新,明确ONFH病理发展过程有助于选择恰当的ONFH保髋手术方式。早期的髓芯减压术与打压植骨术方法简便,可减轻股骨头内压力、缓解疼痛,但无法彻底清除坏死骨,仅应用于早期ONFH。血管化骨移植术的应用填补了前者缺陷,不仅能够彻底清除坏死骨,还可以为股骨头提供有滋养血管的移植骨,有利于股骨头内骨结构的重建。钽棒的应用为股骨头提供了力学支撑,具有预防股骨头塌陷的作用。近十年来,保留髋关节手术开展越来越多,临床疗效也不断得到改善,多种术式相互结合为ONFH保髋治疗提供了更多选择。但无论采用何种术式,保髋手术的理念始终是在保证疗效的前提下,尽可能选择手术创伤小、方法简便、对髋关节骨结构损伤不大的手术方案。
As a common disease in orthopedics, osteonecrosis of the femoral head(ONFH) frequently occurs among young and middle-aged people. Hip joint preserving surgery has attracted more and more attention due to the fact that artificial joint prosthesis has a certain useful life and the rate of hip joint revision is high and the higher risk of many complications. There are a large number of operative methods for preserving hip joint in clinical practice without definitive effectiveness. How to choose appropriate surgical methods at the right time is also a continuous understanding.The pathological process of necrosis of the femur helps to choose the choice of the femoral head necrosis for the treatment of hip operation. Core decompression and impaction bone grafting with simple operative methods can relieve internal pressure of femoral head and pain symptoms, but they cannot remove necrotic bone completely. Hence, they are only used for ONFH in the early stage. Vascularized bone transplantation can fill defects of the former, as it can not only completely remove necrotic bone, but also provide bone graft with nourishing vessels for femoral head, being beneficial to reconstruct the bone structure of femoral head. Subsequently, the application of tantalum rod can provide mechanical support for femoral head to prevent the collapse of femoral head. Hip joint preserving surgery, in recent years, has been performed increasingly, and has obtained improvement in clinical effects. The multiple combination of a variety of its operative methods provides more effective treatments for ONFH. It is an essential notion that hip joint preserving surgery, however with any operative method, should as far as possible select a surgical plan with little trauma, simple methods, and little injury of hip joint bone structure based on ensuring the effectiveness.
As a common disease in orthopedics, osteonecrosis of the femoral head(ONFH) frequently occurs among young and middle-aged people. Hip joint preserving surgery has attracted more and more attention due to the fact that artificial joint prosthesis has a certain useful life and the rate of hip joint revision is high and the higher risk of many complications. There are a large number of operative methods for preserving hip joint in clinical practice without definitive effectiveness. How to choose appropriate surgical methods at the right time is also a continuous understanding.The pathological process of necrosis of the femur helps to choose the choice of the femoral head necrosis for the treatment of hip operation. Core decompression and impaction bone grafting with simple operative methods can relieve internal pressure of femoral head and pain symptoms, but they cannot remove necrotic bone completely. Hence, they are only used for ONFH in the early stage. Vascularized bone transplantation can fill defects of the former, as it can not only completely remove necrotic bone, but also provide bone graft with nourishing vessels for femoral head, being beneficial to reconstruct the bone structure of femoral head. Subsequently, the application of tantalum rod can provide mechanical support for femoral head to prevent the collapse of femoral head. Hip joint preserving surgery, in recent years, has been performed increasingly, and has obtained improvement in clinical effects. The multiple combination of a variety of its operative methods provides more effective treatments for ONFH. It is an essential notion that hip joint preserving surgery, however with any operative method, should as far as possible select a surgical plan with little trauma, simple methods, and little injury of hip joint bone structure based on ensuring the effectiveness.
引文
1中国医师协会骨科医师分会显微修复工作委员会,中国修复重建外科专业委员会骨缺损及骨坏死学组,中华医学会骨科分会显微修复学组.成人股骨头坏死临床诊疗指南(2016).中华骨科杂志,2016,36(15):945-954.
2Zhao DW,Yu M,Hu K,et al.Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the chinese population:results from a nationally representative survey.Chin Med J(Engl),2015,128(21):2843-2850.
3张鹤山,李子荣.股骨头坏死诊断与治疗的专家建议.中华骨科杂志,2007,27(2):146-148.
4赵德伟,程亮亮.国内股骨头坏死保留髋关节手术治疗的十年回顾.中华骨科杂志,2017,37(3):183-192.
5郑召民,崔力扬.髓芯减压术治疗成人股骨头坏死.中国骨肿瘤骨病,2005,4(2):117-119.
6Bozic KJ,Zurakowski D,Thornhill TS.Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head.J Bone Joint Surg(Am),1999,81(2):200-209.
7Beltran J,Knight CT,Zuelzer WA,et al.Core decompression for avascular necrosis of the femoral head:correlation between longterm results and preoperative MR staging.Radiology,1990,175(2):533-536.
8王秀利,王义生,吴学建,等.自体骨髓干细胞种植骨诱导活性材料移植联合髓芯减压术治疗早期股骨头坏死.中华显微外科杂志,2017,40(2):142-145.
9Zhao D,Cui D,Wang B,et al.Treatment of early stage osteonecrosis of the femoral head with autologous implantation of bone marrow-derived and cultured mesenchymal stem cells.Bone,2012,50(1):325-330.
10赵德伟.加强对股骨头缺血性坏死病理生理的认识.中华关节外科杂志(电子版),2014,8(5):560-562.
11Yang S,Wu X,Xu W,et al.Structural augmentation with biomaterial-loaded allograft threaded cage for the treatment of femoral head osteonecrosis.J Arthroplasty,2010,25(8):1223-1230.
12朱旭日,杜斌,孙光权,等.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.中国骨与关节损伤杂志,2015,30(4):343-345.
13Wang CJ,Huang CC,Wang JW,et al.Long-term results of extracorporeal shockwave therapy and core decompression in osteonecrosis of the femoral head with eight-to nine-year followup.Biomed J,1900,35(6):481-485.
14蒋玮,尚希福,王姚斐,等.打压植骨术治疗股骨头坏死的近期疗效.临床骨科杂志,2013,16(2):178-181.
15王亦进,栾舰,崔学芬,等.非创伤性股骨头坏死69例83髋:带血管蒂臀中肌骨瓣移植复合骨形态发生蛋白和自体松质骨的修复.中国组织工程研究,2011,15(43):8159-8162.
16Rosenwasser MP,Garino JP,Kiernan HA,et al.Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis.Clin Orthop Relat Res,1994,(306):17-27.
17Mont MA,Etienne G,Ragland PS.Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head.Clin Orthop Relat Res,2003,(417):84-92.
18韦标方,韦伟,孙丙银,等.高位股骨头颈开窗植骨支撑术治疗早期股骨头坏死.中华骨科杂志,2014,34(7):777-782.
19Feng Y,Wang S,Jin D,et al.Free vascularised fibular grafting with Osteo Set 2 demineralised bone matrix versus autograft for large osteonecrotic lesions of the femoral head.Int Orthop,2011,35(4):475-481.
20Gao YS,Liu XL,Sheng JG,et al.Unilateral free vascularized fibula shared for the treatment of bilateral osteonecrosis of the femoral head.J Arthroplasty,2013,28(3):531-536.
21Wang B,Zhao D,Liu B,et al.Treatment of osteonecrosis of the femoral head by using the greater trochanteric bone flap with double vascular pedicles.Microsurgery,2013,33(8):593-599.
22Zeng YR,He S,Feng WJ,et al.Vascularised greater trochanter bone graft,combined free iliac flap and impaction bone grafting for osteonecrosis of the femoral head.Int Orthop,2013,37(3):391-398.
23Zhao D,Wang B,Lin G,et al.Will a vascularized greater trochanter graft preserve the necrotic femoral head?Clin Orthop Relat Res,2010,468(5):1316-1324.
24Sotereanos DG,Plakseychuk AY,Rubash HE.Free vascularized fibula grafting for the treatment of osteonecrosis of the femoral head.Clin Orthop Relat Res,1997,(344):243-256.
25Soucacos PN,Beris AE,Malizos K,et al.Treatment of avascular necrosis of the femoral head with vascularized fibular transplant.Clin Orthop Relat Res,2001,(386):120-130.
26张长青,李鸿帅,张开刚,等.改良吻合血管游离腓骨移植术治疗股骨头坏死.中华全科医师杂志,2006,5(2):84-86.
27王坤正,同志勤,王春生,等.吻合血管游离腓骨移植治疗股骨头坏死.中华显微外科杂志,2000,23(4):254-256.
28赵德伟.带血管蒂骨瓣移植治疗股骨头坏死的经验与技巧.中华显微外科杂志,2009,32(4):265-266.
29赵德伟,崔振江,王永林,等.带旋髂深血管蒂髂骨膜移植治疗股骨头无菌性坏死的体会.铁道医学,1989,17(1):15-16.
30王义生,殷力,吴学建,等.带肌蒂骨瓣移植术治疗股骨头坏死.中华关节外科杂志(电子版),2008,2(1):3-6.
31Zhao D,Xiaobing Y,Wang T,et al.Digital subtraction angiography in selection of the vascularized greater trochanter bone grafting for treatment of osteonecrosis of femoral head.Microsurgery,2013,33(8):656-659.
32赵德伟,王本杰.微创带血管蒂骨瓣转移术在股骨头缺血性坏死中的应用.中华医学杂志,2007,87(29):2036-2040.
33Zhao D,Huang S,Lu F,et al.Vascularized bone grafting fixed by biodegradable magnesium screw for treating osteonecrosis of the femoral head.Biomaterials,2016,81:84-92.
34Zhao D,Cui D,Lu F,et al.Combined vascularized iliac and greater trochanter graftings for reconstruction of the osteonecrosis femoral head with collapse:reports of three cases with 20 years follow-up.Microsurgery,2012,32(7):546-551.
35Tsao AK,Roberson JR,Christie MJ,et al.Biomechanical and clinical evaluations of a porous tantalum implant for the treatment of early-stage osteonecrosis.J Bone Joint Surg(Am),2005,87(Suppl 2):22-27.
36许伟华,杨述华,冯勇,等.多孔钽棒植入治疗股骨头坏死的适应证及临床疗效观察.中国骨与关节外科,2010,3(1):28-32.
37Aldegheri R,Taglialavoro G,Berizzi A.The tantalum screw for treating femoral head necrosis:rationale and results.Strategies Trauma Limb Reconstr,2007,2(2-3):63-68.
38Zhao D,Liu B,Wang B,et al.Autologous bone marrow mesenchymal stem cells associated with tantalum rod implantation and vascularized iliac grafting for the treatment of end-stage osteonecrosis of the femoral head.Biomed Res Int,2015,2015:240506.
39Ito H,Tanino H,Yamanaka Y,et al.Long-term results of conventional varus half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the femoral head.J Bone Joint Surg(Br),2012,94(3):308-314.
40史振满,史疆,王鑫,等.转子间外展截骨治疗股骨头坏死塌陷的长期观察.创伤外科杂志,2010,12(2):143-145.
2Zhao DW,Yu M,Hu K,et al.Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the chinese population:results from a nationally representative survey.Chin Med J(Engl),2015,128(21):2843-2850.
3张鹤山,李子荣.股骨头坏死诊断与治疗的专家建议.中华骨科杂志,2007,27(2):146-148.
4赵德伟,程亮亮.国内股骨头坏死保留髋关节手术治疗的十年回顾.中华骨科杂志,2017,37(3):183-192.
5郑召民,崔力扬.髓芯减压术治疗成人股骨头坏死.中国骨肿瘤骨病,2005,4(2):117-119.
6Bozic KJ,Zurakowski D,Thornhill TS.Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head.J Bone Joint Surg(Am),1999,81(2):200-209.
7Beltran J,Knight CT,Zuelzer WA,et al.Core decompression for avascular necrosis of the femoral head:correlation between longterm results and preoperative MR staging.Radiology,1990,175(2):533-536.
8王秀利,王义生,吴学建,等.自体骨髓干细胞种植骨诱导活性材料移植联合髓芯减压术治疗早期股骨头坏死.中华显微外科杂志,2017,40(2):142-145.
9Zhao D,Cui D,Wang B,et al.Treatment of early stage osteonecrosis of the femoral head with autologous implantation of bone marrow-derived and cultured mesenchymal stem cells.Bone,2012,50(1):325-330.
10赵德伟.加强对股骨头缺血性坏死病理生理的认识.中华关节外科杂志(电子版),2014,8(5):560-562.
11Yang S,Wu X,Xu W,et al.Structural augmentation with biomaterial-loaded allograft threaded cage for the treatment of femoral head osteonecrosis.J Arthroplasty,2010,25(8):1223-1230.
12朱旭日,杜斌,孙光权,等.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.中国骨与关节损伤杂志,2015,30(4):343-345.
13Wang CJ,Huang CC,Wang JW,et al.Long-term results of extracorporeal shockwave therapy and core decompression in osteonecrosis of the femoral head with eight-to nine-year followup.Biomed J,1900,35(6):481-485.
14蒋玮,尚希福,王姚斐,等.打压植骨术治疗股骨头坏死的近期疗效.临床骨科杂志,2013,16(2):178-181.
15王亦进,栾舰,崔学芬,等.非创伤性股骨头坏死69例83髋:带血管蒂臀中肌骨瓣移植复合骨形态发生蛋白和自体松质骨的修复.中国组织工程研究,2011,15(43):8159-8162.
16Rosenwasser MP,Garino JP,Kiernan HA,et al.Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis.Clin Orthop Relat Res,1994,(306):17-27.
17Mont MA,Etienne G,Ragland PS.Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head.Clin Orthop Relat Res,2003,(417):84-92.
18韦标方,韦伟,孙丙银,等.高位股骨头颈开窗植骨支撑术治疗早期股骨头坏死.中华骨科杂志,2014,34(7):777-782.
19Feng Y,Wang S,Jin D,et al.Free vascularised fibular grafting with Osteo Set 2 demineralised bone matrix versus autograft for large osteonecrotic lesions of the femoral head.Int Orthop,2011,35(4):475-481.
20Gao YS,Liu XL,Sheng JG,et al.Unilateral free vascularized fibula shared for the treatment of bilateral osteonecrosis of the femoral head.J Arthroplasty,2013,28(3):531-536.
21Wang B,Zhao D,Liu B,et al.Treatment of osteonecrosis of the femoral head by using the greater trochanteric bone flap with double vascular pedicles.Microsurgery,2013,33(8):593-599.
22Zeng YR,He S,Feng WJ,et al.Vascularised greater trochanter bone graft,combined free iliac flap and impaction bone grafting for osteonecrosis of the femoral head.Int Orthop,2013,37(3):391-398.
23Zhao D,Wang B,Lin G,et al.Will a vascularized greater trochanter graft preserve the necrotic femoral head?Clin Orthop Relat Res,2010,468(5):1316-1324.
24Sotereanos DG,Plakseychuk AY,Rubash HE.Free vascularized fibula grafting for the treatment of osteonecrosis of the femoral head.Clin Orthop Relat Res,1997,(344):243-256.
25Soucacos PN,Beris AE,Malizos K,et al.Treatment of avascular necrosis of the femoral head with vascularized fibular transplant.Clin Orthop Relat Res,2001,(386):120-130.
26张长青,李鸿帅,张开刚,等.改良吻合血管游离腓骨移植术治疗股骨头坏死.中华全科医师杂志,2006,5(2):84-86.
27王坤正,同志勤,王春生,等.吻合血管游离腓骨移植治疗股骨头坏死.中华显微外科杂志,2000,23(4):254-256.
28赵德伟.带血管蒂骨瓣移植治疗股骨头坏死的经验与技巧.中华显微外科杂志,2009,32(4):265-266.
29赵德伟,崔振江,王永林,等.带旋髂深血管蒂髂骨膜移植治疗股骨头无菌性坏死的体会.铁道医学,1989,17(1):15-16.
30王义生,殷力,吴学建,等.带肌蒂骨瓣移植术治疗股骨头坏死.中华关节外科杂志(电子版),2008,2(1):3-6.
31Zhao D,Xiaobing Y,Wang T,et al.Digital subtraction angiography in selection of the vascularized greater trochanter bone grafting for treatment of osteonecrosis of femoral head.Microsurgery,2013,33(8):656-659.
32赵德伟,王本杰.微创带血管蒂骨瓣转移术在股骨头缺血性坏死中的应用.中华医学杂志,2007,87(29):2036-2040.
33Zhao D,Huang S,Lu F,et al.Vascularized bone grafting fixed by biodegradable magnesium screw for treating osteonecrosis of the femoral head.Biomaterials,2016,81:84-92.
34Zhao D,Cui D,Lu F,et al.Combined vascularized iliac and greater trochanter graftings for reconstruction of the osteonecrosis femoral head with collapse:reports of three cases with 20 years follow-up.Microsurgery,2012,32(7):546-551.
35Tsao AK,Roberson JR,Christie MJ,et al.Biomechanical and clinical evaluations of a porous tantalum implant for the treatment of early-stage osteonecrosis.J Bone Joint Surg(Am),2005,87(Suppl 2):22-27.
36许伟华,杨述华,冯勇,等.多孔钽棒植入治疗股骨头坏死的适应证及临床疗效观察.中国骨与关节外科,2010,3(1):28-32.
37Aldegheri R,Taglialavoro G,Berizzi A.The tantalum screw for treating femoral head necrosis:rationale and results.Strategies Trauma Limb Reconstr,2007,2(2-3):63-68.
38Zhao D,Liu B,Wang B,et al.Autologous bone marrow mesenchymal stem cells associated with tantalum rod implantation and vascularized iliac grafting for the treatment of end-stage osteonecrosis of the femoral head.Biomed Res Int,2015,2015:240506.
39Ito H,Tanino H,Yamanaka Y,et al.Long-term results of conventional varus half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the femoral head.J Bone Joint Surg(Br),2012,94(3):308-314.
40史振满,史疆,王鑫,等.转子间外展截骨治疗股骨头坏死塌陷的长期观察.创伤外科杂志,2010,12(2):143-145.
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