2014年美国骨科医师协会AAOS官方杂志：股骨头坏死：评估和治疗

股骨头坏死：评估和治疗

译者：陶可（北京大学人民医院骨关节科）

摘要：

股骨头坏死可能导致髋关节逐渐破坏。虽然股骨头坏死的病因尚未明确，但危险因素包括皮质类固醇的使用、饮酒、创伤和凝血（功能）异常。病变的大小和位置是疾病进展的预后因素，最好通过 MRI 进行评估。使用药物制剂和生物物理方法治疗股骨头坏死的疗效需要进一步研究。手术治疗基于患者因素和病变特征。对于没有头部塌陷的年轻患者，可以尝试通过使用血管化骨移植物、无血管移植物、骨形态发生蛋白、干细胞或上述方法的组合或旋转截骨术进行髓心减压来保护股骨头。最佳治疗方式尚未确定。当股骨头塌陷时，关节置换术是首选。

文献出处：Charalampos G Zalavras, Jay R Lieberman. Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg. 2014 Jul;22(7):455-64.doi: 10.5435/JAAOS-22-07-455.

Osteonecrosis of the femoral head: evaluation and treatment

Abstract

Osteonecrosis of the femoral head may lead to progressive destruction of the hip joint. Although the etiology of osteonecrosis has not been definitely delineated, risk factors include corticosteroid use, alcohol consumption, trauma, and coagulation abnormalities. Size and location of the lesion are prognostic factors for disease progression and are best assessed by MRI. The efficacy of medical management of osteonecrosis with pharmacologic agents and biophysical modalities requires further investigation. Surgical management is based on patient factors and lesion characteristics. Preservation of the femoral head may be attempted in younger patients without head collapse by core decompression with vascularized bone grafts, avascular grafts, bone morphogenetic proteins, stem cells, or combinations of the above or rotational osteotomies. The optimal treatment modality has not been identified. When the femoral head is collapsed, arthroplasty is the preferred option.

Lateral radiograph of the left hip (A) demonstrating presence of the crescent sign (arrows) and AP radiograph (B) demonstrating mild flattening of the femoral head (arrow).

左侧髋关节 X线片（A）显示存在新月征（箭头），前后AP 位X 线片（B）显示股骨头轻度扁平（箭头）。

Coronal T1-weighted magnetic resonance image of the right hip demonstrating a single-density line (arrow) of low signal intensity that delineates the area of necrotic bone.

右髋的冠状 T1 加权核磁共振图像显示低信号强度的单密度线（箭头），描绘了坏死骨的区域。

Modified Kerboul method. The arc of the necrotic portion of the femoral head on both midcoronal (A) and midsagittal (B) magnetic resonance images is measured, and the sum of the two angles is then calculated. (Reproduced with permission from Ha YC, Jung WH, Kim JR, Seong NH, Kim SY, Koo KH: Prediction of collapse in femoral head osteonecrosis: A modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am 2006;88[suppl 3]:35-40.).

改进的 Kerboul 方法。测量股骨头坏死部分在冠状面 (A) 和矢状面 (B) 磁共振图像上的弧度，然后计算两个角度的总和。（经 Ha YC、Jung WH、Kim JR、Seong NH、Kim SY、Koo KH 许可转载：股骨头坏死塌陷的预测：使用磁共振图像的改良 Kerboul 方法。J Bone Joint Surg Am 2006;88 [增刊 3]：35-40。）。

Core decompression for a small osteonecrotic lesion seen on a coronal T1-weighted magnetic resonance image of the right hip (A). AP fluoroscopic images of the right hip show directing and centering the guidewire at the lesion (B), drilling over the guidewire to create a core tract (C), and removal of the necrotic bone with a burr (D). The femoral head is bone grafted with concentrated stem cells harvested from the iliac crest. The core tract is sealed with demineralized matrix.

在右侧髋关节的冠状 T1 加权核磁共振图像上看到的一个小的股骨头坏死病变的髓心减压（A）。右髋关节 AP位 透视图像显示将导丝引导并居中在病变处 (B)，在导丝上钻孔以创建髓心通道 (C)，并用球形铰刀头去除坏死骨 (D)。股骨头（坏死区域）用从髂嵴采集的浓缩干细胞进行骨髓移植。髓心通道用脱矿质基质填充。

Vascularized fibula graft. The fibular graft is inserted into the core tract and stabilized with a Kirschner wire (K). The peroneal veins and artery are anastomosed to the ascending branches of the lateral femoral circumflex artery (LFCA) and vein.

血管化腓骨移植物。将腓骨移植物插入髓心通道并用克氏针 (K) 固定。腓静脉和动脉与旋股外侧动脉（LFCA）和静脉的升支吻合。