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沈計榮主任醫(yī)師 江蘇省中醫(yī)院 骨傷科 近日，江蘇省中醫(yī)院沈計榮領(lǐng)銜的團隊的研究成果：補腎活血湯聯(lián)合虛擬現(xiàn)實技術(shù)引導(dǎo)下的截骨術(shù)治療股骨頭壞死的研究榮獲2022年中國中醫(yī)藥研究促進會科技進步一等獎?。ㄗC書見下圖）。相關(guān)成果簡介刊登在著名學(xué)術(shù)期刊《中國科技成果》2023年3月。這標(biāo)志著沈計榮教授領(lǐng)銜的江蘇省中醫(yī)院骨傷科股骨頭壞死保髖工作獲得國內(nèi)專家的普遍認可！股骨頭壞死是骨科常見病，全國約有812萬患者。該病多發(fā)于青壯年，致殘率高。因為人工髖關(guān)節(jié)假體使用壽命有限（一般不超過30年），且翻修手術(shù)難度較大，故對于年輕患者，保髖治療具有重大意義。目前，股骨頭壞死的保髖治療是醫(yī)學(xué)界的難題。截骨保髖術(shù)（內(nèi)翻截骨術(shù)與旋轉(zhuǎn)截骨術(shù)）因為手術(shù)難度大、精確度要求高，開展較少。少數(shù)醫(yī)院即使有條件開展截骨保髖手術(shù)，亦存在術(shù)前規(guī)劃困難、截骨不愈合、術(shù)后頭臼關(guān)系不匹配等問題。在國家自然科學(xué)基金面上項目等多項基金資助下，項目組采用補腎活血湯聯(lián)合虛擬現(xiàn)實技術(shù)引導(dǎo)下的截骨術(shù)個體化治療股骨頭壞死（詳情見圖1-3），取得較好療效。2018年，由申報人牽頭成立了全國30家醫(yī)院參與的股骨頭壞死專病聯(lián)盟（圖4）。同年，在中國關(guān)節(jié)外科學(xué)術(shù)大會暨第20屆亞太關(guān)節(jié)學(xué)會年會和中國醫(yī)師協(xié)會骨科醫(yī)師年會上，沈計榮教授應(yīng)邀分別就內(nèi)翻截骨術(shù)與旋轉(zhuǎn)截骨術(shù)發(fā)言（圖5）。近3年來，申請人的保髖研究成果先后以第一完成人身份獲南京市中醫(yī)藥科學(xué)技術(shù)獎（2019年），江蘇省醫(yī)學(xué)新技術(shù)引進獎二等獎（2020年），中國中醫(yī)藥研究促進會科技進步獎二等獎（2020年）。申請人發(fā)表與股骨頭壞死相關(guān)的學(xué)術(shù)論文56篇（SCI期刊論文9篇）。申請人參與制定多個股骨頭壞死臨床診療指南（中醫(yī)正骨，2019；中華骨科雜志，2016；中華關(guān)節(jié)外科雜志，2016），培養(yǎng)相關(guān)領(lǐng)域的研究生10余名。項目研究發(fā)現(xiàn)采用補腎活血湯聯(lián)合虛擬現(xiàn)實技術(shù)引導(dǎo)下的內(nèi)翻截骨術(shù)治療合適的患者，尚未出現(xiàn)保髖失敗，典型病例見圖6。采用旋轉(zhuǎn)截骨術(shù)治療合適的患者，成功率約72.7%，典型病例見圖7。目前，即使開展特別復(fù)雜的保髖手術(shù)（經(jīng)股骨頸基底部旋轉(zhuǎn)截骨術(shù)）聯(lián)合中藥復(fù)方，只需要治療費（手術(shù)加器械加藥品）1.5-3萬元。團隊已在河南省中醫(yī)院、浙江省中醫(yī)院、海安市中醫(yī)院等省內(nèi)外30余家醫(yī)院推廣、應(yīng)用該技術(shù)，節(jié)省醫(yī)療支出數(shù)百萬元，取得了較好的經(jīng)濟與社會效益。立足三十余年臨床經(jīng)驗，總結(jié)古今中外大量文獻，沈計榮教授提出了基于中日友好醫(yī)院分型的股骨頭壞死階梯化治療方案（如圖8），力求做到治療的階梯化、精準(zhǔn)化、個體化。目前沈計榮教授及團隊也在積極開展基于DCE-MRI評估股骨頭血供變化，從而選擇適合患者病情的術(shù)式，旨在提高臨床療效，典型病例見圖9。（相關(guān)研究發(fā)表于《中國組織工程》雜志）。目前該研究正在進一步深入，以期推動股骨頭壞死保髖治療的進一步發(fā)展。雄關(guān)漫道真如鐵，而今邁步從頭躍！2023年01月17日
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陶可主治醫(yī)師 北京大學(xué)人民醫(yī)院 骨關(guān)節(jié)科 2015年美國Baltimore Sinai醫(yī)院：髓心減壓治療股骨頭壞死的最新進展：分期越早，髓心減壓效果越好；目前多采用髓心減壓聯(lián)合干細胞移植等多種模式策略：讓血液重回股骨頭/非關(guān)節(jié)置換保頭(保留股骨頭)治療股骨頭壞死 附一例典型股骨頭壞死病例治療分析 作者：Todd P Pierce, Julio J Jauregui, Randa K Elmallah, Carlos J Lavernia, Michael A Mont, James Nace. 作者單位: Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA. 譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科） 文獻出處：Todd P Pierce, Julio J Jauregui, Randa K Elmallah, Carlos J Lavernia, Michael A Mont, James Nace. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 2015 Sep;8(3):228-32. doi: 10.1007/s12178-015-9280-0. 圖A American Academy of Orthopaedic Surgeons Illustration of (Left) Core decompression. (Right) In this x-ray, the drill lines show the pathway of small drill holes used in a core decompression procedure. 美國骨科醫(yī)師學(xué)會（左）髓心減壓示意圖(2-3多次小直徑孔道減壓)。（右）在這張髖關(guān)節(jié)正位X線片中，鉆孔線顯示了髓心減壓手術(shù)操作中使用的小鉆孔（注：頭端帶螺紋的斯氏針）的路徑。 圖B Core Decompression for Avascular Necrosis of the Hip: The hip joint is a ball and socket joint, where the head of the thigh bone (femur) articulates with the cavity (acetabulum) of the pelvic bone. Sickle cell disease, a group of disorders that affect the hemoglobin or oxygen carrying component of blood, causes avascular necrosis or the death of bone tissue in the hip due to lack of blood supply. Core decompression is indicated in the early stages of avascular necrosis, when the surface of the head is still smooth and round. It is done to prevent total hip replacement surgery, which is indicated for severe cases of avascular necrosis and involves the replacement of the hip joint with an artificial device or prosthesis. 股骨頭缺血性壞死的髓心減壓圖示(單孔大直徑孔道傳統(tǒng)減壓術(shù))：髖關(guān)節(jié)是一個球窩關(guān)節(jié)，大腿骨頭（股骨）的頭部與骨盆骨的空腔（髖臼）相連。鐮狀細胞病是一組影響血液中血紅蛋白或攜氧成分的疾病，會導(dǎo)致髖部缺血性壞死或由于缺乏血液供應(yīng)而死亡。髓心減壓適用于缺血性壞死的早期階段，此時頭部表面仍然光滑圓潤。這樣做是為了防止全髖關(guān)節(jié)置換手術(shù)，全髖關(guān)節(jié)置換手術(shù)適用于嚴(yán)重的缺血性壞死病例，涉及用人工裝置或假體置換髖關(guān)節(jié)。 2019年最新的《改良的ARCO分期(1-4期)》： I期 X線片正常，核磁共振檢查結(jié)果異常。 II期 無新月征，存在影像學(xué)上硬化、骨溶解或局灶性骨質(zhì)疏松癥征象。 III期 新月征，X線片或CT掃描可見軟骨下骨折、部分壞死，和/或股骨頭變平。 IIIA 股骨頭凹陷≤2mm。 IIIB 股骨頭凹陷＞2mm。 IV期 骨關(guān)節(jié)炎證據(jù)，關(guān)節(jié)間隙變窄和髖臼退行性改變。 一例典型的酒精性無菌性股骨頭壞死患者(男性, 49歲)的影像學(xué)檢查及髓心減壓+取自體髂骨骨髓移植微創(chuàng)治療。病例特點：患者大量飲酒近30年，約250ml/日，1年前無明顯誘因出現(xiàn)雙側(cè)髖關(guān)節(jié)疼痛，疼痛呈刺痛，無放射痛，活動后明顯，左側(cè)明顯。髖關(guān)節(jié)活動受限，髖關(guān)節(jié)周圍無紅腫，無發(fā)熱，6個月前完善檢查發(fā)現(xiàn)雙股骨頭壞死，髖關(guān)節(jié)骨關(guān)節(jié)炎，現(xiàn)右側(cè)髖部疼痛明顯，無法正常行走。 圖1 術(shù)前髖關(guān)節(jié)正位X線片 可見右側(cè)股骨頭壞死區(qū)域程明顯的新月征，左側(cè)股骨頭壞死可見小范圍股骨頭范圍病灶，但雙側(cè)股骨頭塌陷/凹陷高度≤ 2mm，2019年改良股骨頭壞死分期應(yīng)為IIIA期。 圖2 術(shù)前髖關(guān)節(jié)蛙式位X線片 可見與正位X線片一致的影像學(xué)改變，雙側(cè)股骨頭壞死區(qū)域主要位于前方。 圖3 術(shù)前髖關(guān)節(jié)CT平掃-冠狀位 結(jié)果發(fā)現(xiàn)右側(cè)股骨頭軟骨下骨板局部硬化，部分區(qū)域骨小梁已壞死吸收，出現(xiàn)囊腔樣骨缺損，股骨頭外側(cè)局部區(qū)域骨小梁結(jié)構(gòu)輕度塌陷。 圖4 術(shù)前髖關(guān)節(jié)CT平掃-軸位-骨窗 與上述冠狀位CT平掃相似地發(fā)現(xiàn)，右側(cè)股骨頭部分區(qū)域骨小梁已壞死吸收，出現(xiàn)囊腔樣骨缺損，主要位于前方。 圖5 術(shù)前髖關(guān)節(jié)CT平掃-軸位-骨窗 右側(cè)股骨頭囊腔樣骨缺損主要位于前方。 圖6 術(shù)前髖關(guān)節(jié)CT平掃-軸位-骨窗 右側(cè)股骨頭囊腔樣骨缺損主要位于前方，左側(cè)股骨頭骨質(zhì)結(jié)構(gòu)相對正常。 圖7 術(shù)前髖關(guān)節(jié)CT平掃-軸位-骨窗 雙側(cè)股骨頭骨質(zhì)結(jié)構(gòu)在下方及后方基本正常。 圖8 術(shù)前髖關(guān)節(jié)CT掃描-三維重建 結(jié)果發(fā)現(xiàn)右側(cè)股骨頭前方/外側(cè)局部區(qū)域軟骨下骨結(jié)構(gòu)輕度塌陷，骨贅增生。 圖9 術(shù)前髖關(guān)節(jié)CT掃描-三維重建 結(jié)果發(fā)現(xiàn)右側(cè)股骨頭前方/外側(cè)局部區(qū)域軟骨下骨結(jié)構(gòu)輕度塌陷，骨贅增生，局限在前下方。 圖10 術(shù)前髖關(guān)節(jié)CT掃描-三維重建 結(jié)果發(fā)現(xiàn)右側(cè)股骨頭前方/外側(cè)局部區(qū)域軟骨下骨結(jié)構(gòu)輕度塌陷，骨贅增生，局限在前下方。 圖11 術(shù)前髖關(guān)節(jié)CT掃描-三維重建 右側(cè)股骨頭后方/外側(cè)/下方局部軟骨下骨結(jié)構(gòu)無明顯改變。 圖12 術(shù)前雙側(cè)髖關(guān)節(jié)T2-MRI平掃-冠狀位 較CT平掃更敏感地(100%)確定雙側(cè)股骨頭壞死，發(fā)現(xiàn)雙側(cè)股骨頭明顯骨髓水腫，且伴隨有髖關(guān)節(jié)滑膜炎、關(guān)節(jié)腔積液，右側(cè)較左側(cè)明顯，右側(cè)骨髓水腫彌漫分布在股骨頭/股骨頸等區(qū)域，炎性水腫液較多，股骨頭負重區(qū)軟骨下骨板已出現(xiàn)壞死塌陷征象，且中間可見壞死與修復(fù)組織交雜交匯；左側(cè)股骨頭壞死負重區(qū)股骨頭壞死，范圍較局限。 圖13 術(shù)前髖關(guān)節(jié)T1-MRI平掃-冠狀位 圖14 術(shù)前髖關(guān)節(jié)T1-MRI平掃-軸位 圖15 術(shù)前髖關(guān)節(jié)T2-MRI平掃-軸位 圖16 術(shù)中透視下進行股骨頭下鉆孔減壓-髖關(guān)節(jié)正位 術(shù)中，選用直徑2.5mm斯氏針，在透視下沿著股骨頸旋轉(zhuǎn)中心，向股骨頭壞死區(qū)域(前上方)進針，深度控制在距離股骨頭軟骨下骨0.5cm。 圖17 術(shù)中透視下進行股骨頭下鉆孔-髖關(guān)節(jié)正位 選用直徑5.5mm空心環(huán)鉆，沿著上述斯氏針導(dǎo)引方向，在透視下向股骨頭壞死區(qū)域進針，深達股骨頭軟骨下骨0.5cm (軟骨下骨壞死塌陷區(qū)域)。 圖18 術(shù)中透視下進行股骨頭下鉆孔-髖關(guān)節(jié)蛙式位 在C型臂透視下，再次確認斯氏針進針方向及深度是否合適。 圖19 透視下將骨髓干細胞注入股骨頭壞死鉆孔區(qū)域 采用骨髓穿刺針在髂前上棘取5ml骨髓液，經(jīng)肝素鈉抗凝等預(yù)處理后，沿空心鉆注射進入壞死區(qū)域。 圖20 傷口較小，自然傷痛較小 術(shù)后傷口長度約1cm，術(shù)后進行美容縫合，不需要拆線，疤痕也會極小。 圖22 術(shù)后髖關(guān)節(jié)正位X線片 圖23 術(shù)后髖關(guān)節(jié)蛙式位X線片 圖24 術(shù)后主動髖關(guān)節(jié)康復(fù)功能鍛煉 術(shù)后24小時候，指導(dǎo)患者在平臥位進行非負重主動直腿抬高鍛煉，增強髖關(guān)節(jié)及下肢肌肉力量，提高韌帶強度，同時還可以避免肌肉萎縮，下肢靜脈血栓形成等風(fēng)險。 圖25 術(shù)后站立主動屈髖康復(fù)功能鍛煉，為適應(yīng)扶拐行走做準(zhǔn)備 圖26 術(shù)后下蹲主動屈髖康復(fù)功能鍛煉，為適應(yīng)坐便器做準(zhǔn)備 圖27 術(shù)后治療團隊與患者合影 術(shù)后醫(yī)囑：保護性扶拐髖關(guān)節(jié)免負重3個月，期間進行主動髖關(guān)節(jié)屈曲、后伸、蚌式運動、側(cè)臥位抬腿等康復(fù)功能鍛煉，6周、12周、6月、12月復(fù)查一次髖關(guān)節(jié)X線片及核磁共振。同時避免深蹲、盤腿、蹺二郎腿等引發(fā)髖關(guān)節(jié)撞擊/擠壓的動作。視患者恢復(fù)情況決定何時完全負重行走，建議每天控制步數(shù)在3千左右，同時控制體重。 A current review of core decompression in the treatment of osteonecrosis of the femoral head Abstract The review describes the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling technique, and (4) the overall outcomes of these procedures. Core decompression has optimal outcomes when used in the earliest, precollapse disease stages. More recent studies have reported excellent outcomes with percutaneous drilling. Furthermore, adjunct treatment methods combining core decompression with growth factors, bone morphogenic proteins, stem cells, and bone grafting have demonstrated positive results; however, larger randomized trial is needed to evaluate their overall efficacy. 該綜述描述了以下內(nèi)容：(1)如何進行傳統(tǒng)的髓心減壓，(2)輔助治療，(3)多種經(jīng)皮鉆孔技術(shù)，以及(4)這些治療操作的總體結(jié)果。髓心減壓在最早的塌陷前疾病階段股骨頭壞死治療使用時具有最佳結(jié)果。最近的研究報告了經(jīng)皮鉆孔的良好結(jié)果。此外，將髓心減壓與生長因子、骨形態(tài)發(fā)生蛋白、干細胞和骨移植相結(jié)合的輔助治療方法已顯示出積極的效果；然而，需要更大規(guī)模的隨機試驗來評估它們的整體療效。 Introduction 介紹 In the treatment of osteonecrosis of the femoral head (ONFH), core decompression is used in the earliest precollapse stages of disease in an attempt to delay and/or prevent the need for total hip arthroplasty (THA). The most ideal lesion treated with this procedure is a precollapse and small (＜15 % of femoral head or Kerboul angle ＜200°) [1–4]. These procedures are typically performed by the drilling and removal of an 8- to 10-mm cylindrical core from the osteonecrotic lesion [5]. In addition, another commonly used technique involves multiple percutaneous drillings [5, 6]. Techniques have been combined with several other adjunctive treatment modalities such as bone grafting and the addition of growth and differentiation factors [7–12]. The purpose of this review is to describe the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling, and (4) the overall outcomes of this procedures. 在股骨頭壞死(ONFH)的治療中，在疾病的早期塌陷前階段使用髓心減壓，以試圖延遲和/或防止進展到全髖關(guān)節(jié)置換術(shù)(THA)。髓心減壓治療的最理想病變是塌陷前和小（＜股骨頭的15%或Kerboul角＜200°）[1-4]。這些操作通常通過從骨壞死病變中鉆孔和移除8到10毫米的圓柱形髓心來完行[5]。此外，另一種常用的技術(shù)涉及多次經(jīng)皮鉆孔[5, 6]。技術(shù)已與其他幾種輔助治療方式相結(jié)合，例如骨移植和添加生長和分化因子[7-12]。本綜述的目的是描述以下內(nèi)容：(1)如何進行傳統(tǒng)的髓心減壓，(2)輔助治療，(3)多次經(jīng)皮鉆孔，以及(4)該程序的總體結(jié)果。 Technique of standard core decompression 標(biāo)準(zhǔn)髓心減壓技術(shù) The patient is placed under general anesthesia and is then prepared and draped in an aseptic manner. Under fluoroscopic guidance, a Kirschner wire is drilled with an entry point laterally, but superior to the lesser trochanter medially. Once it is determined that the guide wire is in the appropriate place, an 8- to 10-mm-wide trephine is inserted into the lesion with care not to penetrate the femoral head nor to violate the articular cartilage. A core of bone is removed from the lesion, the skin is closed with one suture, and a sterile dressing is applied [5]. Following surgery, patients are discharged home the same day and are allowed 50 % weightbearing on the affected leg, for 6 weeks. After 6 weeks, patients can progress to full weight-bearing. Patients are then given abductor strengthening exercises and educated to avoid high impact activities for 1 year [5]. Patients are followed up with plain radiographs and clinical evaluation at 6, 12 weeks, 6, 12 months, and annually thereafter. 將患者置于全身麻醉下，然后以無菌方式準(zhǔn)備和鋪巾單。在透視引導(dǎo)下，克氏針在外側(cè)鉆有一個入口點，但在內(nèi)側(cè)高于小轉(zhuǎn)子。一旦確定導(dǎo)絲位于合適的位置，將8至10毫米寬的環(huán)鉆插入病灶，小心不要刺入股骨頭或侵犯關(guān)節(jié)軟骨。從病變中取出骨髓，用一根縫線縫合皮膚，并使用無菌敷料[5]。手術(shù)后，患者在同一天出院回家，并允許患肢負重50%，持續(xù)6周。6周后，患者可以完全負重（注：視患者恢復(fù)情況決定何時完全負重行走，每天控制步數(shù)在3千左右）。然后對患者進行外展肌強化訓(xùn)練并接受教育，避免在1年內(nèi)避免高強度活動[5]。在第6、12周、6、12個月和此后每年一次對患者進行X線片和臨床評估隨訪。 Overall outcomes of traditional core decompression 傳統(tǒng)髓心減壓的總體結(jié)果 When evaluating outcomes of this procedure, it is important to distinguish the results of older versus more recent studies. In a systematic literature review, Marker et al. [12] evaluated the clinical and radiographic outcomes of core decompression in surgeries done before [13–22] and after 1992 [1, 2, 10, 23–31] (n=1268 and 1337 hips, respectively). The authors demonstrated that in procedures performed before 1992, 41 % of hips required additional surgery after a mean follow-up of 65 months (range, 3 to 216 months). However, in surgeries conducted after 1992, only 30 % of hips required another operation after a mean follow-up of 63 months (range, 1 to 176 months). Given this improvement in the overall efficacy of core decompression, the authors concluded that core decompression is a viable option for treating the early stages of ON. This may be due to improvements in surgical indications or technique as well as improvement in postoperative care. 在評估此手術(shù)操作的結(jié)果時，重要的是要區(qū)分較舊和較新的研究結(jié)果。在系統(tǒng)的文獻綜述中，Marker等[12]評估了在1992年之前[13-22]和之后[1, 2, 10, 23-31]（分別為1268和1337髖）手術(shù)中髓心減壓的臨床和影像學(xué)結(jié)果。作者證明，在1992年之前進行的手術(shù)中，41%的髖關(guān)節(jié)在平均65個月（范圍，3至216 個月）的隨訪后需要額外手術(shù)。然而，在1992年之后進行的手術(shù)中，平均隨訪63個月（范圍為1至176個月）后，只有30%的髖關(guān)節(jié)需要再次手術(shù)。鑒于髓心減壓的整體功效的這種改善，作者得出結(jié)論，髓心減壓是治療ON早期階段的可行選擇。這可能是由于手術(shù)適應(yīng)癥或技術(shù)的改進以及術(shù)后護理的改進。 Similarly, Rajagopal et al. [32?] assessed the efficacy of core decompression in a systematic literature review of four level IV studies (n=139 hips) [13, 27, 33, 34]. After a minimum 2-year follow-up, approximately 26 % of all cases were converted to THA. Furthermore, they found that those in Ficat stage I disease and lesions occupying ＜50 % of the femoral head were more likely to achieve satisfactory outcomes (no additional surgery and Harris Hip Scores ＞70 points). The authors further support the notion that core decompression is best when performed in the earliest stages of the disease. 同樣，Rajagopal等人[32?]在對四項IV級研究（n=139髖）[13,27,33,34]的系統(tǒng)文獻綜述中評估了髓心減壓的功效。經(jīng)過至少2年的隨訪，所有病例中約有26%轉(zhuǎn)為全髖關(guān)節(jié)置換術(shù)。此外，他們發(fā)現(xiàn)處于Ficat I期病變且病變占股骨頭＜50%的患者更有可能獲得令人滿意的結(jié)果（無需額外手術(shù)且Harris髖關(guān)節(jié)評分＞70分）。作者進一步支持這樣一種觀點，即在疾病的最早階段進行髓心減壓是最好的。 Although there is a paucity of studies within the last 10 years assessing long-term (＞10 years) outcomes, there are some older studies evaluating long-term results following decompression. Fairbank et al. [35] evaluated patients in precollapse and postcollapse disease (n=128 hips). After a 10-year follow-up, the hip survival rates those in Ficat stages I, II, and III of disease were 96, 74, and 35 %, respectively. Therefore, long-term studies confirm that those with the best outcomes following this procedure are those with early precollapse disease. 盡管過去10年中評估長期（＞10年）結(jié)果的研究很少，但有一些較早的研究評估了髓心減壓后的長期結(jié)果。Fairbank等[35]評估了塌陷前和塌陷后疾病的患者（n = 128 髖）。經(jīng)過10年的隨訪，F(xiàn)icat I、II和III期患者的髖關(guān)節(jié)存活率分別為96%、74%和35%。因此，長期研究證實，接受此手術(shù)后獲得最佳結(jié)果的是那些患有早期塌陷前病變的人。 In summary, more recent studies have conferred better results than older studies with core decompression. This may be due to improved patient selection or evolving surgical technique. As more long-term outcome studies are published, core decompression will likely gain traction as a treatment of early stage ONFH. 總之，最近的研究比早期的髓心減壓研究取得了更好的結(jié)果。這可能是由于患者選擇的改進或手術(shù)技術(shù)的發(fā)展。隨著更多長期結(jié)果研究的發(fā)表，髓心減壓作為早期ONFH的治療方法可能會受到關(guān)注。 Most studies have reported excellent outcomes for this procedure when perfo med in early precollapse disease stages. Yoon et al. [1] evaluated the role of disease stage and lesion location on the outcomes (n=39 hips).After amean follow-up of 61 months, they found that patients who had Ficat stage II or III disease (n=17 out of 22 hips) were significantly more likely to require THA than those with stage I disease (n=5 out of 17 hips) (p＜0.001). In addition, when the lesions were located laterally or centrally, there was a significantly increased rate of conversion to a THA than those with medial lesions (p=0.009). They also noted that larger sized lesions (＞30 % of femoral head) had a significantly greater chance of clinical failure (p＜0.001). They concluded that the ideal candidate has precollapse disease with lesions less than 15 % of the size of the femoral head. 大多數(shù)研究報告稱，在早期股骨壞死破損前疾病階段進行髓心減壓時，療效非常好。Yoon等[1]評估了疾病分期和病變位置對結(jié)果作用（n=39 髖）。經(jīng)過平均61個月的隨訪，他們發(fā)現(xiàn)患有Ficat II或III期疾病的患者（22髖中的n=17）比I期疾病患者（17髖中的n=5）更可能需要THA（p＜0.001）。此外，當(dāng)病變位于外側(cè)或中央時，與內(nèi)側(cè)病變相比，THA的轉(zhuǎn)化率顯著增加（p = 0.009）。他們還指出，較大尺寸的病變（＞30%的股骨頭）臨床失敗的可能性要大得多（p＜0.001）。他們得出結(jié)論，理想的手術(shù)患者是患有塌陷前病變，病變小于股骨頭大小的15%。 These conclusions are supported by Iorio et al. [2], who demonstrated that patients who had Ficat stage I disease had markedly higher 5-year survivorship than those with stage IIA and IIB disease (75%versus 30%versus 17 %, respectively). Therefore, the authors concluded that excellent survivorship occurs for those with stage I disease, but stage II disease patients may require alternative treatments. 這些結(jié)論得到了Iorio等人的支持[2]，他們證明了Ficat I期患者的5年生存率明顯高于IIA和IIB期患者（分別為75% 對30%對17%）。因此，作者得出結(jié)論，I期疾病患者具有極好的存活率，但II期疾病患者可能需要替代治療。 Additionally, lesion size affects the efficacy of core decompression. Mazieres et al. [3] evaluated 20 hips with Ficat stage II disease. After a mean 24-month follow-up, 50% of the hips (10 hips) showed signs of radiographic progression. When stratifying the cohort by lesion size (＞23 and ≤23 % of the femoral head, respectively), those with smaller lesions (n=8 hips) only had 1 hip with disease progression, while 9 of 12 hips with larger lesions showed radiographic progression. The authors concluded that all decisions regarding this procedure should take into account whether the femoral head has collapsed as well as the volume of the lesions. 此外，病變大小影響髓心減壓的功效。Mazieres等[3]評估了20位患有Ficat II期疾病的髖關(guān)節(jié)。經(jīng)過平均24個月的隨訪，50%的髖關(guān)節(jié)（10髖）顯示放射學(xué)進展的跡象。當(dāng)按病灶大?。ǚ謩e大于股骨頭的23%和≤ 23%）對隊列進行分層時，那些病灶較小的人（n = 8 髖）只有1髖有疾病進展，而12髖中有9髖有較大病灶的影像學(xué)顯示進展。作者得出的結(jié)論是，有關(guān)髓心減壓的所有決定都應(yīng)考慮股骨頭是否塌陷以及病變的體積。 The use of core compression after the femoral head has collapsed has resulted in less than optimal outcomes. After a mean follow-up of 12 years (range, 4 to 18 years), Mont et al. [4] evaluated a cohort with postcollapse ONFH (n=68 hips). Only 29 % of the hips (n=20) had satisfactory outcomes (no additional surgeries and HHS ≥75 points). Furthermore, when categorized by disease stage, 41 % of the Steinberg stage III hips (n=18 out of 44 hips) required a THA, and 92 % of the stage IV hips (n=22 out of 24 hips) underwent a THA. Therefore, diagnosis before femoral head collapse is crucial for core decompression to be effective. 在股骨頭塌陷后使用髓心減壓往往治療效果不太理想。經(jīng)過平均12年（范圍，4至18年）的隨訪，Mont等[4]評估了一個有塌陷后ONFH的隊列（n = 68髖）。只有29%的髖關(guān)節(jié)(n=20)具有令人滿意的結(jié)果（沒有額外手術(shù)且HHS ≥75 分）。此外，按疾病分期分類時，41%的Steinberg III期髖關(guān)節(jié)（44髖中的n=18）需要THA，而92%的IV期髖關(guān)節(jié)（24 髖中的 n=22）接受THA。因此，股骨頭塌陷前的診斷對于髓心減壓術(shù)的有效性至關(guān)重要。 There have been attempts to use various adjunctive therapies with this procedure such as the following: (1) bone grafting [13, 23, 26]; (2) addition of mesenchymal cells [13, 23, 26]; and (3) tantalum rod insertion [9, 11, 36–41]. 已經(jīng)嘗試在髓心減壓過程中使用各種輔助療法，例如：(1)骨移植術(shù)[13, 23, 26]；(2)添加間充質(zhì)細胞[13, 23, 26]；(3)鉭棒植入[9, 11, 36–41]。 Bone grafting 骨移植 Different types of bone grafts have been introduced into core tracts with the goal of providing structured support and further optimizing patient-reported outcomes. It is believed that bone grafting can stimulate repair and act as the foundation on which new bone may form. Wei and Ge [42] assessed the outcomes of a large cohort of patients in ARCO stage II and III ON following core decompression and concurrent nonvascularized bone grafting (n=223 hips). After a mean follow-up of 24 months (range, 7 to 42 months), they found a hip survival rate (no further surgeries required) of 81% and a mean Harris Hip Score (HHS) that increased from 61 to 86 points at latest follow-up. Furthermore, multiple studies have shown that this can be an effective method for delaying the need for THA while subsequently allowing core decompression to be effective in later stages of ON [42–46]. 不同類型的骨移植物已被引入髓心減壓隧道，目的是提供結(jié)構(gòu)化的支持并進一步優(yōu)化患者報告的結(jié)果。人們相信骨移植可以刺激修復(fù)并作為新骨形成的基礎(chǔ)。Wei和Ge[42]評估了大量ARCOII和III期ON患者在髓心減壓和同步非血管化骨移植（n = 223髖）后的結(jié)果。在平均24個月（范圍，7至42個月）的隨訪后，他們發(fā)現(xiàn)髖關(guān)節(jié)存活率（無需進一步手術(shù)）為81%，平均Harris髖關(guān)節(jié)評分(HHS)從61分增加到最新隨訪的86分。此外，多項研究表明，這可能是一種有效的方法，可以延遲對THA的需求，同時提高髓心減壓在ON的晚期階段有效性[42-46]。 Mesenchymal stem cells 間充質(zhì)干細胞 There have been attempts to use core decompression with the addition of bone marrow cells (BMC) [8, 10, 47–49, 50?]. Li et al. [8] compared the use of BMC therapy to core decompression alone in a meta-analysis of 4 studies (n=219 hips) [47–49, 50?]. After a follow-up of 18 months, the authors demonstrated that significantly less patients in the BMC cohort required additional surgeries and/or procedures than those in the core decompression cohort (OR=0.11; p＜0.01). Therefore, the authors concluded that the implantation of BMC may result in better outcomes than the use of core decompression alone. Therefore, BMC implantation may hold future promise as an adjunctive therapy. 已經(jīng)嘗試通過添加骨髓干細胞(BMC)來完成髓心減壓[8, 10, 47–49, 50?]。Li等[8]在4項研究（n=219 髖）的薈萃分析中比較了BMC治療與單獨使用髓心減壓術(shù)[47–49, 50?]。在18個月的隨訪后，作者證明BMC隊列中需要額外手術(shù)和/或程序的患者明顯少于髓心減壓隊列中的患者（OR=0.11；p＜0.01）。因此，作者得出結(jié)論，與單獨使用髓心減壓相比，植入BMC可能會產(chǎn)生更好的結(jié)果。因此，BMC植入作為一種輔助療法可能在未來有希望。 Tantalum rod 鉭棒 Core decompression with the insertion of a porous tantalum rod initially showed some positive results [7, 37, 40]. However, many of these studies were done on very small cohorts, and the removal of these implants has led to complications such as fracture [7, 37, 40, 51–55]. Therefore, we do not recommend this as an adjunctive procedure. Recently, Ye et al. evaluated the efficacy of this adjunct (n=12 hips). After a mean followup of approximately 37 months (range, 6 to 47), 5 hips (42 %) required THA and 1 hip had a hardware failure. 插入多孔鉭棒的髓心減壓最初顯示出一些積極的結(jié)果[7, 37, 40]。然而，這些研究中有許多是在非常小的隊列中進行的，移除這些(多孔鉭棒)植入物會導(dǎo)致骨折等并發(fā)癥[7, 37, 40, 51-55]。因此，我們不建議將多孔鉭棒作為髓心減壓輔助操作。最近，Ye等評估了該輔助裝置的功效（n=12 髖）。在大約37個月（范圍，6至47）的平均隨訪后，5髖（42%）需要THA，1髖出現(xiàn)內(nèi)固定失敗。 Description of multiple percutaneous drilling decompression 多次經(jīng)皮鉆孔減壓的描述 Despite the excellent results with traditional core decompression, there are complications that can occur such as violation of the articular cartilage or subtrochanteric fractures. In an attempt to minimize these complications, instead of drilling one large tract, some have used multiple percutaneous drilling. Using a small diameter pin, multiple passes were made into the lesion [5, 56]. Recently, it has been used by number of surgeons with excellent results [5, 56–58]. 盡管傳統(tǒng)的髓心減壓術(shù)取得了優(yōu)異的效果，但仍可能出現(xiàn)并發(fā)癥，例如侵犯關(guān)節(jié)軟骨或轉(zhuǎn)子下骨折。為了盡量減少這些并發(fā)癥，一些人使用多次經(jīng)皮鉆孔，而不是在一個大管道上鉆孔。使用小直徑鉆孔針，多次通過病灶[5, 56]。最近，它已被許多外科醫(yī)生使用，效果極佳[5, 56–58]。 For this technique, the patient is placed in the supine position on a fracture table, placed under intravenous sedation, and prepared and draped in an aseptic manner. The extremity is placed in slight internal rotation, the Steinman pin or drill is then inserted laterally above the level of the lesser trochanter, and it is advanced under fluoroscopic guidance toward the lesion [5]. Although dependent on surgeon preference, larger sized lesions require more passes (minimum, 2 to 3 passes) than smaller ones (1 pass) [56, 57]. After its completion, the pins are removed, direct pressure is held at the site, and a sterile dressing is applied. Postoperative care is similar to that following traditional decompression with the patient being 50 % weightbearing for 6 weeks. After 6 weeks, the patient is allowed to bear full weight and is given hip and abductor strengthening exercises to complete. The patient is also educated to avoid high impact activities for at least 1 year and is instructed to follow up at 6, 12 weeks, 6, 12 months, and annually thereafter. 對于這項技術(shù)(多次經(jīng)皮鉆孔)，患者被置于在手術(shù)臺上，仰臥位，采用靜脈麻醉，并以無菌方式準(zhǔn)備和鋪單巾。將肢體輕微內(nèi)旋，然后將Steinman螺紋針或鉆針從外側(cè)插入小轉(zhuǎn)子水平上方，并在透視引導(dǎo)下向病變處推進[5]。盡管取決于外科醫(yī)生的偏好，但較大尺寸的病變需要比較小的病變（1次）更多的通道（最少，2-3個通道）[56,57]。完成后，取下鉆針，在該部位保持直接壓力，并使用無菌敷料。術(shù)后注意事項與傳統(tǒng)髓心減壓術(shù)后的注意事項相似，患者負重50%，持續(xù)6周。6周后，患者可以承受全部重量，并進行髖關(guān)節(jié)和外展肌強化練習(xí)來完成。還教育患者至少在1年內(nèi)避免高強度活動，并被指示在6、12周、6、12個月和此后每年進行一次隨訪。 Outcomes of percutaneous drilling 經(jīng)皮鉆孔的結(jié)果 Outcomes associated with this percutaneous drilling technique are comparable to standard core decompression. In 2004, Mont et al. [57] were one of the first to report on this technique using multiple 3.2-mm drillings (2 to 3 holes) to achieve decompression in a cohort of patients who had precollapse ONFH (n=45 hips). Failure was defined as an HHS less than 70 and/or requiring additional surgery.After amean follow-up of 24 months (range, 20 to 39 months), among patients with Ficat stage I disease (n=30 hips), 80 % (24 hips) had successful outcomes by the time of their last follow-up. Similarly, Song et al. [56] evaluated this technique in patients who had both precollapse and postcollapse disease (n=163 hips). They used 3.6-mm Steinmann pins and a mean of 12 holes (range, 4 to 22 holes).At 87-month mean follow-up (range, 60 to 134 months), 66 % of the hips (108 hips) were considered to have successful outcomes (HHS ≥75 points and no additional surgery). Of the patients with Ficat stage I disease, 79%demonstrated clinically successful outcomes (n=31 of 39 hips), while 77 % of patients with stage II ON were deemed clinically successful (n=62 of 81 hips). Furthermore, the authors found that there was a significantly higher survivorship in patients with Ficat stage I or II than in patients with stage III ON (p＜0.01). Moreover, there was a significantly higher survivorship in patients with small (＜25 % involvement, n=15 of 15 hips) or medium lesions (25 to 50 % involvement, n=37 of 44 hips) compared with large lesions (＞50 % involvement, 56 of 204 hips, p＜0.01). 與這種經(jīng)皮鉆孔技術(shù)相關(guān)的結(jié)果可與標(biāo)準(zhǔn)髓心減壓相媲美。2004年，Mont等[57]是最早報告使用多個3.2毫米鉆孔（2到3個孔）在一組患有預(yù)塌陷ONFH（n=45髖）的患者中實現(xiàn)減壓的技術(shù)之一。失敗定義為HHS小于70和/或需要額外手術(shù)。平均隨訪24個月（范圍，20至39個月）后，在患有Ficat I期疾?。╪=30髖）的患者中，80%（24髖）在最后一次隨訪時取得了成功的結(jié)果。同樣，Song等[56]在患有塌陷前和塌陷后疾病的患者（n = 163 髖）中評估了這種技術(shù)。他們使用3.6毫米Steinmann針和平均12個孔（范圍，4到22個孔）。在87個月的平均隨訪（范圍，60至134個月）中，66%的髖關(guān)節(jié)（108髖）被認為具有成功的結(jié)果（HHS ≥75分且未進行額外手術(shù)）。在患有Ficat I期疾病的患者中，79%的患者表現(xiàn)出臨床成功（n=31 of 39 hips），而77%的II期ON患者被認為臨床成功（n=62 of 81 hips）。此外，作者發(fā)現(xiàn)Ficat I或II期患者的生存率明顯高于III期ON患者（p＜0.01）。此外，與大病灶（＞50%）或中等病灶（25%至50%受累，44個髖關(guān)節(jié)中的37個）相比，小病灶（＜25%受累，n=15，15髖）的存活率顯著更高，204髖中有56髖受累，p＜0.01）。 Recently, Omran [59??] assessed and compared the use of the multiple drilling technique (n=33 hips) to the conventional technique (n=61 hips) in a cohort of patients with sickle cell disease in Ficat stage I or II ONFH (n=94 patients). After a minimum follow-up of 2 years, patients had significant reductions in pain and improvement in HHS regardless of the technique. The authors concluded that although the multiple drilling technique is less invasive, it has similar outcomes compared to conventional decompression. 最近，Omran[59??]在一組Ficat I或II期ONFH鐮狀細胞病患者中評估并比較了多次鉆孔技術(shù)（n=33髖）與常規(guī)技術(shù)（n=61髖）的使用（n = 94名患者）。在至少2年的隨訪后，無論采用何種技術(shù)，患者的疼痛均顯著減輕，HHS改善。作者得出的結(jié)論是，雖然多次鉆孔技術(shù)侵入性較小，與傳統(tǒng)減壓相比具有相似的結(jié)果。 In summary, the use of multiple drilling technique of femoral head decompression has demonstrated excellent survivorship and outcomes. When compared to traditional methods, this newer approach has demonstrated similar results and may be easier to perform with fewer complications. 總之，使用多次鉆孔技術(shù)進行股骨頭減壓已顯示出良好的存活率和結(jié)果。與傳統(tǒng)方法相比，這種較新的方法顯示出類似的結(jié)果，并且可能更容易執(zhí)行，并發(fā)癥更少。 Conclusion 結(jié)論 The efficacy of core decompression for the treatment of ONFH remains an area of controversy. However, most of the studies indicate that this management strategy is associated with the best outcomes when used in the earliest, precollapse stages of the disease with small lesions. Efficacy has improved over the past 20 years, and this may be due to improved patient selection or the use of new surgical techniques such as multiple percutaneous drilling. As this treatment modality continues to evolve, further studies should focus on new surgical techniques and adjunctive therapies that may further the prevention and/or delay of THA. 髓心減壓治療ONFH的療效仍然存在爭議。然而，大多數(shù)研究表明，這種治療策略在病灶較小的疾病早期、壞死塌陷前階段使用時可獲得最佳結(jié)果。在過去的20年中，療效有所提高，這可能是由于患者選擇的改進或新手術(shù)技術(shù)的使用，例如多次經(jīng)皮鉆孔。隨著這種治療方式的不斷發(fā)展，進一步的研究應(yīng)側(cè)重于可能進一步預(yù)防和/或延遲THA的新手術(shù)技術(shù)和輔助療法。2022年12月28日1012
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朱凱主治醫(yī)師 中國人民解放軍總醫(yī)院第六醫(yī)學(xué)中心 康復(fù)醫(yī)學(xué)科 股骨頭壞死是一個病理演變過程，初始發(fā)生在股骨頭的負重區(qū)，應(yīng)力作用下壞死骨骨小梁結(jié)構(gòu)發(fā)生損傷即顯微骨折以及隨后針對損傷骨組織的修復(fù)過程。目前，主要的治療方法有： 1、股骨頭髓芯減壓術(shù)； 2、吻合血管或不吻合血管的骨移植術(shù)； 3、旋轉(zhuǎn)截骨術(shù)； 4、人工關(guān)節(jié)置換手術(shù)。 一、股骨頭壞死的治療理念 1、壞死早期的青壯年患者傾向于保髖治療； 2、壞死晚期的老年患者傾向于人工關(guān)節(jié)置換手術(shù)。 二、PRP可應(yīng)用于股骨頭壞死的保髖治療中，可能治療機理 1、PRP促進新生血管形成，為細胞再生提供足夠的營養(yǎng)，防止股骨頭細胞凋亡，促進骨再生； 2、PRP可促進骨髓間充質(zhì)細胞（BMSC）增殖、分化； 3、PRP可誘導(dǎo)BMSC向軟骨細胞分化，促進軟骨再生； 4、PRP可在股骨頭壞死局部抑制細胞的凋亡； 5、PRP可彌補生長因子的不足。 三、PRP治療股骨頭環(huán)伺的適應(yīng)癥 股骨頭壞死的早期，即FicatⅠ期和Ⅱ期，股骨頭關(guān)節(jié)面尚未塌陷。 四、PRP治療股骨頭壞死的方法 1、一般采用PRP結(jié)合股骨頭髓芯減壓術(shù)； 2、對于年輕患者，可采用吻合血管游離腓骨移植術(shù)，有文獻報道此種方法是一種有效方法； 3、有文獻報道，有少數(shù)臨床醫(yī)生采用髖關(guān)節(jié)鏡下應(yīng)用PRP修復(fù)股骨頭，鏡下具有視野清晰，死骨清除徹底，PRP填充準(zhǔn)確等優(yōu)點。2020年03月22日6100
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