Objective To compare effectiveness between sequestrum clearance and impacting bone graft and rotational osteotomy on the base of femoral neck via surgical hip dislocation approach for avascular necrosis of femoral head (ANFH) at Association Research Circulation Osseous (ARCO ) stage Ⅲ. Methods A clinical data of 24 patients (27 hips) with ANFH at ARCO stage Ⅲ, who met the inclusion criteria between June 2012 and November 2017, was retrospectively analysed. Of all patients, 12 patients (14 hips) were treated with sequestrum clearance and impacting bone graft via surgical hip dislocation approach (group A); and 12 patients (13 hips) were treated with rotational osteotomy on the base of femoral neck via surgical hip dislocation approach (group B). There was no significant difference in gender, age, disease duration, and affected side, type, and stage of the ANFH between 2 groups (P>0.05). The operation time of each hip and hospitalization stays of each patient in 2 groups were recorded and compared. Imaging examination was performed to observe the blood supply around femoral head, healing of the osteotomy, and the femoral head collapsed. The function of the hip was evaluated by Harris score. Results There was no significant difference in operation time and hospitalization stays (t=–0.262, P=0.797; t=–0.918, P=0.411). All patients were followed up, the follow-up time of group A was 12-28 months (mean, 19.7 months), and the follow-up time of group B was 14-24 months (mean, 17.8 months). The Harris score in groups A and B increased significantly at 6 months and 12 months after operation when compared with preoperative ones (P<0.05). There was no significant difference between 2 groups at 6 months and 12 months (P>0.05). At 12 months after operation, according to the Harris scoring, there were 3 hips of excellent, 7 hips of good, and 4 hips of poor, with the excellent and good rate of 71.4% in group A; there were 5 hips of excellent, 7 hips of good, and 1 hip of poor, with the excellent and good rate of 92.3% in group B. Digital substraction angiography was performed at 1 week after operation and indicated that the blood supply around the femoral head was not destroyed during the operation. Imaging examination after operation showed that the osteotomy of the greater trochanter all healed in 2 groups and the osteotomy of the femoral neck healed in group B. Hip collapse occurred in 2 patients (2 hips) of group A at 12 months after operation. No hip collapse occurred in group B. Conclusion The rotational osteotomy on the base of femoral neck via surgical hip dislocation approach is superior to sequestrum clearance and impacting bone graft in delaying the collapse and improving the hip function for patients with ANFH at ARCO stage Ⅲ.
Objective Glucocorticoid is the main cause of non-traumatic avascular necrosis of femoral head. To explore the changes of reactive oxygen species (ROS) in the bone microvascular endothel ial cells treated with glucocorticoid so as to investigate the pathogenesis of steroid-induced avascular necrosis of femoral head. Methods The cancellous bone of femoral head was harvested from voluntary donators undergoing total hip arthroplasty, and then the bone microvascular endothel ial cells were isolated by enzyme digestion. The cells at passage 3 were cocultured with different concentrations of hydrocortisone (0, 0.03, 0.10, 0.30, and 1.00 mg/mL) for 24 hours. MTT assay was used for the inhibitory rate of cell prol iferation, flow cytometry for apoptosis rate, and fluorescence probe for the production of ROS and xanthine oxidase (XOD). Results At 2-3 days primary culture, the cells were spindle and arranged l ike cobbles and they reached confluence after 1 week. The inhibitory rates of cell prol iferation in 0.03, 0.10, 0.30, and 1.00 mg/mL groups were 20.22% ± 2.97%, 22.94% ± 4.52%, 43.98% ± 3.35%, and 78.29% ± 3.85%, respectively; and 2 high-concentration groups (0.30 and 1.00 mg/mL groups) were significantly higher (P lt; 0.05) than 2 low-concentration groups (0.03 and 0.10 mg/mL groups). The apoptosis rates in 0, 0.03, 0.10, 0.30, and 1.00 mg/mL groups were 0.10% ± 0.01%, 0.23% ± 0.02%, 1.83% ± 0.04%, 6.34% ± 0.11%, and 15.33% ± 0.53%, respectively; 2 high-concentration groups (0.30 and 1.00 mg/mL groups) were significantly higher (P lt; 0.05) than 0 mg/mL group. In 0, 0.30, and 1.00 mg/ mL groups, the ROS levels were 57.35 ± 7.11, 120.47 ± 15.68, and 166.15 ± 11.57, respectively, and the XOD levels were 0.017 9 ± 0.000 9, 0.028 3 ± 0.001 7, and 0.067 7 ± 0.004 1, respectively; there were significant differences in the levels of ROS and XOD among 3 groups (P lt; 0.05). Conclusion Increasing of ROS production in bone microvascular endothel ial cells can be induced by high concentration glucocorticoid, and it can result in cell injury
【Abstract】 Objective To investigate corresponding relation between structure change of the femoral head with“crescent sign” and stress exerted on the avascular necrosis of femoral head, to explore the mechanism of the “crescent sign” formation. Methods From March 1998 to April 2003, the femoral heads of 18 hips in 16 cases having osteonecrosis and “crescent sign” in X-ray film before total hi p arthroplasty, were collected. General and coronal section plane morphology of the femoral heads were observed. The princi ple of effective stress and stress concentration theory were used to explain the phenomena and structure changes in osteonecrosis of the femoral head. Results Cancellous bone existed as a threedimensional,interconnected network of trabeculae rods and plates, with 50%-90% of porosity and 20-30 mmHg bone marrow pressure. According to the definition of porous media, bones especially cancellous bone was a kind of sol id and l iquid two phases porous media. Cross-sectional structure changes in the junction between subchondral plate and cancellous were the place where stress concentrated. The principle of effective stress and stress concentration theory could explain the phenomena and their relationship that occurred in avascular necrosis of the femoral head. Conclusion The “crescent sign” starts in an area of very focal resorption in the subchondral plate laterally and peripherally. The focal resorption in the subchondral plate breaks the continuity of subchondral plate and causes stress concentration in the resorption region. The concentrated stress accumulates in the junction between subchondral plate and unrepaired necrotic cancellous bone brings on the fracture right below the subchondral plate. The focal resorption of the subchondral plate also provides a pathway for the pore water in the unrepaired necrotic bone skeleton to outflow, therefore cause effective stress increase and unrepaired necrotic bone skeleton be compacted by increased effective stress appl ied on unrepaired necrotic cancellous bone skeleton, and results in the volume decrease of unrepaired necrotic cancellous bone and the formation of cavum below the subchondral plate. The cavum shows “crescent sign” in the X-ray film.
Objective To explore the difference between bone marrow edema syndrome (BMES) and avascular necrosis of femoral head (ANFH). Methods Recent original articles about BMES and ANFH were extensively reviewed, and were comprehensively analysed. Results The pathology, pathogenesis, clinical features, treatment selection, and prognosis are different between these two diseases. Conclusion BMES and ANFH are two different diseases. Micro-fracture may be the cause of bone marrow edema.
【Abstract】 Objective To investigate the spectrum of CT and MR imaging and surgical operation findings in il iopsoasbursitis in patients with avascular necrosis of femoral head so as to enhance the diagnostic abil ity. Methods A total of 1 415 patients with avascular necrosis of the femoral head were analyzed retrospectively; of them, 15 patients were compl icated by il iopsoas bursitis surgically or aspiration of synovial fluid between May 2005 and May 2007. Fifteen cases were all necrosis of the bilateral femoral head and 17 hips were combined with il iopsoas bursitis. There were 14 males and 1 female, aging 29-58 years. The course of disease was 1 month to 3 years. All 15 patients had l imitation of abil ity of the hips and the “4” type sign was positive. The Harris score of hip’s function was 54-78 (mean 62.7). Five patients of them can be touched a palpable cystic mass and tenderness in the inguinal area, and 3 of them associated with femoral neuropathy and 2 patients presented sl ight atrophy of the thigh muscle in suffering side. All these cases were taken X-ray films of positive and frog-leg lateral position, hel ical CTscan with 5 mm thinness, and MRI was performed in 6 patients with T1WI, T2WI, T2WI and fat-saturated inversion recovery sequence. Results The radiographs were the primary basis evidences for diagnosis and degrees of the avascular necrosis of femoral head. According to the standards of Association Research Circulation Osseuse, there were 2 hips at stage II(II C 2), 6 hips at stage Ⅲ ( Ⅲ B 1, Ⅲ C 5 ) and 9 hips at stage IV. The X-ray films showed the bulging of the fat pad and soft tissue swell ing in 6 patients. CT analysis disclosed that the enlarged il iopsoas bursae appeared as hypodense, well-defined, thin-walled (lt; 2 mm) cystic structures. The content of the examined bursae was homogeneous with a CT density of ranging from 12.7 to 41.2 Hu, showing fluid collection. They were round or oval in shape medial to the il iopsoas, exhibiting inverted water-drop cystic shadow just inferior to the femoral head. Sl ight contrast enhancement of the bursal wall was seen after contrast agent administration in 3 cases. MRI demonstrated that the il iopsoas bursitis presented as low signal on T1WI and water-l ike highsignal on T2WI and markedly higher signal on STIR in 6 cases. The demonstration of the extent, size, mass effects and its relation and subsequent affection to surrounding anatomical structures were clearly shown by MRI, and by the communications between the il iopsoas bursa and the adjacent hip joint. Conclusion In the diagnosis of avascular necrosis of femoral head with imaging approaches, much attention should be paid to the abnormal ities around the articular capsule to early identify il iopsoas bursitis for further management.
Objective To review the researches on the jointpreserving procedures for the treatment of the avascular necrosis (AVN) of the femoral head. Methods The latest original literatures about the joint-preserving procedures for the treatment of AVN of the femoral head were extensively reviewed. Results There were many surgical jointpreserving procedures to treat AVN of the femoral head, such as core decompression, bone grafting, and osteotomy. Most researchers achieved excellent clinical results by using the joint-preserving procedures to treat the early stages of AVN of the femoral head. Conclusion Treating AVN of the femoral head by the joint-preserving procedures, especially the free vascularized fibula grafting, can achieve an excellent longterm clinical outcome.
Objective To explore the effectiveness of pedicled il iac bone graft transposition for treatment of avascular necrosis of femoral head (ANFH) after femoral neck fracture. Methods Between June 2002 and December 2006, 22 cases (22 hips, 16 left hips and 6 right hips) of ANFH after femoral neck fracture were treated with il iac bone graft pedicled with ascending branch of the lateral femoral circumflex vessels. There were 18 males and 4 females with an age range from 28 to 48 years (mean, 37.5 years). The time from injury to internal fixation was 2-31 days, and all fractures healed within 12 months after internal fixation. The ANFH was diagnosed at 15-40 months (mean, 22 months) after internal fixation. The ANFH duration was 3-11 months (mean, 8 months). According to Association Research Circulation Osseous (ARCO) staging system, 2 hips were classified as stage IIa, 3 hips as stage IIb, 3 hips as stage IIc, 3 hips as stage IIIa, 7 hips as stage IIIb, and 4 hips as stage IIIc. The preoperative Harris hip score (HHS) was 64.10 ± 5.95. Results All incisions healed by first intention and the patients had no compl ication of lung embol ism, sciatic nerve injury, lower l imb deep venous thrombosis, and numbness and pain of donor site. All patients were followed up 2.5 to 6.3 years (mean, 4.8 years). The fracture heal ing time was 8-12 months, and no femoral neck fracture recurred. The HHS was 90.20 ± 5.35 at last follow-up, showing significant difference when compared with the preoperative value (t= —18.447, P=0.000). The hi p function were excellent in 11 hi ps, good in 10 hips, fair in 1 hip, and the excellent and good rate was 95.5%. Four hips were radiographically progressed in ARCO staging, 18 hips remained stable with a stable rate of 81.8%. Conclusion Pedicled il iac bone graft transposition is an ideal option for treatment of ANFH after internal fixation of femoral neck fracture for the advantages of femoral head revascularization, sufficient cancellous bone supply, and relatively simple procedure.
【Abstract】 Objective To establ ish a stable animal model for glucocorticoid-induced avascular necrosis of femoral head in rabbits. Methods Thirty-six adult New Zealand rabbits were randomly divided into four groups:ten were injected twice with l i popolysaccharide (group A), ten were treated with a combination of l i popolysaccharideand methylprednisolone (group B), ten were injected three times with methylprednisolone (group C), and six wereinjected normal sal ine as a control (group D). MR imaging was performed in the rabbits before the first injection ofl i popolysaccharide or methylprednisolone, and at 2, 4, and 6 weeks after the last injection of l i popolysaccharide ormethylprednisolone. Histopathological changes in the femoral heads were observed by l ight microscope and transmission electron microscope at the end of six weeks after the injection. Vascular infusion with Chinese ink was made to evaluate the morphological changes of blood vessels in the femoral head. The percentage of trabecular bone area and empty lacunae and microvascular density were measured. According to the histological and MR imaging appearance of the femoral heads in all groups, the incidence of osteonecrosis of every group was calculated. Results Listlessness, blepharal hyperemia,less activity and reduced diet were found in the rabbits of groups A and B after injected with l ipopolysaccharide. At 3 weeks after the final injection, the body weight of groups B and C was decreased. At 4 weeks after the final injection, the body weight of groups A and D was increased. No abnormal signal could be detected on MR images in rabbits of all groupsbefore injection and at 2 weeks after the injection. At 4 weeks and 6 weeks after the last injection, irregular low signal on T1-weighted images and irregular low or high signal on T2-weighted images could be detected on MR images in rabbits of groups B and C, no abnormal signal could be detected on MR images in rabbits of groups A and D. At 6 weeks after the last injection,the trabecular bone of group B became thin and sparse, some were broken. The percentages of empty lacunae were 11.8% ± 4.7%, 34.4% ± 6.2%, 20.0% ± 4.7% and 9.3% ± 4.6%; the percentages of trabecular bone area were 59.2% ± 6.8%, 40.1% ± 6.0%, 51.5% ± 5.6% and 63.2% ± 8.3%; and the microvascular densities were 14.3% ± 2.7%, 4.5% ± 2.1%, 10.2% ± 3.1% and 15.4% ± 4.1% in groups A, B, C and D respectively. There were statistically significant differences between group B and groups A, C, D (P lt;0.01). The fatty tamponade accumulated in the medullary cavity and intramedullary vascular sinusoids were pressed by the l ipocytes and became narrow. Limposomes were found in osteocytes and vascular endothel ia of group B and group C. Osteocytes of group B crimpled and pyknosis or karyolysis of chromatin were observed in these osteocytes, nuclearmembrane of the osteocytes was discontinous. Vascular endothel ia became swollen and the cell junctions widened or were destroyed in groups A and B. The incidence of osteonecrosis in group B (88.9%) was higher than that in group C (22.2%, P lt; 0.05). There was no osteonecrosis occurred in groups A and D . Conclusion Methylprednisolone combined with l ipopolysaccharide can induce typical rabbit model for early avascular necrosis of femoral head.
ObjectiveTo assess the effectiveness of pedicled iliac periosteal flap graft for treatment of avascular necrosis of the femoral head (ANFH) after femoral neck fracture in adolescents. MethodsBetween December 2006 and August 2011, 9 patients (9 hips) with ANFH after femoral neck fracture were treated with pedicled iliac periosteal flap graft. There were 6 males and 3 females with an average age of 14.7 years (range, 10-18 years). Fractures were caused by traffic accident injury (5 cases), falling injury from height (3 cases), and fall injury (1 case). The time from injury to internal fixation with Kirschner wires or cannulated screws was 3-16 days, and all fractures healed within 10 months after internal fixation. The interval between fracture fixation and ANFH was 10-42 months (mean, 24.4 months). According to Steinberg staging system, 1 hip was classified as stage Ⅲb, 2 hips as stage Ⅲc, 1 hip as stage IVa, 3 hips as stage IVb, and 2 hips as stage IVc. The Harris scores and Steinberg classification were compared between at pre- and post-operation to assess the outcomes clinically and radiologically. ResultsAll incisions healed by first intention. No complications of infection, deep venous thrombosis of lower limb, and pain and numbness of donor site were observed during or after operation. All patients were followed up 38-76 months (mean, 52 months). Joint pain was relieved; no leg length discrepancy was observed; the walking gait was improved and range of motion of hips was increased. The Harris score was significantly increased from 62.8±3.6 at pre-operation to 92.7±9.9 at last follow-up, showing significant difference (t=-12.244, P=0.000). The hip function was excellent in 5 hips, good in 3 hips, and poor in 1 hip, and the excellent and good rate was 88.89%. Post-operative radiological assessment demonstrated that only 1 hip (stage Ⅲb) had further collapse of the femoral head, the other hips had no incidence of deterioration. The radiological success rate was 88.89% (8/9). ConclusionThe pedicled iliac periosteal flap graft for ANFH after femoral neck fracture in adolescents can provide good osteogenesis and vascular reconstruction of the femoral head.
Objective To investigate the effectiveness of transplanting iliac bone flap with deep iliac circumflex vessels and cancellous bone for the treatment of adult avascular necrosis of the femoral head (ANFH). Methods A retrospective analysis was made on the clinical data of 685 patients (803 hips) with ANFH, who underwent iliac bone flap transplantation with deep iliac circumflex vessels and cancellous bone between March 2002 and January 2010. There were 489 males (580 hips) and 196 females (223 hips) with a mean age of 40.4 years (range, 18-63 years), including 567 unilateral cases (303 left hips and 264 right hips) and 118 bilateral cases. The causes of ANFH included alcohol-induced in 223 cases, steroid-induced in 179 cases, alcohol + steroid-induced in 21 cases, traumatic in 136 cases, acetabular dysplasia in 8 cases, bone cyst in 5 cases, septic arthritis in 2 cases, joint tuberculosis in 3 cases, rheumatoid arthritis in 5 cases, and idiopathic in 103 cases. According to Steinberg staging, 211 hips were rated as stage II, 513 hips as stage III, and 79 hips as stage IV. The preoperative Harris hip score was 60.30 ± 7.02. Results Fat necrosis occurred in 2 cases after operation, primary healing of incision was obtained in the other cases; delayed infection, lower extremity deep vein thrombosis, and pulmonary embolism occurred in 2 cases, respectively. All patients were followed up 36-60 months (mean, 49 months). Harris hip score at last follow-up (83.50 ± 7.31) was significantly higher than that at preoperation (t= — 2 266.980, P=0.000), and the scores were significantly higher than those at preoperation in different stages (P lt; 0.05). The results were excellent in 523 hips, good in 185 hips, fair in 65 hips, and poor in 30 hips, and the excellent and good rate was 88.2%. X-ray examination showed bone fusion of transplanted bone flap and bone graft with an average of 4.2 months (range, 3-6 months); according to Steinberg staging, imaging stable rate was 78.3% (629/803) at last follow-up. Conclusion Iliac bone flap transplantion with deep iliac circumflex vessels and cancellous bone has the advantages of complete decompression of the femoral head, exact flap blood supply, improved blood supply of the femoral head, new support for the femoral head, and participation of osteoinductive effect for the treatment of adult ANFH, so it is an effective treatment for the retention of the femoral head.