針灸課件股骨頭缺血性壞死的早期治療

1、DEVELOPMENT OF CORE DECOMPRESSION OFTHE FEMORAL HEADCore decompression of the hip is the most common procedure currently used to treat the early stages of ON of the femoral head. Ficat and Arlet then hypothesized that ON could be treated successfully by decompressing the femoral head. The goal of co

2、re decompression was to decompress the femoral head pressure, restore normal vascular flows, and alleviate pain in the hip.Even though numerous studies have been published no general consensus has been developed regarding patient selection, surgical technique, classification systems used, or postope

3、rative treatment of these patients.CLASSIFICATION AND STAGINGThe purpose of any classification system is to provide guidelines for treatment and prognosis. Over the years, numerous different classifications systems have been developed to evaluate patients with ON of the femoral head but currently, t

4、here is no standard unified classification system used by all investigators. There is general agreement that the prognosis for a patient with ON of the hip is influenced by the extent and the location of the necrotic area in the femoral head and whether there is involvement of the acetabulum.Ficat a

5、nd Arlet originally developed a four-stage classification system based on radiographic changes and the functional exploration of bone that included intraosseous venography and measurement of bone marrow pressure (Table 1). TABLE 1. Radiographic Classifications of Osteonecrosis of the Femoral Head Fi

6、cat and Arlet Classification SystemStageCriteriaI Normal II Sclerotic or cystic lesions III Subchondral collapseIV Osteoarthritis with decreased articular collapseSince that time, numerous different classification systems have been developed but the University of Pennsylvania System of Classificatio

7、n and Staging has the most potential as a useful clinical and research tool. Because it included MRI evaluations, which allow for the quantification of the extent of femoral head involvement (Table 2). TABLE2.University of Pennsylvania System of classification and StagingStageCriteria0 Normal or non

8、diagnostic radiograph, bone scan, and MRIINormal radiograph; Abnormal bone scan and/or MRIIILucent and sclerotic changes in femoral headIIISubchondral collapse (crescent sign) without flatteningIVFlattening of femoral headVJoint narrowing and/or acetabular changesVIAdvanced degenerative changesCORE

9、DECOMPRESSIONThere have been numerous extensive literature reviews published assessing the clinical results of core decompression. Smith et al reviewed 12 articles published between 1979 and 1991 that included 702 hips with an average followup of 38 months. Using the University of Pennsylvania Stagi

10、ng System, successful results were reported as follows: Stage I, 78%; Stage II, 62%; and Stage III, 41%. Mont and associates assessed 42 reports in which 1206 hips were treated by core decompression and 819 hips were treated by various nonoperative means. nonoperative treatment was not successful. O

11、nly 23% of hips in 21 studies had a satisfactory clinical result when treated nonoperatively. In 24 studies, 65% of the hips treated with core decompression had an overall satisfactory clinical result. Furthermore, when assessing hips treated before collapse, good results were obtained in 71% of the

12、 hips treated with core decompression and in 35% of hips treated nonoperatively.Stulberg et al compared core decompression alone with conservative treatment in a prospective randomized study that included 55 hips. Core decompression was successful in 70% of the hips that were either Ficat Stage I, I

13、I, or III. In contrast, there was limited success with nonoperative treatment (Ficat Stage I, 20%; Ficat Stage II, 0%; Ficat Stage III, 10%). It was concluded that core decompression was more effective than nonoperative treatment for patients with early stages of ON.Koo and associates did a randomiz

14、ed trial on 71 hips that were treated by core decompression or nonoperatively. Radiographic progression was seen in 72% of the hips treated with core decompression and in 79% of the hips that were treated symptomatically. Seventy-two percent of the hips treated with a core decompression eventually r

15、equired a THA and 68% of the hips treated symptomatically required a THA. The investigators concluded that there was no significant advantage in the outcome when patients with ON of the femoral head were treated with core decompression. Smith and associates evaluated 114 hips and showed that there w

16、as a significant decrease in satisfactory results when a crescent sign was present. The success rate in hips with Ficat Stage I ON was 81% but in hips with the crescent sign or definitive collapse of the femoral head the success rates were 20% and 0% Steinberg analyzed 205 patients (297 hips) with a

17、 minimum 2-year followup. The stage of the hip, according to the University of Pennsylvania Classification System, and the lesion site clearly influenced the success rates of core decompression. head involvement15%required THA 22% (Stage I-II )39% (Stage I) 40% (Stage II) Aaron et al evaluated 118 h

18、ips with Ficat Stage II or Ill ON which was treated with core decompression and core decompression and human DBM .Survival percent is show below:core decompression (Group 1 )core decompression and human DBM(Group 2 ) StageFollowup-40 months Followup-34 months II 72% 83% III47% 88% There also has bee

19、n an interest in combining core decompression of the femoral head with bone grafting or electrical stimulation or both to enhance bone repair in the femoral head. Steinberg et al found no advantage to supplementing core decompression with either direct current or capacitative coupling. Bozic et al s

20、tudied 54 hips that had ON of the femoral head with a mean duration of followup of 120 months (range, 24-196 months). A successful result was defined as one in which the hip was asymptomatic with no progression of the disease. An unsuccessful result was defined as radiographic failure or clinical fa

21、ilure or both. The authors showed that the significant predictors of overall failure included an advanced preoperative radiographic stage, a short duration of symptoms, and the use of corticosteroids. No association was seen between age, gender, excessive intake of alcohol or renal transplantation a

22、nd a successful outcome. SURGICAL TECHNIQUEThere is general agreement that the procedure should be done with fluoroscopic guidance in two planes. Before begin-fling the procedure, the area of ON should be identified on AP and lateral radiographs. It is critical that the starting hole for the core de

23、compression site be made just above the level of the lesser trochanter to reduce the risk of development of a stress fracture in the femur. Fluoroscopic views are taken in both radiographic planes. Progressively larger reamers are used over the guide wire (Fig. 1). Reaming should stop at least 5 mm from the articular surface of the femoral head depending on the position of the guide wire. A burr then is used to remove as much necrotic bone as possible. The core tract then can be grafted with autogenous bone obtained from the greater