·綜述·

股骨頭壞死早期治療方法研究進(jìn)展*

鄧云平1 綜述 李偉2 審校

(1.川北醫(yī)學(xué)院, 四川 南充 637000,；2.川北醫(yī)學(xué)院第二臨床醫(yī)學(xué)院·南充市中心醫(yī)院骨科, 四川 南充 637000)

【摘要】股骨頭壞死是一種進(jìn)展性疾病，晚期致殘率非常高,，嚴(yán)重影響人們生活質(zhì)量,。如果早期能得到正確治療，可避免股骨頭塌陷和延緩髖關(guān)節(jié)置換術(shù)時(shí)間。早期股骨頭壞死治療包括非手術(shù)和手術(shù)治療,。非手術(shù)治療包括藥物或者物理等方法,，但目前為止仍沒有一種確切有效的方法。手術(shù)治療包括核心減壓,、干細(xì)胞或骨移植等,，以核心減壓為主聯(lián)合其他療法是目前研究熱點(diǎn)。本文就目前早期治療股骨頭壞死方法進(jìn)行綜述,，為今后臨床及基礎(chǔ)研究提供參考,。

【關(guān)鍵詞】股骨頭壞死； 治療方法,； 早期,； 文獻(xiàn)綜述

股骨頭壞死為骨科常見疾病， 患者數(shù)量正逐年上升,，目前統(tǒng)計(jì)全世界已達(dá)3000萬人,，常見的病因包括骨折或髖關(guān)節(jié)脫位，糖皮質(zhì)激素使用不當(dāng),，長(zhǎng)期飲酒等[1],。股骨頭壞死的形成是由于骨細(xì)胞的血液供給不足導(dǎo)致骨細(xì)胞死亡，最終導(dǎo)致股骨頭表面塌陷和髖關(guān)節(jié)炎[2],。早期治療主要在于減輕疼痛,，延緩人工髖關(guān)節(jié)置換術(shù)時(shí)間。目前早期股骨頭壞死治療方法研究較多,，也取得一定成就,，但治療效果仍不令人滿意，本文就目前股骨頭壞死早期治療方法進(jìn)行綜述,。

1 非手術(shù)治療

1.1 限制負(fù)重療法 限制負(fù)重療法是早期股骨頭壞死的傳統(tǒng)治療方法,，可以防止損傷股骨頭的血液供應(yīng),，從而預(yù)防股骨頭關(guān)節(jié)面塌陷[3],；其主要針對(duì)Ficat或Arlet Ⅰ期和Ⅱ期，股骨頭壞死病變時(shí)<15%,或者遠(yuǎn)離負(fù)重圓頂(內(nèi)側(cè)病變)[4],。但是Mont等[5]研究發(fā)現(xiàn),，使用該方法治療7年后仍有59%的患者出現(xiàn)股骨頭壞死癥狀或者股骨頭表面塌陷。Okazaki等[6]通過動(dòng)物實(shí)驗(yàn)研究負(fù)重與股骨頭壞死的發(fā)展關(guān)系顯示,，鼠股骨頭壞死的發(fā)展與負(fù)重?zé)o關(guān),。盡管限制負(fù)重療法在治療股骨頭壞死的早期階段被廣泛使用，但是作為一個(gè)單獨(dú)治療方法已經(jīng)不被大多數(shù)人接受,，目前只是作為藥物和手術(shù)治療的輔助治療,。

1.2 藥物治療

1.2.1 雙膦酸鹽 雙磷酸鹽能減少新骨改建，促進(jìn)骨單位礦化，增加前體成骨細(xì)胞的分化,，促進(jìn)成骨細(xì)胞產(chǎn)生骨保護(hù)素,，同時(shí)還具有抗炎作用，減少骨壞死水腫,。目前其已經(jīng)廣泛應(yīng)用于骨質(zhì)疏松,，骨壞死等疾病，同時(shí)對(duì)骨吸收增加相關(guān)疾病也有療效,，如佩吉特氏病,、惡性腫瘤的血鈣過多等，可能與抑制甲羥戊酸酶,，從而抑制異戊二烯樣復(fù)合物的合成有關(guān)[7],。一些研究認(rèn)為雙磷酸鹽類藥物能抑制股骨頭壞死病變區(qū)破骨細(xì)胞活性，防止早期股骨頭軟骨下骨小梁斷裂或表面塌陷,，延緩最終需要行全髖關(guān)節(jié)置換手術(shù)時(shí)間[8-9] 。然而Lee等[10]進(jìn)行為期兩年的對(duì)比臨床實(shí)驗(yàn)研究發(fā)現(xiàn),，在股骨頭壞死斯坦伯格Ⅰ期和Ⅱ期(壞死區(qū)中等偏大),，唑來磷酸并不能阻止股骨頭壞死病程進(jìn)展,，也不能降低患者行全髖關(guān)節(jié)置換術(shù)的概率。由于在體內(nèi)半衰期長(zhǎng),，許多研究發(fā)現(xiàn)其能引發(fā)嚴(yán)重并發(fā)癥如顎骨壞死等[11-12],。Outeirino-Fernandez等[13]研究發(fā)現(xiàn)唑來膦酸治療48.25月后會(huì)出現(xiàn)顎骨壞死并發(fā)癥,，所以患者的依從性較低。雙磷酸鹽盡管在臨床前期股骨頭壞死被廣泛使用，但是藥物劑量目前沒有同一規(guī)定,，且還無預(yù)防藥物副作用的措施,。因此，使用這類藥物時(shí)應(yīng)該嚴(yán)密監(jiān)測(cè)相關(guān)的并發(fā)癥,。

1.2.2 抗凝血?jiǎng)?凝血功能障礙容易導(dǎo)致靜脈淤血和動(dòng)脈血流量降低,，進(jìn)而引起骨內(nèi)壓力增高和缺氧，最終導(dǎo)致骨死亡,，這可能是抗凝藥物的治療機(jī)制。同時(shí)具有凝血障礙和骨壞死股骨頭壞死患者,，只要在股骨頭壞死不可逆轉(zhuǎn)階段之前開始抗凝治療,，骨壞死進(jìn)程就可能停止或者恢復(fù)，使本需要行全髖關(guān)節(jié)置換手術(shù)治療的患者免于手術(shù)[14-15],。Chotanaphuti等[16]隨訪研究發(fā)現(xiàn)低分子肝素鈉能顯著降低股骨頭壞死前期階段的發(fā)病率,。

1.2.3 他汀類藥物和促腎上腺皮質(zhì)激素 他汀類藥物治療股骨頭壞死也具有一定的療效，特別是對(duì)于激素型股骨頭壞死,，但是療效尚不統(tǒng)一,，有待更進(jìn)一步研究。Pritchett等[17]使用類固醇藥物時(shí)同時(shí)使用他汀類藥物治療,，平均隨訪7.5年后發(fā)現(xiàn)只有1%出現(xiàn)股骨頭壞死，遠(yuǎn)低于通常3%～20%的發(fā)病率,。但Ajmal 等[18]研究發(fā)現(xiàn)同時(shí)使用他汀類藥物的發(fā)病率卻為4.4%,，不使用他汀類藥物的發(fā)病率為7%，兩者之間無差異,。促腎上腺皮質(zhì)激素也被證實(shí)能治療股骨頭壞死,，作用機(jī)制是能增強(qiáng)成骨細(xì)胞的活性，增加血管內(nèi)皮生長(zhǎng)因子分泌,，提高股骨頭的新血管形成[19],?？傊?，藥物治療效果還是得到了大多數(shù)患者及醫(yī)護(hù)人員的肯定，但因?yàn)槭茉嚾藛T的依從性和藥物廠家的影響,，研究結(jié)果會(huì)有一些差別，許多藥物都還在試驗(yàn)階段,，需要更多的研究證實(shí)。

1.3 體外沖擊波療法 動(dòng)物成骨細(xì)胞的反應(yīng)研究,，偶然發(fā)現(xiàn)體外沖擊波能治療肌肉骨骼系統(tǒng)疾病。在過去10～15年,，治療主要包括近端足底筋膜炎,，肘關(guān)節(jié)肱骨外上髁炎,，肩關(guān)節(jié)炎鈣化和長(zhǎng)骨骨折不愈合等，最近擴(kuò)大到膝關(guān)節(jié)病變,，跟腱疾病和股骨頭壞死方面[20]。對(duì)比研究體外沖擊波治療與核心減壓聯(lián)合腓骨移植治療顯示,，1年后需要行全髖關(guān)節(jié)置換術(shù)分別為3%和21%,，在2年后分別為10%和32%，在8～9年后分別為24%和64%,，在每個(gè)時(shí)間段體外沖擊波療法都能顯著減輕患者疼痛和改善髖關(guān)節(jié)功能,，病變大小有下降的趨勢(shì)[21-22]。動(dòng)物實(shí)驗(yàn)研究發(fā)現(xiàn)[23-24],，體外沖擊波療法能增加BMP-2mRNA和蛋白的表達(dá),，壞死區(qū)股骨頭軟骨下骨 VEGF表達(dá)上調(diào)，誘導(dǎo)新血管生成和改善股骨頭血液供應(yīng),。通過組織病理學(xué)和免疫組織化學(xué)分析，體外沖擊波能促進(jìn)血管新生和壞死骨重建與再生,?？傊w外沖擊波療法是一種新型非侵入性療法,，具有安全,、有效,、方便等特點(diǎn)，且并發(fā)癥發(fā)生率低,，對(duì)非手術(shù)治療研究具有很大意義,。

1.4 高壓氧治療 高壓氧治療對(duì)于股骨頭壞死有許多生理和藥理影響，因?yàn)槠淠芨纳平M織氧合,，通過收縮血管減少水腫,，誘發(fā)血管新生，減少骨內(nèi)壓力和改善微循環(huán)[25-27],。許多研究通過MRI檢查表明高壓氧在股骨頭壞死的早期階段能減輕骨髓水腫,。Reis等[27]的一項(xiàng)研究中MRI掃描結(jié)果顯示,，治療組81%的病人治療顯示出正常的性能,，而非治療組為17%,，表明高壓氧對(duì)股骨頭壞死早期具有治療作用,。目前高壓氧治療研究較少，療效有很大爭(zhēng)議,，很多人都把它當(dāng)成一種輔助治療,，但也有人認(rèn)為在早期股骨頭壞死階段可以作為單獨(dú)治療方法,。

2 手術(shù)治療

2.1 核心減壓術(shù) 核心減壓術(shù)又稱髓芯減壓術(shù),，鉆孔減壓術(shù),，中心減壓術(shù)等,，是治療早期股骨頭壞死研究最多的手術(shù)方法,，能降低股骨頭骨內(nèi)壓力和增加壞死區(qū)域血流,增加新骨形成,，從而達(dá)到有效防止股骨頭塌陷，延緩人工髖關(guān)節(jié)置換的時(shí)間,。Marker等[28]通過臨床實(shí)驗(yàn)發(fā)現(xiàn)患者經(jīng)過減壓63個(gè)月后成功率為70%。傳統(tǒng)核心減壓術(shù)使用8～10 mm帶套管環(huán)鋸進(jìn)行股骨頭鉆孔,，但轉(zhuǎn)子下骨折和髖關(guān)節(jié)融合的風(fēng)險(xiǎn)很大，因此該技術(shù)也在不斷改進(jìn)中。Mont等[29]報(bào)道一項(xiàng)核心減壓新技術(shù)，使用3 mm斯氏針鉆多個(gè)小孔，平均2年后71%具有很好的臨床效果，其中Ⅰ期80%,，Ⅱ期57%,。但Al Omran等[30]比較兩者之間減壓效果發(fā)現(xiàn),，兩者均有顯著效果,，但無差異。Marker等[28]與Al Omran結(jié)論不同，認(rèn)為新技術(shù)比傳統(tǒng)減壓效果更好,。目前大多數(shù)建議使用新技術(shù),，直徑為3.2 mm (至少3 mm)，該方法安全有效,，并且可以最大程度減小傳統(tǒng)手術(shù)方法風(fēng)險(xiǎn)。某些研究報(bào)道核心減壓結(jié)合其他療法臨床效果更好[31-33]。大多數(shù)研究認(rèn)為核心減壓目前仍是性價(jià)比最高的治療股骨頭壞死的手術(shù)治療方法,，但其治療效果嚴(yán)重依賴于病因、病變程度,，如病灶大小,、位置或者關(guān)節(jié)表面是否塌陷。

2.2 間充質(zhì)干細(xì)胞移植治療 間充質(zhì)干細(xì)胞有分化成多種細(xì)胞系的能力，包括成骨細(xì)胞、軟骨細(xì)胞,、脂肪細(xì)胞,、內(nèi)皮細(xì)胞等,。許多研究人員從股骨頭壞死的患者記錄到內(nèi)皮祖細(xì)胞的數(shù)量和集落形成單位的減少[34-35],，而內(nèi)皮祖細(xì)胞的遷移能力受損或者衰老將導(dǎo)致血管生成減少,，間接證明了干細(xì)胞在股骨頭壞死治療的潛在作用[33]。有研究報(bào)道了應(yīng)用干細(xì)胞治療股骨頭壞死,，從髂嵴提取骨髓液注入壞死區(qū)，并且發(fā)現(xiàn)植入干細(xì)胞數(shù)量越多效果更好[36-37],。其他研究隨后也證明了間充質(zhì)干細(xì)胞治療股骨頭壞死的安全性和有效性[38-40],。Daltro等[41]隨訪經(jīng)過間充質(zhì)干細(xì)胞移植后60個(gè)月發(fā)現(xiàn)，患者臨床癥狀顯著改善,，疼痛減輕,，髖關(guān)節(jié)評(píng)分提高,。影像學(xué)觀察受試患者病變組織未發(fā)生繼續(xù)壞死,，只有3.7%患者沒有取得滿意效果,。間充質(zhì)干細(xì)胞治療研究還不是很透徹,，將間充質(zhì)干細(xì)胞局部股骨頭壞死植入是其主要研究熱點(diǎn),，干細(xì)胞采集及來源，所需要的數(shù)量都需要進(jìn)一步研究,。

2.3 骨移植 骨移植是切除股骨頭壞死病灶后,，用健康可存活的新骨支撐軟骨下骨和關(guān)節(jié)軟骨，從而達(dá)到修復(fù)效果,。骨移植具有核心減壓效果,，同時(shí)還能誘導(dǎo)新骨形成。此外,，其還保留了關(guān)節(jié)原來形態(tài)和關(guān)節(jié)軟骨,。通常選用自體脛骨、自體腓骨或者同種異體骨。

單純骨移植，無帶蒂血管，主要運(yùn)用于治療關(guān)節(jié)軟骨完整性較好的股骨頭塌陷之前和塌陷早期(<2mm)患者,。當(dāng)核心加壓治療失敗后，外科醫(yī)師一般使用這種方法治療FicatⅠ和FicatⅡ階段的股骨頭壞死患者[42]。Rosenwasser等[43]報(bào)道通過清創(chuàng)術(shù)和松質(zhì)骨移植治療股骨頭壞死,，87%患者不會(huì)再出現(xiàn)臨床癥狀,，追蹤研究發(fā)現(xiàn)骨關(guān)節(jié)炎病程也只有極小的進(jìn)展,。Seyler等[44]使用自體無血管骨移植經(jīng)過平均36個(gè)月后,，成功率為38.4%,。帶蒂血管骨移植主要治療早期股骨頭壞死Ficat(Ⅰ-Ⅲ)階段，移植物提供支撐結(jié)構(gòu)(血管髂骨,、血管腓骨)防止關(guān)節(jié)塌陷[45-47],。與單純骨移植比較，保留了血運(yùn)，能獲得令人滿意的中長(zhǎng)期效果[48-50]。Kawate等[51]已經(jīng)證明小范圍股骨頭壞死(壞死角<300°，Ⅰ和Ⅱ期)在沒有發(fā)生塌陷前能取得很好治療效果,。大范圍骨壞死(壞死角>300°)或者股骨頭塌陷超過3 mm,，其治療效果不令人滿意,。長(zhǎng)期抽煙,，酗酒，合并周圍血管疾病或其他危險(xiǎn)因素的患者也不考慮該治療方法,，因?yàn)樾枰呛涎?，手術(shù)復(fù)雜且手術(shù)時(shí)間長(zhǎng)[45-47,52-53]。Tetik等[54]比較單純骨移植與帶蒂血管骨移植治療效果,，發(fā)現(xiàn)兩者在早期階段影像學(xué)觀察沒有太大的差異,，但是長(zhǎng)期治療效果帶蒂血管骨移植更優(yōu)于單純骨移植。

2.4 鉭棒植入治療 動(dòng)物模型和臨床試驗(yàn)報(bào)告顯示鉭棒植入能夠促進(jìn)骨生長(zhǎng)和快速固定,，已經(jīng)用于股骨頭壞死的早期階段治療[55-57],。鉭棒植入治療是一種簡(jiǎn)單可再生的微創(chuàng)治療方法，而且對(duì)股骨頭已經(jīng)塌陷的患者也具有一定療效[57],。保存股骨頭完整性關(guān)鍵在于阻止股骨頭塌陷,，鉭棒植入在保留股骨頭的完整性和阻止股骨頭早期塌陷很有優(yōu)勢(shì)。鉭棒植入治療能有效地降低了峰值應(yīng)力與應(yīng)變的比值,，有效支持股骨頭軟骨下應(yīng)力,，且移植物的強(qiáng)度大于對(duì)移植物應(yīng)力的9倍[58]，因此其能代替骨移植[59]。但是鉭棒植入的成功率并不理想,，F(xiàn)loerkemeier 等[60]隨訪研究發(fā)現(xiàn)其成功率為44%,。失敗的原因認(rèn)為與小骨的生成和軟骨下骨的機(jī)械支持力不足有關(guān)[61]。很多研究者認(rèn)為治療早期股骨頭壞死,，核心減壓聯(lián)合鉭棒植入與單純核心減壓沒有太大區(qū)別,，而且前者費(fèi)用更高且更加耗時(shí)，失敗后行全髖關(guān)節(jié)置換術(shù)時(shí)去除移植物困難,，手術(shù)難度增加,。因此，目前認(rèn)為鉭棒植入治療方法不能視為治療股骨頭壞死的標(biāo)準(zhǔn)方法,。

2.5 近端股骨截骨術(shù) 近端股骨截骨術(shù)最早使用于1972年,，能預(yù)防關(guān)節(jié)表面塌陷和骨關(guān)節(jié)炎進(jìn)一步發(fā)展[62-63]。近端股骨截骨術(shù)能旋轉(zhuǎn)壞死股骨頭,，使健康的股骨頭面代替壞死股骨頭面承重,，還能降低骨內(nèi)靜脈壓力和血管重新分布。主要適應(yīng)證：不能接受長(zhǎng)期類固醇治療,，小范圍病變,，關(guān)節(jié)間隙存在，髖臼與壞死區(qū)域角小融合(Kerboul角<200°)[64],。目前主要有兩種方法,，一種是轉(zhuǎn)子間旋轉(zhuǎn)截骨術(shù)，另一種是股骨粗隆內(nèi)翻或者外翻截骨術(shù),，目前報(bào)道成功率一般在62%～93%[65-67],。Jacobs等[68]經(jīng)過5.3年隨訪其成功率為73%；Maistrelli等[69]經(jīng)過2年隨訪成功率為71%,，8.2年成功率下降到58%,；Gallinaro等[70]經(jīng)過10.2年隨訪觀察其成功率為62.5%，如果聯(lián)合自體骨移植其成功率為87%,。然而,，其并沒有被廣泛運(yùn)用于治療股骨頭壞死，主要原因包括技術(shù)復(fù)雜,，并發(fā)癥較多,，增加再次行髖關(guān)節(jié)置換術(shù)難度，另外研究者大多為外科醫(yī)師,，且循證醫(yī)學(xué)為4級(jí)證據(jù),，可信度較低，缺乏基礎(chǔ)研究和對(duì)比研究,，很難評(píng)價(jià)其優(yōu)越性,。

3 小結(jié)

目前對(duì)于股骨頭壞死早期治療仍存在很大爭(zhēng)議,。非手術(shù)療法因?yàn)闊o創(chuàng)、方便,、無需住院仍被大多數(shù)患者接受,。一些新藥的開發(fā)較大地提升了治療效果，但非手術(shù)療法重點(diǎn)仍在于預(yù)防和早期治療,，且缺乏長(zhǎng)期隨訪研究及大樣本隨機(jī)對(duì)照研究,，很難評(píng)價(jià)其中長(zhǎng)期效果。當(dāng)前,，手術(shù)治療仍然是研究熱點(diǎn),，特別是一些新的設(shè)備應(yīng)用，外科技術(shù)的不斷改進(jìn)及創(chuàng)新,，治療成功率也取得了巨大提升。單一治療方法治療效果往往不太令人滿意,，現(xiàn)在多數(shù)研究使用聯(lián)合治療方法,。

【參考文獻(xiàn)】

[1]Tripathy SK, Goyal T, Sen R K. Management of femoral head osteonecrosis: Current concepts[J]. Indian J Orthop, 2015, 49(1): 28-45.

[2]Kaushik AP, Das A, Cui Q. Osteonecrosis of the femoral head: An update in year 2012[J]. World J Orthop, 2012, 3(5): 49-57.

[3]Peskin B, Shupak A, Levin D, et al. Effects of non-weight bearing and hyperbaric oxygen therapy in vascular deprivation-induced osteonecrosis of the rat femoral head[J]. Undersea Hyperb Med, 2001, 28(4): 187-194.

[4]Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head[J]. J Bone Joint Surg Am, 1995, 77(3): 459-474.

[5]Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review[J]. J Bone Joint Surg Am, 2010, 92(12): 2165-2170.

[6]Okazaki S, Nagoya S, Tateda K, et al. Weight bearing does not contribute to the development of osteonecrosis of the femoral head[J]. Int J Exp Pathol, 2012, 93(6): 458-462.

[7]Rizzoli R. [Bisphosphonates treatment in patients with osteoporosis[J]. Ther Umsch, 2012, 69(3): 173-181.

[8]Agarwala S, Shah SB. Ten-year follow-up of avascular necrosis of femoral head treated with alendronate for 3 years[J]. J Arthroplasty, 2011, 26(7): 1128-1134.

[9]Nishii T, Sugano N, Miki H, et al. Does alendronate prevent collapse in osteonecrosis of the femoral head?[J]. Clin Orthop Relat Res, 2006, 443: 273-279.

[10] Lee YK, Ha YC, Cho YJ, et al. Does Zoledronate Prevent Femoral Head Collapse from Osteonecrosis? A Prospective, Randomized, Open-Label, Multicenter Study[J]. J Bone Joint Surg Am, 2015, 97(14): 1142-1148.

[11] Arranz CJ, Flores BE, Ngo PS, et al. [Bisphosphonate related osteonecrosis of the jaw and infection with Actinomyces][J]. Med Clin (Barc), 2012, 139(15): 676-680.

[12] Wong PK, Borromeo GL, Wark JD. Bisphosphonate-related osteonecrosis of the jaw in non-malignant bone disease[J]. Rheumatol Int, 2013, 33(9): 2189-2198.

[13] Outeirino-Fernandez A. Osteonecrosis of the jaw associated with bisphosphonate therapy in primary osteoporosis. Review of the literature[J]. An Sist Sanit Navar, 2013, 36(1): 87-97.

[14] Glueck CJ, Freiberg RA, Fontaine RN, et al. Hypofibrinolysis, thrombophilia, osteonecrosis[J]. Clin Orthop Relat Res, 2001(386): 19-33.

[15] Glueck CJ, Freiberg RA, Fontaine RN, et al. Anticoagulant therapy for osteonecrosis associated with heritable hypofibrinolysis and thrombophilia[J]. Expert Opin Investig Drugs, 2001, 10(7): 1309-1316.

[16] Chotanaphuti T, Thongprasert S, Laoruengthana A. Low molecular weight heparin prevents the progression of precollapse osteonecrosis of the hip[J]. J Med Assoc Thai, 2013, 96(10): 1326-1330.

[17] Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids[J]. Clin Orthop Relat Res, 2001(386): 173-178.

[18] Ajmal M, Matas AJ, Kuskowski M, et al. Does statin usage reduce the risk of corticosteroid-related osteonecrosis in renal transplant population?[J]. Orthop Clin North Am, 2009, 40(2): 235-239.

[19] Disch AC, Matziolis G, Perka C. The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost[J]. J Bone Joint Surg Br, 2005, 87(4): 560-564.

[20] Wang CJ. Extracorporeal shockwave therapy in musculoskeletal disorders[J]. J Orthop Surg Res, 2012, 7: 11.doi.10.1186/1748-799x-7-11.

[21] Wang CJ, Wang FS, Ko J Y, et al. Extracorporeal shockwave therapy shows regeneration in hip necrosis[J]. Rheumatology (Oxford), 2008, 47(4): 542-546.

[22] Wang CJ, Wang FS, Huang CC, et al. Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting[J]. J Bone Joint Surg Am, 2005, 87(11): 2380-2387.

[23] Ma HZ, Zeng BF, Li XL. Upregulation of VEGF in subchondral bone of necrotic femoral heads in rabbits with use of extracorporeal shock waves[J]. Calcif Tissue Int, 2007, 81(2): 124-131.

[24] Ma HZ, Zeng BF, Li XL, et al. Temporal and spatial expression of BMP-2 in sub-chondral bone of necrotic femoral heads in rabbits by use of extracorporeal shock waves[J]. Acta Orthop, 2008, 79(1): 98-105.

[25] Camporesi EM, Vezzani G, Bosco G, et al. Hyperbaric oxygen therapy in femoral head necrosis[J]. J Arthroplasty, 2010, 25(6 Suppl): 118-123.

[26] Yang JC, Pan ZY, Gu H, et al. Quantitative study of therapeutic efficacy on early intervention of hyperbaric oxygen to model of steroid-induced avascular osteonecrosis of femoral head by multi-slice perfusion imaging[J]. Zhonghua Yi Xue Za Zhi, 2008, 88(45): 3210-3216.

[27] Reis ND, Schwartz O, Militianu D, et al. Hyperbaric oxygen therapy as a treatment for stage-I avascular necrosis of the femoral head[J]. J Bone Joint Surg Br, 2003, 85(3): 371-375.

[28] Marker DR, Seyler TM, Ulrich SD, et al. Do modern techniques improve core decompression outcomes for hip osteonecrosis?[J]. Clin Orthop Relat Res, 2008, 466(5): 1093-1103.

[29] Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling[J]. Clin Orthop Relat Res, 2004(429): 131-138.

[30] Al OA. Multiple drilling compared with standard core decompression for avascular necrosis of the femoral head in sickle cell disease patients[J]. Arch Orthop Trauma Surg, 2013, 133(5): 609-613.

[31] Liu Y, Liu S, Su X. Core decompression and implantation of bone marrow mononuclear cells with porous hydroxylapatite composite filler for the treatment of osteonecrosis of the femoral head[J]. Arch Orthop Trauma Surg, 2013, 133(1): 125-133.

[32] Helbig L, Simank HG, Kroeber M, et al. Core decompression combined with implantation of a demineralised bone matrix for non-traumatic osteonecrosis of the femoral head[J]. Arch Orthop Trauma Surg, 2012, 132(8): 1095-1103.

[33] Rackwitz L, Eden L, Reppenhagen S, et al. Stem cell- and growth factor-based regenerative therapies for avascular necrosis of the femoral head[J]. Stem Cell Res Ther, 2012, 3(1): 7.

[34] Hernigou P, Beaujean F, Lambotte JC. Decrease in the mesenchymal stem-cell pool in the proximal femur in corticosteroid-induced osteonecrosis[J]. J Bone Joint Surg Br, 1999, 81(2): 349-355.

[35] Feng Y, Yang SH, Xiao BJ, et al. Decreased in the number and function of circulation endothelial progenitor cells in patients with avascular necrosis of the femoral head[J]. Bone, 2010, 46(1): 32-40.

[36] Hernigou P, Poignard A, Manicom O, et al. The use of percutaneous autologous bone marrow transplantation in nonunion and avascular necrosis of bone[J]. J Bone Joint Surg Br, 2005, 87(7): 896-902.

[37] Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting[J]. Clin Orthop Relat Res, 2002(405): 14-23.

[38] Gangji V, Hauzeur JP. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. Surgical technique[J]. J Bone Joint Surg Am, 2005, 87 Suppl 1(Pt 1): 106-112.

[39] Gangji V, Toungouz M, Hauzeur JP. Stem cell therapy for osteonecrosis of the femoral head[J]. Expert Opin Biol Ther, 2005, 5(4): 437-442.

[40] Yan ZQ, Chen YS, Li WJ, et al. Treatment of osteonecrosis of the femoral head by percutaneous decompression and autologous bone marrow mononuclear cell infusion[J]. Chin J Traumatol, 2006, 9(1): 3-7.

[41] Daltro GC, Fortuna V, de Souza ES, et al. Efficacy of autologous stem cell-based therapy for osteonecrosis of the femoral head in sickle cell disease: a five-year follow-up study[J]. Stem Cell Res Ther, 2015, 6: 110.

[42] Banerjee S, Issa K, Pivec R, et al. Osteonecrosis of the hip: treatment options and outcomes[J]. Orthop Clin North Am, 2013, 44(4): 463-476.

[43] Rosenwasser MP, Garino JP, Kiernan HA, et al. Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis[J]. Clin Orthop Relat Res, 1994(306): 17-27.

[44] Seyler TM, Marker DR, Ulrich SD, et al. Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis[J]. Clin Orthop Relat Res, 2008, 466(5): 1125-1132.

[45] Zhang C, Zeng B, Xu Z, et al. Treatment of femoral head necrosis with free vascularized fibula grafting: a preliminary report[J]. Microsurgery, 2005, 25(4): 305-309.

[46] Matsusaki H, Noguchi M, Kawakami T, et al. Use of vascularized pedicle iliac bone graft combined with transtrochanteric rotational osteotomy in the treatment of avascular necrosis of the femoral head[J]. Arch Orthop Trauma Surg, 2005, 125(2): 95-101.

[47] Lee CK, Rehmatullah N. Muscle-pedicle bone graft and cancellous bone graft for the “silent hip” of idiopathic ischemic necrosis of the femoral head in adults[J]. Clin Orthop Relat Res, 1981(158): 185-194.

[48] Liang K, Xiang Z, Chen S, et al. Folded free vascularized fibular grafts for the treatment of subtrochanteric fractures complicated with segmental bone defects[J]. J Trauma Acute Care Surg, 2012, 72(5): 1404-1410.

[49] Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head[J]. J Bone Joint Surg Am, 2003, 85(6): 987-993.

[50] Sakamoto A, Yoshida T, Uchida Y, et al. Long-term follow-up on the use of vascularized fibular graft for the treatment of congenital pseudarthrosis of the tibia[J]. J Orthop Surg Res, 2008, 3: 13.

[51] Kawate K, Yajima H, Sugimoto K, et al. Indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head[J]. BMC Musculoskelet Disord, 2007, 8: 78.

[52] Aldridge JR, Urbaniak JR. Vascularized fibular grafting for osteonecrosis of the femoral head with unusual indications[J]. Clin Orthop Relat Res, 2008, 466(5): 1117-1124.

[53] Marciniak D, Furey C, Shaffer JW. Osteonecrosis of the femoral head. A study of 101 hips treated with vascularized fibular grafting[J]. J Bone Joint Surg Am, 2005, 87(4): 742-747.

[54] Tetik C, Basar H, Bezer M, et al. Comparison of early results of vascularized and non-vascularized fibular grafting in the treatment of osteonecrosis of the femoral head[J]. Acta Orthop Traumatol Turc, 2011, 45(5): 326-334.

[55] Cohen R. A porous tantalum trabecular metal: basic science[J]. Am J Orthop (Belle Mead NJ), 2002, 31(4): 216-217.

[56] Stronach BM, Duke JN, Rozensweig SD, et al. Subtrochanteric femur fracture after core decompression and placement of a tantalum strut for osteonecrosis of the femoral head[J]. J Arthroplasty, 2010, 25(7): 1165-1168.

[57] Varitimidis SE, Dimitroulias AP, Karachalios TS, et al. Outcome after tantalum rod implantation for treatment of femoral head osteonecrosis: 26 hips followed for an average of 3 years[J]. Acta Orthop, 2009, 80(1): 20-25.

[58] Liu B, Sun W, Yue D, et al. Combined tantalum implant with bone grafting for the treatment of osteonecrosis of the femoral head[J]. J Invest Surg, 2013, 26(3): 158-162.

[59] Schnieders MJ, Dave SB, Morrow DE, et al. Assessing the accuracy of a prototype drill guide for fibular graft placement in femoral head necrosis[J]. Iowa Orthop J, 1997, 17: 58-63.

[60] Floerkemeier T, Thorey F, Daentzer D, et al. Clinical and radiological outcome of the treatment of osteonecrosis of the femoral head using the osteonecrosis intervention implant[J]. Int Orthop, 2011, 35(4): 489-495.

[61] Tanzer M, Karabasz D, Krygier JJ, et al. The Otto Aufranc Award: bone augmentation around and within porous implants by local bisphosphonate elution[J]. Clin Orthop Relat Res, 2005, 441: 30-39.

[62] Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation[J]. Clin Orthop Relat Res, 1978(130): 191-201.

[63] Sugioka Y, Katsuki I, Hotokebuchi T. Transtrochanteric rotational osteotomy of the femoral head for the treatment of osteonecrosis. Follow-up statistics[J]. Clin Orthop Relat Res, 1982(169): 115-126.

[64] Sen RK. Management of avascular necrosis of femoral head at pre-collapse stage[J]. Indian J Orthop, 2009, 43(1): 6-16.

[65] Sugioka Y, Hotokebuchi T, Tsutsui H. Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results[J]. Clin Orthop Relat Res, 1992(277): 111-120.

[66] Ito 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]. J Bone Joint Surg Br, 2012, 94(3): 308-314.

[67] Hasegawa Y, Sakano S, Iwase T, et al. Pedicle bone grafting versus transtrochanteric rotational osteotomy for avascular necrosis of the femoral head[J]. J Bone Joint Surg Br, 2003, 85(2): 191-198.

[68] Jacobs MA, Hungerford DS, Krackow KA. Intertrochanteric osteotomy for avascular necrosis of the femoral head[J]. J Bone Joint Surg Br, 1989, 71(2): 200-204.

[69] Maistrelli G, Fusco U, Avai A, et al. Osteonecrosis of the hip treated by intertrochanteric osteotomy. A four- to 15-year follow-up[J]. J Bone Joint Surg Br, 1988, 70(5): 761-766.

[70] Gallinaro P, Masse A. Flexion osteotomy in the treatment of avascular necrosis of the hip[J]. Clin Orthop Relat Res, 2001(386): 79-84.

Treatment of early stage avascular necrosis of the femoral head

DENG Yunping reviewing LI Wei checking

(1.North Sichuan Medical College Nanchong 637000, Sichuan, China； 2. Department of Orthopedic Surgery,，Nanchong CenteL Hospital,，North Sichuan Medical College，Nanchong 637000,，Sichuan, China)

【Abstract】Avascular necrosis of the femoral head is a progressive disease and late morbidity is very high,，which badly influence peoples life quality. If early get proper treatment, femoral head will avoid collapse and delay the hip replacement time. Early avascular necrosis of the femoral head of treatment includes surgical and non-surgical therapy. Non-surgical treatment including drugs or physical methods. However, there is still no precise and effective method. Surgical treatments include core decompression, stem cells or bone graft. Combination therapy based on the core decompression is still a hot research topic present. The article narrated and commented the methods of early treatment of femoral head necrosis and provided a reference for clinical and scientific research.

【Key words】Avascular necrosis; Therapy; Early stage; Review literature

基金項(xiàng)目：四川省教育廳重點(diǎn)科研課題 (14ZA0185)

通訊作者：李偉, 教授,本刊編委，E-mail：[email protected]

【中圖分類號(hào)】R 681.8

【文獻(xiàn)標(biāo)志碼】A

doi：10.3969/j.issn.1672-3511.2017.02.036

(收稿日期：2015-11-17,；

修回日期：2016-08-18,； 編輯： 張文秀)