Chinese Journal of Tissue Engineering Research ›› 2020, Vol. 24 ›› Issue (21): 3379-3386.doi: 10.3969/j.issn.2095-4344.2654
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Gu Changyuan1, Du Bin2, Sun Guangquan2, Liu Xin2, Lü Paiyun1
Received:
2019-09-23
Revised:
2019-10-10
Accepted:
2019-12-05
Online:
2020-07-28
Published:
2020-04-17
Contact:
Du Bin, Professor, Chief physician, Doctoral supervisor, Department of Orthopedics and Traumatology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
About author:
Gu Changyuan, Master candidate, First Clinical School of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
Supported by:
CLC Number:
Gu Changyuan, Du Bin, Sun Guangquan, Liu Xin, Lü Paiyun. Advantages and disadvantages of common methods of hip-conserving surgery for osteonecrosis of femoral head[J]. Chinese Journal of Tissue Engineering Research, 2020, 24(21): 3379-3386.
2.1 髓芯减压 髓芯减压术最早由FICAT等[10]提出,是治疗早期股骨头坏死最常用的方法,其理论基础为股骨头坏死区存在骨内高压及静脉瘀滞学说,多适用于FicatⅠ/Ⅱ期的股骨头坏死[11],手术方式为利用直径8-12 mm的单孔单隧道或直径3.0-4.0 mm的多孔多隧道在坏死区建立骨隧道并减压,为新生血管提供长入空间,并刺激钉道周围微血管生成,促进坏死区新骨生成。虽然此术式简单易于操作,但传统单隧道因隧道直径较大,破坏了大量正常骨小梁结构,容易造成医源性塌陷,OMRAN[12]通过回顾性病例对照发现,虽然单隧道组(61例)和多隧道组(33例)患者在2年的随访中影像学和髋关节功能恢复方面无明显差异,但分期为FicatⅡA及以下的仍推荐使用多孔多隧道技术。但同时也有相关文献研究表明,细针多孔多隧道扩大了减压范围、降低了因力学强度减弱而引起并发症的发生率,但因针道过细无法清除死骨[13]。除此之外,研究表明髓芯减压对于FicatⅠ期、ⅡA期以局限性、硬化性坏死灶为主的患者疗效较好,而随着分期的进展,往往最终结局仍为股骨头塌陷,且坏死面积越大,塌陷概率越大[14-15]。无论是单孔单隧道或是多孔多隧道,单纯的使用髓芯减压无法获得满意的疗效。虽然髓芯减压术后头内压力迅速释放,患者疼痛评分显著降低,但力学强度减弱或死骨残留仍为影响预后的主要问题。因此建议单纯髓芯减压仅于骨髓水肿期或存在局限性坏死灶时使用,并首选多孔多隧道技术,单隧道所带来的力学支撑减弱弊大于利。 髓芯减压术虽已很少单独应用,但因其在减压的过程中制造了骨隧道,为植骨术或联合骨髓间充质干细胞等生物制剂创造了条件。LAKSHMINARAYANA等[16]一项纳入74髋(46例患者)的随机对照试验将受试者分为2组,处在Ficat Ⅰ期行单纯髓芯减压为组1(36髋),Ficat Ⅱ期行髓芯减压联合骨移植为组2(40髋),经过平均53.5个月随访,结果示组1中25% (n=9)出现进展,组2中30% (n=12)出现进展,意味着即使联合治疗,分期越晚疗效越不显著。HUA等[17]进行了一项纳入32例随机对照试验(1 865髋)的回顾分析,22项研究(1 379髋)行单纯髓芯减压,7项研究(565髋)行髓芯减压联合自体骨移植,9项研究(497髋)行髓芯减压联合自体骨髓移植。该项研究表明,单纯的髓芯减压治疗股骨头坏死成功率最低,且无论是单纯髓芯减压或联合其他治疗手段,保髋成功率随着坏死分期的进展逐级降低(Ⅰ >Ⅱ >Ⅲ),该文作者也认为对于进展期的股骨头坏死,无论分期如何都应谨慎。D’AMBROSI等[18]的研究对26例股骨头坏死受试者(24髋)进行髓芯减压联合骨髓间充质干细胞、富血小板血浆及人工骨填充治疗,术后随访时间75个月,结果显示早期(FicatⅠ/Ⅱ期)股骨头坏死患者生存率为80%,中晚期(Ficat Ⅲ/Ⅳ期)及进展期生存率仅为28.6%。 由此可见,保髋治疗中使用率不断增多的生物制剂虽然在骨再生或帮助成骨上发挥了重要作用,但随着疾病的进展,疗效仍不确切,生物制剂仍需依靠有效的死骨清理和有活力的血供才能发挥作用,髓芯减压技术治疗方法仍较原始,对于围塌陷期的患者,更应尽量避免单纯使用髓芯减压。 2.2 自体或同种异体骨植骨 又称为“非血管化骨移植术”或“非结构性植骨术”[4,13]。与单纯的髓芯减压术不同,这种术式能够暴露大部分股骨头,使术者在直视下清除头内死骨并填充自体或同种异体骨,为头内提供足够的力学支撑和成骨诱导基质,同时能够降低头内压力的作用,为血管长入提供条件。其通常有“费米斯特植骨(Phemister procedure)”“活门板(trapdoor)”和“灯泡式(lightbulb)”3种途径[19-20]。手术方式主要为头颈交界处开窗后清理头内死骨后充分减压,配合自体松质骨、异体松质骨、皮质骨、人工骨或其他生物材料填充头内空腔,给予软骨下骨结构性支撑,该术式广泛应用于FicatⅠ/Ⅱ期和 SteinbergⅠ/Ⅱ/Ⅲ期的股骨头坏死。何伟等[21]采用改良术式腓骨移植治疗围塌陷期的股骨头坏死患者,平均随访时间为36.4个月,保髋成功率达82.2%。后有学者再次改良开窗位置,选择高位股骨头颈部开窗[22],治疗早期(ARCO Ⅱ期)股骨头坏死,平均随访时间24个月,总体优良率提升至84.9%。SEYLER等[23]对39例(Ficat Ⅱ-Ⅲ期)以“活门板”技术行死骨清理联合植骨治疗的病例进行平均36个月(30-60个月)的随访,随访结果示髋关节功能评分从术前的平均50分增至术后75分,在末次随访时有26髋(67%)未行髋关节置换。此种术式也被认为是Ficat Ⅱ期最为有效的治疗方式。 能够进行彻底的死骨清理是此术式的优势,但大量清除了头内坏死骨,特别是外侧柱范围内的死骨,在一定程度上降低了股骨头的力学稳定性。尤其是面对坏死范围较大的患者,为了彻底清除死骨,开窗范围也较大,对关节软骨破坏相应增大,造成软骨应力降低。ZHOU等[24]分别以完全清除死骨和不完全清除死骨2种方案对18例股骨头坏死模型进行生物力学检测,发现相较于完全死骨清理组,非完全死骨清理组(清理3/8-1/2)更能抵抗股骨头塌陷;该研究还证明,股骨头内应力遮挡的发生风险与死骨清理的范围呈正相关。针对术后应力集中的问题,WU等[25]进行了一项针对29例曾行费米斯特植骨(Phemister术)患者长达16年的随访,结果示总的保髋成功率为65.5%,同时也指出,相对于单通道的Phemister术,双通道死骨清理并分别植入异体腓骨在理论上使得股骨头更能抵抗应力,也不会增加股骨近端骨折的风险。值得注意的是,除了Phemister术能够通过钻孔建立规则的双通道,“活门板”和“灯泡式”技术均为建立不规则空腔,2种死骨清理方式是否存在优劣比较,尚无研究考证,可作为生物力学继续探索的方向之一。但无论是何种方式的死骨清理,作者认为对于外侧柱的死骨应予以适当保留,或清理至外侧柱时,应避免为彻底清理而大量刨削软骨下骨;选择入路和清理范围更加规则的Phemister术或更加安全可靠。 此种术式所采用的植入物为非血管化骨,术后新生血管无法完全分布于植骨区,导致囊变,进而降低了其对软骨下骨的支撑力度,影响后期疗效,因此术前股骨头内血供状况评估显得愈发重要。多项研究证实,术前进行股骨头血管造影以明确股骨头供血动脉的完整情况,对于ARCOⅠ-Ⅱ期的股骨头坏死患者具有建设性意义,不仅能够帮助患者选择合适的治疗方案并判断预后,还能对有股骨头坏死高危因素(如长期大剂量应用激素)的患者进行早期筛查诊断[26-28]。作者认为对所有符合此术式条件的患者均应于术前行患侧股骨头血管造影术,根据造影结果判断头内血供是否满足治疗要求,主要关注旋股外侧动脉升支所能到达的范围。但仍有少数患者,术前造影显示血供尚可,却预后不佳,此被认为是死骨清理的方式过于暴力及填充骨打压较实,过度破坏或使新生血管无法长入[17]。 2.3 带血管的骨移植 常规死骨清理后,普通的打压植骨能够利用移植骨将头内坏死区重新填充,并提供必要的力学支撑。但移植骨自身无血供,且植入部位也因临近坏死区而血运不佳,主要起到支撑作用的皮质骨无法获得令人满意的血管长入并会导致植入物吸收或头内囊肿的再次形成,最终造成手术失败[29]。在此基础上,带血管的骨移植术不仅能为头内提供力学支撑,还可提供新鲜血运,为植入后新骨生成创造条件,提高了保髋手术的疗效。 该手术方式可分为2种,一种为吻合血管的游离腓骨移植术[30-33],另一种为带血管蒂或肌蒂的骨瓣移植术[34-36]。游离腓骨移植术需取带腓动、静脉的自体腓骨段,在头内死骨彻底清理后将腓骨段打入,并将腓动、静脉与旋股外侧动、静脉分支吻合,以达到清除死骨、提供支撑和创造血运的目的[37]。带血管蒂或肌蒂的骨瓣移植术常选择缝匠肌肌骨瓣、旋股外侧动脉升支髂骨瓣等作为带血运骨瓣[12],清除头内死骨,打压植骨后将骨瓣固定于头内,并以可吸收螺钉固定骨瓣,以达到清除死骨、提供血运的目的且无需进行血管吻合。FONTECHA等[38]对9例接受过吻合血管的游离腓骨移植治疗的ARCO Ⅱ-Ⅲ期的股骨头坏死青少年患者进行SPECT/CT影像学检查病随访,平均随访时间4年(2-5.9年),结果发现所有患者在每次随访时都有进展性的骨修复和骨再生,在末次随访时未发现进展性的股骨头形变,平均髋关节功能评分也从术前的37.2分增至92.3分。CAO等[39]也通过一项随机对照试验证实,术后6个月SPECT/CT检查下吻合血管的游离腓骨移植相较于髓芯减压联合自体骨移植能够获得更好的血管长入[(95±5)%,(68±6)%,P < 0.001];术后全程随访中,吻合血管的游离腓骨移植组的平均髋关节功能评分也更高。相较于非血管化骨移植术,带血管的骨移植在增加血供方面发挥了独特优势,一定程度上解决了“移植物乏血供”的难题。 带血管的骨移植因治疗方法合理有效,正逐渐成为保留髋关节治疗的主要选择。但在临床实践中,仍有一部分患者保髋失败,通过文献回顾和总结列举其原因如下:①游离腓骨移植术需取自体腓骨,虽不断改进术式,使得所需腓骨段的长度逐渐缩短[40],但为使血供良好,需剥离一定长度的骨膜,在暴露腓骨和切断腓骨的过程中,骨膜破坏概率较大,使得游离腓骨的血供遭到破坏;②腓骨植入后需很好的吻合血管,对术者显微外科技术要求较高,不恰当的血管吻合不仅不能提供良好的血运,还会阻碍头内自身血供的循环,使保髋失败[41];③肌骨瓣移植手术创伤大,需剥离大量肌肉及破坏关节囊,且在肌骨瓣分离后、死骨清理前往往将肌骨瓣反折塞入肌间隙中临时固定,此过程肌骨瓣血运在一定程度上遭到阻断,对后续血管长入不利[42];④术后因肌肉痉挛或不恰当的运动容易引起移植骨瓣脱出,导致手术失败。保髋失败的最终结局往往是全髋关节置换,RYAN等[43]发现吻合血管的游离腓骨移植失败后行全髋关节置换的患者与初次行全髋关节置换患者在术中失血量、手术时长等方面差异均有显著性意义(P <0.001),这是由于初次保髋手术时吻合的旋股外侧动脉升支暴露或再次受到损伤,引起了活动性出血。吻合血管的游离腓骨移植失败组的术中骨折发生率也更高(P=0.053),这被认为是内植物未完全去除,置换时与股骨融合部分相互牵拉所致。HOUDEK等[44]对134例吻合血管的游离腓骨移植术后病例随访1年,证实软组织的深部感染是此术式常见的术后并发症之一。 2.4 多孔钽棒置入 随着材料学和制造技术的不断更新,多孔金属正被广泛应用,多孔钽棒置入在保留髋关节手术中受到了更多的关注,自1997年PEDERSEN等[45]首次报道了在建立3D有限元模型基础上,利用钽棒作为头内支撑物治疗股骨头坏死,之后此种术式变不断被完善改进。钽棒具有与松质骨相似的蜂窝状结构,疏松多孔,且弹性模量与正常骨骼接近,良好的生物相容性不仅能为股骨头提供稳定的力学支撑,还有利于骨长入[46]。钽棒置入术治疗股骨头坏死的主要手术方式为清除头内死骨后置入钽棒至软骨下一定距离,并以自体松质骨或人工骨等材料植骨填充空隙固定钽棒,此术式适用于ARCO Ⅰ,Ⅱ期的股骨头坏死患者。TSAO等[47]针对98例患者113例多孔钽棒置入的多中心研究报告显示其成功率为72.5%。钟贵 华[48]对36例(45髋)成人股骨头坏死患者进行髓芯减压植骨和多孔钽棒置入对照研究,证实术后12个月多孔钽棒置入术组的Harris的评分高于植骨治疗组,差异有显著性意义。近年来,更多学者将钽棒置入术与其他保髋术式和分子生物领域最新成果相结合,在延缓患髋及重建股骨头骨软骨方面取得了较好的疗效[49-51]。 回顾近年来关于多孔钽棒置入术的文献可发现,针对这一治疗方案的远期疗效及最终结局转为全髋关节置换的手术难度仍有较多担忧[52-53]。ZHAO等[54]报道了1例钽棒置入术后失败的病例,该患者术后患髋疼痛9个月,再次入院的术前影像及术中探查发现钽棒末端穿破股骨头软骨面,并出现末端继发骨坏死,此例报道或引发股骨头内钽棒置入角度的相关思考。朱刚等[55]对钽棒置入股骨头不同大小坏死灶区前后的应力分布进行三维有限元分析,发现距离坏死平面30 mm处应力最为集中,且坏死灶越小,应力集中越不明显。此类研究提示钽棒虽有良好的骨长入性能,但在钽棒的末端或因为应力集中、骨长入异常而发生继发性骨坏死,导致手术失败。此外,ZHANG等[56]也发现,钽棒置入前不恰当的髓芯减压或死骨清理也会导致头内应力、压力异常,引起手术失败。尤其是在负重后,因自身重力等原因,打压植骨后的再生成骨无法抵抗此种应力,再次出现微骨折甚至塌陷;此项研究同时证明,髓芯减压所造成的头内微骨折,使得钽棒置入后在植入物周围形成一层致密骨,这种连续致密的骨壳及纤维组织增生或阻塞钽棒的孔隙,使得减压后不久髓内压力再次升高,并引起症状。 此外,因早期行钽棒置入的股骨头坏死患者大多处于保髋成功的“瓶颈期”,有关于钽棒置入术后再次行全髋关节置换的报道也逐渐增多。AURéGAN等[57]一项纳入232例患者(297髋)的系统回顾表明,钽棒置入术后平均随访26.97个月,24.63%的患者转为行全髋关节置换,从初次保髋至行全髋关节置换的平均时长为14.94个月。MA等[58]的一项针对32例由钽棒置入转为全髋关节置换的回顾性病例对照结果表明,其术中失血量和手术时长远大于同期行初次全髋关节置换的患者,且术中因去除钽棒引起骨量丢失而导致的转子骨折风险明显增加。CHENG等[59]也通过5-10年的随访发现,钽棒置入术后转为全髋关节置换患者组相较于初次置换组有更高的骨溶解风险,这被认为是因去除钽棒时遗留在关节腔内的金属碎片微粒导致。钽棒虽有良好的骨长入性能,但应力集中和转为全髋关节置换难度大成为此术式的致命弊端,这也从侧面提示骨替代物或人工骨的制造工艺虽不断精进,但仍与自体骨或同种异体骨有较大差异,这种预后的不确定性使得此术式临床应用较少,疗效有待进一步验证。 2.5 截骨 截骨术治疗股骨头坏死的主要原理是通过截骨,将股骨头的负重坏死区或塌陷区转移至非负重区,使得负重区被正常的骨和关节软骨重新替代,并起到力学支撑的作用,从而避免或延缓关节面塌陷[60]。现今主要术式包括经转子弧形内翻截骨术和经转子旋转截骨术[61-62],也有国内学者将经转子旋转截骨改良为股骨颈基底部旋转截骨。此种术式适用于ARCO Ⅱ,Ⅲ期且坏死范围<30%的患者[19],并对患者的年龄、体质量指数及坏死范围均有限制。LEE等[63]通过文献回顾系统的总结了经转子弧形内翻截骨的优点和患者选择,该研究认为,经转子弧形内翻截骨相较于经转子旋转截骨的手术时间更短、失血更少、异位骨化和二次骨折的发生率更低。患者选择上,年龄、体质量指数、Kerboul角均有限制。直至目前,包括4项日本的研究和1项韩国的研究均报道了经转子弧形内翻截骨能够获得较高的保髋成功率(90%-97.3%),而经转子旋转截骨的成功率则各地区报道不一(17%-100%)。 根据文献报道,很多学者认为旋转截骨治疗塌陷前期或塌陷早期的股骨头坏死患者疗效较好,但近期也有长期随访发现,旋转截骨或其他形式的截骨术后继发的骨性关节炎会成为手术失败或疗效欠佳的独立原因,截骨后塌陷、缺损部分或旋转后的新负重部分因术后活动增加,和髋臼摩擦较大,诱发了骨性关节炎[64]。MORITA等[65]通过长期随访和文献回顾发现,截骨后引起的血管损害是手术失败的主要原因;此外年龄大于40岁可作为手术失败的独立风险因素。KARASUYAMA等[66]通过回顾120例(120髋)接受过经转子旋转截骨的病例,研究引起经转子旋转截骨术后翻修的相关并发症,在11例翻修术中,深部组织感染(n=5)、大转子断端骨不连(n=3)、转子间截骨处骨不连(n=2)、股骨头骨折(n=1)为其主要并发症。此外,针对截骨术后再行全髋关节置换的研究结果也存在争议。GALLAZZI等[67]进行了一项纳入了15项研究的系统回顾,结果显示,随访2-20年中,截骨术后转为全髋关节置换的生存率为43.7%-100%,其中最容易影响全髋关节置换术后生存时间的并发症是股骨骨折,其次是内植固定物移除和神经麻痹。截骨术因其创伤较大、手术难度较大、学习曲线较长、患者接受度不高等原因,近10年来在国内保髋手术中应用相对较少。股骨头并非规则的球形结构,旋转后的负重区即使被正常关节软骨替代,也存在头-臼关系改变继发关节炎的风险,血管损害和骨不连等并发症也明显降低了保髋成功率。因此,对于年龄和体质量指数较大的患者,应慎用截骨术,术前进行常规的骨密度检查和股骨头血供检查也有利于判断预后。 2.6 生物制剂的联合应用 股骨头坏死的明确病理机制尚不完全明朗,但骨细胞缺失或干细胞凋亡一直被认为是股骨头坏死潜在的病理因素之一,因此各类保髋术式联合细胞生物治疗也逐渐流行,这些研究认为,将生物制剂注入或植入股骨头坏死区,能够使坏死细胞重塑、恢复局部细胞群并实现细胞再生[68]。目前常用生物制剂包括富血小板血浆、透明质酸和骨髓间充质干细胞。王骏等[69]的一项最终纳入52篇文献的荟萃分析表明,联合生物制剂或细胞疗法的保髋手术治疗比单纯的保髋手术能获得更好的疗效,并能增加术后新骨生成,在远期预后上具有积极意义。但细胞疗法仍处在实验性治疗阶段,原料细胞和血液的获取方法有待进一步标准化;后期的处理和移植方法,以及和保髋手术的兼容程度都是优化的方向[70]。现今,虽没有关于生物制剂应用于保髋治疗的不良事件报道,但安全谨慎的操作方式仍是保证远期疗效的关键。 "
[1] ZALAVRAS CG, LIEBERMAN JR. Osteonecrosis of the femoral head: evaluation and treatment. J Am Acad Orthop Surg. 2014;22(7):455-464. [2] AURÉGAN JC, VILLAIN B, BÉGUÉ T. What is the rate of patients undergoing a total hip arthroplasty after core decompression and insertion of a tantalum rod in osteonecrosis of the femoral head: a systematic review. Int Orthop. 2018; 42(7):1631-1638. [3] 欧志学,贾晓军,庞智晖,等. 何伟教授治疗股骨头坏死塌陷前期经验介绍[J].新中医,2011,43(5):155-156. [4] 中国医师协会骨科医师分会显微修复工作委员会, 中国修复重建外科专业委员会骨缺损及骨坏死学组, 中华医学会骨科分会显微修复学组. 成人股骨头坏死临床诊疗指南(2016)[J]. 中华骨科杂志, 2016,36(15):945-954. [5] ZHANG Y, SUN R, ZHANG L, et al. Effect of blood biochemical factors on nontraumatic necrosis of the femoral head: Logistic regression analysis. Der Orthopäde. 2017; 46(12):737-743. [6] NAM KW, KIM YL, YOO JJ, et al. Fate of untreated asymptomatic osteonecrosis of the femoral head. J Bone Joint Surg Am. 2008;90(3):477-484. [7] 中华老年骨科与康复电子杂志编辑委员会.股骨头坏死保髋治疗指南(2016版)[J]. 中华老年骨科与康复电子杂志, 2016, 2(2): 65-70. [8] 李子荣.骨坏死[M].北京:人民卫生出版社, 2012:183-188. [9] 刘毓,何伟.何伟教授保髋治疗股骨头坏死塌陷晚期经验介绍[J]. 新中医,2010,42(7):142-144. [10] FICAT RP, ARLET J. Necrosis of the femoral head// Hungefford DS. Ischemia and necrosis of bone. Baltimore: Williams and ilkins, 1980: 53-74. [11] FICAT RP. Idiopathic bone necrosis of the femoral head:early diagnosis and treatment. J Bone Joint Surg Br. 1985;67:3-9. [12] OMRAN AA. Multiple drilling compared with standard core decompression for avascular necrosis of the femoral head in sickle cell disease patients. Arch Orthop Trauma Surg. 2013; 133(5):609-613. [13] 赵德伟,程亮亮. 国内股骨头坏死保留髋关节手术治疗的十年回顾[J].中华骨科杂志, 2017,37(3):183-192. [14] BOZIC KJ, ZURAKOWSKI D, THORNHILL TS. Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head. JBJS. 1999; 81(2): 200-209. [15] BELTRAN J, KNIGHT CT, ZUELZER WA, et al. Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging. Radiology. 1990; 175(2): 533-536. [16] LAKSHMINARAYANA S, DHAMMI IK, JAIN AK, et al. Outcomes of core decompression with or without nonvascularized fibular grafting in avascular necrosis of femoral head: Short term followup study. Indian J Orthop. 2019;53(3): 420. [17] HUA KC, YANG XG, FENG JT, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res. 2019;14(1): 306. [18] D'AMBROSI R, BIANCARDI E, MASSARI G, et al. Survival analysis after core decompression in association with platelet-rich plasma, mesenchymal stem cells, and synthetic bone graft in patients with osteonecrosis of the femoral head. Joints. 2018;6(1): 16-22. [19] 赵德伟,谢辉. 成人股骨头坏死保髋手术治疗的策略及探讨[J]. 中国修复重建外科杂志, 2018,32(7):1-5. [20] 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. Clin Orthop Relat Res. 1994;(306):17-27. [21] 何伟,陈镇秋,张庆文,等. 蛙式侧位分型在植骨支撑术治疗酒精性股骨头坏死中的意义[J]. 中华关节外科杂志(电子版), 2011, 5(1):20-23. [22] 韦标方,韦伟,孙丙银,等. 高位股骨头颈开窗植骨支撑术治疗早期股骨头坏死[J].中华骨科杂志, 2014,34(7): 777-782. [23] SEYLER TM, MARKER DR, ULRICH SD, et al. Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis. Clin Orthop Relat Res. 2008;466(5): 1125-1132. [24] ZHOU G, ZHANG Y, ZENG L, et al. Should thorough Debridement be used in Fibular Allograft with impaction bone grafting to treat femoral head necrosis: a biomechanical evaluation. BMC Musculoskeletal Disorders. 2015;16(1):140. [25] WU CT, YEN SH, LIN PC, et al. Long-term outcomes of phemister bone grafting for patients with non-traumatic osteonecrosis of the femoral head. Int Orthop. 2019; 43(3): 579-587. [26] ZHAO D, XIAOBING Y, WANG T, et al. Digital subtraction angi- ography in selection of the vascularized greater trochanter bone grafting for treatment of osteonecrosis of femoral head. Microsurgery. 2013;33(8):656-659. [27] FU W, LIU B, WANG B, et al. Early diagnosis and treatment of steroid-induced osteonecrosis of the femoral head. Int Orthop. 2019;43(5): 1083-1087. [28] QIU X, CHENG L, WANG B, et al. Micro perfusion and quantitative analysis of the femoral head intraosseous artery. Orthop Surg. 2018;10(1): 69-74. [29] PIERCE TP, ELMALLAH RK, JAUREGUI JJ, et al. A current review of non-vascularized bone grafting in osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 2015;8(3): 240-245. [30] FENG Y, WANG S, JIN D, et al. Free vascularised fibular grafting with OsteoSet demineralised bone matrix versus autograft for large osteonecrotic lesions of the femoral head. Int Orthop. 2011;35(4): 475-481. [31] 田雷,王坤正,党晓谦,等.吻合血管游离腓骨移植治疗股骨头坏死的中期及远期疗效评估[J].中华关节外科杂志(电子版), 2012, 6(6):879-887. [32] GAO YS , LIU XL , SHENG JG , et al. Unilateral free vascularized fibula shared for the treatment of bilateral osteonecrosis of the femoral head. J Arthroplasty. 2013;28(3): 531-536. [33] DING H, CHEN SB, GAO YS, et al. Free vascularized fibular grafting for patients receiving postoperative corticosteroids. Orthopedics. 2014;37(4):e357-e361. [34] ZHAO DW, ZHANG Y, WANG WM, et al. Tantalum rod implantation and vascularized iliac grafting for osteonecrosis of the femoral head. Orthopedics. 2013;36(6): 789-795. [35] CHEN CC , LIN CL , CHEN WC , et al. Vascularized iliac bone-grafting for osteonecrosis with segmental collapse of the femoral head. J Bone Joint Surg. 2009; 91(10): 2390-2394. [36] ZENG YR, HE S, FENG WJ, et al. Vascularised greater trochanter bone graft, combined free iliac flap and impaction bone grafting for osteonecrosis of the femoral head. Int Orthop. 2013;37(3): 391-398. [37] 武殿伟. 吻合血管游离腓骨移植治疗股骨头坏死的手术技巧和效果探讨[J]. 黑龙江医学, 2017,41(11):42-43. [38] FONTECHA CG, ROCA I, BARBER I, et al. Femoral head bone viability after free vascularized fibular grafting for osteonecrosis: SPECT/CT study. Microsurgery. 2016;36(7): 573-577. [39] CAO L, GUO C, CHEN J, et al. Free vascularized fibular grafting improves vascularity compared with core decompression in femoral head osteonecrosis: a randomized clinical trial. Clin Orthop Relat Res. 2017;475(9): 2230-2240. [40] 刘晓琳,盛加根,张长青,等.单侧供体吻合血管游离腓骨移植治疗双侧股骨头缺血性坏死[J].中国修复重建外科杂志, 2011,25(6): 641-645. [41] URBANIAK JR, COOGAN PG, GUNNESON EH, et al. Treatment of ostenecrosis of the femoral head with free vascularized fibula grafting-a long-term follow-up-study of 103 hips. J Bone Joint Surg Am. 1995;77A: 681-694. [42] 刘德淮,庄小强,白宇,等. 髓芯减压植骨术与缝匠肌肌骨瓣移植术治疗FicatⅢ期股骨头缺血性坏死的远期疗效比较[J]. 实用骨科杂志, 2014,20(6):495-499. [43] RYAN SP, WOOSTER B, JIRANEK W, et al. Outcomes of conversion total hip arthroplasty from free vascularized fibular grafting. J Arthroplasty. 2019;34(1): 88-92. [44] HOUDEK MT, BAYNE CO, BISHOP AT, et al. The outcome and complications of vascularised fibular grafts. Bone Joint J. 2017; 99(1): 134-138. [45] PEDERSEN DR, BROWN TD, POGGIE RA. Finite element characterization of a porous tantalum material for treatment of avascular necrosis. Trans Orthop Res Soc. 1997; 22: 598. [46] COHEN R. A porous tantalum trabecular metal: basic science. Am J Orthop (Belle Mead NJ). 2002;31(4):216-217. [47] TSAO AK. Biomechanical and Clinical Evaluations of a Porous Tantalum Implant for the Treatment of Early-Stage Osteonecrosis. J Bone Joint Surg Am. 2005;87(suppl_2):22. [48] 钟贵华. 髓芯减压植骨与多孔钽棒植入修复非创伤性股骨头坏死[J]. 中国组织工程研究, 2012,16(29):5501-5505. [49] LIU B, YANG F, WEI X, et al. An exploratory study of articular cartilage and subchondral bone reconstruction with bone marrow mesenchymal stem cells combined with porous tantalum/Bio-Gide collagen membrane in osteonecrosis of the femoral head. Mater Sci Eng C Mater Biol Appl. 2019;99: 1123-1132. [50] ZHAO D, LIU B, WANG B, et al. Autologous bone marrow mesenchymal stem cells associated with tantalum rod implantation and vascularized iliac grafting for the treatment of end-stage osteonecrosis of the femoral head. Biomed Res Int. 2015;2015:240506. [51] LI B, YANG M, YU L. Vascular bundle transplantation combined with porous bone substituted scaffold for the treatment of early-stage avascular necrosis of femoral head. Med Hypotheses. 2019;132: 109374. [52] VARITIMIDIS SE, DIMITROULIAS AP, KARACHALIOS TS, et al. Outcome after tantalum rod implantation for treatment of femoral head osteonecrosis. Acta Orthopaedica. 2009; 80(1): 20-25. [53] NADEAU M, SÉGUIN C, THEODOROPOULOS JS, et al. Short term clinical outcome of a porous tantalum implant for the treatment of advanced osteonecrosis of the femoral head. Mcgill J Med. 2007; 10(1):4-10. [54] ZHAO D, WANG Z, HUANG S. Case report combined therapy of vascularized pedicle bone grafts and tantalum rods for tantalum rod implantation failure. Int J Clin Exp Med. 2018; 11(2): 1027-1032. [55] 朱刚,张立贵,郑重,等.股骨头坏死区钽棒置入前后应力分布的三维有限元分析[J].中国组织工程研究, 2016,20(26):3883-3889. [56] ZHANG X, WANG J, XIAO J, et al. Early failures of porous tantalum osteonecrosis implants: a case series with retrieval analysis. Int Orthop. 2016; 40(9): 1827-1834. [57] AURÉGAN JC, VILLAIN B, BÉGUÉ T. What is the rate of patients undergoing a total hip arthroplasty after core decompression and insertion of a tantalum rod in osteonecrosis of the femoral head: a systematic review. Int Orthop. 2018; 42(7):1631-1638. [58] MA J, WANG B, YUE D, et al. Outcomes of conversion THA after failed porous tantalum implant for osteonecrosis of the femoral head: a comparative matched study. Hip Int. 2019: 1120700019863036. [59] CHENG Q, TANG J, GU J, et al. Total hip arthroplasty following failure of tantalum rod implantation for osteonecrosis of the femoral head with 5-to 10-year follow-up. BMC Musculoskeletal Disorders. 2018;19(1): 289. [60] 刘予豪,周驰,陈雷雷,等 基于股骨头坏死围塌陷期理论的保髋术式总结[J]. 中国修复重建外科杂志, 2017,31(8):120-125. [61] NISHIO A, SUGIOKA Y. A new technique of the varus osteotomy at the upper end of the femur. Orthop Traumatol. 1971;20(3):381-386. [62] SUGIOKA Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res. 1978; (130): 191-201. [63] LEE YK, LEE B, PARVIZI J, et al. Which Osteotomy for Osteonecrosis of the Femoral Head and Which Patient for the Osteotomy? Clin Orthop Surg. 2019;11(2): 137-141. [64] KAWANO K, MOTOMURA G, IKEMURA S, et al. Long-term hip survival and factors influencing patient-reported outcomes after transtrochanteric anterior rotational osteotomy for osteonecrosis of the femoral head: A minimum 10-year follow-up case series. Mod Rheumatol. 2019: 1-7. [65] MORITA D, HASEGAWA Y, OKURA T, et al. Long-term outcomes of transtrochanteric rotational osteotomy for non-traumatic osteonecrosis of the femoral head. Bone Joint J. 2017;99-B(2):175-183. [66] KARASUYAMA K, MOTOMURA G, IKEMURA S, et al. Risk factor analysis for postoperative complications requiring revision surgery after transtrochanteric rotational osteotomy for osteonecrosis of the femoral head. J Orthop Surg Res. 2018;13(1): 6. [67] GALLAZZI E, MORELLI I, PERETTI G, et al. What Is the Impact of a Previous Femoral Osteotomy on THA? A Systematic Review. Clin Orthop Relat Res. 2019;477(5): 1176-1187. [68] PAPAVASILIOU AV, TRIANTAFYLLOPOULOS I, PAXINOS O, et al. The role of cell therapies and hip arthroscopy in the management of osteonecrosis: an update. J Hip Preserv Surg. 2018;5(3):202-208. [69] 王骏,葛乔枫,武壮壮,等. 股骨头坏死手术治疗最新进展: 如何达到保髋治疗的目的[J]. 中国组织工程研究, 2018, 22(31): 5056-5061. [70] EJNISMAN L, SAFRAN MR. Biologics in hip preservation. Ann J. 2018; 3(6):50. |
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