In order to study the curative effect of vascularized bone graft in the treatment of avascular necrosis of talus, 24 patients were treated with vascularized bone grafts, in which 9 cases had received 1st cuneiform bone graft with a malleolaris anteriomedialis, 4 cases with the 1st cuneiform bone graft with the medial tarsal artery and 11 cases with vascularized cuboid bone graft with the lateral tarsal artery. All of the patients were followed up for 3-5.5 years. The clinical observation and X-ray examination showed that function of the ankle joint was completely or almost normal in 16 cases, and the bone repair was excellent. There was slight pain in the ankle joint in 4 cases. The efficiency rate of the treatment was 83.3%. It could be concluded that vascularized bone graft might be an effective method in the treatment of avascular necrosis of talus.
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.
Objective
To discuss the correlation between the letpin level and the pathogenesis of avascular necrosis of the femoral head (ANFH) by measuring the leptin expression of the femoral head in patients with ANFH.
Methods
Between July 2009 and February 2011, 16 patients with ANFH (including 10 cases of steroid-induced ANFH and 6 cases of alcohol-induced ANFH, ANFH group) and 11 patients with proximal femur fracture (control group) were included in the experiment. There was no significant difference in age, weight, and body mass index between 2 groups (P gt; 0.05). The peripheral blood and bone marrow were extracted to measure the blood lipid level and the free fat (FF) content, respectively. ELISA was used to detect the levels of the leptin, soluble leptin receptor (sLR), osteoprotegerin (OPG), and soluble receptor activator of nuclear factor κB (sRANKL); the leptin biological activity and the activity of osteoclasts were calculated. The femoral head specimens were harvested to count leptin-positive cells by immunohistochemical staining.
Results
No significant difference in the blood lipid level was found between 2 groups (P gt; 0.05), but the FF content in ANFH group was significantly lower than that in control group (t=
—
14.230, P=0.000). The intramedullary leptin expression was found in both groups; however, the intramedullary leptin level in ANFH group decreased significantly when compared with the level in control group (t=4.425, P=0.002). There were significant differences in the levels of leptin, OPG, and sRANKL between 2 groups (P lt; 0.05). The leptin biological activity of ANFH group was significantly lower than that of control group (P lt; 0.05), but the activity of osteoclasts of ANFH group was significantly higher than that of control group (P lt; 0.05). There was a positive correlation between the leptin level and leptin biological activity (r=0.922 7, P=0.000 0), and a negative correlation between the leptin level and OPG content (r=
—
0.396 2, P=0.040 8), FF content (r=
—
0.806 1, P=0.000 0), while it had no correlation between the leptin level and sLR and sRANKL content (P gt; 0.05).
Conclusion
Intramedullary expression and bioactivity of the leptin decrease significantly in ANFH patients, which may play an important role in the pathogenesis of ANFH.
Objective To study the effectiveness of avascular necrosis of the femoral head treated by lesions clearance, compact bone grafting, and porous tantalum rod implantation. Methods Between March 2008 and May 2010, 14 patients (16hips) with avascular necrosis of the femoral head were treated by lesions clearance, compact bone grafting, and implantation of porous tantalum rod. Of 15 cases, 13 were male (15 hips) and 1 was female (1 hip) with a median age of 42.2 years (range, 18-73 years), including traumatic in 1 case (1 hip), alcohol ic in 4 cases (4 hips), and steroid-induced in 9 cases (11 hips); 3 hips were at Association Research Circulation Osseous (ARCO) stage I and 13 hips were at ARCO stage II. The Harris score was 51.89 ± 12.42, and the X-ray score was 31.88 ± 4.03. All the cases were diagnosed by X-ray films and MRI. The median disease duration was 2.5 years (range, 6 months to 7 years). All the patients accepted the operation of lesions clearance by slotting at the neck of femur, then, compact bone grafting, and implantation of porous tantalum rod were performed. The affected l imb could not bear weight loading at 1-3 months after operation and partly bear weight loading after 3 months of operation. Results Primary heal ing of incision was achieved in all patients and no compl ication occurred. The patients were followed up 24 months on average (range, 13-36 months). Two patients underwent total hip arthroplasty at 4 months and 2 years respectively because of even worsened pain and collapsed femoral heads; 12 patients achieved obvious pain rel ief with a survival rate 87.5%(14/16). The postoperative Harris score was 84.89 ± 17.96, showing significant difference when compared with preoperative score (t= —8.038,P=0.001). The X-ray examination showed definite ossification, increased density, regular arrangement of the trabeculae and no collapsed femoral head. The X-ray score was 32.19 ± 6.57, showing no significant difference when compared with preoperative score (t= —2.237, P=0.819). Conclusion Lesions clearance, compact bone grafting, and implantation of porous tantalum rod for avascular necrosis of the femoral head have a good short-term cl inical result.
Eight cases(10 hips) of avascular necrosis of femoral head in adults were treated with transplantation of sartorius musculo-skeletal graft through the greater trochanter since August 1990. The patients were followed up for 12 to 20 months,with disappearance of pain in 7 cases. The degree of hip motion was markedly increased. The good results rated 87.5 percent.
Objective To comprehend the pathological features and possible pathogenesis of avascular necrosis of the femoral head (ANFH) by morphology and immunohistochemical observation of osterix (OSX) and adiponectin through in vitro traumatic and non-traumatic ANFH specimens, so as to provide a theoretical basis for cl inical treatment. Methods Sixty-six ANFH specimens were collected from 66 cl inical cases undergoing hip replacement surgery. Twenty-four cases of traumatic ANFH (group A) included 17 males and 7 females, aged 21 to 70 years with an average of 56.5 years; 23 cases of steroid-induced ANFH (group B) included 16 males and 7 females, aged 56 to 72 years with an average of 61 years; and 19 cases of alcohol ic ANFH (group C) were males, aged 55 to 67 years with an average of 58.5 years. Bone tissue was got from weight-bearing and non-weight-bearing area of the femoral head respectively. The basic pathological changes was observed by HE staining under the optical microscope, and the percentage of empty bone lacuna and the percentage of trabecular bone area were calculated. The morphological changes of ANFH in different groups were observedby scanning electron microscope (SEM). OSX and adiponectin expression were detected by immunohistochemical technique. Results Gross of the femoral head surface in each group was rough, collapse, articular cartilage loss, osteophyte formation; cross section: dark red in group A, and yellow in groups B and C. HE staining showed that weight-bearing area of ANFH have similar morphological features in three groups. In non-weight-bearing area of groups B and C, the fat cells in bone marrow markedly increased and were hypertrophic; however there were more fibrous tissue in group A. There were statistically significant differences (P lt; 0.001) in the percentage of empty bone lacuna of the weight-bearing and non-weight-bearing area among three groups. There were no statistically significant differences (P gt; 0.05) in the percentage of trabecular bone area among three groups. The SEM observation showed that three groups had similar pathological changes. Brown granules for OSX and adiponectin positive substance were mainly located in the osteoblast of bone marrow of the femoral head. There was statistically significant difference (P lt; 0.05) in the average absorbency (A) value of OSX between group A and groups B, C, but there was no statistically significant difference (P gt; 0.05) between groups B and C. While there was no statistically significant difference (P gt; 0.05) in the A value of adiponectin among three groups. Conclusion Hormones and alcohol necrosis have more obviously fatty degeneration, but the repair capacity of traumatic femoral head necrosis is ber than that of hormones and alcohol necrosis. Alcohol and hormones have inhibitory action on the OSX-mediated osteogenic differentiation. Hormones and alcohol may not affect osteoblast expressing adiponectin and its receptors.
Objective To investigate the operative method of trabecular metal rod implant for the treatment of the early adult avascular necrosis of the femoral head (ANFH) and its cl inical efficacy. Methods From March 2005 to January 2007, 28 patients of ANFH were treated by trabecular metal rod implant, including 18 males and 10 females aged 18-56 years old (average 30.6 years old). The ANFH was induced by trauma in 7 cases, steroid in 10 cases, alcohol in 5 cases and unknownreason in 6 cases. There were 22 cases of unilateral ANFH and 6 of bilateral ANFH, involving 18 left hips and 16 right hips. According to Association Research Circulation Osseous (ARCO) international classification of osteonecrosis launched in 1997, 16 cases (16 hips) were classified as stage I, 12 cases (15 hips) as stage I, 1 case (1 hip) as stage III and 2 cases (2 hips) as stage IV. Harris score was 50.3 ± 2.2 preoperatively. The course of disease was 12-24 months (average 16 months). Results All wounds healed by first intention, and no postoperative compl ication occurred. All the cases were followed up for 18-36 months (average 26 months). The pain and functional l imitation of patients were improved significantly. The Harris score was 85.7 ± 2.4 18 months after operation, showing a significant difference when compared with preoperative score (P lt; 0.05). Twenty-three cases were graded as excellent, 3 as good and 2 as fair, with the excellent and good rate of 92.86%. Conclusion Trabecular metal rod implant is an effective method for the treatment of early ANFH and can minimize the occurrence of compl ications, but the follow-up observation of its long-term herapeutic effect is still needed.
Objective To compare the cl inical outcomes of the core decompression combined with autologous bone marrow mesenchymal stem cells (BMSCs) transplantation with the isolated core decompression for the treatment of earlyavascular necrosis of the femoral head (ANFH). Methods From May 2006 to October 2008, 8 patients (16 hips) with earlyANFH were treated. There were 7 males and 1 female with an average age of 35.7 years (range, 19-43 years). According to the system of the Association Research Circulation Osseous (ARCO): 4 hips were classified as stage II a, 2 as stage II b, 1 as stage II c, and 1 as stage III a in group A; 2 hips were classified as stage II a, 2 as stage II b, 3 as stage II c, and 1 as stage III a in group B. The average disease course was 1.1 years (range, 4 months to 2 years). The patients were randomly divided into 2 groups according to left or right side: group A, only the core decompression was used; group B, both the core decompression and autologous BMSCs transplantation were used. The Harris score and visual analogue scale (VAS) score were determined, imaging evaluation was carried out by X-rays and MRI pre- and post-operatively. The erythrocyte sedimentation rate, C-reactive protein, l iver function, renal function, and immunoglobul in were detected for safety evaluation. Results All incisions healed by first intention. Eight patients were followed up 12-42 months (23.5 months on average). The cl inical symptoms of pain and claudication were gradually improved. The Harris scores and VAS scores of all patients were increased significantly at 3, 6, and 12 months after operation (P lt; 0.05). There was no significant difference between groups A and B 3 and 6 months after operation (P gt; 0.05), but there was significant difference between groups A and B 12 months after operation (P lt; 0.05). The necrosis area of femoral head in groups A and B were 18.13% ± 2.59% and 13.25% ± 2.12%, respectively, showing significant difference (P lt; 0.05). In group A, femoral head collapsed 12 months after operation in 1 case of stage III. No compl ication of fever, local infectionoccurred. Conclusion The core decompression and the core decompression combined with BMSCs transplantation are both effective for the treatment of early ANFH. The core decompression combined with BMSCs transplantation is better than core decompression in the rel ief of pain and postponing head collapse.
【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 investigate the effect of glucocorticoid on the expression levels of osteoprotegerin (OPG)/receptor activator of nuclear factor kappa B ligand (RANKL)-matrix metalloproteinases (MMP)/tissue inhibitor of matrix metalloproteinase (TIMP) system in bone tissues of femoral head of rats, and to discuss its interrelated action mechanism in glucocorticoid-induced avascular necrosis of femoral head (ANFH).?Methods?Forty adult Sprague Dawley rats, weighing 250-300 g, half males and half females, were randomly divided into 4 groups: high dose glucocorticoid group (HD, n=10), medium dose glucocorticoid group (MD, n=10), low dose glucocorticoid group (LD, n=10), and control group (n=10). The rats in HD group, MD group, and LD group were intramuscularly injected with 25.0, 12.5, and 7.0 mg/kg of prednisolone respectively, and the rats in the control group were injected with physiological saline. After 4 weeks intervention, the osteonecrosis of left femoral heads was observed by HE staining, total RNA was extracted from the right femoral head bone tissue and the mRNA expression levels of OPG, RANKL, MMP-2, MMP-9, TIMP-1, and TIMP-2 were detected by RT-PCR.?Results?After injection of prednisolone, 4 rats of HD group and 1 rat of MD group died of systemic failure caused by the decreased food and weight culminating in cachexia. HE staining showed that the integrity of bone trabecula and osteon was destroyed at different levels, discontinuous bone chips formed, and osteocytes were replaced by granulation tissue in some lacunae in HD, MD, and LD groups; the integrated osteon was observed, the lamellar structure formed concentric circles around the blood vessel and osteocytes were seen in the lacunae in the control group. The necrosis rates of femoral head were 83.3% (5/6), 66.7% (6/9), 30.0% (3/10), and 0 (0/10) in HD, MD, LD, and control groups. The results of RT-PCR showed: the mRNA expression levels of the OPG, TIMP-1, TIMP-2 in HD, MD, and LD groups were lower than those in the control group, showing significant differences (P lt; 0.05) and there was negative correlation with the hormone dosage. The difference in OPG expression was significant between the hormone groups (P lt; 0.05); the differences in the TIMP-1 and TIMP-2 expressions were not significant between the LD group and MD group (P gt; 0.05), but there were significant differences when compared with HD group (P lt; 0.05). The RANKL, MMP-2, and MMP-9 mRNA expression levels in HD, MD, and LD groups were higher than those in the control group and there was a positive correlation with the hormone dosage, showing significant differences when compared MD and HD groups with control group (P lt; 0.05); there was no significant difference in RANKL expression between HD group and MD group (P gt; 0.05), but there was significant difference when compared HD and MD groups with LD group (P gt; 0.05); no significant difference was observed in the MMP-2 and MMP-9 expression between MD group and LD group (P gt; 0.05), but the differences were significant when compared with HD group (P lt; 0.05).?Conclusion?Glucocorticoid-induced ANFH may be related to the expression levels of OPG/RANKL-MMP/TIMP mRNA regulated by glucocorticoid.
