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陶可主治医师 北京大学人民医院 骨关节科 股骨头坏死：基础知识2019年(致每一位曾经或正在遭受股骨头坏死折磨的病患，都需要了解的科学知识)作者：MichelleJLespasio,NipunSodhi,MichaelAMont.作者单位:DepartmentofOrthopedicSurgery,BostonMedicalCenter,MA.译者：陶可（北京大学人民医院骨关节科）摘要在本报告中，我们对骨股骨头坏死进行了简明且最新的回顾，股骨头骨坏死是一种病理性、疼痛性且常常致残的疾病，据报道是由于受影响的骨骼区域的血液供应暂时或永久中断造成的。我们将讨论髋关节股骨头骨坏死的流行病学（疾病分布）、发病机制（发展机制）、病因（相关危险因素、原因和疾病）、临床表现（报告的症状和查体结果）、诊断和分类以及治疗方案。ConnectionsEveryactivityofthelivingorganismisconnectedwithaseparatepartofthebodywhenceitarises.Therefore,anactivityisnecessarilydamagedwhenthepartwhichproducesitisaffected.—GalenofPergamon,130AD-210AD,prominentGreekphysician,surgeon,andphilosopherintheRomanEmpire生物体的每项活动都与其产生该活动的身体的一个单独部分相关。因此，当产生某项活动的部分受到影响时，该活动必然会受到损害。—佩加蒙的盖伦，公元130年至公元210年，罗马帝国著名的希腊内科医生、外科医生和哲学家Figure1Left,radiographofahealthyhipjoint.Right,radiographofahipjointwheretheosteonecrosishasprogressedtocollapseofthefemoralhead.图1左图是健康髋关节的X线片；右图是髋关节股骨头坏死已发展到塌陷阶段的X线片。Figure2ProgressionofosteonecrosisusingtheFicat＆Arletclassificationsystem.Osteonecrosiscanprogressfromanormal,healthyhip(StageI)tothecollapseofthefemoralhead(StageIV). 图2使用Ficat和Arlet分类系统的股骨头骨坏死进展情况。股骨头骨坏死可以从正常、健康的髋关节（第一阶段）发展到股骨头塌陷(并骨关节炎)（第四阶段）。介绍本文的目的是介绍影响股骨头或髋关节的骨坏死(ON)的最新情况，以及如何在成年人群中最好地治疗该病。具体来说，本报告将涵盖髋关节股骨头坏死(ON)的流行病学、发病机制、病因、临床表现、诊断和分类以及治疗方案。股骨头坏死(ON)，也称为缺血性坏死、无菌性坏死或缺血性骨坏死，与许多导致成熟骨细胞死亡的疾病和危险因素有关，从而导致骨破坏（例如塌陷）或终末期髋关节骨关节炎。这种情况可能发生在身体的任何骨骼（例如上肢、膝关节、肩关节和脚踝关节），或者在不同时间发生在超过1处骨骼，但最常见的是影响髋关节。当最初在髋关节以外的区域进行诊断时，应同时对髋关节进行临床评估以及放射线和其他影像学研究。股骨头坏死(ON)的原因分为外伤性（与损伤相关）或非外伤性（与损伤无关）。准确诊断和分类股骨头坏死(ON)对于帮助指导治疗选择非常重要。识别相关风险因素和患者教育对于成功治疗股骨头坏死(ON)非常重要。针对相关危险因素、药物管理和/或手术，包括关节保留手术和全髋关节置换术(THA)，在股骨头坏死(ON)患者的临床管理中也发挥着重要作用。髋关节股骨头坏死的流行病学尽管股骨头坏死(ON)的确切患病率尚不清楚，但据估计，美国每年有20,000至30,000名新诊断患者。在美国，约10%的THA患者的诊断是股骨头坏死(ON)。股骨头坏死(ON)影响所有年龄段的人，但最常见于30至65岁之间的患者。诊断时的平均年龄通常小于50岁。男女比例因相关合并症而异。例如，与酒精相关的股骨头坏死(ON)是在男性中更常见，而与系统性红斑狼疮(SLE)相关的股骨头坏死(ON)是在女性中更常见。每年有超过20,000人因髋关节股骨头坏死需要住院治疗。在许多病例中，双侧髋关节都受到影响。通常，股骨头坏死(ON)会影响股骨头及颈部(近端骨骺)。髋关节股骨头骨坏死的发病机制/假说髋关节股骨头坏死(ON)发生的机制仍不清楚。在大多数情况下，股骨头坏死(ON)被认为是遗传倾向、代谢因素和影响血液供应的局部因素（包括血管损伤、骨内压升高和机械应力）综合作用的结果。大多数专家都认为产生干细胞和血小板的股骨头和骨髓缺乏血液供应，导致骨细胞（成熟骨内的细胞）和/或间充质细胞（形成软骨、骨和脂肪的干细胞）死亡。结果是死亡组织脱矿质或被新的但较弱的骨组织吸收（小梁变薄），随后导致软骨下骨折和股骨头塌陷。其他提出的股骨头坏死(ON)发病机制包括由过量糖皮质激素影响骨和静脉内皮细胞的不利影响引起的血管收缩引起的变化，以及过量糖皮质激素相关的股骨头坏死(ON)涉及循环脂质的变化，可能会在供应骨的动脉中引起微栓子。髋关节股骨头骨坏死的病因创伤性和非创伤性因素的结合可直接导致股骨头骨坏死。在纵向队列研究和荟萃分析的基础上，发现了在股骨头坏死(ON)发展中起明确病因作用的直接危险因素。然而，相关风险因素是与股骨头坏死(ON)最终进展(直接)相关的大部分因素。股骨头坏死(ON)的外伤原因股骨头坏死(ON)的创伤性原因包括股骨颈骨折或脱位以及骨髓成分的直接损伤（例如与放射损伤、气压失调或沉箱病相关）。股骨颈骨折或脱位的机制是骨外血管受损，导致髋关节受影响区域的血液供应中断。髋关节脱位是另一种类型的创伤性损伤，影响约20%的创伤相关股骨头坏死(ON)患者。沉箱病（例如潜水减压）会导致氮气气泡的形成，从而阻塞小动脉，导致股骨头坏死(ON)。出现症状的患者可能会在经历此过程数年后出现髋关节股骨头坏死(ON)。压力的深度和持续时间以及暴露的次数是这种疾病进展的重要因素。股骨头坏死(ON)的非外伤原因许多研究报告称，长期使用皮质类固醇激素与股骨头坏死(ON)的发生相关，可能与药物的持续时间和总剂量直接相关。长期使用高剂量糖皮质激素治疗的患者似乎处于发生股骨头坏死(ON)的最大风险；然而，这些患者通常有多种其他危险因素。接受长期治疗的患者中有9%至40%会发生糖皮质激素诱发的股骨头坏死(ON)，而接受短期治疗的患者则发生率要低得多。一项荟萃分析和系统评价发现，近7%的患者发生股骨头坏死(ON)使用＜2g皮质类固醇激素。根据这项荟萃分析，接受泼尼松剂量低于15mg/d至20mg/d治疗的患者发生股骨头坏死(ON)的风险较低。一项针对98,390名患者的基于人群的研究表明接受单次短期、低剂量甲强龙逐渐减量治疗的患者股骨头坏死(ON)的发生率为0.13%，而未接受甲强龙逐渐减量治疗的患者的股骨头坏死(ON)发生率为0.08%。约31%的股骨头坏死(ON)患者与饮酒有关。与股骨头坏死(ON)相关的过量饮酒被认为是由于脂质形成过多和细胞内脂质沉积增加导致骨生成减少所致，导致骨细胞死亡和股骨头坏死(ON)。高剂量皮质类固醇激素和过量饮酒共同构成了髋关节股骨头坏死(ON)发展的最高相关直接危险因素，并且占与创伤无关的病例的80%以上。一项研究比较了112名患有特发性髋关节股骨头坏死(ON)患者与168名对照者(没有全身性皮质类固醇激素使用史)，与对照者相比，经常饮酒者的风险升高，并且与酒精存在明显的剂量反应关系。对于当前饮酒量低于400毫升/周、400毫升/周至1000毫升/周和超过1000毫升/周的消费者来说，相对风险分别为3.3、9.8和17.9。股骨头坏死(ON)在镰状细胞病患者中很常见，因为它容易导致红细胞镰状化和骨髓增生。大约50%的受影响患者在35岁时出现股骨头坏死(ON)。镰状细胞血红蛋白病可直接导致血管阻塞和股骨头坏死(ON)。据报道，3%至30%的系统性红斑狼疮SLE患者会发生股骨头坏死(ON)，最危险的是服用糖皮质激素和常规剂量泼尼松剂量大于20mg/d的患者。据报道，高达60%的戈谢病（一种遗传性疾病）患者患有股骨头坏死(ON)，因为它能够直接阻碍血管供应。戈谢病是一种常染色体隐性遗传代谢疾病，其中一种脂肪（脂质）称为葡萄糖脑苷脂不能被充分降解。通常情况下，身体会产生一种称为葡萄糖脑苷脂酶（细胞膜的正常部分）的酶，它会分解并回收葡萄糖脑苷脂。其他不太常见但与股骨头坏死(ON)明显相关的患者包括抗磷脂抗体、库欣病和系统性红斑狼疮SLE患者。急性淋巴细胞白血病、慢性粒细胞白血病和急性粒细胞淋巴瘤的发展，使患者因使用类固醇激素治疗这些疾病而面临更高的股骨头坏死(ON)风险。胰腺炎（通常与使用皮质类固醇激素有关）、怀孕、化疗、吸烟、血管炎、胸膜炎和中枢神经系统因素，例如导致交感神经纤维数量减少的炎症反应（如类风湿性关节炎、克罗恩病）、夏科足和炎症性肠病），与股骨头坏死(ON)相关。有一些证据表明股骨头坏死(ON)可能具有相关风险因素的遗传基础。例如，当过度饮酒是相关风险因素时，男性受到的影响是女性的3倍。然而，当狼疮或皮质类固醇激素的使用成为相关危险因素时，女性比男性更容易受到影响。系统性红斑狼疮SLE在女性中的发病率大约是男性的9倍。这种易感性增加是可能的，至少部分原因是与激素和性染色体有关的差异。血液透析、高尿酸患者的慢性肾衰竭或终末期肾病、贫血/痛风、HIV感染、高脂血症、器官移植和血管内凝血也与股骨头坏死(ON)的发生有关。尽管存在许多可能的关联和联系，但估计20%的股骨头坏死(ON)病例被标记为特发性或病因不明。髋关节股骨头骨坏死的临床表现髋关节疼痛是股骨头坏死(ON)晚期最常见的症状，尽管一小部分患者可能没有症状。腹股沟疼痛是最常见的症状，其次是大腿和臀部疼痛。疼痛可能因负重或关节运动而出现。大约三分之二的股骨头坏死(ON)患者会出现休息时疼痛，大约三分之一的患者会出现夜间疼痛。身体多个部位的疼痛很少见，表明存在多灶性过程。髋关节股骨头坏死(ON)的体格表现通常是非特异性的，但可能会导致受影响关节的活动范围减小、行走疼痛、Trendelenburg征和/或骨摩擦音。髋关节股骨头骨坏死的临床评估髋关节股骨头坏死(ON)通常通过：1)回顾患者病史，2)获得适当的放射学评估，3)确定病情阶段，以及4)制定治疗方案来解决。在评估患者是否患有股骨头坏死(ON)，问题应针对评估疼痛史、药物使用（尤其是皮质类固醇）、手术、怀孕、创伤、慢性疾病（尤其是镰状细胞病、戈谢病、自身免疫性疾病和白血病）、吸烟和/或饮酒。当询问受伤/疾病时，重要的是要仔细探讨与髋部骨折、脱位或沉箱病相关的伤害，因为沉箱病是非创伤性的。髋关节股骨头骨坏死的诊断和分类在疾病的初始阶段诊断髋关节股骨头骨坏死对于治疗很重要；在初始阶段，疾病可能不会进展。大多数情况下，早期股骨头坏死(ON)患者一般没有症状，是偶然发现的；不幸的是，大多数患者直到股骨头坏死(ON)发展到后期才前来接受评估。尽管目前还没有已知的明确治疗方法可以永久阻止股骨头坏死(ON)进展到后期，但目前有一些治疗方法用于此目的，例如降脂剂、抗凝剂和双磷酸盐。当患者出现症状、影像学检查结果一致、并且其他引起疼痛和骨异常的原因不太可能或已被排除时，就可以准确地做出股骨头坏死(ON)的诊断。除了临床和体检之外，放射线照片和磁共振成像（MRI）扫描等成像技术也用于诊断。首先，进行普通放射线照相评估，然后进行MRI。据报道，MRI对于检测早期股骨头坏死(ON)的特异性和敏感性＜99%。MRI图像还可以通过对异常骨占据的股骨头区域进行数字化，定量评估病变的大小或受影响骨的受累程度。MRI变化包括T1加权图像上界限分明且均匀的局灶性病变，具有分隔正常骨和缺血骨的单密度线，以及T2加权图像上的第二条高强度线（特征性双线征标志）代表血管丰富的肉芽组织。这种级别的成像细节非常有用，因为受影响骨骼病变的大小和范围很重要，可以帮助指导治疗。然而，对于终末期疾病，股骨头坏死(ON)患者可能没有必要使用MRI，因为此阶段的治疗选择可能有限。这些发现通常使用4个阶段的Ficat和Arlet系统进行分类，如此处和表1中所述。X线片可以在腹股沟疼痛等症状出现后数月内保持正常（第一阶段）。最早的放射学检查结果通常是轻微的骨密度变化，然后是硬化和囊性变（第二阶段）。然后，检查结果会从软骨下骨塌陷（第III期）发展到特征性新月征（在股骨头近端前外侧看到软骨下射线可透性），并随后出现股骨头球形度丧失（测量圆度）或股骨头最终关节塌陷，可见髋臼空间变窄和退行性变化（第四阶段）。要寻找的关键放射学特征包括1)阶段（塌陷前与塌陷后）、2)病变大小和3)股骨头凹陷程度。右侧股骨头坏死的X线片表现：双线征，承重区右侧髋关节股骨头坏死X线片（上图）及MRI表现（下图）生成骨骼三维图像的计算机断层扫描具有中等敏感性，但不具有特异性，可能会给患者带来显着的辐射负担。如果股骨头已经塌陷，计算机断层扫描可能具有一定的特异性。幸运的是，大多数临床医生无需计算机断层扫描即可诊断出股骨头骨坏死，而计算机断层扫描通常用于区分塌陷前和塌陷后疾病。髋关节股骨头骨坏死的鉴别诊断由于有症状的髋关节股骨头坏死(ON)患者可能会出现与许多其他髋关节病变类似的症状，因此在最终诊断之前应充分排除这些症状。骨髓水肿综合征和软骨下骨折是也需要考虑的许多潜在诊断中的两个。与骨坏死相关的病因创伤相关的危险因素股骨颈骨折脱位或骨折脱位镰状细胞性贫血症血红蛋白病沉箱病（气压失调）戈谢病辐射非创伤相关的危险因素皮质类固醇激素饮酒系统性红斑狼疮库欣病皮质醇分泌过多（罕见）慢性肾功能衰竭/血液透析胰腺炎妊娠高脂血症器官移植血管内凝血血栓性静脉炎吸烟高尿酸血症/痛风艾滋病病毒感染其他潜在风险因素特发性原因骨髓水肿综合征，也称为髋部暂时性骨质减少，可能单独发生或与损伤相关，特别是那些导致神经损伤的创伤。在后一种情况下，慢性疼痛和短暂性骨质减少是复杂区域疼痛综合征（也称为反射性交感神经营养不良、灼痛等术语）的特征。骨髓水肿综合征可根据组织学和MRI与股骨头坏死(ON)相鉴别。股骨头软骨下骨折通常发生在已有骨质减少的患者中，通常被认为代表不全骨折。这些骨折可能很难通过平片观察到。早期病变有时会出现轻微的扁平化；股骨头塌陷是进行性的。髋关节股骨头骨坏死的临床治疗在制定针对症状性髋关节骨关节炎的最佳治疗方法时要考虑的因素应旨在治疗骨关节炎的分期和受累程度、骨受累的程度和位置、症状的存在（或不存在）以及患者的合并症。治疗的目标是尽可能长时间地保留天然髋关节，同时考虑患者年龄、活动能力、职业和生活方式等生活质量问题。处理髋关节股骨头坏死(ON)的三种主要治疗选择包括1)非手术治疗、2)关节保留手术和3)全髋关节置换术THA。非创伤性原因引起的髋关节股骨头坏死(ON)的影响引起了特别关注。对于受影响的患者，67%的人报告没有任何症状，但最终可能会出现关节塌陷。无症状的中等、尤其是大面积股骨头骨坏死的自然病程是病情恶化，最终发展为终末期疾病，许多患者出现股骨头塌陷。对于有症状的患者，大约80%至85%的病例会在2年内导致股骨头塌陷。因此，早期诊断股骨头坏死(ON)可能会提供早期治疗的机会，这可以防止塌陷，并最终避免股骨头塌陷而需要进行的全髋关节置换的手术治疗。然而，大多数患者在病程晚期就诊，对于那些已知或可能存在危险因素的患者，特别是使用大剂量皮质类固醇激素的患者，必须高度怀疑（存在股骨头坏死(ON)）。同样，对于无症状的股骨头坏死(ON)患者，应考虑影响股骨头坏死病变的大小、范围和位置。一般来说，影响股骨头15%以下的病变最好采用非手术治疗；15%至30%之间的病变应进行手术治疗；尽管进行了手术干预，但涉及超过30%股骨头的病变仍可能进展至塌陷，并最终需要全髋关节置换术THA。髋关节股骨头骨坏死的非手术治疗选择物理治疗物理治疗可以缓解和减轻一些症状，但通常不会阻止进行性髋关节骨性关节炎进展到后期。同样，使用拐杖或手杖等辅助装置限制负重可能有助于控制疼痛、虚弱和痛性步态等症状。如果治疗的目标是防止髋关节需要全髋关节置换，那么物理治疗是不合适的，并且迄今为止没有证据表明负重限制有助于防止进行性骨关节炎疾病进展为终末期疾病。药物非甾体类抗炎药和对乙酰氨基酚可以暂时缓解有症状患者的疼痛。当其他药物无法有效控制中度至重度疼痛时，在考虑手术选择时，可以明智地短期使用阿片类药物。目前正在使用但未经证实或可靠地用于治疗股骨头坏死(ON)的研究药物选择包括1)抗凝剂、2)双膦酸盐抗吸收剂、3)降胆固醇他汀类药物和4)高压氧。早期股骨头坏死(ON)的手术选择髓心减压髓心减压是一种微创手术技术，用于控制病情早期（塌陷前）的症状（例如Ficat和ArletI期和II期）。该手术包括在股骨头上钻孔以缓解压力并为新血管创造通道以滋养受影响的区域。已发表的髓心减压成功率差异很大，从40%到100%不等，具体取决于患者群体。髓心减压后的成功率在最早疾病阶段的患者中可见。成功进行髓心减压手术的患者通常会在几个月后恢复独立行走，并且可以完全缓解疼痛。骨移植髓心减压可以与骨移植相结合，帮助再生健康的骨骼并支撑髋关节的软骨。骨移植物是移植到坏死或死骨区域的健康骨组织。一种标准技术使用自体移植，涉及从身体的一个部位取出骨头并将其移动到身体的另一部位。从捐赠者或尸体上采集的骨移植物称为同种异体移植物，通常通过骨库获取。骨髓抽吸浓缩物髓心减压配合骨髓抽吸浓缩物注射是使用浓缩骨髓，将其注射到股骨头坏死的死骨中。这项研究技术从患者的骨髓中采集干细胞并将其注射到股骨头坏死(ON)区域。骨髓抽吸浓缩被认为可以防止疾病进一步发展并刺激新骨生长。经皮钻孔另一种手术选择是经皮钻孔。在此过程中，通过股骨颈经皮钻一个孔，到达股骨头的受影响部位。一份对45个髋关节进行平均随访24个月的报告显示，30个患有Ficat和ArletI期疾病的髋关节中有24个（80%）取得了成功的结果（定义为Harris髋关节评分＜70）。一项最近的研究比较了多个钻探与标准髓心减压相比，显示经皮钻探获得更好的结果。晚期股骨头坏死(ON)的手术选择血管化骨移植血管化腓骨移植是一种更为复杂的外科手术，其中从腓骨及其血液供应中取出一段骨。然后将移植物移植到股骨颈和股骨头上形成的孔道中，并重新连接动脉和静脉以帮助愈合股骨头坏死(ON)。截骨术髋关节截骨术可以将坏死骨从主要承重区域去除。尽管该手术可能会延迟THA手术，对于股骨头轻度塌陷前或早期塌陷后的股骨头坏死患者最有用。然而，截骨术的一个结果是使得未来可能的全髋关节置换术更具挑战性，并且通常与骨不连的风险增加有关。非血管化骨移植非血管化骨移植手术有3种类型：1)活板门手术、2)灯泡技术和3)Phemister技术。活板门手术一种自体松质骨和皮质骨移植术，已成功用于Ficat和ArletIII期髋关节股骨头坏死(ON)的中小型病变患者。对23名Ficat和ArletIII期或IV期股骨头坏死(ON)患者进行的30次（在股骨头上制作的）活板门手术的结果显示，根据Harris评分系统的判定，结果均良好或极好。灯泡技术灯泡技术使用股骨颈前部的皮质窗口。可以使用该窗口去除坏死骨，随后可以用非血管化骨移植物填充。Wang等对110名接受灯泡手术的患者（138髋）进行了评估。在平均25个月的随访中，平均Harris髋关节评分从62分提高到79分。在最近的随访中，总共94个髋关节(68%)被认为取得了成功。ARCO分期IIa期患者中100%、IIb期患者中77%、IIc和IIIa期患者中51%出现放射学改善。Phemister技术在Phemister技术中，通过股骨颈插入环钻以形成通向病变部位的管道。然后插入第二个环钻以形成通往病变部位的另一条管道。然后可以将皮质支柱移植物放置在病变处。最近的一项评论报告称，该手术的临床成功率在36%至90%之间。全髋关节置换术（THA）一旦股骨头发生严重塌陷，置换髋关节是唯一实用的手术选择，并且可以在晚期股骨头坏死中提供最可预测的疼痛缓解。全髋关节置换术（THA）成功地缓解了大多数患者的疼痛并恢复了功能。在全髋关节置换术（THA）中，构成髋关节的患病软骨和骨骼被由金属和塑料制成的人工关节假体取代。人工髋关节置换术通常可以使用15年，然后就会磨损并需要修复。对于较年轻的患者，由于可能存在活动限制，全髋关节置换术（THA）可能不是最佳解决方案。此外，由于假肢有使用寿命限制（长期使用后部件会磨损），这些患者可能需要在以后的生活中进行全髋关节置换术（THA）翻修。必须仔细考虑全髋关节置换术并与生活质量问题进行权衡，但年轻患者并非绝对禁忌。关于髋关节股骨头坏死(ON)的患者教育预防股骨头坏死(ON)对患者进行有关危险因素、治疗和管理的教育对于患者对其病情做出更明智的决定至关重要。股骨头坏死(ON)教育过程涉及识别个人的相关疾病和与股骨头坏死(ON)相关的危险因素。无症状股骨头坏死的患者进展为有症状疾病和股骨头塌陷的可能性很高。对无症状疾病患者的教育是预防性的，也是必要的，以确保改变危险因素和优化护理。预防非创伤性股骨头坏死(ON)需要：1)避免过量饮酒，定义为男性每周＜15杯饮酒，女性每周＜8杯饮酒，2)避免吸烟，以及3)将皮质类固醇激素减少到尽可能低的治疗剂量。告知患者皮质类固醇激素的使用与股骨头坏死(ON)潜在发展之间的相关性对于治疗这种疾病至关重要。预防股骨头坏死(ON)的进展应告知诊断为早期骨关节炎的患者采取上述预防措施，并应避免对关节施加过度压力，遵循健康饮食，并保持适当的体重以减缓骨关节炎的进展。尽管健康饮食本身并不能直接减少患者关节的压力，但减肥（如果超重/肥胖）会减少髋关节的轴向负荷，从而减少施加到股骨头/颈（股骨头和股骨颈）的压力。结论股骨头坏死(ON)是一种病理性的、经常引起疼痛的病症，涉及组织坏死区域，可影响身体的任何骨关节。髋关节是最常见的股骨头坏死(ON)部位，当最初诊断出股骨头坏死(ON)发生在身体的其他部位时，应始终利用放射线筛查和MRI扫描进行正确评估。越早诊断股骨头坏死，无需手术干预或采用微创手术技术来挽救髋关节的机会就越大。做出股骨头坏死(ON)诊断后，将考虑病变的大小、范围和位置以及分类阶段，以制定最佳的治疗计划。在此过程中，症状的存在或不存在很重要。治疗的目标包括尝试尽可能长时间地保留天然髋关节，并考虑患者的生活方式和生活质量问题。迄今为止，治疗股骨头坏死(ON)的两种主要治疗选择包括髋关节保留手术（保髋治疗）和全髋关节置换术THA。对患者进行有关潜在危险因素和股骨头坏死(ON)发展的教育，对于预防该病症和/或潜在地预防或阻止早期疾病进展为晚期疾病至关重要。OsteonecrosisoftheHip:APrimerAbstractInthisreport,wedeliveraconciseandup-to-datereviewofosteonecrosis,apathologic,painful,andoftendisablingconditionthatisbelievedtoresultfromthetemporaryorpermanentdisruptionofbloodsupplytoanaffectedareaofbone.Wewilldiscusstheepidemiology(diseasedistribution),pathogenesis(mechanismofdevelopment),etiology(associatedriskfactors,causes,anddisorders),clinicalmanifestations(reportedsymptomsandphysicalfindings),diagnosisandclassification,andtreatmentoptionsforhiposteonecrosis.文献出处：MichelleJLespasio,NipunSodhi,MichaelAMont.OsteonecrosisoftheHip:APrimer.ReviewPermJ.2019;23:18-100.doi:10.7812/TPP/18-100.INTRODUCTIONTheintentofthisarticleistopresentanupdateonosteonecrosis(ON)affectingthefemoralheadorhipjointandhowitcanbestbemanagedintheadultpopulation.Specifically,thisreportwillencompasstheepidemiology,pathogenesis,etiology,clinicalmanifestations,diagnosisandclassification,andtreatmentoptionsforhipON.ON,alsoreferredtoasavascularnecrosis,asepticnecrosis,orischemicbonenecrosis,isassociatedwithmanydisordersandriskfactorsthatcausematurebonecellstodie,leadingtobonedestruction(eg,collapse)orend-stagearthritisofthefemoralhead.Theconditioncanoccurinanyboneinthebody(eg,upperextremity,knees,shoulders,andankles),orinmorethan1boneatdifferenttimes,butitmostcommonlyaffectsthehipjoint.Wheninitiallydiagnosedinanareaotherthanthehip,thehipshouldsimultaneouslybeevaluatedclinicallyandwithradiographicandotherimagingstudies.ThecausesofONareclassifiedaseithertraumatic(relatedtoaninjury)oratraumatic(notrelatedtoaninjury).AccuratelydiagnosingandclassifyingONareimportantinhelpingtodirecttreatmentoptions.IdentificationofassociatedriskfactorsandpatienteducationareimportantinsuccessfulmanagementofON.Targetingassociatedriskfactors,pharmacologicmanagement,and/orsurgery,includingjointpreservingproceduresandtotalhiparthroplasty(THA),alsoplaysignificantrolesintheclinicalcareofpatientswithON.EPIDEMIOLOGYOFHIPOSTEONECROSISAlthoughtheexactprevalenceofONisunknown,theincidenceisestimatedtobebetween20,000to30,000newlydiagnosedpatientseachyearintheUS.1ONistheunderlyingdiagnosisinapproximately10%ofallTHAintheUS.2,3ONaffectspeopleofallages,althoughitismostcommonlyseeninpatientsbetweentheagesof30and65years.4Themeanageatdiagnosisistypicallyyoungerthanage50years.3Themale-to-femaleratiovariesdependingontheassociatedcomorbidities.Forexample,alcohol-associatedONismorecommoninmen,whereasONassociatedwithsystemiclupuserythematosus(SLE)ismorecommoninwomen.3Morethan20,000peopleeachyearrequirehospitaltreatmentforhipON.4Inmanyofthesecases,bothhipsareaffectedbythecondition.Mostcommonly,ONaffectstheproximalend(epiphysis)ofthefemur(hipbone).PATHOGENESISOFHIPOSTEONECROSISThemechanism(s)bywhichhipONdevelopsremainsunclear.Forthemostpart,hipONisbelievedtoresultfromthecombinedeffectsofgeneticpredisposition,metabolicfactors,andlocalfactorsaffectingbloodsupplyincludingvasculardamage,increasedintraosseouspressure,andmechanicalstresses.2,5,6Mostexpertsagreethatalackofbloodsupplytothefemoralheadandbonemarrow,whichproducesstemcellsandplatelets,causesdeathoftheosteocytes(cellswithinmaturebone)and/ormesenchymalcells(stemcellsthatformcartilage,bone,andfat).7Theresultisdemineralizationorresorptionofthedeadtissuebynewbutweakerosseoustissue(trabecularthinning),subsequentlyleadingtosubchondralfractureandcollapseofthefemoralhead.OtherproposedmechanismsforthepathogenesisofONincludevasoconstriction-inducedchangescausedbytheadverseeffectsofexcessglucocorticosteroidsaffectingboneandvenousendothelialcells8,9andexcessglucocorticoid-associatedONinvolvingalterationsincirculatinglipidsbelievedtocausemicroemboliinthearteriesthatsupplybonewithblood.10ETIOLOGYOFHIPOSTEONECROSISAcombinationoftraumaticandatraumaticfactorscandirectlycontributetotheetiologyofON(seeSidebar:EtiologicFactorsAssociatedwithOsteonecrosis).Onthebasisoflongitudinalcohortstudiesandmeta-analyses,directriskfactorshavebeendiscoveredthatplayadefinitiveetiologicroleinthedevelopmentofON.Associatedriskfactors,however,accountformostofthelinkstotheeventualdevelopmentofON.11TraumaticCausesofHipOsteonecrosisTraumaticcausesofONincludefemoralneckfracturesordislocationsaswellasdirectinjuryofboneofmarrowelements(eg,relatedtoradiationinjury,dysbarism,orCaissondisease).Themechanisminvolvedinfemoralneckfracturesordislocationsisdamagetotheextraosseousbloodvessels,whichresultsindisruptedbloodsupplytotheaffectedregionofthehip.Hipdislocationisanothertypeoftraumaticinjury,whichaffectsapproximately20%oftrauma-relatedONpatients.12Caissondisease(eg,decompressioninscubadiving)causestheformationofnitrogenbubblesthatcanoccludearterioles,leadingtoON.PatientswhodevelopsymptomscandevelophipONyearsafterexposuretothisprocess.Thedepthanddurationofpressureandnumberofexposuresareimportantfactorsintheprogressionofthisdisorder.13AtraumaticCausesofHipOsteonecrosisNumerousstudiesreportprolongeduseofcorticosteroidsassociatedwiththedevelopmentofONcanbedirectlyrelatedtodurationandtotaldosageofthemedication.14–16PatientstreatedwithprolongedhighdosesofglucocorticoidsappeartobeatthegreatestriskofdevelopingON;however,thesepatientsoftenhavemultipleotherriskfactors.Glucocorticoid-inducedONdevelopsin9%to40%ofpatientsreceivinglong-termtherapy,anddevelopsmuchlessfrequentlyinpatientsreceivingshort-termtherapy.17Onemeta-analysisandsystematicreviewidentifiedanincidenceofONinnearly7%ofpatientswhoused＜2gofcorticosteroids.18Fromthismeta-analysis,alowerriskwasseeninpatientstreatedwithdosesofprednisonelessthan15mg/dto20mg/d.18Onepopulation-basedstudyof98,390patientsshowedtheincidenceofhipONamongpatientswhohadreceivedasingleshort-term,low-dosemethylprednisolonetaperpackwas0.13%,comparedwith0.08%inpatientswhowerenotprescribedamethylprednisolonetaperpack,thusindicatinganumberneededtoharmof2041patients.19Alcoholusehasbeenassociatedwithapproximately31%ofpatientswhodevelophipON.3,20–22ExcessivealcoholconsumptionrelatedtoONofthehipisbelievedtoresultfromthedecreasedbonegenesiscausedbyexcesslipidformationandincreasedintracellularlipiddeposits,leadingtoosteocytedeathandON.23HighdosesofcorticosteroidsandexcessivealcoholusetogetherpresentthehighestassociateddirectriskfactorsforthedevelopmentofhipON24andaccountformorethan80%ofcasesnotrelatedtotrauma.3,6Onestudycompared112patientswhohadidiopathichipONandnohistoryofsystemiccorticosteroidusewith168controls.3,20Anelevatedriskforregularalcoholdrinkersandacleardose-responserelationshipwithalcoholwerenoted,comparedwithcontrols.Therelativeriskswere3.3,9.8,and17.9forcurrentconsumersoflessthan400mL/wk,400mL/wkto1000mL/wk,andmorethan1000mL/wkofalcohol,respectively.9ONiscommoninpatientswithsicklecelldiseasebecauseofitspropensitytocauseredbloodcellsicklingandbonemarrowhyperplasia.Approximately50%ofaffectedpatientsdevelopONbytheageof35years.25SicklecellhemoglobinopathycandirectlycausevascularobstructionandON.ThedevelopmentofONhasbeenreportedin3%to30%ofpatientswithSLE,andthosemostatriskarepatientswhohavetakenglucocorticoidswithregulardosesofprednisonegreaterthan20mg/d.3,26–28ONhasbeenreportedinasmanyas60%ofpatientswithGaucherdisease(ahereditarydisorder)becauseofitsabilitytodirectlyobstructvascularsupply.3,29,30Gaucherdiseaseisanautosomalrecessiveinheriteddisorderofmetabolismwhereatypeoffat(lipid)calledglucocerebrosidecannotbeadequatelydegraded.Normally,thebodymakesanenzymecalledglucocerebrosidase(anormalpartofthecellmembrane)thatbreaksdownandrecyclesglucocerebroside.31OtherlesscommonbutapparentlinkstohipONincludepatientswithantiphospholipidantibodies,Cushingdisease,29andSLE.Thedevelopmentofacutelymphoblasticleukemia,chronicmyeloidleukemia,andacutemyeloidlymphoma3,32placespatientsatincreasedriskforONrelatedtothetreatmentwithsteroidsfortheseconditions.Pancreatitis(usuallyassociatedwithuseofcorticosteroids),pregnancy,chemotherapy,smoking,vasculitis,pleuritis,andcentralnervoussystemfactorssuchasaninflammatoryresponseresultinginareductioninthenumberofsympatheticnervefibers(asseeninrheumatoidarthritis,Crohndisease,Charcotfoot,andinflammatoryboweldisease),havebeenassociatedwithON.33ThereissomeevidencethathipONmayhaveageneticbasisunderlyingassociatedriskfactors.34Forexample,menareaffectedasmuchas3timesmorethanwomenwhenexcessivealcoholuseistheassociatedriskfactor.However,whenlupusorcorticosteroidusearetheassociatedriskfactors,womenareaffectedmoreoftenthanmen.26,27,32SLEisapproximately9timesmorecommoninwomenthaninmen.35Thisincreasedsusceptibilitymaybemadepossible,atleastinpart,owingtodifferencesrelatedtohormonesandsexchromosomes.35Chronicrenalfailureorend-stagerenaldiseaseinpatientsonhemodialysis,hyperuricemia/gout,HIVinfection,hyperlipidemia,organtransplantation,andintravascularcoagulationarealsolinkedtothedevelopmentofON.31,32,36–39Despitethemanypossibleassociationsandlinks,anestimated20%ofONcasesarelabeledasidiopathicorofunknownetiology.7CLINICALMANIFESTATIONSOFHIPOSTEONECROSISHippainisthemostcommonlyreportedsymptomoflater-stageON,althoughasmallproportionofpatientsmaynothavesymptoms.Paininthegroinisthemostcommonlyreportedsymptom,followedbypainreferredintothethighandbuttock.Paincanpresentwithweightbearingorjointmotion.Painatrestoccursinapproximatelytwo-thirdsofpatientswithON,andpainatnightoccursinapproximatelyone-thirdofpatients.33Paininmultiplelocationsofthebodyisrareandsuggestsamultifocalprocess.PhysicalfindingsofhipONaregenerallynonspecificbutmayentailreducedrangeofmotionoftheaffectedjoint,painfulambulation,Trendelenburgsign,and/orcrepitus.3,40,41ClinicalAssessmentofHipOsteonecrosisONofthehipisgenerallyaddressedby1)reviewofapatient’smedicalhistory,2)obtainingappropriateradiologicevaluation,3)determiningthestageofthecondition,and4)developingaplanfortreatmentoptions.42,43WhenevaluatingapatientforON,questionsshouldbedirectedatassessingahistoryofpain,useofmedications(especiallycorticosteroids),surgery,pregnancy,trauma,chronicmedicalconditions(especiallysicklecelldisease,Gaucherdisease,autoimmunedisease,andleukemia),smoking,and/oralcoholuse.Whenaskingaboutinjuries/illnesses,itisimportanttocarefullyexploreinjuriesrelatedtohipfractures,dislocations,orscubadivingbecauseCaissondiseaseisatraumatic.DIAGNOSISANDCLASSIFICATIONOFHIPOSTEONECROSISDiagnosinghipONintheinitialstagesofthedisorderisimportantformanagement43–46;atinitialstages,thediseasemaynotprogress.Inmostcases,patientswithearly-stageONaregenerallywithoutsymptomsandareidentifiedincidentally;unfortunately,mostpatientsdonotpresentforevaluationuntiltheONhasreachedlaterstages.AlthoughthereispresentlynodefinitivetreatmentknowntopermanentlyhaltONfromprogressingtolaterstages,therearetreatmentmethods,suchaslipidloweringagents,anticoagulants,andbisphosphonates,currentlybeingusedforthispurpose.36–38AdiagnosisofONcanaccuratelybemadewhenapatientissymptomatic,imagingfindingsarecompatible,andothercausesofpainandbonyabnormalitieseitherareunlikelyorhavebeenexcluded.Beyondtheclinicalandphysicalexamination,imagingtechniquessuchasradiographsandmagneticresonanceimaging(MRI)scanningarealsousedfordiagnosis.Plainradiographicevaluationisperformedfirst,followedbyMRI.MRIhasbeenreportedtobe＜99%specificandsensitivefordetectingearlyON.47,48MRIimagescanalsoquantitativelyassessthesizeofthelesionorinvolvementoftheaffectedbonebydigitizingtheareaofthefemoralheadoccupiedbybonewithabnormaltexture.49MRIchangesincludewell-demarcatedandhomogeneousfocallesionsonT1-weightedimageswithasingle-densitylineseparatingnormalandischemicbone,aswellasasecondhigh-intensitylineonT2-weightedimages(thepathognomonicdouble-linesign)representinghypervasculargranulationtissue.3Thislevelofimagingdetailisusefulbecausethesizeandextentofthelesionoftheaffectedboneisimportantandcanhelpdirecttreatment.Forend-stagedisease,however,useofMRIinpatientswithONmaybeunnecessarybecausetreatmentoptionsatthisstagecanbelimited.Thesefindingsareoftenclassifiedusingthe4-stageFicatandArletsystem,whichisdescribedhereandinTable1.Theplainradiographcanremainnormalformonthsaftertheonsetofsymptomssuchasgroinpain(StageI).Theearliestradiographicfindingsareusuallymilddensitychanges,followedbysclerosisandcysts(StageII).Findingsthenprogresstothepathognomoniccrescentsign(subchondralradiolucencyseenintheanterolateralaspectoftheproximalfemoralhead)fromsubchondralcollapse(StageIII),andsubsequentlossofsphericity(measurementoftheroundness)orcollapseofthefemoralheadwitheventualjoint-spacenarrowinganddegenerativechangesintheacetabulumthatarevisible(StageIV).Keyradiographicfeaturestolookforinclude1)stage(precollapsevspostcollapse),2)sizeoflesion,and3)amountofheaddepression.Table1Ficat＆ArletclassificationsystemofthefemoralheadClassificationClinicalRadiographsMRIStage0Nosymptoms;preclinicalNormalNormalStage1PossiblegroinpainNormalormildosteopeniaPossibleedemaStage2Groinpainandstiffness;painwithactivityOsteopeniaand/orsubchondralcysts;diffuseporosis;precollapseofjointspaceOutlinesareaofinvolvementofthefemoralheadStage3Groinpain,stiffness,radiationofpain;painwithactivityCrescentsignand/orsubchondralcollapse(flattening)ofjointwithsecondarydegenerativechanges;lossofsphericityoffemoralheadSameasradiographsStage4Groinpainandlimp;painatrestEnd-stagediseasewithcollapse;extensivedestructionofjoint;reducedjointspaceSameasradiographsOpeninaseparatewindowMRI=magneticresonanceimagingAcomputedtomographyscanproducinga3-dimensionalpictureofthebonehasmoderatesensitivitybutisnonspecificandcanposeasignificantradiationburdentopatients.Computedtomographycanhavesomespecificityifthereisalreadyfemoralheadcollapse.Fortunately,mostcliniciansareassuredwiththeirdiagnosisofONwithoutcomputedtomographyscanning,whichisgenerallyreservedfordistinguishingprecollapseandpostcollapsedisease.DifferentialDiagnosisofHipOsteonecrosisBecausepatientswithsymptomatichipONcanpresentwithsymptomssimilartomanyotherhippathologies,theseshouldbeadequatelyruledoutbeforefinaldiagnosis.Bonemarrowedemasyndromeandsubchondralfracturesaretwoofmanypotentialdiagnosesthatneedtoalsobeconsidered.EtiologicFactorsAssociatedwithOsteonecrosisTraumatic-associatedriskfactorsFemoralneckfractureDislocationorfracture-dislocationSicklecelldiseaseHemoglobinopathiesCaissondisease(dysbarism)GaucherdiseaseRadiationAtraumatic-associatedriskfactorsCorticosteroidadministrationAlcoholuseSystemiclupuserthyematosusCushingdiseaseHypersecretionofcortisol(rare)Chronicrenalfailure/hemodialysisPancreatitisPregnancyHyperlipidemiaOrgantransplantationIntravascularcoagulationThrombophlebitisCigarettesmokingHyperuricemia/goutHIVOtherpotentialriskfactorsIdiopathiccausesBonemarrowedemasyndrome,alsoknownastransientosteopeniaofthehip,mayoccurinisolationorinassociationwithinjuries,particularlythosethatresultinneurologicdamage.Inthelattersituation,chronicpainandtransientosteopeniaarefeaturesofthecomplexregionalpainsyndrome(alsoknownasreflexsympatheticdystrophy,causalgia,andotherterms).3BonemarrowedemasyndromecanbedifferentiatedfromONonthebasisofhistologicandMRIfindings.Subchondralfractureofthefemoralheadtypicallyoccursinpatientswithpreexistingosteopeniaandisgenerallythoughttorepresentaninsufficiencyfracture.50Thesefracturesmaybedifficulttovisualizewithplainradiographs.Subtleflatteningissometimespresentwithearlylesions;collapseofthefemoralheadisprogressive.CLINICALMANAGEMENTOFHIPOSTEONECROSISFactorstoconsiderwhendevelopinganoptimalmanagementapproachforsymptomaticONofthehipshouldbeaimedattreatingthestageanddegreeofinvolvementofON,theextentandlocationofbonyinvolvement,thepresence(orabsence)ofsymptoms,andthepatient’scomorbidities.Thegoaloftherapyistopreservethebiologicalhipjointforaslongaspossiblewhilealsotakingintoconsiderationqualityoflifeissuessuchaspatientage,mobility,occupation,andlifestyle.ThreemaintherapeuticoptionsformanagementofhipONinclude1)nonoperativemanagement,2)joint-preservingprocedures,and3)THA.TheeffectsofatraumaticcausesofhipONposespecialconcerns.Forthoseaffected,67%reportnosymptomsbutmayeventuallygoontohaveacollapsedjoint.51Thenaturalhistoryofasymptomaticmedium-sized,andespeciallylarge,osteonecroticlesionsisprogressiontoworseningoftheconditionandeventuallyend-stagediseaseandcollapseofthehipinasubstantialnumberofpatients.Forthosewithsymptoms,approximately80%to85%ofcaseswillresultincollapseofthefemoralheadwithin2years.6EarlydiagnosisofONmaythereforeprovidetheopportunityforearlytreatment,whichcanpreventcollapseand,ultimately,theneedfortotaljointarthroplasty.However,mostpatientspresentlateinthecourseofthedisease,andahighindexofsuspicionisnecessaryforthosewithknownorprobableriskfactors,particularlypatientswithhigh-dosecorticosteroiduse.3SimilarlyforpatientswithasymptomatichipON,thesize,extent,andlocationofthenecroticlesionaffectingthefemoralheadshouldbeconsidered.Generally,lesionsaffectinglessthan15%ofthefemoralheadarebestmanagednonoperatively;lesionsbetween15%to30%shouldbemanagedsurgically;andlesionsinvolvingmorethan30%ofthefemoralheadarelikelytoprogresstocollapse,despitesurgicalintervention,andeventuallyrequireTHA.3,52,53NonsurgicalTreatmentOptionsinHipOsteonecrosisPhysicalTherapyPhysicaltherapymayprovidereliefandalleviatesomesymptomsbutgenerallywillnotprecludeprogressivehipONfromadvancingtolaterstages.54Similarly,restrictingweight-bearingwiththeuseofassistivedevicessuchascrutchesoracanemaybeusefultocontrolsymptomsofpain,weakness,andantalgicgait.PhysicaltherapyisnotappropriateifthegoaloftreatmentistopreventthehipfromrequiringTHA,andtodatethereisnoevidencethatweight-bearingrestrictionsarehelpfulinpreventingprogressiveONdiseasefromadvancingtoend-stagedisease.MedicationsNonsteroidalanti-inflammatorydrugsandacetaminophenmayprovidetemporaryreliefofpaininsymptomaticpatients.Opioidmedicationsmaybeusedjudiciouslyandforshortperiodsoftimewhenotheragentsareineffectivetomanagemoderate-to-severepainwhilesurgicaloptionsarebeingconsidered.InvestigationalmedicationoptionscurrentlybeingusedbutthatarenotprovenorreliablyusedtotreatONinclude1)anticoagulants,2)bisphosphonateantiresorptiveagents,3)cholesterolloweringstatins,and4)hyperbaricoxygen.SurgicalOptionsinEarly-StageHipOsteonecrosisCoreDecompressionCoredecompressionisaminimallyinvasivesurgicaltechniqueperformedtomanagesymptomsinearlystages(precollapse)ofthecondition(eg,FicatandArletStagesIandII).Theprocedureinvolvesdrillingholesintothefemoralheadtorelievepressureandcreatechannelsfornewbloodvesselstonourishtheaffectedareas.Thepublishedsuccessratesofcoredecompressionvarygreatlyfrom40%to100%,dependingonpatientpopulation.35Highersuccessratesaftercoredecompressionareseeninpatientswiththeearliestdiseasestages.Patientswithsuccessfulcoredecompressionprocedurestypicallyreturntounassistedambulationafterseveralmonthsandcanhavecompletepainrelief.55BoneGraftingCoredecompressioncanbecombinedwithbonegraftingtohelpregeneratehealthyboneandsupportcartilageatthehipjoint.Abonegraftishealthybonetissuethatistransplantedtotheareaofnecroticordeadbone.Astandardtechniqueusesanautograftthatinvolvestakingbonefromonepartofthebodyandmovingittoanotherpartofthebody.Abonegraftthatisharvestedfromadonororcadaveriscalledanallograftandistypicallyacquiredthroughabonebank.BoneMarrowAspirateConcentrationThebonemarrowaspirateconcentrationinjectionprocedurewithcoredecompressioninvolvestheuseofconcentratedbonemarrowthatisinjectedintothedeadboneofthehip.Thisinvestigationaltechniqueharvestsstemcellsfromapatient’sbonemarrowandinjectsthemintotheareaofON.9Thebonemarrowaspirateconcentrationprocedureishypothesizedtopreventfurtherprogressionofthediseaseandtostimulatenewbonegrowth.56PercutaneousDrillingAnothersurgicaloptionispercutaneousdrilling.Inthisprocedure,aholeisdrilledpercutaneouslythroughthefemoralnecktotheaffectedsiteinthefemoralhead.Onereporton45hipswithameanfollow-upof24monthsreported24(80%)of30hipswithFicatandArletStageIdiseasehadsuccessfuloutcomes(definedasHarrisHipScore＜70).57Amorerecentstudycomparingmultipledrillingvsstandardcoredecompressionshowedfavorableresultsinfavorofpercutanteousdrilling.28SurgicalOptionsinAdvanced-StageHipOsteonecrosisVascularizedBoneGraftAvascularizedfibulagraftisamoreinvolvedsurgicalprocedureinwhichasegmentofboneistakenfromthefibulawithitsbloodsupply.Thegraftisthentransplantedintoaholecreatedinthefemoralneckandhead,andthearteryandveinarereattachedtohelphealtheareaofON.55OsteotomyOsteotomyinhipONcanbeperformedtoremovenecroticboneawayfromprimaryweight-bearingareas.AlthoughthisoperationmaydelayTHAsurgery,itismostusefulinpatientswithidiopathicONwhodemonstratesmallprecollapseorearlypostcollapseofthefemoralhead.Aconsequenceofosteotomies,however,isthattheymakesubsequentTHAmorechallengingandareoftenassociatedwithanincreasedriskofnonunionofthebone.NonvascularizedBoneGraftThereare3typesofnonvascularizedbonegraftingsurgeries:1)trapdoorprocedure,2)lightbulbtechnique,and3)Phemistertechnique.ThetrapdoorprocedureisoneinwhichautogenouscancellousandcorticalbonegraftinghavebeensuccessfulinFicatandArletStageIIIhipONinpatientswithsmall-tomedium-sizedlesions.Areviewoftheresultsof30trapdooroperationsperformedon23patientswithFicatandArletStageIIIorStageIVONofthefemoralheadperformedthroughaso-calledtrapdoormadeinthefemoralheadrevealedagoodorexcellentresultasdeterminedbytheHarrisHipScoresystem.11LightbulbTechniqueThelightbulbtechniqueusesacorticalwindowintheanterioraspectofthefemoralneck.Necroticbonecanberemovedusingthiswindow,whichcanbelaterpackedwithnonvascularizedbonegraft.Wangetal55evaluated110patients(138hips)whounderwentthelightbulbprocedure.Atmeanfollow-upof25months,meanHarrisHipScoresimprovedfrom62to79points.Atotalof94hips(68%)wereconsideredtohavesuccessfuloutcomesatlatestfollow-up.Radiographicimprovementswerenotedin100%ofAssociationResearchCirculationOsseousStageIIapatients,77%instageIIbpatients,and51%instageIIcandIIIapatients.55PhemisterTechniqueInthePhemistertechnique,atrephineisinsertedthroughthefemoralnecktocreateatracttothelesion.Asecondtrephineistheninsertedtocreateanothertracttothelesionsite.Acorticalstrutgraftcanthenbeplacedinthelesion.Arecentreviewreportsthisproceduretohaveaclinicalsuccessraterangingfrom36%to90%.25TotalHipArthroplastyOncethefemoralheadhasundergonemajorcollapse,replacingthehipjointistheonlypracticaloperativeoptionandoffersthemostpredictablepainreliefinadvancedON.THAissuccessfulinrelievingpainandrestoringfunctioninthemajorityofpatients.45–47InTHA,thediseasedcartilageandboneconstitutingthehipjointisreplacedwithartificialimplantsmadeofmetalandplastic.Aprosthetichipreplacementgenerallylasts15yearsbeforeitmightwearoutandneedtoberevised.Fortheyoungeragegroup,aTHAmaybeasuboptimalsolutionbecauseofpossibleactivityrestrictions.Additionally,becauseprostheseshavelongevityrestrictions—componentswearafterlong-termuse—thesepatientswilllikelyrequirearevisionTHAlaterinlife.THAmustbecarefullyconsideredandbalancedagainstqualityoflifeissues,butitisnotabsolutelycontraindicatedforyoungerpatients.PATIENTEDUCATIONABOUTHIPOSTEONECROSISPreventionofOsteonecrosisPatienteducationaboutriskfactors,therapies,andmanagementisessentialforpatientstomakebetter-informeddecisionsabouttheircondition.TheprocessofONeducationinvolvesidentificationofanindividual’sassociateddisordersandriskfactorsrelatedtoON.PatientswithasymptomaticONmayhaveahighprevalenceofprogressiontosymptomaticdiseaseandfemoralheadcollapse.Educationforpatientswithasymptomaticdiseaseisprecautionaryandimperativetoensuremodificationofriskfactorsandoptimizationofcare.PreventingatraumaticONrequires1)avoidingexcessiveuseofalcoholdefinedas＜15drinks/wkformenand＜8drinks/wkforwomen,102)avoidingsmoking,and3)reducingcorticosteroidstothelowestpossibletherapeuticdose.InformingpatientsaboutthecorrelationbetweencorticosteroiduseandpotentialdevelopmentofONiscriticalinmanagementofthiscondition.PreventionofProgressionofOsteonecrosisPatientsdiagnosedwithearly-stageONshouldbeadvisedoftheaforementionedprecautionsandshouldavoidplacingexcessivepressureontheirjoints,followahealthydiet,andmaintainanappropriateweighttomitigateprogressionofON.Althoughahealthydietinitselfdoesnotdirectlyreducepressureonapatient’sjoints,weightloss(ifoverweight/obese)willreduceaxialloadsonthehipjoint,whichinturndecreasesthestrainappliedtothefemoralhead/neck(toboththetensionandthecompressionsides).42CONCLUSIONONisapathologicandoftenpainfulconditioninvolvingnecroticareasoftissuethatcanaffectanybonyjointinthebody.ThehipjointisthemostcommonlocationforONandshouldalwaysbeproperlyevaluated,utilizingradiographicscreeningandMRIscanning,whenONisinitiallydiagnosedinanotherbodypart.TheearlieradiagnosisofONismade,thebettertheopportunitytosavethehipjointwithoutsurgicalinterventionorwithminimallyinvasivesurgicaltechniques.AfteradiagnosisofONismade,thesize,extent,andlocationofthelesionandtheclassificationstagesareconsideredtodevelopanoptimalplanofcare.Thepresenceorabsenceofsymptomsisimportantinthisprocess.Thegoalsoftreatmentinvolveattemptingtopreservethebiologicalhipjointforaslongaspossibleandconsiderationofapatient’slifestyleandqualityoflifeissues.Todate,the2maintherapeuticoptionsformanagementofhipONincludejoint-preservingproceduresandTHA.PatienteducationaboutpotentialriskfactorsanddevelopmentofONisessentialtopreventtheconditionand/ortopotentiallypreventorhaltprogressionofearly-stagediseasetolater-stagedisease.2023年07月10日834
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陶可主治医师 北京大学人民医院 骨关节科 股骨头坏死：病因、诊断及治疗方式：2019英国医学杂志(BMJ)(医学生及低年资住院医师培训之)综述作者：JonathanNLamb,ColinHolton,PhilipO'Connor,PeterVGiannoudis作者单位:LeedsInstituteofRheumaticandMusculoskeletalMedicine,SchoolofMedicine,UniversityofLeeds,Leeds,UK.译者：陶可（北京大学人民医院骨关节科）股骨头坏死你需要了解什么？•股骨头坏死(AVNFH)的常见危险因素包括：酗酒、使用类固醇激素、化疗和免疫抑制剂药物以及镰状细胞性贫血。•如果患者髋部疼痛持续超过6周且X线片正常，请考虑对髋部进行核磁共振MRI扫描，并转诊至骨科（保髋治疗）团队。•早期治疗可使髋关节7年后存活率提高至88%。Fig1Demonstrationofhiprotationtoelicithippainwiththepatientsitting(A)andsupine(B,C,D).图1 演示通过患者坐位(A)和仰卧位(B、C、D)引起髋部疼痛的髋关节旋转活动(髋关节查体之内外旋转活动)。Fig2Typicalchangesseenonplainradiograph(top)andMRI(bottom)ofthehipinearlyandlateAVNFH.TheappearanceofearlyAVNFHisnotapparentonplainradiographbutisvisibleonMRI.图2 早期和晚期股骨头坏死(AVNFH)髋关节平片（上）和MRI（下）中看到的典型变化。早期股骨头坏死(AVNFH)的在平片上表现不明显，但在MRI上可见明显信号的改变。Fig3ProposedpathwayformanagingAVNFHinaprimarycaresetting.图3 在基层医疗机构中管理股骨头坏死(AVNFH)的建议诊治流程。 典型病例：一名36岁的女性向她的全科医生报告，有左侧腹股沟疼痛放射到膝盖的病史。疼痛很严重，走路时更严重，并伴有跛行。一年后，患者再次去看全科医生，尽管进行了镇痛，但疼痛仍持续存在。髋关节和膝关节的平片显示髋关节间隙轻微变窄，没有其他特征，她被转诊到二级骨科诊所。髋关节磁共振成像(MRI)扫描显示股骨头缺血性坏死(AVNFH)伴塌陷的典型特征。什么是股骨头缺血性坏死？股骨头坏死（AVNFH）由于微循环异常而导致软骨下骨结构完整性丧失。潜在的发病机制尚不清楚；风险因素可能会以某种方式影响微循环，但这尚未得到研究证实。共同的终点是微循环异常和坏死。软骨下骨随后塌陷，导致进行性、继发性髋关节骨关节炎。在英国，平均发病年龄为58.3岁，每10万名患者中有2人患病。平均而言，股骨头坏死（AVNFH）比典型骨关节炎发生得更早。它在男性中更为常见，发病率最高的是25至44岁的男性和55至75.3岁的女性。在英国，它是50.4岁以下人群全髋关节置换术的第三大常见适应症。以下因素与股骨头坏死（AVNFH）风险增加相关：•血液甘油三酯、总胆固醇、低密度脂蛋白胆固醇和非高密度脂蛋白胆固醇水平高；•男性；•城市居民；•股骨头坏死（AVNFH）家族史；•大量吸烟；•滥用酒精；•超重；•凝血病；•血管病变；•艾滋病病毒；•大量接触类固醇激素、化疗和免疫抑制药物。类固醇激素已被证明会使骨坏死（非部位特异性）的几率增加3倍，而免疫抑制剂则增加6倍。Zhao报告称，服用皮质类固醇激素的患者发生股骨头坏死（AVNFH）的几率高出35倍，患有“酗酒”状态的患者则高出6倍。为什么股骨头坏死（AVNFH）会漏诊呢？股骨头坏死（AVNFH）很少见。患有这种疾病的患者可能同时患有慢性风湿病和血液病。这可能会导致诊断的不确定性，特别是考虑到在这些情况下使用化疗、免疫调节剂和类固醇激素时，这些都是股骨头坏死（AVNFH）的危险因素。查体可以帮助识别可能引起疼痛的解剖结构，因为髋关节疼痛可能源自髋关节和非髋关节的多个部位。临床表现可能会被错过，因为由于时间和空间的限制，在基层医疗机构中准确确定单纯由于髋关节运动时造成的腹股沟疼痛可能具有挑战性(比较困难)。股骨头坏死（AVNFH）早期阶段的正常X线片可能会错误地让人放心并延迟适当的转诊。如果X线片呈阴性并且患者继续抱怨髋关节疼痛，医生可能会诊断为非特异性髋关节疼痛（考虑到肌肉骨骼的原因）并建议患者接受物理治疗。在新发病例中，18.75%只能通过MRI进行诊断，并且在普通X线片上很容易被漏诊。只有MRI扫描才具有诊断意义。为什么及早确诊股骨头坏死（AVNFH）很重要？早期诊断和转诊至关重要，因为骨质破坏通常发生在发病后2年内，因此不可能进行保留髋关节的治疗干预(保髋治疗在股骨头坏死发病2年内)。股骨头坏死（AVNFH）的早期发现使多学科团队有时间改变可能引发股骨头坏死（AVNFH）发作的治疗方法。股骨头髓心减压术可降低中短期内进一步手术的需要，但仅适用于疾病的最早阶段。一旦患者进展为继发性髋关节骨关节炎，关节置换通常是不可避免的。然而，考虑到股骨头坏死（AVNFH）患者年龄较小，翻修手术和相关发病率的终生风险很大。如何诊断股骨头坏死（AVNFH）？股骨头坏死（AVNFH）诊断从仔细询问病史和检查开始，以确定髋关节疼痛的来源。最终需要MRI来诊断股骨头坏死（AVNFH），并且还可以诊断髋关节疼痛的其他原因。仔细的询问病史病史显示疼痛持续超过6周，通常位于腹股沟和大腿，负重和运动时疼痛更严重。通常没有外伤史。询问危险因素，如果患者有任何“危险信号”，请进行髋关节MRI检查。股骨头坏死（AVNFH）通常是双侧的，双侧股骨头坏死（AVNFH）的风险通常是在单侧确诊后的2年内。框1：需要转介或进一步评估的危险信号：•髋关节X线检查正常，髋关节疼痛超过6周；•患有髋关节疼痛和危险因素的患者，包括：o既往单侧股骨头坏死（AVNFH），o酗酒，o大量接受类固醇激素治疗，o免疫治疗，Ø化疗，o镰状细胞病和其他凝血病，Ø艾滋病毒，o新近妊娠。查体腹股沟、大腿和膝关节前侧疼痛的再现并伴有单独的大腿旋转不能诊断股骨头坏死（AVNFH），但有助于区分髋关节疼痛与脊柱和膝关节疼痛。这可以在患者坐位或仰卧时进行（图1）。影像学检查早期股骨头坏死（AVNFH）在X线片上并不明显。如果患者持续感到疼痛，则需要进一步检查和转诊。股骨头坏死（AVNFH）通过髋关节MRI进行诊断，当与临床症状密切相关时，还可以诊断各种可治疗的髋关节疼痛（例如风湿病、肌腱疾病和骨病）（图2）。仅当有其他原因或高度怀疑风湿病或感染时，才应考虑进行其他检查，例如血液检查。转诊如果患者的髋关节MRI显示有股骨头坏死（AVNFH）改变时，请就诊于骨科医生（图3）。在二级医疗机构就诊时，股骨头坏死（AVNFH）诊断应与开具类固醇激素、化疗和免疫治疗原发病的任何治疗团队共享。药物和手术治疗取决于患者的特征和股骨头坏死（AVNFH）的阶段。使用前列环素类似物和双膦酸盐对塌陷前股骨头坏死（AVNFH），可以减轻症状并防止关节形合度破坏，但其疗效目前尚不清楚。手术治疗仍存在争议，但大多数塌陷前股骨头坏死（AVNFH）患者均接受髓心减压手术，并辅以或不辅以药物治疗，以减轻疼痛，并有可能在长达7年的时间里避免88%的患者进行全髋关节置换术治疗。术后恢复包括12个月的非负重康复锻炼，并在8周后逐渐恢复工作和驾驶。通常在术后12个月即可感受到完全的治疗益处。专业的三级医疗机构可以提供新的治疗方法，例如骨移植和截骨术，以分别促进血管再生和减轻受损髋关节表面的负荷。一旦发生塌陷，全髋关节置换术可以为患者提供快速、可靠的疼痛缓解和功能改善，但与未来有髋关节翻修的风险，特别是对于年轻患者。 AvascularnecrosisofthehipWhatyouneedtoknow•CommonriskfactorsforAVNFHarealcoholism,useofsteroids,chemotherapyandimmunosuppressantmedication,andsicklecellanaemia.•ConsiderMRIscanofthehipandreferraltoanorthopaedicteamifapatienthasapainfulhipforlongerthansixweekswithnormalradiographs.•Earlytreatmentimprovesthechancesofhipsurvivalbyupto88%atsevenyears. A36yearoldwomanpresentstoherGPwithahistoryofleftgroinpainradiatingtotheknee.Thepainissevere,worseonwalking,andassociatedwithalimp.ThepatientrevisitstheGPayearlaterwithpersistentpaindespiteanalgesia.Plainradiographsofthehipandkneeshowslightnarrowingofthehipjointspacewithnootherfeaturesandsheisreferredtoasecondarycareorthopaedicclinic.Amagneticresonanceimaging(MRI)scanofthehipshowsclassicfeaturesofavascularnecrosisofthefemoralhead(AVNFH)withcollapse.Whatisavascularnecrosisofthefemoralhead?Osteonecrosisofthefemoralhead(AVNFH)causeslossofintegrityofsubchondralbonestructureduetoabnormalmicrocirculation.Theunderlyingpathogenesisisunclear1;riskfactorsarelikelytoaffectmicrocirculationinsomewaybutthishasnotbeenconfirmedbyresearch.Thecommonendpointisabnormalmicrocirculationandnecrosis.Subchondralbonesubsequentlycollapses,whichleadstoprogressivesecondaryarthritis.MeanageofpresentationintheUKis58.3years,withaprevalenceoftwoper100000patients.2Onaverage,AVNFHoccursearlierinlifethantypicalosteoarthritis.Itismorecommoninmenandthehighestprevalenceisinmenaged25to44andwomenaged55to75.3IntheUKitisthethirdmostcommonindicationfortotalhipreplacementinpeopleunder50.4ThefollowingfactorsareassociatedwithanincreasedriskofAVNFH35:•Highlevelsofbloodtriglycerides,totalcholesterol,lowdensitylipoproteincholesterol,andnon-highdensitylipoproteincholesterol•Malesex•Urbanresidence•FamilyhistoryofAVNFH•Heavysmoking•Alcoholabuse•Overweight•Coagulopathies•Vasculopathies•HIV•Highexposuretosteroids,chemotherapy,andimmunosuppressantmedication.Steroidshavebeenshowntoincreaseoddsofosteonecrosis(non-sitespecific)byafactorofthreeandimmunosuppressantsbyafactorofsix.ZhaoreportedthattheoddsofAVNFHwere35timesgreaterinpatientstakingcorticosteroidsandsixtimesgreaterinpatientswith“alcoholism”status.3Whyisitmissed?AVNFHisrare.Patientswiththeconditioncanhavecoexistingchronicrheumaticandhaematologicalproblems.Thismayleadtodiagnosticuncertainty,particularlygiventheuseofchemotherapy,immunomodulatoryagents,andsteroidsintheseconditions,whichareallriskfactorsforAVNFH.Aphysicalexaminationcanhelpidentifytheanatomicalstructuresthatmightbecausingthepain,sincehippaincanoriginatefrommultiplehipandnon-hipareas.Presentationsmaybemissedbecauseaccuratereproductionofgroinpainonisolatedhipmovementscanbechallengingtoelicitinaprimarycaresettingduetotimeandspaceconstraints.NormalplainradiographsintheearlystagesofAVNFHcanbefalselyreassuringanddelayappropriatereferral.Iftheplainradiographisnegativeandthepatientcontinuestocomplainofhippain,thedoctormaygiveadiagnosisofnon-specifichippain(giventhatmusculoskeletalpresentationsarecommoninprimarycare)andsendthepatientforphysiotherapy.Ofnewpresentations,18.75%arediagnosableonlywithMRIandareeasilymissedonnormalplainradiographs.3OnlytheMRIscanisdiagnostic.Whydoesitmatter?Earlydiagnosisandreferralareessentialsincebonedestructionnormallyoccurswithintwoyearsofdiseaseonset,makingjointpreservinginterventionimpossible.6EarlyidentificationofAVNFHgivesthemultidisciplinaryteamtimetochangemedicaltreatmentswhichmightbeprovokingonsetofAVNFH.Surgicaldecompressionofthefemoralheadreducestheneedforfurthersurgeryintheshorttomediumtermbutisonlysuitablefortheearlieststagesofdisease.5Oncepatientshaveprogressedtosecondaryhiparthritis,jointreplacementisusuallyinevitable.However,giventheyoungerageofpatientswithAVNFH,thelifetimeriskofrevisionsurgeryandassociatedmorbidityisgreat.HowisAVNFHdiagnosed?AVNFHdiagnosisstartswithacarefulhistoryandexaminationtodeterminethatthehipisthesourceofpain.UltimatelyanMRIisrequiredtodiagnoseAVNFHandmayalsodiagnoseothercausesofhippain.AcarefulhistoryAhistoryshowingpainlastinglongerthansixweeks,typicallylocatedinthegroinandthighandwhichisworseonweightbearingandmovementiskey.6Usuallythereisnohistoryoftrauma.AskaboutriskfactorsandreferforMRIofthehipifthepatienthasany“redflags”(box1).AVNFHisoftenbilateralandtheriskofbilateralAVNFHishighestwithintwoyearsofunilateraldiagnosis.6Box1:Redflagsrequiringreferralorfurtherassessment•Hippainformorethansixweekswithnormalhipradiograph•PatientspresentingwithhippainandriskfactorsincludingopreviousunilateralAVNFHoalcoholexcessohighexposuretosteroidtherapyoimmunologictherapyochemotherapyosicklecelldiseaseandothercoagulopathiesoHIVorecentpregnancyExaminationReproductionofpaininthegroin,thigh,andanterioraspectofkneewithisolatedthighrotationwillnotdiagnoseAVNFH,butwillhelptodifferentiatehippainfrompainoriginatingfromthespineandknee.Thiscanbeperformedwiththepatientsittingorsupine(fig1).RadiologicaltestsEarlyAVNFHisnotapparentonplainradiographs.Ifthepatientcontinuestobeinpain,furtherinvestigationandreferraliswarranted.AVNFHisdiagnosedonMRIofthehips,7whichmayalsodiagnoseabreadthoftreatablehippain(suchasrheumatologicaldisease,musculotendinousdisease,andbonydisease)whencarefullycorrelatedwithclinicalsymptoms8(fig2).Otherinvestigations,suchasbloodtests,shouldonlybeconsideredifindicatedforotherreasonsorifthereisahighsuspicionofrheumatologicaldiseaseorinfection.ReferralIfthepatienthassignsofAVNFHonMRIofthehip,refertoanorthopaedicsurgeonforconsultation(fig3).Insecondarycare,AVNFHdiagnosisshouldbesharedwithanycareteamsinvolvedintheadministrationofsteroids,chemotherapy,andimmunologictherapy.MedicalandsurgicaltreatmentdependonthepatientcharacteristicsandstageofAVNFH.Medicaltreatmentofpre-collapsediseasewithprostacyclinanaloguesandbisphosphonatesmayreducesymptomsandpreventlossofjointcongruitybuttheirefficacyisnotcurrentlywelldefined.6Surgically,treatmentremainscontroversial,butmostpatientswithpre-collapseAVNFHareofferedcoredecompressionsurgerywithorwithoutadjunctivepharmacologicaltherapytoreducepainandpotentiallypreventtheneedfortotalhipreplacementin88%ofpatientsforuptosevenyears.910Postoperativerecoveryinvolvesaperiodofnon-weightbearingfor12monthsandgradualreturntoworkanddrivingat8weeks.Fullbenefitisusuallyfeltat12monthsaftersurgery.Specialisttertiarycentresmayoffernoveltreatmentssuchasbonegraftingandosteotomiestoencouragevascularregrowthandunloaddamagedhiparticularsurface,respectively.Oncecollapsehasoccurred,totalhipreplacementcangivepatientsrapid,reliablepainreliefandimprovedfunctionbutisassociatedwiththeriskoffuturerevision,particularlyinyoungerpatients.Afulldescriptionofalltheoptionsisbeyondthescopeofthisarticleandpatientsshoulddiscussallavailableoptionswiththeirsurgeontoenableinformedshareddecisionmaking.文献出处：JonathanNLamb,ColinHolton,PhilipO'Connor,PeterVGiannoudis.Avascularnecrosisofthehip.BMJ.2019May30;365:l2178.doi:10.1136/bmj.l2178.2023年07月09日396
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