Objective?To explore the difference between bone marrow edema syndrome (BMES) and avascular necrosis of femoral head (ANFH).?Methods?Recent original articles about BMES and ANFH were extensively reviewed, and were comprehensively analysed.?Results?The pathology, pathogenesis, clinical features, treatment selection, and prognosis are different between these two diseases.?Conclusion?BMES and ANFH are two different diseases. Micro-fracture may be the cause of bone marrow edema.
Objective To review the researches on the jointpreserving procedures for the treatment of the avascular necrosis (AVN) of the femoral head. Methods The latest original literatures about the joint-preserving procedures for the treatment of AVN of the femoral head were extensively reviewed. Results There were many surgical jointpreserving procedures to treat AVN of the femoral head, such as core decompression, bone grafting, and osteotomy. Most researchers achieved excellent clinical results by using the joint-preserving procedures to treat the early stages of AVN of the femoral head. Conclusion Treating AVN of the femoral head by the joint-preserving procedures, especially the free vascularized fibula grafting, can achieve an excellent longterm clinical outcome.
ObjectiveTo evaluate the effect of leucocyte- and platelet-rich plasma (L-PRP) on the osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs) in treating avascular necrosis of the femoral head (ANFH) in rabbits. MethodsTwenty-four New Zealand white rabbits (4-6 months old, both genders, weighing 2.0-3.0 kg) were used for the establishment of bilateral ANFH models and divided into 4 groups (n=6). BMSCs were isolated from the bone marrow of iliac crest, cultured and identified. L-PRP was prepared by Landesberg method. Core decompression only (group A), core decompression and L-PRP implantation (group B), core decompression and BMSCs implantation (group C), and core decompression and implantation of BMSCs and L-PRP were performed in 4 groups. To evaluate bone formation and remodeling of the defects, X-ray photography was taken at 2, 4, and 8 weeks postoperatively. The modified Lane-Sandhu scoring system was used to evaluate the bone formation. Two rabbits were sacrificed at 2, 4, 8 weeks after operation to harvest the specimens for histological observation, new blood vessel count and new bone area ratio. ResultsThe observations of radiology and histology displayed different degrees of bone regeneration at bone defect sites in each group. At 2, 4, and 8 weeks postoperatively, the results of Lane-Sandhu X-ray photography scoring, new blood vessel count, and new bone area ratio showed that groups C and D were significantly better than groups A and B, group D was significantly better than group C. and group B was significantly better than group A (P<0.05). ConclusionThese findings demonstrate that L-PRP can promote osteogenic differentiation of BMSCs in treating ANFH in rabbits, and core decompression associated with BMSCs and L-PRP is an effective and feasible method to treat ANFH.
Objective To investigate the effectiveness of free vascularized fibula grafting with unilateral fibula as donor in treatment of bilateral avascular necrosis of femoral head (ANFH). Methods Between June 2007 and January 2008, 14 patients with bilateral ANFH were treated with free vascularized fibula grafting with unilateral fibula as donor. There were 12males and 2 females with an average age of 36.6 years (range, 17-57 years). The necrosis was caused by use of steroids in 3 cases, consumption of alcohol in 4 cases, and idiopathic condition in 7 cases. According to Steinberg system, 16 hips were classified as stage II, 10 hips as stage III, and 2 hips as stage IV. The preoperative Harris hip scores were 77.50 ± 4.19, 69.70 ± 2.76, 59.50 ± 0.50 in patients at stages II, III, and IV, respectively. The duration of operation and the bleeding volume were recorded. The X-ray examination, the Harris hip score, and the compl ications were used to evaluate the effectiveness. Results The duration of the fibula osteotomy was 10-32 minutes (mean, 20 minutes). The duration of the total operation was 100-240 minutes (mean, 140 minutes). The bleeding volume was 200-500 mL (mean, 280 mL). All patients achieved heal ing of incision by first intention. The patients were followed up 12-40 months (mean, 24 months). One case had numbness and hyperthesia of the anterolateral thigh; 1 case had abnormal sensation of the dorsal foot; 1 case had discomfort of the ankle; and they restored to normal at 1 year after operation. According to X-ray films 1 year after operation, the improvement was achieved in 23 hi ps (82.1%) and no deterioration in 5 hips (17.9%). At 1 year after operation, the Harris hip scores were 93.90 ± 4.84, 88.50 ± 8.13, and 78.00 ± 0.00 inpatients at stages II, III, and IV, respectively, showing significant differences when compared with preoperative ones (P lt; 0.05). Conclusion Unilateral free vascularized fibula grafting has lots of virtues, such as short surgical time, less bleeding volume, l ittle injury, and good results of function recovery. It could be an effective and safe method in treating bilateral ANFH.
【Abstract】 Objective To introduce a new method using calcium phosphate cement/Danshen drug del ivery systemfor avascular necrosis of femoral head and to evaluate its cl inical outcome. Methods From May 2000 to June 2005, 48 patients (54 hips) with avascular necrosis of femoral head were treated with calcium phosphate cement/Danshen drug del ivery system implantation in the involved femoral head. There were 32 males(36 hips) and 16 females(18 hips) with an average age of 38.7 years (26-62 years). Twenty-one cases had the history of drinking or smoking, 15 cases had the history of receiving hormonotherapy and 2 had the history of injury in hip joint. The disease course was 2-32 months. According to standard of Association Research Circulation Osseous (ARCO) staging, 9 hips were classified as stage I, 31 as stage II and 14 as stage III. The operation consisted of removal of necrotic bone under weight-loading cartilage and the implantation of calcium phosphate cement/Danshen drug del ivery system, all mani pulations were done through a bone tunnel in trochanter. The function of hi p joint were evaluated and X-ray films were taken pre- and post-operatively. Results No phlebothrombosis of leg and foreign body action occurred in all cases, and incision healed by first intention. The postoperative follow-up averaged 42.5 months, ranging from 22 to 73 months. According to the evaluation criterion of Dandong 1995 for adult avascular necrosis of femoral head, the results were excellent in 33 hi ps, good in 17, fair in 3 and poor in 1, the excellent and good rate was92.6 %. Conclusion This method is relatively simple with less invasion, it not only improves the microcirculation of femoral head by local appl ication of traditional Chinese medicine, but also provide mechanic buttress in the weight-loaded area, which is beneficial to repair and reconstruction of femoral head. It may be a choice of minimally invasion surgery for femoral head necrosis.
【Abstract】 Objective To establ ish a stable animal model for glucocorticoid-induced avascular necrosis of femoral head in rabbits. Methods Thirty-six adult New Zealand rabbits were randomly divided into four groups:ten were injected twice with l i popolysaccharide (group A), ten were treated with a combination of l i popolysaccharideand methylprednisolone (group B), ten were injected three times with methylprednisolone (group C), and six wereinjected normal sal ine as a control (group D). MR imaging was performed in the rabbits before the first injection ofl i popolysaccharide or methylprednisolone, and at 2, 4, and 6 weeks after the last injection of l i popolysaccharide ormethylprednisolone. Histopathological changes in the femoral heads were observed by l ight microscope and transmission electron microscope at the end of six weeks after the injection. Vascular infusion with Chinese ink was made to evaluate the morphological changes of blood vessels in the femoral head. The percentage of trabecular bone area and empty lacunae and microvascular density were measured. According to the histological and MR imaging appearance of the femoral heads in all groups, the incidence of osteonecrosis of every group was calculated. Results Listlessness, blepharal hyperemia,less activity and reduced diet were found in the rabbits of groups A and B after injected with l ipopolysaccharide. At 3 weeks after the final injection, the body weight of groups B and C was decreased. At 4 weeks after the final injection, the body weight of groups A and D was increased. No abnormal signal could be detected on MR images in rabbits of all groupsbefore injection and at 2 weeks after the injection. At 4 weeks and 6 weeks after the last injection, irregular low signal on T1-weighted images and irregular low or high signal on T2-weighted images could be detected on MR images in rabbits of groups B and C, no abnormal signal could be detected on MR images in rabbits of groups A and D. At 6 weeks after the last injection,the trabecular bone of group B became thin and sparse, some were broken. The percentages of empty lacunae were 11.8% ± 4.7%, 34.4% ± 6.2%, 20.0% ± 4.7% and 9.3% ± 4.6%; the percentages of trabecular bone area were 59.2% ± 6.8%, 40.1% ± 6.0%, 51.5% ± 5.6% and 63.2% ± 8.3%; and the microvascular densities were 14.3% ± 2.7%, 4.5% ± 2.1%, 10.2% ± 3.1% and 15.4% ± 4.1% in groups A, B, C and D respectively. There were statistically significant differences between group B and groups A, C, D (P lt;0.01). The fatty tamponade accumulated in the medullary cavity and intramedullary vascular sinusoids were pressed by the l ipocytes and became narrow. Limposomes were found in osteocytes and vascular endothel ia of group B and group C. Osteocytes of group B crimpled and pyknosis or karyolysis of chromatin were observed in these osteocytes, nuclearmembrane of the osteocytes was discontinous. Vascular endothel ia became swollen and the cell junctions widened or were destroyed in groups A and B. The incidence of osteonecrosis in group B (88.9%) was higher than that in group C (22.2%, P lt; 0.05). There was no osteonecrosis occurred in groups A and D . Conclusion Methylprednisolone combined with l ipopolysaccharide can induce typical rabbit model for early avascular necrosis of femoral head.
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 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.
【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 review the relationshi p between heritable hypercoagulable state (HHCS) and avascular necrosis of femoral head (ANFH). Methods The latest original articles about the relationshi p between HHCS and ANFH were extensively reviewed. Results Several genetic mutations which could cause HHCS, such as thrombophilic factor V G1691A gene, thrombophilic factor II G20210A gene, 5, 10-methylenetetrahydrofolate reductase C677T gene, plasminogen activator inhibitor 1 4G/5G, and tissue factor pathway inhibitor gene, may be genetic risks of ANFH. Conclusion HHCS may be a genetic cause of ANFH. Further studies are needed to confirm the relationship between HHCS and Chinese ANFH.