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沈计荣主任医师 江苏省中医院 骨伤科 近日，江苏省中医院沈计荣领衔的团队的研究成果：补肾活血汤联合虚拟现实技术引导下的截骨术治疗股骨头坏死的研究荣获2022年中国中医药研究促进会科技进步一等奖！（证书见下图）。相关成果简介刊登在著名学术期刊《中国科技成果》2023年3月。这标志着沈计荣教授领衔的江苏省中医院骨伤科股骨头坏死保髋工作获得国内专家的普遍认可！股骨头坏死是骨科常见病，全国约有812万患者。该病多发于青壮年，致残率高。因为人工髋关节假体使用寿命有限（一般不超过30年），且翻修手术难度较大，故对于年轻患者，保髋治疗具有重大意义。目前，股骨头坏死的保髋治疗是医学界的难题。截骨保髋术（内翻截骨术与旋转截骨术）因为手术难度大、精确度要求高，开展较少。少数医院即使有条件开展截骨保髋手术，亦存在术前规划困难、截骨不愈合、术后头臼关系不匹配等问题。在国家自然科学基金面上项目等多项基金资助下，项目组采用补肾活血汤联合虚拟现实技术引导下的截骨术个体化治疗股骨头坏死（详情见图1-3），取得较好疗效。2018年，由申报人牵头成立了全国30家医院参与的股骨头坏死专病联盟（图4）。同年，在中国关节外科学术大会暨第20届亚太关节学会年会和中国医师协会骨科医师年会上，沈计荣教授应邀分别就内翻截骨术与旋转截骨术发言（图5）。近3年来，申请人的保髋研究成果先后以第一完成人身份获南京市中医药科学技术奖（2019年），江苏省医学新技术引进奖二等奖（2020年），中国中医药研究促进会科技进步奖二等奖（2020年）。申请人发表与股骨头坏死相关的学术论文56篇（SCI期刊论文9篇）。申请人参与制定多个股骨头坏死临床诊疗指南（中医正骨，2019；中华骨科杂志，2016；中华关节外科杂志，2016），培养相关领域的研究生10余名。项目研究发现采用补肾活血汤联合虚拟现实技术引导下的内翻截骨术治疗合适的患者，尚未出现保髋失败，典型病例见图6。采用旋转截骨术治疗合适的患者，成功率约72.7%，典型病例见图7。目前，即使开展特别复杂的保髋手术（经股骨颈基底部旋转截骨术）联合中药复方，只需要治疗费（手术加器械加药品）1.5-3万元。团队已在河南省中医院、浙江省中医院、海安市中医院等省内外30余家医院推广、应用该技术，节省医疗支出数百万元，取得了较好的经济与社会效益。立足三十余年临床经验，总结古今中外大量文献，沈计荣教授提出了基于中日友好医院分型的股骨头坏死阶梯化治疗方案（如图8），力求做到治疗的阶梯化、精准化、个体化。目前沈计荣教授及团队也在积极开展基于DCE-MRI评估股骨头血供变化，从而选择适合患者病情的术式，旨在提高临床疗效，典型病例见图9。（相关研究发表于《中国组织工程》杂志）。目前该研究正在进一步深入，以期推动股骨头坏死保髋治疗的进一步发展。雄关漫道真如铁，而今迈步从头跃！2023年01月17日
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陶可主治医师 北京大学人民医院 骨关节科 2015年美国Baltimore Sinai医院：髓心减压治疗股骨头坏死的最新进展：分期越早，髓心减压效果越好；目前多采用髓心减压联合干细胞移植等多种模式策略：让血液重回股骨头/非关节置换保头(保留股骨头)治疗股骨头坏死 附一例典型股骨头坏死病例治疗分析 作者：Todd P Pierce, Julio J Jauregui, Randa K Elmallah, Carlos J Lavernia, Michael A Mont, James Nace. 作者单位: Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA. 译者：陶可（北京大学人民医院骨关节科） 文献出处：Todd P Pierce, Julio J Jauregui, Randa K Elmallah, Carlos J Lavernia, Michael A Mont, James Nace. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 2015 Sep;8(3):228-32. doi: 10.1007/s12178-015-9280-0. 图A American Academy of Orthopaedic Surgeons Illustration of (Left) Core decompression. (Right) In this x-ray, the drill lines show the pathway of small drill holes used in a core decompression procedure. 美国骨科医师学会（左）髓心减压示意图(2-3多次小直径孔道减压)。（右）在这张髋关节正位X线片中，钻孔线显示了髓心减压手术操作中使用的小钻孔（注：头端带螺纹的斯氏针）的路径。 图B Core Decompression for Avascular Necrosis of the Hip: The hip joint is a ball and socket joint, where the head of the thigh bone (femur) articulates with the cavity (acetabulum) of the pelvic bone. Sickle cell disease, a group of disorders that affect the hemoglobin or oxygen carrying component of blood, causes avascular necrosis or the death of bone tissue in the hip due to lack of blood supply. Core decompression is indicated in the early stages of avascular necrosis, when the surface of the head is still smooth and round. It is done to prevent total hip replacement surgery, which is indicated for severe cases of avascular necrosis and involves the replacement of the hip joint with an artificial device or prosthesis. 股骨头缺血性坏死的髓心减压图示(单孔大直径孔道传统减压术)：髋关节是一个球窝关节，大腿骨头（股骨）的头部与骨盆骨的空腔（髋臼）相连。镰状细胞病是一组影响血液中血红蛋白或携氧成分的疾病，会导致髋部缺血性坏死或由于缺乏血液供应而死亡。髓心减压适用于缺血性坏死的早期阶段，此时头部表面仍然光滑圆润。这样做是为了防止全髋关节置换手术，全髋关节置换手术适用于严重的缺血性坏死病例，涉及用人工装置或假体置换髋关节。 2019年最新的《改良的ARCO分期(1-4期)》： I期 X线片正常，核磁共振检查结果异常。 II期 无新月征，存在影像学上硬化、骨溶解或局灶性骨质疏松症征象。 III期 新月征，X线片或CT扫描可见软骨下骨折、部分坏死，和/或股骨头变平。 IIIA 股骨头凹陷≤2mm。 IIIB 股骨头凹陷＞2mm。 IV期 骨关节炎证据，关节间隙变窄和髋臼退行性改变。 一例典型的酒精性无菌性股骨头坏死患者(男性, 49岁)的影像学检查及髓心减压+取自体髂骨骨髓移植微创治疗。病例特点：患者大量饮酒近30年，约250ml/日，1年前无明显诱因出现双侧髋关节疼痛，疼痛呈刺痛，无放射痛，活动后明显，左侧明显。髋关节活动受限，髋关节周围无红肿，无发热，6个月前完善检查发现双股骨头坏死，髋关节骨关节炎，现右侧髋部疼痛明显，无法正常行走。 图1 术前髋关节正位X线片 可见右侧股骨头坏死区域程明显的新月征，左侧股骨头坏死可见小范围股骨头范围病灶，但双侧股骨头塌陷/凹陷高度≤ 2mm，2019年改良股骨头坏死分期应为IIIA期。 图2 术前髋关节蛙式位X线片 可见与正位X线片一致的影像学改变，双侧股骨头坏死区域主要位于前方。 图3 术前髋关节CT平扫-冠状位 结果发现右侧股骨头软骨下骨板局部硬化，部分区域骨小梁已坏死吸收，出现囊腔样骨缺损，股骨头外侧局部区域骨小梁结构轻度塌陷。 图4 术前髋关节CT平扫-轴位-骨窗 与上述冠状位CT平扫相似地发现，右侧股骨头部分区域骨小梁已坏死吸收，出现囊腔样骨缺损，主要位于前方。 图5 术前髋关节CT平扫-轴位-骨窗 右侧股骨头囊腔样骨缺损主要位于前方。 图6 术前髋关节CT平扫-轴位-骨窗 右侧股骨头囊腔样骨缺损主要位于前方，左侧股骨头骨质结构相对正常。 图7 术前髋关节CT平扫-轴位-骨窗 双侧股骨头骨质结构在下方及后方基本正常。 图8 术前髋关节CT扫描-三维重建 结果发现右侧股骨头前方/外侧局部区域软骨下骨结构轻度塌陷，骨赘增生。 图9 术前髋关节CT扫描-三维重建 结果发现右侧股骨头前方/外侧局部区域软骨下骨结构轻度塌陷，骨赘增生，局限在前下方。 图10 术前髋关节CT扫描-三维重建 结果发现右侧股骨头前方/外侧局部区域软骨下骨结构轻度塌陷，骨赘增生，局限在前下方。 图11 术前髋关节CT扫描-三维重建 右侧股骨头后方/外侧/下方局部软骨下骨结构无明显改变。 图12 术前双侧髋关节T2-MRI平扫-冠状位 较CT平扫更敏感地(100%)确定双侧股骨头坏死，发现双侧股骨头明显骨髓水肿，且伴随有髋关节滑膜炎、关节腔积液，右侧较左侧明显，右侧骨髓水肿弥漫分布在股骨头/股骨颈等区域，炎性水肿液较多，股骨头负重区软骨下骨板已出现坏死塌陷征象，且中间可见坏死与修复组织交杂交汇；左侧股骨头坏死负重区股骨头坏死，范围较局限。 图13 术前髋关节T1-MRI平扫-冠状位 图14 术前髋关节T1-MRI平扫-轴位 图15 术前髋关节T2-MRI平扫-轴位 图16 术中透视下进行股骨头下钻孔减压-髋关节正位 术中，选用直径2.5mm斯氏针，在透视下沿着股骨颈旋转中心，向股骨头坏死区域(前上方)进针，深度控制在距离股骨头软骨下骨0.5cm。 图17 术中透视下进行股骨头下钻孔-髋关节正位 选用直径5.5mm空心环钻，沿着上述斯氏针导引方向，在透视下向股骨头坏死区域进针，深达股骨头软骨下骨0.5cm (软骨下骨坏死塌陷区域)。 图18 术中透视下进行股骨头下钻孔-髋关节蛙式位 在C型臂透视下，再次确认斯氏针进针方向及深度是否合适。 图19 透视下将骨髓干细胞注入股骨头坏死钻孔区域 采用骨髓穿刺针在髂前上棘取5ml骨髓液，经肝素钠抗凝等预处理后，沿空心钻注射进入坏死区域。 图20 伤口较小，自然伤痛较小 术后伤口长度约1cm，术后进行美容缝合，不需要拆线，疤痕也会极小。 图22 术后髋关节正位X线片 图23 术后髋关节蛙式位X线片 图24 术后主动髋关节康复功能锻炼 术后24小时候，指导患者在平卧位进行非负重主动直腿抬高锻炼，增强髋关节及下肢肌肉力量，提高韧带强度，同时还可以避免肌肉萎缩，下肢静脉血栓形成等风险。 图25 术后站立主动屈髋康复功能锻炼，为适应扶拐行走做准备 图26 术后下蹲主动屈髋康复功能锻炼，为适应坐便器做准备 图27 术后治疗团队与患者合影 术后医嘱：保护性扶拐髋关节免负重3个月，期间进行主动髋关节屈曲、后伸、蚌式运动、侧卧位抬腿等康复功能锻炼，6周、12周、6月、12月复查一次髋关节X线片及核磁共振。同时避免深蹲、盘腿、跷二郎腿等引发髋关节撞击/挤压的动作。视患者恢复情况决定何时完全负重行走，建议每天控制步数在3千左右，同时控制体重。 A current review of core decompression in the treatment of osteonecrosis of the femoral head Abstract The review describes the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling technique, and (4) the overall outcomes of these procedures. Core decompression has optimal outcomes when used in the earliest, precollapse disease stages. More recent studies have reported excellent outcomes with percutaneous drilling. Furthermore, adjunct treatment methods combining core decompression with growth factors, bone morphogenic proteins, stem cells, and bone grafting have demonstrated positive results; however, larger randomized trial is needed to evaluate their overall efficacy. 该综述描述了以下内容：(1)如何进行传统的髓心减压，(2)辅助治疗，(3)多种经皮钻孔技术，以及(4)这些治疗操作的总体结果。髓心减压在最早的塌陷前疾病阶段股骨头坏死治疗使用时具有最佳结果。最近的研究报告了经皮钻孔的良好结果。此外，将髓心减压与生长因子、骨形态发生蛋白、干细胞和骨移植相结合的辅助治疗方法已显示出积极的效果；然而，需要更大规模的随机试验来评估它们的整体疗效。 Introduction 介绍 In the treatment of osteonecrosis of the femoral head (ONFH), core decompression is used in the earliest precollapse stages of disease in an attempt to delay and/or prevent the need for total hip arthroplasty (THA). The most ideal lesion treated with this procedure is a precollapse and small (＜15 % of femoral head or Kerboul angle ＜200°) [1–4]. These procedures are typically performed by the drilling and removal of an 8- to 10-mm cylindrical core from the osteonecrotic lesion [5]. In addition, another commonly used technique involves multiple percutaneous drillings [5, 6]. Techniques have been combined with several other adjunctive treatment modalities such as bone grafting and the addition of growth and differentiation factors [7–12]. The purpose of this review is to describe the following: (1) how traditional core decompression is performed, (2) adjunctive treatments, (3) multiple percutaneous drilling, and (4) the overall outcomes of this procedures. 在股骨头坏死(ONFH)的治疗中，在疾病的早期塌陷前阶段使用髓心减压，以试图延迟和/或防止进展到全髋关节置换术(THA)。髓心减压治疗的最理想病变是塌陷前和小（＜股骨头的15%或Kerboul角＜200°）[1-4]。这些操作通常通过从骨坏死病变中钻孔和移除8到10毫米的圆柱形髓心来完行[5]。此外，另一种常用的技术涉及多次经皮钻孔[5, 6]。技术已与其他几种辅助治疗方式相结合，例如骨移植和添加生长和分化因子[7-12]。本综述的目的是描述以下内容：(1)如何进行传统的髓心减压，(2)辅助治疗，(3)多次经皮钻孔，以及(4)该程序的总体结果。 Technique of standard core decompression 标准髓心减压技术 The patient is placed under general anesthesia and is then prepared and draped in an aseptic manner. Under fluoroscopic guidance, a Kirschner wire is drilled with an entry point laterally, but superior to the lesser trochanter medially. Once it is determined that the guide wire is in the appropriate place, an 8- to 10-mm-wide trephine is inserted into the lesion with care not to penetrate the femoral head nor to violate the articular cartilage. A core of bone is removed from the lesion, the skin is closed with one suture, and a sterile dressing is applied [5]. Following surgery, patients are discharged home the same day and are allowed 50 % weightbearing on the affected leg, for 6 weeks. After 6 weeks, patients can progress to full weight-bearing. Patients are then given abductor strengthening exercises and educated to avoid high impact activities for 1 year [5]. Patients are followed up with plain radiographs and clinical evaluation at 6, 12 weeks, 6, 12 months, and annually thereafter. 将患者置于全身麻醉下，然后以无菌方式准备和铺巾单。在透视引导下，克氏针在外侧钻有一个入口点，但在内侧高于小转子。一旦确定导丝位于合适的位置，将8至10毫米宽的环钻插入病灶，小心不要刺入股骨头或侵犯关节软骨。从病变中取出骨髓，用一根缝线缝合皮肤，并使用无菌敷料[5]。手术后，患者在同一天出院回家，并允许患肢负重50%，持续6周。6周后，患者可以完全负重（注：视患者恢复情况决定何时完全负重行走，每天控制步数在3千左右）。然后对患者进行外展肌强化训练并接受教育，避免在1年内避免高强度活动[5]。在第6、12周、6、12个月和此后每年一次对患者进行X线片和临床评估随访。 Overall outcomes of traditional core decompression 传统髓心减压的总体结果 When evaluating outcomes of this procedure, it is important to distinguish the results of older versus more recent studies. In a systematic literature review, Marker et al. [12] evaluated the clinical and radiographic outcomes of core decompression in surgeries done before [13–22] and after 1992 [1, 2, 10, 23–31] (n=1268 and 1337 hips, respectively). The authors demonstrated that in procedures performed before 1992, 41 % of hips required additional surgery after a mean follow-up of 65 months (range, 3 to 216 months). However, in surgeries conducted after 1992, only 30 % of hips required another operation after a mean follow-up of 63 months (range, 1 to 176 months). Given this improvement in the overall efficacy of core decompression, the authors concluded that core decompression is a viable option for treating the early stages of ON. This may be due to improvements in surgical indications or technique as well as improvement in postoperative care. 在评估此手术操作的结果时，重要的是要区分较旧和较新的研究结果。在系统的文献综述中，Marker等[12]评估了在1992年之前[13-22]和之后[1, 2, 10, 23-31]（分别为1268和1337髋）手术中髓心减压的临床和影像学结果。作者证明，在1992年之前进行的手术中，41%的髋关节在平均65个月（范围，3至216 个月）的随访后需要额外手术。然而，在1992年之后进行的手术中，平均随访63个月（范围为1至176个月）后，只有30%的髋关节需要再次手术。鉴于髓心减压的整体功效的这种改善，作者得出结论，髓心减压是治疗ON早期阶段的可行选择。这可能是由于手术适应症或技术的改进以及术后护理的改进。 Similarly, Rajagopal et al. [32?] assessed the efficacy of core decompression in a systematic literature review of four level IV studies (n=139 hips) [13, 27, 33, 34]. After a minimum 2-year follow-up, approximately 26 % of all cases were converted to THA. Furthermore, they found that those in Ficat stage I disease and lesions occupying ＜50 % of the femoral head were more likely to achieve satisfactory outcomes (no additional surgery and Harris Hip Scores ＞70 points). The authors further support the notion that core decompression is best when performed in the earliest stages of the disease. 同样，Rajagopal等人[32?]在对四项IV级研究（n=139髋）[13,27,33,34]的系统文献综述中评估了髓心减压的功效。经过至少2年的随访，所有病例中约有26%转为全髋关节置换术。此外，他们发现处于Ficat I期病变且病变占股骨头＜50%的患者更有可能获得令人满意的结果（无需额外手术且Harris髋关节评分＞70分）。作者进一步支持这样一种观点，即在疾病的最早阶段进行髓心减压是最好的。 Although there is a paucity of studies within the last 10 years assessing long-term (＞10 years) outcomes, there are some older studies evaluating long-term results following decompression. Fairbank et al. [35] evaluated patients in precollapse and postcollapse disease (n=128 hips). After a 10-year follow-up, the hip survival rates those in Ficat stages I, II, and III of disease were 96, 74, and 35 %, respectively. Therefore, long-term studies confirm that those with the best outcomes following this procedure are those with early precollapse disease. 尽管过去10年中评估长期（＞10年）结果的研究很少，但有一些较早的研究评估了髓心减压后的长期结果。Fairbank等[35]评估了塌陷前和塌陷后疾病的患者（n = 128 髋）。经过10年的随访，Ficat I、II和III期患者的髋关节存活率分别为96%、74%和35%。因此，长期研究证实，接受此手术后获得最佳结果的是那些患有早期塌陷前病变的人。 In summary, more recent studies have conferred better results than older studies with core decompression. This may be due to improved patient selection or evolving surgical technique. As more long-term outcome studies are published, core decompression will likely gain traction as a treatment of early stage ONFH. 总之，最近的研究比早期的髓心减压研究取得了更好的结果。这可能是由于患者选择的改进或手术技术的发展。随着更多长期结果研究的发表，髓心减压作为早期ONFH的治疗方法可能会受到关注。 Most studies have reported excellent outcomes for this procedure when perfo med in early precollapse disease stages. Yoon et al. [1] evaluated the role of disease stage and lesion location on the outcomes (n=39 hips).After amean follow-up of 61 months, they found that patients who had Ficat stage II or III disease (n=17 out of 22 hips) were significantly more likely to require THA than those with stage I disease (n=5 out of 17 hips) (p＜0.001). In addition, when the lesions were located laterally or centrally, there was a significantly increased rate of conversion to a THA than those with medial lesions (p=0.009). They also noted that larger sized lesions (＞30 % of femoral head) had a significantly greater chance of clinical failure (p＜0.001). They concluded that the ideal candidate has precollapse disease with lesions less than 15 % of the size of the femoral head. 大多数研究报告称，在早期股骨坏死破损前疾病阶段进行髓心减压时，疗效非常好。Yoon等[1]评估了疾病分期和病变位置对结果作用（n=39 髋）。经过平均61个月的随访，他们发现患有Ficat II或III期疾病的患者（22髋中的n=17）比I期疾病患者（17髋中的n=5）更可能需要THA（p＜0.001）。此外，当病变位于外侧或中央时，与内侧病变相比，THA的转化率显着增加（p = 0.009）。他们还指出，较大尺寸的病变（＞30%的股骨头）临床失败的可能性要大得多（p＜0.001）。他们得出结论，理想的手术患者是患有塌陷前病变，病变小于股骨头大小的15%。 These conclusions are supported by Iorio et al. [2], who demonstrated that patients who had Ficat stage I disease had markedly higher 5-year survivorship than those with stage IIA and IIB disease (75%versus 30%versus 17 %, respectively). Therefore, the authors concluded that excellent survivorship occurs for those with stage I disease, but stage II disease patients may require alternative treatments. 这些结论得到了Iorio等人的支持[2]，他们证明了Ficat I期患者的5年生存率明显高于IIA和IIB期患者（分别为75% 对30%对17%）。因此，作者得出结论，I期疾病患者具有极好的存活率，但II期疾病患者可能需要替代治疗。 Additionally, lesion size affects the efficacy of core decompression. Mazieres et al. [3] evaluated 20 hips with Ficat stage II disease. After a mean 24-month follow-up, 50% of the hips (10 hips) showed signs of radiographic progression. When stratifying the cohort by lesion size (＞23 and ≤23 % of the femoral head, respectively), those with smaller lesions (n=8 hips) only had 1 hip with disease progression, while 9 of 12 hips with larger lesions showed radiographic progression. The authors concluded that all decisions regarding this procedure should take into account whether the femoral head has collapsed as well as the volume of the lesions. 此外，病变大小影响髓心减压的功效。Mazieres等[3]评估了20位患有Ficat II期疾病的髋关节。经过平均24个月的随访，50%的髋关节（10髋）显示放射学进展的迹象。当按病灶大小（分别大于股骨头的23%和≤ 23%）对队列进行分层时，那些病灶较小的人（n = 8 髋）只有1髋有疾病进展，而12髋中有9髋有较大病灶的影像学显示进展。作者得出的结论是，有关髓心减压的所有决定都应考虑股骨头是否塌陷以及病变的体积。 The use of core compression after the femoral head has collapsed has resulted in less than optimal outcomes. After a mean follow-up of 12 years (range, 4 to 18 years), Mont et al. [4] evaluated a cohort with postcollapse ONFH (n=68 hips). Only 29 % of the hips (n=20) had satisfactory outcomes (no additional surgeries and HHS ≥75 points). Furthermore, when categorized by disease stage, 41 % of the Steinberg stage III hips (n=18 out of 44 hips) required a THA, and 92 % of the stage IV hips (n=22 out of 24 hips) underwent a THA. Therefore, diagnosis before femoral head collapse is crucial for core decompression to be effective. 在股骨头塌陷后使用髓心减压往往治疗效果不太理想。经过平均12年（范围，4至18年）的随访，Mont等[4]评估了一个有塌陷后ONFH的队列（n = 68髋）。只有29%的髋关节(n=20)具有令人满意的结果（没有额外手术且HHS ≥75 分）。此外，按疾病分期分类时，41%的Steinberg III期髋关节（44髋中的n=18）需要THA，而92%的IV期髋关节（24 髋中的 n=22）接受THA。因此，股骨头塌陷前的诊断对于髓心减压术的有效性至关重要。 There have been attempts to use various adjunctive therapies with this procedure such as the following: (1) bone grafting [13, 23, 26]; (2) addition of mesenchymal cells [13, 23, 26]; and (3) tantalum rod insertion [9, 11, 36–41]. 已经尝试在髓心减压过程中使用各种辅助疗法，例如：(1)骨移植术[13, 23, 26]；(2)添加间充质细胞[13, 23, 26]；(3)钽棒植入[9, 11, 36–41]。 Bone grafting 骨移植 Different types of bone grafts have been introduced into core tracts with the goal of providing structured support and further optimizing patient-reported outcomes. It is believed that bone grafting can stimulate repair and act as the foundation on which new bone may form. Wei and Ge [42] assessed the outcomes of a large cohort of patients in ARCO stage II and III ON following core decompression and concurrent nonvascularized bone grafting (n=223 hips). After a mean follow-up of 24 months (range, 7 to 42 months), they found a hip survival rate (no further surgeries required) of 81% and a mean Harris Hip Score (HHS) that increased from 61 to 86 points at latest follow-up. Furthermore, multiple studies have shown that this can be an effective method for delaying the need for THA while subsequently allowing core decompression to be effective in later stages of ON [42–46]. 不同类型的骨移植物已被引入髓心减压隧道，目的是提供结构化的支持并进一步优化患者报告的结果。人们相信骨移植可以刺激修复并作为新骨形成的基础。Wei和Ge[42]评估了大量ARCOII和III期ON患者在髓心减压和同步非血管化骨移植（n = 223髋）后的结果。在平均24个月（范围，7至42个月）的随访后，他们发现髋关节存活率（无需进一步手术）为81%，平均Harris髋关节评分(HHS)从61分增加到最新随访的86分。此外，多项研究表明，这可能是一种有效的方法，可以延迟对THA的需求，同时提高髓心减压在ON的晚期阶段有效性[42-46]。 Mesenchymal stem cells 间充质干细胞 There have been attempts to use core decompression with the addition of bone marrow cells (BMC) [8, 10, 47–49, 50?]. Li et al. [8] compared the use of BMC therapy to core decompression alone in a meta-analysis of 4 studies (n=219 hips) [47–49, 50?]. After a follow-up of 18 months, the authors demonstrated that significantly less patients in the BMC cohort required additional surgeries and/or procedures than those in the core decompression cohort (OR=0.11; p＜0.01). Therefore, the authors concluded that the implantation of BMC may result in better outcomes than the use of core decompression alone. Therefore, BMC implantation may hold future promise as an adjunctive therapy. 已经尝试通过添加骨髓干细胞(BMC)来完成髓心减压[8, 10, 47–49, 50?]。Li等[8]在4项研究（n=219 髋）的荟萃分析中比较了BMC治疗与单独使用髓心减压术[47–49, 50?]。在18个月的随访后，作者证明BMC队列中需要额外手术和/或程序的患者明显少于髓心减压队列中的患者（OR=0.11；p＜0.01）。因此，作者得出结论，与单独使用髓心减压相比，植入BMC可能会产生更好的结果。因此，BMC植入作为一种辅助疗法可能在未来有希望。 Tantalum rod 钽棒 Core decompression with the insertion of a porous tantalum rod initially showed some positive results [7, 37, 40]. However, many of these studies were done on very small cohorts, and the removal of these implants has led to complications such as fracture [7, 37, 40, 51–55]. Therefore, we do not recommend this as an adjunctive procedure. Recently, Ye et al. evaluated the efficacy of this adjunct (n=12 hips). After a mean followup of approximately 37 months (range, 6 to 47), 5 hips (42 %) required THA and 1 hip had a hardware failure. 插入多孔钽棒的髓心减压最初显示出一些积极的结果[7, 37, 40]。然而，这些研究中有许多是在非常小的队列中进行的，移除这些(多孔钽棒)植入物会导致骨折等并发症[7, 37, 40, 51-55]。因此，我们不建议将多孔钽棒作为髓心减压辅助操作。最近，Ye等评估了该辅助装置的功效（n=12 髋）。在大约37个月（范围，6至47）的平均随访后，5髋（42%）需要THA，1髋出现内固定失败。 Description of multiple percutaneous drilling decompression 多次经皮钻孔减压的描述 Despite the excellent results with traditional core decompression, there are complications that can occur such as violation of the articular cartilage or subtrochanteric fractures. In an attempt to minimize these complications, instead of drilling one large tract, some have used multiple percutaneous drilling. Using a small diameter pin, multiple passes were made into the lesion [5, 56]. Recently, it has been used by number of surgeons with excellent results [5, 56–58]. 尽管传统的髓心减压术取得了优异的效果，但仍可能出现并发症，例如侵犯关节软骨或转子下骨折。为了尽量减少这些并发症，一些人使用多次经皮钻孔，而不是在一个大管道上钻孔。使用小直径钻孔针，多次通过病灶[5, 56]。最近，它已被许多外科医生使用，效果极佳[5, 56–58]。 For this technique, the patient is placed in the supine position on a fracture table, placed under intravenous sedation, and prepared and draped in an aseptic manner. The extremity is placed in slight internal rotation, the Steinman pin or drill is then inserted laterally above the level of the lesser trochanter, and it is advanced under fluoroscopic guidance toward the lesion [5]. Although dependent on surgeon preference, larger sized lesions require more passes (minimum, 2 to 3 passes) than smaller ones (1 pass) [56, 57]. After its completion, the pins are removed, direct pressure is held at the site, and a sterile dressing is applied. Postoperative care is similar to that following traditional decompression with the patient being 50 % weightbearing for 6 weeks. After 6 weeks, the patient is allowed to bear full weight and is given hip and abductor strengthening exercises to complete. The patient is also educated to avoid high impact activities for at least 1 year and is instructed to follow up at 6, 12 weeks, 6, 12 months, and annually thereafter. 对于这项技术(多次经皮钻孔)，患者被置于在手术台上，仰卧位，采用静脉麻醉，并以无菌方式准备和铺单巾。将肢体轻微内旋，然后将Steinman螺纹针或钻针从外侧插入小转子水平上方，并在透视引导下向病变处推进[5]。尽管取决于外科医生的偏好，但较大尺寸的病变需要比较小的病变（1次）更多的通道（最少，2-3个通道）[56,57]。完成后，取下钻针，在该部位保持直接压力，并使用无菌敷料。术后注意事项与传统髓心减压术后的注意事项相似，患者负重50%，持续6周。6周后，患者可以承受全部重量，并进行髋关节和外展肌强化练习来完成。还教育患者至少在1年内避免高强度活动，并被指示在6、12周、6、12个月和此后每年进行一次随访。 Outcomes of percutaneous drilling 经皮钻孔的结果 Outcomes associated with this percutaneous drilling technique are comparable to standard core decompression. In 2004, Mont et al. [57] were one of the first to report on this technique using multiple 3.2-mm drillings (2 to 3 holes) to achieve decompression in a cohort of patients who had precollapse ONFH (n=45 hips). Failure was defined as an HHS less than 70 and/or requiring additional surgery.After amean follow-up of 24 months (range, 20 to 39 months), among patients with Ficat stage I disease (n=30 hips), 80 % (24 hips) had successful outcomes by the time of their last follow-up. Similarly, Song et al. [56] evaluated this technique in patients who had both precollapse and postcollapse disease (n=163 hips). They used 3.6-mm Steinmann pins and a mean of 12 holes (range, 4 to 22 holes).At 87-month mean follow-up (range, 60 to 134 months), 66 % of the hips (108 hips) were considered to have successful outcomes (HHS ≥75 points and no additional surgery). Of the patients with Ficat stage I disease, 79%demonstrated clinically successful outcomes (n=31 of 39 hips), while 77 % of patients with stage II ON were deemed clinically successful (n=62 of 81 hips). Furthermore, the authors found that there was a significantly higher survivorship in patients with Ficat stage I or II than in patients with stage III ON (p＜0.01). Moreover, there was a significantly higher survivorship in patients with small (＜25 % involvement, n=15 of 15 hips) or medium lesions (25 to 50 % involvement, n=37 of 44 hips) compared with large lesions (＞50 % involvement, 56 of 204 hips, p＜0.01). 与这种经皮钻孔技术相关的结果可与标准髓心减压相媲美。2004年，Mont等[57]是最早报告使用多个3.2毫米钻孔（2到3个孔）在一组患有预塌陷ONFH（n=45髋）的患者中实现减压的技术之一。失败定义为HHS小于70和/或需要额外手术。平均随访24个月（范围，20至39个月）后，在患有Ficat I期疾病（n=30髋）的患者中，80%（24髋）在最后一次随访时取得了成功的结果。同样，Song等[56]在患有塌陷前和塌陷后疾病的患者（n = 163 髋）中评估了这种技术。他们使用3.6毫米Steinmann针和平均12个孔（范围，4到22个孔）。在87个月的平均随访（范围，60至134个月）中，66%的髋关节（108髋）被认为具有成功的结果（HHS ≥75分且未进行额外手术）。在患有Ficat I期疾病的患者中，79%的患者表现出临床成功（n=31 of 39 hips），而77%的II期ON患者被认为临床成功（n=62 of 81 hips）。此外，作者发现Ficat I或II期患者的生存率明显高于III期ON患者（p＜0.01）。此外，与大病灶（＞50%）或中等病灶（25%至50%受累，44个髋关节中的37个）相比，小病灶（＜25%受累，n=15，15髋）的存活率显着更高，204髋中有56髋受累，p＜0.01）。 Recently, Omran [59??] assessed and compared the use of the multiple drilling technique (n=33 hips) to the conventional technique (n=61 hips) in a cohort of patients with sickle cell disease in Ficat stage I or II ONFH (n=94 patients). After a minimum follow-up of 2 years, patients had significant reductions in pain and improvement in HHS regardless of the technique. The authors concluded that although the multiple drilling technique is less invasive, it has similar outcomes compared to conventional decompression. 最近，Omran[59??]在一组Ficat I或II期ONFH镰状细胞病患者中评估并比较了多次钻孔技术（n=33髋）与常规技术（n=61髋）的使用（n = 94名患者）。在至少2年的随访后，无论采用何种技术，患者的疼痛均显着减轻，HHS改善。作者得出的结论是，虽然多次钻孔技术侵入性较小，与传统减压相比具有相似的结果。 In summary, the use of multiple drilling technique of femoral head decompression has demonstrated excellent survivorship and outcomes. When compared to traditional methods, this newer approach has demonstrated similar results and may be easier to perform with fewer complications. 总之，使用多次钻孔技术进行股骨头减压已显示出良好的存活率和结果。与传统方法相比，这种较新的方法显示出类似的结果，并且可能更容易执行，并发症更少。 Conclusion 结论 The efficacy of core decompression for the treatment of ONFH remains an area of controversy. However, most of the studies indicate that this management strategy is associated with the best outcomes when used in the earliest, precollapse stages of the disease with small lesions. Efficacy has improved over the past 20 years, and this may be due to improved patient selection or the use of new surgical techniques such as multiple percutaneous drilling. As this treatment modality continues to evolve, further studies should focus on new surgical techniques and adjunctive therapies that may further the prevention and/or delay of THA. 髓心减压治疗ONFH的疗效仍然存在争议。然而，大多数研究表明，这种治疗策略在病灶较小的疾病早期、坏死塌陷前阶段使用时可获得最佳结果。在过去的20年中，疗效有所提高，这可能是由于患者选择的改进或新手术技术的使用，例如多次经皮钻孔。随着这种治疗方式的不断发展，进一步的研究应侧重于可能进一步预防和/或延迟THA的新手术技术和辅助疗法。2022年12月28日948
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朱凯主治医师 中国人民解放军总医院第六医学中心 康复医学科 股骨头坏死是一个病理演变过程，初始发生在股骨头的负重区，应力作用下坏死骨骨小梁结构发生损伤即显微骨折以及随后针对损伤骨组织的修复过程。目前，主要的治疗方法有： 1、股骨头髓芯减压术； 2、吻合血管或不吻合血管的骨移植术； 3、旋转截骨术； 4、人工关节置换手术。 一、股骨头坏死的治疗理念 1、坏死早期的青壮年患者倾向于保髋治疗； 2、坏死晚期的老年患者倾向于人工关节置换手术。 二、PRP可应用于股骨头坏死的保髋治疗中，可能治疗机理 1、PRP促进新生血管形成，为细胞再生提供足够的营养，防止股骨头细胞凋亡，促进骨再生； 2、PRP可促进骨髓间充质细胞（BMSC）增殖、分化； 3、PRP可诱导BMSC向软骨细胞分化，促进软骨再生； 4、PRP可在股骨头坏死局部抑制细胞的凋亡； 5、PRP可弥补生长因子的不足。 三、PRP治疗股骨头环伺的适应症 股骨头坏死的早期，即FicatⅠ期和Ⅱ期，股骨头关节面尚未塌陷。 四、PRP治疗股骨头坏死的方法 1、一般采用PRP结合股骨头髓芯减压术； 2、对于年轻患者，可采用吻合血管游离腓骨移植术，有文献报道此种方法是一种有效方法； 3、有文献报道，有少数临床医生采用髋关节镜下应用PRP修复股骨头，镜下具有视野清晰，死骨清除彻底，PRP填充准确等优点。2020年03月22日6000
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