骨科-股骨头坏死ONFH
股骨头坏死ONFH Osteonecrosis of the femoral head,医院骨科,提 纲,提 纲,First described in 1794 by James Russel. A book on bone necrosis. Fully described by Phemister in 1930 This entity was reviewed by Mankin and Brower with 5 cases in 1962.,Overview,Osteonecrosis, also known as aseptic necrosis, avascular necrosis (AVN), and ischemic necrosis. Compromise of the bone vasculature, leading to the death of bone and marrow cells (bone marrow infarction), and ultimate mechanical failure is common to most proposed etiologies. The process is most often progressive, resulting in joint destruction within a few months to two years in the majority of patients,Overview,Epidemiology,50years The male-to-female ratio varies depending upon the associated co-morbidities. （NONFH8,120,000, M. 1.2% vs F. o.51%) Specific data not available. Estimated new cases： 15,000/year in USA 200,000/year in China20-38/100000 in Korea,Overview,提 纲,A variety of traumatic and atraumatic factors Traumatic：hip fracture and dislocation，fractures of the scaphoid and lunate, knee Atraumatic Long term Steroid：duration/initial dose/total dosage Excessive Alcohol Dysbarism Hemoglobinopathy Collagen disorder RadiationPregnancy Bisphosphonate use Idiopathic：Gene COL2A1 mutation,Etiology and Pathology,Bone marrow cell infarction：约在血流中断后612h，造血细胞最先死亡。 12h后，为骨细胞和骨母细胞死亡。 15天后脂肪细胞死亡。 2weeks empty lacuna. 空骨陷窝 组织学是金标准，最早。 影像学2周或更长,Etiology and Pathology,第一PPT模板网 www.1ppt.com/tubiao,vascular damage genetic predisposition metabolic factors intraosseous pressure osteoperosis,Mechanical stress + Ischemia,Deformity,Steroid induced ONFH,Controversial combined,trauma,Decreased blood flow,Intravascular coagulation,alcohol & corticosteroid,Vascular interruption,Thrombotic occlusion,Fat emboli,Ischemia,Osteocyte necrosis,Bone repair,Collapse,Etiology,Pathogenesis,Decreased blood flow,Pathophysiology,Histopathology,Etiology and Pathology,Case1,Pathology,Cartilage,Sclerosis,Fibrous T.,Dead bone,Normal,Etiology and Pathology,Cartilage,Sclerosis,Fibrous T.,Dead bone,Normal,囊性变,Traumatic AVN,HIP FRACTURE:FEMORAL NECK FRACTURE HIP DISLOCATION ACETABULAR FRACTURE SCFE： Slipped Capital Femoral Epiphysis,BLOOD SUPPLY TO THE FEMORAL HEAD 圆韧带内的小凹动脉，少量供血 股骨干的滋养动脉升支，少量供血 旋股内、外侧动脉，主要供血。（旋股内侧动脉损伤是股骨头坏死主要因素）,BLOOD SUPPLY,正常,受损,PATHOLOGY(HE),正常股骨头,坏死股骨头,DISPLACEMENT,Garden型: 不完全骨折 Garden型:完全骨折，没有移位 Garden型:完全骨折，部分移位 Garden型:完全骨折，完全移位 移位程度越大，越易发生坏死,Dynamic MR,Kamano 75th AAOS Annual Meeting Gd-DTPA增强1.5 T MRI 41 patients with femoral neck fractures,SPECT-CT,临床诊疗指南,年龄65岁以上且骨折为Garden型、型。 无严重的合并症。 术前生活质量及活动水平较好。 术前生活质量及活动水平差，相对高龄患者建议行半髋关节置换术。,提 纲,CLINICAL MANIFESTATIONS,My be entirely asymptomatic Pain around the hip area, especially groin pain, may radiating to the knee, present with knee pain or even with back pain. Limp: restriction of motion, the greater degree of AVN, the greater restriction of ROM.,临床表现与诊断,PHYSICAL EXAMINATION,Not specific 患髋“4”字试验阳性 Inequality of leg length，,临床表现与诊断,Ficat分期,0期：无疼痛，平片正常，骨扫描与磁共振出现异常 I期：有疼痛，平片正常，骨扫描与磁共振出现异常 II期(过度期)：有疼痛，平片见到囊性变或/和硬化，骨扫描与磁共振出现异常，没有出现软骨下骨折 III期：有疼痛，平片见到股骨头塌陷，骨扫描与磁共振出现异常，见到新月征（软骨下塌陷）或/和软骨下骨台阶样塌陷 IV期：有疼痛，平片见到髋臼病变，出现关节间隙狭窄和骨关节炎，骨扫描与磁共振出现异常,临床表现与诊断,IMAGE FINDINGS,X线 CT MRI SPECT-CT 动脉造影,MRI continues to be the most sensitive and specific for diagnosis in symptomatic and asymptomatic patients, especially in early stage disease,临床表现与诊断,X ray,至少2-3M后表现，病变常位于股骨头前上部。 间隙不狭窄，头不变形 股骨头轻度变形，出现轻度台阶征，股骨头尚未明显塌陷、碎裂。 头密度不均匀，出现囊样或扇形骨质破坏区，周围可有高密度新骨增生。 头明显变形、压缩、塌陷、骨密度不均匀,髋关节间隙狭窄和退行性骨关节炎。,临床表现与诊断,CT,尤其对一些微小病灶的部位和内部变化、是否存在塌陷（软骨下骨折,头无变形）显示更为清晰 敏感性不及MRI和同位素,临床表现与诊断,临床表现与诊断,Crescent sign,Subchondral bone fracture,MRI：Normal,临床表现与诊断,MRI FINDINGS,此期被称为股骨头缺血坏死临床前期，也称Silent Hip。 患者无自觉症状，X线、CT、核素扫描及MRI等检查均为阴性。 但骨缺血坏死改变已存在，已有髓腔压力增高，骨髓活检可证实骨缺血坏死存在。,临床表现与诊断,MRI findings,髋关节间隙正常，股骨头光整、不变形。 典型的MRI表现为股骨头前上部负重区在T1W上显示线样低信号区，T2W上显示为局限性信号升高或“双线征”。 在MRI上出现“双线征”，这是股骨头缺血坏死的特异性MRI表现之一。,临床表现与诊断,Figure 1 : MRI in weighted Spin echo sequence in T1 (T1) = normal hip T2 with fat suppression,Double line sign,MRI findings,髋关节间隙正常，无狭窄。 股骨头表面毛糙、开始变形。 软骨下皮质出现骨折，进一步发展出现轻微塌陷、阶梯状改变。 新月体形成：新月体代表无法修复的坏死骨发生引力性骨折，在T1W上为带状低信号区，T2W上，由于细胞内液渗出或关节液充填骨折线而呈高信号 股骨头表面软骨的完整性受到一定影响,临床表现与诊断,关节软骨彻底破坏，髋关节间隙狭窄，合并关节退行性改变。 髋臼面软骨下骨质可出现囊性变，髋臼缘骨赘增生 股骨头因骨坏死、囊变、骨折而显著塌陷、变形，受累范围可局限于股骨头上部或累及整个股骨头。 股骨头出现分节碎裂、骨折移位。,MRI findings,临床表现与诊断,股骨头坏死核医学表现,早期：坏死股骨头表现为局限性放射性缺损而无周围浓聚反应。 中期：坏死股骨头表现为放射性缺损区周围有浓聚反应，形成所谓炸面圈征。 晚期：整个股骨头呈球形或类球形明显浓聚，有时可为不规则浓聚。,临床表现与诊断,核医学表现早期,双侧坏死,临床表现与诊断,核医学表现中期,炸面圈征,临床表现与诊断,核医学表现晚期,单侧坏死,临床表现与诊断,DIAGNOSIS,病史：髋部创伤、类固醇激素、长期酗酒等 症状与体征： 疼痛 性质 部位有其特点：髋部、膝部疼痛 跛行 早期 后期 单侧 双侧各有不同 髋关节活动功能障碍 双下肢不等长、患肢肌肉萎缩 “4”字试验阳性，髋关节屈曲挛缩试(Thomas征)阳性。,临床表现与诊断,鉴别诊断,髋关节骨关节炎 Osteoarthritis OA 类风湿关节炎 Rheumatoid Arthritis RA 髋关节结核 TB 化脓性关节炎 Pyogenic Arthritis 强直性脊柱炎 AS 肿瘤,临床表现与诊断
