股骨头坏死的关节镜下表现及分析

Arthroscopic manifestations of necrosis of the femoral head

目的关节镜下观察股骨头坏死的病理表现并对其进行分析。方法对27例(38髋)股骨头坏死施行髋关节镜手术,其中男19例,女8例。FicatⅠ期8髋,Ⅱ期21髋,Ⅲ期7髋,Ⅳ期2髋。关节镜下探查股骨头、髋臼和滑膜组织的外观及质地,同时镜下行关节清理及股骨头微钻孔髓心减压术。结果镜下见Ⅰ期:股骨头表面关节软骨完整无破坏,外观及触探质地正常。滑膜组织充血肿胀。Ⅱ期:股骨头表面大部分区域正常,负重区软骨软化,有裂隙,触探有凹陷,软骨下骨坏死区域有裂隙形成,但软骨钙化层与软骨尚未分离。坏死骨表面硬化,如沙砾样粗糙。滑膜组织增生。Ⅲ期:软骨大面积剥脱,与软骨下骨分离。软骨下骨塌陷、碎裂,内有无效修复的肉芽组织。Ⅳ期:呈骨性关节炎样改变,关节间隙变窄,股骨头表面软骨缺损,软骨下骨外露、坏死、塌陷,髋臼软骨退变。结论关节软骨的损害是股骨头坏死病程中的重要环节。关节镜技术对股骨头坏死的价值主要在于评估关节软骨的受累程度,对治疗方法的选择具有重要的参考价值。

Objective To observe arthroscopic manifestations of necrosis of the femoral head and to evaluate the results. Methods Arthroscopic operations were performed in 38 hips in 27 patients （ 19 male and 8 female） with necrosis of the femoral head. There were 8 hips of Ficat stage Ⅰ , 21 hips of stage Ⅱ , 7 hips of stage Ⅲ , and 2 hips of stage Ⅳ, respectively. The arthroscopic operation included an assessment of the appearance and texture of the femoral head, the acetabulum, and the synovium, debridement of the joint, and femoral head decompression by drilling small holes. Results Arthroscopically, the Ficat stage I hips were considered to have a intact articular surface, with normal appearance and instrument compression, displaying a hyperaemia and swelling of the synovial tissue. The stage Ⅱ hips presented a major portion of the normal articular surface, chondromalacia of the weight bearing portion of the femoral head, fissures on the articular surface, and sinking with instrument compression. A cleavage plane was formed between the fractured and collapsed necrotic subchondral bone, but the cartilage still communicated with the calcificated layer. The surface of necrotic bone was sclerosesed and rough like sandstones. Hyperplasia of the synovial tissue was seen. The stage Ⅲ hips manifested a massive disassociation of the articular surface from the underlying subchondral bone and the delamination of the femoral head. The subchondral bone was collapsed and disintegrated, with ineffective repaired granulation tissue in it. The stage Ⅳ hips displayed narrowing of the joint space, extensive chondral lesions of the femoral head, collapse of necrotic subchondral bone exposed, and degenerative changes on the acetabulum side, all of which were consistent with the end - stage of osteoarthritis. Conclusions Articular cartilage impairment plays an important role in the process of the necrosis of the femoral head. The value of hip arthroscopic examinations lies in accurate evaluation of the extent of the chondral impairment and important reference for the choice of procedures.