Cell therapy of hip osteonecrosis with autologous bone marrow grafting.
Cell therapy of hip osteonecrosis with autologous bone marrow grafting.
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DOI：
10.4103/0019-5413.45322
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发表时间：
2009-01
影响因子：
1
通讯作者：
Rouard H
中科院分区：
文献类型：
--
作者：
Hernigou P;Poignard A;Zilber S;Rouard H
股骨头骨坏死后骨重塑导致爬行替代不足的原因之一可能是股骨近端和粗隆区祖细胞数量少。由于缺乏祖细胞，治疗方式应刺激和引导骨重塑，使其达到足够的爬行替代，以保持股骨头的完整性。植骨椎体减压是治疗股骨头坏死的常用方法。在目前的系列研究中，从髋关节早期骨坏死患者的髂骨中获得的自体骨髓进行移植，假设在软骨下塌陷阶段之前，增加股骨近端祖细胞的数量将刺激骨重塑和爬行替代，从而改善功能结果。1990年至2000年间，342例早期（I期和II期）无血管性骨坏死患者（534髋）接受了髋关节骨坏死手术患者的核心减压和髂骨自体骨髓移植。在534例髋关节中，服用皮质类固醇的患者中有19%髋部受到骨坏死的影响，过量饮酒的患者中有28%，镰状细胞病患者中有31%。患者在减压和自体骨髓移植时的平均年龄为39岁（范围：16-61岁）。用小套管针减压后，将抽取的骨髓通过浓度减少体积注入股骨头。为了测量移植的祖细胞数量，以成纤维细胞集落形成单位作为基质细胞活性的指标。患者随访8 ~ 18年。结果取决于Harris髋关节评分的变化，x线分期的进展，通过MRI上不同切口的坏死区域数字化确定的体积变化，以及是否需要进行髋关节置换术。534例髋关节塌陷（I期和II期）前手术的患者中，有94例髋关节（演变为塌陷）需要全髋关节置换术。术前和术后MRI检查显示，手术时69例伴有I期股骨头坏死的髋关节股骨头坏死完全消退；这些髋部在x线平片上未显示任何变化。治疗前69例骨坏死仅呈边缘带状异常信号，体积小于20立方厘米。病灶内与股骨头坏死区外的信号保持正常。在最近的随访中（平均12年），371例没有塌陷的髋关节，术前骨坏死的平均体积为26 cm3（最小12 cm3，最大30 cm3）。在最近一次随访（平均12年）MRI上测量的异常信号的平均体积为12 cm3。异常信号作为后遗症持续存在，在T1图像上可见病灶内低强度信号区，边缘带状模式消失。根据我们的经验，手术的最佳适应症是有症状的髋关节伴有骨坏死而没有塌陷。一些患有Steinberg III期骨坏死（软骨下透光，无塌陷）的患者在5 - 10年内获得了成功的结果（无需进一步手术）。因此，在选定的患者中，甚至更晚期的疾病也可以考虑进行核心减压。髋部移植大量祖细胞的患者预后更好。
One of the reasons for bone remodeling leading to an insufficient creeping substitution after osteonecrosis in the femoral head may be the small number of progenitor cells in the proximal femur and the trochanteric region. Because of this lack of progenitor cells, treatment modalities should stimulate and guide bone remodeling to sufficient creeping substitution to preserve the integrity of the femoral head. Core decompression with bone graft is used frequently in the treatment of osteonecrosis of the femoral head. In the current series, grafting was done with autologous bone marrow obtained from the iliac crest of patients operated on for early stages of osteonecrosis of the hip before collapse with the hypothesis that before stage of subchondral collapse, increasing the number of progenitor cells in the proximal femur will stimulate bone remodeling and creeping substitution and thereby improve functional outcome. Between 1990 and 2000, 342 patients (534 hips) with avascular osteonecrosis at early stages (Stages I and II) were treated with core decompression and autologous bone marrow grafting obtained from the iliac crest of patients operated on for osteonecrosis of the hip. The percentage of hips affected by osteonecrosis in this series of 534 hips was 19% in patients taking corticosteroids, 28% in patients with excessive alcohol intake, and 31% in patients with sickle cell disease. The mean age of the patients at the time of decompression and autologous bone marrow grafting was 39 years (range: 16–61 years). The aspirated marrow was reduced in volume by concentration and injected into the femoral head after core decompression with a small trocar. To measure the number of progenitor cells transplanted, the fibroblast colony forming unit was used as an indicator of the stroma cell activity. Patients were followed up from 8 to 18 years. The outcome was determined by the changes in the Harris hip score, progression in radiographic stages, change in volume determined by digitizing area of the necrosis on the different cuts obtained on MRI, and by the need for hip replacement. Total hip replacement was necessary in 94 hips (evolution to collapse) among the 534 hips operated before collapse (Stages I and II). Sixty-nine hips with stage I osteonecrosis of the femoral head at the time of surgery demonstrated total resolution of osteonecrosis based on preoperative and postoperative MRI studies; these hips did not show any changes on plain radiographs. Before treatment, these 69 osteonecrosis had only a marginal band like pattern as abnormal signal and a volume less than 20 cubic centimeters. The intralesional area had kept a normal signal as regards the signal of the femoral head outside the osteonecrosis area. For the 371 other hips without collapse at the most recent follow up (average 12 years), the mean preoperative volume of the osteonecrosis was 26 cm3 (minimum 12, maximum 30 cm3). The mean volume of the abnormal signal measured on MRI at the most recent follow up (mean 12 years) was 12 cm3. The abnormal signal persisting as a sequelae was seen on T1 images as an intralesional area of low intensity signal with a disappearance of the marginal band like pattern. According to our experience, best indication for the procedure is symptomatic hips with osteonecrosis without collapse. In some patients who had Steinberg stage III osteonecrosis (subchondral lucency, no collapse) successful outcomes (no further surgery) has been obtained between 5 to 10 years. Therefore in selected patients, even more advanced disease can be considered for core decompression. Patients who had the greater number of progenitor cells transplanted in their hips had better outcomes.
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DOI：
10.1302/0301-620x.77b1.7822393
发表时间：
1995-01-01
影响因子：
--
作者：
STEINBERG, ME;HAYKEN, GD;STEINBERG, DR
通讯作者：
STEINBERG, DR
DOI：
10.2106/00004623-199711000-00015
发表时间：
1997-11-01
影响因子：
5.3
作者：
Hernigou, P;Bernaudin, F;Vernant, JP
通讯作者：
Vernant, JP
影响因子：
5.3
作者：
Hernigou, P;Poignard, A;Rouard, H
通讯作者：
Rouard, H
DOI：
10.2106/00004623-199711000-00012
发表时间：
1997-11-01
影响因子：
5.3
作者：
Muschler, GF;Boehm, C;Easley, K
通讯作者：
Easley, K
DOI：
10.1097/01.blo.0000038472.05771.79
发表时间：
2002-12-01
影响因子：
4.2
作者：
Hernigou, P;Beaujean, F
通讯作者：
Beaujean, F