现代技术是否提高股骨头坏死钻孔减压的疗效 ppt课件

Do Modern Techniques Improve Core Decompression Outcomes for Hip Osteonecrosis ? ? 2011-09-13 Content IntroductionContent Introduction Journal : Clin Orthop Relat Res IF: 2.116 Published year: 2008 Author: From Sinai Hospital of Baltimore USA Systematic Review Abstract Object: to determine whether the efficacy improved during the last 15 years Method: 1.compared the success rates before 1992 VS 1992-2007 2.evaluated the outcomes of our 52 patients (79 hips) treated with multiple small- diameter drillings. Result: 1.decrease in additional surgeries and increase in radiographic success 2.small lesions and Ficat Stage I had the best results with 79% no radiographic progression Conclusion: core decompression is a safe and effective procedure QuestionsQuestions 1.whether the efficacy of core decompression has improved during the last 15 years ? 2.whether modern techniques provide better outcomes than those non-operative treatment ? 3.whether the outcomes treated using small -diameter drilling were similar to other modern studies ? 4.whether patients less radiographic progression and smaller lesion sizes using small diameter drilling would be less likely to have poor outcomes ? Inclusion criteriaInclusion criteria 1.provided radiographic outcomes and/or indicated whether patients underwent additional surgeries 2.Only the most recent studies were included at multiple times at different followups 3.the use of ancillary cancellous bone grafting 4.previously unpublished results at our institution treated using a small- diameter drilling Exclusion criteriaExclusion criteria 1.not provide sufficient data to analyze outcomes 2.fewer than 10 patients 3.Patients younger than 18 years old 4.used long cortical strut bone grafting or vascularized bone grafting 5.a mean followup of less than 18 months Criteria for assessing effectiveness Measure Inclusion/Exclusion criteria Examples Additional surgery 1. Include additional surgeries THA, vascularized bone associated with progression grafting, osteotomy of osteonecrosis. 2. Exclude surgeries not directly Evacuation of a hematoma related to long-term failure of core decompression. Radiographic failure 1. Include progression to collapse. Progression from 2. Include progression Ficat II to III. from collapse to further Steinberg IV to V. stage of degeneration 3. Exclude progression Progression from without collapse. ARCO I to II. Pre-1992 studies (23) Author/Year NO. Follow-up (m) Additional surgery(%) Radiographic failure(%) Solomon/1981 22 24 (648) 5 (23) Ficat/1985 133 114 (60204) 28 (21) Camp et al./1986 40 18 (340) 6 (15) 8 (20) Hopson et al./1988 20 39 (1278) 12 (57) Saito et al./1988 17 48 (24168) 9 (53) Tooke et al./1988 45 36 (1284) 16 (36) 16 (36) Aaron et al./1989 50 26 28 (56) 32 (64) Aaron et al./1989 56 27 18 (32) 22 (39) Beltran et al./1990 34 23 (1147) 16 (47) Trancik et al./1990 11 45 (2460) 5 (45) 11 (100) Kristensen et al./1991 18 39 (1260) 3 (17) Stulberg et al./1991 28 27 8 (29) 21 (75) Total 1337 65(3216) 446 (41) 302 (44) 1992 to 2007 studies (26) Author/Year NO. Follow-up (m) Additional surgery(%) Radiographic failure(%) Kane et al./1996 19 (2460) 11 (58) 11 (58) Markel et al./1996 54 (253) 26 (48) Chang et al./1997 84 57 (24 to 165) 22 (26) 59 (70) Mazieres et al./1997 20 24 9 (45) 9 (45) Powell et al./1997 34 48 9 (26) Iorio et al./1998 33 64 (24120) 11 (33) 18 (55) Scully et al./1998 98 (2150) 52 (53) Chen et al./2000 27 28 (12128) 10 (37) Lavernia et al./2000 67 41 16 (24) Aigner et al./2002 45 69 (31120) 7 (16) 12 (27) Gangji et al./2004 10 24 0 (0) 1 (10) Ha et al./2006 18 (5096) 14 (78) Total 1268 63 (1176) 366 (30) 250 (37) historical VS modern studies Data Studies（pre 1992） Studies（1992-2007) p-Value Demographic variables Mean age (range) 39 (1583) years 39 (1372) years Mean followup (range) 65 (3216) months 63 (1176) months Preoperative ficat stage Ficat Stage I 32% 29% 0.302 Ficat Stage II 42% 52% 0.001 Ficat Stage III 27% 19% 0.001 Additional surgery Overall 41% 30% 0.001 Ficat Stage I 15% 20% 0.413 Ficat Stage II 44% 35% 0.056 Ficat Stage III 67% 66% 0.939 Radiographic failure Overall 44% 37% 0.001 Ficat Stage I 22% 21% 0.919 Ficat Stage II 47% 48% 0.887 Ficat Stage III 66% 50% 0.708 Nonoperative treatment (18) Author/Year NO. Follow-up (m) Additional surgery(%) Radiographic failure(%) Coste et al./1965 100 24 73 (73) Merle et al./1965 90 36 (1248) 61 (68) Boettcher et al./1970 5 (minimum 24) 4 (80) Zizic et al./1985 15 44 13 (87) Musso et al./1986 50 30 34 (68) 41 (82) Steinberg et al./1989 55 21 (6120) 46 (84) Churchill et al./1991 18 60 9 (50) 8 (44) Stulberg et al./1991 22 27 20 (91) 11 (50) Robinson et al./1993 16 39 (2461) 7 (44) 9 (56) Bradway et al./1993 15 23 (366) 13 (87) 15 (100) Jergesen et al./1997 19 111 (5181) 11 (58) 7 (41) Neumayr et al./2006 21 36 3 (14) Total 792 53 (3240) 271 (63) 455 (72) Multiple small-diameter drilling VS other studies Data Small-diameter technique Other studies（1992-2007) p-Value Demographics Number of hips 242 1026 Mean age (range) 39 (1872) 39 (1271) Mean followup 80 (36134) 58 (1176) Outcomes Additional surgery 32% 29% 0.520 Radiographic failure 34% 37% 0.437 Results-1 the success rates were higher for the studies during the last 15 years compared to before 1992 1.Without additional surgery from 59% to 70% (p0.001) 2.radiographic success increased from 56% to 63% (p0.05) 3. fewer patients who were Ficat Stage III after 1992 (p0.001) Results-2 higher proportions of failures nonoperative treatment VS the core decompression studies from 1992 to 2007 1. underwent surgery at a mean of 67%VS30% (p0.001) 2. radiographic failure rates at 72% VS37% (p0.001) Results-3 the small-diameter drilling technique results similar to other studies of the last 15 years higher Ficat stages and larger lesion sizes had increased failure rates patients who had small lesions and Ficat Stage I with 79% of these hips showing no radiographic stage progression Limits of the study the small numbers of patients in many of the reports it was difficult to determine when the core decompressions were performed to stratify the study only midterm mean followups (range, 18 months to 144 months), and the long-term outcome is unclear the level of evidence for the scientific literature lack of prospective randomized multicenter studies Conclusions Recent techniques provide better clinical scores or radiographic outcomes than pre- 1992 studies. However, it is unclear whether this improvement is due to improved patient selection or surgical technique. Core decompression is a safe and effective procedure for the early stages of ONFH. We will use core decompression to treat patients who have early small- and medium- sized lesions and are Ficat Stage I or II. advantages f