球囊扩张骨水泥填充治疗股骨头缺血坏死的实验性研究
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摘要
研究背景：股骨头缺血性坏死是指不同原因导致股骨头血供破坏或骨细胞变性导致骨的有活力成分死亡的病理过程。依据发病原因包括创伤性非创伤性两种，但其病理过程和自我修复的过程都是相似的，都是导致股骨头的松质骨和软骨下骨出现坏死，纤维性修复后其力学强度逐步下降。在早期并不出现明显的骨结构和力学性能的改变，但在股骨头负重情况下，由于修复坏死区域的力学性能差，不能承重和传递应力，导致股骨头塌陷。如果不及时进行有效治疗，80%的股骨头坏死患者会在1~3年内发生股骨头塌陷，严重者不得不接受关节置换手术治疗。对于中青年股骨头缺血性坏死的病人应用人工关节置换术并发症发生率高，远期效果不理想。对于股骨头缺血性坏死的患者，采用保留股骨头的治疗方法，预防或延缓股骨头的塌陷，可以使患者免除或者延缓人工关节置换术。
保留股骨头的外科手术治疗术式较多。早期降低股骨头内的压力，改善股骨头的血运，利用股骨头的自我修复能力修复坏死区。研究认为坏死区域的力学性能的下降是导致继发出现股骨头塌陷的主要原因，因而设想通过骨移植对股骨头软骨下进行力学支撑，来预防或延缓塌陷的发生。但是单纯的骨移植术由于移植物的力学性能不足以即刻支撑股骨头负重，带血管蒂骨瓣转移术的术式需要较高的显微外科技术，且供区致病率高。多孔钽棒植入术对于坏死范围广泛和多发病变，以及合并慢性疾患需长期应用激素治疗的患者，其治疗效果不佳。总之，现有的各种保留股骨头的外科手术方法，对防治股骨头坏死塌陷都存在不同程度的不足之处。
骨水泥或者骨替代材料填充骨坏死的缺损部位是股骨头缺血性坏死的一种治疗方法，其基本操作是清除股骨头坏死区坏死组织并填充骨水泥成分或者其他替代材料，使塌陷的软骨面复位，重建股骨头的球形轮廓，并且增加股骨头坏死区域的强度，避免再次出现塌陷。目前对其具体的机制尚不清楚。椎体后凸成型技术经皮穿刺后，利用球囊扩张后对压缩的椎体复位并在椎体内形成空隙，在低压下缓慢注入骨水泥。后凸成型技术具有微创、改善疼痛症状好，安全，便于操作等优点，被广泛接受和应用。应用后凸成型技术的微创操作技术，经皮穿刺，将球囊通过穿刺的工作管道植入股骨头的坏死区域，行球囊扩张后，恢复股骨头塌陷的外形，并在局部造成空隙，可以在低压状态下注入骨水泥或者相应替代物填充空隙，对股骨头软骨下骨进行有效支撑，可能会通过增加股骨头坏死区域的力学强度，改善股骨头的力学性能，避免或者延迟出现股骨头塌陷的时间。
目的：建立球囊扩张骨水泥填充和股骨头缺血性坏死的三维有限元分析模型，采用有限元分析方法模拟加载，分析股骨头股骨头不同部位应力分布情况，并进行标本生物力学测试进行验证，探讨球囊扩张骨水泥填充对缺血性坏死股骨头的生物力学影响。
方法：
1.建立球囊扩张骨水泥填充和股骨头缺血性坏死的三维有限元分析模型。采用新鲜人股骨头坏死标本，在C形臂下模拟穿刺、球囊扩张手术过程，穿刺进入股骨头坏死区域后，球囊扩张并注入骨水泥。采用双源螺旋CT薄层扫描，采集扫描的图像，利用计算机软件辅助建立球囊扩张骨水泥填充和股骨头缺血坏死区的三维有限元模型。
2.通过三维有限元模型对比分析在模拟生理负荷下，模拟加载及求解，采用模拟平地步行单髋的峰值受力情况。对股骨头缺血坏死模型、球囊扩张骨水泥成型模型进行有限元分析。测定股骨头顶端、股骨头负重区和股骨颈的Von-Mises应力值，对比骨水泥填充前后应力的变化和分布情况。
3.采用生物力学测试仪器分别记录在载荷为100N，200N，300N，400N，500N，600N和700N情况下，股骨头标本的位移情况，采用自身对照研究，对不同载荷下的两组（坏死模型和骨水泥模型）的位移对比验。分析股骨头刚度的变化，并对有限分析的结果进行验证。
检验方法对有限元分析模型的所采集的股骨头不同区域的应力结果采用非参数分析的秩和检验，对生物力学测试的股骨头刚度的结果采用配对T检验，统计软件采用SPSS17.0进行数据分析，采用p＜0.05为两组有统计学差异，p＜0.01为显著统计学差异。
结果：
1.在骨水泥填充于股骨头的坏死区域后，股骨头的负重区表面的应力水平有明显下降。负重区的应力显著下降，改变了股骨头的力学结构，有利于周围骨组织的修复，从而降低了进一步出现股骨头塌陷的几率，这为骨水泥填充的术式提供了理论支持。
2.在填充骨水泥后，骨水泥成分由于其刚度高于周围的松质骨，骨应力向骨水泥的填充部位增加，证实骨水泥能够有效承担载荷，骨水泥的作用是股骨头支撑力得到加强的原因。
3.股骨头内填充骨水泥后，发现骨水泥填充后的股骨头最大位移的范围较坏死范围增大，表明有效载荷面积增大，单位面积内应力下降，也可能是骨水泥填充后负重区域应力下降的原因。
4.水泥模型的标准差股骨颈周围应力的标准差明显小于坏死模型，提示其应力离散程度明显较坏死模型低，表明水泥模型其应力分布更加均匀。按照4分区对比不同股骨颈区域骨水泥模型和坏死模型的应力变化，发现股骨颈内侧承担了更多的压应力，外侧承担的应力水平有下降。因此，骨水泥填充后，股骨颈周围的应力分布更加均匀，降低了出现股骨颈应力集中。
5.对股骨头标本进行载荷-位移下力学测定，结果骨水泥填充组和坏死模型的载荷-移位变化均呈现类似线性的改变。比较标本生物力学测试和有限元模型分析的研究结果发现，两种研究方法均能够呈现出坏死模型和骨水泥模型在不同应力下的线性改变趋势相近，同等条件的应力条件下，骨水泥模型其发生的应变位移小于坏死模型。这一方面表明填充骨水泥后，坏死的股骨头的刚度增加，对抗变形的能力增强；另外一方面也验证了有限元模型能够较好的模拟标本生物力学实验。
结论：
1.经皮球囊扩张骨水泥填充股骨头坏死区域，骨水泥能够有效承载负荷，减轻负重区的承载负荷，股骨头应力分散改善股骨头的承载能力，对股骨头进行有效的支持以预防塌陷进展；
2.经皮球囊扩张骨水泥填充股骨头坏死区域，股骨颈周围应力分布均匀，理论上降低出现股骨颈骨折并发症的几率；
3.经皮球囊扩张骨水泥填充股骨头坏死区域可以增加股骨头的刚度，增加对载荷的变形能力。
4.有限元分析模型能够有效模拟经皮球囊扩张骨水泥填充股骨头坏死区域的生物力学变化。
总之，经皮球囊扩张骨水泥填充股骨头坏死区域，改变了股骨头、颈在承重是的生物力学机制，增强了股骨头的支撑能力，能够有效抵抗股骨头塌陷，避免股骨头塌陷进一步进展。
Background：Avascular necrosis of femoral head refers to the pathological process of boneactive ingredient loss due to destruction in blood supply or bone cells degeneration. Bothtraumatic and none traumatic causes share the same basic pathological process of necrosis ofcancellous bone and subchondral bone, fibrous repaired followed by mechanical strengthdeclination. At first, there’s no obvious bone structure and mechanical property changing, butthe mechanical property of the area of necrosis is poor, cannot load and transfer stress, leadingto the collapse of femoral head. The femoral head would collapse in80%patients during1to3years if not effectively treated. Some severed patients would have to be operated by total hipreplacement. The complications of THR occurred in young patients are much higher thanothers and the long-term effect is poor. The femoral head reserved surgery can prevent or retaincollapse, avoid or delay the artificial joint replacement.
There are many different head reserved surgeries. Blood supply can be improved in earlystages by decreasing the pressure inside the femoral head, self-repairing in the femoral necroticarea. Studies suggest that the mechanical property of the necrotic area in the femoral headdecreasing would be the main reason for the collapse. It’s assumed that transfer of bone graft tofemoral subchondral area can support the head to prevent or retain collapse. But bone graftalone can’t support femoral head immediately due to poor mechanical properties. Transfer ofvascular pedicle bone flap needs high microsurgical technique and the complications at donorarea are high. Porous tantalum rod implantation is not effective for large and multiple lesions,hormones induced necrosis or ANFH combined with chronic diseases. In brief, all kinds ofhead reserved surgeries have different deficiencies.
Bone cement or bone graft substitutes filling in the defects of osteonecrosis area is a kindof treatment. Fundamental techniques includes debridement of necrotic tissue, filling with bone cement or substitutes and reduction of cartilage surface collapse.Reconstruction of thefemoral head spherical contour and increasing the intensity of the necrotic area are assumed toavoid collapse again.The mechanism of the treatment is unclear yet. Kyphoplasty canreducethe heigh of compressed vertebral body by balloon inflating percutaneously and fill thecave with bone cement under low pressure. It is widely accepted and used for it’s amini-invasive process which can relief pain safely and easy to manipulate. It is assumedkyphoplasty technique can be used to treat ANFH. Balloon can be inserted into necrotic area ofthe femoral head to reduce collapsed head by inflating and cause local cave. Then bone cementor bone graft substitutes can be filled into the cave to support subchondral bone effectively.It’s assumed that mechanical strength of the necrotic area may increase and mechanicalproperties may be improved so that the collapse of the femoral head may be avoided orpostponed.
Objective: To evaluate the effect of balloon inflating and cement filling in treatment ofavauscular necrosis of femoral head. Establish a three-dimensional computer simulated modeland use finite element analysis techniques to simulate load and calculate the changes of stresspre-and postoperation. To verify finite element analysis by biomechanical testing of femoralhead specimens.
Methods：
1. Establish a three-dimensional finite element analysis model of the balloon inflatingand bone cement filling procedure in the treatment of avascular necrosis. Select freshspecimens of femoral head necrosis of human, simulate percutaneous puncture and ballooninfalting procedure under C-arm fluoroscopy, after entering the necrotic area, inflate theballoon and fill in the bone cement. Use dual sources spiral CT thin-layer scan and collect allscanned images, apply computer aid technique to establish balloon inflating and bone cementfilling procedure and avascular necrosis three-dimensional finite element model.
2. Analyze physiological load using three-dimensional finite element model, simulatingload and calculating stress, and applying the peak load force of the hip during flat groundwalking. Apply finite element analysis on the avascular necrosis model and balloon augmentbone cement filling model to measure the Von-Mises force of the top, neck and the weight bearing area of the femoral head, in order to compare the alternation of force before and afterthe filling of bone cement.
3. Use biomechanical tester to record the displacement of the femoral head specimen atthe loads100N，200N，300N，400N，500N，600N and700N, compare the displacement ofthe two models (necrosis model and bone cement model) under control study. Analyze thestiffness chages of the femoral head and verify the result of the finite element analysis.
The study applies non-parametric rank sum examination in the inspection of the load resulton different femoral head areas collected by finite element analysis model. Paired Texamination is applied in the inspection of biomechanic testing results of the femoral headstiffness. Statistical software uses SPSS17.0in data analysis, p <0.05represents statisticaldifference of the two groups, p <0.01represents significant difference.
Results：
1. After bone cement filled in the necrosis area, the load reduced significantly on theweight bearing area of the femoral head. The reduction in the load alternated the mechanicalstructure of the femoral head that promotes repair of surrounding bone tissue. This lowers thecollapse rate of the femoral head and provides theoretical support for the balloon augment bonecement filling procedure in the treatment of avascular necrosis.
2. The filled bone cement shares higher stiffness than the surrounding cancellous bone, sothe loading force concentrates on the bone cement portion. The bone cement is proven toeffectively bear load, the support force of the femoral head is reinforced by the load bearing ofthe bone cement.
3. The maximum movement range of the femoral head increased after the filling of bonecement that proves the incensement effective load bearing area. The reduction of stress per unitarea could also be responsible for the load declination of the weight bearing area.
4. The standard deviation of the bone cement model and the stress load of the femoral neckare significantly lower that the necrosis model that implies the bone cement model shares lessstress dispersion degree and more stress uniformity than the necrosis model. Test the stressload of the femoral neck of the bone cement model and the necrosis model in4divisions. Theresult reflected less stress on the inner side of the femoral neck and more stress on the outer side of the femoral neck. Hence, the load distribution became more uniformed on the femoralneck after bone cement filling that reduces the force concentration on the femoral neck.
5. Both the bone cement model and the necrosis model display similar linear change underload-displacement examination of the femoral head. Comparing the results of finite elementanalysis and bio-mechanical testing, conclusion can be drawn that both methods could displaythe similar linear change of the bone cement model and the necrosis model under various loads.Also, the study discovered the bone cement model shares less displacement that the necrosismodel under the same load condition. This proves that the stiffness and the anti-deformationability of the necrosis femoral head increases after bone cement filling. On the other hand, thesimilarity of the linear changes verifyed that finite element model could highly simulatebiomechanical examination of human specimens.
Conclusions：
1. Percutaneous balloon inflating and bone cement filling of the necrosis area in femoralhead can carry load effectively, reduce load of the weight-loading area, disperse the stress onthe surface, improve supporting capacity and prevent collapse progressing.
2. Percutaneous balloon inflating and bone cement filling in the necrosis area of femoralhead can diverse the stress on femoral neck surface, reduce risks of neck fracture complicationsin theoretically.
3. Percutaneous balloon inflating and bone cement filling in the necrosis area of femoralhead can increase stiffness of femoral head, increase the support capacity under load.
4. Finite element model could simulate biomechanical changes of percutaneous ballooninflating and bone cement filling procedure accurately.
In brief, percutaneous balloon inflating and bone cement filling in the necrosis area offemoral head can change the biomechanics mechanism of femoral head and neck, improvesupporting capacity under load, resist and prevent head collapse progressing.
保留股骨头的外科手术治疗术式较多。早期降低股骨头内的压力，改善股骨头的血运，利用股骨头的自我修复能力修复坏死区。研究认为坏死区域的力学性能的下降是导致继发出现股骨头塌陷的主要原因，因而设想通过骨移植对股骨头软骨下进行力学支撑，来预防或延缓塌陷的发生。但是单纯的骨移植术由于移植物的力学性能不足以即刻支撑股骨头负重，带血管蒂骨瓣转移术的术式需要较高的显微外科技术，且供区致病率高。多孔钽棒植入术对于坏死范围广泛和多发病变，以及合并慢性疾患需长期应用激素治疗的患者，其治疗效果不佳。总之，现有的各种保留股骨头的外科手术方法，对防治股骨头坏死塌陷都存在不同程度的不足之处。
骨水泥或者骨替代材料填充骨坏死的缺损部位是股骨头缺血性坏死的一种治疗方法，其基本操作是清除股骨头坏死区坏死组织并填充骨水泥成分或者其他替代材料，使塌陷的软骨面复位，重建股骨头的球形轮廓，并且增加股骨头坏死区域的强度，避免再次出现塌陷。目前对其具体的机制尚不清楚。椎体后凸成型技术经皮穿刺后，利用球囊扩张后对压缩的椎体复位并在椎体内形成空隙，在低压下缓慢注入骨水泥。后凸成型技术具有微创、改善疼痛症状好，安全，便于操作等优点，被广泛接受和应用。应用后凸成型技术的微创操作技术，经皮穿刺，将球囊通过穿刺的工作管道植入股骨头的坏死区域，行球囊扩张后，恢复股骨头塌陷的外形，并在局部造成空隙，可以在低压状态下注入骨水泥或者相应替代物填充空隙，对股骨头软骨下骨进行有效支撑，可能会通过增加股骨头坏死区域的力学强度，改善股骨头的力学性能，避免或者延迟出现股骨头塌陷的时间。
目的：建立球囊扩张骨水泥填充和股骨头缺血性坏死的三维有限元分析模型，采用有限元分析方法模拟加载，分析股骨头股骨头不同部位应力分布情况，并进行标本生物力学测试进行验证，探讨球囊扩张骨水泥填充对缺血性坏死股骨头的生物力学影响。
方法：
1.建立球囊扩张骨水泥填充和股骨头缺血性坏死的三维有限元分析模型。采用新鲜人股骨头坏死标本，在C形臂下模拟穿刺、球囊扩张手术过程，穿刺进入股骨头坏死区域后，球囊扩张并注入骨水泥。采用双源螺旋CT薄层扫描，采集扫描的图像，利用计算机软件辅助建立球囊扩张骨水泥填充和股骨头缺血坏死区的三维有限元模型。
2.通过三维有限元模型对比分析在模拟生理负荷下，模拟加载及求解，采用模拟平地步行单髋的峰值受力情况。对股骨头缺血坏死模型、球囊扩张骨水泥成型模型进行有限元分析。测定股骨头顶端、股骨头负重区和股骨颈的Von-Mises应力值，对比骨水泥填充前后应力的变化和分布情况。
3.采用生物力学测试仪器分别记录在载荷为100N，200N，300N，400N，500N，600N和700N情况下，股骨头标本的位移情况，采用自身对照研究，对不同载荷下的两组（坏死模型和骨水泥模型）的位移对比验。分析股骨头刚度的变化，并对有限分析的结果进行验证。
检验方法对有限元分析模型的所采集的股骨头不同区域的应力结果采用非参数分析的秩和检验，对生物力学测试的股骨头刚度的结果采用配对T检验，统计软件采用SPSS17.0进行数据分析，采用p＜0.05为两组有统计学差异，p＜0.01为显著统计学差异。
结果：
1.在骨水泥填充于股骨头的坏死区域后，股骨头的负重区表面的应力水平有明显下降。负重区的应力显著下降，改变了股骨头的力学结构，有利于周围骨组织的修复，从而降低了进一步出现股骨头塌陷的几率，这为骨水泥填充的术式提供了理论支持。
2.在填充骨水泥后，骨水泥成分由于其刚度高于周围的松质骨，骨应力向骨水泥的填充部位增加，证实骨水泥能够有效承担载荷，骨水泥的作用是股骨头支撑力得到加强的原因。
3.股骨头内填充骨水泥后，发现骨水泥填充后的股骨头最大位移的范围较坏死范围增大，表明有效载荷面积增大，单位面积内应力下降，也可能是骨水泥填充后负重区域应力下降的原因。
4.水泥模型的标准差股骨颈周围应力的标准差明显小于坏死模型，提示其应力离散程度明显较坏死模型低，表明水泥模型其应力分布更加均匀。按照4分区对比不同股骨颈区域骨水泥模型和坏死模型的应力变化，发现股骨颈内侧承担了更多的压应力，外侧承担的应力水平有下降。因此，骨水泥填充后，股骨颈周围的应力分布更加均匀，降低了出现股骨颈应力集中。
5.对股骨头标本进行载荷-位移下力学测定，结果骨水泥填充组和坏死模型的载荷-移位变化均呈现类似线性的改变。比较标本生物力学测试和有限元模型分析的研究结果发现，两种研究方法均能够呈现出坏死模型和骨水泥模型在不同应力下的线性改变趋势相近，同等条件的应力条件下，骨水泥模型其发生的应变位移小于坏死模型。这一方面表明填充骨水泥后，坏死的股骨头的刚度增加，对抗变形的能力增强；另外一方面也验证了有限元模型能够较好的模拟标本生物力学实验。
结论：
1.经皮球囊扩张骨水泥填充股骨头坏死区域，骨水泥能够有效承载负荷，减轻负重区的承载负荷，股骨头应力分散改善股骨头的承载能力，对股骨头进行有效的支持以预防塌陷进展；
2.经皮球囊扩张骨水泥填充股骨头坏死区域，股骨颈周围应力分布均匀，理论上降低出现股骨颈骨折并发症的几率；
3.经皮球囊扩张骨水泥填充股骨头坏死区域可以增加股骨头的刚度，增加对载荷的变形能力。
4.有限元分析模型能够有效模拟经皮球囊扩张骨水泥填充股骨头坏死区域的生物力学变化。
总之，经皮球囊扩张骨水泥填充股骨头坏死区域，改变了股骨头、颈在承重是的生物力学机制，增强了股骨头的支撑能力，能够有效抵抗股骨头塌陷，避免股骨头塌陷进一步进展。
Background：Avascular necrosis of femoral head refers to the pathological process of boneactive ingredient loss due to destruction in blood supply or bone cells degeneration. Bothtraumatic and none traumatic causes share the same basic pathological process of necrosis ofcancellous bone and subchondral bone, fibrous repaired followed by mechanical strengthdeclination. At first, there’s no obvious bone structure and mechanical property changing, butthe mechanical property of the area of necrosis is poor, cannot load and transfer stress, leadingto the collapse of femoral head. The femoral head would collapse in80%patients during1to3years if not effectively treated. Some severed patients would have to be operated by total hipreplacement. The complications of THR occurred in young patients are much higher thanothers and the long-term effect is poor. The femoral head reserved surgery can prevent or retaincollapse, avoid or delay the artificial joint replacement.
There are many different head reserved surgeries. Blood supply can be improved in earlystages by decreasing the pressure inside the femoral head, self-repairing in the femoral necroticarea. Studies suggest that the mechanical property of the necrotic area in the femoral headdecreasing would be the main reason for the collapse. It’s assumed that transfer of bone graft tofemoral subchondral area can support the head to prevent or retain collapse. But bone graftalone can’t support femoral head immediately due to poor mechanical properties. Transfer ofvascular pedicle bone flap needs high microsurgical technique and the complications at donorarea are high. Porous tantalum rod implantation is not effective for large and multiple lesions,hormones induced necrosis or ANFH combined with chronic diseases. In brief, all kinds ofhead reserved surgeries have different deficiencies.
Bone cement or bone graft substitutes filling in the defects of osteonecrosis area is a kindof treatment. Fundamental techniques includes debridement of necrotic tissue, filling with bone cement or substitutes and reduction of cartilage surface collapse.Reconstruction of thefemoral head spherical contour and increasing the intensity of the necrotic area are assumed toavoid collapse again.The mechanism of the treatment is unclear yet. Kyphoplasty canreducethe heigh of compressed vertebral body by balloon inflating percutaneously and fill thecave with bone cement under low pressure. It is widely accepted and used for it’s amini-invasive process which can relief pain safely and easy to manipulate. It is assumedkyphoplasty technique can be used to treat ANFH. Balloon can be inserted into necrotic area ofthe femoral head to reduce collapsed head by inflating and cause local cave. Then bone cementor bone graft substitutes can be filled into the cave to support subchondral bone effectively.It’s assumed that mechanical strength of the necrotic area may increase and mechanicalproperties may be improved so that the collapse of the femoral head may be avoided orpostponed.
Objective: To evaluate the effect of balloon inflating and cement filling in treatment ofavauscular necrosis of femoral head. Establish a three-dimensional computer simulated modeland use finite element analysis techniques to simulate load and calculate the changes of stresspre-and postoperation. To verify finite element analysis by biomechanical testing of femoralhead specimens.
Methods：
1. Establish a three-dimensional finite element analysis model of the balloon inflatingand bone cement filling procedure in the treatment of avascular necrosis. Select freshspecimens of femoral head necrosis of human, simulate percutaneous puncture and ballooninfalting procedure under C-arm fluoroscopy, after entering the necrotic area, inflate theballoon and fill in the bone cement. Use dual sources spiral CT thin-layer scan and collect allscanned images, apply computer aid technique to establish balloon inflating and bone cementfilling procedure and avascular necrosis three-dimensional finite element model.
2. Analyze physiological load using three-dimensional finite element model, simulatingload and calculating stress, and applying the peak load force of the hip during flat groundwalking. Apply finite element analysis on the avascular necrosis model and balloon augmentbone cement filling model to measure the Von-Mises force of the top, neck and the weight bearing area of the femoral head, in order to compare the alternation of force before and afterthe filling of bone cement.
3. Use biomechanical tester to record the displacement of the femoral head specimen atthe loads100N，200N，300N，400N，500N，600N and700N, compare the displacement ofthe two models (necrosis model and bone cement model) under control study. Analyze thestiffness chages of the femoral head and verify the result of the finite element analysis.
The study applies non-parametric rank sum examination in the inspection of the load resulton different femoral head areas collected by finite element analysis model. Paired Texamination is applied in the inspection of biomechanic testing results of the femoral headstiffness. Statistical software uses SPSS17.0in data analysis, p <0.05represents statisticaldifference of the two groups, p <0.01represents significant difference.
Results：
1. After bone cement filled in the necrosis area, the load reduced significantly on theweight bearing area of the femoral head. The reduction in the load alternated the mechanicalstructure of the femoral head that promotes repair of surrounding bone tissue. This lowers thecollapse rate of the femoral head and provides theoretical support for the balloon augment bonecement filling procedure in the treatment of avascular necrosis.
2. The filled bone cement shares higher stiffness than the surrounding cancellous bone, sothe loading force concentrates on the bone cement portion. The bone cement is proven toeffectively bear load, the support force of the femoral head is reinforced by the load bearing ofthe bone cement.
3. The maximum movement range of the femoral head increased after the filling of bonecement that proves the incensement effective load bearing area. The reduction of stress per unitarea could also be responsible for the load declination of the weight bearing area.
4. The standard deviation of the bone cement model and the stress load of the femoral neckare significantly lower that the necrosis model that implies the bone cement model shares lessstress dispersion degree and more stress uniformity than the necrosis model. Test the stressload of the femoral neck of the bone cement model and the necrosis model in4divisions. Theresult reflected less stress on the inner side of the femoral neck and more stress on the outer side of the femoral neck. Hence, the load distribution became more uniformed on the femoralneck after bone cement filling that reduces the force concentration on the femoral neck.
5. Both the bone cement model and the necrosis model display similar linear change underload-displacement examination of the femoral head. Comparing the results of finite elementanalysis and bio-mechanical testing, conclusion can be drawn that both methods could displaythe similar linear change of the bone cement model and the necrosis model under various loads.Also, the study discovered the bone cement model shares less displacement that the necrosismodel under the same load condition. This proves that the stiffness and the anti-deformationability of the necrosis femoral head increases after bone cement filling. On the other hand, thesimilarity of the linear changes verifyed that finite element model could highly simulatebiomechanical examination of human specimens.
Conclusions：
1. Percutaneous balloon inflating and bone cement filling of the necrosis area in femoralhead can carry load effectively, reduce load of the weight-loading area, disperse the stress onthe surface, improve supporting capacity and prevent collapse progressing.
2. Percutaneous balloon inflating and bone cement filling in the necrosis area of femoralhead can diverse the stress on femoral neck surface, reduce risks of neck fracture complicationsin theoretically.
3. Percutaneous balloon inflating and bone cement filling in the necrosis area of femoralhead can increase stiffness of femoral head, increase the support capacity under load.
4. Finite element model could simulate biomechanical changes of percutaneous ballooninflating and bone cement filling procedure accurately.
In brief, percutaneous balloon inflating and bone cement filling in the necrosis area offemoral head can change the biomechanics mechanism of femoral head and neck, improvesupporting capacity under load, resist and prevent head collapse progressing.
引文
1. Ohzono K，Saito M，Takaoka K，et al. Natural history of nontraumatic avascular necrosisof the femoral head.[J].J Bone Joint Surg(Br).1991,73:68-72
2. Sakamoto M, Shimizu K, Iida S, et al.Osteonecrosis of the femoral head: a prospectivestudy with MRI.[J].J Bone Joint Surg(Br).1997,79:213-219
3. Libberan,Berry DJ,Mont MA,et al.Osteonecrosis of the hip:management in thetwenty-first centery[J].J Bone Joint Surg(Am),2003,84(5):834-853
4. Mont M A, Carbone J J, Fairbank A C. Core decompression versus nonoperativemanagement for osteonecrosis of the hip[J]. Clin Orthop1996;(324):169-78.
5. Reis N D, Schwartz O, Militianu D, Ramon Y, Levin D, Norman D, Melamed Y, Shupak A,Goldsher D, Zinman C. Hyperbaric oxygen therapy as a treatment for stage-I avascularnecrosis of the femoral head.[J].J Bone Joint Surg (Br)2003;85:371-5.
6.何伟，袁浩，方斌，等.中药对股骨头坏死修复愈合机制的探讨[J].医用生物力学，2000,15（3）：162-5
7.姜文学,屈承端,金辉等.仿生脉冲电磁场防治激素性股骨头坏死的实验研究[J].中华骨科杂志,2007,27(5)：389-391
8. Ficat RP. Treatment of avascular necrosis of the femoral head.[J].Hip.1983:279-95.
9. Lavernia C J, Sierra R J. Core decompression in atraumatic osteonecrosis of the hip.[J].JArthroplasty2000;15:171-8.
10. Scully S P, Aaron R K, Urbaniak J R. Survival analysis of hips treated with coredecompression or vascularized fibular grafting because of avascular necrosis.[J].J BoneJoint Surg (Am)1998;80:1270-5.
11. Johnson JT, Crothers O. Revascularization of the femoral head. A clinical andexperimental study.[J].Clin Orthop Relat Res.1976Jan-Feb;(114):364-73.
12. Sugioka Y, Yamamoto T. Transtrochanteric posterior rotational osteotomy forosteonecrosis.[J].Clin Orthop Relat Res.2008May;466(5):1104-9.
13. Ueo T, Tsutsumi S, Yamamuro T, et al. Biomechanical aspects of the development ofaseptic necrosis of the femoral head.[J].Arch Orthop Trauma Surg.1985;104(3):145-9
14. Plakseychuk A, Kim S H, Park B C, Varitimidis S E, Rubash H E, Sotereanos DG.Vascularized compared with non vascularized fibular grafting for the treatment ofosteonecrosis of the femoral head.[J]. J Bone Joint Surg (Am)2003;85:589-96.
15. Eisenachenk A，Loutenbach M，Schweflick G，et aI．Treatment of femoral head necrosiswith vasculafized iliac crest transplants[J]．Clin Orthop,2001(386)：100-105．
16. Judet H，Gilbert A．Long term results of free vascularized fibular grafting for femoral headnecrosis[J]．Clin Othop．2001(368)：114．1l9
17.应明.多孔钽及在人工关节中的应用[J]..生物骨科材料与临床研究，2006（2）：1-3.
18.翁习生，翟吉良.多孔钽金属棒在早期股骨头缺血坏死中的应用[J].中国骨与关节外科，2008,1（4）：339-343
19. Aldegheri R,Taglialavoro G，Berizzi A.The tantalum screw for treating femoral headnecrosis：rational and results.[J].Strategies Trauma Limb Reconstr，2007,2（2-3）：63-68
20.赵德伟.带血管蒂骨瓣移植治疗股骨头坏死的经验与技巧.[J].中华显微外科杂志,2009,32(4):265-266.
21. Wood ML, McDowell CM, Kelley SS. Cementation for femoral head osteonecrosis: apreliminary clinic study.[J].Clin Orthop Relat Res.2003;(412):94-102.
22. Saha S, Pal S. Mechanical properties of bone cement: A review.[J]. Biomed Mater Res,1984,18:435
23.陈珑,倪才方.椎体成形术中非骨水泥渗漏引起心血管系统的变化[J].介入放射学杂志,2006,15(6)377-381
24.邹德威,马华松,邵水霖等.球囊扩张椎体后凸成形术治疗老年骨质疏松脊柱压缩骨折[J].中华骨科杂志,2003,23(5)：257-261
25.刘安庆，张银光，王春生，等.人股骨生物力学特性的三维有限元分析[J]西安医科大学学报,2001,22(3):242-4
26.桂鉴超,周强,顾湘杰,等.股骨质量对人工髋关节置换之影响的三维有限元分析[J]骨与关节损伤杂志,2000,15(3):212-4
27.张美超,史风雷,赵卫东等.髋关节外展不同角度股骨颈应力分布的有限元分析[J].第一军医大学学报,2005,25(10):1244-1246.
1.刘安庆，张银光．王春牛．等．人股骨生物力学特性的三维有限元分析[J]．西安医科大学学报，200l，22(3)：242-244
2.薛文,王坤正,凌伟等.螺旋CT扫描建立成人股骨头坏死三维有限元模型[J].陕西医学杂志,2005,34(11):1339-1341
3.张美超，赵卫东，原林，等.建立数字化虚拟中国男性一号膝关节的有限元模型[J].第一军医大学学报，2003,23（6）：527-529
4. Escott EJ,Rubinstein D, Free DICOM image viewing and processing software for yourdesktop computer: what’s available and what it can do for you[J]．Radiographics，2003,23(5)：1341-1357．
5. Jang SH, Kim WY. Defining a new annotation object for DICOM image: a practicalapproach [J].Computer Med Imaging Graph,2004,28(7):371-375
6.盛选禹，唐受琴.CATIA有限元分析命令详解与实例[M]第1版，北京：机械工业出版社，2005.
7.史风雷，吕丈新，李晓辉，等．内支撑术治疗成人股骨头坏死的临床观察和有限元分析[J]中国骨与关节损伤杂志,2008,23(3)186-188
8.张美超，史风雷，赵卫东，等．髋关节外展不同角度股骨颈应力分布的有限元分析[J]第一军医大学学报，2005，25(10)：1244-1246
9.朱新勇,方驰华,鲍苏苏等.基于64排螺旋CT扫描数据三维肝脏手术仿真的研究[J].中华外科杂志,2008,46(1)：27-29
10.赵德伟．徐达传．崔旭．股骨头不同区域囊变对力学承载的影响[J]．中华骨科杂志．2005．25(4)：232-235．
11. Brown TD,Hild GL.Precollapse stress redistributions on femoral head osteonecrosis:Athree-dimensional finite element analysis[J].Biomechanical Engineering,1983,105:171
12.薛文,王坤正,凌伟等.以三维有限元方法分析骨水泥充填成人股骨头坏死区域的力学变化[J].中国临床康复,2005,9(30)：109-111
13. Yang JW, Koo KH, Lee MC, et al. Mechanics of femoral head osteonecrosis usingthree-dimensional finite element method[J].Arch Orthop Trauma Surg.2002,122(2):88-92.
14. J.H.Keyak.Improved prediction of proximal femoral fracture loading using nonlinear finiteelement models[J].Medical Engineering&Physics,2001,25(7):165-173
15.刘海，谢力勤，徐孝根，等.给定荷载下的骨骼重建的有限元分析[J].清华大学学报（自然科学版），2002,42（8）：1079-1082
16. Dieter Christian Wirtz.Concept and development of an orthotropic FE model of theproximal femur[J].Journal of Biomechanics,2003,36(2):289-293
17. Sparks DR,Beason DP,Etheridge BS,et al.Contact pressure in the flexed hip joint duringlateral trochanteric loading.[J].J Orthop Res2005:23(2)359-366
18.陈奕芩，不同负荷形态对股骨头缺血性坏死影响的有限元素分析[J]，中华创伤骨科杂志,2007,9:515-518
19. Brown TD，Way ME，Ferguson AB．Mechanical characteristics of bone in femoral capitalaseptic necrosis[J]．Clin Orthop.1981．1(56)：240-247
20.王金熙，董天华，陈贤志，等．实验性股骨头缺血性坏死修复过程的生物力学研究[J].中华外科杂志，1993，31(6)：374-376
21.杨述华，杨操，李宝兴．强化力学结构治疗股骨头坏死的临床研究[J]．中华骨科杂志，2006，26(5)：313-315．
1. Ohzono K, Saito M.Sogano,et al.The fate of nontraumatic avascular necrosis of thefemoral head:a radiologic classification to formulate prognosis.[J].Clin Orthop,1992,277:73-8
2. Hungerford DS. Osteonecrosis: avoiding total hip arthroplasty.[J].J Arthroplasty.2002;17(4Suppl1):121-4.
3. Belmar CJ, Steinberg ME, Hartman-Sloan KM. Does pain predict outcome in hips withosteonecrosis?[J]. Clin Orthop Relat Res.2004;425:158-62.
4. Hungerford DS, Jones LC. Asymptomatic osteonecrosis: should it be treated?[J].ClinOrthop Relat Res.2004;429:124-30.
5. Ficat RP. Treatment of avascular necrosis of the femoral head.[J].Hip.1983:279-95.
6. Lavernia C J, Sierra R J. Core decompression in atraumatic osteonecrosis of the hip.[J]. JArthroplasty2000;15:171-8.
7. Scully S P, Aaron R K, Urbaniak J R. Survival analysis of hips treated with coredecompression or vascularized fibular grafting because of avascular necrosis.[J].J Bone JointSurg (Am)1998;80:1270-5.
8. Johnson JT, Crothers O. Revascularization of the femoral head. A clinical andexperimental study.[J]. Clin Orthop Relat Res.1976Jan-Feb;(114):364-73.
9. Brown TD, Way ME, Ferguson AB Jr. Mechanical characteristics of bone in femoralcapital aseptic necrosis.[J].Clin Orthop Relat Res.1981May;(156):240-7.
10. Steinberg ME,Larcom PG,Stafford B,et al.Core decompression with bone grafting forosteonecrosis of thr femoral head.[J].Clin Orthop Relat Res,2011,(386):71-78
11. Urbaniak JR,Harvey EJ.Revascularization of the femoral head in autogenecrosis.[J].J AmAcad Orthop Surg.1998;6:44-54
12. Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for thetreatment of postcollapse osteonecros is of the femoral head.[J]. J Bone Joint Surg [Am]2003;85:987–93
13. Konstantinos N. Malizos,, Leigh D. Quarles, et al. Analysis of failures after vascularizedfibular grafting in femoral head necrosis[J].Orthop Clin N Am35(2004)305–314
14. Toth AP, Dailiana ZH, Gunneson EE, Berend KR,Urbaniak JR. Free vascularized fibulargrafting following failed core decompression for femoral head osteonecrosis [abstract255]. In:Proceedings of the2002Annual Meeting of the American Academy of Orthopaedic Surgeons.Dallas (TX): American Academy of Orthopaedic Surgeons;2002. p.701.
15. Gore DR, Gardner GM, Sepic SB, et al. Function following partial fibulectomy.[J]. ClinOrthop1987;220:206.
16. Vail TP, Urbaniak JR. Donor-site morbidity with the use of vascularized autogenousfibular grafts.[J]. J Bone Joint Surg1996;78A:204.
17. Babhulkar SSK, Pande C, Babhulkar S. Ankle instability after fibular resection.[J].J BoneJoint Surg Br.1995;77(2):258-61.
18. Murray JA, Schlafly B. Giant-cell tumors in the distal end of the radius. Treatment byresection and fibular autograft interpositional arthrodesis.[J].J Bone Joint Surg Am.1986Jun;68(5):687-94
19. Judet H, Gilbert A. Long-term results of free vascularized fibular grafting for femoralhead necrosis.[J].Clin Orthop.2001;386:114-9.
20. Tsao AK,Roberson JR,Christie MJ,et al.Biomechanical and clinical evaluations of aporous tantalum implant for the treatment of osteonecrosis of the femoral head.[J].Bone JointSurg Am,2005;87(Suppl2):22-27
21. Veillette CJ,Mehdian H,Schemitsch EH,et al.Survuvoship analysis and radiographicoutcome following tantalum rod insertion for osteonecrosis of the femoral head.[J].J BoneJoint Surg Am,2006;88(Suppl3):48-55
22. Tanzer M, Bobyn JD, Krygier JJ, et al.Histopathological retrieval analysis of clinicallyfailed porous tantalum osteonecrosis implants.[J].J Bone Joint SurgAm,2008;90(6):1282-1289
23. Hernigou P, Bachir D, Galacteros F. Avascular necrosis of the femoral head in sickle-celldisease. Treatment of collapse by the injection of acrylic cement.[J].J Bone Joint Surg Br.1993;75(6):875-80
24. Wood ML, McDowell CM, Kelley SS. Cementation for femoral head osteonecrosis: apreliminary clinic study.[J].Clin Orthop Relat Res.2003;(412):94-102.
25. Oakland RJ,Furtado NR,Wilcox RX,et al.Rhe biomechanical effectiveness of prophylacticvertebroplasty:a dynamic cadaveric study[J].J Neurosurg Spine,2008,8(5):442-449
26. Keller TS,Kosmopulos V,Lieberman IH.Vertebroplasty and kyphoplasty affect vertebralmotion segment stiffness and stress distributions:a microstructural finite-elementstudy[J].spine,2005,30(11):1258-1265
27. Heim KA, Sullivan C, Parekh SG.Cuboid reduction and fixation using a kyphoplastyballoon: a case report.[J]. Foot Ankle Int.2008Nov;29(11):1154-7.
28.王禹吉，孙俊英，瞿玉兴，等.股骨头表面置换后股骨近端的生物力学研究[J].医用生物力学，2007,22（3）：294-297
29.张美超，史风雷，赵卫东，等.髋关节外在不同角度股骨颈应力分布的有限元分析[J]第一军医大学学报，2005；25（10）：1244-1226
30. Camp JF, Colwell CW Jr. Core decompression of the femoral head for osteonecrosis.[J]. JBone Joint Surg Am,1986;68:1313-9.
31. Volokh KY, Yoshida H, Leali A, et al. Prediction of femoral head collapse inosteonecrosis.[J].J Biomech Eng.2006Jun;128(3):467-70.
32. Heini PF, Franz T, Fankhauser C, et al. Femoroplasty-augmentation of mechanicalproperties in the osteoporotic proximal femur: a biomechanical investigation of PMMAreinforcement in cadaver bones.[J]. Clin Biomech (Bristol Avon)2004;19:506–12.
33. Von der Linden P, Gisep A, Boner V, Windolf M, Appelt A, Suhm N. Biomechanicalevaluation of a new augmentation method for enhanced screw fixation in osteoporoticproximal femoral fractures.[J].J Orthop Res2006;24:2230–7.
34. LoizouCL, ParkerMJ.Avascular necrosis after internal fixationof intracapsular hipfractures; a study of the outcome for1023patients.[J]. Injury2009;40(November(11)):1143–6
35. Ewald FC, Poss R, Pugh J, et al.Hip cartilage supported by methacrylate in caninearthroplasty.[J] Clin Orthop Relat Res.1982;(171):273-9
36. Vallo CI,Montemartini PE,Fanovich MA,et al.Polymethylmethacrylate-based bone cementmodified with hydroxyapatite[J].J Biomed Mater Res,1999,48(2)：150-158
37. Castaldini A,Cavallini A.Setting properties of bone cement with added synthetichydroxyapatite[J]Biomaterial,1985，6（1）：55-60
38. Dalby MJ,Di Silvio L,Harper EJ,et al.Increasing hydroxyapatite incorporation into poly(methylmethacrylate) cement increases osteoblast adhesion and response [J]. Biomaterials,2002,23(2):569-576
39. Lafforgue P. Osteonecrosis of the femoral head.[J].Rev Prat2006;56:817.
40. Babbush CA. Histologic evaluation of human biopsies after dental augmentation withdemineralized bone matrix putty.[J].Implant Dent2003;12:325.
41. Han B, Tang B, Nimni ME. Quantitative and sensitive in vitro assay for osteo-inductiveactivity of demineralized bone matrix.[J].J Orthop Res2003;21:648.
42. Ranly DM, McMillan J, Keller T, et al. Platelet-derived growth factor inhibitsdemineralized bone matrix-induced intramuscular cartilage and bone formation. A study ofimmunocompromised mice.[J].J Bone Joint Surg Am2005;87:2052.
43. Gangji V, Rooze M, De Maertelaer V.et al.Inefficacy of the cementation of femoral headcollapse in glucocorticoid-induced osteonecrosis.[J].Int Orthop.2009Jun;33(3):639-42.
44. Weinstein RS, Nicholas RW, Manolagas SC, Apoptosis of osteocytes in glucocorticoidinduced osteonecrosis of the hip.[J].J Clin Endocrinol Metab,2000,85:2907–2912
1. Ueo T, Tsutsumi S, Yamamuro T, et al.Biomechanical aspects of the development ofaseptic necrosis of the femoral head.[J].Arch Orthop Trauma Surg.1985;104(3):145-9.
2. Arlet ME，Bonjean M, Chavassieux PM, et al.Bone histology in adults with asepticnecrosis. Histomorphometric evaluation of iliac biopsies in seventy-seven patients.[J].JBone Joint Surg Am.1983Dec;65(9):1319-27.
3. Ohzono K.Diagnostic criteria, staging system and classification of idiopathic osteonecrosisof the femoral head.[J].Clin Calcium.2007Jun;17(6):849-55.
4.赵德伟,徐达传,崔旭等.股骨头不同区域囊变对力学承载的影响[J].中华骨科杂志,2005,25(4)232-235
5.张美超,史风雷,赵卫东等.髋关节外展不同角度股骨颈应力分布的有限元分析[J].第一军医大学学报,2005,25(10):1244-1246.
6. Polgar K,Gill HS,Viceconti M,et al.Strain distribution within the human femur due tophysiological and simplified loading:finite element analysis using the muscle standardizedfemur model.[J].Proc Inst Mech Eng.2003:217(3):173-189
7.刘杨,牛文鑫,陈正龙等.健康人体正常站立位完整股骨生物力学的有限元分析[J].中国组织工程研究与临床康复,2008,12(52)：10251-10253
1. Chan TW，Dalinka MK，Steinberg ME，et a1．MRI appearance of femoral headosteonecrosis following core decompression and bone grafting．Skeletal Radiol，199l，20：103-107．
2.和树政，许振华，刘保民．骨内高压下骨微循环形态扫描电镜观察．中华骨科杂志，1990，11：215-218．
3.张毓洲，许露玫，许振华，等．正常与骨内高压下骨髓微循环冷冻割断扫描电镜观察．中华骨科杂志，1999，19：303-305．
4. Castro FP Jr,Barrack RI.Core decompression and conservative treatment for avascularnecrosis of the femoral head:a meta-analysis.USA,Am J orthop,2000,29,(3):187-194
5. Lieberman JR. Core decompression fore osteonecrosis of the hip.ClinOrthop,2004,4(18):29-33
6. Simank HG，Brocai DR，Brill C，et a1．Comparison of results of core decompression andintertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Coxregression and survivorship analysis．J Arthroplasty，200l，16：790-794．
7. Bozic KJ Zurakowski D，Thornhill TS.Survivorship analysis of hips treated with coredecompression for nontraumatic osteonecrosis of the femoral head.J Bone Joint Surg（AM）1999；81（2）：200
8. Beltran J，Knight CT，Zuelzer WA，et al.Core decompression for avascular necrosis of thefemoral head： correlation between long-term results and preoperative MRstaging.Radiology1990；175（2）：533
9. Markel Dc，Miskovsky C, Sculco TP，et al. Core decompression for o-steonecrosis of thefemoral head.Clin Orthop1996；323：22
10. Mazieres B．Bone morphogenetic protein and bone necrosis：a perspective．ARCO NewsLetter，1994，6：3-5．
11. Mazieres B，Chiron PH，Aziza R，et a1．Bone morphogenetic protein (BMP)used in coredecopmression surgical technique the hip in pig model，pathological findings．ARCONews Letter，1994，6：12l-122．
12.郑召民，董天华．带血供骨移植加BMP治疗股骨头坏死．中华实验外科杂志，1998，15：375．
13.郑召民，董天华．带血供骨移植加BMP治疗股骨头坏死的临床初步报告．中华创伤杂志，1999，15：335-337．
14. Bednarek A, Atras A, G ga a J, et al. Operative technique and results of coredecompression and filling with bone grafts in the treatment of osteonecrosis of femoralhead.Ortop Traumatol Rehabil.2010;12(6):511-8.
15. Woodhouse CF．The transplantation of patent arteries to bone[J]．J Int Coll surg，1963，39：437—446．
16.侍德，刘番．血管束骨内植入后骨组织变化的实验研究[J]．中华外科杂志，1986，24(5)：271-273．
17. Duchow J, Kubale R, Hopf T. Color Doppler imaging assessment of blood flow invascularized pedicle grafts for avascular necrosis of the femoral head: angiographiccorrelation.J Ultrasound Med.1998，17(8):509-12.
18.吴斗，刘强，李钢，等.血管束骨内移植治疗青少年股骨头缺血性坏死[J]中华显微外科杂志，2009,32（4）：275-277
19.范丽娟，苏奇，余焕群．多组血管束植入股骨头修整与再造治疗中晚期股骨头缺血性坏死骨与关节损伤杂志，2003，18(9)：596-597．
20. Chen S, Qin J, Mu T,et al.Effect of tissue engineered bone implantation with vascularbundle and sensory nerve bundle on expression of neurokinin1receptor and vasoactiveintestinal peptide type1receptor in vivo].Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.2010;24(7):785-91.
21. Gartsman GM, Weiland AJ, Moore JR, et al.Blood vessel implantation into ischemicbone.J Reconstr Microsurg.1985Jan;1(3):215-22.
22. Phemister DB.Resection and bone transplantation in the treatment of bone sarcoma.ProcInst Med Chic.1946Oct15;16(7):227.
23. Rosenwasser MP，Garino JP，Kierna HA，et al.Long term follow up of thoroughdebridement and cancellous bone grafting of the femoral head for avascular necrosis 〔J〕Clin Orthop1994；306：17-27
24. Mont.MA，Einborn TA，Sponseller PD，et al。The trapdoor paocedure using autogenouscortical and cancellous bone graft for osteonecrosis of the femoral head〔J〕.J Bone JointSurg （Br），1998；80：56-62
25.杨述华，杨操，李宝兴，等.强化力学结构治疗股骨头缺血性坏死的临床研究.中华骨科杂志，2006,26:313-316.
26. Aldridge JM3rd, Berend KR, Gunneson EE, et al.Free vascularized fibular grafting forthe treatment of postcollapse osteonecrosis of the femoral head. Surgical technique.JBone Joint Surg Am.2004;86-A Suppl1:87-101.
27.姚树源，尚天裕．于建华，等.带旋髂深血管蒂骨膜移植治疗成人股骨头无菌性坏死[J]中华骨科杂志，1994；14：324—326
28.王岩，朱盛修，赵德伟，带旋髂深血管蒂髂骨骨膜移植治疗股骨头缺血性坏死及疗效评价[J]中华骨科杂志，1995,15；567
29.赵德伟，崔大平.股骨头缺血性坏死修复与再造的长期随访观察[J]中国矫形外科杂志，2008,16（7），481-484
30. Eisenschenk A, Lantenbach M，Treatment of femoral head necrosis with vascularizediliac crest transplants.Clin Orthop，2001，386:100
31. Matsusaki H, Noguchi M, Kawakami T, Tani T,et al.Use of vascularized pedicle iliac bonegraft combined with transtrochanteric rotational osteotomy in the treatment of avascularnecrosis of the femoral head.Arch Orthop Trauma Surg.2005;125(2):95-101
32. Chen CC, Lin CL, Chen WC, et al. Vascularized iliac bone-grafting for osteonecrosis withsegmental collapse of the femoral head.J Bone Joint Surg Am.2009;91(10):2390-4.
33. Korompilias AV, Beris AE, Lykissas MG, et al.Femoral head osteonecrosis: Why choosefree vascularized fibula grafting. Microsurgery.2011;31(3):223-8.
34. Soucacos PN, Beris AE, Malizos K, et al. Treatment of avascular necrosis of thefemoral head with vascularized fibular transplant [J]Clin Orthop Relat Res.2001;(386):120-30.
35. Sugioka Y.Orthopedists should never forget the utility of osteotomy as an option forregenerative medicine: the importance of joint preservation surgery and its dissemination.JOrthop Sci.2007Jan;12(1):1-3.
36. Schneider E, Ahrendt J, Niethard FU, Bl sius K.et al.Long-term results followingintertrochanteric varus osteotomy in aseptic femur head necrosis in the adult[J].Rofo.1989;150(4):402-6.
37. Gallinaro P．Masse A．Flexion osteotomy in the treatment of avascular necrosis of thehip．Clin Orthop，200l,386：79-84
38. Hiranuma Y, Atsumi T, Kajiwara T, et al.Evaluation of instability after transtrochantericanterior rotational osteotomy for nontraumatic osteonecrosis of the femoral head.J OrthopSci.2009;14(5):535-42
39.陈振光，余国荣，陈廖斌，等.臀下血管吻合支大转子骨瓣移位重建股骨头的应用解剖研究[J]中华实验外科杂志，1993；10（2），58-59
40.赵德伟.带血管蒂骨瓣移植治疗股骨头坏死的经验与技巧.中华显微外科杂志,2009,32(4):265-266.
41.窦亚栋，赵德伟，郭林.带蒂大转子骨瓣修复股骨头生物力学研究.中国骨与关节外科,2010,3(1):68-72.
42.肖嵩华，赵德伟，刘宇鹏，等.带血管蒂的大转子骨与筋膜瓣转移髋关节成形术解放军医学杂志，2003,28（10）；932-933
43.王家宽，葛卫宝，李俊，等.旋髂深血管蒂骨膜瓣与旋股外血管蒂阔筋膜张肌髂骨瓣复合移植治疗成人股骨头缺血性坏死[J]实用手外科杂志，2008，22（3）；158-160
44.杨振虎，王晓玲，侯岩珂，等.带阔筋膜张肌蒂髂骨移植治疗股骨头坏死16例[J]中国中西医结合外科杂志，2003,9（3）;223-224
45. Dewei Zhao, Benjie Wang, Lin Guo, etal. Will a Vascularized Greater Trochanter GraftPreserve the Necrotic Femoral Head? Clin Orthop Relat Res,2010,468:1316-1324
46.赵德伟，田丰德，郭林，等.带血管蒂大转子骨瓣转移治疗股骨头缺血性坏死的生物力学研究.中国临床解剖学杂志,2009,27(5):580-583
47. Hernigou P.Treatment of hip necrosis by sequestrectomy and replacement with bonecement.Acta Orthop Belg.1999;65Suppl1:89-94.
48.董天华，刘松，朱国梁，等.羟基磷灰石骨水泥植入治疗股骨头缺血性坏死的中期疗效观察，中华骨科杂志，2002,22（2）84-87.
49. Wood ML, McDowell CM, Kelley SS. Cementation for femoral head osteonecrosis: apreliminary clinic study.Clin Orthop Relat Res.2003;(412):94-102.
50.沈仲远，李广海，骨水泥填充加钛钉支撑治疗中青年股骨头坏死塌陷的初步报告，中医正骨，2004,18（4），56.
51. Gangji V, Rooze M, De Maertelaer V, Inefficacy of the cementation of femoral headcollapse in glucocorticoid-induced osteonecrosis. Int Orthop.2009Jun;33(3):639-42.
52.王岩，赵德伟，王继芳，等。镍-钛记忆合金网球治疗成人股骨头缺血性坏死初步报告，中华外科杂志，1998,36（10）
53.康鹏德，裴福兴，王坤正，磷酸钙骨水泥／rhBMP一2修复犬股骨头软骨下骨缺损重建力学性能的实验研究，中国矫形外科杂志，2004,12（21~22）1696-1670
54. Fernández-Fairen M, Murcia A, Iglesias R, et al,Osteointegration of porous tantalum stemsimplanted in avascular necrosis of the hip.Acta Ortop Mex.2008Jul-Aug;22(4):215-21
55.许伟华，杨述华，冯勇，等，多孔钽棒植入治疗股骨头坏死的适应证及临床疗效观察，中国骨与关节外科杂志，2010,2（3）；28-32
56.宫宁基,王韶进,刘文广等.髓芯减压多孔钽棒植入术与带蒂股方肌肌骨瓣移植术治疗Ficat Ⅱ期成人股骨头坏死的疗效比较[J].山东大学学报（医学版）,2010,48(7).
57.刘沧君,张孟增,路福志等.成人股骨头缺血坏死影像诊断与介入治疗探讨(附80例报告)[J].放射学实践,2000,15(5)600-606
58.党洪胜,裴福兴,沈彬等.基因修饰的成骨细胞经髓芯减压移植治疗早期股骨头缺血性坏死的实验观察[J].中华医学杂志,2008,88(7)484-489
59. James LA, Ibrahim T, Esler CN Microbiological culture results for the femoral head. Arethey important to the donor?.J Bone Joint Surg Br.2004Aug;86(6):797-800.
60.童培建,金红婷,何帮剑，等.干细胞介入治疗股骨头缺血性坏死的实验研究[J].中华骨科杂志,2010,30(6).600-606
61.赵德伟，崔大平，郭林，等.关节镜下髓芯减压基因转染骨髓间质干细胞修复兔股骨头缺血性坏死,中华骨科杂志,2008,28(11),945-948.
62. Xu M, Peng D.Mesenchymal stem cells cultured on tantalum used in early-stage avascularnecrosis of the femoral head. Med Hypotheses.2011Feb;76(2):199-200.
63.姜文学,尤佳,李轶津等.髋关节表面置换术的近期疗效及其并发症分析[J].中华骨科杂志,2009,29(9)858-863，
64. Mont MA, Rajadhyaksha AD, Hungerford DS, et al. Outcomes of limited femoralresurfacing arthroplasty compared with hip arthroplasty for osteonecrosis of the femoralhead. J Arthroplasty,2001,16:134
65. Sinuier M，Judet T，Sinuier T，et al. Preliminary results of partial surface replacementof the femoral head in osteonecrosis[J].J Arthroplasty.1999,14(1):45-51.
66. Bose VC, Baruah BD.Resurfacing arthroplasty of the hip for avascular necrosis of thefemoral head: a minimum follow-up of four years.J Bone Joint Surg Br.2010Jul;92(7):922-8
2. Sakamoto M, Shimizu K, Iida S, et al.Osteonecrosis of the femoral head: a prospectivestudy with MRI.[J].J Bone Joint Surg(Br).1997,79:213-219
3. Libberan,Berry DJ,Mont MA,et al.Osteonecrosis of the hip:management in thetwenty-first centery[J].J Bone Joint Surg(Am),2003,84(5):834-853
4. Mont M A, Carbone J J, Fairbank A C. Core decompression versus nonoperativemanagement for osteonecrosis of the hip[J]. Clin Orthop1996;(324):169-78.
5. Reis N D, Schwartz O, Militianu D, Ramon Y, Levin D, Norman D, Melamed Y, Shupak A,Goldsher D, Zinman C. Hyperbaric oxygen therapy as a treatment for stage-I avascularnecrosis of the femoral head.[J].J Bone Joint Surg (Br)2003;85:371-5.
6.何伟，袁浩，方斌，等.中药对股骨头坏死修复愈合机制的探讨[J].医用生物力学，2000,15（3）：162-5
7.姜文学,屈承端,金辉等.仿生脉冲电磁场防治激素性股骨头坏死的实验研究[J].中华骨科杂志,2007,27(5)：389-391
8. Ficat RP. Treatment of avascular necrosis of the femoral head.[J].Hip.1983:279-95.
9. Lavernia C J, Sierra R J. Core decompression in atraumatic osteonecrosis of the hip.[J].JArthroplasty2000;15:171-8.
10. Scully S P, Aaron R K, Urbaniak J R. Survival analysis of hips treated with coredecompression or vascularized fibular grafting because of avascular necrosis.[J].J BoneJoint Surg (Am)1998;80:1270-5.
11. Johnson JT, Crothers O. Revascularization of the femoral head. A clinical andexperimental study.[J].Clin Orthop Relat Res.1976Jan-Feb;(114):364-73.
12. Sugioka Y, Yamamoto T. Transtrochanteric posterior rotational osteotomy forosteonecrosis.[J].Clin Orthop Relat Res.2008May;466(5):1104-9.
13. Ueo T, Tsutsumi S, Yamamuro T, et al. Biomechanical aspects of the development ofaseptic necrosis of the femoral head.[J].Arch Orthop Trauma Surg.1985;104(3):145-9
14. Plakseychuk A, Kim S H, Park B C, Varitimidis S E, Rubash H E, Sotereanos DG.Vascularized compared with non vascularized fibular grafting for the treatment ofosteonecrosis of the femoral head.[J]. J Bone Joint Surg (Am)2003;85:589-96.
15. Eisenachenk A，Loutenbach M，Schweflick G，et aI．Treatment of femoral head necrosiswith vasculafized iliac crest transplants[J]．Clin Orthop,2001(386)：100-105．
16. Judet H，Gilbert A．Long term results of free vascularized fibular grafting for femoral headnecrosis[J]．Clin Othop．2001(368)：114．1l9
17.应明.多孔钽及在人工关节中的应用[J]..生物骨科材料与临床研究，2006（2）：1-3.
18.翁习生，翟吉良.多孔钽金属棒在早期股骨头缺血坏死中的应用[J].中国骨与关节外科，2008,1（4）：339-343
19. Aldegheri R,Taglialavoro G，Berizzi A.The tantalum screw for treating femoral headnecrosis：rational and results.[J].Strategies Trauma Limb Reconstr，2007,2（2-3）：63-68
20.赵德伟.带血管蒂骨瓣移植治疗股骨头坏死的经验与技巧.[J].中华显微外科杂志,2009,32(4):265-266.
21. Wood ML, McDowell CM, Kelley SS. Cementation for femoral head osteonecrosis: apreliminary clinic study.[J].Clin Orthop Relat Res.2003;(412):94-102.
22. Saha S, Pal S. Mechanical properties of bone cement: A review.[J]. Biomed Mater Res,1984,18:435
23.陈珑,倪才方.椎体成形术中非骨水泥渗漏引起心血管系统的变化[J].介入放射学杂志,2006,15(6)377-381
24.邹德威,马华松,邵水霖等.球囊扩张椎体后凸成形术治疗老年骨质疏松脊柱压缩骨折[J].中华骨科杂志,2003,23(5)：257-261
25.刘安庆，张银光，王春生，等.人股骨生物力学特性的三维有限元分析[J]西安医科大学学报,2001,22(3):242-4
26.桂鉴超,周强,顾湘杰,等.股骨质量对人工髋关节置换之影响的三维有限元分析[J]骨与关节损伤杂志,2000,15(3):212-4
27.张美超,史风雷,赵卫东等.髋关节外展不同角度股骨颈应力分布的有限元分析[J].第一军医大学学报,2005,25(10):1244-1246.
1.刘安庆，张银光．王春牛．等．人股骨生物力学特性的三维有限元分析[J]．西安医科大学学报，200l，22(3)：242-244
2.薛文,王坤正,凌伟等.螺旋CT扫描建立成人股骨头坏死三维有限元模型[J].陕西医学杂志,2005,34(11):1339-1341
3.张美超，赵卫东，原林，等.建立数字化虚拟中国男性一号膝关节的有限元模型[J].第一军医大学学报，2003,23（6）：527-529
4. Escott EJ,Rubinstein D, Free DICOM image viewing and processing software for yourdesktop computer: what’s available and what it can do for you[J]．Radiographics，2003,23(5)：1341-1357．
5. Jang SH, Kim WY. Defining a new annotation object for DICOM image: a practicalapproach [J].Computer Med Imaging Graph,2004,28(7):371-375
6.盛选禹，唐受琴.CATIA有限元分析命令详解与实例[M]第1版，北京：机械工业出版社，2005.
7.史风雷，吕丈新，李晓辉，等．内支撑术治疗成人股骨头坏死的临床观察和有限元分析[J]中国骨与关节损伤杂志,2008,23(3)186-188
8.张美超，史风雷，赵卫东，等．髋关节外展不同角度股骨颈应力分布的有限元分析[J]第一军医大学学报，2005，25(10)：1244-1246
9.朱新勇,方驰华,鲍苏苏等.基于64排螺旋CT扫描数据三维肝脏手术仿真的研究[J].中华外科杂志,2008,46(1)：27-29
10.赵德伟．徐达传．崔旭．股骨头不同区域囊变对力学承载的影响[J]．中华骨科杂志．2005．25(4)：232-235．
11. Brown TD,Hild GL.Precollapse stress redistributions on femoral head osteonecrosis:Athree-dimensional finite element analysis[J].Biomechanical Engineering,1983,105:171
12.薛文,王坤正,凌伟等.以三维有限元方法分析骨水泥充填成人股骨头坏死区域的力学变化[J].中国临床康复,2005,9(30)：109-111
13. Yang JW, Koo KH, Lee MC, et al. Mechanics of femoral head osteonecrosis usingthree-dimensional finite element method[J].Arch Orthop Trauma Surg.2002,122(2):88-92.
14. J.H.Keyak.Improved prediction of proximal femoral fracture loading using nonlinear finiteelement models[J].Medical Engineering&Physics,2001,25(7):165-173
15.刘海，谢力勤，徐孝根，等.给定荷载下的骨骼重建的有限元分析[J].清华大学学报（自然科学版），2002,42（8）：1079-1082
16. Dieter Christian Wirtz.Concept and development of an orthotropic FE model of theproximal femur[J].Journal of Biomechanics,2003,36(2):289-293
17. Sparks DR,Beason DP,Etheridge BS,et al.Contact pressure in the flexed hip joint duringlateral trochanteric loading.[J].J Orthop Res2005:23(2)359-366
18.陈奕芩，不同负荷形态对股骨头缺血性坏死影响的有限元素分析[J]，中华创伤骨科杂志,2007,9:515-518
19. Brown TD，Way ME，Ferguson AB．Mechanical characteristics of bone in femoral capitalaseptic necrosis[J]．Clin Orthop.1981．1(56)：240-247
20.王金熙，董天华，陈贤志，等．实验性股骨头缺血性坏死修复过程的生物力学研究[J].中华外科杂志，1993，31(6)：374-376
21.杨述华，杨操，李宝兴．强化力学结构治疗股骨头坏死的临床研究[J]．中华骨科杂志，2006，26(5)：313-315．
1. Ohzono K, Saito M.Sogano,et al.The fate of nontraumatic avascular necrosis of thefemoral head:a radiologic classification to formulate prognosis.[J].Clin Orthop,1992,277:73-8
2. Hungerford DS. Osteonecrosis: avoiding total hip arthroplasty.[J].J Arthroplasty.2002;17(4Suppl1):121-4.
3. Belmar CJ, Steinberg ME, Hartman-Sloan KM. Does pain predict outcome in hips withosteonecrosis?[J]. Clin Orthop Relat Res.2004;425:158-62.
4. Hungerford DS, Jones LC. Asymptomatic osteonecrosis: should it be treated?[J].ClinOrthop Relat Res.2004;429:124-30.
5. Ficat RP. Treatment of avascular necrosis of the femoral head.[J].Hip.1983:279-95.
6. Lavernia C J, Sierra R J. Core decompression in atraumatic osteonecrosis of the hip.[J]. JArthroplasty2000;15:171-8.
7. Scully S P, Aaron R K, Urbaniak J R. Survival analysis of hips treated with coredecompression or vascularized fibular grafting because of avascular necrosis.[J].J Bone JointSurg (Am)1998;80:1270-5.
8. Johnson JT, Crothers O. Revascularization of the femoral head. A clinical andexperimental study.[J]. Clin Orthop Relat Res.1976Jan-Feb;(114):364-73.
9. Brown TD, Way ME, Ferguson AB Jr. Mechanical characteristics of bone in femoralcapital aseptic necrosis.[J].Clin Orthop Relat Res.1981May;(156):240-7.
10. Steinberg ME,Larcom PG,Stafford B,et al.Core decompression with bone grafting forosteonecrosis of thr femoral head.[J].Clin Orthop Relat Res,2011,(386):71-78
11. Urbaniak JR,Harvey EJ.Revascularization of the femoral head in autogenecrosis.[J].J AmAcad Orthop Surg.1998;6:44-54
12. Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for thetreatment of postcollapse osteonecros is of the femoral head.[J]. J Bone Joint Surg [Am]2003;85:987–93
13. Konstantinos N. Malizos,, Leigh D. Quarles, et al. Analysis of failures after vascularizedfibular grafting in femoral head necrosis[J].Orthop Clin N Am35(2004)305–314
14. Toth AP, Dailiana ZH, Gunneson EE, Berend KR,Urbaniak JR. Free vascularized fibulargrafting following failed core decompression for femoral head osteonecrosis [abstract255]. In:Proceedings of the2002Annual Meeting of the American Academy of Orthopaedic Surgeons.Dallas (TX): American Academy of Orthopaedic Surgeons;2002. p.701.
15. Gore DR, Gardner GM, Sepic SB, et al. Function following partial fibulectomy.[J]. ClinOrthop1987;220:206.
16. Vail TP, Urbaniak JR. Donor-site morbidity with the use of vascularized autogenousfibular grafts.[J]. J Bone Joint Surg1996;78A:204.
17. Babhulkar SSK, Pande C, Babhulkar S. Ankle instability after fibular resection.[J].J BoneJoint Surg Br.1995;77(2):258-61.
18. Murray JA, Schlafly B. Giant-cell tumors in the distal end of the radius. Treatment byresection and fibular autograft interpositional arthrodesis.[J].J Bone Joint Surg Am.1986Jun;68(5):687-94
19. Judet H, Gilbert A. Long-term results of free vascularized fibular grafting for femoralhead necrosis.[J].Clin Orthop.2001;386:114-9.
20. Tsao AK,Roberson JR,Christie MJ,et al.Biomechanical and clinical evaluations of aporous tantalum implant for the treatment of osteonecrosis of the femoral head.[J].Bone JointSurg Am,2005;87(Suppl2):22-27
21. Veillette CJ,Mehdian H,Schemitsch EH,et al.Survuvoship analysis and radiographicoutcome following tantalum rod insertion for osteonecrosis of the femoral head.[J].J BoneJoint Surg Am,2006;88(Suppl3):48-55
22. Tanzer M, Bobyn JD, Krygier JJ, et al.Histopathological retrieval analysis of clinicallyfailed porous tantalum osteonecrosis implants.[J].J Bone Joint SurgAm,2008;90(6):1282-1289
23. Hernigou P, Bachir D, Galacteros F. Avascular necrosis of the femoral head in sickle-celldisease. Treatment of collapse by the injection of acrylic cement.[J].J Bone Joint Surg Br.1993;75(6):875-80
24. Wood ML, McDowell CM, Kelley SS. Cementation for femoral head osteonecrosis: apreliminary clinic study.[J].Clin Orthop Relat Res.2003;(412):94-102.
25. Oakland RJ,Furtado NR,Wilcox RX,et al.Rhe biomechanical effectiveness of prophylacticvertebroplasty:a dynamic cadaveric study[J].J Neurosurg Spine,2008,8(5):442-449
26. Keller TS,Kosmopulos V,Lieberman IH.Vertebroplasty and kyphoplasty affect vertebralmotion segment stiffness and stress distributions:a microstructural finite-elementstudy[J].spine,2005,30(11):1258-1265
27. Heim KA, Sullivan C, Parekh SG.Cuboid reduction and fixation using a kyphoplastyballoon: a case report.[J]. Foot Ankle Int.2008Nov;29(11):1154-7.
28.王禹吉，孙俊英，瞿玉兴，等.股骨头表面置换后股骨近端的生物力学研究[J].医用生物力学，2007,22（3）：294-297
29.张美超，史风雷，赵卫东，等.髋关节外在不同角度股骨颈应力分布的有限元分析[J]第一军医大学学报，2005；25（10）：1244-1226
30. Camp JF, Colwell CW Jr. Core decompression of the femoral head for osteonecrosis.[J]. JBone Joint Surg Am,1986;68:1313-9.
31. Volokh KY, Yoshida H, Leali A, et al. Prediction of femoral head collapse inosteonecrosis.[J].J Biomech Eng.2006Jun;128(3):467-70.
32. Heini PF, Franz T, Fankhauser C, et al. Femoroplasty-augmentation of mechanicalproperties in the osteoporotic proximal femur: a biomechanical investigation of PMMAreinforcement in cadaver bones.[J]. Clin Biomech (Bristol Avon)2004;19:506–12.
33. Von der Linden P, Gisep A, Boner V, Windolf M, Appelt A, Suhm N. Biomechanicalevaluation of a new augmentation method for enhanced screw fixation in osteoporoticproximal femoral fractures.[J].J Orthop Res2006;24:2230–7.
34. LoizouCL, ParkerMJ.Avascular necrosis after internal fixationof intracapsular hipfractures; a study of the outcome for1023patients.[J]. Injury2009;40(November(11)):1143–6
35. Ewald FC, Poss R, Pugh J, et al.Hip cartilage supported by methacrylate in caninearthroplasty.[J] Clin Orthop Relat Res.1982;(171):273-9
36. Vallo CI,Montemartini PE,Fanovich MA,et al.Polymethylmethacrylate-based bone cementmodified with hydroxyapatite[J].J Biomed Mater Res,1999,48(2)：150-158
37. Castaldini A,Cavallini A.Setting properties of bone cement with added synthetichydroxyapatite[J]Biomaterial,1985，6（1）：55-60
38. Dalby MJ,Di Silvio L,Harper EJ,et al.Increasing hydroxyapatite incorporation into poly(methylmethacrylate) cement increases osteoblast adhesion and response [J]. Biomaterials,2002,23(2):569-576
39. Lafforgue P. Osteonecrosis of the femoral head.[J].Rev Prat2006;56:817.
40. Babbush CA. Histologic evaluation of human biopsies after dental augmentation withdemineralized bone matrix putty.[J].Implant Dent2003;12:325.
41. Han B, Tang B, Nimni ME. Quantitative and sensitive in vitro assay for osteo-inductiveactivity of demineralized bone matrix.[J].J Orthop Res2003;21:648.
42. Ranly DM, McMillan J, Keller T, et al. Platelet-derived growth factor inhibitsdemineralized bone matrix-induced intramuscular cartilage and bone formation. A study ofimmunocompromised mice.[J].J Bone Joint Surg Am2005;87:2052.
43. Gangji V, Rooze M, De Maertelaer V.et al.Inefficacy of the cementation of femoral headcollapse in glucocorticoid-induced osteonecrosis.[J].Int Orthop.2009Jun;33(3):639-42.
44. Weinstein RS, Nicholas RW, Manolagas SC, Apoptosis of osteocytes in glucocorticoidinduced osteonecrosis of the hip.[J].J Clin Endocrinol Metab,2000,85:2907–2912
1. Ueo T, Tsutsumi S, Yamamuro T, et al.Biomechanical aspects of the development ofaseptic necrosis of the femoral head.[J].Arch Orthop Trauma Surg.1985;104(3):145-9.
2. Arlet ME，Bonjean M, Chavassieux PM, et al.Bone histology in adults with asepticnecrosis. Histomorphometric evaluation of iliac biopsies in seventy-seven patients.[J].JBone Joint Surg Am.1983Dec;65(9):1319-27.
3. Ohzono K.Diagnostic criteria, staging system and classification of idiopathic osteonecrosisof the femoral head.[J].Clin Calcium.2007Jun;17(6):849-55.
4.赵德伟,徐达传,崔旭等.股骨头不同区域囊变对力学承载的影响[J].中华骨科杂志,2005,25(4)232-235
5.张美超,史风雷,赵卫东等.髋关节外展不同角度股骨颈应力分布的有限元分析[J].第一军医大学学报,2005,25(10):1244-1246.
6. Polgar K,Gill HS,Viceconti M,et al.Strain distribution within the human femur due tophysiological and simplified loading:finite element analysis using the muscle standardizedfemur model.[J].Proc Inst Mech Eng.2003:217(3):173-189
7.刘杨,牛文鑫,陈正龙等.健康人体正常站立位完整股骨生物力学的有限元分析[J].中国组织工程研究与临床康复,2008,12(52)：10251-10253
1. Chan TW，Dalinka MK，Steinberg ME，et a1．MRI appearance of femoral headosteonecrosis following core decompression and bone grafting．Skeletal Radiol，199l，20：103-107．
2.和树政，许振华，刘保民．骨内高压下骨微循环形态扫描电镜观察．中华骨科杂志，1990，11：215-218．
3.张毓洲，许露玫，许振华，等．正常与骨内高压下骨髓微循环冷冻割断扫描电镜观察．中华骨科杂志，1999，19：303-305．
4. Castro FP Jr,Barrack RI.Core decompression and conservative treatment for avascularnecrosis of the femoral head:a meta-analysis.USA,Am J orthop,2000,29,(3):187-194
5. Lieberman JR. Core decompression fore osteonecrosis of the hip.ClinOrthop,2004,4(18):29-33
6. Simank HG，Brocai DR，Brill C，et a1．Comparison of results of core decompression andintertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Coxregression and survivorship analysis．J Arthroplasty，200l，16：790-794．
7. Bozic KJ Zurakowski D，Thornhill TS.Survivorship analysis of hips treated with coredecompression for nontraumatic osteonecrosis of the femoral head.J Bone Joint Surg（AM）1999；81（2）：200
8. Beltran J，Knight CT，Zuelzer WA，et al.Core decompression for avascular necrosis of thefemoral head： correlation between long-term results and preoperative MRstaging.Radiology1990；175（2）：533
9. Markel Dc，Miskovsky C, Sculco TP，et al. Core decompression for o-steonecrosis of thefemoral head.Clin Orthop1996；323：22
10. Mazieres B．Bone morphogenetic protein and bone necrosis：a perspective．ARCO NewsLetter，1994，6：3-5．
11. Mazieres B，Chiron PH，Aziza R，et a1．Bone morphogenetic protein (BMP)used in coredecopmression surgical technique the hip in pig model，pathological findings．ARCONews Letter，1994，6：12l-122．
12.郑召民，董天华．带血供骨移植加BMP治疗股骨头坏死．中华实验外科杂志，1998，15：375．
13.郑召民，董天华．带血供骨移植加BMP治疗股骨头坏死的临床初步报告．中华创伤杂志，1999，15：335-337．
14. Bednarek A, Atras A, G ga a J, et al. Operative technique and results of coredecompression and filling with bone grafts in the treatment of osteonecrosis of femoralhead.Ortop Traumatol Rehabil.2010;12(6):511-8.
15. Woodhouse CF．The transplantation of patent arteries to bone[J]．J Int Coll surg，1963，39：437—446．
16.侍德，刘番．血管束骨内植入后骨组织变化的实验研究[J]．中华外科杂志，1986，24(5)：271-273．
17. Duchow J, Kubale R, Hopf T. Color Doppler imaging assessment of blood flow invascularized pedicle grafts for avascular necrosis of the femoral head: angiographiccorrelation.J Ultrasound Med.1998，17(8):509-12.
18.吴斗，刘强，李钢，等.血管束骨内移植治疗青少年股骨头缺血性坏死[J]中华显微外科杂志，2009,32（4）：275-277
19.范丽娟，苏奇，余焕群．多组血管束植入股骨头修整与再造治疗中晚期股骨头缺血性坏死骨与关节损伤杂志，2003，18(9)：596-597．
20. Chen S, Qin J, Mu T,et al.Effect of tissue engineered bone implantation with vascularbundle and sensory nerve bundle on expression of neurokinin1receptor and vasoactiveintestinal peptide type1receptor in vivo].Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.2010;24(7):785-91.
21. Gartsman GM, Weiland AJ, Moore JR, et al.Blood vessel implantation into ischemicbone.J Reconstr Microsurg.1985Jan;1(3):215-22.
22. Phemister DB.Resection and bone transplantation in the treatment of bone sarcoma.ProcInst Med Chic.1946Oct15;16(7):227.
23. Rosenwasser MP，Garino JP，Kierna HA，et al.Long term follow up of thoroughdebridement and cancellous bone grafting of the femoral head for avascular necrosis 〔J〕Clin Orthop1994；306：17-27
24. Mont.MA，Einborn TA，Sponseller PD，et al。The trapdoor paocedure using autogenouscortical and cancellous bone graft for osteonecrosis of the femoral head〔J〕.J Bone JointSurg （Br），1998；80：56-62
25.杨述华，杨操，李宝兴，等.强化力学结构治疗股骨头缺血性坏死的临床研究.中华骨科杂志，2006,26:313-316.
26. Aldridge JM3rd, Berend KR, Gunneson EE, et al.Free vascularized fibular grafting forthe treatment of postcollapse osteonecrosis of the femoral head. Surgical technique.JBone Joint Surg Am.2004;86-A Suppl1:87-101.
27.姚树源，尚天裕．于建华，等.带旋髂深血管蒂骨膜移植治疗成人股骨头无菌性坏死[J]中华骨科杂志，1994；14：324—326
28.王岩，朱盛修，赵德伟，带旋髂深血管蒂髂骨骨膜移植治疗股骨头缺血性坏死及疗效评价[J]中华骨科杂志，1995,15；567
29.赵德伟，崔大平.股骨头缺血性坏死修复与再造的长期随访观察[J]中国矫形外科杂志，2008,16（7），481-484
30. Eisenschenk A, Lantenbach M，Treatment of femoral head necrosis with vascularizediliac crest transplants.Clin Orthop，2001，386:100
31. Matsusaki H, Noguchi M, Kawakami T, Tani T,et al.Use of vascularized pedicle iliac bonegraft combined with transtrochanteric rotational osteotomy in the treatment of avascularnecrosis of the femoral head.Arch Orthop Trauma Surg.2005;125(2):95-101
32. Chen CC, Lin CL, Chen WC, et al. Vascularized iliac bone-grafting for osteonecrosis withsegmental collapse of the femoral head.J Bone Joint Surg Am.2009;91(10):2390-4.
33. Korompilias AV, Beris AE, Lykissas MG, et al.Femoral head osteonecrosis: Why choosefree vascularized fibula grafting. Microsurgery.2011;31(3):223-8.
34. Soucacos PN, Beris AE, Malizos K, et al. Treatment of avascular necrosis of thefemoral head with vascularized fibular transplant [J]Clin Orthop Relat Res.2001;(386):120-30.
35. Sugioka Y.Orthopedists should never forget the utility of osteotomy as an option forregenerative medicine: the importance of joint preservation surgery and its dissemination.JOrthop Sci.2007Jan;12(1):1-3.
36. Schneider E, Ahrendt J, Niethard FU, Bl sius K.et al.Long-term results followingintertrochanteric varus osteotomy in aseptic femur head necrosis in the adult[J].Rofo.1989;150(4):402-6.
37. Gallinaro P．Masse A．Flexion osteotomy in the treatment of avascular necrosis of thehip．Clin Orthop，200l,386：79-84
38. Hiranuma Y, Atsumi T, Kajiwara T, et al.Evaluation of instability after transtrochantericanterior rotational osteotomy for nontraumatic osteonecrosis of the femoral head.J OrthopSci.2009;14(5):535-42
39.陈振光，余国荣，陈廖斌，等.臀下血管吻合支大转子骨瓣移位重建股骨头的应用解剖研究[J]中华实验外科杂志，1993；10（2），58-59
40.赵德伟.带血管蒂骨瓣移植治疗股骨头坏死的经验与技巧.中华显微外科杂志,2009,32(4):265-266.
41.窦亚栋，赵德伟，郭林.带蒂大转子骨瓣修复股骨头生物力学研究.中国骨与关节外科,2010,3(1):68-72.
42.肖嵩华，赵德伟，刘宇鹏，等.带血管蒂的大转子骨与筋膜瓣转移髋关节成形术解放军医学杂志，2003,28（10）；932-933
43.王家宽，葛卫宝，李俊，等.旋髂深血管蒂骨膜瓣与旋股外血管蒂阔筋膜张肌髂骨瓣复合移植治疗成人股骨头缺血性坏死[J]实用手外科杂志，2008，22（3）；158-160
44.杨振虎，王晓玲，侯岩珂，等.带阔筋膜张肌蒂髂骨移植治疗股骨头坏死16例[J]中国中西医结合外科杂志，2003,9（3）;223-224
45. Dewei Zhao, Benjie Wang, Lin Guo, etal. Will a Vascularized Greater Trochanter GraftPreserve the Necrotic Femoral Head? Clin Orthop Relat Res,2010,468:1316-1324
46.赵德伟，田丰德，郭林，等.带血管蒂大转子骨瓣转移治疗股骨头缺血性坏死的生物力学研究.中国临床解剖学杂志,2009,27(5):580-583
47. Hernigou P.Treatment of hip necrosis by sequestrectomy and replacement with bonecement.Acta Orthop Belg.1999;65Suppl1:89-94.
48.董天华，刘松，朱国梁，等.羟基磷灰石骨水泥植入治疗股骨头缺血性坏死的中期疗效观察，中华骨科杂志，2002,22（2）84-87.
49. Wood ML, McDowell CM, Kelley SS. Cementation for femoral head osteonecrosis: apreliminary clinic study.Clin Orthop Relat Res.2003;(412):94-102.
50.沈仲远，李广海，骨水泥填充加钛钉支撑治疗中青年股骨头坏死塌陷的初步报告，中医正骨，2004,18（4），56.
51. Gangji V, Rooze M, De Maertelaer V, Inefficacy of the cementation of femoral headcollapse in glucocorticoid-induced osteonecrosis. Int Orthop.2009Jun;33(3):639-42.
52.王岩，赵德伟，王继芳，等。镍-钛记忆合金网球治疗成人股骨头缺血性坏死初步报告，中华外科杂志，1998,36（10）
53.康鹏德，裴福兴，王坤正，磷酸钙骨水泥／rhBMP一2修复犬股骨头软骨下骨缺损重建力学性能的实验研究，中国矫形外科杂志，2004,12（21~22）1696-1670
54. Fernández-Fairen M, Murcia A, Iglesias R, et al,Osteointegration of porous tantalum stemsimplanted in avascular necrosis of the hip.Acta Ortop Mex.2008Jul-Aug;22(4):215-21
55.许伟华，杨述华，冯勇，等，多孔钽棒植入治疗股骨头坏死的适应证及临床疗效观察，中国骨与关节外科杂志，2010,2（3）；28-32
56.宫宁基,王韶进,刘文广等.髓芯减压多孔钽棒植入术与带蒂股方肌肌骨瓣移植术治疗Ficat Ⅱ期成人股骨头坏死的疗效比较[J].山东大学学报（医学版）,2010,48(7).
57.刘沧君,张孟增,路福志等.成人股骨头缺血坏死影像诊断与介入治疗探讨(附80例报告)[J].放射学实践,2000,15(5)600-606
58.党洪胜,裴福兴,沈彬等.基因修饰的成骨细胞经髓芯减压移植治疗早期股骨头缺血性坏死的实验观察[J].中华医学杂志,2008,88(7)484-489
59. James LA, Ibrahim T, Esler CN Microbiological culture results for the femoral head. Arethey important to the donor?.J Bone Joint Surg Br.2004Aug;86(6):797-800.
60.童培建,金红婷,何帮剑，等.干细胞介入治疗股骨头缺血性坏死的实验研究[J].中华骨科杂志,2010,30(6).600-606
61.赵德伟，崔大平，郭林，等.关节镜下髓芯减压基因转染骨髓间质干细胞修复兔股骨头缺血性坏死,中华骨科杂志,2008,28(11),945-948.
62. Xu M, Peng D.Mesenchymal stem cells cultured on tantalum used in early-stage avascularnecrosis of the femoral head. Med Hypotheses.2011Feb;76(2):199-200.
63.姜文学,尤佳,李轶津等.髋关节表面置换术的近期疗效及其并发症分析[J].中华骨科杂志,2009,29(9)858-863，
64. Mont MA, Rajadhyaksha AD, Hungerford DS, et al. Outcomes of limited femoralresurfacing arthroplasty compared with hip arthroplasty for osteonecrosis of the femoralhead. J Arthroplasty,2001,16:134
65. Sinuier M，Judet T，Sinuier T，et al. Preliminary results of partial surface replacementof the femoral head in osteonecrosis[J].J Arthroplasty.1999,14(1):45-51.
66. Bose VC, Baruah BD.Resurfacing arthroplasty of the hip for avascular necrosis of thefemoral head: a minimum follow-up of four years.J Bone Joint Surg Br.2010Jul;92(7):922-8