摘要
目的：回顾性研究打压支撑植骨术加中药的治疗方案对围塌陷期ONFH的疗效,客观分析围塌陷期概念在指导临床治疗的意义；比较酒精性和激素性股骨头坏死在临床疗效、影像进展及中医证型等方面的差异；评价ARCO分期分型因素在分期体系中的作用：分析中医辨病、辨证理论在股骨头坏死治疗中的意义。
方法：2004年1月至2006年12月,在广州中医药大学第一附属医院髋关节疾病治疗中心住院的ONFH患者,期间接受打压支撑植骨术加中药治疗,并且术后能完成连续性随访2年以上的患者,共83例123髋。男66例(79.5%)99髋(80.5%),女17例(20.5%)24髋(19.5%),激素性坏死35例(42.2%)54髋(43.9%),酒精性48例(57.8%)69髋(56.1%)。ARCOⅡ期47髋(38.2%),Ⅲ期76髋(61.8%)；坏死范围15%～30%的66髋(53.7%),大于30%的57髋(46.3%)；坏死部位B型19髋(15.4%),C1型39骸(31.7%),C2型65髋(52.8%)；术前股骨头未塌陷47髋(38.2%),塌陷小于2mm的26髋(21.1%),塌陷2～4mm的26髋(21.1%),塌陷大于4mm的24髋(19.5%)。随访24～60个月,平均39.35个月。总结末次随访时Harris髋关节功能评分,比较酒精性和激素性ONFH疗效的差异,分别分析ARCO分期系统中的分期、范围、部位及股骨头塌陷的程度等因素对Harris评分及股骨头生存率的影响,对Harris评分的比较,两组比较采用独立样本的t检验,多组比较采用单因素方差分析,生存率分析用Kaplan-Meier法,两两比较采用log-rank检验,将患者手术日期至最后一次随访之间的时间作为生存时间,将Harris评分为差的(<70分)作为失效事件。用Mann-Whitney检验比较酒精性和激素性股骨头坏死的塌陷进展情况。单独研究塌陷前期坏死股骨头(47髋)的生存率,采用Kaplan-Meier法,将塌陷作为失效事件,将术后至股骨头塌陷的随访时间为生存时间,分别分析坏死分期、范围、部位与股骨头塌陷相关性；在对各相关因素进行Linear Regression回归分析。最后,分析中医辨病辨正治疗在股骨头坏死治疗中的作用；根据中医辨正分型,比较各证型Harris评分和股骨头生存率。所有结果采用spss11.5统计软件处理。
结果：末次随访Harris评分优34髋(27.6%),良26髋(21.2%),可37髋(30.1%),差25髋(21.1%),临床优良率48.8%,有效率78.9%。共7髋转向全髋关节置换术。通过比较末次随访Harris评分,塌陷进展情况,塌陷前期股骨头生存率及中医证型分布等因素,酒精性和激素性ONFH差异均无统计学意义。ARCO分期分型因素中,坏死分期、范围对临床结果均有显著性影响。坏死部位对临床Harris评分及股骨头生存率方面均有影响,但是C1和C2型之间差异无显著性意义。术前坏死股骨头塌陷的程度对临床疗效有显著性影响,术前塌陷大于4mm的坏死股骨头和其它各组差异有显著性意义,而其它各组无显著性差异。中医证型比较,末次随访Harris评分差异无统计学意义。
结论：打压支撑植骨术加中药的治疗方案治疗围塌陷期股骨头坏死具有肯定的临床疗效,股骨头塌陷4mm以下只要髋臼不受影响,均可以纳入保髋治疗范围。在ARCO分期系统的影响因素中,坏死分期、范围在指导治疗方案的选择和判断预后方面具有重要的实用价值。但坏死部位的作用不是不可或缺的,在测量坏死范围的情况下,部位分型在分期系统中可以省略,以简化分期系统。与全髋关节置换相比较,基于Harris评分的髋关节疗效评价标准应该适当放宽,结合本研究的结果,应将Harris评分大于等于70分作为评判疗效的标准。从本研究的结果,还不能认为酒精性和激素性ONFH在临床疗效方面等存在差异。运用中医辨病辨正理论为基础,将中药治疗纳入治疗方案,是为了加快坏死骨的修复,但ONFH的中医证型与临床结果之间没有显著的相关性。
Objective:This retrospective study composed four purpose:(1) The effect of the treatment about Impacting Bone Graft combined with traditional Chinese medicine treating Pericollapse Stage ONFH will be evaluated. Then, the concept of Pericollapse Stage was objectively evaluated on guiding treatment. (2) Difference between the alcohol-induced and steriod-induced ONFH will be compared according to clinical effect, radiology progression, and the distribution difference of the syndrome types by TCM theory. (3) The contribution of the factors composed in the ARCO classification system will be analasised in this clinical study. (4) the rerationship between the clinical result and the theory of diease differentiation and syndrome differentiation will be analasised.
Methods:From January 2004 to December 2006, There were 83 (123 hips) ONFH cases were treated with Impacting Bone Graft combined with TCM at the hip center of the first hospital of Guangzhou TCM university. All these case were related with alcohol abuse or steriod adminstration, and should be consistently followed up at least for 2 years. there were 66 (79.5%) male and 17 (20.5%) female cases,35 (42.2%) steriod-induced and 48 (57.8%) alcohol-induced. According to ARCO classification, stageⅡ47 (38.2%) hips, stageⅢ76 (61.8%) hips. According to lesion size,66 (53.7%) hips were 15%～30%,57 (46.3%) hips were >30%. According to lesion region,19 (15.4%) hips B type,39 (31.7%) hips C1 type,65 (52.8%) hips C2 type. According to the colleps extent of the femur head,47 (38.2%) hips zero,26 (21.1%) hips<2mm, 26 (21.1%) hips 2～4mm,24 (19.5%) hips >4mm. The follow up time was 24～60 months, average 39.35 months. At the last follow up,the Harris score was collected, the difference of the treatment effect between the AONFH and the SONFH was analysised. The factors, such as lesion stage, size, region and extent of the collaps of the femur head, was analysed one by one with their influence on the Harris score and survival rate. The Independent-Samples T Test procedure Wes used to compare means for two groups of cases based on stage(stageⅡ, stage III), percent involvement (15% to 30%[moderate], or>30%[severe]), and reason(alcohol or steriod). The One-Way ANOVA procedure was used for a quantitative dependent variable based on lesion region(B,C1,C2), extent of the collaps (zero,<2mm,2～4mm,>4mm.). The log rank test was used to compare Kaplan-Meier survival curves for the time from surgery to the last follow up for separate groupings based on stage (stageⅠ, stageⅢ), percent involvement(15% to 30%[moderate], or >30% [severe]), reason(alcohol or steriod), and lesion region(B, Cl, C2), in this procedure, that Harris score less than 70 was seen as failure event. The Mann-Whitney procedure was used to compare progression of the femur head collaps between the AONFH and the SONFH. In the precollaps ONFH group, the log rank test was used to compare Kaplan-Meier survival curves for the time from surgery to the time the femur head collaps happened for separate groupings based on stage(stageⅡ, stage III), percent involvement(15% to 30%[moderate], or>30% [severe]), reason(alcohol or steriod),and lesion region(B, C1, C2), in this procedure, that collaps of the femur head was seen as failure event. Linear Regression was used to compare the factos with regard to their ability to predict the time to progression. Finaly, the clinical effect was evaluated with regard to diease differentiation and syndrome differentiation by TCM theory. According to Harris score, we compared the clinical result and the survival rate of the femur head based on different syndrome types of femoral head necrosis by TCM theory. All of the data was analyzed by the statistical packages SPSS 11.5 for windows.
Results:According to Harris score at the last follow up, we got the clinical results:excellent 34 (27.6%) hips, good 26 (21.2%) hips, fair 37 (30.1%) hips, poor 25 (21.1%) hips, and the clinical excellent rate was 48.8%, and the clinical effective rate was 78.9%. Of all the hips, there were 7 hips converted to total hip arthroplasty in the end. Comparing AONFH and SONFH, there wasn't significant difference based on Harris score, collaps extent of the femur head, survival rate of the precollaps hips, and distribution of syndrome types of femoral head necrosis by TCM theory. With regard to factors in ARCO classification, there was significant difference based on stage(stage II, stageⅢ), percent involvement (15% to 30%[moderate], or>30%[severe]). Though there was statistical difference based on lesion region (B, C1, C2), yet,there was not significant difference between Cl and C2. The collaps extent of the femur head before operation could infuence the clinical result significantly, but the difference just existed between the group>4mm and the other group(zero,<2mm,2～4mm). According to Harris score, there was not significant difference based on distribution of syndrome types of femoral head necrosis by TCM theory.
Conclusion:The Impacting Bone Graft combined with TCM is a effective therapeutic regimen for the pericollapse stage ONFH. As long as the collaps of the femur head is not more than 4mm, the hip can be treated with this regimen, considering the factors in the ARCO classification, the stage and lesion size play a important role on chosing therapeutic method and assess prognosis. But the lesion region is not indispensable, if lesion size would be measured,the factor of lesion region can be delected from the classification system, so as to simplify the classification system. Comparing to other similar studies, it looks like the excellent rate(48.8%) and effective rate(78.9%) is lower, but considering the more cases of ARCOⅢand percent involvement (>30% [severe]), maybe the result is better. Comparing to total hip replacement,the Evaluation Criterion for surgery conserving hips based on Harris score should be lower. Refering the results of this study, that the Harris score 70 should be seen as the criterion assigning the effective clinical result. Just based on this study, there is not significant difference between AONFH and SONFH on clinical result. Using the theory of diease differentiation and syndrome differentiation, the TCM was composed to the therapeutic regimen, the purpose for this is to accelerate reparing reaction of the necrosis bone. There is not significant relationship between the syndrome types of femoral head necrosis by TCM theorv and the clinical result.
引文
[1]吴云波.坚持中医诊疗体系的正确方向—也谈辨正与辨病的关系.南京中医学院学报,1991,7(3)：129-132.
[2]McCarthy EF. Aseptic necrosis of bone. An historic perspective. Clin Orthop Relat Res,1982, (168):216-21.
[3]李雄,袁浩.袁浩教授对股骨头坏死中医药论治的学术思想.中国中医骨伤科杂志,1999,7(1)：61-62
[4]刘伯龄,赵文海.股骨头无菌性坏死的辨证施治.中国骨伤,1991,4(001)：1-4.
[5]诸福度,崔明.股骨头缺血性坏死的中医药疗法.中国骨伤,1994,7(006)：46-46.
[6]刘少军.股骨头坏死的中医临床思路与方法探讨.中国医药学报,2002,(01)：44-47.
[7]李雄.袁浩教授治疗股骨头缺血性坏死的思路.广州中医药大学学报,1998,15(A12)：31-35.
[8]徐传毅.袁浩教授从血瘀论治激素性股骨头坏死经验.中医药学刊,2003,21(002)：194-195.
[9]陈卫衡,刘道兵,张洪美,等.股骨头坏死的三期四型辨证思路.中国中医基础医学杂志,2003,9(012)：51-52.
[10]陈卫衡,林娜,郭效东.等.非创伤性股骨头坏死与血浆脂蛋白的相关性研究.中国骨伤,2003,16(002)：69-70.
[11]杨俐,陈学忠,尹方.高脂血症痰浊病机探讨.中医药临床杂志,2005,17(006)：539-540.
[12]王淑玲,郭宏昌,陈修芳.补肾化痰中药对烟熏大鼠慢支模型血清IL-2 IL-8及免疫器官脏器系数的影响.中医药学刊,2005,23(9)：1677-1677·
[13]王彬,胡心愿.浅谈股骨头坏死的中医三期论治.陕西中医学院学报,2004,27(005)：45-46.
[14]潘子毅.中西医结合治疗小儿股骨头缺血坏死100例报告.浙江中医学院学报,1993,17(002)：35-37.
[15]张晓刚,李红专,张乾军,等.中医药治疗股骨头缺血性坏死的研究进展·甘肃中医,2001,14(002)：59-62.
[16]张铁刚,章艳霞.股骨头坏死中医三型分治的临床总结.中国中西医结合外科杂志,1998,4(006)：354-355.
[17]马素英.马氏骨片治疗股骨头坏死128例X线变化.中国骨伤,1996,9(004)：23-24.
[18]邓沂,张晓刚.中医对股骨头坏死的认识.甘肃中医学院学报,1998,15(004)：54-56.
[20]梁茂新,洪治平.对新版《中药新药临床研究指导原则》的若干意见.世界科学技术：中医药现代化,2004,6(005)：40-43.
[21]Lieberman JR, Berry DJ, Mont MA, et al. Osteonecrosis of the hip: management in the 21st century. Instr Course Lect,2003,52:337-55.
[22]Ohzono K, Saito M, Takaoka K, et al. Natural history of nontraumatic avascular necrosis of the femoral head. Journal of Bone & Joint Surgery, British Volume,1991,73(1):68.
[23]Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. The Journal of Bone and Joint Surgery,1995,77(3):459.
[24]Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. Journal of Bone & Joint Surgery, British Volume, 1985,67(1):3.
[25]Koo KH, Kim R, Kim YS, et al. Risk period for developing osteonecrosis of the femoral head in patients on steroid treatment. Clin Rheumatol, 2002,21(4):299-303.
[26]Mont MA, Fairbank AC, Petri M, et al. Core decompression for osteonecrosis of the femoral head in systemic lupus erythematosus. Clin Orthop Relat Res,1997, (334):91-7.
[27]Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res,2004,(429):131-8.
[28]Mont MA, Marulanda GA, Seyler TM, et al. Core decompression and nonvascularized bone grafting for the treatment of early stage osteonecrosis of the femoral head. Instr Course Lect,2007,56:213-20.
[29]Lieberman JR. Core decompression for osteonecrosis of the hip. Clin Orthop Relat Res,2004, (418):29-33.
[30]Steinberg ME. Core decompression of the femoral head for avascular necrosis:indications and results. Can J Surg,1995,38 Suppl 1:S18-24.
[31]Steinberg ME, Larcom PG, Strafford B, et al. Core decompression with bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res,2001, (386):71-8.
[32]Israelite C, Nelson CL, Ziarani CF, et al. Bilateral core decompression for osteonecrosis of the femoral head. Clin Orthop Relat Res, 2005,441:285-90.
[33]PHEMISTER DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg Am,1949,31A(1):55-66.
[34]何伟,李勇,张庆文,等.自体或同种异体腓骨联合打压植骨治疗股骨头坏死的初步研究.中国修复重建外科杂志,2009,(05)：530-533.
[35]SUGIOKA Y, KATSUKI I, HOTOKEBUCHI T. Transtrochanteric rotational osteotomy of the femoral head for the treatment of osteonecrosis: follow-up statistics. Clinical Orthopaedics and Related Research, 1982,169:115.
[36]SUGIOKA Y, HOTOKEBUCHI T, TSUTSUI H. Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head:indications and long-term results. Clin Orthop Relat Res, 1992,277:111.
[37]Dean MT, Cabanela ME. Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. Journal of Bone & Joint Surgery, British Volume,1993,75(4):597.
[38]Mont MA, Fairbank AC, Krackow KA, et al. Corrective osteotomy for osteonecrosis of the femoral head. The results of a long-term follow-up study. The Journal of Bone and Joint Surgery,1996,78(7):1032.
[39]SUGIOKA Y. Transtrochanteric rotational osteotomy in the treatment of idiopathic and steroid-induced femoral head necrosis, Perthes'disease, slipped capital femoral epiphysis, and osteoarthritis of the hip. Clinical Orthopaedics and Related Research,1984,184:12.
[40]Sugano N, Takaoka K, Ohzono K, et al. Rotational osteotomy for non-traumatic avascular necrosis of the femoral head. Journal of Bone & Joint Surgery, British Volume,1992,74(5):734.
[41]Saito S, Ohzono K, Ono K. Joint-preserving operations for idiopathic avascular necrosis of the femoral head. Results of core decompression, grafting and osteotomy. Journal of Bone & Joint Surgery, British Volume, 1988,70(1):78.
[42]Belal MA, Reichelt A. Clinical results of rotational osteotomy for treatment of avascular necrosis of the femoral head. Arch Orthop Trauma Surg,1996,115(2):80-84.
[43]崔永锋,袁浩,何伟,等.双螺钉支撑内固定加植骨治疗不同病因股骨头坏死的疗效比较.中国中医骨伤科杂志,2009,(04)：39-40.
[44]Mont MA, Marulanda GA, Jones LC, et al. Systematic analysis of classification systems for osteonecrosis of the femoral head. The Journal of Bone and Joint Surgery,2006,88(Supplement 3):16.
[45]Phemister DB. THE RECOGNITION OF DEAD BONE BASED ON PATHOLOGICAL AND X-RAY STUDIES. Ann Surg,1920,72(4):466-85.
[46]Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. Journal of Bone & Joint Surgery, British Volume, 1985,67(1):3.
[47]Steinberg ME, Hayken GD, Steinberg DR. A new method for evaluation and staging of avascular necrosis of the femoral head. Bone Circulation, 1984:398-403.
[48]Kerboul M, Thomine J, Postel M, et al. The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. Journal of Bone & Joint Surgery, British Volume,1974,56(2):291.
[49]Mazieres B, Marin F, Chiron P, et al. Influence of the volume of osteonecrosis on the outcome of core decompression of the femoral head. Ann Rheum Dis,1997,56(12):747.
[50]Steinberg ME, Bands RE, Parry S, et al. Does lesion size affect the outcome in avascular necrosis. Clin Orthop Relat Res, 1999, (367):262-71.
[51]Mont MA, Jones LC, Pacheco I, et al. Radiographic predictors of outcome of core decompression for hips with osteonecrosis stage Ⅲ. Clin Orthop Relat Res,1998, (354):159-68.
[52]Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br,1995,77(1):34-41.
[53]Ohzono K, Saito M, Takaoka K, et al. Natural history of nontraumatic avascular necrosis of the femoral head. J Bone Joint Surg Br, 1991,73(1):68-72.
[54]Sugano N, Takaoka K, Ohzono K, et al. Prognostication of nontraumatic avascular necrosis of the femoral head. Significance of location and size of the necrotic lesion[J]. Clin Orthop Relat Res, 1994,303(303):155-64.
[55]Sugano N, Ohzono K, Masuhara K, et al. Prognostication of osteonecrosis
of the femoral head in patients with systemic lupus erythematosus by magnetic resonance imaging. Clinical Orthopaedics and Related Research, 1994,305:190.
[56]Sugano N, Atsumi T, Ohzono K, et al. The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. Journal of Orthopaedic Science,2002,7(5):601-605.
[57]李子荣.股骨头骨坏死的ARCO分期.中华外科杂志,1996,34(3)：186-187.
[58]Steinberg ME, Steinberg DR. Classification systems for osteonecrosis: an overview. Orthop Clin North Am,2004,35(3):273-83, vii-viii.
[59]Ha YC, Jung WH, Kim JR, et al. Prediction of collapse in femoral head osteonecrosis:a modified Kerboul method with use of magnetic resonance images. The Journal of Bone and Joint Surgery,2006,88 (Supplement 3):35.
[60]Mont MA, Einhorn TA, Sponseller PD, et al. The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head. J Bone Joint Surg Br,1998,80(1):56-62.
[61]Koo KH, Kim R. Quantifying the extent of osteonecrosis of the femoral head. JOURNAL OF BONE AND JOINT SURGERY-BRITISH VOLUME-1995,77:875-875.
[62]赵凤朝,张念非.坏死面积比例在预测股骨头塌陷中的价值[J].中华骨科杂志,2005,25(9)：520-523.
[63]Cherian SF, Laorr A, Saleh KJ, et al. Quantifying the extent of femoral head involvement in osteonecrosis. J Bone Joint Surg Am, 2003,85-A(2):309-15.
[64]Nishii T, Sugano N, Ohzono K, et al. Significance of lesion size and location in the prediction of collapse of osteonecrosis of the femoral head:a new three-dimensional quantification using magnetic resonance imaging[J]. J Orthop Res,2002,20(1)(1):130-6.
[65]Hernigou P, Lambotte JC. Volumetric analysis of osteonecrosis of the femur. Anatomical correlation using MRI[J]. J Bone Joint Surg Br, 2001,83(5):672-5.
[66]董天华.成人股骨头缺血性坏死的现代新概念.苏州医学院学报,2000,(12)：1079-1081.
[67]李子荣.科学诊断和治疗股骨头坏死.中国修复重建外科杂志,2005,(09)：685-686.
[68]Marker DR, Seyler TM, McGrath MS, et al. Treatment of early stage osteonecrosis of the femoral head. J Bone Joint Surg Am,2008,90 Suppl 4:175-87.
[69]Myers TG, Mihalko WM, Brown TE, et al. Outcomes of total hip arthroplasty for osteonecrosis of the hip:systematic review and meta-analysis. Current Orthopaedic Practice,2010,21(1):81.
[70]Dudkiewicz I, Covo A, Salai M, et al. Total hip arthroplasty after avascular necrosis of the femoral head:does etiology affect the results. Arch Orthop Trauma Surg,2004,124(2):82-85.
[71]Johannson HR, Zywiel MG, Marker DR, et al. Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty:a systematic literature review. Int Orthop,2010.
[72]段瑞奇.不带血管腓骨支撑植骨术加中药治疗围塌陷期股骨头坏死疗效分析.广州：广州中医药大学,2006.
[73]Yoon TR, Song EK, Rowe SM, et al. Failure after core decompression in osteonecrosis of the femoral head. Int Orthop,2001,24(6):316-8.
[74]Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res, 1996, (324):169-78.
[75]Soohoo NF, Vyas S, Manunga J, et al. Cost-effectiveness analysis of core decompression. J Arthroplasty,2006,21(5):670-81.
[77]孙洪江.非创伤性股骨头缺血性坏死的临床病因分析.中国矫形外科杂志,2002,(11)：26-28.
[78]王荣田,陈卫衡,林娜,等.股骨头坏死的病因构成及发病特征分析.中国骨与关节损伤杂志,2009,(09)：792-795.
[79]Chernetsky SG, Mont MA, LaPorte DM, et al. Pathologic features in steroid and nonsteroid associated osteonecrosis. Clin Orthop Relat Res, 1999, (368):149-61.
[80]崔永锋,袁浩,韩凤岳,等.激素性和酒精性股骨头坏死组织形态学的比较研究.中国骨与关节损伤杂志,2008,23(12)：972-974.
[81]徐传毅,何伟.生脉成骨方对股骨头坏死Ⅰ型胶原表达的调节作用研究.现代中西医结合杂志,2003,12(006)：574-576.
[82]史风雷,李刚,王海彬,等.袁氏生脉成骨胶囊对激素诱导骨髓基质细胞成脂分化的拮抗作用.广州中医药大学学报,2003,20(004)：302-304.
[83]徐传毅.袁浩教授从血瘀证论治激素性股骨头坏死经验.中医药学刊,2003,(02)：194-195.
[84]何伟,樊粤光,李雄.等.活血化瘀中药对激素性股骨头坏死血浆TXB_2与6-keto-PGF_(1 α)影响的实验研究.中国骨伤,2002,(09)：24-26.
[85]何伟,方斌,樊粤光.非创伤性股骨头坏死血液流变学改变及意义.中国中医骨伤科杂志,2001,(06)：26-28.
[86]何伟,李雄,樊粤光.酒精性股骨头坏死血液流变学改变及意义.中医正骨,2001,(10)：8-9+63-64.
[88]陈卫衡,孙凯,张洪美,等.股骨头坏死中医证型与相关理化指标关系的研究.中国骨伤,2005,(09)：513-516.
[89]张庆文.中药治疗股骨头坏死必须注意的几个问题.江苏中医药,2008,(05)：5-6.