Bayne O, Langer F, Pritzker K P, Houpt J, Gross A E
Orthop Clin North Am. 1985 Oct;16(4):727-40.
In summary, patients with spontaneous osteonecrosis of the knee requiring surgery were elderly and generally had late stage IV disease. They seemed to do better with osteotomy and debridement than with osteochondral allograft replacement because they could not tolerate restricted weight bearing. Patients with steroid-induced osteonecrosis did well initially after allograft replacement (6 to 18 months), especially in experiencing pain relief. However, because of the continuous use of high doses of steroids, revascularization of the allografts was poor, resulting in graft subsidence. Patients have better long-term results following osteotomy and debridement. Patients with traumatic osteonecrosis and osteochondritis dissecans had the best results following osteochondral allograft replacements. In conclusion, based on our series and others, our current surgical approach in the management of osteonecrosis of the knee is as follows: 1. In patients with spontaneous osteonecrosis with asymptomatic small lesions, nonsurgical treatment is recommended. For an asymptomatic or symptomatic large lesion with associated angular deformity, the active patient should have a tibial osteotomy for stages I and II and tibial osteotomy and debridement for stages III and IV. Less active patients with symptomatic stage III or IV disease should have unicompartmental or total knee prosthetic arthroplasty. 2. For steroid-induced osteonecrosis, osteochondral allografts are not recommended. If the patient's systemic disease has a limited prognosis, or if the patient has multijoint involvement, total knee or unicompartmental arthroplasty is warranted. If the patient has a good prognosis and is active, debridement with or without realignment should be performed. 3. For traumatic osteonecrosis in the younger patient or for osteochondritis dissecans, fresh osteochondral allograft replacement is recommended. High tibial osteotomy in combination with allograft replacement should also be done if there is associated malalignment. The realignment should be done prior to or simultaneously with the allograft (providing the osteotomy is done on the side of the joint opposite the allograft).
总之，需要手术治疗的膝关节自发性骨坏死患者多为老年人，且通常处于疾病晚期（IV期）。与异体骨软骨移植置换术相比，他们接受截骨术和清创术的效果似乎更好，因为他们无法耐受限制负重。类固醇诱导性骨坏死患者在异体移植置换术后初期效果良好（6至18个月），尤其是在缓解疼痛方面。然而，由于持续使用高剂量类固醇，异体骨的血管再生不良，导致移植物下沉。患者接受截骨术和清创术后的长期效果更好。创伤性骨坏死和剥脱性骨软骨炎患者接受异体骨软骨移植置换术后效果最佳。总之，根据我们的系列研究及其他研究，我们目前治疗膝关节骨坏死的手术方法如下：1.对于无症状小病灶的膝关节自发性骨坏死患者，建议采用非手术治疗。对于伴有角度畸形且无症状或有症状的大病灶，活动能力较好且处于I期和II期疾病的患者应进行胫骨截骨术，处于III期和IV期疾病的患者应进行胫骨截骨术和清创术。活动能力较差且处于有症状的III期或IV期疾病的患者应进行单髁或全膝关节置换术。2.对于类固醇诱导性骨坏死，不建议进行异体骨软骨移植。如果患者的全身性疾病预后有限，或患者有多关节受累，则有必要进行全膝关节或单髁置换术。如果患者预后良好且活动能力较好，则应进行清创术，可伴有或不伴有重新排列。3.对于年轻患者的创伤性骨坏死或剥脱性骨软骨炎，建议进行新鲜异体骨软骨移植置换术。如果伴有对线不良，还应进行高位胫骨截骨术并结合异体移植置换术。重新排列应在异体移植之前或同时进行（前提是截骨术在与异体移植相对的关节侧进行）。
