Patel D V, Breazeale N M, Behr C T, Warren R F, Wickiewicz T L, O'Brien S J
Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA.
Knee Surg Sports Traumatol Arthrosc. 1998;6(1):2-11. doi: 10.1007/s001670050064.
Osteonecrosis of the knee should be differentiated into two main categories: (1) primary, spontaneous, or idiopathic osteonecrosis and (2) secondary osteonecrosis (e.g., secondary to factors such as steroid therapy, systemic lupus erythematosus, alcoholism, Caisson decompression sickness, Gaucher's disease, hemoglobinopathies, etc.). Spontaneous or primary osteonecrosis of the knee presents with an acute knee pain in elderly patients. It is three times more common in women than in men. Traumatic and vascular theories have been proposed as a causative factor of osteonecrosis of the knee, but the precise etiology still remains speculative. High index of clinical awareness and a good history and physical examination are essential to make an early, accurate diagnosis. Plain radiographs are often normal during the early course of the disease and, in such instances, radioisotope bone scan and magnetic resonance imaging may be helpful. In the early stage of the disease, nonoperative treatment is indicated and many patients, if diagnosed early, have a benign course with a satisfactory pain relief and a good knee function. In patients with advanced stage of the disease, treatment options include arthroscopic debridement, curettage or drilling of the lesion, bone grafting, high tibial osteotomy, use of osteochondral allograft, and unicompartmental or total knee arthroplasty. The choice of treatment should be based on factors such as age of the patient, severity of symptoms, activity level and functional demands on the knee, site and stage of the lesion, and extent of deformity and secondary osteoarthritis. The clinical features and treatment of steroid-induced osteonecrosis of the knee are briefly discussed. In recent years, "postmeniscectomy" osteonecrosis has been reported, but at present its prevalence and pathophysiology remain unknown. It is possible that this may be a preexisting condition that was not recognized at the time of initial consultation or osteonecrosis may develop after meniscectomy in occasional cases.
（1）原发性、自发性或特发性骨坏死；（2）继发性骨坏死（如继发于类固醇治疗、系统性红斑狼疮、酒精中毒、减压病、戈谢病、血红蛋白病等因素）。膝关节自发性或原发性骨坏死在老年患者中表现为急性膝关节疼痛。女性的发病率是男性的三倍。创伤和血管理论已被提出作为膝关节骨坏死的致病因素，但确切病因仍属推测。高度的临床意识以及良好的病史和体格检查对于早期准确诊断至关重要。在疾病早期，X线平片通常正常，在这种情况下，放射性核素骨扫描和磁共振成像可能会有所帮助。在疾病早期，应采取非手术治疗，许多患者如果早期诊断，病程良性，疼痛缓解满意，膝关节功能良好。对于疾病晚期的患者，治疗选择包括关节镜清创、病变刮除或钻孔、植骨、高位胫骨截骨、使用同种异体骨软骨移植以及单髁或全膝关节置换术。治疗方法的选择应基于患者年龄、症状严重程度、活动水平和膝关节功能需求、病变部位和阶段以及畸形和继发性骨关节炎的程度等因素。本文简要讨论了类固醇诱导的膝关节骨坏死的临床特征和治疗。近年来，有“半月板切除术后”骨坏死的报道，但目前其患病率和病理生理学仍不清楚。有可能这是一种在初次就诊时未被认识的既往疾病，或者在偶尔情况下，骨坏死可能在半月板切除术后发生。
