To examine the relative frequency of patients with idiopathic osteonecrosis of the femoral head (ION) and its trend in recent years, all inclusive patients with ION who underwent surgery during the past 16.5 years at our hospital were studied. The total 16.5-year period was divided into 3, and change of the number of patients with ION per 10, 000 initial visit patients at our department during the 3 periods was analyzed. The analysis was performed by classifying patients by gender and inducible factors (steroid and alcohol) .
The total number of patients with ION did not show any significant changes during the period. The number of patients with ION with steroid use, especially female patients, had increased significantly, whereas female patients without any inducible factors significantly deceased. Our results should be tested in a larger sample study.

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大腿骨頭壊死症は無腐性，虚血性の壊死病変である．その発生機序は諸説報告があるが不明な点が多い．また病理学的報告も多数なされているが，骨頭の血管形態に関する報告は少ない．今回われわれは大腿骨頭壊死症の摘出骨頭において骨頭の血管形態の観察を行い変形性股関節症との違いについて比較検討したので報告する．対象は人工股関節置換術あるいは人工骨頭挿入術時に摘出した骨頭で，大腿骨頭壊死症28症例28骨頭とし，コントロール群として変形性股関節症6症例6骨頭を用いた．摘出骨頭を骨頭中央冠状面で2分割し，中央スライスにてHE標本を作製した．骨頭全体における血管形態の観察，境界領域における血管数および血管径の計測を行い比較検討した．誘因別（アルコール，ステロイド），性別での比較では血管径，血管数共に有意な差はみられなかった．血管形態の観察に関しては境界領域において15症例（53.6%）で血管内腔の『島状隆起』を認めたが，コントロール群ではみられなかった．また，周囲の修復領域では血管に富む肉芽組織や線維性修復反応がみられた．損傷血管は線維芽細胞の遊走および血管内皮細胞の増生・被覆により修復されるが，大腿骨頭壊死症では修復過程の途中で反復性に機械的刺激を受けることになる．この刺激により修復過程にある肉芽組織がさらに内腔に向かって不規則に隆起し，さらに乳頭状隆起となり，乳頭状隆起したものが切れ方により島状隆起として観察されたと考えられる．これは島状隆起内に細小血管がみられることや周囲に修復反応がみられることからも裏付けられると考えられる．そしてコントロール群ではみられなかったことから，本疾患に特徴的な所見ではないかと考えられる．次いで血管数に関してはStage 4がStage 2とStage 3を合わせたもの（Stage 2＋3）に比して有意に多く，血管径に関してはC2がC1に比して有意に大きかった．血管数に関してStage 4がStage 2＋3に比して有意に多かったのは，本疾患は通常の炎症反応と異なり，修復と壊死が繰り返されるため経過が長く，修復と壊死の反復が多いStage 4では血管数がより増加すると考えられる．そしてこの2つの所見は本疾患の反復性の修復と壊死を裏付けるものと考えられる．

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大腿骨頭壊死の原因は諸説あるが，大腿骨頭壊死への栄養動脈の循環障害の可能性を大とする説が多い．これまでに選択的動脈造影により大腿骨頭周辺から骨頭内の血管病変について検索がなされてきたが，末梢の微小血管までの報告は少ない^1）．今回われわれは，大腿骨頭壊死後の修復血管進入部周囲やMRI T1強調画像における帯状低信号領域（以下band部）における血管形態の組織学的評価を行った．MRIは骨頭壊死の早期発見^2）や壊死組織範囲の決定に有効であり，MRIにおけるband像は組織学的には細胞性修復反応や血管に富む肉芽組織や修復反応を示している．Band部で囲まれた領域には骨梁の壊死と骨髄の無反応性の壊死が認められ，band部の末梢側は正常組織とされている^3）．対象は大腿骨頭壊死症に対して人工股関節置換術を施行した際に摘出した28骨頭で男性21例・女性7例，平均年齢46.9歳（27～66歳），Stage 3A：6例・Stage 3B：16例・Stage 4：6例であった．摘出された大腿骨頭はホルマリン固定後に，K-CXで脱灰ののちに冠状断でパラフィン切片を作製しヘマトキシリンエオジン染色後に光学顕微鏡で観察した．光学顕微鏡画像をOLYMPUS AX 80で取り込こんだ後，WinROOF V5.01を用いて血管径と血管数を測定した．観察部位は(1)band部・(2)band部の外側遠位部・(3)band部の外側近位部・(4)正常部の4箇所とした．結果は血管径についてはband部とband部の外側遠位で，Stage 4はStage 3と比較して有意に血管径が小さかった．血管数についてはband部とband部の外側遠位は，正常部とband部の外側近位と比較して有意に血管数が多い結果となった．これらの結果について以下のように考察した．骨頭壊死後の修復血管の進入は骨頭外側から起こり，修復血管の増生を反映してband部の外側遠位部とband部で血管数が多くなると考えた．またStage 4は荷重ストレスに曝される期間が長く，今回観察した病理所見ではStage 4はStage 3と比較して線維化が強く組織球等の炎症細胞浸潤が強い傾向があった．荷重ストレスにより進入が頓挫した修復血管の周囲で，時間経過により間質の線維組織の増生が起こり血管は相対的に小さくなると考えた．つまり修復血管の消退する過程を反映して，Stage 4のband部とband部の外側遠位において血管径が小さくなると考えた．

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Fifty-two patients with avascular necrosis of the femoral head (ANF) were examined to determine the prognosis and decide on treatment. In steroid-induced or bilaterally-involved ANF, collapse of the femoral head occurred more quickly than in idiopathic or unilaterallyaffected patients. According to pathological classification, using Kaplan-Meier's survivership methods, the prognosis of type II patients was poorest and that of type I-C was poorer than that of type I-B.

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Band like sclerosis (BS) of osteonecrosis of the femoral head (ONFH) on X-ray, which conforms to a low intensity band lesion on Magnetic Resonance Imaging (MRI), is one of the charasteristic features of ONFH. BS is histologically characterized as the repair process against necrotic tissue such as appositional bone formation.
We histologically examined 12 band like sclerotic lesions on X-ray. BS consists of bone debris produced by the collapse.
We should consider that collapse.
We should consider that BS in ONFH represents not only appositional bone formation but also the accumulaton of necrotic bone debris.

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We investigated the operative results of 26 patients (34 hips) treated by hemiarthroplasty (Prosthesis)or total hip arthroplasty (THA) for avascular necrosis of the femoral head (ANF) classified according to the etiology.
Clinical results using JOA hip score averaged 79.7 points in prosthesis and 91.2 points in THA after surgery. There was no correlation between them.
On X-ray findings, the rate of loosening was shown for 23.1% of prosthesisind-ucedusing of steroid and 30.0% of prosthesis induced alcohol drinking. There was no loosening in THA.
It is important to prevent loosening in prosthesis in ANF induced-steroid and induced-drinking.

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Clinical and radiological studies were performed on avascular necrosis of the femoral head (ANF) in 220 hips of 140 patients including 51 hips of 28 patients with systemic lupus erythematosus (SLE group). Sixty-nine hips of 41 patients were treated with corticosteroid administration (S group) and 100 hips of 71 patients without corticosteroid administration (Non-S group). All patients with SLE were treated with corticosteroid administration.
Thirty-one femoral heads (11 heads of SLE group, 9 heads of S group and 11 heads of Non-S group) were resected at operations and studied histologically.
Seventy-seven hips at an early stage showed that collapse of the femoral heads occurred in 80% within 3 years and no differences were found among these three group.
In the SLE group, bilateral involvement, multiple bone necrosis and predilection for young females were apparent. Collapse of the femoral head and subcapital fractures were more frequently seen in the SLE group.
Histologically, almost all heads even in the SLE group showed repair process such as enchondral ossification and appositional bone formation, while the heads with subcapital fracture showed no such changes.

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Femoral head fracture following idiopathic osteonecrosis of the femoral head (ION) is rare. The patient was a 50-year-old woman with Systemic Lupus Erythematosus (SLE). In 2003, 10 months after the onset of SLE, she developed pain in the left hip without any history of injury and was subsequently unable to walk. Roentgenographs showed a left femoral head fracture, but osteonecrosis was not apparent. Femoral head replacement was performed. There was no significant collapse of the femoral head. Subcondral tissue showed complete necrosis. At the superior portion of the fracture, there were invading fibrous connective tissue, resorption of live bone, new woven bone formation, and appositional bone formation, as well as the ordinary fracture.
This case was diagnosed as fracture of the femoral head head following ION according to the microscopic examination findings. The femoral head fracture was the first sign of ION.

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Idiopathic necrosis of the femoral head is generally considered to be a rare disease, the etiology is unknown, it is usually progressive and once collapse of the femoral head develops, joint destruction almost invariably follows.
We have treated three patients with idiopathic necrosis of the femoral head, using an Omnifit HA coated stem. The patients were a 58 years-old male, a 29 years-old female and a 58 years-old female. After surgery, all patients showed a marked improvement as an early clinical outcome. They quickly returned to their jobs and social life.

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Femoral neck fracture following aseptic necrosis of the femoral head is rarely reported. We have experienced two such cases and reported here. Histologically, the extracted femoral head had wide necrotic area with process of bone resorption and formation being present partially. The mechanism of the fracture was suggested that the widened necrosis of the femoral head caused physical stress upon the cervical region resulting in fracture.

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【はじめに】片側特発性大腿骨頭壊死の発症15年後に反対側に大腿骨頭壊死を生じた症例を経験した．【症例】56歳，男性．41歳時にMRI，骨シンチグラフィー等により左大腿骨頭壊死の診断を受け当院で大腿骨内反骨切り術を施行した．当時約15年の飲酒歴があり焼酎3～4合をほぼ毎日飲酒していた．ステロイド使用歴はなかった．その後も焼酎2～3合をほぼ毎日飲酒し続けており56歳時に右股関節痛出現，近医でMRIにて右大腿骨頭壊死の診断を受け手術希望で当院受診．早期社会復帰の希望が強く人工股関節全置換術を行った．【考察】

は片側発生後2年を超えて反対側に発生することは稀とされている．今回片側発症15年後に反対側に発症した症例を経験した．アルコール性大腿骨頭壊死は，飲酒の継続が反対側発生につながる可能性を示唆する報告がある．本症例も片側発生後に飲酒が継続され反対側発生の一因になったと考えられた．

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Ten coxae of nine patients with intracapsular fractures of the femoral neck were examined by magnetic resonance imaging (MRI). In five of the ten, specimens were obtained by needle biopsy and examined microscopically. Cases were staged into four groups: according to Garden's classification Stage I, II, III and IV. In some cases of Stage I and II, partial bone necrosis was detected by MRI. Even cases of Stage I or II with bone necrosis rarely suffered from the complication of late segmental collapse. In Stage III or IV cases, extensive bone necrosis was detected by MRI, and in these cases consideration had to be given to the possible occurrence of late segmental collapse. The low signal area surrounded by a zone of non-signal area (so called “band pattern”) demonstrated on MRI corresponded to bone necrosis seen microscopically.

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 This case report concerns a 44-year-old man who developed idiopathic osteonecrosis of the femoral head (ION), for which total hip arthroplasty was performed. The patient developed pure red cell aplasia (PRCA) at 33 years old and received steroid pulse medical treatment for this condition. Internal use of steroid medicine was continued for 6 years. The patient needed frequent red blood cell transfusions, receiving on average 1200 ml a month to improve anemia resulting from PRCA, but developed hemochromatosis and ION. To treat the left hip joint disorder, total hip arthroplasty was performed. Histologically, the synovium of the hip joint was papillary, and hemosiderin was deposited in this. We diagnosed this synovitis as hemosiderotic synovitis. In this case, nonconformity of the morphology of the joint was found along with denaturation of the cartilage as a result of ION. The possibility of synovitis and arthropathy were associated with internal hemorrhage of the joint, grit necrosis, immunoreaction caused by the damaged organization, and hemochromatosis.

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We studied postoperative radiological and clinical results in 30 hips of 15 cases of osteonecrosis of the femoral head induced by corticosteroid. The cases consisted of 5 males and 10 females, aged from 19 to 73 years, with an average age of 31.8. The range of length of follow-up was from 1 year, 2 months to 10 years. The underlying disorders of the affected hips were SLE in 5 cases, nephrosis in 5, and others in 5. Hip prosthetic replacement of the bilateral hip was performed in 6 cases, unilateral hip prosthesis and transtrochanteric rotational osteotomy on the contralateral side in 6, and bilateral transtrochanteric rotational osteotomy in 3. Overall clinical results as measured by JOA score were excellent with both osteotomy and prosthesis; however, radiological studies showed 6 hips with distal migration and 2 hips with central migration among the 18 hips which underwent prosthetic replacement, and advanced collapse occurred in one hip with transtrochateric rotational osteotomy.
Prosthetic replacement is considered to produce difficult problems such as loosening in long-term cases, and we therefore recommend osteotomy for the surgical treatment in young adults with necrosis of the femoral head.

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