中国修复重建外科杂志

中国修复重建外科杂志

经外科脱位入路打压植骨术与旋转截骨术治疗 ARCO 期股骨头缺血性坏死的比较研究

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目的比较经髋关节外科脱位入路,采用死骨清理打压植骨术或股骨颈基底部旋转截骨术治疗国际骨循环协会(ARCO)Ⅲ期股骨头缺血性坏死(avascular necrosis of femoral head,ANFH)的疗效。方法 将 2012 年 6 月—2017 年 12 月收治并符合选择标准的 24 例(27 髋)ANFH 患者纳入研究。髋关节外科脱位入路后,12 例(14 髋)行死骨清理打压植骨术(A 组),12 例(13 髋)行股骨颈基底部旋转截骨术(B 组)。两组患者性别、年龄、病程以及 ANFH 侧别、类型、分期等一般资料比较,差异均无统计学意义(P>0.05)。记录两组每侧髋关节手术时间、患者住院时间;影像学检查观察股骨头有无塌陷、截骨块愈合情况,股骨头周围血供情况;采用 Harris 评分评估髋关节功能。结果 两组每侧髋关节手术时间、患者住院时间比较差异均无统计学意义(t=–0.262,P=0.797;t=–0.918,P=0.411)。患者均获随访,A 组随访时间为 12~28 个月,平均 19.7 个月;B 组为 14~24 个月,平均 17.8 个月。两组术后 6、12 个月 Harris 评分均较术前明显提高(P<0.05);两组间比较差异均无统计学意义(P>0.05)。术后 12 个月 A 组获优 3 髋、良 7 髋、差 4 髋,优良率 71.4%;B 组获优 5 髋、良 7 髋、差 1 髋,优良率 92.3%。术后 1 周数字减影血管造影检查示,与术前相比两组股骨头周围血供均未被破坏。术后影像学复查显示两组大粗隆截骨块均愈合,B 组股骨颈截骨均愈合;术后 12 个月仅 A 组 2 例(2 髋)出现新的塌陷。患者关节间隙较术前均无狭窄,无软骨下骨硬化及骨囊肿形成。结论 对于 ARCO Ⅲ期 ANFH 患者,髋关节外科脱位入路后行股骨颈基底部旋转截骨术在延缓塌陷、提高髋关节功能方面优于死骨清理打压植骨术。

Objective To compare effectiveness between sequestrum clearance and impacting bone graft and rotational osteotomy on the base of femoral neck via surgical hip dislocation approach for avascular necrosis of femoral head (ANFH) at Association Research Circulation Osseous (ARCO ) stage Ⅲ. Methods A clinical data of 24 patients (27 hips) with ANFH at ARCO stage Ⅲ, who were met the inclusion criteria between June 2012 and December 2017, was retrospectively analysed. Of all patients, 12 patients (14 hips) were treated with sequestrum clearance and impacting bone graft via surgical hip dislocation approach (group A); and 12 patients (13 hips) were treated with rotational osteotomy on the base of femoral neck via surgical hip dislocation approach (group B). There was no significant difference in gender, age, disease duration, and affected side, type, and stage of the ANFH between 2 groups (P>0.05). The operation time of each hip and hospitalization stays of each patient in 2 groups were recorded. Imaging examination was performed to observe the blood supply around femoral head, healing of the osteotomy, and the femoral head collapsed. The function of the hip was evaluated by Harris score. Results There was no significant difference in operation time and hospitalization stays (t=–0.262, P=0.797; t=–0.918, P=0.411). All patients were followed up, the follow-up time of group A was 12-28 months (mean, 19.7 months), and the follow-up time of group B was 14-24 months (mean, 17.8 months). The Harris score in groups A and B increased significantly at 6 months and 12 months after operation when compared with preoperative ones (P<0.05). There was no significant difference between 2 groups at 6 months and 12 months (P>0.05). At 12 months after operation, according to the Harris scoring, there were 3 hips of excellent, 7 hips of good, and 4 hips of poor, with the excellent and good rate of 71.4% in group A; there were 5 hips of excellent, 7 hips of good, and 1 hip of poor, with the excellent and good rate of 92.3% in group B. Digital substraction angiography was performed at 1 week after operation and indicated that the blood supply around the femoral head was not destroyed during the operation. Imaging examination after operation showed that the osteotomy of the greater trochanter all healed in 2 groups and the osteotomy of the femoral neck healed in group B. Hip collapse occurred in 2 patients (2 hips) of group A at 12 months after operation. No hip collapse occurred in group B. Conclusion The rotational osteotomy on the base of femoral neck via surgical hip dislocation approach is superior to sequestrum clearance and impacting bone graft in delaying the collapse and improving the hip function for patients with ANFH at ARCO stage Ⅲ.

关键词: 股骨头缺血性坏死; 外科脱位入路; 打压植骨; 旋转截骨

Key words: Avascular necrosis of femoral head; surgical hip dislocation approach; impacting bone graft; rotational osteotomy

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