中国修复重建外科杂志

中国修复重建外科杂志

髋关节外科脱位打压植骨术与髓芯减压支撑植骨术治疗 ARCO 期股骨头缺血性坏死疗效比较

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目的比较经髋关节外科脱位打压植骨术与髓芯减压支撑植骨术治疗国际骨循环研究会(ARCO)Ⅲ期股骨头缺血性坏死(avascular necrosis of the femoral head,ANFH)的疗效。方法回顾性分析 2013 年 10 月—2016 年 4 月收治并符合选择标准的 60 例(69 髋)ARCO Ⅲ期非创伤性 ANFH 患者临床资料。其中,24 例(28 髋)行经髋关节外科脱位打压植骨支撑术治疗(A 组),36 例(41 髋)行髓芯减压、坏死病灶清除,并打压植骨、同种异体腓骨支撑术治疗(B 组)。两组患者性别构成、年龄、侧别、ANFH 类型及分期、病程以及术前髋关节 Harris 评分、疼痛视觉模拟评分(VAS)等一般资料比较,差异均无统计学意义(P>0.05)。术后采用 Harris 评分评价髋关节功能,X 线片复查观察股骨头形态改变情况,评价患者保髋临床是否成功。结果术后两组切口均Ⅰ期愈合。两组患者均获随访,A 组随访时间为 12~48 个月,平均 25.8 个月;B 组为 12~54 个月,平均 26.4 个月。A 组 5 髋保髋临床失败,股骨头生存率为 82.1%,中位生存时间为 43 个月;B 组 19 髋临床失败,股骨头生存率为 53.7%,中位生存时间为 42 个月;两组生存曲线分布差异有统计学意义(χ2=4.123,P=0.042),A 组术式优于 B 组。末次随访时 A、B 组保髋成功患者髋关节 Harris 评分明显高于术前,VAS 评分明显低于术前(P<0.05),两指标组间比较差异无统计学意义(P>0.05)。X 线片复查显示,两组植骨均融合,融合时间组间比较差异无统计学意义(t=0.752,P=0.456)。A 组大转子截骨处均愈合良好,1 例髋关节周围出现异位骨化。结论对于股骨头轻度塌陷的 ARCO ⅢA 期患者,两种术式治疗疗效确切;对于股骨头塌陷较严重的 ARCO ⅢB 期患者,经髋关节外科脱位打压植骨术后股骨头生存率优于髓芯减压支撑植骨术。

ObjectiveTo compare effectiveness of sequestrum clearance and impacting bone graft via surgical hip dislocation approach and core decompression and bone graft for avascular necrosis of the femoral head (ANFH) at Association Research Circulation Osseous (ARCO) stage Ⅲ.MethodsA clinical data of 60 patients (69 hips) of non-traumatic ANFH at ARCO stage Ⅲ, which met the inclusion criteria between October 2013 and June 2016, was retrospectively analyzed. Among them, 24 patients (28 hips) were treated with sequestrum clearance and impacting bone graft via surgical hip dislocation approach (group A); and 36 patients (41 hips) were treated with core decompression, sequestrum clearance, impacting bone graft, and nonvascular fibular allograft supporting (group B). There was no significant difference in gender, age, disease duration, affected side, type and stage of the ANFH, and preoperative Harris score and visual analogue scale (VAS) between the two groups (P>0.05). After operation, the function of the hip was evaluated by Harris score, imaging examination was performed to observe the femoral head shape and evaluate whether the hip preserving success.ResultsThe incisions of two groups primarily healed. All patients were followed up. The follow-up time was 12-48 month (mean, 25.8 months) in group A and 12-54 months (mean, 26.4 months) in group B. At last follow-up, 5 hips in group A were classified as clinical failure, femoral head survival rate was 82.1%, the median survival time was 43 months. While 19 hips in group B hip were classified as clinical failure, femoral head survival rate was 53.7%, the median survival time was 42 months. The survival curve between the two groups was statistically significant (χ2= 4.123, P=0.042), and the surgical procedures of group A was superior to group B. In the two groups, the Harris scores at last follow-up were significantly higher than preoperative ones (P<0.05), and VAS score were significantly lower than the preoperative ones (P<0.05). There was no significant difference in Harris score and VAS score at last follow-up between the two groups (P>0.05). All grafted bones got fusion according to the X-ray films, and there was no significant difference in the fusion time between the two groups (t=0.752, P=0.456). Ine group A, greater trochanter bone cutting were healed well; and the heterotopic ossification around the hip joint occurred in 1 case.ConclusionThe surgery of impacting bone graft via surgical hip dislocation approach and core decompression and bone graft can be applied to ANFH at ARCO stage ⅢA which was mild collapse and obtain satisfactory effectiveness. While for the patients of ANFH at ARCO stage Ⅲ B with severe collapse, the hip survival rate of the former is better than that of the latter.

关键词: 股骨头缺血性坏死; 髋关节外科脱位; 打压植骨术; 股骨头塌陷

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

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