摘要
背景:改良髓芯减压技术(ACD)是近年来开始用于早期股骨头缺血性坏死(ONFH)的保头治疗新技术。目的:观察ACD治疗早期ONFH的临床疗效,探讨该技术的手术适应证。方法:2018年3月至2019年4月采用ACD治疗早期ONFH患者28例39髋,男22例30髋,女6例9髋;年龄17~61岁,平均(38.3±11.7)岁;体重指数(BMI)为17.0~31.4 kg/m^2,平均(25.9±3.8)kg/m^2。激素致ONFH 12髋,酒精致ONFH 14髋,特发性ONFH 13髋。术前分期/分型:按Ficat分期,39髋均为2期;按国际骨循环学会(ARCO)分期(2019版),2期36髋,3A期(新月征阳性)3髋;按日本骨坏死研究会(JIC)分型,B型7髋,C1型18髋,C2型(外侧柱完全受累)14髋。所有病例均由同一术者主刀,记录手术相关情况及手术并发症。术后每3个月进行随访,行影像学及临床评估。将股骨头严重塌陷(>2 mm)或接受全髋关节置换术(THA)定义为临床保头失败,统计保头失败率和分期进展率。比较不同分期/分型病例的失败率差异。结果:手术时间20~40 min,切口长度2~3 cm,术中出血量50~100 ml。无一例出现股骨颈骨折等明显手术并发症。4髋于术后3~6个月诉伤口疼痛,X线片均发现人工骨少量外溢。39髋全部获得随访,随访时间为12~24个月,平均(16.7±3.2)个月。术后6个月复查X线片示人工骨吸收完成,仅少量残留于植骨中央区。末次随访39髋中10髋临床保头失败,其中1髋已接受THA,总体保头失败率为25.6%(10/39)。另有3髋ARCO分期由2期进展为3A期,总体分期进展率为33.3%(13/39)。术前JIC分型为C2型的14髋中8髋保头失败(57.1%),C1型的18髋中2髋保头失败(11.1%),B型的7髋中无保头失败病例。结论:ACD治疗股骨头外侧柱受损不严重的早期ONFH具有简单易行和安全性高的特点,JIC分型B型和C1型是ACD的最佳适应证,可以获得较满意的保头成功率。中远期疗效可能受限于人工骨吸收后支撑强度下降。JIC分型C2型采用ACD治疗的保头失败率高,需要考虑其他保头技术。
Background:Advanced core decompression(ACD)is a recently introduced novel technique for early stage osteonecrosis of the femoral head(ONFH).Objective:To evaluate the early outcome and discuss the optimal indications of ACD.Methods:From March 2018 to April 2019,ACD was performed in 28 ONFH patients(39 hips)including 22(30 hips)males and 6(9 hips)females with the average age of(38.3±11.7)years and range of 17-61 years;average body mass index(BMI)of(25.9±3.8)kg/m^2 and range of 17.0-31.4 kg/m^2.Etiology of ONFH included steroid use in 12 hips,alcohol assumption in 14 hips and spontaneous in 13 hips.Preoperative staging/subtyping included 39 hips of stage 2 according to Ficat system;36 hips of stage 2 and 3 hips of stage 3 A according to Association Research Circulation Osseous(ARCO,2019)system;7 hips of type B,18 hips of type C1 and 14 hips of type C2 according to Japanese Investigation Committee(JIC)system.All the surgeries were performed by the same surgeon.Surgery related indexes and complications were recorded.Patients were followed up every 3 months after surgery,and radiological and clinical evaluations were carried out each time.Clinical failure was defined as collapse of the femoral head larger than 2 mm or total hip arthroplasty preformed.Overall failure rate was calculated as well as progression rate according to ARCO(2019).Results:Operating time ranged from 20 to 40 min.Incision length ranged from 2 to 3 cm.Intraoperative blood loss ranged from 50 to 100 ml.No femoral neck fracture or other related complications were observed during the surgery and follow-up.4 hips suffered from incision related pain for 3-6 months due to bone substitute leakage into the soft tissue around the bone trajectory entrance evidenced by X-ray.All hips were successfully followed up for more than 1 year(12-24 months)and(16.7±3.2)months on average.At 6 months after surgery,the bone substitute was completely absorbed only with some residual in central area of the trajectory.At the last follow-up,10 hips failed including 1 hip undergoing THA and others waiting for THA.The overall failure rate was 25.6%(10/39).Another 3 hips had progressed from ARCO(2019)stage 2 to 3 A,and the overall progression rate was 33.3%(13/39).According to JIC system,8 of 14 hips(57.1%)failed in C2 group,2 of 18 hips(11.1%)failed in C1 group,and none of 7 hips failed in type B group.Conclusions:ACD is a simple and safe technique for early-stage ONFH with non-severe destruction on the lateral column of the femoral head.According to JIC system,type B and C1 are the optimal indication for ACD which can predict a favorable success rate,and the decrease of supporting strength after absorption of the bone substitute may lead to failure in a medium to long duration after surgery;type C2 treated with ACD has a high failure rate,which appeals for other better techniques in future.
作者
杨德金
陈明学
周一新
YANG Dejin;CHEN Mingxue;ZHOU Yixin(Department of Orthopaedics,Beijing Jishuitan Hospital,Beijing 100035,China)
出处
《中华骨与关节外科杂志》
2020年第6期456-461,共6页
Chinese Journal of Bone and Joint Surgery
基金
北京市医院管理中心“青苗”计划专项经费资助(QML20190401)
北京积水潭医院学科新星(XKXX201803)
北京市优秀人才资助项目(2017000021469G229)
关键词
股骨头缺血性坏死
改良髓芯减压
人工骨
Osteonecrosis of the Femoral Head
Advanced Core Decompression
Bone Substitute
作者简介
通信作者:周一新,E-mail:orthoyixin@yahoo.com
