联合骨瓣移植打压植骨术结合中医治疗成人股骨头坏死临床研究
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摘要
目的：
通过对临床病例的回顾性研究分析,观察带血管蒂大转子骨瓣联合游离髂骨瓣移植打压植骨术结合中医中药治疗成人股骨头坏死的疗效。
方法：
2003年至2009年间在我院关节一科采用带血管蒂大转子骨瓣联合游离髂骨瓣移植打压植骨手术,并术后结合袁氏生脉成骨片成骨片、中医理疗等方法治疗临床确诊为成年人股骨头缺血性坏死的患者。现对其进行回顾性研究,按病例纳入及排除标准,最终随放到46例符合本研究要求的病例。术前情况及术后随访记录均采用Harris评分标准评价临床疗效；影像学方面以术前及术后末次随访x线片为依据,测量术前术后股骨头正位片上股骨头的高度变化以及关节间隙变化,分析影像学变化的意义,最后结合Harris评分综合分析术前术后的整体疗效。
结果：
本研究中共随访患者46例50髋,其中女性8例,男性38例。根据国际骨循环协会(Association Research Circulation Osseus, ARCO)分期,Ⅱ期6例,Ⅲ期42例,Ⅳ期2例,平均年龄为31.74±9.90(18-53)岁,随访时间为12至84个月,平均随访时间为25.70±16.53月,平均手术持续时间为3小时,术中出血平均约200ml,整体平均术前Harris得分为65.42±10.85分,末次随访平均Harris得分为88.32±8.96分,其中Ⅱc术前平均得分为79.34±1.53,术后86.50±5.22,Ⅲb术前69.50±12.93,术后95.70±6.32,Ⅲc期术前65.44±8.04,术后86.72±9.51。影像学参照按袁彦等应用的评定标准分为优、良、可、差四个级别,结果示总优良率达88.0%,Ⅱc、Ⅲb等影像学表现优良率均为100%,Ⅲc为81.3%,Ⅳ2例患者影像学也得到明显改善,然例数太少,不能充分说明本手术对其有明确疗效。其中6例影像学表现进展或失败,然而回顾各进展或失败病例的X线片,其再塌陷范围均在4mm以内,且<2mm者居多,临床表现未受再塌陷的明显影响,疼痛、活动及生活情况等均较术前改善。无1例随访期间需全髋置换,总体的表现稳定。
结论：
本课题研究采用了病灶清除带血管蒂大转子骨瓣骨瓣联合游离髂骨瓣±打压植骨术,同时解决股骨头坏死区病灶清除、力学重建及血运重建,对中、青年股骨头缺血性坏死ARCOⅡ期、Ⅲ期的患者,临床观察初显良好疗效。
Objective:
Based on clinical cases were analyzed retrospectively, observe curative effect after the vascularized greater trochanter bone graft, which is used as a treatment of the osteonecrosis of the femoral head (ONFH). And it usually combined with free iliac crest flap and impaction bone grafting. This method is discussed in alleviating pain symptoms, improve microcirculation, promote restoration and prevent collapse of clinical application value in different ARCO stages. Compare to the surgical methods of the same type, discover the superiority of this surgery, and for the treat merit of ONFH of the exploration of an effective surgical method, and the evidence of chosen.
Methods:
1. from 2003 to 2009,50 hips in 46 patients, who were diagnosed ONFH in the First Hospital Affiliated to Guangzhou University of Chinese Medicine, were gathered. No surgery patients, such as contraindications to native acetabulum lesions, the operation area without skin lesions, tolerated anesthesia, etc. lateral femoral circumflex artery without significant variation and vascular patency.
2. All patients, who have underwent the vascularized greater trochanter combined free iliac flap and impaction bone grafting, and Chinese medical and medicine was use as adjuvant therapy after the operation, were adopted the preoperative and postoperative follow-up evaluation criteria of clinical curative effect by Harris score, preoperative X-ray analysis and postoperative symptoms, signs and X-ray films.
Results:
Harris reference criteria that include joint pain, the ability to walk, life ability, joint deformities and activity ability score, The mean Harris score was 65.42±10.85 before the operation; it was 88.32±8.96 improved, and the cases in ARCOⅡ、Ⅲstages showing marked improvement. Radiological resuls were good or fair in 88.0% of all case, and 6 cases were reported become deteriorated or failure, but no one collapsed more than 4mm, and most of them were only a little deteriorated than before, which were in less than 2mm collapse of the head. No THA was taken in the follow-up, and all of the clinical results after the operation shown significantly improving.
Conclusion:
the vascularized greater trochanter bone graft combined free iliac flap and impaction bone grafting, shows effective and reliable. And with vascular implantation, blood supply was reconstructed to the femoral head. And femoral head is opened a windows to remove the necrosis bones. It can reduce the pressure inside the bones, and improve the clinical symptoms such as pain and claudication. With bone support and osteoinduction, the creeping substitution for new bone, curative effect is distinct advantages for youth, for the avascular necrosis ARCOⅡ、Ⅲstage patients, it provides a more effective treatment methods.
通过对临床病例的回顾性研究分析,观察带血管蒂大转子骨瓣联合游离髂骨瓣移植打压植骨术结合中医中药治疗成人股骨头坏死的疗效。
方法：
2003年至2009年间在我院关节一科采用带血管蒂大转子骨瓣联合游离髂骨瓣移植打压植骨手术,并术后结合袁氏生脉成骨片成骨片、中医理疗等方法治疗临床确诊为成年人股骨头缺血性坏死的患者。现对其进行回顾性研究,按病例纳入及排除标准,最终随放到46例符合本研究要求的病例。术前情况及术后随访记录均采用Harris评分标准评价临床疗效；影像学方面以术前及术后末次随访x线片为依据,测量术前术后股骨头正位片上股骨头的高度变化以及关节间隙变化,分析影像学变化的意义,最后结合Harris评分综合分析术前术后的整体疗效。
结果：
本研究中共随访患者46例50髋,其中女性8例,男性38例。根据国际骨循环协会(Association Research Circulation Osseus, ARCO)分期,Ⅱ期6例,Ⅲ期42例,Ⅳ期2例,平均年龄为31.74±9.90(18-53)岁,随访时间为12至84个月,平均随访时间为25.70±16.53月,平均手术持续时间为3小时,术中出血平均约200ml,整体平均术前Harris得分为65.42±10.85分,末次随访平均Harris得分为88.32±8.96分,其中Ⅱc术前平均得分为79.34±1.53,术后86.50±5.22,Ⅲb术前69.50±12.93,术后95.70±6.32,Ⅲc期术前65.44±8.04,术后86.72±9.51。影像学参照按袁彦等应用的评定标准分为优、良、可、差四个级别,结果示总优良率达88.0%,Ⅱc、Ⅲb等影像学表现优良率均为100%,Ⅲc为81.3%,Ⅳ2例患者影像学也得到明显改善,然例数太少,不能充分说明本手术对其有明确疗效。其中6例影像学表现进展或失败,然而回顾各进展或失败病例的X线片,其再塌陷范围均在4mm以内,且<2mm者居多,临床表现未受再塌陷的明显影响,疼痛、活动及生活情况等均较术前改善。无1例随访期间需全髋置换,总体的表现稳定。
结论：
本课题研究采用了病灶清除带血管蒂大转子骨瓣骨瓣联合游离髂骨瓣±打压植骨术,同时解决股骨头坏死区病灶清除、力学重建及血运重建,对中、青年股骨头缺血性坏死ARCOⅡ期、Ⅲ期的患者,临床观察初显良好疗效。
Objective:
Based on clinical cases were analyzed retrospectively, observe curative effect after the vascularized greater trochanter bone graft, which is used as a treatment of the osteonecrosis of the femoral head (ONFH). And it usually combined with free iliac crest flap and impaction bone grafting. This method is discussed in alleviating pain symptoms, improve microcirculation, promote restoration and prevent collapse of clinical application value in different ARCO stages. Compare to the surgical methods of the same type, discover the superiority of this surgery, and for the treat merit of ONFH of the exploration of an effective surgical method, and the evidence of chosen.
Methods:
1. from 2003 to 2009,50 hips in 46 patients, who were diagnosed ONFH in the First Hospital Affiliated to Guangzhou University of Chinese Medicine, were gathered. No surgery patients, such as contraindications to native acetabulum lesions, the operation area without skin lesions, tolerated anesthesia, etc. lateral femoral circumflex artery without significant variation and vascular patency.
2. All patients, who have underwent the vascularized greater trochanter combined free iliac flap and impaction bone grafting, and Chinese medical and medicine was use as adjuvant therapy after the operation, were adopted the preoperative and postoperative follow-up evaluation criteria of clinical curative effect by Harris score, preoperative X-ray analysis and postoperative symptoms, signs and X-ray films.
Results:
Harris reference criteria that include joint pain, the ability to walk, life ability, joint deformities and activity ability score, The mean Harris score was 65.42±10.85 before the operation; it was 88.32±8.96 improved, and the cases in ARCOⅡ、Ⅲstages showing marked improvement. Radiological resuls were good or fair in 88.0% of all case, and 6 cases were reported become deteriorated or failure, but no one collapsed more than 4mm, and most of them were only a little deteriorated than before, which were in less than 2mm collapse of the head. No THA was taken in the follow-up, and all of the clinical results after the operation shown significantly improving.
Conclusion:
the vascularized greater trochanter bone graft combined free iliac flap and impaction bone grafting, shows effective and reliable. And with vascular implantation, blood supply was reconstructed to the femoral head. And femoral head is opened a windows to remove the necrosis bones. It can reduce the pressure inside the bones, and improve the clinical symptoms such as pain and claudication. With bone support and osteoinduction, the creeping substitution for new bone, curative effect is distinct advantages for youth, for the avascular necrosis ARCOⅡ、Ⅲstage patients, it provides a more effective treatment methods.
引文
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[2]胡蕴玉等,现代骨科基础与临床,北京：人民卫生出版社,2006,10,第15章第1、2、3节.
[3]Sevitt, Thompson. The distribution and anastomoses of arteries supplying the head and neck of the femur. J Bone Joint Surg(Br).1965; 47(7):560.
[4]Jones LC, Hungerford M, et al. Osteonecrosis:etiology, diagnosis, and treatment Curr Opin Rheumatol,2004,16 (4):443—449.
[5]Satoshi Nagoya, Masato Nagao, Junichi Takada, Hiroki Kuwabara, Takuro Wada, Yutaka Kukita and Toshihiko Yamashita. Predictive factors for vascularized iliac bone graft for nontraumatic osteonecrosis of the femoral head, J Orthop Sci (2004) 9:566—570.
[6]Sugano N, Atsumi T, Ohzono K, et al. Quantifying the extent of femoral head involvement in osteonecrosis. J Bone Joint Surg Am,2003,85(2):309—315
[7]Mont MA, Ragland PS, Etienne G Core decompression of the femoral head for osteonecrosis using percutaneous multiple small—diameter drilling. Clin Orthop Relat Res,2004,4 (29):131—138.
[8]Bozic KJ, Zurakowski D, Thornhill TS. Survivorship analysis of hips treated with core decompression for nontraumatic osteonecrosis of the femoral head[J].J Bone Joint Surg (AM),1999,81(2):200.
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