游离髂骨瓣联合带血管蒂大转子骨瓣移植对中青年ARCOⅢ期股骨头坏死患者的保髋作用
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摘要
背景:临床上经常采用单纯游离髂骨瓣移植伴或者不伴带血管大转子骨瓣移植治疗中青年ARCOⅢ期非创伤性股骨头坏死患者,但以上2项术式的疗效优势尚不十分明确。目的:比较游离髂骨瓣与其联合带血管蒂大转子骨瓣移植治疗中青年ARCOⅢ期股骨头坏死患者的临床疗效。方法:选择2009年1月至2013年11月于广州中医药大学第一附属医院行髂骨瓣联合带血管蒂大转子骨瓣移植(A组)与游离髂骨瓣移植(B组)的ARCOⅢ期股骨头坏死患者,年龄18-45岁。2组患者对治疗方案均知情同意,且得到医院伦理委员会批准。记录2组患者术口长度、住院时间、手术时间及出血量,比较组间ARCOⅢ期各亚型术前及末次随访Harris评分及疼痛目测类比评分,并统计髋关节优良率及保髋率。结果与结论:(1)共纳入71例患者(A组37例42髋,B组34例38髋),随访3.5-7年;(2)A组手术时间和术中出血量均大于B组,差异有显著性意义(P <0.05);(3)组内比较,2组术后末次随访ARCOⅢ期各亚型Harris评分及目测类比评分均较术前明显改善;组间比较,A组ARCOⅢb、c型患者术后髋关节Harris评分及目测类比评分均优于B组,差异均有显著性意义(P <0.05);2组ARCOⅢa期患者间Harris评分及目测类比评分差异无显著性意义(P> 0.05);(4)A、B组保髋率分别为91%和74%,差异有显著性意义(Z=3.9,P <0.05);据Harris评分结果,A、B组髋关节优良率分别为82%和75%;(5)2组患者术后均未出现严重并发症;(6)结果表明,游离髂骨瓣伴或不伴带血管蒂大转子骨瓣移植均为治疗中青年ARCOⅢ期股骨头坏死患者的有效方法,能明显改善髋关节功能并缓解疼痛,但前者治疗ARCOⅢ期b、c型股骨头坏死更具优势。
BACKGROUND: Free iliac flap combined with or without vascularised greater trochanter bone grafting is adopted in the treatment of young and middle-aged patients with non-traumatic ARCO III necrosis of the femoral head. However, the efficacy of these two operation treatments is still unclear.OBJECTIVE: To compare the clinical outcomes of free iliac flap combined with or without vascularised greater trochanter bone graft in young and middle-aged patients with ARCO III necrosis of the femoral head.METHODS: Those ARCO III necrosis of the femoral head patients aged 18-45 years who were treated with free iliac flap combined with vascularised greater trochanter bone graft(group A) or with free iliac flap(group B) from January 2009 to November 2013 at the First Affiliated Hospital of Guangzhou University of Chinese Medicine were included in this study. All patients signed the informed consents and the study was approved by the ethics committee of the hospital. The incision length, hospitalization time, operation time and blood loss were recorded.The Harris scores and Visual Analogue Scale scores at baseline and end of follow-up in ARCO III subtypes were compared. The good and excellent rate of hip joint and hip preserving rate were calculated.RESULTS AND CONCLUSION:(1) A total of 71 patients(group A 37 patients with 42 hips; group B 34 patients with 38 hips) were included.The follow-up time was 3.5-7 years.(2) The operation time and intraoperative blood loss in the group A were significantly higher than those in the group B(P < 0.05).(3) The Harris scores and Visual Analogue Scale scores were improved significantly after surgery in ARCO III subtypes of two groups. The Harris scores and Visual Analogue Scale scores in the group A were significantly superior to group B in necrosis of the femoral head patients with ARCO III b and c(P < 0.05). The Harris scores and Visual Analogue Scale scores had no significant difference between two groups in necrosis of the femoral head patients with ARCO III a(P > 0.05).(4) The hip preserving rate in the groups A and B was 91% and 74%(Z=3.9, P < 0.05), respectively. According to the result of Harris scores, the good and excellent rate of hip joint in the groups A and B was 82% and 75%, respectively.(5) There were no serious complications after surgery.(6) These results imply that free iliac flap combined with or without vascularised greater trochanter bone grafting is an effective treatment method for young and middle-aged patients with ARCO III necrosis of the femoral head. They can effectively improve the hip joint function and release joint pain. However, free iliac flap combined with vascularised greater trochanter bone grafting can achieve good clinical outcomes in young and middle-aged patients with ARCO III b and c necrosis of the femoral head.
BACKGROUND: Free iliac flap combined with or without vascularised greater trochanter bone grafting is adopted in the treatment of young and middle-aged patients with non-traumatic ARCO III necrosis of the femoral head. However, the efficacy of these two operation treatments is still unclear.OBJECTIVE: To compare the clinical outcomes of free iliac flap combined with or without vascularised greater trochanter bone graft in young and middle-aged patients with ARCO III necrosis of the femoral head.METHODS: Those ARCO III necrosis of the femoral head patients aged 18-45 years who were treated with free iliac flap combined with vascularised greater trochanter bone graft(group A) or with free iliac flap(group B) from January 2009 to November 2013 at the First Affiliated Hospital of Guangzhou University of Chinese Medicine were included in this study. All patients signed the informed consents and the study was approved by the ethics committee of the hospital. The incision length, hospitalization time, operation time and blood loss were recorded.The Harris scores and Visual Analogue Scale scores at baseline and end of follow-up in ARCO III subtypes were compared. The good and excellent rate of hip joint and hip preserving rate were calculated.RESULTS AND CONCLUSION:(1) A total of 71 patients(group A 37 patients with 42 hips; group B 34 patients with 38 hips) were included.The follow-up time was 3.5-7 years.(2) The operation time and intraoperative blood loss in the group A were significantly higher than those in the group B(P < 0.05).(3) The Harris scores and Visual Analogue Scale scores were improved significantly after surgery in ARCO III subtypes of two groups. The Harris scores and Visual Analogue Scale scores in the group A were significantly superior to group B in necrosis of the femoral head patients with ARCO III b and c(P < 0.05). The Harris scores and Visual Analogue Scale scores had no significant difference between two groups in necrosis of the femoral head patients with ARCO III a(P > 0.05).(4) The hip preserving rate in the groups A and B was 91% and 74%(Z=3.9, P < 0.05), respectively. According to the result of Harris scores, the good and excellent rate of hip joint in the groups A and B was 82% and 75%, respectively.(5) There were no serious complications after surgery.(6) These results imply that free iliac flap combined with or without vascularised greater trochanter bone grafting is an effective treatment method for young and middle-aged patients with ARCO III necrosis of the femoral head. They can effectively improve the hip joint function and release joint pain. However, free iliac flap combined with vascularised greater trochanter bone grafting can achieve good clinical outcomes in young and middle-aged patients with ARCO III b and c necrosis of the femoral head.
引文
[1]刘立云,王琳,邢庆胜.臀中肌支大转子骨瓣治疗早期股骨头坏死疗效观察[J].风湿病与关节炎,2015,4(10):36-38.
[2]Zhao DW,Yu M,Hu K,et al.Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the chinese population:results from a nationally representative survey.Chin Med J(Engl).2015;128(21):2843-2850.
[3]李林,黄克,梁红锁,等.股骨头坏死保髋治疗的研究进展[J].微创医学,2015,10(3):346-349.
[4]刘予豪,周驰,陈雷雷,等.基于股骨头坏死围塌陷期理论的保髋术式总结[J].中国修复重建外科杂志,2017,31(8):1010-1015.
[5]Dong S,Cai X,Zhu Z.Technical summary and modified instruments of free vascularized fibular grafting for osteonecrosis of femoral head].Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.2017;31(2):129-133.
[6]高俊峰.钽棒植入与骨瓣移植治疗成年人早期股骨头坏死的近期疗效对比[J].临床与病理杂志,2017,37(1):16-23.
[7]凌观汉,姚兰,欧志学,等.成人股骨头坏死早中期保髋治疗的研究进展[J].风湿病与关节炎,2017,6(4):60-64.
[8]李祥雨,姜劲挺,张伦广,等.论缺血性股骨头坏死治疗进展[J].辽宁中医药大学学报,2018,20(1):120-122.
[9]陈山林,田光磊,李文军,等.吻合血管股骨内侧髁骨瓣移植治疗难治性舟骨骨折不愈合[J].中华骨科杂志,2010,30(5):487-491.
[10]Roth A,Beckmann J,Smolenski U,et al.S3 guideline.part 2:non-traumatic avascular femoral head necrosis in adults-untreated course and conservative treatment.Z Orthop Unfall.2015;153(5):488-497.
[11]包伟东,孙永强,刘国杰.股骨头坏死的保头治疗进展[J].风湿病与关节炎,2016,5(9):72-76.
[12]Cao L,Guo C,Chen J,et al.Free vascularized fibular grafting improves vascularity compared with core decompression in femoral head osteonecrosis:a randomized clinical trial.Clin Orthop Relat Res.2017;475(9):2230-2240.
[13]邓云平,李伟.股骨头坏死早期治疗方法研究进展[J].西部医学,2017,29(2):292-296.
[14]李飞龙.自体或异体腓骨打压植骨术结合中药对不同分期股骨头坏死疗效观察[D].广州:广州中医药大学,2013.
[15]海国栋,张春雷.髋关节囊减压联合同种异体骨打压植骨移植治疗非创伤缺血性股骨头坏死临床观察[J].临床医学,2014,34(9):13-15.
[16]李一奇,田永金.浅析股骨头坏死的临床表现与治疗[J].医学美学美容(中旬刊),2015,24(2):266-266.
[17]赵德伟,谢辉,王子华,等.带旋股外侧血管升支髂骨瓣转移治疗股骨头缺血性坏死的临床研究[J].中华关节外科杂志(电子版),2017,11(3):234-239.
[18]Zhao D,Wang B,Guo L,et al.Will a vascularized greater trochanter graft preserve the necrotic femoral head.Clin Orthop Relat Res.2010;468(5):1316-1324.
[19]Zeng YR,He S,Feng WJ,et al.Vascularised greater trochanter bone graft,combined free iliac flap and impaction bone grafting for osteonecrosis of the femoral head.Int Orthop.2013;37(3):391-398.
[20]Wang BL,Sun W,Shi ZC,et al.Treatment of nontraumatic osteonecrosis of the femoral head using bone impaction grafting through a femoral neck window.Int Orthop.2010;34(5):635-639.
[21]ünal MB,Cansu E,Parmaks?zo?lu F,et al.Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting:Results of 7.6-year fol ow-up.Acta Orthop Traumatol Turc.2016;50(5):501-506.
[22]孙瑞波,刘又文,张颖.钽棒和缝匠肌骨瓣植入分期治疗早期股骨头坏死疗效观察[J].风湿病与关节炎,2015,4(1):35-38.
[23]Fontecha CG,Roca I,Barber I,et al.Femoral head bone viability after free vascularized fibular grafting for osteonecrosis:SPECT/CT study.Microsurgery.2016;36(7):573-577.
[24]ünal MB,CansüE,Parmaks?zo?lu F,et al.Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting:results of 7.6-year fol ow-up.Acta Orthop Traumatol Turc.2016;50(3):323-329.
[25]Chughtai M,Piuzzi NS,Khlopas A,et al.An evidence-based guide to the treatment of osteonecrosis of the femoral head.Bone Joint J.2017;99-B(10):1267-1279.
[26]Zhao D,Cui D,Lu F,et al.Combined vascularized iliac and greater trochanter graftings for reconstruction of the osteonecrosis femoral head with col apse:reports of three cases with 20 years follow-up.Microsurgery.2012;32(7):546-551.
[27]Liu ZH,Guo WS,Li ZR,et al.Porous tantalum rods for treating osteonecrosis of the femoral head.Genet Mol Res.2014;13(4):8342-8352.
[28]Zhao D,Zhang Y,Wang W,et al.Tantalum rod implantation and vascularized iliac grafting for osteonecrosis of the femoral head.Orthopedics.2013;36(6):789-795.
[29]Zhou GQ,Pang ZH,Chen QQ,et al.Reconstruction of the biomechanical transfer path of femoral head necrosis:a subject-specific finite element investigation.Comput Biol Med.2014;52:96-101.
[30]Zhou G,Zhang Y,Zeng L,et al.Should thorough Debridement be used in Fibular Allograft with impaction bone grafting to treat Femoral Head Necrosis:a biomechanical evaluation.BMC Musculoskelet Disord.2015;16:140.
[31]赵德伟,田丰德,郭林,等.带血管蒂大转子骨瓣转移治疗股骨头缺血坏死的生物力学研究[J].中国临床解剖学杂志,2009,27(5):580-583.
[32]徐福东,庄至坤,吴昭克,等.带旋股外侧血管横支大转子骨瓣移植术治疗股骨头坏死的近期疗效[J].中国中医骨伤科杂志,2015,23(12):65-66.
[33]朱绍灵.大转子骨瓣联合植骨术治疗股骨头坏死ARCOⅢ期的临床疗效及有限元研究[D].广州:广州中医药大学,2012.
[34]刘盛飞,施明祥,陈庆真.带血管大转子骨瓣植入联合中药内服治疗股骨头坏死20例临床观察[J].中国民族民间医药,2014,23(19):47-48.
[35]张天一,董巍,米盼盼,等.三维有限元分析大转子骨瓣转移治疗股骨头缺血坏死应力分布变化[J].中国组织工程研究,2018,22(7):1090-1095.
[2]Zhao DW,Yu M,Hu K,et al.Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the chinese population:results from a nationally representative survey.Chin Med J(Engl).2015;128(21):2843-2850.
[3]李林,黄克,梁红锁,等.股骨头坏死保髋治疗的研究进展[J].微创医学,2015,10(3):346-349.
[4]刘予豪,周驰,陈雷雷,等.基于股骨头坏死围塌陷期理论的保髋术式总结[J].中国修复重建外科杂志,2017,31(8):1010-1015.
[5]Dong S,Cai X,Zhu Z.Technical summary and modified instruments of free vascularized fibular grafting for osteonecrosis of femoral head].Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.2017;31(2):129-133.
[6]高俊峰.钽棒植入与骨瓣移植治疗成年人早期股骨头坏死的近期疗效对比[J].临床与病理杂志,2017,37(1):16-23.
[7]凌观汉,姚兰,欧志学,等.成人股骨头坏死早中期保髋治疗的研究进展[J].风湿病与关节炎,2017,6(4):60-64.
[8]李祥雨,姜劲挺,张伦广,等.论缺血性股骨头坏死治疗进展[J].辽宁中医药大学学报,2018,20(1):120-122.
[9]陈山林,田光磊,李文军,等.吻合血管股骨内侧髁骨瓣移植治疗难治性舟骨骨折不愈合[J].中华骨科杂志,2010,30(5):487-491.
[10]Roth A,Beckmann J,Smolenski U,et al.S3 guideline.part 2:non-traumatic avascular femoral head necrosis in adults-untreated course and conservative treatment.Z Orthop Unfall.2015;153(5):488-497.
[11]包伟东,孙永强,刘国杰.股骨头坏死的保头治疗进展[J].风湿病与关节炎,2016,5(9):72-76.
[12]Cao L,Guo C,Chen J,et al.Free vascularized fibular grafting improves vascularity compared with core decompression in femoral head osteonecrosis:a randomized clinical trial.Clin Orthop Relat Res.2017;475(9):2230-2240.
[13]邓云平,李伟.股骨头坏死早期治疗方法研究进展[J].西部医学,2017,29(2):292-296.
[14]李飞龙.自体或异体腓骨打压植骨术结合中药对不同分期股骨头坏死疗效观察[D].广州:广州中医药大学,2013.
[15]海国栋,张春雷.髋关节囊减压联合同种异体骨打压植骨移植治疗非创伤缺血性股骨头坏死临床观察[J].临床医学,2014,34(9):13-15.
[16]李一奇,田永金.浅析股骨头坏死的临床表现与治疗[J].医学美学美容(中旬刊),2015,24(2):266-266.
[17]赵德伟,谢辉,王子华,等.带旋股外侧血管升支髂骨瓣转移治疗股骨头缺血性坏死的临床研究[J].中华关节外科杂志(电子版),2017,11(3):234-239.
[18]Zhao D,Wang B,Guo L,et al.Will a vascularized greater trochanter graft preserve the necrotic femoral head.Clin Orthop Relat Res.2010;468(5):1316-1324.
[19]Zeng YR,He S,Feng WJ,et al.Vascularised greater trochanter bone graft,combined free iliac flap and impaction bone grafting for osteonecrosis of the femoral head.Int Orthop.2013;37(3):391-398.
[20]Wang BL,Sun W,Shi ZC,et al.Treatment of nontraumatic osteonecrosis of the femoral head using bone impaction grafting through a femoral neck window.Int Orthop.2010;34(5):635-639.
[21]ünal MB,Cansu E,Parmaks?zo?lu F,et al.Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting:Results of 7.6-year fol ow-up.Acta Orthop Traumatol Turc.2016;50(5):501-506.
[22]孙瑞波,刘又文,张颖.钽棒和缝匠肌骨瓣植入分期治疗早期股骨头坏死疗效观察[J].风湿病与关节炎,2015,4(1):35-38.
[23]Fontecha CG,Roca I,Barber I,et al.Femoral head bone viability after free vascularized fibular grafting for osteonecrosis:SPECT/CT study.Microsurgery.2016;36(7):573-577.
[24]ünal MB,CansüE,Parmaks?zo?lu F,et al.Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting:results of 7.6-year fol ow-up.Acta Orthop Traumatol Turc.2016;50(3):323-329.
[25]Chughtai M,Piuzzi NS,Khlopas A,et al.An evidence-based guide to the treatment of osteonecrosis of the femoral head.Bone Joint J.2017;99-B(10):1267-1279.
[26]Zhao D,Cui D,Lu F,et al.Combined vascularized iliac and greater trochanter graftings for reconstruction of the osteonecrosis femoral head with col apse:reports of three cases with 20 years follow-up.Microsurgery.2012;32(7):546-551.
[27]Liu ZH,Guo WS,Li ZR,et al.Porous tantalum rods for treating osteonecrosis of the femoral head.Genet Mol Res.2014;13(4):8342-8352.
[28]Zhao D,Zhang Y,Wang W,et al.Tantalum rod implantation and vascularized iliac grafting for osteonecrosis of the femoral head.Orthopedics.2013;36(6):789-795.
[29]Zhou GQ,Pang ZH,Chen QQ,et al.Reconstruction of the biomechanical transfer path of femoral head necrosis:a subject-specific finite element investigation.Comput Biol Med.2014;52:96-101.
[30]Zhou G,Zhang Y,Zeng L,et al.Should thorough Debridement be used in Fibular Allograft with impaction bone grafting to treat Femoral Head Necrosis:a biomechanical evaluation.BMC Musculoskelet Disord.2015;16:140.
[31]赵德伟,田丰德,郭林,等.带血管蒂大转子骨瓣转移治疗股骨头缺血坏死的生物力学研究[J].中国临床解剖学杂志,2009,27(5):580-583.
[32]徐福东,庄至坤,吴昭克,等.带旋股外侧血管横支大转子骨瓣移植术治疗股骨头坏死的近期疗效[J].中国中医骨伤科杂志,2015,23(12):65-66.
[33]朱绍灵.大转子骨瓣联合植骨术治疗股骨头坏死ARCOⅢ期的临床疗效及有限元研究[D].广州:广州中医药大学,2012.
[34]刘盛飞,施明祥,陈庆真.带血管大转子骨瓣植入联合中药内服治疗股骨头坏死20例临床观察[J].中国民族民间医药,2014,23(19):47-48.
[35]张天一,董巍,米盼盼,等.三维有限元分析大转子骨瓣转移治疗股骨头缺血坏死应力分布变化[J].中国组织工程研究,2018,22(7):1090-1095.
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