应用关节镜技术微创治疗股骨头早期坏死

摘要

目的 评价应用关节镜技术微创病灶清除、植骨、钛棒支撑治疗早期股骨头坏死(osteonecrosis of the femoral head, ONFH) 的临床效果.方法 将2003年～ 2013年确诊为ONFH ARCO分期Ⅱ期58例74个股骨头作为研究对象,其中15个股骨头为ⅡA期、34个股骨头为ⅡB期、25个股骨头为ⅡC期;C型臂X线透视引导及关节镜辅助下,经皮微创有效进行股骨头内病灶清除及髓芯减压,植入复合自体骨髓的骨诱导活性材料(osteoinductive absorbing material, OAM),将羟基磷灰石涂层空心钛棒放置股骨头软骨下骨质.术后6、12、24、36个月进行随访,评价指标包括:疼痛VAS评分,髋关节Harris评分,X线影像学观察及临床疗效.结果 本组随访时间24～ 36个月,平均32个月,其中10例末次随访时股骨头塌陷行THR,其致病诱因均为激素.本组所有病例术后病理组织学显示为骨坏死.术前与术后每个时间点的疼痛VAS评分、髋关节Harris评分相比较,差异有统计学意义(P<0. 05),亦即此手术方法可以明显缓解髋关节疼痛且改善功能.术后24月随访X线分期显示,ⅡB期有5例(5个股骨头)病变为ⅡC期,其中4例又进展为Ⅲ期并且行全髋关节置换术(total hip arthroplasty, THA);术后24个月原ⅡC期有6例(6个股骨头)病变恶化发生股骨头塌陷,术后30个月实施THA.本组术后总改善率79. 72％,改善率最好为ⅡA期93. 33％,ⅡB期为次之82. 35％,ⅡC期为最低68％,无变化及加重的ONFH病例其诱因均为激素性.结论 应用关节镜技术微创病灶清除、植骨、钛棒支撑治疗早期ONFH,具有准确定位、手术微创、病灶清除彻底、重建骨质结构、永久机械支撑特点,除激素性ⅡC期之外的其他Ⅱ期病变在改善疗效和预防关节面塌陷方面效果佳.%Objective To evaluate curative effect of precise focal clearance, bone graft and titanium rod support treated the early osteonecrosis of the femoral head with the assist of minimally invasive arthroscope. Methods A total of 58 patients(74 hips) diagnosed as stage Ⅱ ONFH according to the ARCO staging system during 2003 ～ 2013 were enrolled in this study. There were15 hips at stage ⅡA, 34 hips at stage ⅡB and 25 hips at stage ⅡC. Minimally invasive percutaneous decompression and focal clearance within the femoral head were accurately performed by the C-arm and arthroscopy, and then the OAMcomposite of autologous bone marrow was implanted and the femoral head was supported using the hydroxyapatite coated hollow titanium rod. VAS pain score, Harris hip score, X-ray examination and clinical efficacy were assessed at 6, 12, 24 and 36 month postoperatively. Results 24 ～ 36 months follow-up, average 32 months, including 10 cases at the time of the last follow-up show femoral head collapse and then underwent THRA, its pathogenic cause was hormone. All cases of postoperative pathological histology shows as osteonecrosis. The VAS score and the Harris score after operation were better than preoperative, the difference had statistical significance (P< 0. 05), showing thismethod can reduce pain, improving the function of hip joint. As for the X-ray staging, 5 cases (5 hips) progressed from stage ⅡB to stage ⅡC, four cases of them further progressed to stage Ⅲ and then underwent totail hip arthroplasty. The femoral head of 6 cases (6 hips) staged ⅡC collapsed at 24 months after the operation and then underwent THRA after 30 months. In this study, the total improvement rate after the surgery was 79. 72％ (93. 33％ for IIA, 82. 35％ for IIB and 68％ for ⅡC). Conclusion Precise focal clearance, bone graft and titanium rod support treated the early osteonecrosis of the femoral head with the assist of minimally invasive arthroscope can get accurate positioning, minimally invasive surgery, thorough removal of lesions, reconstruction of bone structure and permanent mechanical support effect. In addition to stage ⅡC patients who had a history of the use of hormone, other stage Ⅱ patients in improving efficacy and preventing joint surface collapse effect is better.