经股骨粗隆部旋转截骨术治疗股骨头坏死

Transtrochateric rotational osteotomy for osteonecrosis of the femoral head

目的探讨经股骨粗隆部旋转截骨术治疗股骨头坏死的适应证,手术技术及临床疗效.方法 1992年10月～2001年5月,19例23髋股骨头坏死行经股骨粗隆部截骨术.其中男14例,女5例.年龄22～43岁(平均33.4岁).其中酒精性坏死10例12髋、皮质类固醇性坏死6例7髋、创伤性坏死2例2髋、减压病性坏死1例2髋.按Ficat分期,Ⅱ期8例8髋,Ⅲ期11例15髋.术前Harris评分为46～74分(平均56分).术前摄双髋关节正位和屈髋90°,外展45°旋转中立X线片,以确定坏死部位和角度.按日本Sugioka技术,在股骨粗隆部截骨,将股骨头颈及部分粗隆向前或向后旋转(依坏死部位确定),2～3枚松质骨加压螺钉固定.17例19髋获得18个月～11年随访(平均54个月).结果随访时Harris评分为55～94分(平均80.5分),其中大于80分(优和良)14髋,优良率73.2%,小于79分5髋,其中4髋已行全髋关节置换术.股骨头颈旋转角度55°～80°,平均60°.所有患者粗隆部截骨均达骨性愈合,1例大粗隆截骨因加压钢丝断裂不愈合.术中并发症为旋股内动脉断裂1髋,股骨粗隆下骨折2髋.结论经股骨粗隆旋转截骨术可用于选择性治疗股骨头坏死,即坏死区位于负重面,股骨头未被坏死累及面大于1/3,Ficat Ⅱ期和Ⅲ期早期的中青年(<45岁)患者.后旋及加大旋转度效果更好.该手术有一定的技术难度,有较长的学习曲线,应慎重从事.

Objective To explore the indications, operative technique and clinical results of the transtrochanteric rotational osteotomy ( TRO ) for osteonecrosis of the femoral head ( ONFH) . Methods Nineteen patients (23 hips) with ONFH underwent TRO from October 1992 to May 2001 were reviewed. There were 14 males and 5 females. The age was ranging from 22 to 43 years old with an average age of 33. 4 years old. The etiology were as followed: alcoholism 10 cases (12 hips) ; steroid 6 cases (7 hips); trauma 2 cases (2 hips) ; caisson disease 1 case (2 hips). Ficat stage: Ⅱ 8cases 8 hips; Ⅲ 11 cases 15 hips. Harris hip score 46 to 74 with mean score 56 preoperatively. In order to determine the location and extent of osteonecrosis, A-P view and accurats lateral view (the film should be placed parallel to the femoral neck with the hip in precisely 90° and flexion 45° of abduction and neutral rotation) were taken in both hips preoperatively. The surgical technique described by Sugioka were used in all patients. Results Seventeen patients(19 hips) were followed up ranging from 18 to 11 years with mean 54 months. The Harris hip score was from 55 to 94 with mean 80. 5. Fourteen hips score more than 80 and good to excellent rate was 73. 2% . Harris score were less than 79 in 5 cases and 4 hips of these 5 hips were revised by total hip arthroplasty. The rotation angle was from 55°to 80°with mean 60°. Complications: The circumflex femoral medial artery injury was found in 1 hip; subtrochanteric fracture was found in 2 hips and 1 osteotomy site nonunion occured. Conclusion TRO can be used to treat ONFH. The indications include:(1) younger patients (less than 45 years old). (2) Ficat stage Ⅱ and Ⅲ with more than one third intact articular surface of the femoral head. The better results could be obtained using posterior rotation and lager rotational angle. The Sugioka osteotomy should be used carefully because of its complicated surgical technique