改良吻合血管游离腓骨移植治疗股骨头缺血性坏死的手术技术

SURGICAL TECHNIQUE OF MODIFIED FREE VASCULARIZED FIBULAR GRAFTING FOR TREATMENT OF OSTEONECROSIS OF THE FEMORAL HEAD

目的探讨改良的吻合血管游离腓骨移植治疗股骨头缺血性坏死的手术技术、临床疗效及其并发症. 方法 2000年10月～2004年8月,共治疗124例(139髋)股骨头缺血性坏死患者,男83例(93髋),女41例(46髋);年龄16～57岁,平均36.4岁.其中创伤性49例(54髋),激素性29例(32髋),酒精性19例(21髋),特发性27例(32髋).SteinbergⅡ期50髋,Ⅲ期71髋,Ⅳ期18髋,Harris评分平均分别为:79.3、69.3和58.4分.采用改良的游离腓骨切取技术,设计髋前小切口入路,并采用改良的坏死清理技术.记录手术时间、总出血量及切口长度.术后行X线摄片、Harris评分及并发症的评价. 结果游离腓骨手术时间为10～30 min,平均15 min.总手术时间为80～120 min,平均90 min.髋部切口长为6～12 cm,平均8 cm.总出血量为100～300 ml,平均200 ml.术后并发症少,平均住院时间7 d.患者随访6个月～3年8个月,其中随访1年以上65例(78髋)患者的X线片显示:62髋(79.5%)的股骨头坏死有不同程度改善,14髋(17.9%)无明显变化,2髋(2.6%)恶化.Harris评分平均为:Ⅱ期94.4分,Ⅲ期86.0分,Ⅳ期74.1分.术后10例出现股前外侧皮肤麻木和感觉减退,1例小腿伤口延迟愈合,6例足背感觉异常,5例出现一过性供体肌力减弱,3例踝关节活动不适,但均未对日常生活产生明显影响. 结论改良的吻合血管游离腓骨移植术具有出血少、解剖清晰、操作简便、创伤小、并发症少及术后功能恢复较好等优点,是治疗股骨头缺血性坏死的一种有效的保头治疗方法.

Objective To evaluate the surgical technique, clinical results, and the complications of modified free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. Methods From October 2000 to August 2004, 124 patients （139 hips） with osteonecrosis of the femoral head were treated with modified free vascularized fibular grafting. There were 83 males（93 hips） and 41 females （46 hips）, with a mean age of 36.4 years （16-57）, The disease was caused by trauma in 49 cases（54 hips）, use of steroids in 29 cases （32 hips）, consumption of alcohol in 19 cases （21 hips） and idiopathic condition in 27 cases （32 hips）, Of 139 hips, 50 were classified as stage Ⅱ ; 71 as stage Ⅲ , 18 as stage Ⅳ according to Steinberg system; the Harris hip scores were 79.3, 69.3 and 58.4, respectively, At the operation, modified technique of the fibular osteotomy was adopted. A front hip operative approach was designed and a modified technique of removing the necrotic bone in femoral head was applied. During operation, the duration of operation, the bleeding volume, and the length of incisions were recorded. The follow-up items included the results of X-ray examination, the Harris score of the hip, and the evaluation of the complications. Results The duration of the fibular osteotomy was 10 to 30 min（15 min on average）. The duration of the total operation was 80 to 120 min （90min on average）, The length of incision at the hip was 6 to 12 cm （8 cm on average）. The bleeding volume was 100 to 300ml（200mlon average）. The average hospitalization days was 7 days. After operation, Harris hip scores in most cases were improved. According to postoperative X ray, 62 hips （79, 5%） were improved to different extents and 14 hips （17.9%） had no significant changes. Deterioration occurred in 2 hips （2.6%）. Conclusion The modified free vascularized fibular grafting has lots of virtues, such as less bleeding volume, more clear anatomic structure, more convenience for operation, less damage, less complications, and better results of function recovery. It is an effective method for treating osteonecrosis of the femoral head.