多孔髓芯减压联合干细胞移植治疗股骨头坏死的早期随访结果

Multiple drilling core decompression combined with stem cell transplantation in the treatment of femoral head necrosis:An early follow-up

目的:探讨多孔髓芯减压联合自体骨髓干细胞移植治疗股骨头坏死的疗效及临床分析。方法:选择2003-02/2006-12在南京医科大学附属南京第一医院骨关节中心采用多孔髓芯减压联合干细胞移植治疗的股骨头坏死患者22例,共28髋,年龄17～48岁,根据世界骨循环研究学会(ARCO)的国际骨坏死分期标准:Ⅰ期13髋,Ⅱ期11髋,Ⅲ期4髋。长期使用激素史9例,长期酗酒史6例,外伤史5例,原因不明者2例。纳入标准:有髋关节疼痛,功能受限;经髋关节X射线片及MRI检查确诊;ARCO分期Ⅰ～Ⅲ期;患者知情同意并签署知情同意书。排除标准:其他髋关节疾病。自患者髂前上棘处行骨髓穿刺分离与培养骨髓间充质干细胞。取患肢大粗隆下大腿外侧纵向直切口约3.0cm,钝性分离至股骨,在C形臂机引导下自股骨头中心钻入3枚直径4.0mm斯氏针,选位置较好的斯氏针,将直径约8.0mm特制套管在斯氏针的引导下钻至股骨头关节软骨面下1.0～2.0mm,不穿破关节面。将一长注射器针头置入股骨头坏死中心,立即行X射线正侧位摄片,确保针头位于股骨头内,从针头向股骨头内加压注入自体骨髓间充质干细胞悬液1.5～2.0mL。术后12个月随访,每3个月1次,随访时门诊复查,拍正、侧位和蛙式位X射线片,行MRI检查,观察病情变化。使用髋关节Harris评分进行疗效评价,>90分为优,75～90分为良,60～74分为可,<60分评定为差。若Harris评分提高,X射线骨形态变化改善及MRI股骨头坏死区体积变小可认为联合治疗有效。结果:①22例患者均完成随访,进入结果分析。②随访3个月时X射线及MRI检查:2例(2髋)激素引起的Ⅲ期患者股骨头发生进一步变形及塌陷,其余患者在随访期间未出现严重并发症,不良反应及病情恶化。股骨头坏死体积由术前31.07%减小到17.46%。激素组治疗前后股骨头坏死体积差值小于外伤、酗酒组,就本随访资料而言激素组疗效不如外伤及酗酒组。③随访12个月Harris评分:由术前54.3上升到84.6,有较明显提高,其中优7髋(25.0%),良15髋(53.6%),可4髋(14.3%),差2髋(0.07%)。结论:多孔髓芯减压联合干细胞移植是治疗股骨头坏死的一种新手段,尤其适合于年青、ARCO-Ⅰ或Ⅱ期、非激素导致的股骨头坏死治疗。

AIM： To explore the therapeutic effect and clinical analysis on the treatment of femoral head necrosis by multiple drilling core decompression with autologous bone marrow stem cells （MSCs）. METHODS： Totally 28 hips in 22 patients with femoral head necrosis aged from 17 to 48 and treated by multiple drilling core decompression combined MSCs were enrolled from Orthopeadics Center of Nanjing First Hospital Affiliated to Nanjing Medical University between February 2003 and December 2006. There were 13 cases of phase Ⅰ, Ⅱ cases of phase Ⅱ and 4 cases of phase Ⅲ based on ARCO classification. There were 9 patients having history of cortex hormones application, 6 of heavy drinking history, 5 of traumatic history and 2 of unknown reason. Inclusive criteria .hip joint pain, functional limitation, final diagnosed by coxa X-rey examination and MRI scanning, phase Ⅰ -Ⅲ based on ARCO classification. Patients knew the facts and signed the informed consent. Exclusive criteria： other hip joint diseases. Bone marrow aspiration was performed in anterior superior lilac spine in order to harvest bone marrow, from which mesenchymal stem cells were isolated and cultured. At affected extremity thigh lateral a incision was cut length wise about 3.0 cm long which was below major trochanter, blunted dissection to femur, three k-wires of 4.0 mm diameter were drilled to the center of femoral head necrosis region under the guide of C-arm machine, then 8.0 mm diameter specially made bolster was drilled to 1.0-2.0 mm below arthrodial cartilage of femoral head under the guide of one k-wire, make sure it did not perforate the arthrodial cartilage. One long syringe needle was inserted into the center of the necrosis region. X-ray examination was performed immediately to make sure the needle was in the femoral head, then infused 1.5-2.0 mL autologous bone marrow stem cells suspension into femoral head through the needle. Totally 12 months＇ follow-up after operation （once per three months） was done. X-ray examination at positive, lateral and frog leg position and MRI scanning were performed to observe the change of pathogenetic condition in clinic service recheck. Harris score was used to evaluate curative effect, more than 90 points as excellent, 75-90 points as good, 60-74 points as not good and less than 60 points as bad. It was thought that therapeutic alliance was effective, if Harris scores were elevated, morphologic change of femoral head ameliorated and the volume of necrotic zone was diminished. RESULTS： （1）Totally 22 patients completed follow-up and were involved in the result analysis. （2）X-ray and MRI test at month 3： Only 2 patients （2 hips） of phase Ⅲ with cortex hormones application history had necrotic femoral head deformed and collapsed worse. The others were seen no severe complications, adverse effects and pathogenetic aggravations. The volume of necrotic femoral head decreased from 31.07% to 17.46%. The differences of necrotic region volume of cortex hormones application groups were smaller than other groups, and the therapeutic effect of heavy drinking and traumatic groups were better than that of cortex hormones application groups in this study. （3）Harris scores at month 12. The Harris scores increased from 54.3 to 84.6, which were elevated obviously. 7 hips were excellent （25.0%）, 15 hips were good （53.6%）, 4 hips were not good （14.3%） and 2 hips were bad （0.07%）. CONCLUSION. Multiple drilling core decompression with autologous MSCs is a new method on the treatment of femoral head necrosis, especially for those young patients in phase Ⅰ （or phase Ⅱ ） who are non-hormone induced.