微创带血管蒂骨瓣转移术在股骨头缺血性坏死中的应用

Treatment of osteonecrosis of femoral head with minimally invasive vascularized bone grafting

目的探讨应用微创带血管蒂骨瓣转移的方法治疗股骨头缺血性坏死的临床效果。方法 232例均为于我院手术且资料完整者,单侧发病,年龄22～55岁(平均39.8岁)。按 Ficat 分期标准分为,Ⅱ期114例,Ⅲ期96例,Ⅳ期22例。采用带旋股外侧血管升支髂骨瓣转移术83侧;旋股外侧血管升支臀中肌支大转子骨瓣转移术66侧;带旋股外侧血管横支的大转子骨瓣转移术54例;联合带旋股外侧血管横支、升支臀中肌支大转子骨瓣转移术29例。切口平均长度9.8 cm。术后平均随访39个月(10～62个月),根据 Harris 髋关节功能评分标准进行临床评价,根据手术前后 Ficat 分期改变进行影像学评价,对其中的58例进行手术前后数字减影血管造影检查以明确坏死股骨头血运重建状况。结果术后 Harris 髋关节功能评分明显提高(术前平均57分,术后平均87.8分),临床成功率为87.5%,影像学成功率为79.7%。Kaplan-Meier 生存分析提示 Ficat Ⅳ期病例生存率较 FicatⅡ、Ⅲ期明显降低,差异有统计学意义(P<0.01,P=0.0084)。56侧重建股骨头手术前后数字减影血管造影(DSA)造影评估提示血管蒂充盈好,骨瓣血运丰富。术后16～58个月23例改行人工全髋关节置换,其中 FicatⅡ4例,Ⅲ期11例和Ⅳ期8例。结论应用微创化带旋股外侧血管升支,横支或联合双血管蒂骨瓣转移治疗股骨头缺血性坏死,骨瓣血供确切,股骨头血运重建良好,早中期随访疗效满意。

Objective To evaluate the clinical effect of treatment of osteonecrosis of the femoral head （ONFH） by minimally invasive vascularized bone grafting. Methods 232 ONFH patients （232 hips）, 146 males and 86 females, aged 39,8 （22 -55）, 114 being at the Ficat and Arlet stage Ⅱ , 96 at stage Ⅲ, and 22 at stage Ⅳ, were treated with minimally invasive vascularized bone grafting ： pedicled iliac bone flap bone flap with ascending branch of the lateral femoral circumflex artery （ALFCA） in 83 cases, pedicled greater trochanter bone flap with transversal branch of the lateral femoral circumflex artery （TLFCA） in 66 cases, pedicled greater trochanter bone flap with gluteal muscle branch of ascending branch of the lateral femoral circumflex artery （GALFCA） in 54 cases, and pedicled greater trochanter bone flap with double blood vessels （TLFCA and GALFCA） in 29 cases. The mean incision length was 9.8 cm （7-11 cm）. All patients were followed up for 39 months （10-62 months ） and were assessed clinically and radiologically according to Harris scoring. Selective digital subtraction angiography was performed in 58 cases to confirm the blood reconstruction of femoral head. Results The postoperative Harris score was 87.8, higher than the preoperative Harris score （57）. The clinical success rate was 87.5% and the radiological success rate was 79. 7%. Kaplan-Meier survivorship curves showed that the overall survival rate was 90. 09%, the survival rates of the patients at the Ficat stage Ⅱ and Ficat stage Ⅲ were 96.49% and 88.54% respectively, both significantly higher than that of the patients at the Ficat stage Ⅳ （63.64%, P 〈 0.01 ,P =0.0084）. DSA demonstrated satisfactory filling of the vessel pedicles and abundant blood supply in 56 of the 58 necrotic femoral heads. Twenty-three cases had to undergo total hip replacement 16-58 month after the minimally invasive vascularized bone grafting. Conclusion Blood supply of bone flap and blood reconstruction of femoral head can be achieved by using minimally invasive vascularized bone grafting in treatment of osteonecrosis of the femoral head with a satisfactory clinical effect in early to mid-term follow-up.