髓芯减压加自体骨髓干细胞移植治疗股骨头坏死的早期随访结果

Core decompression plus implantation of autologous bone marrow stem cells for early stage osteonecrosis of the femoral head: A follow-up evaluation

目的:早期股骨头缺血性坏死目前多采用髓芯减压术式,临床证明自体骨髓移植治疗骨不连可促进骨的修复与愈合。回顾性总结分析髓芯减压联合自体骨髓干细胞移植治疗早期股骨头坏死的效果。方法:①对象:选取2005-05/2006-08中日友好医院骨坏死与关节保留重建中心医院收治的股骨头缺血性坏死患者52例/71髋作为髓芯减压联合自体骨髓干细胞移植组,其中ARCO分期I^II期37例/49髋,III期8例/9髋。因干细胞抽取困难或失败,以同期收治的股骨头缺血性坏死患者15例/20髋作为单纯髓芯减压组,其中ARCO分期I^II期10例/13髋,III期3例/4髋。两组患者对治疗及实验均签署知情同意书,实验经医院医学伦理委员会批准。②实验方法:两组患者术前常规Harris评分,拍摄双髋关节正位、蛙式侧位X片、CT平扫加二维重建及MRI。髓芯减压联合自体骨髓干细胞移植组自患者双侧髂前上棘连续抽取骨髓300~400mL,分离采集中间层单个核细胞2.16×1010L-1。在C臂X光透视机引导下用2~3枚1.5mm导针钻入,对照术前X线和二维CT反复确认坏死病灶后,以3mm空心钻钻入,于骨坏死区的股骨头软骨下骨5mm处用50mL注射器将浓缩的细胞悬液缓慢注入股骨头内。单纯髓芯减压组仅行空心钻钻入坏死区。术后随访12个月。结果:髓芯减压联合自体骨髓干细胞移植组45例/58髋、单纯髓芯减压组13例/17髋完成12个月以上随访。①术前两组Harris评分基本相似(P>0.05);术后与单纯髓芯减压组比较,髓芯减压加自体骨髓干细胞移植组Harris评分明显升高,优良率显著提高(F=3.149,P<0.05)。②髓芯减压加自体骨髓干细胞移植组58髋中,9髋出现新月征和塌陷加重,其中6髋为术前ARCO分期IIIa期,1髋行人工关节置换。单纯髓芯减压组17髋中,6髋出现新月征和塌陷加重,其中4髋为术前ARCO分期IIIa期,1髋行人工关节置换。两组比较差异有显著性意义(F=3.032,P<0.05)。结论:髓芯减压联合自体骨髓干细胞移植是治疗ARCO分期I^II期股骨头缺血性坏死安全有效的方法,临床Harris评分和病理影像学观察均优于单纯髓芯减压术式。对于ARCO分期III期患者,两种方法治疗效果均欠佳。

AIM： Early stage osteonecrosis of the femoral head is always treated with the core decompression, and clinical evidences show that autologous bone marrow transplantation could enhance bone repair and healing in the treatment of bone nonunion. This retrospective study was designed to analyze the curative effect of autologous bone marrow stem cells transplantation and core decompression for treating osteonecrosis of femoral head in early stage. METHODS： （1）Fifty-two patients （71 hips） with osteonecrosis of femoral head were treated with autologous bone marrow stem cells transplantation and core decompression in the Center for Osteonecrosis and Joint Preserving ＆ Reconstruction of China-Japan Friendship Hospital from May 2005 to August 2006. According to the system of Association Research Circulation Osseous （ARCO）, 37 cases （49 hips） were classified in stages Ⅰ-Ⅱ, and 8 cases （9 hips） in stage Ⅲ. Meanwhile 15 patients （20 hips） only treated with core decompression because of the failure or difficulty of aspirating stem cells, were taken as control group, including 10 cases （13 hips） in stages Ⅰ-Ⅱ and 3 case （4 hips） in stage Ⅲ. All the patients in both groups signed the informed consents, and the experiment was approved by the Ethics Committee of the hospital.（2）Before operation, all the patients were scored with Harris system. X-ray at anteroposterion and frog leg position, 2-dimensinal reconstruction and CT scan, MRI were taken for all the patients. Bone marrow of 300 400 mL was collected from bilateral anterosuperior iliac spine of patients. Mononuclear cells were harvested and cell counting was 2.16×10^7 L^-1. Two or three guide pins with 1.5 mm diameter were drilled into necrotic zone, with the guide of C-arm X-ray fluoroscopic machine. In the experimental group, guide pin was affirmed to be in the zone of necrosis according to preoperative X-ray and 2-dimensional CT, and then drilled with the hollow drill for the injected of cell suspension into the 5 mm under subcartilaginous bone of femoral head with 50 mL injector. Control group was only treated with hollow drill putting into necrotic zone but without bone marrow aspiration. After operation, all the patients were followed up for 12 months. RESULTS： There were 45 patients （58 hips） treated with autologous bone marroe stem cells transplantation and core decompression were followed up more than 12 months, while 13 patients （17 hips） of control group received the follow-up for more than 12 months as well.（1）There was no significant difference in Harris score between two groups before operation （P 〉 0.05）, while the experimental group showed obviously increasing score and gained high fineness rate （F=3.149,P 〈 0.05） after operation.（2）Among 58 hips of the experimental group, 9 hips aggravated such as collapse or crescent sign, including 6 hips belonging to ARCO Ⅲa and 1 hip got total hip arthroplasty. While 6 hips of 17 cases in the control group appeared more serious collapse or crescent sign, among those 4 hips belonged to ARCO Ⅲa, and 1 hip got total hip arthroplasty. There were significant differences between two groups （F=3.032, P 〈 0.05）. CONCLUSION： Autologous bone marrow stem cells transplantation and core decompression is an easy and safe method for treating stage Ⅰ-Ⅱ osteonecrosis of the femoral head. It is better than simply core decompression in both clinical Harris scores and radiographic evaluation. But for stage Ⅲ patients, curative effect of both methods is negative.