股骨近端骨纤维结构不良的外科治疗—一种分区方法

Surgical treatment for fibrous dysplasia of proximal femur-a partition method

[目的]通过对39例接受外科治疗的股骨近端骨纤维结构不良病例进行回顾性分析，提出用于指导外科治疗的分区方法，并根据分区方法探讨股骨近端骨纤维结构不良的外科治疗策略。[方法]对1998～2009年收治的39例股骨近端骨纤维结构不良症病例进行回顾性分析，根据患者术前X线平片判断病变范围，并根据股骨近端受累范围提出分区方法。分析分区类型与外科治疗方案的关系。并通过对患者术后局部病灶控制情况及术后功能（MSTS93评分）评价外科治疗的效果。[结果]根据39例病变范围，并结合股骨近端解剖特点，将股骨近端分为四个区：Ⅰ区，股骨干（小粗隆以下）；Ⅱ区，粗隆间（小转子至股骨颈基底部）；Ⅲ区，股骨颈；Ⅳ区，股骨头。根据上述分区，病变分为7种类型，Ⅰ型9例，Ⅱ型12例，Ⅲ型3例，Ⅰ＋Ⅱ型6例，Ⅱ＋Ⅲ型5例，Ⅱ＋Ⅲ＋Ⅳ型2例，I＋Ⅱ＋Ⅲ型2例，I＋Ⅱ＋Ⅲ＋Ⅳ型1例。手术主要采用病变刮除植骨＋内固定。内固定方式有DHS，髓内钉及人工关节置换，其中DHS最常见于Ⅱ区受累（57．58％），其次为Ⅲ区受累（24．24％）；髓内针固定见于Ⅰ区受累（64．70％）及Ⅱ区受累（35．30％）。病变累及三区及三区以上的病例，采用关节置换。本组39例均得到随访，中位随访时间为6．3年（0．5～11年）。MSTS93评分：（91．70±9．64）％。局部复发率12．82％（5／39），均未发现局部畸形加重。本组病例随访结果满意，选取的治疗方法较为合理。[结论]制订股骨近端骨纤维结构不良外科治疗方案时．应先考虑病变部位特点，从而选用合理的内固定方式，达到较好的外科治疗效果；本文提出的分区方法可以作为术前制订外科治疗方案的参考。

[ Objective ] To retrospectively analyze 39 cases of surgical treatment of fibrous dysplasia of proximal femur, in order to propose a partition method which can be used to guide the surgical treatment, and probe the surgical treatment strategy according to the partition method of fibrous dysplasia of proximal femur. [Methods]The data on 39 cases of fibrous dysplasia of proximal femoral from 1998 to 2009 were retrospectively analyzed. The study determined extent of the lesion according to preoperative X - ray film and proposed partitioning method in accordance with the scope of proximal femoral involvement, analyzed the relation of partition type and surgical treatment , and evaluated the effect of surgical treatment through the postoperative localized lesions control and functional score （ MSTS 93） . [ Results] According to the scope of 39 cases of lesions, combined with characteristics of proximal femoral anatomy, proximal femur was divided into four zones： area Ⅰ, femoral shaft （below small protuberance）; area Ⅱ, intertrochanteric （small rotor to the neck base division） ; area Ⅲ, femoral neck; areaⅣ, the femoral head. Based on the above partition, lesions were divided into 7 types, typeⅠ, type Ⅱ , type Ⅲ , type Ⅰ ＋ Ⅱ , type Ⅱ ＋Ⅲ , type Ⅱ ＋ Ⅲ ＋ Ⅳ , type Ⅰ＋ Ⅱ ＋ Ⅲ , type Ⅰ＋ Ⅱ ＋ Ⅲ ＋Ⅳ. Surgical treatment was performed mainly with curettage of bone lesions, bone grafting and fixation. Internal fixation included DHS, intramedullary nails, and artificial joint replacement, DHS was most common in area Ⅱ involvement （57. 58% ）, followed by area Ⅲ involvement （24. 24% ） . Intramedullary nail was most common in area I involvement （64.7%） and area Ⅱ involvement （35.30% ） . For lesions involving ≥3 zones, joint replacement was carried out. The patients were all followed up, with a median time of 6. 3 years （0. 5 - 11 years） . Local recurrence rate wasl2.82% （5/39） , local deformity was not found deterious. The followed up resuits were satisfactory. The selected treatment was reasonable. [ Conclusion] When making a surgical treatment regimen for fibrous dysplasia of the proximal femur, Surgeons should consider lesion characteristics, and choose a reasonable internal fixation to achieve better surgical results. Partition method prolapsed in this paper can be formulated as one of preoperative surgical treatment options.