激素性股骨头缺血性坏死早期辨治及临床疗效评价

Differential Treatment and Clinical Efficacy of Early Steroid-induced Avascular Necrosis of Femoral Head

目的:提高早期激素性股骨头缺血性坏死(SANFH)的辨治疗效,完善疗效评价系统。方法 :选择激素性股骨头缺血性坏死患者,按ARCO分期,将Ⅰ、Ⅱ期各60例定为早期,共120例。Ⅰ期患者随机分为对照组30例和治疗组30例,对照组30例口服活血健骨片治疗,治疗组根据中医辨证分型(筋脉瘀滞证、热毒蕴结证、肝肾亏虚证)口服汤剂治疗。Ⅱ期患者随机分为对照组30例及治疗组30例,两组均采用股骨头髓芯减压术,术后1周开始服药,对照组口服活血健骨片,治疗组根据辨证分型(筋脉瘀滞证、热毒蕴结证、肝肾亏虚证)口服汤剂。所有患者每三个月复查X线片,分别于治疗后0.5年、1年、1.5年、2年随诊复查进行临床疗效评价;每年行MR检查1次。治疗后1年随访。结果:临床症状、体征、X线表现的改善,治疗组明显优于对照组(P<0.05)。治疗与分期的关系,治疗越早,临床疗效越明显,比较有极显著性差异(P<0.01)。MRI治疗前后比较发现,在减少股骨头坏死范围(股骨头坏死指数及股骨头坏死面程度)方面,Ⅰ期治疗组与对照组无显著性差异(P>0.05),Ⅱ期治疗组明显优于对照组(P<0.05);在减轻骨内压、改善骨内循环、促进股骨头修复方面(线样征、骨髓水肿),治疗组优于对照组(P<0.05);关节积液分级评价,治疗组分级较治疗前有显著改善,但与对照组比较没有显著性差异。结论:SANFH不同分期疗效的比较具有极显著性差异,提示本病治疗越早,疗效越好;早期(Ⅰ、Ⅱ期)SANFH采用活血通脉汤加减辨证治疗对改善临床症状及X线表现疗效显著,且明显优于采用单一的药物治疗;MR在早期SANFH的疗效评价中优势明显。

Objective ：To improve the curative efficacy of dialectical therapy for early steroid-induced avascular necrosis of the femoral head（SANFH） and perfect its evaluation system of curative efficacy. Methods： Total 120 patients with SANFH were selected. According to ARCO,stage Ⅰ and stage Ⅱ were defined as early stage. Among the 120 patients,60 cases were at stage Ⅰ ,the others at stage Ⅱ. Patients at stage Ⅰwere randomly divided into control group of 30 patients and treatment group of 30 patients. The 30 patients in control group were treated with oral medicine Huoxue Jiangu tablets, Patients in treatment group,according to syndromes（syndrome of tendon and vessel stasis,syndrome of pathogenic heat accumulation,syndrome of liver and kidney deficiency） differentiated by TCM,were treated with oral decoction. Patients at stage llwere randomly divided into control group of 30 patients and treatment group of 30 patients. All patients in the two groups were performed core decompression on their femoral head. One week after the operation,medication started. The control group was given Huoxue Jiangu tablets and the treatment group was given oral decoction according to the above syndromes（syndrome of tendon and vessel stasis,syndrome of pathogenic heat accumulation,syndrome of liver and kidney deficiency）. All patients were checked by X-ray every three months. Evaluation of clinical curative efficacy was made during the follow-up reexamination,respectively six months, 1 year, 1.5 years and 2 years after operation. The patients took MRI examination every year and thefollow-up review was made 1 year after the operation. Results ： On improvements of clinical symptoms, signs and X-ray manifestation,the treatment group was significantly better than the control group（P〈0.05）.On relationship between treatment and stages,treatments given at earlier stage showed better effects. The difference was significant （P〈0.01）. On MRI images before and after treatment,there was no significant dif ference（P〉0.05） between the treatment group and the control group of stage Ⅰ in reducing area of necrosis of femoral head （ANFH index and the extent of necrosis of femoral head）,but the treatment group of stage Ⅱ was significantly better than the control group （P〈0.05）. On reducing intraosseous pressure,improving circulation within bone and promoting recovery of femoral head （line-like sign,marrow edema）,the treatment group was better than the control group（P〈0.05）. On grading evaluation of joint effusion,the grade of treatment group was significantly improved after treatment. But compared with the control group, there was no significant difference. Conclusions：The differences of curative efficacy between treatments of SANFH at different stages were extremely different,which suggests earlier treatment for the disease will bring better curative efficacy. For SANFH at early stage（stage Ⅰ and Ⅱ ）,using Huoxue Tongmai decoction as a dialectical therapy can significantly improve the clinical symptoms and X-ray manifestation. And the effect was obviously superior to the treatment which just used a single medicine. MRI had an obvious advantage in the evaluation of curative efficacy on early SANFH.