3D打印导航模板在带血管蒂髂骨瓣移植治疗股骨头缺血性坏死中的临床应用

CLINICAL APPLICATION OF THREE DIMENSIONAL PRINTED NAVIGATION TEMPLATES FOR TREATMENT OF OSTEONECROSIS OF FEMORAL HEAD WITH PEDICLED ILIAC BONE GRAFT

目的探讨数字化设计结合3D打印技术制备的导航模板应用于带血管蒂髂骨瓣移植治疗股骨头缺血性坏死的可行性以及早期疗效。方法 2014年2月-6月,收治15例（24髋）股骨头缺血性坏死患者。男11例（17髋）,女4例（7髋）;年龄18-56岁,平均38岁。左髋2例,右髋4例;双髋9例。股骨头缺血性坏死类型：激素性7例（12髋）,酒精性5例（8髋）,创伤性1例（1髋）,特发性2例（3髋）。病程1-24个月,平均7.5个月。术前Harris评分为（56.60±6.97）分。按照国际骨循环协会（ARCO）分期：ⅡB期5髋,ⅡC期8髋,ⅢB期6髋,ⅢC期5髋。术前根据CT扫描设计并3D打印制作导航模板,将其用于带血管蒂髂骨瓣移植术中指导股骨头坏死灶定位及清除。结果手术时间120-160 min,平均135 min;术中出血量200-300 mL,平均255 mL。术后切口均Ⅰ期愈合,无下肢深静脉血栓形成、感染等手术相关并发症发生。患者均获随访,随访时间12-16个月,平均14个月。术后第2天X线片及CT检查显示,于导航模板引导下股骨头坏死灶及周围硬化骨均彻底清除,带血管蒂髂骨瓣位置满意,未穿透关节面。髂骨瓣及植骨均达骨性融合,融合时间2-3个月,平均2.7个月;与术前相比,末次随访时坏死股骨头未出现进一步塌陷。患者髋关节疼痛明显缓解,关节活动范围增加;末次随访时Harris评分（89.53±5.83）分,与术前比较差异有统计学意义（t=14.319,P=0.000）;获优12髋,良10髋,中2髋。结论带血管蒂髂骨瓣移植治疗股骨头缺血性坏死术中采用3D打印导航模板有利于精确定位并彻底清除坏死灶及周围硬化骨,早期疗效满意。

Objective To investigate the feasibility and early effectiveness to treat osteonecrosis of the femoral head（ONFH） with pedicled iliac bone graft assisted by individual digital design and three dimensional（3D） printed navigation templates. Methods Between February and June 2014, 15 patients（24 hips） with ONFH underwent pedicled iliac bone graft assisted by individual digital design and 3D printed navigation templates. There were 11 males（17 hips） and 4 females（7 hips） with a mean age of 38 years（range, 18-56 years） and a mean disease duration of 7.5 months（range, 1-24 months）; the left hip was involved in 2 cases, the right hip in 4 cases, and both hips in 9 cases. There were 7 cases（12 hips） of steroid-induced ONFH, 5 cases（8 hips） of alcohol-induced ONFH, 1 case（1 hip） of traumatic ONFH, and 2 cases（3 hips） of idiopathic ONFH. The preoperative Harris score was 56.60±6.97. According to Association Research Circulation Osseous（ARCO） staging system, 5 hips were classified as stage IIB, 8 hips as stage IIC, 6 hips as stage IIIB, and 5 hips as stage IIIC. The navigation templates were designed and printed to assist accurate location and debridement of necrosis area according to preoperative CT scanning at the beginning of pedicled iliac bone grafting procedure. Results The mean operation time was 135 minutes（range, 120-160 minutes）, mean amount of bleeding was 255 mL（range, 200-300 mL）. All the wounds healed primarily, no complication of deep vein thrombosis or infection was observed. All patients were followed up 12-16 months（mean, 14 months）. The location of necrosis area was in accordance with preoperative design, which was removed completely without penetration of joint surface, pedicled iliac bone graft was performed at the right site according to postoperative imaging examination. Radiographically, graft fusion was achieved at 2.7 months（range, 2-3 months） in all patients. All the hips had no collapse during follow-up. Hip pain was relieved, and range of motion was improved. The Harris score was significantly improved to 89.53±5.83 at last followup（t=14.319, P=0.000）. The results were excellent in 12 hips, good in 10 hips, and fair in 2 hips according to Harris score standard. Conclusion Pedicled iliac bone graft assisted by individual digital design and 3D printed navigation templates for treatment of adult ONFH has the advantages of accurate location and complete debridement of necrosis area, so satisfactory results can be obtained.