髓芯减压术后二次减压治疗早中期股骨头坏死

Secondary core decompression after core decompression for the treatment of early and middle stage osteonecrosis of the femoral head

目的回顾性分析髓芯减压术后二次减压术治疗早中期股骨头坏死（ONFH）的临床疗效。方法选取2008年7月至2013年4月于安徽医科大学解放军第三〇七医院只接受股骨头髓芯减压、死骨刮除、人工骨打压植入术治疗的30例（50髋）ONFH患者,设为单次减压组;选取2010年1月至2013年4月于安徽医科大学解放军第三〇七医院接受单次髓芯减压术术后半年同意行二次减压治疗的30例（42髋）ONFH患者,设为二次减压组。按照国际骨循环研究会分期,所有ONFH均为Ⅰ期、Ⅱ期。采用髋关节Harris评分系统评估术后患髋功能改善情况,应用视觉模拟评分法（VAS）进行临床疼痛测定,通过影像学（X线、CT、磁共振成像）评定股骨头是否塌陷及病灶修复情况。组间数据采用t检验、χ~2检验进行比较分析。结果 60例（92髋）ONFH患者术后均获得随访,随访时间为25~84个月。术后25个月时,两组髋关节Harris评分较术前均有显著提高,差异均有统计学意义（P值均小于0.05）;二次减压组髋关节Harris评分[（91.21±3.32）分]显著高于单次减压组[（81.60±2.60）分],差异有统计学意义（t=-15.592,P〈0.05）。两组VAS评分较术前均有显著降低,差异均有统计学意义（P值均小于0.05）;二次减压组VAS评分[（2.20±0.71）分]显著低于单次减压组[（3.27±1.51）分],差异有统计学意义（t=3.503,P=0.001）。单次减压组髋关节Harris评分优2髋,良36髋,尚可5髋,优良率为76.0%,股骨头保存率为86.0%;二次减压组髋关节Harris评分优35髋,良5髋,尚可2髋,优良率为95.2%,股骨头保存率为100.0%。两组髋关节Harris评分优良率比较差异有统计学意义（χ~2=6.548,P=0.011）,两组股骨头保存率比较差异有统计学意义（χ~2=4.529,P=0.033）。两组髋关节Harris评分为优的37髋的股骨头外形修复均完整;评分为良的41髋中有6髋外形不圆,但股骨头内未出现骨折,剩余基本维持球形;评分为差的7髋出现软骨下骨折、关节间隙狭窄,其中3髋行全髋关节置换术。结论髓芯减压术后二次减压术可再次诱发股骨头内创伤修复过程,进一步改善患髋功能、减轻髋关节疼痛,起到较好的治疗作用。

Objective Retrospective analysis of the clinical effect of secondary decompression after core decompression in the treatment of early and middle stage osteonecrosis of the femoral head （ ONFH ） . Methods Thirty ONFH patients （50 hips） of the 307th Hospital of People′s Liberation Army, Anhui Medical University received core decompression, sequestrum erasion, impaction of bone filling particle from July 2008 to April 2013 were regarded as the single decompression group. Thirty ONFH patients （42 hips） of the 307th Hospital of People′ s Liberation Army, Anhui Medical University obtained secondary decompression after single decompression from January 2010 to April 2013 were looked as the secondary decompression group. The necrosis stage was divided into the association research circulation osseousⅠstage or Ⅱstage. Harris hip score was used to evaluate the postoperative improvement of the hip function and the visual analogue scale （ VAS） to assess the intensity of pain. The collapse and repair of lesions of the femoral head were detected based on the radiological datas （ X-Ray, CT and MRI） . The data between the two groups was compared by t test and Chi square test. Results Sixty patients （92 hips） were all followed up,and the follow up-time was 25-84 months. At the time of 25 months after the operation, Harris hip scores in the two groups were significantly increased compared with preoperation, and there were signifficant differences between the two groups（P values were less than 0. 05）. The Harris hip score in the secondary decompression group [（91. 21±3. 32）points]was significantly higher than that in the single decompression group [（81. 60± 2. 60）points], and the difference was statistically significant （t=-15. 592, P＜0. 05）. VAS scores were significantly reduced compared with preoperation in the two groups, and there were signifficant differences between the two groups（P values were less than 0. 05）. The VAS score in the secondary decompression group[（2. 20±0. 71） points] was significantly lower than that in the single decompression group [（3. 27 ±1.51）points], and the difference was statistically significant （t=3. 503, P=0. 001）. In the single decompression group, the excellent function was obtained in 2 hips, good function in 36 hips and fair function in 5 hips. The good rate was 76. 0%, and the survival rate of the femoral head was 86. 0%. In the secondary group, the excellent function was obtained in 35 hips, good function in 5 hips and fair function in 2 hips. The good rate was 95. 2%, and the survival rate of the femoral head was 100. 0%. There were signifficant differences in the good rate of the Harris hip score（χ2=6. 548, P=0. 011） and the survival rate of the femoral head （χ2 =4. 529, P=0. 033）. The femoral head repaired completely in the 37 hips of excellent function, 6 hips repaired incompletely among the 41 hips of good function, but did not appear fracture. Seven hips of fair function appeared narrowing of joint space and subchondral fracture, and 3 hips were cured by total hip arthroplasty. Conclusions Secondary decompression after core decompression can induce the process of wound repair in femoral head again, further improve the hip function, alleviate the pain, and play a good therapeutic on hip joint.