非手术保髋治疗非创伤性股骨头坏死的临床研究

Non-surgical Therapeutic Outcomes of Nontraumatic Osteonecrosis of Femoral Head

目的评析非手术保髋治疗非创伤性股骨头坏死(NONFH)的疗效。方法选择1996年6月—2012年12月接受中医药联合辅助疗法治疗的NONFH患者,以接受全髋关节置换(THA)或者保髋手术(HPS)为观察终点,评价其治疗前后髋关节功能(HHS)、影像学[国际骨循环研究协会(ARCO)分期和日本骨坏死研究会(JIC)分型]进展情况,测量外侧股骨头指数(LHI)及外侧壁指数(LWI),量化股骨头外侧壁厚度。结果纳入NONFH患者64例93髋,平均随访(6.64±3.63)年。末次随访时ARCOⅡ期、Ⅲ期患者分别有12.70%(8/63)、3.33%(1/30)病髋接受THA,病程中出现关节面塌陷63髋,有14.29%(9/63)接受THA;JIC B、C1、C2型分别有4.00%(1/25)、5.17%(3/58)、50.00%(5/10)病髋接受THA。总体股骨头5、10、15、20年生存率分别为97.39%、85.84%、56.33%、56.33%;JIC B型的生存率优于C型的生存率(P=0.0006),ARCOⅡ期的生存率虽高于Ⅲ期的生存率,但差异无统计学意义(P=0.8994)。未接受THA或HPS84髋,其HHS由(89.12±5.78)分提高至(93.73±11.04)分(P=0.001);病程中出现关节面塌陷而未接受THA或HPS 54髋,其治疗后HHS为(92.89±6.54)分。治疗后总体LHI由(45.16%±15.46%)增加至(46.60%±16.72%),但差异无统计学意义(P=0.481);LWI由(20.57%±6.78%)增加至(43.35%±18.62%,P=0.000)。治疗后LHI、LWI与HHS均呈正相关(r=0.325,P=0.001;r=0.289,P=0.005)。结论中早期NONFH患者依据股骨头外侧壁厚度合理选择行非手术保髋治疗,可取得良好的保髋疗效,或可使患者"带塌陷生存",避免手术。

Objective To evaluate the outcomes of nontraumatic osteonecrosis of the femoral head(NONFH)treated with non-surgical therapeutics.Methods NONFH patients undergoing non-surgical therapeutics were enrolled between June 1996 and December 2012.Considering accepting total hip arthroplasty(THA)or hip-preserving surgery(HPS)as the end point,the pre-treatment and last follow-up Harris Hip Scores(HHS)and imaging progressions including the Association Research Circulation Osseous(ARCO)Stage and the Japanese Investigation Committee(JIC)Classification were evaluated,and the lateral head index(LHI)and lateral wall index(LWI)were measured to quantify the thickness of lateral wall of femoral head.Results Totally 64 patients(93 hips)were successfully enrolled,with mean follow-up of(6.64±3.63)years.At the last follow-up,12.70%(8/63)and 3.33%(1/30)of ARCO stageⅡandⅢrespectively received THA;14.29%(9/63)of patients with articular surface collapse(63 hips)received THA;among the JIC B,C1,and C2 types,4.00%(1/25),5.17%(3/58),and 50.00%(5/10)received THA.The femoral head survival rate of five years,ten years,fifteen years and twenty years was 97.39%,85.84%,56.33%and 56.33%,respectively,the survival rate of JIC B classification was higher than the JIC C classification′s(P=0.0006),although the survival rate of ARCOⅡstage was superior to the ARCOⅢstage′s,the difference was not statistically significant(P=0.8994).For those who did not receive THA or HPS(84 hips),their HHS improved from(89.12±5.78)to(93.73±11.04,P=0.001),the recent follow-up HHS of the collapse surviving from THA or HPS(54 hips)was(92.89±6.54).Until recent follow-up,the LHI was improved from(45.16%±15.46%)to(46.60%±16.72%),the difference was not statistically significant(P=0.481),and the LWI was improved from(20.57%±6.78%)to(43.35%±18.62%,P=0.000).Additionally,there was a positive correlation between LHI,LWI and HHS at the recent follow-up(r=0.325,P=0.001;r=0.289,P=0.005).Conclusion Middle and early stage patients with NONFH can receive non-surgical hip-sparing treatment based on the thickness of the outer wall of the femoral head,which can achieve excellent efficacy,even enable patients to survive with the femoral head collapse and avoid surgery.