头颈开窗打压植骨联合缝匠肌骨瓣移植术治疗ARCOⅡ期股骨头坏死的疗效分析

Curative effect analysis of strut bone grafting through femoral head and neck fenestration combined with sartorius bone flap grafting for ARCO stage Ⅱ osteonecrosis of the femoral head

目的结合可有效重建股骨头内的血运和生物力学,促进头内修复,提高保髋成功率。文中探究头颈开窗打压植骨联合缝匠肌骨瓣移植术治疗ARCO Ⅱ期股骨头坏死的临床疗效和影响因素,初步探讨保髋术后股骨头内修复趋势方法对江苏省中医院2014年6月-2019年6月行头颈开窗打压植骨联合缝匠肌骨瓣移植术的非创伤性股骨头坏死患者进行回顾分析。比较患者术前与术后的Harris评分、术后股骨头内修复情况,采用Kaplan-Meier生存曲线、Cox多因素风险回归模型分析该术式的临床疗效和相关影响因素。结果33例患者(35髋)均顺利完成手术。在2年随访期内,2髋因提前到达随访终点而进行关节置换,其余患者均获得2年完整随访。术后2年随访时,Harris评分术前(70.61±3.78)分提高到(92.55±4.47)分,差异具有统计学意义(P<0.05)。影像资料随访显示头内骨修复充分,影像学评分和RHS评分分别达到(35.15±4.96)分和(93.18±5.70)分。2021年6月末次随访时,共8髋行关节置换,保髋成功率77.14%,生存时间7~84个月,平均(47.2±19.42)个月。单因素方差分析显示,术前Harris评分、术后3个月的RHS评分和影像学评分、术后6个月的RHS评分和影像学评分结果是影响保髋疗效的风险因素。Cox多因素回归分析结果提示,术前Harris评分和术后3个月的影像学评分为手术成功的保护性因素。术前Harris评分和术后3月影像学评分每增加1分,手术失败的发生风险分别降低4.9%(HR=0.049,95%CI:0.003~0.935,P=0.045)和3.8%(HR=0.038,95%C1:0.002~0.734,P=0.030)。Kaplan-Meier生存曲线分析显示失败病例主要发生在术后2~3年间,3年后的生存率基本稳定。结论头颈开窗打压植骨联合缝匠肌骨瓣移植术治疗ARCO II期股骨头坏死患者可获得良好疗效,术后3〜6月内股骨头坏死的修复程度能指导保髋疗效和预后。

Objective The combination can effectively reconstruct the blood flow and biomechanics in the femoral head,promote the repair in the head,and improve the success rate of hip preservation.This paper aims to investigate the curative effect and influencing factors of strut bone grafting through femoral head and neck fenestration combined with sartorius bone flap grafting for ARCO stage Ⅱ osteonecrosis of the femoral head,and to explore the trend of femoral head repair after hip preservation.Methods A retrospective analysis was performed on patients with non-traumatic femoral head necrosis who underwent strut bone grafting through femoral head and neck fenestration combined with sartorius bone flap grafting in Jiangsu Provincial Hospital of Traditional Chinese Medicine from June 2014 to June 2019.The preoperative and postoperative Harris score and postoperative femoral head repair were compared,and Kaplan Meier survival curve and Cox multi-factor risk regression model were used to analyze the clinical efficacy and related influencing factors of the operation.Results All 33 patients(35 hips)were successfully operated.During the 2-year follow-up period,2 hips undenvent joint replacement due to reaching the end point early,and the remaining patients received a complete 2-year follow-up.The Harris score increased from 70.61±3.78 to 92.55±4.47 at 2 years of follow-up(P<0.05).The follow-up of imaging data showed that the skull bone was adequately repaired,and the imaging score and RHS score were 35.15±4.96 and 93.18±5.70,respectively.At the last follow-up in June 2021,a total of 8 hips underwent joint replacement,with a success rate of 77.14%and a survival time of 7-84 months,with an average of(47.2±19.42)montlis.One-way analysis of variance showed that preoperative Hams score,RHS score and imaging score at 3 months after surgery,and RHS score and imaging score at 6 months after surges were the risk factors affecting the efficacy of hip preservation.Cox multivariate regression analysis indicated that preoperative Harris score and 3 months postoperative imaging score were protective factors for surgical success.With each 1 point increase in preoperative Hania score and imaging score at 3 months after the operation,the risk of surgical failure was reduced by 4.9%(HR=0.049,95%CI:0.003-0.935,P=0.045)and 3.8%(HR=0.038,95%CI:0.002-0.734,P=0.030).Kaplan Meier survival curve analysis showed that the failure cases mainly occurred in 2~3 years after operation,and the survival rate after 3 years was basically stable.Conclusion The strut bone grafting through femoral head and neck fenestration combined with sartorius bone flap grafting achieves satisfactory clinical efficacy for treatment of ARCO stage II osteonecrosis of femoral head(ONFH).The repair degree of femoral head necrosis within 3-6 months after surgery can guide the efficacy and prognosis of hip preservation.