股骨头坏死保髋手术对后续全髋关节置换的影响

Influence of hip-preservation surgeries on subsequent total hip arthroplasty for osteonecrosis of the femoral head

背景:保留髋关节手术是目前治疗年轻早期股骨头坏死的重要手段,但保髋手术种类较多且各类术式都存在自身的局限性以及难以避免的失败率,部分患者在接受了保髋手术治疗后效果欠佳,而在后续治疗中不得不接受全髋关节置换。目的:文章就治疗股骨头坏死的各类保髋手术对后续全髋关节置换影响的研究进展情况作一综述。方法:以“股骨头坏死、保髋手术、髓芯减压、骨移植、截骨、钽棒植入、髋关节表面置换”为中文检索词,以“Osteonecrosis of the femoral head,Hip-preservation surgery,Core decompression,Bone grafting,Osteotomy,Porous tantalum implantation,Hip resurfacing arthroplasty”为英文检索词,分别检索中国知网、PubMed数据库以及Embase数据库。通过阅读文题和摘要进行初步筛选;排除重复性研究、低质量期刊及内容不相关的文献,最后纳入58篇文献进行综述。结果与结论:(1)目前临床应用的保髋术式主要包括髓芯减压、非血管化植骨、带血运的植骨及截骨和钽棒植入等几大类。不同保髋术式各有其特点,对后续全髋关节置换影响也存在差异。(2)单纯的髓芯减压作为“微创”手术对后续全髋关节置换影响较小,但其可能改变转子间区域骨结构,增加了全髋关节置换中骨折的风险。(3)骨移植的植入骨材料(特别是移植腓骨)残留影响到全髋关节置换中开髓、扩髓以及股骨柄假体放置,而带血运的植骨(特别是带肌骨瓣植骨)增大了软组织的创伤,不利于全髋关节置换后髋关节功能恢复。(4)截骨造成了更大的局部软组织创伤和股骨畸形,对后续全髋关节置换影响最大。截骨后续全髋关节置换具有较高难度,以对后续全髋关节置换影响作为参考依据,截骨较其他保髋术式存在劣势。(5)钽棒植入存在植入物去除增加后续全髋关节置换难度的问题,且尽管研究发现其残留钽碎片短期内不会增加假体的线性磨损率,但残留钽碎片中长期的影响仍存在担忧。(6)虽然各类保髋术式均在一定程度上增加了后续全髋关节置换的难度,但文献报道结果总体上是积极的,尚未有不利于全髋关节置换假体存活率和髋关节功能的文献报道,全髋关节置换仍可作为保髋失败后的可靠治疗手段。

BACKGROUND:Hip-preservation surgery is an important method for the treatment of young patients with early femoral head necrosis.However,there are many types of hip-preservation surgery,and all kinds of hip-preservation surgery have their own limitations and inevitable failure rate.Some patients received poor results after hip-preservation surgery,and had to undergo total hip arthroplasty.OBJECTIVE:To review the research progress on the influence of various hip-preservation surgeries on subsequent total hip arthroplasty for osteonecrosis of the femoral head.METHODS:Databases of Embase,CNKI and PubMed were searched with the key words of "osteonecrosis of the femoral head,hip-preservation surge ry;core decompression,bone grafting,osteotomy,porous to ntalum implantation,hip resurfacing arthroplasty in Chinese and English,respectively.By reading the titles and abstracts,repetitive studies and low-quality or irrelevant articles were excluded.Finally,58 articles were included for reviewing.RESULTS AND CONCLUSION:(1) At present,the clinical application of hip-preservation surgery mainly includes core decompression,non-vascula rized bone grafting,vascularized bone grafting,osteotomy,tantalum rod implantation and other categories,and diffe rent hip-preservation surgeries have their own characte ristics and different influences on subsequent total hip arthroplasty.(2) As a "minimally invasive" operation,simple core decompression has little impact on subsequent total hip arthroplasty,but it may change the bone structure in the intertrochante ric region and increase the risk of intraoperative fracture in total hip arthroplasty.(3) Residual bone graft materials(especially fibula graft) in bone grafting affected the opening and expansion of medullary cavity and placement of femoral stem prosthesis during total hip arthro plasty.Vascula rized bone grafting(especially musculos keletal flap graft) increased the trauma of soft tissue,which was not conducive to the functional recove ry of hip joint after total hip arthro plasty.(4) Osteotomy has the greatest influence on subsequent total hip arthroplasty,because it causes greater local soft tissue trauma and femoral deformity.Total hip arthroplasty after osteotomy is relatively difficult,and compared with other hip-preservation surgeries,osteotomy has disadvantages based on its influence on subsequent total hip arthroplasty.(5) There is a problem that the removal of tantalum rod implants increases the difficulty of total hip arthro plasty in the follow-up,and although the study found that the residual tantalum fragments did not increase the linear wear rate of the prosthesis in the short term,we still need to pay attention to the long-term effects of residual tantalum fragments.(6) Although all types of hip-preservation surgeries increase the difficulty of subsequent total hip arthro plasty to a certain extent,lite rature reports are generally positive.There is no literature report that previous hip-preservation surgery is not conducive to the prosthesis survival rate and hip function sco re after subsequent total hip arthroplasty,and total hip arthro plasty can still be used as a reliable treatment after hip preservation failure.