【作者】 庞智晖；

【导师】 何伟；

【作者基本信息】 广州中医药大学 ， 中医骨伤科学， 2008， 博士

【摘要】 背景:激素性股骨头坏死仍然是骨科中尚未解决的问题之一,目前占所有股骨头坏死病例的一半左右,已经成为临床的常见病、多发病,具有较高的致残性。塌陷在股骨头坏死的病程中普遍存在,是疾病性质转归的关键,一旦发病,临床面临的关键问题是如何预测和防治塌陷。多种因素和塌陷相关,目前对塌陷及其相关问题尚缺乏全面准确的认识,临床上一方面缺乏简便可行的判断预后和评价保髋疗效的方法,另一方面也缺乏有效纠正塌陷、维持股骨头生物力学稳定的手段。根据髋臼的解剖分区、髋臼的应力分布特点、股骨头的应力分布特点和股骨头坏死区域的分布及塌陷特点,有感于正位分型的局限性,并受Ohzono和Sugano的启发,笔者发展完善了股骨头坏死的蛙位分型,并假设股骨头前外侧柱和激素性股骨头坏死预后与保髋疗效有密切相关性,正蛙位分型相结合能准确反映股骨头前外侧柱的状况,进而预测股骨头坏死的预后和评价保髋疗效。为了证实上述假设,笔者进行了相关的临床研究。方法:2004年1月～2006年12月按照设计的诊断标准、纳入标准和排除标准募集在广州中医药大学第一附属医院髋关节病重点专科住院治疗的SONFH患者35例61髋,行中药辅助改良减压植骨内稳定术。对所有病例记录一般情况、基础疾病、激素使用情况、累及单双髋、ARCO分期、正蛙位分型;塌陷前的修正坏死范围指数;塌陷后的塌陷程度;骨髓水肿和关节积液分级;疼痛评分;再次塌陷的时间和程度;并进行疗效评价。将有关队列资料或数据输入SPSS13.0统计软件进行相关统计分析,Kaplan-Meier生存率分析以股骨头再次塌陷＞4mm为终点。结果:1、本组病例的总有效率为77.05%,其中优占40.98%,良占14.75%,中占21.31%;总失败率为22.95%。蛙位分型C2与失败率呈显著的负相关,所有蛙位分型为C2的病例,其失败率均接近40%。排除所有蛙位C2型的病例,有效率为86.84%,优为52.63%,良为15.79%,中为18.42%,失败率为13.16%。2、临床证候分型,本组病例中气滞血瘀型的占50%,没有发现单独的风寒湿痹型、痰湿型、气血虚弱型和肝肾不足型,常见气滞血瘀型兼后四种证型,其中兼痰湿型最多,占22.22%。3、以再塌陷＞4mm为终点的Kaplan-Meier生存率分析显示,研究终止时(平均随访24.64个月)股骨头的生存率约为80%。4、Spearman相关系数分析显示:(1)术前正蛙位分型与术后前外侧柱塌陷正相关;(2)术前ARCO分期与术后正位塌陷正相关,与蛙位塌陷无明显相关;(3)术前正位塌陷值与术后死骨修复、头臼和谐及关节稳定负相关,与术后软骨退变正相关;(4)术前蛙位塌陷值与术后死骨修复、头臼和谐及关节稳定负相关,与术后软骨退变正相关;(5)术前正位分型与术后软骨退变正相关,与术后死骨修复、关节稳定及头臼和谐负相关;(6)术前蛙位分型与术后软骨退变正相关,与术后死骨修复、头臼和谐及关节稳定负相关;(7)术前ARCO分期与术后软骨退变正相关,与术后死骨修复、头臼和谐负相关,与关节稳定无显著相关。5、Logistic回归显示,与预后相关的危险指标为术前蛙位分型,术前蛙位分型越大则预后越差,术前蛙位分型每加重一个等级,为没有加重时,预后加重这个等级的14.96倍。。6、逐步cox回归结果显示,在上述与生存时间相关的多因素中,危险指标为术前蛙位分型,术前蛙位分型越大,则股骨头生存时间越小,术前蛙位分型每增大一个等级则生存时间减少的可能性是无增大时的6.937倍。结论:1、蛙位分型可以客观地反映股骨头前外侧柱坏死分布和塌陷情况,股骨头前外侧柱的完整性和稳定性与股骨头坏死预后和保髋疗效正相关,股骨头前外侧柱越完整越稳定,预后和保髋疗效就越好。正、蛙位分型相结合比单独正位分型能更全面地揭示股骨头前外侧柱的整体状况,减少观察盲区,具有更强的判断预后和评价疗效的能力,有利于中医辩证施治。2、蛙位分型没有超过C1型,并且坏死区域为前外侧柱残留的正常骨质所包容,形成“包容性修复”,则预后良好;如果蛙位分型达C2型,并且坏死区域是开放的,没有前外侧柱正常骨质的保护,形成“开放性坏死,尤其是横贯股骨头的坏死区”,则预后不良。3、围塌陷期的保髋手术要围绕着修复股骨头前外侧柱的完整性并尽可能维持其稳定性、防止发生严重的再塌陷这个核心进行。4、改良减压植骨内稳定术只适用于蛙位分型C1型及以下者,不适用于蛙位分型达C2者。5、髓芯减压的方向在尽可能保存残留的前外侧柱正常骨质的基础上,以股骨头前外侧的坏死中心区为宜;髓芯减压的深度要达软骨下骨板但不能穿出软骨面;松质骨打压的程度以股骨头基本恢复球形和头内新月征、台阶征和裂隙征基本消失为度,打压的质骨的厚度以5mm为宜;植入腓骨的条近端要修平,四周用1.5mm的克氏针钻孔;内稳定的空心加压螺钉要放在腓骨的正后方或者后内方。更多还原

【Abstract】 Background.Steroid-induced Osteonecrosis of the Femoral Head（SONFH）is still one of unfathomed issues of Orthopaedics.Currently it has occupied assumably 50%of all Osteonecrosis of the Femoral Head（ONFH）cases,and has became a common disease with high incidence and risk of disabled.Collapse of femoral head is ubiquitous during the course of ONFH.It is the key of the conversion of the diseases.Once ONFH occurs,the clinical linchpin is how to predict and prevent collapse.Numerous factors are relative with the collapse of necrotic femoral head,presently cognition of collapse is still lack of entirety and accuracy.On the one hand,the clinical doctors are devoid of simple,convenient, feasible means to estimate prognosis and evaluate the Joint-Preserving Procedures curative effect.On the other hand,they are also short of effective measures to correct collapse and maintain the biomechanics stabilization of femoral head.According to acetabulum anatomic regions,acetabulum stress force distribution,femoral head stress force distribution,the characteristic of femoral head necrotic zone distribution and necrotic femoral head collapse,and the insufficiency of the anteroposterior x-ray view classification of osteonecrosis,illuming by Ohzono and Sugano,the author develops the frog leg view classification of osteonecrosis which was firstly established by LIU Shao Jun MD,and make a hypothesis that the anterolateral column of femoral head has a consanguineous relativity with prognosis and the Joint-Preserving Procedures curative effect of the SONFH.The author also assumes that the anteroposterior x-ray view classification combines with the frog leg view classification of osteonecrosis can reflect the conditions of the the anterolateral column of femoral head precisely,so that it can be used to estimate prognosis and evaluate the Joint-Preserving Procedures curative effect accurately.In order to testify the hypothesis above,the author carry out an clinic investigation.Method.All patients who were hospitalized in Department of Arthrosis Surgery of the 1^st affiliated hospital of GuangZhou University of Traditional Chinese Medicine were recruited strictly in the light of diagnosis criteria,bringing into criteria and excluding criteria devised in the project between January 2004 and December 2006.Then finally we get 35 SONFH cases（61 hips）which fulfilled the criteria above.All patients’ general information,basic disease,usage of Steroid,single or bilateral involved,ARCO Stage, Anteroposterior x-ray view and Flog Leg x-ray view Classification,Modified Index of necrotic extent before collapse,Collapse Degree after collapse,grade of Bone Marrow Edema and Hip Joint Fluid,grade of hip pain,the occure time and degree of post-operation collapse were all registered detailedly.After that evaluate curative effect and put data into the statistical software SPSS13.0 to analyse the results.The termination of Kaplan-Meier survivorship analysis is defined as collapse more than 4 millimeter after operation.Findings.1.Total effective rate of this head-preserving procedures was 77.05%,among these excellent rate was 40.98%,good rate was 14.75%,fair rate was 21.31%.General poor rate was 22.95%.There was a high negative correlation between Type C2 and failure,the poor rate of all the cases with Type C2 was near 40%.Excluding Type C2 the other cases’ effective rate was 86.84%,excellent rate was 52.63%,good rate was 15.79%,fair rate was 18.42%,poor rate was 13.16%.2.Traditional Chinese Medicine Syndrome-types Classification.Tagnancy of Qi and Blood Stasis type（TQBS）occupys 50%in all the studied cases.Wind Cold Damp impediment type,Phlegm-dampness type,Qi - deficiency and Phlegm - dampness type, Liver-Kiney deficiency type cannot be found alone.Type TQBS combined with the other four types frequently.Type TQBS mostly combined with Phlegm-dampness type,the combinative rate was 22.22%.3.Kaplan-Meier survivorship curves demonstrated that the rate of survival of the necrotic femoral head was about 80%for a mean of 24.64 months（range,13-38 months）follow-up at the end of the study.4.Spearman Rank Correlation Coefficient Assay:（1）Positive correlation was found between the preoperative anteroposterior x-ray view classification,frog leg view classification and postoperative collapse degree of the anterolateral column of femoral head.（2）Positive correlation was found between preoperative ARCO stages and postoperative collapse degree of anteroposterior x-ray view of femoral head.The correlation was not statistically significant between preoperative ARCO stages and postoperative collapse degree of frog leg view of femoral head.（3）Positive correlation was found between preoperative anteroposterior x-ray view collapse degree and postoperative cartilage degeneration.Negative correlation between preoperative anteroposterior x-ray view collapse degree and postoperative necrotic zone restoration,harmony of femeral head and acetabulum,stabilization of hip joint were observed.（4）Positive correlation was found between preoperative frog leg x-ray view collapse degree and postoperative cartilage degeneration.Negative correlation between preoperative frog leg view x-ray collapse degree and postoperative necrotic zone restoration, harmony of femeral head and acetabulum,stabilization of hip joint were observed.（5）Positive correlation was found between preoperative anteroposterior x-ray view Classification and postoperative cartilage degeneration.Negative correlation between preoperative anteroposterior x-ray view Classification and postoperative necrotic zone restoration,harmony of femeral head and acetabulum,stabilization of hip joint were observed.（6）Positive correlation was found between preoperative frog leg x-ray view Classification and postoperative cartilage degeneration.Negative correlation between preoperative frog leg x-ray view Classification and postoperative necrotic zone restoration,harmony of femeral head and acetabulum,stabilization of hip joint were observed.（7）Positive correlation was found between preoperative ARCO stages and postoperative cartilage degeneration.Negative correlation between preoperative ARCO stages and postoperative necrotic zone restoration,harmony of femeral head and acetabulum were observed.The correlation was not statistically significant between preoperative ARCO stages and postoperative stabilization of hip joint5.Multiple logistic regression analysis showed that the dangerous prognostic index was preoperative frog leg x-ray view Classification.The higer the preoperative frog leg x-ray view Classification,the worse the prognosis was.The preoperative frog leg x-ray view Classification increased per grade leaded to the prognosis increased 14.96 folds compared with the prognosis which the frog leg x-ray view Classification did not increase.6.COX regression analysis showed that the dangerous index was preoperative frog leg x-ray view Classification among those factors associated with the femoral head survivorship time.The higer the preoperative frog leg x-ray view Classification,the less the femoral head survivorship time was.The preoperative frog leg x-ray view Classification increased per grade leaded to the femoral head survivorship time decreased 6.937 folds compared with the time which the frog leg x-ray view Classification did not increase.Interpretation.1.Frog leg view x-ray classification can reflect the distribution of necrotic zone and collapse condition of anterolateral column of femoral head precisely.Positive correlation was found between integrality,stability of anterolateral column of femoral head and prognosis,Joint-Preserving Procedures curative effect of SONFH,the more integrated and stabile,the better the prognosis and curative effect were.The anteroposterior x-ray view classification combined with the frog leg x-ray view classification could reveal the total conditions of the the anterolateral column of femoral head more accurately compared with using the anteroposterior x-ray view classification alone.It also decreased the blind area of observation,was more effective to estimate prognosis and evaluate curative effect,it was propitious to treated SONFH with traditional medicine as well.2.If the grade of frog leg x-ray view classification did not exceed Type C1,and necrotic zone was contained medially by remained normal bone of anterolateral column of femoral head,forming contained restoration,thus prognosis would be good.If the grade of frog leg x-ray view classification achieved Type C2 and necrotic region was open without protection of normal bone of anterolateral column,forming open restoration,especially generating traversing femoral head necrotic portion,thus the prognosis would be poor.3.Joint-Preserving Procedures during peri-collapse period should aim at restoring the integrality and maintaining the stability of anterolateral column of femoral head,avoiding severe recollapse.4.Modified core decompression combined with non-vascularized fibula graft,impaction bone grafting and stabilization inner femoral head with titanium hollow compression screw procedure was only applicable to frog leg x-ray view classification equal and less than type C1,it was inapplicable to type C2.5.Orientation of core decompression shoud aim at the center of necrotic zone in femoral head anterolateral column preserving as much as possible normal bone of anterolateral femoral head portion.Depth of core decompression shoud achieve subchondral bone plate but never traverse through chondral.The degree of impaction bone grafting should be limited in recovering the shape of femoral head,eliminating the crescent sign,sidestep sign and crack sign in femoral head.Depth of impaction bone grafting should be limited in 5 millimeter.The peak of implanted fibula shuld be cut flat and drilled around its body with Kirschner wire（1.5 mm diameter）.The titanium hollow compression screw stabilized femoral head inner should be located just behind or posterior and medial behind the fibula.更多还原