分析双粗通道减压植骨+结构性骨支撑治疗早期股骨头坏死(ONFH)的临床疗效。

依据纳入与排除标准，选择自2016年10月至2020年10月在航空总医院骨关节科行双粗通道减压植骨+结构性骨支撑治疗的早期ONFH患者93例(133髋)纳入研究，其中国际骨循环研究会(ARCO)分期：Ⅱ期60髋，Ⅲ期73髋；中日友好医院(CJFH)分型：C型20髋，L1型42髋，L2型49髋，L3型22髋。患者麻醉后，首先将直径10 mm的髓心减压钻头自大粗隆外侧沿前内侧导针扩髓直至软骨下方3 mm左右，应用植骨器将7.5 mg同种异体松质骨骨粒经减压通道植入坏死区域；然后将直径10 mm的髓心减压钻头自大粗隆外侧沿前外侧导针扩髓直至软骨下方3 mm左右，将2.5 mg骨粒植入通道顶部压实，选择合适长度的支撑棒沿着导针插入外上道并拧紧，取出导针再次透视确保支撑棒位置良好，冲洗并缝合切口。分析比较术前及末次随访时所有患者、不同ARCO分期、不同CJFH分型早期ONFH患者Harris髋关节功能评分。分析比较末次随访时所有患者、不同ARCO分期、不同CJFH分型早期ONFH患者的影像学进展率与保髋成功率。数据行配对t检验、χ²检验。

随访时间平均(29.26±10.02)个月。末次随访时，患者总体Harris髋关节功能评分由术前(78.99±13.50)分提高到(82.49±17.18)分，差异有统计学意义(t＝－1.890，P＝0.021)。术前及末次随访时ARCO Ⅱ期患者Harris评分比较，差异无统计学意义(t＝0.944，P＝0.349)，ARCO Ⅲ期患者Harris髋关节功能评分由术前(73.83±10.98)分提高到(82.43±17.72)分，差异有统计学意义(t＝－3.797，P<0.05)。末次随访时CJFH分型中C型、L2型、L3型患者术前及末次随访时的Harris髋关节功能评分比较，差异均无统计学意义(t＝－1.855、－0.639、1.749，P＝0.079、0.526、0.095)。L1型患者末次随访时Harris髋关节功能评分为(87.45±15.27)分，较术前[(79.11±13.36)分]明显提高，差异有统计学意义(t＝－2.393，P＝0.010)。通过影像学评估，末次随访时影像学总体进展率为27.07%(36/133)。ARCO Ⅱ期患者的影像学进展率为26.67%(16/60)，ARCO Ⅲ期患者的影像学进展为27.40%(20/73)，ARCO Ⅱ期和ARCO Ⅲ期患者的影像学进展率比较差异无统计学意义(χ²＝0.009，P＝1.000)。通过CJFH分型分析，不同CJFH分型的早期ONFH患者术后影像学进展率由高到低依次是L3型50.00%(11/22)、L2型30.61%(15/49)、L1型16.67%(7/42)、C型15.00%(3/20)，差异有统计学意义(χ²＝9.950，P＝0.018)。末次随访时共18髋行全髋关节置换术(THA)，平均时间为术后(18.17±8.22)个月，保髋成功率为86.47%(115/133)。ARCO Ⅱ期患者的保髋成功率为90.00%(54/60)，ARCO Ⅲ期患者的保髋成功率为83.56%(61/73)，ARCO Ⅱ期和ARCO Ⅲ期患者的保髋成功率比较差异无统计学意义(χ²＝1.167，P＝0.318)。根据CJFH分型分析发现，不同CJFH分型的早期ONFH患者的保髋成功率由高到低依次为L1型95.24%(40/42)、C型90.00% (18/20)、L2型87.76%(43/49)、L3型63.64%(14/22)，差异有统计学意义(χ²＝11.085，P＝0.015)。

双粗通道减压植骨+结构性骨支撑是延缓甚至终止早期ONFH自然进展的有效方法，尤其适用于ARCOⅢ期及CJFH分型C型、L1型、L2型患者。

To analyze the clinical efficacy of double channel decompression and bone grafting plus structural bone support in the treatment of early osteonecrosis of the femoral head(ONFH).

According to the inclusion and exclusion criteria, a total of 93 patients (133 hips) with early ONFH who underwent double channel decompression and bone grafting plus structural bone support in the Department of Bone and Joint Surgery, Aviation General Hospital from October 2016 to October 2020 were enrolled in the study, including Association Research Circulation Osseous (ARCO) stage Ⅱ 60 hips, ARCO stage Ⅲ 73 hips, China-Japan Friend ship Hospital (CJFH) type: type C 20 hips, type L1 42 hips, type L2 49 hips, type L3 22 hips. After the anesthesia was taken for the patients, firstly, the 10 mm diameter midullary decompression drill bit was used to reamer the medullary along the anteromaterial guide needle on the outside of the greater trochanter until about 3 mm below the cartilage. A 7.5 mg allogeneic scellous bone granules was implanted into the necrotic area through a decompression channel with a bone grafting. Then, the 10 mm diameter midullary decompression drill bit was used to reamer the medullary along the anterolateral guide needle on the outside of the greater trochanter until about 3 mm below the cartilage. The 2.5 mg bone granules were implanted at the top of the channel and compacted. A support rod of appropriate length was inserted into the second channel along the guide wire and tightened. The guide wire was removed and fluoroscoped again to ensure that the support rod was in good position. Harris hip function scores of all ONFH patients, different ARCO stages and CJFH types of early ONFH patients were compared before operation and at last follow-up respectively. The imaging progression rate and hip preservation success rate of all ONFH patients, different ARCO stages and CJFH types of early ONFH patients were compared before operation and at last follow-up respectively. Data were processed with paired t test and chi-square test.

The mean follow-up was (29.26±10.02) months. At the last follow-up, Harris hip function scores of patients was changed from (78.99±13.50) points before operation to (82.49±17.18) points, the difference was statistically significant (t=-1.890, P=0.021). There was no statistically significant difference in Harris hip function scores between ARCO stage Ⅱ patients before operation and at last follow-up (t= 0.944, P=0.349). The Harris hip function score of ARCO stage Ⅲ patients at last follow-up was (82.43±17.72) points, which was significantly higher than that before surgery [(73.83±10.98) points], and the difference was statistically significant (t=-3.797, P<0.05). There were no statistically significant differences in Harris hip function scores between patients with type C, L2 and L3 of CJFH types before operation and at last follow-up (t=-1.855, -0.639, 1.749; P=0.079, 0.526, 0.095). Harris hip function score of type L1 patients at last follow-up was (87.45±15.27) points, which was significantly higher than that before operation [(79.11±13.36) points], and the difference was statistically significant (t=-2.393, P=0.010). As assessed by imaging, the overall imaging progression rate was 27.07% (36/133) at last follow-up. The imaging progression rate of ARCO stage Ⅱ and ARCO stage Ⅲ were 26.67%(16/60) and 27.40%(20/73), there was no statistically significant difference in the imaging progression rate between the two stages (χ²=0.009, P=1.000). According to CJFH types analysis, the postoperative imaging progression rates of early ONFH patients were type L3 50.00%(11/22), type L2 30.61%(15/49), type L1 16.67%(7/42), type C 15.00%(3/20) from high to low. There were statistically significant differences in imaging progression rates among different CJFH types (χ²=9.950, P=0.018). At the last follow-up, 18 hips underwent total hip orthroplasty (THA), and the average time was (18.17±8.22) months. The overall success rate was 86.47% (115/133). The success rates of ARCO stage Ⅱ and ARCO stage Ⅲ were 90.00%(54/60) and 83.56% (61/73), there was no statistically significant difference in the success rates between the two stages (χ²=1.167, P=0.318). According to CJFH types analysis, the success rate of different CJFH types were type L1 95.24%(40/42), type C 90.00%(18/20), type L2 87.76%(43/49), type L3 63.64%(14/22) from high to low and the differences were statistically significant (χ²=11.085, P=0.015).

Double rough channel decompression and bone grafting plus structural bone support is an effective method to delay or even stop the natural progression of early ONFH, especially for patients with ARCO stage Ⅲ and type C, L1 and L2 with CJFH type.