目前,关于SHD联合IBG和PVIBGT医治股骨头坏死(ONFH)的疗效差别,缺少相干研讨。首先,这项研究旨在比较手术髋关节脱位联合冲击骨移植(SHD-IBG)和带蒂血管化髂骨移植(PVIBGT)治疗ONFH的有效性。这项研究调查了两组患者髋关节保护失败的患者,以更好地理解失败的原因。选取2012年1月至2022年7月ARCO期IIIA期股骨头坏死患者30例(34髋)。根据手术方式不同分为A组(SHD-IBG)和B组(PVIBGT)。首先,比较SHD-IBG和PVIBGT术后1年的疗效;其次,评估SHD-IBG髋关节保留治疗的中长期疗效;最后,根据对保留髋关节衰竭患者股骨头摘除的研究,综合分析两组患者髋关节保存失败的原因。A组:11名男性(13髋),4名女性(4髋);B组:9名男性(11髋),6个女性(6个臀部)。首先,两组术后1年Harris评分的平均值:术前:70.7,术后1年:A组:78.9;术前:69.5,术后1年:B组:81.5,差异均有统计学意义(P<0.05)。与术前相比,DCE-MRI定量分析显示,术后1年,坏死区灌注增加,修复反应区灌注过度改善.其次,A组,随访2.5-11年(平均77个月),髋关节保存率为88.2%,最后一次随访时Harris的平均得分为73.2.术后DCE-MRI半定量分析显示坏死区和修复区的灌注曲线与正常区相似。这表明股骨头内的不稳定性得到了有效改善,灌注部分恢复。第三,根据Micro-CT和病理研究,这两组患者的髋关节保护失败,所有这些患者的股骨头明显塌陷和变形。它们的小梁很薄,部分杂乱无章,软骨下骨骨折,软骨与软骨下骨分离。坏死区的小梁稀疏,杂乱无章的安排,失去连续性,小梁陷阱中的细胞消失。坏死区域被纤维组织覆盖,修复区部分修复。力学有限元分析显示,在股骨的承重区域和周围皮质骨观察到最大等效应力。DCE-MRI显示修复反应区表现为异常高灌注。在这项研究中,术后1年比较SHD-IBG和PVIBGT的疗效,SHD-IBG的长期随访时间为2.5-11年(平均77个月),结合DCE-MRI结果,我们发现PVIBGT的短期效应比SHD-IBG更显著。SHD-IBG在中远期随访中可获得满意的髋关节保存效果。
Currently, there is a lack of relevant research on the efficacy difference between SHD combined with IBG and PVIBGT in the treatment of osteonecrosis of the femoral head(ONFH). Firstly, this study intends to compare the effectiveness of surgical hip dislocation combined with impacting bone grafts (SHD-IBG) and pedicled vascularised iliac bone graft transfer (PVIBGT) in treating ONFH. And the study investigates patients who suffered from hip preservation failures from both groups to better comprehend failure reasons. 30 patients (34 hips) with ARCO stage IIIA femoral head necrosis were selected between January 2012 and July 2022. They were divided into group A(SHD-IBG) and group B (PVIBGT) according to different surgical methods. Firstly, compared the 1-year effect between SHD-IBG and PVIBGT at 1 year postoperatively; Secondly, assessed the medium and long-term efficacy of SHD-IBG hip preservation treatment; Lastly, based on study of the femoral head removed from patients with hip preservation failure in the two groups, the reasons for the failure of hip preservation were comprehensively analyzed in the two groups. Group A: 11 males (13 hips), 4 females (4 hips);Group B: 9 males (11 hips), 6 females (6 hips).Firstly, the average Harris scores of the two groups at 1 year after surgery: preoperative: 70.7, 1 year after surgery: 78.9 in group A; preoperative: 69.5, 1 year after surgery: 81.5 in group B. The differences were statistically significant (P < 0.05).Compared to the preoperative period, quantitative analysis by DCE-MRI showed an increase in perfusion in the necroticarea and an improvement in hyperperfusion in the repair-responsive area one year after the surgery. Secondly, in group A, the hip preservation rate was 88.2% at 2.5-11 (average of 77 months) years of follow-up, and the mean Harris score at the last follow-up was 73.2.Semi-quantitative analysis of postoperative DCE-MRI showed that the perfusion curves of necrotic and repaired areas were similar to those of the normal area. This suggests the instability within the femoral head had been effectively improved, and the perfusion had partially recovered. Thirdly, according to Micro-CT and pathologica studies of patients with hip preservation failure in these two groups, all these patients\' femoral head was significantly collapsed and deformed. Their trabeculae was thin and partially disorganized, with fractures in the subchondral bone and separation of the cartilage from the subchondral bone. The necrotic areas had sparse trabeculae, disorganized arrangement, loss of continuity, and disappearance of cells in the trabecular traps. The necrotic area was covered with fibrous tissue, and partial restoration was observed in the repair area. Mechanical finite element analysis showed that the maximum equivalent force was observed in the weight- bearing area and the cortical bone surrounding the shaft of femurand. The result of DCE-MRI showed that the repair reaction area exhibited abnormal hyperperfusion. In this study, the efficacy of SHD-IBG and PVIBGT was compared at 1 year after operation, and the long-term follow-up of SHD-IBG was 2.5-11 (mean 77 months) years, combined with DCE-MRI results, we found that the short-term effect of PVIBGT was more significant than that of SHD-IBG. SHD-IBG can achieve satisfactory hip preservation in the medium and long term follow-up.