多孔钽棒植入术治疗股骨头坏死的中长期疗效及术后失效行THA与初次行THA疗效比较

目的评估接受髓心减压、同种异体骨植骨、多孔钽棒植入术(简称多孔钽棒植入术)治疗的股骨头坏死(ONFH)患者的中长期临床疗效以及术后失效是否会影响后续全髋关节置换术(THA)的临床效果。 方法选择2008年1月至2011年12月广州中医药大学髋关节研究中心收治的非创伤性ONFH患者38例40髋。所有患髋均行多孔钽棒植入术。在透视下先行股骨头内髓内减压,清除部分死骨并行同种异体骨植骨,最后旋入1枚多孔钽棒。多孔钽棒植入术失效后行THA的患者设为二次手术组(n＝12),二次手术组行THA时,行股骨颈截骨同时截断植入钽棒,同时取出近端残端。按照1例二次手术组患者匹配4~6例性别、年龄相近(±15岁)原则纳入非创伤性ONFH[国际骨循环研究会(ARCO) Ⅳ期]既往无保髋手术史、初次行THA的患者57例,设为对照组。对照组患者行初次THA。分析及比较总体患者、不同ARCO期、不同日本骨坏死调查委员会(JIC)型ONFH患者多孔钽棒植入术术后24、60、96个月的保髋率。评估总体患者、不同ARCO期、不同JIC型ONFH患者多孔钽棒植入术术后24、60、96个月的Harris髋关节评分。同时比较二次手术组与对照组患者术前、术后60个月的Harris髋关节评分。收集所有患者患髋的正位、蛙位X线片,以及MRI和CT扫描数据,采用改良的Nish Ⅱ方法评估髋关节塌陷的进展并计算末次随访影像学进展率;比较末次随访时影像学进展的不同ARCO期、不同JIC型ONFH患者的保髋率。数据行Wilcoxon符号秩检验、Mann Whitney U检验与χ²检验。 结果接受多孔钽棒植入术后平均随访(117.1±4.1)个月。术后24、60、96个月的保髋率分别为92.5%(37/40)、82.5%(33/40)、75%(30/40)。术后24、60个月,ARCO Ⅱ期患者与ARCO Ⅲ期患者保髋率比较,差异均无统计学意义(χ²＝0.001、1.396,P＝1.000、0.457);术后96个月,ARCO Ⅱ期患者保髋率[89.6%(23/27)]比ARCO Ⅲ期患者[53.8%(7/13)]高,差异有统计学意义(χ²＝4.596,P＝0.042)。术后24、60个月,JIC C1型患者与JIC C2型患者保髋率比较,差异均无统计学意义(χ²＝0.041、0.145,P＝0.839、0.703);术后96个月,JIC C1型患者保髋率[83.3%(25/30)]比JIC C2型患者[50.0%(5/10)]高,差异有统计学意义(χ²＝4.444,P＝0.035)。多孔钽棒植入术术前,ONFH患者Harris髋关节评分为59 (55,61)分,术后24、60、96个月Harris髋关节评分分别为72(61,80)、89(82,91)、94(91,96)分,比较差异有统计学意义(Z＝4.627,P<0.05)。术前,术后60、96个月,ARCO Ⅱ期患者与ARCO Ⅲ期患者Harris髋关节评分比较,差异均无统计学意义(Z＝123.5、180.0、101.0,P＝0.114、0.994、0.871);术后24个月,ARCO Ⅱ期与ARCO Ⅲ期患者Harris髋关节评分比较,差异有统计学意义(Z＝100.0,P＝0.043)。术前,术后96个月,JIC C1型患者与JIC C2型患者Harris髋关节评分比较,差异均无统计学意义(Z＝164.0、90.0,P＝0.279、0.355);术后24、60个月,JIC C1型患者与JIC C2型患者Harris髋关节评分比较,差异均有统计学意义(Z＝96.5、93.0,P＝0.042、0.038)。末次随访总体影像学进展率为55.0%(22/40)。ARCO Ⅱ期患者影像学进展率为48.1%(13/27),与ARCO Ⅲ期患者[69.2%(9/13)]相比,差异无统计学意义(χ²＝1.255,P＝0.391);JIC C1型患者影像学进展率为46.7% (14/30),与JIC C2型患者[80%(8/10)]相比,差异无统计学意义(χ²＝1.835,P＝0.086)。影像学进展的ARCO Ⅲ期患者保髋率[11.1%(1/9)]与影像学进展的ARCO Ⅱ期患者保髋率[76.9%(10/13)]相比,差异有统计学意义(χ²＝3.035,P＝0.024)。影像学进展的JIC C2型患者保髋率[12.5%(1/8)]与影像学进展的JIC C1型患者髋关节的保髋率[71.4%(10/14)]相比,差异有统计学意义(χ²＝2.659,P＝0.009)。二次手术组、对照组接受THA术前、术后60个月Harris髋关节评分比较差异均有统计学意义(Z＝6.511、7.471,P<0.05)。术后60个月,二次手术组、对照组Harris髋关节评分分别为88 (85,93)、94 (92,96)分,比较差异均无统计学意义(Z＝-1.711,P＝0.090)。 结论多孔钽棒植入术治疗ONFH在中长期的随访中,ARCO Ⅱ期、JIC C1型患者保髋率较高,ARCO Ⅲ期或JIC C2型患者效果一般,应用该技术的关键在于选择合适的患者。晚期ONFH患者行THA和多孔钽棒植入术失效后接受THA的患者的临床效果相似。

Medium-long term clinical outcomes of porous tantalum rod implantation in the treatment of osteonecrosis of the femoral head and efficacy comparison of THA postoperative failure and primary THA

ObjectiveTo evaluate the medium-long term clinical outcomes of osteonecrosis of the femoral head (ONFH) patients treated with decompression of the femoral head, allograft, and porous tantalum rod implantation (porous tantalum rod implantation for short), and whether postoperative failure would affect the clinical outcomes of subsequent total hip arthroplasty (THA). MethodsA total of 38 patients (40 hips) with non traumati ONFH admitted to Hip Research Center, Guangzhou University of Chinese Medicine from January 2008 and December 2011 were selected. All affected hips were implanted with porous tantalum rod implantation. Intramedullary decompression of the femoral head was performed under fluoroscopy to remove part of the dead bone and allograft bone. Finally, a porous tantalum rod was inserted. Patients who underwent THA after the failure of porous tantalum rod implantation were assigned to the second surgery group (n=12). In the second surgery group, femoral neck osteotomy was performed and tantalum rod was truncated and implanted, and the proximal residual end was removed at the same time. Fifty-seven patients who had no previous history of hip preservaton surgery and underwent primary THA in non traumatic ONFH [Association Research Circulation Osseous Committee (ARCO) Ⅳ] were included as the control group according to the principle that 1 patient in the second surgery group was matched with 4-6 patients of similar gender and age (±15 years old). Primary THA was performed in the control group. The hip preservation rates of patients at 24, 60 and 96 months after porous tantalum rod implantation were analyzed and compared in the whole population, different ARCO stages and different Japanese Osteonecrosis Investigation Committee (JIC) ONFH patients. The hip preservation rates of patients with different radiographically progressive of ARCO stages and different JIC types of ONFH were compared at the last follow-up. Harris hip scores at 24, 60, and 96 months after porous tantalum rod implantation were evaluated in the population, different ARCO stages, and different JIC types of ONFH. Harris hip scores of the second surgery group and the control group were compared before and 60 months after surgery. Anteroposterial and frog radiographs, as well as MRI and CT scan data were collected from all patients. The progression of hip collapse was assessed by the method of modified Nish Ⅱ and the radiographic progression rate was calculated at the last follow-up. Data were processed with Wilcoxon signed-rank test, Mann Whitney U test and chi-square test. ResultsThe mean follow-up time was (117.1±4.1) months after porous tantalum rod implantation. and the hip preservation rates at 24, 60 and 96 months after surgery were 92.5%(37/40), 82.5%(33/40) and 75%(30/40), respectively. At 24, 60 months after surgery, there were no statistically significant differences in hip preservation rates between ARCO Ⅱ patients and ARCO Ⅲ patients (χ²=0.001, 1.396; P=1.000, 0.457). At 96 months after surgery, the hip preservation rate of ARCO Ⅱ patients [89.6% (23/27)] was higher than that of ARCO Ⅲ patients [53.8% (7/13)], the difference was statistically significant (χ²=4.596, P=0.042). At 24 and 60 months after surgery, there were no statistically significant differences in hip preservation rates between JIC C1 patients and JIC C2 patients (χ²=0.041, 0.145; P=0.839, 0.703). At 96 months after surgery, the hip preservation rate of JIC C1 patients [83.3% (25/30)] was higher than that of JIC C2 patients [50.0% (5/10)], the difference was statistically significant (χ²=4.444, P=0.035). Before receiving porous tantalum rod implantation, the Harris hip score of ONFH patients was 59 (55, 61) points, and the Harris hip scores of ONFH patients were 72(61, 80), 89 (82, 91), and 94(91, 96) points at 24, 60, and 96 months after surgery, respectively, the difference was statistically significant (Z=4.627, P<0.05). There were no statistically significant differences in Harris hip scores between ARCO Ⅱ patients and ARCO Ⅲ patients before surgery, 60 and 96 months after surgery (Z=123.5, 180.0, 101.0; P=0.114, 0.994, 0.871). At 24 months after surgery, there were no statistically significant differences in Harris hip scores between between ARCO Ⅱ patients and ARCO Ⅲ patients (Z=100.0, P=0.043). Before and 96 months after surgery, there were no statistically significant differences in Harris hip scores between JIC C1 patients and JIC C2 patients (Z=164.0, 90.0; P=0.279, 0.355). At 24 and 60 months after surgery, there were statistically significant differences in Harris hip score between JIC C1 patients and JIC C2 patients (Z=96.5, 93.0, P=0.042, 0.038). The overall radiographic progression rate at the last follow-up was 55.0%(22/40). The imaging progression rate of ARCO Ⅱ patients was 48.1%(13/27), compared with ARCO Ⅲ patients [69.2%(9/13)], there was no statistically significant difference (χ²=1.255, P=0.391). The imaging progression rate of JIC C1 patients was 46.7% (14/30), compared with JIC C2 patients [80%(8/10)], there was no statistically significant difference (χ²=1.835, P=0.086). There was statistically significant difference in hip preservation rates between ARCO Ⅲ patients with radiographic progression[11.1%(1/9)] and ARCO Ⅱ patients with radiographic progression[76.9% (10/13)](χ²=3.035, P=0.024). The hip preservation rate of JIC C2 patients with radiographic progression [12.5% (1/8)] was significantly different from that of JIC C1 patients with radiographic progression [71.4% (10/14)](χ²=2.659, P=0.009). There were statistically significant differences in Harris hip scores in the second surgery group and the control group before THA and 60 months after THA (Z=6.511, 7.471; P<0.05). At 60 months after surgery, the Harris hip score of the second surgery group and the control group was 88 (85, 93) points and 94 (92, 96), respectively, there was no statistically significant difference (Z=0.044, P=0.090). ConclusionsIn the medium-long term follow-up, porous tantalum rod implantation in the treatment of ONFH has a high hip preservation rate in ARCO Ⅱ and JIC C1 patients, while the effect of ARCO Ⅲ or JIC C2 patients is not so good. The key to the application of this technology is to select the appropriate patients. Patients with advanced ONFH who underwent THA and patients who underwent THA after porous tantalum rod implantation failed has similar clinical outcomes.