单中心前瞻性研究囊性变对早期股骨头坏死微创保髋手术后疗效的影响

目的观察囊性变是否影响早期股骨头坏死(ONFH)保髋手术后的疗效。 方法前瞻性临床随访观察2017年6月至2020年11月航空总医院收治的早期ONFH的患者病历资料。根据术前影像学(CT与MRI)评估结果分组，其中股骨头内有囊性变的患者设为囊性变组，共32例患者37髋；股骨头内不存在囊性变的患者设为非囊性变组，共50例患者59髋。所有患者均采用经大粗隆单一入路双孔道减压植骨+结构性骨支撑微创保髋手术，通过内下通道对股骨头坏死内下区域进行减压植骨，经外上通道对股骨头坏死外上区域进行减压植骨+结构性骨支撑。术后3、6、12个月及之后每年进行1次随访，以最终行髋关节置换术即认为手术失败随访终止，术前和末次随访数据纳入研究进行数据分析。采用Harris髋关节评分对髋关节的功能进行评估；比较2组患者髋关节功能评分、优良率以及不同分型患者(C+L1型、L2+L3型)髋关节功能评分；比较2组患者影像学进展率、失败率。所有纳入研究的患者术前与随访时均行髋关节正侧位X线、CT检查，术后影像学评估如股骨头无塌陷或原有塌陷无加重即认为影像学稳定，如发生软骨下骨折或塌陷加重即认为影像学进展。以最终行髋关节置换即认为手术失败。数据行Wilcoxon符号秩检验、χ²检验，采用Kaplan-Meier方法进行生存分析。 结果所有患者均纳入研究，平均随访(30.6±8.6)个月。囊性变组患者末次随访时的Harris髋关节评分为(82.43±16.36)分，较术前(75.67±13.43)分]明显提高，差异有统计学意义(P＝0.022)；优良率由术前的37.84%(14/37)提高到62.16%(23/37)，差异有统计学意义(χ²＝4.378，P<0.05)。非囊性变组患者末次随访时的Harris髋关节评分为(81.76±17.68)分，较术前(82.90±12.77)分]无明显变化，差异无统计学意义(P＝0.965)；优良率由术前的55.93%(33/59)提高到62.71%(37/59)，差异无统计学意义(χ²＝0.562，P>0.05)。术前囊性变组患者Harris髋关节评分明显低于非囊性变组，差异有统计学意义(P＝0.021)，末次随访时，囊性变组与非囊性变组的Harris髋关节评分比较，差异无统计学意义(P＝0.778)。囊性变组C+L1型患者Harris髋关节评分术前与末次随访时比较差异无统计学意义(P＝0.417)；L2+L3型患者Harris髋关节评分术前明显低于末次随访时，差异有统计学意义(P＝0.040)。非囊性变组C+L1型患者Harris髋关节评分术前与末次随访时比较差异无统计学意义(P＝0.088)；L2+L3型患者Harris髋关节评分术前与末次随访时比较差异无统计学意义(P＝0.189)。术前，囊性变组C+L1型患者Harris髋关节评分明显低于非囊性变组C+L1型患者，差异有统计学意义(P＝0.022)；末次随访时，2组中C+L1型患者Harris髋关节评分比较差异无统计学意义(P＝0.335)。术前，囊性变组L2+L3型患者Harris髋关节评分与非囊性变组L2+L3型患者比较差异无统计学意义(P＝0.261)，末次随访时2组中L2+L3型患者Harris髋关节评分比较差异无统计学意义(P＝0.323)。末次随访时，囊性变组患者的影像学进展率为27.03%(10/37)，非囊性变组为22.03%(13/59)，比较差异无统计学意义(χ²＝0.311，P＝0.577)；囊性变组C+L1型患者影像学进展率38.46%(5/13)高于非囊性变组C+L1型患者4.76%(1/21)]，差异有统计学意义(χ²＝4.170，P＝0.019)，而囊性变组、非囊性变组L2+L3型患者影像学进展率分别为20.83%(5/24)、32.43%(12/37)，比较差异无统计学意义(χ²＝0.974，P＝0.324)。末次随访时囊性变组失败率为13.51%(5/37)，非囊性变组失败率为11.86%(7/59)，比较差异无统计学意义(χ²＝0.000，P>0.05)。Kaplan-Meier生存曲线示，2组总体生存曲线进展平缓，未表现出明显的与临床失败相关的时间界。 结论股骨头囊性变区域可能对ARCOII期或C+L1型的ONFH患者的髋关节功能和影像学进展有一定影响，但是不建议作为影响早期ONFH保髋手术预后的危险因素。

A single-center prospective study on the effect of cystic changes on the outcome of minimally invasive hip preservation surgery for early osteonecrosis of the femoral head

ObjectiveTo observe whether cystic changes affects the outcome of hip preservation surgery of early osteonecrosis of the femoral head (ONFH). MethodsProspective clinical follow-up was conducted to observe the clinical data of patients with early ONFH at Aviation General Hospital from June 2017 to November 2020. According to the evaluation of preoperative imaging (CT and MRI), patients were divided into the cystic changes group, with a total of 32 patients and 37 hips. Patients without cystic changes were assigned to the non-cystic group, with a total of 50 patients and 59 hips. All patients were treated with minimally invasive single approach to double-channel core decompression and bone grafting with structural bone support by the great trochanter. Decompression bone grafting was performed on the inner and lower areas of femoral head necrosis through the inner and lower channels, and decompression bone grafting plus structural bone support was performed on the outer and upper areas of femoral head necrosis through the outer and upper channels. Follow-up was performed at 3, 6, 12 months after surgery and once a year thereafter. Follow-up was terminated if total hip arthroplasty was done, which considered a failure. Data from the preoperative and last follow-up visits were included in the study for data analysis. Hip function was assessed by Harris hip score. Hip function scores, excellent and good rates and hip function scores of patients with different types (C+ L1, L2+ L3) were compared between the two groups. Imaging progression rate and failure rate of 2 groups were compared. All the patients included in the study underwent anteroposterior and lateral hip joint X-ray and CT examination before and during the follow-up. Postoperative imaging evaluation was considered as stable if there was no collapse of femoral head or no aggravation of original collapse, and imaging progress was considered if subchondral fracture or aggravation of collapse occurred. A final THA was considered a failure. Data were processed with Wilcoxon signed-rank test and chi-square test, and kaplan-Meier method was used for survival analysis. ResultsAll patients were included in the study and followed up for a mean of (30.6±8.6) months. The Harris hip score of the cystic changes group at the last follow-up was(82.43±16.36) points, significantly higher than that before surgery(75.67±13.43) points], and the difference was statistically significant (P=0.022). The excellent and good rate increased from 37.84%(14/37) to 62.16%(23/37), and the difference was statistically significant(χ²=4.378, P<0.05). The Harris hip score of the non-cystic group was (81.76±17.68) points at the last follow-up, compared with that before surgery (82.90±12.77) points], and the difference was not statistically significant (P=0.965). The excellent and good rate increased from 55.93%(33/59) to 62.71%(37/59), and the difference was not statistically significant(χ²=0.562, P>0.05). Before surgery, Harris hip score in the cystic changes group was significantly lower than that in the non-cystic group, and the difference was statistically significant (P=0.021); at the last follow-up, there was no statistically significant difference in Harris hip score between the two groups (P=0.778). In cystic changes group, there was no statistically significant difference in Harris hip score of C+ L1 patients before surgery and at the last follow-up (P=0.417); Harris hip score of L2+ L3 patients was significantly lower before surgery than that at the last follow-up, and the difference was statistically significant (P=0.040). In non-cystic group, there was no statistically significant difference in Harris hip score of C+ L1 patients before surgery and at the last follow-up (P=0.088); there was no statistically significant difference in Harris hip score of L2+ L3 patients before surgery and at the last follow-up (P=0.189). Before surgery, Harris hip score of C+ L1 patients was significantly lower in the cystic changes group than that in the non-cystic group (P=0.022). At the last follow-up, there was no statistically significant difference in Harris hip score between the two groups (P=0.335). Before surgery, there was no statistically significant difference in the Harris hip score of L2+ L3 patients between the two groups(P=0.261). At the last follow-up, there was no statistically significant difference in the Harris hip score of L2+ L3 patients between the two groups (P=0.323). At the last follow-up, the rate of imaging progression was 27.03% (10/37)in the cystic changes group and 22.03%(13/59) in the non-cystic group, and there was no statistically significant difference (χ²=0.311, P=0.577). The imaging progression rate of patients with C+ L1 in the cystic changes group was 38.46%(5/13), which was higher than that in the non-cystic group 4.76%(1/21)], the difference was statistically significant (χ²=4.170, P=0.019). The imaging progression rates of L2+ L3 patients in the cystic changes group and non-cystic group were 20.83%(5/24) and 32.43%(12/37), respectively, and there was no statistically significant difference (χ²=0.974, P=0.324). At the last follow-up, the failure rate was 13.51% (5/37) in the cystic changes group and 11.86% (7/59) in the non-cystic group, and there was no statistically significant difference (χ²=0.000, P>0.05). Kaplan-meier survival curve showed that the overall survival curve of the two groups progressed smoothly, and there was no obvious time boundary associated with clinical failure. ConclusionThe cystic changes area of the femoral head may affect the hip function and imaging progression of ONFH patients in stage of ARCO Ⅱ or C+ L1, but it is not recommended as a risk factor for the prognosis of ONFH in early stage.