股骨头坏死保髋治疗常用术式的利与弊

文题释义：股骨头坏死：非创伤性股骨头坏死是造成青壮年髋关节功能障碍或功能丧失的常见疾病，其病因主要为糖皮质激素的大量应用和酒精的过多摄入，根据坏死分期和患髋情况可选择不同的治疗方案，目前此疾病尚无令人满意的完全性治疗手段，延迟或避免关节置换成为主流研究方向。 保留髋关节手术：为延迟或避免行全髋关节置换的一类治疗方法。保髋术式类型较多，针对不同坏死类型可选择不同术式，且各有利弊。现多将多种术式联合应用，取长补短，以达到最好疗效。随着生物制剂和细胞疗法的不断发展，保髋手术与其结合正成为新的趋势。 背景：非创伤性股骨头坏死的保留髋关节治疗方法众多，临床治疗中多以各类坏死分期作为术式选择的决定性因素。以往的相关文献对各类术式有效性的分析较多，但对于失败原因或风险评估介绍较少。 目的：探讨除了坏死分期之外，对于术式本身是否有其他内、外源因素也同时影响了保髋成功率。 方法：由第一作者检索2010至2019年PubMed、Web of Science、Medline、知网、万方数据库中相关文献，检索词为“osteonecrosis of femoral head，core decompression，non-vascularized bone grafting，vascularized free bone grafting，porous tantalum rod implantation，osteotomy，biological agents，cytotherapy，保留髋关节手术，保髋术，髓芯减压术，不带血管的骨移植术，带血管的骨移植术，多孔钽棒置入术，截骨术，生物制剂，细胞疗法”。共检索到214篇文献，查阅全文，依据纳入与排除标准，最终纳入70篇文献进行分析总结。 结果与结论：①各保髋术式均有利弊，须评估利弊风险；②髓芯减压虽操作简单，却不宜单独使用；非血管化骨移植在死骨清理时应适当保留外侧柱，以应对力学减弱；带血管的骨移植转为全髋关节置换术中失血较多、骨折风险较高；钽棒置入易造成应力集中，临床应用较少；③截骨术作为一种创伤较大的保髋手术除了考虑坏死分期外，对患者年龄、体质量指数、坏死范围等均应做详细术前规划；④无论哪种术式，都应长远考虑转为全髋关节置换的手术风险；⑤各术式联合应用，结合生物制剂或能取得更好的疗效。 ORCID: 0000-0001-6117-6147(顾长源) 中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Advantages and disadvantages of common methods of hip-conserving surgery for osteonecrosis of femoral head

BACKGROUND:There are many methods for the treatment of non-traumatic necrosis of the femoral head.In the clinical treatment,various stages of necrosis are the decisive factors for the choice of operation.In the past,there are many studies about the effectiveness of various techniques,but few studies concern the causes of failure or risk assessment.OBJECTIVE:To explore whether other internal and external factors affect the success rate of hip preservation besides necrosis stage.METHODS:The first author retrieved PubMed,Web of Science,Medline,CNKI and Wanfang database for related studies published from 2010 to 2019.The key words were“osteonecrosis of femoral head,core decompression,non-vascularized bone grafting,vascularized free bone grafting,porous tantalum rod implantation,osteotomy,biological agents,cytotherapy”in English,and“hip-conserving surgery,hip preservation,core decompression,bone graft without blood vessel,bone graft with blood vessel,porous tantalum rod placement,osteotomy,biologics,cell therapy”in Chinese.A total of 214 articles were retrieved,and the full text was consulted.Based on the inclusion and exclusion criteria,70 articles were finally included for analysis and summary.RESULTS AND CONCLUSION:(1)The advantages and disadvantages of each hip-conserving surgery should be evaluated.(2)Although core decompression is simple,it should not be used alone;the lateral column should be reserved properly when the non-vascularized bone transplantation is used to clean up the dead bone,so as to deal with the mechanical weakening;the blood loss and fracture risk are higher when the vascularized bone transplantation is converted to total hip replacement;the stress concentration is easily caused by tantalum rod implantation,and the clinical application is less.(3)Osteotomy,as a kind of hip-conserving surgery with great trauma,should be planned in detail for patients’age,body mass index,and necrotic range,besides considering the necrotic stage.(4)The risk of total hip replacement should be considered in the long run no matter which operation.(5)The combination of various surgical methods and biological agents may achieve better results.