股骨头坏死的改良外科脱位病灶清除植骨术（开放获取）

Modified surgical dislocation for debridement and bone grafting of femoral head necrosis

摘要:

[目的] 介绍股骨头坏死的不截大粗隆改良外科脱位病灶清除植骨术的手术技术和初步临床结果。[方法] 患者全麻+神经阻滞后取侧卧位，患侧朝上。同侧髂骨取自体骨后以股骨大粗隆为核心，在髋关节外侧沿股骨长轴取长约10 cm 纵行直切口，自臀大肌与阔筋膜张肌间隙切开阔筋膜，向近端分离臀小肌与臀中肌之间间隙约3 cm，在大粗隆及股骨前侧将臀小肌止点锐性切断，显露关节囊，沿股骨颈长轴切开关节囊，内收外旋患肢，脱出股骨头。自股骨头颈结合处前方沿股骨颈轴线用小骨头刀凿开直径约2 cm 骨槽窗口，刮除股骨头坏死组织，经骨窗将修剪成颗粒骨的自体髂骨松质骨植入股骨头坏死区域。[结果] 本组患者均顺利完成手术，术中及术后均未出现严重并发症。随访12~24 个月，末次随访患者Harris 髋关节功能评分（89.0±8.4） 分显著高于术前（60.5±7.0） 分，髋关节股骨头优良率为87.5%。[结论] 不截大粗隆的改良外科脱位病灶清除植骨术治疗中日友好医院股骨头坏死分型L3 型合并国际骨循环学会（the Association Research Circulation Osseous, ARCO） 分期Ⅲ期股骨头坏死的技术可行，是一个相对微创、安全实用的保髋治疗选择，短期显著改善患者术后髋关节功能。

Abstract:

[Objective] To introduce the surgical technique and preliminary clinical results of debridement and bone grafting of femo-ral head necrosis through a modified surgical dislocation without greater trochanter osteotomy. [Methods] After general anesthesia andnerve block, place the patient in lateral position with the affected side facing upward. Harvest bone autografts form the iliac crest on thesame side, and then make a straight longitudinal incision about 10 cm in length along the long axis of the femur with the femoral greater tro-chanter as the center. Cut the fascia between the gluteus maximus and the tensor fascia lata, dissect the gap between gluteus minimus andgluteus medius about 3cm, and sever the gluteus minimus sharply near to its insertion on the greater trochanter. Cut capsule sharply alongthe long axis of the femoral neck to expose the joint. As adduct and rotate outward the affected limb, dislocate the femoral head. Make bonefenestration 2 cm in diameter along the femoral neck axis in front at the junction of the femoral head and neck with drill and chisel. After cu-reting the necrotic tissue within the femoral head properly, implant the iliac bones trimmed into the granular shape into the cavity of thefemoral head through the bone fenestration. [Results] All the patients in this group successfully completed the operation, and no seriouscomplications occurred during and after the operation. The Harris hip function score significantly improved from (60.5±7.0) preoperativelyto (89.0±8.4) at the last follow-up, with the excellent rate of 87.5% in term of clinical evaluation at the latest follow-up. [Conclusion] Thismodified surgical dislocation without greater trochanter osteotomy is technically feasible for debridement and bone grafting of CJFH L3 com-bined with ARCO III femoral bone necrosis. It is a relatively minimally invasive, safe and practical hip salvage option, significantly improvethe hip function of patients in a short period.