股骨头坏死三维规划股骨颈基底部旋转截骨术

Three-dimensional planed rotational osteotomy at femoral neckbase for femoral head necrosis

摘要:

[目的]介绍股骨头坏死（osteonecrosis of femoral head, ONFH）三维规划股骨颈基底部旋转截骨术的手术技术及初步临床结果。[方法] 对 16 例 （17 髋） 股骨头坏死患者行上述手术治疗。将术前 CT 数据转化为可实施操作和观察的三维模型， 使用构建面工具在股骨颈基底部上建立截骨线，在确保无髋关节撞击的情况下，取股骨头负重区完整率最高时的规划旋转角度，必要时可适度进行股骨头内翻调整。患者全麻后侧卧位，以大粗隆顶点为中心行纵切口，行大转子截骨。屈曲、外展、外旋髋关节，“Z”字形切开关节囊。自内向外切断大转子后方 1/3 的骨质。沿股骨颈中轴线置入克氏针 1 枚作为旋转轴，再垂直于股骨颈中轴线方向置入 2 枚平行克氏针作为定位轴，于两定位轴之间垂直截断股骨颈，以两定位轴的相对角度作为参照，按照术前规划方案进行旋转。使坏死区偏离负重区，确保旋转对股骨头血运无明显影响，用三枚空心螺钉固定，复位固定大转子骨块，关闭切口。[结果]所有手术顺利完成，无严重并发症发生。11 例（12 髋）术中旋转角度与术前设计一致，5 例（5 髋） 误差 5°~10°。随访 12~36 个月，与术前相比，末次随访时，VAS 评分 [(5.2±0.5), (0.7±0.6), P＜0.001] 、Harris 评分 [(70.8±8.6), (87.5±5.4), P＜0.001]、iHOT-12 评分 [(66.4±9.0), (84.9±9.8), P＜0.001] 均显著改善。至末次随访时，13 例（14 髋）影像学显示负重区股骨头形态良好。[结论]三维规划技术为股骨颈基底部旋转截骨术实施提供了准确的技术参数，初步临床结果满意。

Abstract:

[Objective] To introduce the surgical technique and preliminary clinical results of three-dimensional planned rotational osteotomy at the femoral neckbase for osteonecrosis of the femoral head (ONFH). [Methods] A total of 16 patients (17 hips) received the abovementioned surgical treatment for femoral head necrosis. The preoperative CT data were transformed into a three- dimensional model that could be operated and observed. The osteotomy line was designed at the base of the femoral neck using the construction surface tool. Under the condition of ensuring no hip joint impact, the planned rotation angle was taken when the integrity rate of the weight-bearing area of the femoral head was the highest. If necessary, the coxa vara adjustment could be moderately carried out. In the real operation, the patient was in a lateral position after general anesthesia. A longitudinal incision was made with greater trochanter as the center, and osteotomy of the greater trochanter was conducted. Under hip flexion, abduction and external rotation, "Z"-shaped capsulotomy was done, and bone cutting of rear one-third femoral neck base was performed inside out. One Kirschner wire was inserted along the central axis of the femoral neck as the rotation axis, and then two parallel Kirschner pins were inserted perpendicularly to the central axis of the femoral neck as rotation levers. The remaining femoral neck base was cut perpendicularly between the two levers, and the femoral head was rotated according to the preoperative design by using the relative angles of the two positioning axes as the reference to transfer the femoral head necrotic area out the weight-bearing area properly, without significant impact on the blood supply of the femoral head. Finally, the femoral neck base osteotomy was fixed with three cannulated screws, and the greater trochanter was reduced and fixed with screws, the incision was closed in layers. [Results] All patients had the operation performed successfully without serious complications. Of them, 11 patients (12 hips) had intraoperative rotation angles completely consistent with the preoperative design, 5 patients (5 hips) had differences from 5° to 10°. The VAS score [(5.2±0.5), (0.7± 0.6), P＜0.001], Harris score [(70.8±8.6), (87.5±5.4), P＜0.001] and iHOT-12 score [(66.4±9.0), (84.9±9.8), P＜0.001] were significantly improved at the latest follow-up range from 12 to 36 months after operation compared with those before the operation. At the last follow-up, 13 patients (14 hips) presented good femoral head shape in the weight-bearing area on the images. [Conclusion] This preoperative three-dimensional planning provides accurate technical parameters for the rotational osteotomy at the femoral neck base, and achieves satisfactory preliminary clinical outcome.