Kawate Kenji, Yajima Hiroshi, Sugimoto Kazuya, Ono Hiroshi, Ohmura Tetsuji, Kobata Yasunori, Murata Keiichi, Shigematsu Koji, Kawamura Kenji, Kawahara Ikuo, Maegawa Naoki, Tamai Katsuya, Takakura Yoshinori, Tamai Susumu
Department of Orthopaedic Surgery, Nara Medical University, Japan.
BMC Musculoskelet Disord. 2007 Aug 8;8:78. doi: 10.1186/1471-2474-8-78.
The present study aimed to determine the indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head.
Seventy-one hips (60 patients) were clinically followed for a minimum of 3 years. Average follow-up period was 7 years. Etiologies were alcohol abuse in 31 hips, steroid use in 27, idiopathic in 7 and trauma in 6. Preoperative staging of the necrotic lesion was done using the Steinberg's classification system. The outcomes of free vascularized fibular grafting were determined clinically using the Harris hip-scoring system, radiographically by determining progression, and survivorship by lack of conversion to total hip replacement.
The average preoperative Harris hip score was 56 points and the average score at the latest follow-up examination was 78 points. Forty-seven hips (67%) were clinically rated good to excellent, 4 hips (6%) were rated fair, and 20 hips (28%) were rated poor. Thirty-six hips (51%) did not show radiographic progression while 35 hips (49%) did, and with an overall survivorship of 83% at 7 years. Steroid-induced osteonecrosis was significantly associated with poor scores and survival rate (68%). Preoperative collapse was significantly associated with poor scores, radiographic progression and poor survival rate (72%). A large extent of osteonecrosis greater than 300 degrees was significantly associated with poor scores, radiographic progression and poor survival rate (67%). There was no relationship between the distance from the tip of the grafted fibula to the subchondral bone of the femoral head and postoperative radiographic progression.
In conclusion, small osteonecrosis (less than 300 degrees of the femoral head) without preoperative collapse (Steinberg's stages I and II) is the major indication for free vascularized fibular grafting. Steroid-induced osteonecrosis is a relative contraindication. Large osteonecrosis (greater than 300 degrees) with severe preoperative collapse (greater than 3 mm) is a major contraindication. Hips with 2 negative factors such as severe preoperative collapse and a large extent of osteonecrosis, require hip replacements.
本研究旨在确定游离血管化腓骨移植治疗股骨头坏死的适应证。
对71髋（60例患者）进行了至少3年的临床随访。平均随访时间为7年。病因包括31髋酒精滥用、27髋使用类固醇、7髋特发性及6髋创伤。采用斯坦伯格分类系统对坏死病变进行术前分期。使用Harris髋关节评分系统临床评估游离血管化腓骨移植的结果，通过确定进展情况进行影像学评估，并通过未转换为全髋关节置换来评估生存率。
术前Harris髋关节平均评分为56分，最近一次随访检查时平均评分为78分。47髋（67%）临床评定为良好至优秀，4髋（6%）评定为中等，20髋（28%）评定为差。36髋（51%）未出现影像学进展，而35髋（49%）出现进展，7年总体生存率为83%。类固醇诱导的骨坏死与评分低和生存率低显著相关（68%）。术前塌陷与评分低、影像学进展和生存率低显著相关（72%）。大于300度的大面积骨坏死与评分低、影像学进展和生存率低显著相关（67%）。移植腓骨尖端至股骨头软骨下骨的距离与术后影像学进展之间无相关性。
总之，术前无塌陷（斯坦伯格I期和II期）的小面积骨坏死（小于股骨头300度）是游离血管化腓骨移植的主要适应证。类固醇诱导的骨坏死是相对禁忌证。术前严重塌陷（大于3mm）的大面积骨坏死（大于300度）是主要禁忌证。具有严重术前塌陷和大面积骨坏死等两个阴性因素的髋关节需要进行髋关节置换。
