摘要目的 探讨髓芯减压自体骨髓单个核细胞移植联合打压植骨治疗双侧早期股骨头坏死的疗效.方法 2011年1月至2017年1月中日友好医院骨关节科收治的双侧股骨头坏死患者44例(88髋),男35例,女9例;年龄(34.9± 7.2)岁(范围22~48岁).双髋分别接受髓芯减压自体骨髓单个核细胞移植和打压植骨手术.随访期间评估Harris髋关节评分、疼痛视觉模拟评分(visual analogue score,VAS),摄正位、蛙式侧位X线片及CT片行影像学评估.以需要接受全髋关节置换术或其他外科手术干预,或Harris髋关节评分低于70分作为终点事件计算髋关节5年生存率.结果 打压植骨侧随访(50.5±34.2)个月,髓芯减压自体骨髓单个核细胞移植侧随访(54.0±33.1)个月.打压植骨侧15髋手术失败,髓芯减压自体骨髓单个核细胞移植侧13髋手术失败,两侧髋关节5年累积生存率分别为64.7%和72.1%[HR=1.178,95% CI(0.561, 2.477)].打压植骨侧ARCOⅢB+ⅢC期与ⅢA期的髋关节5年生存率分别为42.9%和74.2%[HR=3.258,95% CI(1.172, 9.059)];髓芯减压自体骨髓单个核细胞移植侧ARCOⅠ期、Ⅱ期和ⅢA期的髋关节5年生存率分别为50.0%、75.3%和71.4%,差异无统计学意义(χ2=0.757,P=0.685).年龄、性别、体重指数、术前Harris髋关节评分、病因与髓芯减压自体骨髓单个核细胞移植或打压植骨的髋关节生存率无关(P＞0.05).打压植骨侧与髓芯减压自体骨髓单个核细胞移植侧术前VAS评分分别为(4.80±0.62)分和(3.27±1.17)分,差异有统计学意义(t=8.625,P<0.001);末次随访时分别降低至(2.84± 1.95)分和(2.25±2.08)分,与术前比较差异均有统计学意义(t=2.712,P<0.001;t=7.087,P<0.001),两侧比较差异有统计学意义(t=2.489,P=0.017).两侧术前Harris髋关节评分分别为(77.02±5.03)分和(82.57±5.71)分,差异有统计学意义(t=7.822,P<0.001);末次随访时打压植骨侧增高至(81.57±12.81)分,与术前比较差异有统计学意义(t=2.389,P=0.021),而髓芯减压自体骨髓单个核细胞移植侧与术前比较差异无统计学意义(t=0.451,P=0.654),两侧比较差异无统计学意义(t=1.353,P=0.183).结论 打压植骨术和髓芯减压自体骨髓单个核细胞移植术均为治疗早期股骨头坏死比较安全有效的手术方式.股骨头坏死ARCO分期是影响打压植骨术髋关节5年生存率的危险因素,但对髓芯减压自体骨髓单个核细胞移植的髋关节5年生存率没有明显影响.

abstractsObjective To compare the efficacy of core decompression with autologous bone marrow mononuclear cell grafting with impacted bone grafting in treating bilateral femoral head necrosis. Methods From January 2011 to January 2017, a total of 44 patients with bilateral femoral head necrosis (88 hips) were admitted to the Department of Orthopaedics, China-Japan Friendship Hospital, including 35 males and 9 females with aged 34.9±7.2 years old (ranged from 22-48 years). Core decompres-sion with autologous bone marrow mononuclear cell and impacted bone grafting were conducted to each hip joint for every patient. All patients were followed up for every 3 months at the first year postoperatively and for every 6 months thereafter. The following clinical measurement were recorded, Harris hip score (HHS), visual analogue score (VAS), the anterior-posterior and frog lateral ra-diographs, and CT. The 5-year survival rate of the hip was calculated with the endpoint event being defined as a need for total hip arthroplasty or other surgical intervention, or a HHS less than 70. Results The postoperative follow-up duration was 50.5±34.2 months in the impacted bone grafting group and 54.0±33.1 months in the core decompression with autologous bone marrow mono-nuclear cells group. Fifteen hips in the impacted bone grafting group and 13 hips in the core decompression with autologous bone marrow mononuclear cell group failed during the follow-up. The 5-year cumulative survival rates of the hips in two groups were 64.7% and 72.1% , respectively [ HR=1.178, 95% CI (0.561, 2.477)]. In the impacted bone grafting group, the 5-year survival rates of the hip joints at the ARCO IIIB+IIIC and IIIA stages were 42.9% and 74.2% , respectively [ HR=3.258, 95% CI (1.172, 9.059)]. In the core decompression with autologous bone marrow mononuclear cell group, the 5-year survival rates of hips at the ARCO stage I, II and IIIA stages were 50.0%, 75.3%, and 71.4%, respectively (χ2=0.757, P=0.685). Age, gender, BMI, preoperative HHS and etiology did not affect the effects of core decompression with autologous bone marrow mononuclear cell grafting or impacted bone grafting (P>0.05). The preoperative VAS of the impacted bone grafting group and the core decompression with autologous bone marrow mononuclear cell grafting group were 4.80±0.62 and 3.27±1.17, respectively (t=8.625, P<0.001). At the last follow-up, the VAS was reduced to 2.84±1.95 and 2.25±2.08, respectively (t=2.712, P=0.01; t=7.087, P<0.001) with significant differ-ence in postoperative VAS between the two groups (t=2.489, P=0.017). The preoperative HHS of the impacted bone grafting group and the core decompression with autologous bone marrow mononuclear cell grafting group were 77.02±5.03 and 82.57±5.71, re-spectively (t=7.822, P<0.001). At the last follow-up, the HHS increased to 81.57±12.81 and 83.55±12.87, respectively. The differ-ence between the preoperative and postoperative HHS was statistically significant in the impacted bone grafting group (t=2.389, P=0.021) but not in the core decompression with autologous bone marrow mononuclear cell grafting group (t=0.451, P=0.654). There was no significant difference in postoperative HHS between the two groups (t=1.353, P=0.183). Conclusion Both impacted bone grafting and core decompression with autologous bone marrow mononuclear cell grafting are safe and effective methods in treating femoral head necrosis. The ARCO stage is a risk factor affecting the prognosis of hips after impacted bone grafting, which has no ef-fect on the mid-term survival of hips after core decompression with autologous bone marrow mononuclear cell grafting.