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中华关节外科杂志(电子版) ›› 2023, Vol. 17 ›› Issue (06) : 773 -779. doi: 10.3877/cma.j.issn.1674-134X.2023.06.003

临床论著

富血小板血浆联合植骨治疗早期非创伤性股骨头坏死
许正文, 李振†(), 侯振扬, 苏长征, 朱彪   
  1. 277500　滕州，济宁医学院附属滕州市中心人民医院关节运动医学二科
  • 收稿日期:2023-06-06 出版日期:2023-12-01
  • 通信作者: 李振
  • 基金资助:
    济宁医学院教师科研扶持基金(JYFC2019FKJ084)

Platelet rich plasma combined with bone grafting for treatment of early non-traumatic osteonecrosis of femoral head

Zhengwen Xu, Zhen Li†(), Zhenyang Hou, Changzheng Su, Biao Zhu   

  1. Second Department of joint and sports medicine, Tengzhou Central People's Hospital Affiliated to Jining Medical College, Tengzhou 277500, China
  • Received:2023-06-06 Published:2023-12-01
  • Corresponding author: Zhen Li
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引用本文：

许正文, 李振, 侯振扬, 苏长征, 朱彪. 富血小板血浆联合植骨治疗早期非创伤性股骨头坏死[J]. 中华关节外科杂志(电子版), 2023, 17(06): 773-779.

Zhengwen Xu, Zhen Li, Zhenyang Hou, Changzheng Su, Biao Zhu. Platelet rich plasma combined with bone grafting for treatment of early non-traumatic osteonecrosis of femoral head[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2023, 17(06): 773-779.

目的

观察自体富血小板血浆(PRP)联合直接前入路(DAA)头颈开窗刮除植骨对国际骨循环研究协会(ARCO)Ⅰ、Ⅱ期非创伤性股骨头坏死(NONFH)疗效。

方法

回顾分析2018年1月至2021年1月在济宁医学院附属滕州市中心人民医院就诊初次接受保髋手术的ARCOⅠ、Ⅱ期NONFH患者43例(43髋)，排除先天性髋关节脱位、炎性髋关节疾病、恶性肿瘤或急慢性感染患者，分为PRP组(21例)、对照组(22例)。两组患者均行DAA入路头颈开窗刮除植骨术，PRP组患者植骨混合自体PRP。采用独立样本t检验、Fisher精确检验比较两组随访结果、股骨头改善率、术后并发症发病率，采用配对样本t检验比较组内术前、术后随访结果。

结果

两组患者均顺利完成手术与随访，两组患者术后VAS、Harris评分均较术前改善(PRP组VAS评分t＝13.743，Harris评分t＝25.208；对照组VAS评分t＝15.603，Harris评分t＝20.860，均为P<0.05)；PRP组VAS评分术前术后差值(5.1±1.7)、Harris评分术前术后差值(29.9±5.5)均高于对照组的(3.7±1.1)和(25.2±5.7)(VAS t＝3.000、Harris评分t＝2.814，均为P<0.05)；PRP组股骨头改善率95.2%高于对照组63.6%(P＝0.021)；PRP组下肢肌肉静脉丛血栓发病率23.8%高于对照组发病率0%(P＝0.021)。

结论

DAA入路头颈开窗刮除植骨治疗可以降低ARCOⅠ、Ⅱ期NONFH患者的髋部疼痛、提高髋关节功能；与对照组相比，联合PRP治疗患者可以获得更佳的髋部疼痛降低及髋关节功能提升、更高的股骨头改善率，但是存在更高的下肢肌肉静脉丛血栓发病率。

关键词: 富血小板血浆, 股骨头坏死, 治疗结果
Objective

To observe the efficacy of autologous platelet-rich plasma (PRP) combined with direct anterior approach (DAA) femoral head and neck opening and scraping bone grafting in Association Research Circulation Osseous (ARCO) stageⅠand Ⅱnon-traumatic osteonecrosis of femoral head(NONFH).

Methods

Retrospective analysis was carried out on 43 patients (43 hips) with NONFH in ARCO stageⅠ and Ⅱwho underwent hip salvage surgery in Tengzhou Central People's Hospital Affiliated to Jining Medical College from January 2018 to January 2021. Patients with congenital dislocation of the hip, inflammatory hip disease, malignant tumor, acute or chronic infection were excluded. The patients were divided into PRP group (21 cases) and control group (22 cases). All the patients underwent DAA approach head and neck open scraping and bone grafting. The PRP group received bone grafting combined with autologous PRP. Independent-samples t test and Fisher’s exact test were used to compare the follow-up results, femoral head improvement rate, and incidence of postoperative complications between the two groups. Paired-samples t test was used to compare the preoperative and postoperative follow-up results within each group.

Results

Both groups successfully completed the surgery and follow-up. The postoperative VAS and Harris scores of both groups improved compared with the preoperative period (PRP group VAS scores t=13.743, Harris scores t=25.208; control group VAS scores t=15.603, Harris scores t=20.860; all P<0.05). The preoperative and postoperative differences of VAS and Harris scores of the PRP group were (5.1±1.7)and (29.9±5.5), which were higher than(3.7±1.12)and(25.2±5.7)of the control group (VAS scores t=3.000, Harris scores t=2.814, bothP<0.05). The improvement rate of femoral head in PRP group was 95.2% which was higher than 63.6%of the control group (P=0.021). The incidence of lower extremity muscular venous plexus thrombosis in the PRP group was 23.8% higher than 0%in the control group (P=0.021).

Conclusions

DAA access to head and neck opening and scraping bone grafting reduces hip pain and improves hip function in patients with NONFH of ARCO stage Ⅰ and Ⅱ. Patients treated with PRP achieve better hip pain reduction, hip function enhancement, and a higher rate of femoral head improvement compared with the control group, but a higher incidence of lower extremity muscular venous plexus thrombosis has been observed.

Key words: Platelet-rich plasma, Femur head necrosis, Treatment outcome
图1 右侧股骨头坏死行PRP联合DAA入路植骨手术前后影像。图A为术前双侧髋关节MRI，箭头处可见股骨头信号不均一，存在局灶高信号区并被低信号带包围；图B为术后3个月双髋正位X光片，箭头处示坏死区域面积168.97 mm2；图C为术后24个月双髋正位X光片，箭头处示坏死区域面积121.18 mm2，坏死面积缩小，植骨区底部可见硬化带形成
Figure 1 Pre-and postoperative images of necrosis of right femoral head treated by DAA approach bone grafting combined with PRP. A is MRI of bilateral hips before surgery, the arrow showed the signal of femoral head was heterogeneous, and there was focal hyperintense area surrounded by hypointense zones; B is anteroposterior view of bilateral hips in X-ray image three months after operation, the arrow showed the necrotic area of 168.97 mm2; C is anteroposterior view of bilateral hips in X-ray image 24 months after operation, the arrow showed the necrotic area of 121.18 mm2 which was shrunk, and the sclerotic zone could be seen at the bottom of the bone graft area
图2 左侧股骨头坏死行DAA入路刮除植骨手术前后影像。图A为术前双髋关节MRI，箭头示左股骨头局灶高信号，周围可见骨髓水肿；图B为术后3个月双髋关节正位X光片，箭头示坏死区域面积107.01 mm2；图C为术后24个月双髋关节正位X光片，箭头示坏死区域面积217.14 mm2，坏死面积扩大、植入骨吸收
Figure 2 Pre-and postoperative images of necrosis of left femoral head treated by DAA approach bone grafting. A is MRI of bilateral hips before surgery, the arrow showed focal hyperintensity in the femoral head and bone marrow edema around it; B is anteroposterior view of bilateral hips in X-ray image three months after operation, the arrow showed the necrotic area of 107.01 mm2; C is anteroposterior view of bilateral hips in X-ray image 24 months after operation, the arrow showed the necrotic area of 217.14 mm2，which was expanded，and the implanted bone was absorbed
图3 制备完成PRP与凝血酶共同置于注射枪中
Figure 3 After preparation, PRP and thrombin were placed in the injection gun together
图4 T形切开关节囊，箭头所指为头颈结合部
Figure 4 T-incision was made on articular capsule, the arrow showed the junction of femoral head and neck
图5 股骨头坏死面积测量，经PACS(医疗影像系统)测量股骨头坏死面积为289.19 mm2
Figure 5 Measurement of the area of femoral head necrosis, area of femoral head necrosis measured by PACS system was 289.19 mm2
表1 患者一般情况
Table 1 General situation of the patients
组别Groups 例数Number of cases 年龄[岁，(±s)]Age 性别Gender(例) BMI[kg/m2, (±s)] ARCO分期Stage
男Male 女Female Ⅰ Ⅱ
PRP组PRP group 21 47.9±7.8 15 6 24.7±3.7 6 15
对照组Control group 22 48.4±8.9 19 3 23.2±2.7 4 18
统计值Statistical value   t＝0.198 － t＝1.550 －
P值   >0.05 0.281* >0.05 0.488*
表2 PRP组与对照组随访结果(±s)
Table 2 Follow-up results of PRP group and control group
组别Groups 例数Number of cases VAS评分
术前Before operation 术后After operation 术前术后差值Pre- and postoperative differences
PRP组PRP group 21 5.9±1.6 0.9±0.6a 5.1±1.7
对照组Control group 22 5.2±1.2 1.5±0.7b 3.7±1.1
t值   1.784 2.777 3.000
P值   >0.05 0.008 0.005
组别Groups 例数Number of cases Harris评分
术前Before operation 术后After operation 术前术后差值Pre- and postoperative differences
PRP组PRP group 21 64.9±5.3 94.8±1.2c 29.9±5.5
对照组Control group 22 61.8±5.9 87.0±1.7d 25.2±5.7
t值   1.760 17.754 2.814
P值   >0.05 <0.001 0.007
表3 PRP组与对照组股骨头改善率
Table 3 Improvement rate of femoral head in PRP group and control group
组别Groups 例数Number of cases 改善(例)Improvement 恶化(例)Deterioration 改善率(%)Improvement rate
PRP组PRP group 21 20 1 95.2
对照组Control group 22 14 8 63.6
P值       0.021*
表4 PRP组与对照组并发症发病率
Table 4 Incidencerate of complications in PRP group and control group
组别Groups 例数Number of cases LFCN损伤LFCN injury 下肢肌肉静脉丛血栓Lower extremity muscular venous plexus thrombosis
出现(例)Occurrence 未出现(例)No occurrence 发病率(%)Incidence 出现(例)Occurrence 未出现(例)No occurrence 发病率(%)Incidence
PRP组PRP group 21 0 21 0 5 16 23.8
对照组Control group 22 2 22 9.1 0 22 0
P值       0.488*     0.021*
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