髋臼股骨头成形术结合通络生骨胶囊治疗成人髋臼发育不良
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摘要
研究目的:50岁时患髋关节骨关节炎者5%—50%是由发育性髋臼发育不良引起的。髋臼发育不良继发骨关节炎的治疗较为困难,保守治疗难以奏效。因此,对髋臼发育不良伴有临床症状者,多需手术治疗已为多数学者所共识。髋关节股骨头臼匹配良好,无或有轻微骨关节炎者,可根据情况进行髋臼加盖成形术或各种截骨术。对于骨关节炎较严重,髋臼与股骨头的对应关系差者,则不适宜做截骨术治疗。若患者年龄大于50岁,可考虑工人全髋关节置换。对于不适宜截骨术治疗的髋臼发育不良伴较严重骨关节炎的中青年患者来说,缺乏比较好的治疗方法。
我们曾用血管植入术治疗股骨头坏死各期的中青年患者,对于晚期骨关节炎股骨头包容不好者,进行股骨头成形、髋臼造盖成形来改善包容。这联合术式达到了促进骨坏死的修复、预防关节脱位的目的,免除或延缓了人工全髋关节置换。我们将这联合术式结合服用中成药通络生骨胶囊用于成人髋臼发育不良伴骨关节炎的治疗,取得了良好效果。
本研究通过实验来调查通络生骨胶囊对兔全层膝关节软骨缺损修复的作用,通过临床观察来分析髋臼股骨头成形术结合通络生骨胶囊治疗成人髋臼发育不良的疗效机制,以此来判断这一方法是否能让髋臼发育不良伴较严重骨关节炎的中青年患者免除或延缓人工全髋关节置换。
研究方法:1.实验方面,建立新西兰兔膝关节髌股关节面直径为4mm,深5mm的全层关节软骨缺损模型。将50只兔分为通络生骨胶囊低、中、高剂量组,对照组(复方丹参片组)和模型组。造模后对照组给复方丹参片治疗,0.36g/kg/天,灌胃;低、中、高剂量组分别予药物通络生骨胶囊2g/Kg/天、4g/Kg/天和8g/Kg/天,灌胃。模型组不予任何药物。造模第12周处死动物,取材进行HE染色、甲苯胺蓝染色、苦味酸天狼猩红染色和扫描电镜检查,进行形态学观察,并按Wakitani法对修复组织进行组织学评分。
2.临床方面,从1997年1月至2003年1月采用髋臼股骨头成形术结合通络生骨胶囊治疗的89例(122髋)成人髋臼发育不良患者。其中,男9例,女80例,年龄18～65岁,平均47.1岁。发病时间最短为6个月,最长为35年,平均11.9年。平均随访3.8年(2-6年)。122髋中Crowe Ⅰ型84髋,Ⅱ型38髋。对髋关节骨关节炎的X线分期,采用Tonnis法,122髋中0期15髋,1期36髋,2期27髋,3期44髋。用髋关节百分法进行临床评估。测量X片上的关节间隙作为评估骨关节炎进展的指标,并测量术前和术后的股骨头覆盖率、Sharp角、CE角、股骨头中心高度和水平距离。
对骨关节炎0期和1期患者可只进行髋臼加盖成形术;对骨关节炎2期和3期
Objective : 5%~50% hip osteoarthitis is caused by developemental dysplasia of the hip. Secondary HOA, after DDH, is difficult to treat. Conservative treatments can not get good results. The Operation-treatment is necessary to DDH with clinical symptom. In accord to condition , shelf operation or sorts of osteotomies can be performed when patients have good joint congruency with preosteoarthritis or early osteoarthritis. Osteotomy is not suitable to bad joint congruency with severe osteoarthritis. THR can be considered to patients who are in his fifties. To young adults with severe OA, there are not good treatment.We had used blood vessels bundles implantion to treat young adults' ANFH. WE performed shelf operation when hip joint was subdislocation. The method could avoid or delay THR. We used this association precedure combining with TONG-LUO-SHENG-GU capsule to treat developemental acetabular dysplasia with OA, and got good results.To determine arthroplasty combining with TONG-LUO-SHENG-GU capsule whether let young adults with DDH avoid or delay THR, we investigated TONG-LUO-SHENG-GU capsule' s effect in helping full-thinkness articular cartilage defectness restore by experiment and the effect of arthroplasty combining with TONG-LUO-SHENG-GU capsule treating DDH by clicinical observation.Motheds: Experimentally, model was established by drilling a 4mm diameter, 5mm deep articular cartilage defectness in the trochlea groove of the New Zealand rabbits' right femoral. Fifty rabbits were divided into five groups: TONG-LUO-SHENG-GU capsule low dose group, middle dose group , high dose group, control group (complex dang-seng tablet group) and model group. Postoperativelly, control group was lavaged with complex dang-seng tablet, 0. 36g/kg/day;low dose group, media dose group and high
dose group were lavaged with TONG-LUO-SHENG-GU capsule, 2g/kg/day, 4g/kg/day, 8g/kg/day respectively;model group was not given any medicine.All rabbits were killed by twelve weeks after operation. The distal femoral portion was studied histologically using hematoxylin and eosin, toluidine blue, picric acid-Sirius red and scanning electron microscopy. Repairing tissues were analyzed using Wakitani' grading scale.Clinically, from January 1997 to January 2003, 89 patients (122 hips) with acetabular dysplasia were treated with the acetabulum and femoral-head-plasty combination with TONG-LUO-SHENG-GU capsule. Nine men and eigthty female, the mean age at the time of surgery was 47.1 years (range 18-65 years). Preoperatively, the average duration of the symptoms was 11.9 years (range 6months-35years). The average postoperative follow-up period was 3.8 years (range 2-6 years). According to Crowe classification, 84 hips belong to type I , 38 hips belong to type II. The HOA grade according to T6nnis radiographic classification, 15 hips belong to stage zero, 36 hips belong to stage one, 27 hips belong to stage two , 44 hips belong to stage three. Clinical manifestations were evaluated according to hip one hundred scores. The joint space was measured on radiographs as an index of the progression of osteoarthritis. At the same time, AHI, Sharp angle, CE angle, height and level distant of the femoral head were measured on radiographs. Preoperatively, average AHI was 63%. average Sharp angle was 46. 64° , average CE angle was 8.27° .Patients with OA stage zero or one, were performedacetabuloplasty(shelf operation);Patients with OA stage two or three , were performed femoral head and acetabular-plasty, multi-blood bundle implation, subchondral drilling. Postoperationly, tibial tubercle traction was continued. TONG-LUO-SHENG-GU capsule was administrated, 4# tid, P0;femoral quadriceps were exercised isometric contraction first day after operation. Patients with OA zero or one stage, were performed acetabuloplasty(shelf operation);Patients with OA two or three stage, were performed femoral head and acetabular-plasty, multi-blood bundle., implation, subchondral drilling. Postoperationly, tibial tubercle traction was continued. TONG-LUO-SHENG-GU capsule was administrated, 4# tid, PO;femoral quadriceps were exercised isometric contraction first day after operation. The third day, patients began to do hip' s extend-flexion
movement and gluteus medius' s traction exercises, meanwhile hip were given physical therapy. Leg-cover traction was substituted for the skeletal traction at six weeks post operation at night, and patients were allowed to walk with two crutchs if implanting shelf bone had gotten union. Gradually, patients were allowed to walk with part weight bearing after three months. When patients was walking forward and backward, two hips should abduct beyond himself shoulder' s breadth with toe ing-in, four times everyday, half an hour every time. Hip joint movements and muscles exercises were continued. AHI was 63% preoperatively and 100% postoperatively;Sharp angle was 46.64° preoperatively and 26.73° postoperatively;CE angle was 8.27° preoperatively and 58.82° postoperatively. Both of the horizontal distance and vertical distance of the femoral head between the supposed rotational center were decreased significantly after operation. All of patiens were performed shelf operation, only one shelf was broken and three shelf bones were absorbed more than 50% , there were not important vascular nerve complications postoperatively.Results: Experimentally, the diameter 4mm full-thickness defects in rabitts kness could not restore by itself. The complex dang-seng tablet could help the defects restore , there were fibrocartilage cells and hyaline cartilage cells in the repair tissues. Collagen in the repair tissues were I and II collagen. TONG-LUO-SHENG-GU capsule could prompt the defects' restore . The major components are hyaline cartilage cells and II collagens. The quality of rapair tissues is relative with dose, high dose group is best, but still different from normal hyaline cartilage.Clinically, most people were pain-free. Follow-up according to the hip one hundred scores, 35 hips was excellent (28.7%), 51 hips good (41.8%),27 hips fair (22.1%), 9 hips bad (7. 4%). Good rate of Crowe I was 75%, that of Crowe II was 60.5%;Good rate of early OA stage (zero and first stage) was 8$. 6% (44 hips in 52 hips), good rate of advanced OA stage (second and third stage) was 60% (42 hips in 70 hips).The post-operatively, average AHI was 100%, average Sharp was 26. 73° , average CE angle was 58.82° .The femoral head center was moved medially and joint space was increased.
Conclusion: The acetabulum and femoral-head-plasty could better the joint congruency. The biomechanical stess was dispersed, because joint contact area increased and the center of femoral head was moved medially. Implanting multiple blood vessels bundles could improve blood circulation of the femoral head, made osteocyst absorb, repaired subchondral bone, supported nourishment to cartilage, prevented cartilage degeneraion, delayed OA occurrence and progression. According high pressure in the bone decreasing, after implanting blood bundles and subchondral drill, pains of the hip were relieved. TONG-LUO-SHENG-GU capsule, subchondral drill, joint distraction and joint remodel movement could restore the degenerative articular cartilage.Crowe type land typeIIof adults DDH with advanced OA are desirable selection criteria. We hold that the treatment of the acetabulum and femoral-head-plasty combination with TONG-LUO-SHENG-GU capsule is a effective mothed to adults acetabula dysplasia. The procedure is simple and safe, can delay or avoid the total hip replacement.
我们曾用血管植入术治疗股骨头坏死各期的中青年患者,对于晚期骨关节炎股骨头包容不好者,进行股骨头成形、髋臼造盖成形来改善包容。这联合术式达到了促进骨坏死的修复、预防关节脱位的目的,免除或延缓了人工全髋关节置换。我们将这联合术式结合服用中成药通络生骨胶囊用于成人髋臼发育不良伴骨关节炎的治疗,取得了良好效果。
本研究通过实验来调查通络生骨胶囊对兔全层膝关节软骨缺损修复的作用,通过临床观察来分析髋臼股骨头成形术结合通络生骨胶囊治疗成人髋臼发育不良的疗效机制,以此来判断这一方法是否能让髋臼发育不良伴较严重骨关节炎的中青年患者免除或延缓人工全髋关节置换。
研究方法:1.实验方面,建立新西兰兔膝关节髌股关节面直径为4mm,深5mm的全层关节软骨缺损模型。将50只兔分为通络生骨胶囊低、中、高剂量组,对照组(复方丹参片组)和模型组。造模后对照组给复方丹参片治疗,0.36g/kg/天,灌胃;低、中、高剂量组分别予药物通络生骨胶囊2g/Kg/天、4g/Kg/天和8g/Kg/天,灌胃。模型组不予任何药物。造模第12周处死动物,取材进行HE染色、甲苯胺蓝染色、苦味酸天狼猩红染色和扫描电镜检查,进行形态学观察,并按Wakitani法对修复组织进行组织学评分。
2.临床方面,从1997年1月至2003年1月采用髋臼股骨头成形术结合通络生骨胶囊治疗的89例(122髋)成人髋臼发育不良患者。其中,男9例,女80例,年龄18～65岁,平均47.1岁。发病时间最短为6个月,最长为35年,平均11.9年。平均随访3.8年(2-6年)。122髋中Crowe Ⅰ型84髋,Ⅱ型38髋。对髋关节骨关节炎的X线分期,采用Tonnis法,122髋中0期15髋,1期36髋,2期27髋,3期44髋。用髋关节百分法进行临床评估。测量X片上的关节间隙作为评估骨关节炎进展的指标,并测量术前和术后的股骨头覆盖率、Sharp角、CE角、股骨头中心高度和水平距离。
对骨关节炎0期和1期患者可只进行髋臼加盖成形术;对骨关节炎2期和3期
Objective : 5%~50% hip osteoarthitis is caused by developemental dysplasia of the hip. Secondary HOA, after DDH, is difficult to treat. Conservative treatments can not get good results. The Operation-treatment is necessary to DDH with clinical symptom. In accord to condition , shelf operation or sorts of osteotomies can be performed when patients have good joint congruency with preosteoarthritis or early osteoarthritis. Osteotomy is not suitable to bad joint congruency with severe osteoarthritis. THR can be considered to patients who are in his fifties. To young adults with severe OA, there are not good treatment.We had used blood vessels bundles implantion to treat young adults' ANFH. WE performed shelf operation when hip joint was subdislocation. The method could avoid or delay THR. We used this association precedure combining with TONG-LUO-SHENG-GU capsule to treat developemental acetabular dysplasia with OA, and got good results.To determine arthroplasty combining with TONG-LUO-SHENG-GU capsule whether let young adults with DDH avoid or delay THR, we investigated TONG-LUO-SHENG-GU capsule' s effect in helping full-thinkness articular cartilage defectness restore by experiment and the effect of arthroplasty combining with TONG-LUO-SHENG-GU capsule treating DDH by clicinical observation.Motheds: Experimentally, model was established by drilling a 4mm diameter, 5mm deep articular cartilage defectness in the trochlea groove of the New Zealand rabbits' right femoral. Fifty rabbits were divided into five groups: TONG-LUO-SHENG-GU capsule low dose group, middle dose group , high dose group, control group (complex dang-seng tablet group) and model group. Postoperativelly, control group was lavaged with complex dang-seng tablet, 0. 36g/kg/day;low dose group, media dose group and high
dose group were lavaged with TONG-LUO-SHENG-GU capsule, 2g/kg/day, 4g/kg/day, 8g/kg/day respectively;model group was not given any medicine.All rabbits were killed by twelve weeks after operation. The distal femoral portion was studied histologically using hematoxylin and eosin, toluidine blue, picric acid-Sirius red and scanning electron microscopy. Repairing tissues were analyzed using Wakitani' grading scale.Clinically, from January 1997 to January 2003, 89 patients (122 hips) with acetabular dysplasia were treated with the acetabulum and femoral-head-plasty combination with TONG-LUO-SHENG-GU capsule. Nine men and eigthty female, the mean age at the time of surgery was 47.1 years (range 18-65 years). Preoperatively, the average duration of the symptoms was 11.9 years (range 6months-35years). The average postoperative follow-up period was 3.8 years (range 2-6 years). According to Crowe classification, 84 hips belong to type I , 38 hips belong to type II. The HOA grade according to T6nnis radiographic classification, 15 hips belong to stage zero, 36 hips belong to stage one, 27 hips belong to stage two , 44 hips belong to stage three. Clinical manifestations were evaluated according to hip one hundred scores. The joint space was measured on radiographs as an index of the progression of osteoarthritis. At the same time, AHI, Sharp angle, CE angle, height and level distant of the femoral head were measured on radiographs. Preoperatively, average AHI was 63%. average Sharp angle was 46. 64° , average CE angle was 8.27° .Patients with OA stage zero or one, were performedacetabuloplasty(shelf operation);Patients with OA stage two or three , were performed femoral head and acetabular-plasty, multi-blood bundle implation, subchondral drilling. Postoperationly, tibial tubercle traction was continued. TONG-LUO-SHENG-GU capsule was administrated, 4# tid, P0;femoral quadriceps were exercised isometric contraction first day after operation. Patients with OA zero or one stage, were performed acetabuloplasty(shelf operation);Patients with OA two or three stage, were performed femoral head and acetabular-plasty, multi-blood bundle., implation, subchondral drilling. Postoperationly, tibial tubercle traction was continued. TONG-LUO-SHENG-GU capsule was administrated, 4# tid, PO;femoral quadriceps were exercised isometric contraction first day after operation. The third day, patients began to do hip' s extend-flexion
movement and gluteus medius' s traction exercises, meanwhile hip were given physical therapy. Leg-cover traction was substituted for the skeletal traction at six weeks post operation at night, and patients were allowed to walk with two crutchs if implanting shelf bone had gotten union. Gradually, patients were allowed to walk with part weight bearing after three months. When patients was walking forward and backward, two hips should abduct beyond himself shoulder' s breadth with toe ing-in, four times everyday, half an hour every time. Hip joint movements and muscles exercises were continued. AHI was 63% preoperatively and 100% postoperatively;Sharp angle was 46.64° preoperatively and 26.73° postoperatively;CE angle was 8.27° preoperatively and 58.82° postoperatively. Both of the horizontal distance and vertical distance of the femoral head between the supposed rotational center were decreased significantly after operation. All of patiens were performed shelf operation, only one shelf was broken and three shelf bones were absorbed more than 50% , there were not important vascular nerve complications postoperatively.Results: Experimentally, the diameter 4mm full-thickness defects in rabitts kness could not restore by itself. The complex dang-seng tablet could help the defects restore , there were fibrocartilage cells and hyaline cartilage cells in the repair tissues. Collagen in the repair tissues were I and II collagen. TONG-LUO-SHENG-GU capsule could prompt the defects' restore . The major components are hyaline cartilage cells and II collagens. The quality of rapair tissues is relative with dose, high dose group is best, but still different from normal hyaline cartilage.Clinically, most people were pain-free. Follow-up according to the hip one hundred scores, 35 hips was excellent (28.7%), 51 hips good (41.8%),27 hips fair (22.1%), 9 hips bad (7. 4%). Good rate of Crowe I was 75%, that of Crowe II was 60.5%;Good rate of early OA stage (zero and first stage) was 8$. 6% (44 hips in 52 hips), good rate of advanced OA stage (second and third stage) was 60% (42 hips in 70 hips).The post-operatively, average AHI was 100%, average Sharp was 26. 73° , average CE angle was 58.82° .The femoral head center was moved medially and joint space was increased.
Conclusion: The acetabulum and femoral-head-plasty could better the joint congruency. The biomechanical stess was dispersed, because joint contact area increased and the center of femoral head was moved medially. Implanting multiple blood vessels bundles could improve blood circulation of the femoral head, made osteocyst absorb, repaired subchondral bone, supported nourishment to cartilage, prevented cartilage degeneraion, delayed OA occurrence and progression. According high pressure in the bone decreasing, after implanting blood bundles and subchondral drill, pains of the hip were relieved. TONG-LUO-SHENG-GU capsule, subchondral drill, joint distraction and joint remodel movement could restore the degenerative articular cartilage.Crowe type land typeIIof adults DDH with advanced OA are desirable selection criteria. We hold that the treatment of the acetabulum and femoral-head-plasty combination with TONG-LUO-SHENG-GU capsule is a effective mothed to adults acetabula dysplasia. The procedure is simple and safe, can delay or avoid the total hip replacement.
引文
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