| Background:Osteonecrosis of the femoral head(ONFH)is a common disease in orthopedics.The effect of conservative treatment of this disease is poor,and there is a high rate of disability.OFNH in the middle or late stages will cause serious hip joint dysfunction,and there is atheory that it is animmortal cancer.For patients with ONFH in the early or middle stages,《 Chinese guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults(2020)》 recommend the use of core decompression and bone transplantation with or without vascularized for hip conservation treatment.Among them,free vascularized fibular grafting(FVFG)has a definite curative effect and has become the treatment method explicitly recommended in this guideline.The ascending branch of the lateral femoral circumflex artery is traditionally used as the donor vessel in the treatment of ONFH with FVFG.The ascending branch of the lateral femoral circumflex artery provides part of the blood supply to the femoral head and neck.In order to avoid further damage to the blood supply of the femoral head,we developed an modified surgical method based on the application of FVFG in the treatment of ONFH of Urbaniak in Duke University.The main content of the improvement is to use the descending branch of the lateral femoral circumflex artery as the donor vessel.The descending branch of the lateral femoral circumflex artery does not provide blood supply to the femoral head,in this way,the ascending branch of the lateral femoral circumflex artery will not be damaged,and the blood supply of the femoral head can be maximally preserved.When the author’s team used modified FVFG to treat ONFH in the early stage,it was found that the established bone tunnel could not completely match the fibular flap,it was difficult to remove the necrotic bone in the necrotic area of the femoral head,there was serious loss of normal bone in the traditional bone tunnel preparation process,and there was no effective special bone graft equipment in the operation.Therefore,based on years of experience of FVFG in treating ONFH,to solve the above problems,the fibular flap was anatomically measured and studied,and a set of bone collector(patent No.ZL2017 2 1093587.0)was designed and applied to 18patients(20 hips)who were treated with modified FVFG from October 2011 to November 2018.Purpose of research:To explore the clinical application and effect of self-developed bone collector in the treatment of ONFH with modified FVFG.Research methods:The author’s team designed the femoral tunnel bone collector based on the anatomical measurement data of the fibular valve diameter.Methods: In the Huahai Medical Image Archiving and Communication System(Med PACS5.0)of our hospital,60 cases of adult lower leg CT plain scanning+3D reconstruction images were randomly selected.The axial images of the fibula at 11 cm,16cm and 21 cm below the tip of the fibular head were selected respectively.Take the three vertices of the cross section of the fibula triangle as the external circle.The diameter of the circumscribed circle was measured by the system software.SAS 9.4 software was used to calculate the mean value of the axial circumscribed circle diameter of the three planes of the fibula,expressed as mean ± standard deviation.Results: The axial circumscribed circle diameters of 11 cm,16 cm and 21 cm under the tip of the fibular head were14.47 ± 1.52,14.80 ± 1.74 and 14.52 ± 1.69 respectively.0.5~1mm thick periosteum is generally left after the fibular flap is cut.So the bone collector designed according to the measurement results includes three kinds of outer diameters of 13,15 and17mm(see Chapter 3 for the specific design scheme).During the operation,according to the maximum diameter of the fibular flap,a suitable model of bone collector can be selected to establish the femoral bone tunnel.Retrospective analysis was made on 18 patients(20 hips)with ONFH admitted to the PLA Rocket Force Characteristic Medical Center from October 2011 to November 2018.According to the ARCO staging criteria: 9 hips were in Phase II,9 hips were in Phase III,and 2hips were in Phase IV.The femoral neck tunnel was prepared with the self-developed bone collector,and the modified FVFG was used to treat ONFH.Harris score was used to evaluate surgical treatment.The Harris score form was composed of four parts:pain,function,limb deformity,and range of motion of joints.The total score of Harris was 100 points,90~100 points were excellent,80~89 points were good,70~79 points were fair,and<70 points were poor.Harris score before and after the operation was expressed as mean ± standard deviation.T-test was used for analysis(p<0.05).All data analyses were performed with SAS 9.4 software.Results:1.According to the anatomical measurement of fibular flap,we designed and manufactured bone collector of 13,15 and 17 mm in diameter.The position of the femoral head necrosis area and the measurement results of the femoral neck diameter and fibular flap diameter can be determined according to the preoperative image data.During the operation,the appropriate type of bone collector can be selected to accurately prepare the bone tunnel.2.According to the preoperative imaging data,under the X-ray fluoroscopy of C-arm,the bone collector can accurately reach the necrotic bone area of the femoral head under the positioning and guidance of the guide needle for accurate removal of necrotic bone tissue.3.The main part of the bone extractor is a cylindrical hollow drill bit.While preparing the bone tunnel,it can completely remove and use the normal bone beyond the necrosis area,avoiding the loss of normal bone caused by the traditional head pulp nail drill bit drilling bone into bone mud,and providing sufficient autologous bone graft materials for the next bone graft.4.The bone collector is equipped with an inner core matching its inner diameter.After the bone tunnel is established,the bone in the bone collector can be completely removed by pushing the inner core with a matching push rod.Similarly,bone graft can be accurately implanted into the load-bearing area under the femoral head.5.All patients were followed up for 21~62 months,with an average of 39 months.The Harris score of the hip joint of 18 patients(20 hips)was 78.60 ± 9.19 points before surgery.The operation time was 280~670 min,with an average of 381 min.The amount of bleeding during the operation was 200~800 ml,with an average of 450 ml.One patient suffered from sinus and tissue necrosis after surgery,and was cured after multiple debridements.The rest of the patients had Class A healing.The postoperative X-ray film showed that the position of the fibular flap was good.The last follow-up showed that the bone healing was achieved.The degree of femoral head necrosis improved in 15 hips,4 hips without progress,1 hip with progress,and the effective rate was 95%.Harris score was 89.05 ± 6.51 points at the last follow-up,and the excellent and good rate was 90%.The hip joint pain and joint mobility were improved to varying degrees,with a statistically significant difference compared with that before surgery(t=4.19,P=0.0005).Conclusions:Using self-developed bone collector,we can prepare the femoral neck tunnel and remove necrotic bone tissue accurately.It can also reduce bone waste,and facilitate bone grafting of the femoral head.It can help surgeons performing modified FVFG to treat ONFH. |
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