| Objective:1.The Finite Element Analysis(FEA)was applied to evaluate the biomechanical conditions of normal hip model,the pre-and post-operative model of bone grafting and fibular support by decompression of femoral head core,and the pre-and post-operative model of femoral head neck fenestration and bone grafting.2.Through animal experiment,the mechanism of Bushen Huoxue Decoction in the treatment of femoral head necrosis was explored.3.By retrospective study,to comprehensively evaluate the clinical efficacy of various hip-preserving surgical methods combined with Bushen Huoxue Decoction,and to assess the effect of various factors on the prognosis of hip-preserving surgery,and guide the selection of clinical individualized surgical plan.Methods:1.The raw data of CT and MRI before and after the operation of normal hip joint and femoral head core decompression and compression of bone graft fibula support,and the operation of femoral head neck fenestration and bone removal and compression of bone graft were imported into modeling software.Through 3D modeling,geometric modeling,structural gridding and finite element material assignment,five 3D finite element models were established and analyzed.The main indicators are:1.Stress situation of hip joint at 0°,30° and 60° of flexion:(a)Mises distribution map and stress peak in subchondral bone region of hip joint;(b)Mises distribution diagram and stress peak in necrotic area;(c)Mises distribution diagram and stress peak in the neck junction region of femoral head;(d)Mises distribution plot of lateral femoral shaft region(surgical core decompression opening)and stress peak 2.Maximum subchondral bone displacement value on femoral head surface.2.By using horse serum combined with dexamethasone to establish early rabbit model of osteonecrosis of femur,12 rabbits were randomly divided into two groups:Bushen Huoxue Decoction group and control group,and 6 rabbits of the same batch were selected as blank group.After 6 weeks of drug intervention,the basal metabolic rate and trabecular density were measured,and the cells in femoral head were stained with HE staining,MASSON staining,TRAP staining,and immunohistochemical analysis of vascular endothelial growth factor were performed to observe the early intervention effect of Bushen Huoxue Decoction on femoral head necrosis in rabbits.3.From January 2009 to December 2016,218 patients(292 hips)who met the inclusion criteria and 166 patients(210 hips)who were successfully followed-up were selected as the patients with pericollapse femoral osteonecrosis treated with traditional Chinese medicine decoction assisted by hip surgery.Among them,92 patients(126 hips)who underwent femoral head core decompression and compression bone grafting and fibula support,25 patients(29 hips)who underwent head and neck fenestration and 19 patients(21 hips)who underwent head and neck fenestration and removal of dead bone graft.18 patients(20 hips)of head and neck fenestrations were treated with bone grafting with large trochanteric flap of lateral circumflex artery,and 12 patients(14 hips)of surgical dislocation of head and neck fenestrations were treated with bone grafting.The average clinical follow-up time of all patients was 58.5 months(30-92 months).All patients were followed up for more than 2.5 years.The preoperative and high-risk factors were recorded.The preoperative and postoperative Harris scores and radiographic evaluation were recorded and compared for efficacy analysis.The overall survival rate,the survival rate of each operation and the factors affecting the survival rate were evaluated with joint replacement as the end point event.Results:1.In five models,the maximum stress area of the subchondral bone is at the top of the femoral head.With the degree of flexion of hip joint from o0°to 30°-60°,the stress of subchondral bone gradually increases.After femoral head necrosis,the maximum Mises stress of subchondral bone in the weight-bearing region of femoral head was significantly higher than that of normal femoral head at 0°,300°and 600°of flexion.The femoral head core was used to decompress and compress the bone graft and fibular support,and the head and neck fenestration lesion was removed and impacted bone graft was performed.The maximum Mises stress decreased significantly at 0°,30°and 600°of flexion compared with that before operation.The maximum Mises stress in the necrotic area was significantly lower than the normal femoral head at 0°,30°,and 600°of flexion after both hip preservation procedures.The maximum Mises stress at the head and neck junction of the precore decompression model was lower than that of the normal model,the maximum Mises stress at 0°,30° and 60° of flexion after operation was higher than that before operation,and the maximum Mises stress at the head and neck junction of the precore decompression model was higher than that of the normal model.The maximum Mises stress decreased at 0°,30°,and 600°of flexion postoperatively.The maximum subchondral bone displacement at the femoral head surface decreased at 0°,30°,and 600°of flexion compared with that before surgery.2.After the successful model intervention,the basal metabolic rate variables,trabecular bone density under HE staining,bone mass under CT and osteogenic activity under MASSON staining in the Bushen Huoxue decoction group were higher than those in the control group,and the difference was statistically significant(P<0.05).However,TRAP staining had the lowest osteoclastic activity in the blank group.The results of VEGF immunohistochemistry showed that the vascular regeneration ability of Bushen Huoxue Decoction group was significantly higher than that of the blank group and the control group,and the difference had statistical significance(P<0.05).3.After five kinds of hip-preserving surgery combined with Bushen Huoxue Decoction:(1)the postoperative Harris scores of the patients were significantly superior to the preoperative scores,and the differences had statistical significance(P<0.05).The postoperative imaging score of patients was significantly better than the preoperative score,and the difference had statistical significance(P<0.05);The comprehensive score of patients after operation was significantly improved compared with that before operation,and the difference had statistical significance(P<0.05).2.The survival rate of femoral head was calculated by using joint replacement as the end point.The suirvival rate of femoral head was 85.2%in 25 patients who underwent TFHA.The correlation study(Spearman’s correlation analysis)showed that JIC classification(r=-0.348,p<0.05)There was correlation with clinical composite score after hip-preserving treatment.(3)In the multi-factor analysis(COX analysis)of the femoral head core decompression and compression of the bone graft fibula support with artificial joint replacement as the endpoint event,the Wald x2 of the variable degree of collapse was 2.142,p=0.026<0.05,which was statistically significant;In the multi-factor analysis(COX analysis)of femoral head neck fenestration and bone removal and compression grafting with artificial joint replacement as the endpoint,the Wald x2 of variable JIC was 4.652,p＝0.025<0.05,which was statistically significant;In a multivariate analysis (COX analysis)of bone flap grafting with sartorius muscle in the neck and head fenestrations with artificial joint replacement as the endpoint,the Wald x2 of variable JIC was 3.845,p＝0.036<0.05,which was statistically significant.The variable lateral wall integrity Wald x2 was 2.362,p＝0.046<0.05,which was statistically significant.In a multivariate analysis(COX analysis)of cervical and cervical fenestrations treated with artificial joint replacement as the endpoint,the Wald x2 of variable degree of collapse was 4.669,p = 0.035<0.05,which was statistically significant.There was no statistically significant difference in the factors influencing the multifactorial analysis(COX analysis)of the surgical dislocation head and neck fenestrations for bone removal and compression grafting with artificial joint replacement as the endpoint(p>0.05)Conclusion:1.By means of modeling software,pre-treatment software and Finite Element Analysis(FEA)software,five states of normal femoral head and femoral head were established,which were preoperative and postoperative,fenestration of head and neck and compression of bone graft.The model is proved to be reliable.2.By means of the Finite Element Analysis(FEA)of five models,including normal model,femoral neck core decompression and compression bone graft fibula support before and after operation,and head and neck fenestration cleaning and compression bone grafting before and after operation,proved that at each angle of 0°,300°and 600°of hip joint flexion,the stress conduction and displacement of hip joint were improved after two kinds of hip protection methods,which proved that two kinds of hip protection methods had good mechanical recovery effect on femoral head necrosis.3.Femoral neck core decompression and bone grafting and fibular support were safe and reliable in the treatment of femoral head necrosis,and there was no disruption of normal cortical bone conduction at the direct operation site.4.Bushen Huoxue Decoction can increase the basal metabolic rate and trabecular density of rabbit femoral head necrosis model,and also can improve the regeneration and repair ability of blood vessels in femoral head.5.Five kinds of hip-preserving surgeries(femoral head core decompression and compression bone grafting and fibular support,femoral head and neck fenestration and removal of dead bone graft and head and neck fenestration and removal of dead bone graft and bone flap grafting with sartorius muscle.In combination with Bushen Huoxue Decoction for the treatment of femoral head necrosis in the early and mid-term,the clinical efficacy and radiological changes were improved significantly compared with those before operation.6.There was no significant difference in survival and prognosis between different hip-preserving surgery groups.Among the influencing factors,JIC classification and lateral wall integrity grading before treatment were the important factors affecting clinical comprehensive score.The degree of collapse affects the survival rate of femoral head after decompression of femoral head core and compression of bone graft and fibula support;JIC type affects the survival rate of femoral head after bone removal and compression grafting in the neck of femoral head;JIC type and lateral wall integrity influence the survival rate of femoral head after bone removal and compression grafting with sartorius muscle flap in head and neck fenestrations.The degree of collapse affects the survival rate of head and neck fenestrations for the removal of dead bone and compression grafting of greater trochanter bone flap with transverse branch of lateral circumflex artery. |
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