The Evaluation Of Mid-term Followup Curative Effect And Biomechanics Analysis Of ARCO Ⅲ Osteonecrosis Of The Femoral Head Treated With The Joint-preserving Therapy

Background:The femoral head of Osteonecrosis of Femoral Head (ONFH) patients had often collapsed at first clinical visit for doctor as limited of economy, medicine development level and public treat consciousness in China now. The mainstream view of modern medicine thought that the joint-preserving therapy would very difficult and the only definite effect of treatment methods was Hip Joint Replacement if the femoral head had collapsed.But they would endured multiple replacement risks and Higher financial burden in their life if they would had got replacement,because ONFH multipled in young and middle-aged.So,if joint-preserving therapy could treated successfully ONFH,it would had important clinical value and scientific value,as still accorded with the present condition of our country.But the effectiveness of joint-preserving therapy was always disputed because all kinds of one lacked convincing evidence,especially mid-term and long-term followup clinical imformation. This outcome had affected directly skill develop of joint-preserving,even induced gradually declining of jont-preserving for collapsed ONFH.There was about 10 years when it treated ONFH with the improved Minimally Invasive surgery of core-decompression and support bone grafting and traditional Chinese medicine (TCM) which was found by Department of Arthrosis Surgery of the 1st affiliated hospital of GuangZhou University of Traditional Chinese Medicine.It was necessary to evaluate mid-term curative effect of above one and make biomechanical analysis for the theory of preventing second collapse with the improved Minimally Invasive surgery of core-decompression and support bone grafting.Objective:In the first section,to evaluate mid-term curative effect of ARCO III (collapsed) ONFH which was treated with the improved Minimally Invasive surgery of core-decompression and support bone grafting and traditional Chinese medicine (TCM).To discuss the relativity of joint-preserving prognosis and Multiple Factors (different pathogeny,necrosis area,necrosis position,the pretreatment anteroposterior x-ray view classification, flog leg x-ray view classification, pretreatment collapse degree of the femoral head.course, classification of bone marrow edema and classification of femoral head bone lateral wall of integrity) and to evaluate joint-perserving efficiency. To analys the theory of preventing second collapse with the improved Minimally Invasive surgery of core-decompression and support bone grafting by stress study. In the second section.to establish three-dimensional finite element models based on individual patient's CT and MRI data,performed surgical simulative operation.loaded stress and then made the biomechanical analysis. The purpose of second section was to verify the instability pathological characteristics of inside of femoral head of ONFH through biomechanical simulative study and to test the biomechanical efficiency of the operation.Through above study,we could provided clinical and biomechanical theory evidence for the joint-perserving therapeutic plan.and illustrated the idea and double importance of combine Biological repair and mechanical repair.Method:In the retrospective study,all ARCO III ONFH patients who were performed with the improved Minimally Invasive surgery of core-decompression and support bone grafting and TCM in Department of Arthrosis Surgery of the 1st affiliated hospital of GuangZhou University of Traditional Chinese Medicine were recruited strictly in the light of diagnosis criteria.bringing into criteria and excluding criteria devised in the project between January 2004 and September 2007. Finally we had got 83 cases(101 hips) which fulfilled the criteria above. there were 76 cases(93 hips) which were followed up successfully in 83 cases(101 hips)which fulfilled the criteria above and 7 cases(8 hips) which were loss of follow-up.The follow-up rate was 91.6%.Among 76 cases, there were male 63 cases(78 hips.83.9%), female 13 cases(15 hips,16.1%), left lateral 34 hips(36.6%),right lateral 59 hips(64.3%), alcohol-induced ONFH 43 cases(52 hips,55.9%),steroid-induced ONFH 28 cases(34 hips,36.6%) and idiopathic ONFH 5 cases(7 hips,7.5%). Their average age was 36.5 years old(18-56). All patients'general information, pathogeny, necrosis area,necrosis position, the pretreatment anteroposterior x-ray view classification, flog leg x-ray view classification,pretreatment collapse degree of the femoral head,course, classification of bone marrow edema.classification of femoral head bone lateral wall of integrity, pretreatment Harris score, post-treatment Harris score,post-treatment iconography score and post-treatment clinical comprehensive score were all registered detailedly and evaluated the curative effect.After that,put data into the statistical software SPSS 16.0 to analyse the results. The termination of Kaplan-Meier survivorship analysis is defined as hip Joint Replacement.The section two was to establish three-dimensional finite element models based on individual patient's CT and MRI DICOM format data, extracted the data,performed surgical simulative operation,loaded stress, came to data and graphical results and then made a conclusion.Findings:Finally,The average clinical follow-up time of all patients was 68.5 months(42～84 months),all of which was above 3.5 years at least.The average iconographic follow-up time was 48.1 months(36～77 months).1.At the end-point of follow-up,there were 11 cases(12 hips) which had been performed hip joint replacement.The survival rate of femoral Head was 87.1%.The average survival time of femoral head was 64.13 months(7-84 months).2. For 81 hips which were preserved the femoral head at the end-point of follow-up,there was positive statistical significance through paired T test(P<0.01).The result revealed there was different between pretreatment Harris score with post-treatment Harris score,and post-treatment Harris score was obviously higher than pretreatment.3. For 81 hips which were preserved the femoral head at the end-point of follow-up,their average of post-treatment clinical comprehensive score was 87.4(33.4～100),and the fine rate of one was 84.0%(68 hips/81 hips) 4. Among 81 hips which were preserved the femoral head at the end-point of follow-up, it was negative statistical significance for the fine rate of clinical comprehensive score of different grade or class of the multiple Factors through chi-squared test. In this group research data, shows that these factors also not thought their different grade or class would make a different post-treatment clinical comprehensive curative effect.5. Except of pretreatment collapse degree of the femoral head,it has negative statistical significance for the correlativity study between the multiple factors and prognosis through Cox regression analysis.It was said collapse degree was a risk factor related to prognosis.The greater collapse degree was,the more bad prognosis was.6. Except of the pretreatment anteroposterior x-ray view classification and classification of femoral head bone lateral wall of integrity,it has negative statistical significance for the correlativity study between the multiple factors and post-treatment clinical comprehensive score through Spearman correlation study.The closer to outboard of necrosis site in the pretreatment anteroposterior x-ray view classification(C2>C1>B) was,the more bad the score was.The more complete femoral head bone lateral wall was,the higher the score was.7. It has all negative statistical significance for the comparative analysis between different grade or class of the multiple factors and post-treatment survival rate of femoral head (success or not of joint-preserving)through chi-squared test.8. It has all negative statistical significance for the comparative analysis between different grade or class of the multiple factors and post-treatment prognosis of femoral head survival through Kaplan-Meier method and log-rank test when compared to each other.9. Outcome about Syndrome and type Differentiation of TCM study:Qi Stagnation and Blood Stasis type 43 hips, Arthralgia due to wind cold-dampness type 24 hips. Phlegm-dampness type 19 hips, Hepatic and renal insufficient type 7 hips and Qi and blood weak type 0 hips. It was negative statistical significance for the fine rate of clinical comprehensive score of different Syndrome and type Differentiation of TCM through chi-squared test. It was positive statistical significance for the grade of post-treatment Harris score of different Syndrome and type Differentiation of TCM through chi-squared test. It has negative statistical significance for the comparative analysis between different Syndrome and type Differentiation of TCM and post-treatment prognosis of femoral head survival through Kaplan-Meier method and log-rank test.10. Outcome of stress studyrit was showed that the collapse risk of necrosis region of loaded parts of femoral head was significantly reduced by simulating the improved Minimally Invasive surgery of core-decompression and support bone grafting.The DXM(MAXIMUM DISPLACEMENT) was changed from preoperative 0.353E-06mm to postoperative 0.440E-06mm,but the site of DXM was moved from necrosis region of loaded parts of femoral head to region of femoral subtrochanteric and femoral neck base. The SMX(MAXIMUM STRESS) was reduced significantly from preoperative 64.308 Mpa to postoperative 5.424 MPa and the major principal stress was reduced from preoperative 99.828 Mpa to postoperative 5.519 MPa on equivalent stress diagram.The site of stress concentration was moved from necrosis region of loaded parts of femoral head to region of femoral subtrochanteric and femoral neck base.Conclus ion:1. All kinds of instability pathological characteristics inside of femoral head after collapse was the important pathological changes of characteristics of ARCO III ONFH.2. It had got a satisfactory mid-term followup curative effect above 5.5 years(clinical average followup time) to treat ARCO III ONFH with the improved Minimally Invasive surgery of core-decompression and support bone grafting and TCM.3. The joint-preserving therapy which was the improved Minimally Invasive surgery of core-decompression and support bone grafting and TCM established new therapy mode which could promoted necrosis repair by combining surgery with TCM.local with overall, correcting collapse with improving instability pathological characteristics inside of femoral head.4. The surgery of core-decompression and support bone grafting and TCM was not appropriate to all of ARCO III ONFH.It would be accord to the therapy principle of individual. There were close relations between the classification of femoral head bone lateral wall of integrity and prognosis of ONFH.5. It was showed that the collapse or collapse increase risk of necrosis region of loaded parts of femoral head was significantly reduced by simulating the improved Minimally Invasive surgery of core-decompression and support bone grafting.The surgery operation could reduce and disperse abnormal concentrated stress on necrosis region of loaded parts of femoral head of ONFH,and reconstruct normal stress distribution of femoral head,and provide stabile and appropriate mechanical environment for biological repair.It was conducive to prevent or decrease collapse again.