Objective:To analyze the predictive value of enhanced MRI in the outcome of prolapsed and sequestrated lumbar disc herniation through a retrospective analysis.Methods:A retrospective analysis of the data of 64 patients with prolapsed and sequestrated lumbar disc herniation from January 2015 to December 2018, including 38 males and 26 females; age 35.72±12.44 years (range, 22-64 years) ; 43 cases of prolapsed type, 21 cases of sequestrated type. Conservative treatment was the first choice for all patients, in case of surgical indications during the treatment, percutaneous endoscopic lumbar discectomy or fenestration discectomy will be performed. Enhanced MRI was performed at the first and last inspections, the volume of the protrusion, the thickness of rim enhancement (Tr), and the extent of rim enhancement (Er) were measured and calculated at the same time. According to the ring around the protrusion, the size of the rim-enhancement area was divided into type I-III; then compared the relationship between the rim-enhancement signal differentiation and the resorption rate of protrusions, and the correlation between Tr, Er values and the resorption rate of protrusions during the initial inspection.Results:Among the 64 patients, 42 patients completed conservative treatment, and 22 received surgical treatment. According to the rim-enhancement signal differentiation, 23 cases were treated conservatively for type I, 3 cases were treated by surgery; 16 cases were treated for type II conservatively, 7 cases were treated by surgery; 3 cases were treated for type III conservatively, and 12 cases were treated by surgery. All patients were followed up for 12 to 34 months. Among 42 conservatively treated patients, The volume of the protrusion before treatment was 2 645.67±690.86 mm 3, and the volume of the protrusion after treatment was 842.76±573.35 mm 3. The volume of protrusions before and after treatment was statistical significance ( t=11.897, P<0.001), Tr was 1.38±0.83 mm, and Er was 73.08%±34.39%, the resorption rate of protrusions was 65.10%±24.50%, and 39 cases (92.86%, 39/42) reached the standard for protrusion resorption (resorption rate ≥30%); 23 cases of type I , the resorption rate was 76.54%±18.62%; 16 cases of type II had an resorption rate of 56.81%±21.44%; 3 cases of type III had an resorption rate of 21.58%±12.19%. The resorption rate of type III were compared by single factor analysis of variance, and the difference was statistically significant ( F=12.885, P<0.001); 32 cases of both type I and II (82.05%, 32/39) had significant resorption (resorption rate ≥50%), and no case of type Ⅲ had significant resorption, comparing with type I and II, the difference was statistically significant ( P=0.010); Tr was positively correlated with resorption rate ( r=0.569, P<0.001), Er was positively correlated with resorption rate ( r=0.677, P<0.001). Conclusion:Under close clinical observation, parts of the prolapsed or sequestrated lumbar disc herniations can be conservatively treated, and the herniated disc can be resorption in many people and the clinical symptoms were alleviated. Rim-enhancement signal differentiation by enhanced MR has a better predictive value for the outcome of the herniation, type I is more prone to resorption, preferred conservative treatment, type Ⅲ is not easy to resorption, preferred surgery treatment, and the higher thickness of rim enhancement, the greater extend the rim-enhancement, the more prone to resorption phenomenon.

OBJECTIVE:To explore the risk factors of osteonecrosis of femoral head after internal fixation of femoral neck fracture in young patients, to describe the quality of life of patients with surviving femoral head, and to quantify the predictive factors. METHODS:From January 2013 to December 2016, 172 patients (174 hips) with femoral neck fracture treated by closed reduction and cannulated screw internal fixation were selected for retrospective analysis. The general data of the patients were summarized, including age, gender, body mass index, trauma mechanism, trauma operation interval, trauma season and whether the internal fixation was removed. The imaging data included the Garden classification and Pauwel classification of fractures, femoral head retroversion angle, postoperative fracture reduction, screw distribution. Single factor analysis and multi-factor Logistic regression analysis were carried out to explore the risk factors of femoral head necrosis and internal fixation failure. The patients who survived the internal fixation were followed up. The quality of life of the patients was evaluated by the health survey of SF-36. The Harris score of hip joint function was used to evaluate the hip joint function. The predictors of the quality of life of the patients after the operation of femoral neck fracture were analyzed by multiple linear regression analysis. RESULTS:Total 172 patients(174 hips) were included in the study, 29 patients(16.67%) had necrosis of the femoral head. In multivariate Logistic regression analysis, the significant differences were reduction quality (OR=0.126, P=0.027) and posterior inclination angle (OR=4.380, P=0.010). One hundred and thirty six patients (137 hips) who survived the femoral head were included in the quality of life survey. Harris score was 90.14±7.92, including excellent 96 hips (70.07%), good 28 hips (20.44%), medium 13 hips (9.49%) and poor 0 hip. In SF-36 score, physical health summary (PCS) was 46.12±9.12, mental health summary(MCS) was 50.21±3.97, there was no linear correlation between them (P>0.05). In multiple linear regression analysis, the variables with significant difference in PCS were reduction quality and retroversion angle, and the variables with significant difference in MCS were fracture displacement and trauma mechanism. CONCLUSION:Poor reduction quality and posterior inclination angle>15° are the risk factors of femoral head necrosis. The function of hip joint and MCS of patients with femoral neck fracture recovered well, but PCS could not recover to the average level of normal people. The reduction quality and retroversion angle could be used as the predictors of PCS, and the displacement and trauma mechanism of fracture could be used as the predictors of MCS.

目的 分析股密葆干预治疗股骨颈骨折的临床疗效.方法 选取2017年1月～2018年3月我科收治住院的接受闭合复位空心钉内固定手术的肾虚血瘀型股骨颈骨折患者48例,采用随机数字表法分为对照组和治疗组,每组24例.对照组行闭合复位空心拉力螺钉内固定术,治疗组在对照组基础上于术后1周口服股密葆方.比较两组骨折愈合时间,术后6个月和12个月Harris评分、PCS和MCS得分,术后12个月股骨颈短缩情况,以及末次随访时步行能力,评价两组治疗方法的优劣.结果 治疗组平均骨折愈合时间为(5.00±2.39)个月,短于对照组的(6.72±3.18)个月,差异具有统计学意义(<0.05).两组术后6个月和12个月Harris评分、术后6个月PCS和MCS得分、术后12个月MCS得分比较,差异无统计学意义(>0.05);术后12个月,治疗组PCS得分高于对照组(<0.05).两组术后12个月时股骨颈短缩情况以及末次随访时步行能力比较,差异无统计学意义(>0.05).结论 股密葆方干预治疗股骨颈骨折短期疗效显著,可促进骨折愈合、改善患者术后12个月关节功能及生理功能.

OBJECTIVE:To observe clinical efficacy of Yishen Huoxue decoction(YSHXD) for the treatment of non-traumatic osteonecrosis of femoral head at early and middle stage. METHODS:From January to June 2016, 69 patients (72 hips) with non-traumatic osteonecrosis of femoral head at early and middle stage were divided into treatment group and control group according to therapeutic methods. In treatment group, there were 35 patients 43 hips, including 15 males and 20 females, aged from 28 to 62 years old with an average of(41.80±11.03) years old, 6 hips were at the stage I, 27 hips were at the stageII, 10 hips were at the stage IIIa according to ARCO classification; and treated by using YSHXD, one dose a day for 12 months. In control group, there were 34 patients 39 hips, including 16 males and 18 females, aged from 31 to 61 years old with an average of (43.35±13.52) years old, 5 hips were at the stage I, 26 hips were at the stageII, 8 hips were at the stage IIIa according to ARCO classification; and treated by using alendronate sodium tablets 70 mg every week for 12 months. Preoperative and postoperative HSS score at 2 weeks were observed and compared, EQ-5D index was used to compare clinical effects. ARCO classification was applied to imaging evaluation, the stage of ARCO over IIIa was considered as end point of observation. The final following-up time and ARCO classification were recorded and performed Kaplan-Meier survival analysis. RESULTS:All patients were followed-up from 26 to 76 months with an average of(43.50±13.26) months. Postoperative Harris score at 2 years in treatment group (84.92±7.56) was higher than that of before treatment (73.58±10.02) (P<0.05), and higher than that of control group(79.61±10.92)(P<0.05), especially the scores of joint function and activity were higher than those of control group(P<0.05). EQ-5D index in treatment group 0.66±0.12 was higher than that of control group 0.59±0.12(P<0.05). Nine hips were collapsed in treatment group at final follow-up, and 10 hips were collapsed in control group, and had no statistical difference between two groups (P>0.05). There was no statistical difference in kaplan-meier survival analysis curves between two groups (P>0.05). There were statistical difference in survival rate between the early, middle ARCO stage and different Harris evaluation. CONCLUSIONS:YSHXD for the treatment of non-traumatic osteonecrosis of femoral head at early and middle stage has obviously clinical effects, could improve hip joint function, and quality of life, and delay the process of femoral head necrosis collapse.

股骨头坏死(Osteonecrosis of the Femeral Head,ONFH)是骨科常见疾病之一,早中期ONFH若不积极治疗将进一步导致关节间隙丢失、继发性骨关节炎、塌陷等,引起患髋疼痛强直.坏死股骨头塌陷源于受累区域骨组织生物应力减弱,一旦发生塌陷,预后较差,较塌陷前相比,治疗手段将更为局限且有创伤性.特别对较年轻患者,应首先尽可能考虑保髋治疗,本文就有关文献对此作一概述.

股骨头无菌性坏死是骨科常见疾病之一,多见于髋部外伤、长期大量使用皮质类固醇、酗酒、潜水员减压病、系统性红斑狼疮、血红蛋白病等患者,早中期股骨头无菌性坏死进一步发展将导致关节间隙丢失、继发性骨关节炎、塌陷等,引起患髋疼痛强直,一旦发生塌陷,预后较差,治疗也很棘手,因此,积极防治早中期股骨头无菌性坏死意义重大.苏州市中医医院姜宏教授运用益肾活血方股密葆治疗早中期股骨头无菌性坏死取得良好疗效.笔者有幸跟师学习,受益匪浅,现将姜教授临证经验总结如下.