基于X线片建立股骨头坏死新分型体系的临床意义

doi:10.3877/cma.j.issn.1674-134X.2018.06.019

目的

观察围塌陷期股骨头坏死在影像学上的表现形式，进行分类总结。

方法

选择在广州中医药大学第一附属医院确诊为围塌陷期股骨头坏死且有完整影像资料的患者，排除髋部有先天畸形或有影响髋关节功能的疾病等。在双侧髋关节标准正位片上观察股骨头坏死硬化带的形态及其与髋臼"眉弓"的对应关系，在双侧髋关节蛙式侧位片上观察股骨头坏死硬化带的形态及其与股骨头前外侧柱的对应关系，根据不同表现形式进行分类。

结果

共纳入266例435髋，在双侧髋关节标准正位片上观察到6种股骨头坏死硬化带的表现形式，分别是A型(硬化带边缘在眉弓内侧1/3以内)19(4.4%)，B型(硬化带边缘在"眉弓"中间1/3内)89髋(20.1%)，C1型(硬化带边缘在眉弓外侧1/3内)155髋(35.6%)，C2型(硬化带边缘超过髋臼外侧缘)87髋(20.0%)，D1型(硬化带呈环形，位于股骨头中心)47髋(10.8%)，D2型(硬化带呈环形，位于股骨头负重区软骨下骨板)38髋(8.7%)。在双侧髋关节蛙式侧位片上观察到5种股骨头坏死硬化带的表现形式，分别是1型(硬化带边缘位于股骨头后内侧柱或中央柱)3髋(0.7%)，2型(硬化带边缘位于股骨头后内侧柱或中央柱，深部累及前外侧柱)51髋(11.7%)，3型(硬化带边缘位于股骨头前外侧柱)316髋(72.6%)，4型(硬化带呈环形，位于股骨头中心)32髋(7.4%)，5型(硬化带呈环形，位于股骨头负重区软骨下骨板)33髋(7.6%)。总结出435髋共有19种匹配结果，结合纳入髋数的塌陷率，初步确定蛙位3型匹配正位B、C1、C2和D2时，需要采取外科干预。

结论

根据股骨头坏死硬化带在影像学上的表现形式建立正位和蛙式侧位分型，充分考虑股骨头外侧柱和前外侧柱的坏死累及情况，更能反映疾病的本质，为临床诊断、治疗和预后判断提供参考。

关键词: 股骨头坏死, 分类法

Objective

To observe the imaging manifestations of osteonecrosis of the femoral head (ONFH) during pericollapse stage and make classification and summary.

Methods

The research recruited ONFH patients who had complete image data from the First Affiliated Hospital of Guangzhou University of Chinese Medicine in the pericollapse stage, and the patients with congenital hip deformities and other diseases affecting the hip were exluded. The shape of sclerotic zone and its corresponding relations with "eyebrow arch" of acetabulum and anterolateral column of the femoral head were observed on bilateral hip standard radiograph and lateral radiograph of "frog position" respectively. The classification was performed according to the manifestation patterns.

Results

A total of 266 patients with 435 hips were enrolled. Six patterns of manifestation of the sclerotic zone were observed on bilateral hip standard radiograph, including type A (the edge of sclerotic zone was within the medial 1/3 of acetabular "eyebrow arch" ), type B (the edge was within the middle 1/3), type C1 (the edge was within the lateral 1/3), type C2 (the edge extends laterally to the acetabular edge), type D1 and type D2 (all the sclerotic zones presented ring shape locating at the center of the femoral head and the subchondral bone plate of the weight-bearing area of femoral head). Altogether 19 hips (4.4%) were type A, 89 hips (20.1%) were type B, 155 cases (35.6%) were type C1, 87 cases (20.0%) were type C2, 47 cases (10.8%) were type D1 and 38 cases (8.7%) were type D2. Five manifestation patterns of the sclerotic zone were also observed on bilateral hip frog lateral radiographs, including type 1 (the edge of sclerotic zone located at the posterior medial or central column of the femoral head), type 2(the edge was similar to type 1, and the anterolateral column was involved in the deep), type 3 (the edge located at the anterolateral column), type 4 and type 5 (all the edges presented ring shape locating at the center of the femoral head and the subchondral bone plate of the weight-bearing area of femoral head). Altogether three hips (0.7%) were type 1, 51 hips (11.7%) were type 2, 316 hips (72.6%) were type 3, 32 hips (7.4%) were type 4 and 33 hips (7.6%) were type 5.

Conclusion

Developing the anteroposterior and lateral images of "frog position" classification system based on the radiographic manifestation patterns of sclerotic zone in necrotic femoral head while considering the necrotic involvement of lateral and anterolateral column will be conducive to better understanding the nature of disease and provide useful information for clinical diagnosis, therapy and prognosis.

Key words: Femur head necrosis, Classification

图1 评估股骨头坏死分型的标准双髋部X线片和蛙式侧位片标准拍片体位。图A为双髋关节正位片，示高密度硬化带围成的坏死区域；图B为双髋关节蛙式侧位片，示高密度硬化带围成的坏死区域；图C双侧髋关节蛙式侧位片标准拍摄体位，患者仰卧，双髋双膝弯曲，大腿外旋与台面成30°

图2 ONFH(股骨头坏死)正位分型示意图。图A为正位分型Type-A、Type-B、Type-C1、Type-C2、Type-D1、Type-D2示意图；图B为对应的左侧髋关节正位X线片，示高密度硬化带围成的坏死区域；图C为图B中X线片的方框区域放大后图像，黑线代表坏死区域

图3 ONFH(股骨头坏死)蛙位分型示意图。图A为蛙位分型Type-1、Type-2、Type-3、Type-4、Type-5示意图；图B为对应的左侧髋关节蛙式侧位X线片，示高密度硬化带围成的坏死区域；图C为图B中X线片的方框区域放大后图像，黑线代表坏死区域，红线将股骨头分为25%的前外侧柱、50%的中央柱及25%的后内侧柱

表1 正位与蛙位分型在不同病因中的分布情况(n＝435)

病因	正位分型髋数						蛙位分型髋数
病因	A	B	C1	C2	D1	D2	1	2	3	4	5
创伤性	3(0.1%)	7(1.6%)	12(2.8%)	9(2.1%)	－	2(0.5%)	1(0.2%)	2(0.5%)	29(6.7%)	－	1(0.2%)
激素性	13(3.0%)	56(12.9%)	81(18.6%)	39(9.0%)	28(6.4%)	22(5.0%)	2(0.5%)	34(7.8%)	160(36.8%)	20(4.6%)	23(5.3%)
酒精性	3(0.1%)	18(4.1%)	42(9.7%)	28(6.4%)	11(2.5%)	11(2.5%)	－	13(3.0%)	86(19.8%)	6(1.4%)	8(1.8%)
特发性	0(0)	8(1.8%)	20(4.6%)	11(2.5%)	8(1.8%)	3(0.1%)	－	2(0.5%)	41(9.4%)	6(1.4%)	1(0.2%)

表1 正位与蛙位分型在不同病因中的分布情况(n＝435)

病因	正位分型髋数						蛙位分型髋数
病因	A	B	C1	C2	D1	D2	1	2	3	4	5
创伤性	3(0.1%)	7(1.6%)	12(2.8%)	9(2.1%)	－	2(0.5%)	1(0.2%)	2(0.5%)	29(6.7%)	－	1(0.2%)
激素性	13(3.0%)	56(12.9%)	81(18.6%)	39(9.0%)	28(6.4%)	22(5.0%)	2(0.5%)	34(7.8%)	160(36.8%)	20(4.6%)	23(5.3%)
酒精性	3(0.1%)	18(4.1%)	42(9.7%)	28(6.4%)	11(2.5%)	11(2.5%)	－	13(3.0%)	86(19.8%)	6(1.4%)	8(1.8%)
特发性	0(0)	8(1.8%)	20(4.6%)	11(2.5%)	8(1.8%)	3(0.1%)	－	2(0.5%)	41(9.4%)	6(1.4%)	1(0.2%)

表2 正位与蛙位分型的匹配(n＝435)

?	?	正位分型
?	?	A	B	C1	C2	D1	D2
?	1	－	1	2	－	－	－
?	2	1	32	9	1	4	4
蛙位分型	3	15	56	141	86	7	11
?	4	－	－	－	－	32	－
?	5	3	－	3	－	4	23

表2 正位与蛙位分型的匹配(n＝435)

?	?	正位分型
?	?	A	B	C1	C2	D1	D2
?	1	－	1	2	－	－	－
?	2	1	32	9	1	4	4
蛙位分型	3	15	56	141	86	7	11
?	4	－	－	－	－	32	－
?	5	3	－	3	－	4	23

图4 正位分型与蛙位分型匹配的X线片。正蛙位对应分型共19种，以"正位分型(Type-A、Type-B、Type-C1、Type-C2、Type-D1、Type-D2型)-蛙位分型(Type-1、Type-2、Type-3、Type-4、Type-5型)"表示)。图A为3个髋关节的正位A型，分别对应蛙位的2型、3型和5型；图B为3个髋关节的正位B型，分别对应蛙位的1型、2型和3型；图C为4个髋关节的正位C1型，分别对应蛙位的1型、2型、3型和5型；图D为两个髋关节的正位C2型，分别对应蛙位的2型和3型；图E为4个髋关节的正位D1型，分别对应蛙位的2型、3型、4型和5型；图F为3个髋关节的正位D2型，分别对应蛙位的2型、3型和5型

图5 正位分型与蛙位分型匹配分布的塌陷率及适应症界定。括号内数据表示塌陷率；F代表非手术保髋，W代表微创保髋手术，Q代表切开保髋手术；问号表示病例数少于3例；空白区表示无病例分布

[1]	Cui L, Zhuang Q, Lin J, et al. Multicentric epidemiologic study on six thousand three hundred and ninety five cases of femoral head osteonecrosis in China[J]. Int Orthop, 2016, 40(2): 267-276.
[2]	Sun W, Li ZR, Wang BL, et al. Relationship between preservation of the lateral pillar and collapse of the femoral head in patients with osteonecrosis[J/OL]. Orthopedics, 2014, 37(1): e24-e28. URL
[3]	何伟．如何把握股骨头坏死患者的保髋治疗时机[J]．中国骨与关节杂志，2016，5(2)：82-86.
[4]	Zhao D, Xie H, Xu Y, et al. Management of osteonecrosis of the femoral head with pedicled iliac bone flap transfer: a multicenter study of 2190 patients[J/OL]. Microsurgery, 2017. doi: 10.1002/micr.30195.
[5]	Cao L, Guo CA, Chen JF, et al. Free vascularized fibular grafting improves vascularity compared with core decompression in femoral head osteonecrosis: a randomized clinical trial[J]. Clin Orthop Relat Res, 2017, 475(9): 2230-2240.
[6]	Eward WC, Rineer CA, Urbaniak JR, et al. (2012)The vascularized fibular graft in precollapse osteonecrosis: is long-term hip preservation possible？[J]. Clin Orthop Relat Res, 2012, 470(10): 2819-2826.
[7]	Marcus ND, Enneking WF, Massam RA. The silent hip in idiopathic aseptic necrosis.Treatment by bone grafting[J]. J Bone Joint Surg, 1973, 55(7): 1351-1366.
[8]	Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip[J]. Clin Orthop, 1978, 130(130): 191-201.
[9]	Ficat RP, Arlet J. Necrosis of the femoral head//Hungefford DS. Ischemia and necrosis of bone. Baltimore: Williams and Wilkins, 1980, 53-74.
[10]	Ficat RP. Idiopathic bone necrosis of the femoral head：Early diagnosis and treatment[J]. J Bone Joint Surg Br, 1985, 67(1): 3-9.
[11]	Ohzono K, Saito M, Takaoka K, et al. Natural history of nontraumatic avascular necrosis of the femoral head[J]. J Bone Joint Surg Br, 1991, 73(1): 68-72.
[12]	Gardeniers JW. ARCO international stage of osteonecrosis[J]. ARCO Newsletter, 1993, 5：79-82.
[13]	Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis[J]. J Bone Joint Surg Br, 1995, 77(1): 34-41.
[14]	Sugano N, Atsumi T, Ohzono K, et al. The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head[J]. J Orthop Sci, 2002, 7(5): 601-605.
[15]	庞智晖，何伟，张庆文，等．中药辅助改良减压植骨内稳定术治疗围塌陷期激素性股骨头坏死[J]．中国中医骨伤科杂志，2009，17(1)：30-33.
[16]	李子荣．股骨头坏死临床诊疗规范[J]．中国矫形外科杂志，2016，8(1)：49-54.
[17]	李子荣，刘朝晖，孙伟，等．基于三柱结构的股骨头坏死分型——中日友好医院分型[J]．中华骨科杂志，2012，32(6)：515-520.
[18]	Clohisy JC, Nunley RM, Otto RJ, et al. The frog-leg lateral radiograph accurately visualized hip cam impingement abnormalities[J]. Clin Orthop Relat Res, 2007, 462: 115-121.
[19]	Yu T, Xie LM, Zhang ZN, et al. Prediction of osteonecrosis collapse of the femoral head based on the proportion of the proximal sclerotic rim[J]. Int Orthop, 2015, 39(6): 1045-1050.
[20]	Meier R, Kraus TM, Schaeffeler CA, et al. Bone marrow oedema on MR imaging indicates ARCO stage 3 disease in patients with AVN of the femoral head[J]. Eur Radiol, 2014, 24(9): 2271-2278.
[21]	何伟，李勇，张庆文，等．自体或同种异体腓骨联合打压植骨治疗股骨头坏死的初步研究[J]．中国修复重建外科杂志，2009，23(5)：530-533.
[22]	Nagoya S, Nagao M, Takada J, et al. Predictive factors for vascularized iliac bone graft for nontraumatic osteonecrosis of the femoral head[J]. J Orthop Sci, 2004, 9(6): 566-570.
[23]	Wu W, He W, Wei QS, et al. Prognostic analysis of different morphology of the necrotic-viable interface in osteonecrosis of the femoral head[J]. Int Orthop, 2018, 42(1): 133-139.
[24]	Kang JS, Moon KH, Kwon DG, et al. The natural history of asymptomatic osteonecrosis of the femoral head[J]. Int Orthop, 2013, 37(3): 379-384.
[25]	陈镇秋，何伟，张庆文．打压支撑植骨术治疗早期酒精性股骨头坏死的临床研究[J]．中华骨科杂志，2010，30(1)：42-47.

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摘要

选择文件类型/文献管理软件名称

选择包含的内容

Clinical significance for new type of necrotic femoral head based on X-ray

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Clinical significance for new type of necrotic femoral head based on X-ray