根据股骨头负重区判断非创伤性股骨头坏死带塌陷生存

doi:10.3877/cma.j.issn.1674-134X.2024.03.002

中华关节外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (03) : 307 -313. doi: 10.3877/cma.j.issn.1674-134X.2024.03.002

临床论著

根据股骨头负重区判断非创伤性股骨头坏死带塌陷生存

江梦钰¹, 陈志文¹, 胡云浩¹, 凡一诺², 方汉军³, 刘予豪³, 王海彬³, 何伟⁴, 陈镇秋³, 周驰⁵^,^†(

)

^1. 510499　广州中医药大学第一临床医学院
^2. 510080　广州中医药大学第三临床医学院
^3. 510405　广州中医药大学第一附属医院
^4. 510378　广州中医药大学第三附属医院
^5. 510405　广州中医药大学第一附属医院;525000　广州中医药大学（茂名市中医院）

收稿日期:2023-11-27 出版日期:2024-06-01
通信作者: 周驰

Judging on survival of non-traumatic femoral head necrosis zone collapse according to weight-bearing area of femoral head

Mengyu Jiang¹, Zhiwen Chen¹, Yunhao Hu¹, Yinuo Fan², Hanjun Fang³, Yuhao Liu³, Haibin Wang³, Wei He⁴, Zhenqiu Chen³, Chi Zhou⁵^,^†()

^1. The First Clinical of Medical School of Guangzhou University of Chinese Medicine, Guangzhou 510499, China
^2. The Third Clinical of Medical Schoolof Guangzhou University of Chinese Medicine, Guangzhou 510080, China
^3. The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
^4. The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510378, China
^5. The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, China;Maoming Hospital of Guangzhou University of Chinese Medicine, Maoming 525000, China

Received:2023-11-27 Published:2024-06-01
Corresponding author: Chi Zhou

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引用本文：

江梦钰, 陈志文, 胡云浩, 凡一诺, 方汉军, 刘予豪, 王海彬, 何伟, 陈镇秋, 周驰. 根据股骨头负重区判断非创伤性股骨头坏死带塌陷生存[J/OL]. 中华关节外科杂志(电子版), 2024, 18(03): 307-313.

Mengyu Jiang, Zhiwen Chen, Yunhao Hu, Yinuo Fan, Hanjun Fang, Yuhao Liu, Haibin Wang, Wei He, Zhenqiu Chen, Chi Zhou. Judging on survival of non-traumatic femoral head necrosis zone collapse according to weight-bearing area of femoral head[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2024, 18(03): 307-313.

目的

本研究旨在通过股骨头负重区完整率来探讨股骨头坏死（ONFH）“带塌陷生存”的条件，评估其诊断国际骨循环研究协会（ARCO ⅢA）期患者结局的可靠性。

方法

选择广州中医药大学第一附属医院（2010年至2017年）的非创伤性股骨头坏死患者中属于ARCO ⅢA期“带塌陷”的患者，拥有正常沟通能力，临床就诊影像学资料完整，知情同意，定期复查。同时排除患有其他严重慢性病史的老年患者，影像学资料不完整、用药不当、进行全髋关节置换术或保髋手术患者。通过日本骨坏死研究会（JIC）分型对进行分类，根据结局分为塌陷进展组和带塌陷生存组。通过X线平片的标准正位（AP）和蛙位（FL）测量外侧股骨头负重区完整率（APIR）和前侧股骨头负重区完整率（FLIR），并明确该指标与结局的关系。然后通过单因素和多因素logistic回归分析确定塌陷进展的危险因素，最后采用受试者工作特征（ROC）曲线分析负重区完整率对塌陷进展和带塌陷生存诊断的可靠性。

结果

共纳入72例（90髋）ARCO ⅢA期ONFH患者，其中带塌陷生存37髋随访时间85（72，166）个月，塌陷进展53髋随访时间24（6，78）个月；JIC分型（χ²=21.312，P<0.001）是影响“带塌陷生存”的因素；ROC曲线分析结果显示，APIR的临界值为16.6%［线下面积（AUC）=91.0%，Youden指数=0.78，P<0.000 1）］，即APIR≥16.6%时与带塌陷生存相关；FLIR 的临界值为16.1%（AUC=89.7%，Youden指数=0.82，P<0.000 1），即FLIR≥16.1%时与带塌陷生存相关。该结果提示APIR和FLIR与结局相关。

结论

前外侧股骨头负重区完整率与带塌陷生存密切相关，提示ARCOⅢA期ONFH患者可根据APIR和FLIR判断是否符合“带塌陷生存”的条件，以此合理选择治疗手段。

关键词: 股骨头, 坏死, 负重, 预后

Objective

To explore the condition of "survival with collapse" of femoral head necrosis (ONFH) and evaluate its reliability in diagnosing the outcome of patients with International Association Research Circulation Osseous (ARCO) stage ⅢA by using the integrity rate of femoral head weight-bearing area.

Methods

Patients with non-traumatic femoral head necrosis in the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine from 2010 to 2017 who belonged to ARCO stage ⅢA "with collapse" were selected. The enrolled patients had normal communication skills, complete imaging data of clinical visits, informed consent and were regular followed up. The elderly patients with other severe chronic diseases, the patients with incomplete imaging data, inappropriate medication and history of total hip arthroplasty or hip-preserving surgery were excluded. The patients were categorised by the Japan Investigation Committee (JIC) type, and divided into the collapse progression group and the survival with collapse group according to the outcome. Anteroposterior-view intact ratio (APIR) and frog-leg view intact ratio(FLIR) were measured by standard anteroposterior view(AP) and frog-leg view (FL) of radiograph, the relationship between this index and the outcome was clarified. Univariate and multivariate logistic regression analyses were then performed to identify risk factors for progression of collapse. The reliability of weight-bearing zone integrity on the diagnosis of collapse progression and survival with collapse was analyzed using the receiver operating characteristic (ROC) curve.

Results

A total of 72 patients (90 hips) with ONFH of ARCO stage ⅢA were enrolled. Among them, 37 hips survived with collapse were followed up for 85(72, 166)months , and 53 hips with collapse progression were followed up for 24 (6, 78) months. JIC type was the key influent factor of the survival with collapse (χ²=21.312, P<0.001). ROC curve analysis showed that the critical value of APIR was 16.6%［area under curve(AUC)=91.0%, Youden index=0.78, P<0.0001］. APIR≥16.6% was significantly related to survival with collapse. The critical value of FLIR was 16.1% (AUC=89. 7% , Youden exponent = 0.82, P<0.001), which suggested that FLIR≥ 16.1% was significantly related to survival with collapse. APIR and FLIR were significantly correlated with the outcome.

Conclusion

The anterolateral femoral head weight-bearing area integrity rate is closely related to "survival with collapse", which suggests that patients with ONFH of ARCO stage ⅢA can be judged whether they are eligible for "survival with collapse" according to the APIR and FLIR, so as to rationally choose the treatment.

Key words: Femoral head, Necrosis, Weight-bearing, Prognosis

图1 股骨头负重区完整率的测量方法注：C点为髋臼最外缘，F点为泪滴最低点，CF线中垂线与髋臼交于D点；以C点为中心作地面垂线与股骨头相交于A点，B点是坏死区累及股骨头壁的外侧边界；弧长（AB）代表股骨头在负重部分非坏死区域的长度，弧长（CD）表示承重部分髋臼的轮廓长度；左图示APIR（外侧股骨头负重区完整率）=弧长（AB）／弧长（CD）×100%；右图示FLIR（前侧股骨头负重区完整率）=弧长（AB）／弧长（C-D）×100%

Figure 1 Measurement of integrity rate of weight-bearing area of femoral head Note: Point C is the outermost edge of the acetabulum, point F is the lowest point of the teardrop, and point D is the intersection of the vertical line of the midpoint of the CF line and the acetabulum. The vertical line with the central axis through point C intersects the femoral head at point A, and B is the outer boundary of the necrotic area involving the wall of the femoral head. Arc length AB represents the contour length of the femoral head in the non-necrotic area of the weight-bearing part. Arc length CD represents the contour length of the acetabulum in the weight-bearing part.The left figure shows APIR（anteroposterior-view intact ratio）= arc length AB/ arc length CD×100%; the right figure shows FLIR (frog-leg view intact ratio)= arc length AB/ arc length CD×100%

图2 JIC（日本骨坏死调查委员会）分型影像图注：左、中、右图分别为JIC分型B型、C1型和C2型的X线片

Figure 2 JIC(Japanese Investigation Committee) typing image map Note: Left, middle and right figures are X-ray images of JIC type

表1 ARCO ⅢA期股骨头坏死相关资料与带塌陷生存的相关性

Table 1 Correlation between the data of femoral head necrosis of ARCO ⅢA and the survival with collapse

组别 Groups	髋数 Number of hips	性别（髋） Gender (hip)		随访时长［个月，M（P₂₅，P₇₅）］ Follow-up time（month）	年龄分组（例） Age grouping
组别 Groups	髋数 Number of hips	男 Male	女 Female	随访时长［个月，M（P₂₅，P₇₅）］ Follow-up time（month）	18～35岁	36～55岁	>55岁
塌陷进展组 Collapse progression group	53	39	14	24（6，78）	25	25	3
带塌陷生存组 Survival with collapse group	37	23	14	85（72,166）	19	17	1
统计值 Statistical values		χ²=1.327		Z=-6.621	χ²=0.488
P值		>0.05		<0.001	>0.05
组别 Groups	髋数 Number of hips	病因（髋） Causes（hip）			JIC分型（髋） JIC type（hip）
组别 Groups	髋数 Number of hips	激素 Corticosteroid	酒精 Alcohol	特发 Idiopathic	B	C1	C2
塌陷进展组 Collapse progression group	53	26	23	4	1	32	20
带塌陷生存组 Survival with collapse group	37	25	10	2	7	29	1
χ²值		3.031			21.312
P值		>0.05			<0.001

表1 ARCO ⅢA期股骨头坏死相关资料与带塌陷生存的相关性

Table 1 Correlation between the data of femoral head necrosis of ARCO ⅢA and the survival with collapse

组别 Groups	髋数 Number of hips	性别（髋） Gender (hip)		随访时长［个月，M（P₂₅，P₇₅）］ Follow-up time（month）	年龄分组（例） Age grouping
组别 Groups	髋数 Number of hips	男 Male	女 Female	随访时长［个月，M（P₂₅，P₇₅）］ Follow-up time（month）	18～35岁	36～55岁	>55岁
塌陷进展组 Collapse progression group	53	39	14	24（6，78）	25	25	3
带塌陷生存组 Survival with collapse group	37	23	14	85（72,166）	19	17	1
统计值 Statistical values		χ²=1.327		Z=-6.621	χ²=0.488
P值		>0.05		<0.001	>0.05
组别 Groups	髋数 Number of hips	病因（髋） Causes（hip）			JIC分型（髋） JIC type（hip）
组别 Groups	髋数 Number of hips	激素 Corticosteroid	酒精 Alcohol	特发 Idiopathic	B	C1	C2
塌陷进展组 Collapse progression group	53	26	23	4	1	32	20
带塌陷生存组 Survival with collapse group	37	25	10	2	7	29	1
χ²值		3.031			21.312
P值		>0.05			<0.001

表2 APIR、FLIR与ARCO ⅢA期股骨头结局的关系［%,M（P₂₅，P₇₅）］

Table 2 Relationship between APIR、FLIR and the femoral head outcome in ARCOⅢA stage

	髋数 Number of hips	负重区完整率 Integrity rate of weight-bearing area	Z值	P值
APIR
塌陷进展组Collapse progression group	31	12.4（8.9，16.0）	-5.674	<0.001
带塌陷生存组Survival with collapse group	34	23.3（18.8，31.3）	-5.674	<0.001
FLIR
塌陷进展组Collapse progression group	31	7.9（2.1，13.6）	-5.490	<0.001
带塌陷生存组Survival with collapse group	34	21.7（17.3，29.2）	-5.490	<0.001

表2 APIR、FLIR与ARCO ⅢA期股骨头结局的关系［%,M（P₂₅，P₇₅）］

Table 2 Relationship between APIR、FLIR and the femoral head outcome in ARCOⅢA stage

	髋数 Number of hips	负重区完整率 Integrity rate of weight-bearing area	Z值	P值
APIR
塌陷进展组Collapse progression group	31	12.4（8.9，16.0）	-5.674	<0.001
带塌陷生存组Survival with collapse group	34	23.3（18.8，31.3）	-5.674	<0.001
FLIR
塌陷进展组Collapse progression group	31	7.9（2.1，13.6）	-5.490	<0.001
带塌陷生存组Survival with collapse group	34	21.7（17.3，29.2）	-5.490	<0.001

表3 前外侧股骨头负重区完整率的ROC曲线分析

Table 3 ROC curve of weight-bearing area integrity rate of anterolateral femoral head

	界值(%) Boundary value	AUC (%)	95%置信区间 95% confidence interval	Youden 指数 Youden index	P值
APIR	16.6	91.0	（0.828，0.991）	0.78	<0.001
FLIR	16.1	89.7	（0.797，0.997）	0.82	<0.001

表3 前外侧股骨头负重区完整率的ROC曲线分析

Table 3 ROC curve of weight-bearing area integrity rate of anterolateral femoral head

	界值(%) Boundary value	AUC (%)	95%置信区间 95% confidence interval	Youden 指数 Youden index	P值
APIR	16.6	91.0	（0.828，0.991）	0.78	<0.001
FLIR	16.1	89.7	（0.797，0.997）	0.82	<0.001

图3 APIR（外侧股骨头负重区完整率）和FLIR（前侧股骨头负重区完整率）的ROC（受试者工作特征）曲线分析

Figure 3 ROC(receiver operating characteristic) curve analysis of APIR(anteroposterior-view intact ratio) and FLIR(frog-leg view intact ratio)

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Judging on survival of non-traumatic femoral head necrosis zone collapse according to weight-bearing area of femoral head

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Judging on survival of non-traumatic femoral head necrosis zone collapse according to weight-bearing area of femoral head