皮质类固醇与骨坏死关系的临床研究

Clinical research of correlation between osteonecrosis and steroid

目的探讨严重急性呼吸综合征(SARS)患者骨坏死发生的时间、发生率与皮质激素用量的关系.方法对551例SARS患者进行骨坏死普查,男131例,女420例,年龄21～59岁,平均(33±9)岁.其中12例未用激素,539例应用剂量不等的皮质激素(80～30 000 mg).从停药至普查的时间为3～9个月.全部患者行双髋、双膝、双踝、双肩及双腕MRI检查及X线摄片,部分患者做CT扫描.股骨头坏死按ARCO分期,膝关节坏死按Lotka分期,肩关节坏死按Gruess分期.采用独立检验、秩和检验、多因素逐步Logistic回归分析行统计学处理.结果 12例未用激素者,未检出骨坏死.539例应用激素者检出骨坏死176例(32.7%),其中累及股骨头为130例210髋、累及膝关节98例130膝、累及肱骨头21例36肩、累及踝关节16例26踝(距骨,跟骨)、累及腕关节11例17腕(月骨,舟状骨)、髌骨3例4膝、髂骨1例1处、长骨干(股骨,胫骨)梗死18例.股骨头坏死除11例15髋为Ⅱ期外,其余均为Ⅰ期.ⅠA为45髋、ⅠB为77髋、ⅠC为73髋.膝及肩关节坏死均为Ⅰ期.单关节受累34例,双关节受累45例,多关节受累93例,单纯骨干梗死4例.激素用量:发生骨坏死组为(5842±4988) mg,未发生骨坏死组为(2719±2571) mg(P<0.0001);用药时间:发生骨坏死组为(39±17) d,未发生骨坏死组为(27±15) d(P<0.01);激素冲击用量:发生骨坏死组为(340±207) mg/d,未发生骨坏死组为(211±160) mg/d(P<0.01);激素冲击治疗时间:发生骨坏死组为(28±13) d,未发生骨坏死组为(18±11) d(P<0.01).检出骨坏死的时间均在用药后6个月以内.结论应用剂量不等皮质激素的SARS患者约1/3发生骨坏死,骨坏死常为多灶性,发生时间早;MRI为早期诊断骨坏死的金标准,对大剂量激素应用者宜尽早用MRI监测.

Objective To explore the correlation between the dosage of corticosteroid, time of onset and incidence of osteonecrosis （ON） in patients with SARS. Methods From July 2003 to January 2004, general survey carried out for ON in 551 patients with SARS. Five hundred and fifty-one patients except 12 were administrated by corticosteroid from 80 mg to 30 000 mg. The age of patients was （ 33 ± 9 ） years old ranging from 19 to 59 years old. One hundred and thirty-one were male, and four hundred and twenty were female. MRI and X-ray film were taken in all patients including both hips, knees, shoulders, ankles and wrists. CT scan was taken in partial patients. Common classification system were used for staging of hip （ARCO）, knee （Lotka） and shoulder （Cruess）. Independent test, rank-sum test and multiple factor logistic regression analysis were used for statistical analysis. Results No osteonecrosis was detected in 12 patients without corticosteroid. Osteonecrosis was detected in 176 patients （32. 7 percent） among 539 patients. There were ON of femoral head in 130 cases （210 hips）, ON of knee in 98 cases （130 knees）,ON of humeral head in 21 cases （36 shoulders） , ON of talus and calcaneus in 16 cases （26 ankles） , ON of scaphoid and lunate in 11 cases （ 17 wrists） , ON of patella in 3 cases （4 patella） , ON of ilum in 1 case and bone infarction （femur, libia） in 18 cases. One hundred and nineteen cases （ 195 hips） with ONFH were in stage Ⅰ （ⅠA 45 hips, ⅠB 77 hips, ⅠC 73 hips）. Eleven cases（15hips） were in stage Ⅱ. All osteonecrosis of the knee and humoral head was stage Ⅰ. Thirty-four patients with ON had one joint affected, 45 patients had 2 joints, 93 patients had more than 3 joints. The dosage of corticosteroid was （5842 ±4988） mg in ON group and （2719 ± 2571 ）mg in non-ON group （P 〈0. 0001 ）. The duration of steroid was （38 ± 17 ） d in ON group and （27 ± 15 ） d in non-ON group （P 〈 0.01 ）. The dosage of pulse treatment was （340 ＋ 207 ） mg/d in ON group and （211± 160） mg/d in non-ON group （P〈0.01）. The duration of pulse treatment was （28＋13） d in ON group and （18±11） d in non-ON group （P〈0.01）. All patients with ON weredetected with in 6 months from adminitstration. Conclusion About one-third patients with SARS who were treated with a high dose of corticosteroid occurred osteonecrosis. ON is frequently multiple focuses. The actual time of onset of ON is early of steroid used. MRI is golden standard for early diagnosis of ON. The patients who were treated with a high dose of corticosteroid should be inspected initially bv MRI.