坏死及支撑区三维空间分布对腓骨支撑保髋结局的影响

Effect of three-dimensional spatial distribution of necrotic and support areas on outcomes of fibular support for hip preservation

背景:坏死区分布在保髋治疗中有重要影响,目前探讨股骨头坏死在三维空间分布上的差异对腓骨支撑术的临床结局是否存在影响的研究较少。目的:利用CT三维重建探究股骨头坏死区和腓骨支撑区的空间分布与临床结局的关系,为优化腓骨支撑术的适用条件、提高腓骨支撑术的保髋疗效提供一定依据。方法:以2010年1月至2021年1月收治并符合纳入标准的80例使用腓骨支撑术保髋的股骨头坏死患者为研究对象,至少随访2年。根据临床结局分为2组,保髋成功组55例,保髋失败组25例。根据患者术前和术后CT影像进行三维重建,参照三柱理论,将股骨头划分为外九区、中九区、内九区共27个区域(L1-9,C1-9,M1-9),探究患者股骨头坏死区、腓骨支撑区的空间分布情况及其与临床结局的关系。结果与结论:①术前股骨头坏死区分布主要集中在股骨头前外侧的L1、L2、L4、L5、C1、C2、C4、C5(外九区和中九区的前中部上中段)区域,术后腓骨支撑区分布主要集中于L5、L6、C5、C6(外九区和中九区的中部中下段)区域;②保髋成功组与保髋失败组在L8(外九区的后部中段)、C3(中九区的前部下段)、C6(中九区的中部下段)、M2(内九区的前部中段)区域的股骨头坏死分布差异有显著性意义(P<0.05),在L5、L6区域(外九区的中部中下段)的腓骨支撑分布差异有显著性意义(P<0.05);其中L8区域可作为腓骨支撑术保髋失败的独立预测因素,L8单一因素预测模型曲线下面积为0.698[95%CI(0.575,0.822)],敏感度为76%,特异性为63.6%;③结果提示,当坏死区涉及L8、C3、C6、M2区域,尤其是L8区域时,腓骨支撑术保髋治疗的失败率可能升高;当腓骨支撑区涉及L5、L6区域时,保髋疗效常不理想。

BACKGROUND:The distribution of the necrotic area plays an important role in hip preservation treatment.At present,there are few studies on whether the difference in the three-dimensional spatial distribution of osteonecrosis of the femoral head affects the clinical outcome of fibular support.OBJECTIVE:To explore the relationship between the spatial distribution and clinical outcome at the sites of osteonecrosis of the femoral head and fibular support using CT three-dimensional reconstruction so as to provide a basis for optimizing the applicable conditions of fibular support and improving the hip preservation effect of fibular support.METHODS:Eighty patients with osteonecrosis of the femoral head who were treated with fibular support for hip preservation from January 2010 to January 2021 were selected as the study subjects according to the inclusion criteria.They were followed up for at least 2 years.According to the clinical outcome,the patients were divided into the successful hip preservation group(n=55)and the failure hip preservation group(n=25).3D reconstruction was performed according to the preoperative and postoperative CT images of the patients.According to the three-column theory,the femoral head was divided into outer nine areas,middle nine areas and inner nine areas(L1-9,C1-9,and M1-9)to explore the spatial distribution of necrotic area of the femoral head and fibular support area and its relationship with clinical outcome.RESULTS AND CONCLUSION:(1)Before operation,the necrotic area of the femoral head was mainly distributed in L1,L2,L4,L5,C1,C2,C4,and C5(the upper and middle part of the anterior part of the outer ninth area and the middle part of the middle ninth area).After operation,the fibular support area was mainly distributed in L5,L6,C5,and C6(the middle and lower part of the outer ninth area and the middle and lower part of the middle ninth area).(2)There were significant differences in the distribution of osteonecrosis of the femoral head between the successful hip preservation group and the failure hip preservation group in L8(the posterior middle part of the outer ninth area),C3(the anterior lower part of the middle ninth area),C6(the lower middle part of the middle part of the inner ninth area)and M2(the anterior middle part of the inner ninth area)(P<0.05).There was a significant difference in the distribution of fibular support in L5 and L6(middle and lower part of outer nine)(P<0.05).Among them,the L8 region could be used as an independent predictor of hip preservation failure in fibular support surgery.The area under the curve of the L8 single factor prediction model was 0.698[95%CI(0.575,0.822)];the sensitivity was 76%,and the specificity was 63.6%.(3)It turns out,when the necrotic area involves L8,C3,C6,and M2,especially L8,the failure of fibular support may increase,and when the fibular support involves L5 and L6,the effect of hip preservation is often not ideal.