儿童及青少年股骨颈骨折后股骨头坏死影像学特征与疾病进展的关系

Relationship between radiographic characteristics and disease progression in children and adolescent femoral neck-fracture-induced osteonecrosis

目的分析儿童及青少年股骨颈骨折后股骨头坏死的影像学特点及其与疾病进展的关系。方法收集广州中医药大学第一附属医院治疗的58例儿童及青少年股骨颈骨折后股骨头坏死患者影像学资料。研究对象的入选标准包括:年龄小于18岁的儿童及青少年;明确股骨颈骨折病史;符合股骨头坏死诊断标准。排除标准包括:大剂量激素使用史或酗酒史;诊断Legg-Calve-Perthes病、戈谢氏病、镰状细胞性贫血症、先天性髋关节发育不良、类风湿性关节炎、强直性脊柱炎、股骨颈骨折骨不连、术后感染;已接受针对股骨头坏死治疗,或影像资料不完整的患者。其中男性38例,女性20例,平均年龄(14.7±2.9)岁,均为单侧坏死(左侧31例,右侧27例)。通过Steinberg分期评估疾病进展,Spearman相关性检验或Fisher精确检验分析坏死面积、日本厚生省骨坏死研究会(JIC)分型以及蛙位分型等影像学特点与疾病进展的关系。结果初次就诊时,根据Steinberg分期,Ⅰ期3例(5.2%),Ⅱ期21例(36.2%),Ⅲ期5例(8.6%),Ⅳ期25例(43.1%),Ⅴ期4例(6.9%)。Steinberg分期与坏死面积(r=0.5,P<0.01)、JIC分型(r=0.5,P<0.01)以及蛙位分型(r=0.5,P<0.01)呈正相关。在已塌陷的29例患者中,19例出现髋关节失稳,表现为严重塌陷后头臼不匹配、关节半脱位。蛙位C2型失稳率为90.0%(18/20),蛙位C1型为11.1%(1/9),其差异具有统计学意义(P<0.01);正位C2型失稳率为68.0%(17/25),正位C1型为50%(2/4),其差异无统计学意义(P>0.05)。结论儿童及青少年股骨颈骨折后股骨头坏死塌陷风险极高,严重塌陷可导致髋关节失稳,尤其多见于蛙位C2型坏死。

Objective To evaluate the radiographic characteristics of pediatric femoral neck fracture induced osteonecrosis, and the relationship with the disease progression. Methods Initial radiographic data of 58 cases of children and adolescent femoral neck-fracture-induced osteonecrosis（ 38 boys and 20 girls） treated by the First Affiliated Hospital of Guangzhou University of Chinese Medicine were reviewed,with a mean age of（ 14. 7 ± 2. 9） years. The inclusion criteria included： younger than 18 years,diagnosis of osteonecrosis induced by femur neck fracture. The exclusion criteria included： usage of glucocorticoid, insobriety; Perthes disease, Gaucher＇s disease, sickle cell disease, developmental dysplasia of hip,rheumatoid arthritis and ankylosing spondylitis,nonunion or infection after femur neck fracture; not initial treatment or incomplete data. All the cases were unilaterally involved,31 cases of left side and 27 cases of right side. Steinberg staging system was used to define the disease progression. Its association with radiographic characteristics,such as lesion size,Japanese Investigation Committee（ JIC）classification and frog-view classification were analyzed by Spearmen and Fisher exact test. Results When the diagnosis of pediatric femoral-neck-fracture-induced osteonecrosis was established, according to Steinberg staging system,there were three cases（ 5. 2%） in stage Ⅰ,21（ 36. 2%） in stageⅡ,five cases（ 8. 6%） in stage Ⅲ,25（ 43. 1%） in stage Ⅳ and four cases（ 6. 9%） in stage Ⅴ. The positive associations were found between Steinberg staging system and lesion size（ r = 0. 5,P 0. 01）,JIC classification（ r = 0. 5,P 0. 01） and frog-view classification（ r = 0. 5,P 0. 01）. In the patients of collapsed stage,19 cases were defined as hip instability. According to frog-view classification,rate of hip instability in type C2 was 90. 0%（ 18/20）,which was significantly higher than 11. 1%（ 1/9） in type C1（ P 0. 01）. Whereas in JIC classification,rate of hip instability in type C2 was 68. 0%（ 17/25）,which was higher than 50. 0%（ 2/4） in type C1; however,the difference was not significant（ P 0. 05）.Conclusion Children and adolescent femoral neck-fracture-induced osteonecrosis is at a high risk of femoral head collapse; severe collapse can result in hip instability,which is highly associated with frogview classification.