基于CT坏死区重建的股骨头坏死侧位分型及其临床验证

A novel lateral classification of osteonecrosis of femoral head based on CT reconstruction of necrotic area and its clinical verification

目的分析股骨头坏死(osteonecrosis of the femoral head,ONFH)不同日本厚生省骨坏死研究会(JIC)分型的股骨头塌陷与手术情况,总结各分型ONFH的预后规律,并对C1型探索基于CT坏死区重建的ONFH侧位分型的临床意义并验证其临床作用。方法以2004年5月—2016年12月收治的119例(155髋)ONFH患者为研究对象,JIC分型:A型34髋,B型33髋,C1型57髋,C2型31髋。各JIC分型患者的年龄、性别、侧别、ONFH类型差异均无统计学意义(P>0.05)。分析不同JIC分型的1、2、5年股骨头塌陷及手术情况,以及不同JIC分型、激素性/非激素性ONFH、无症状与有症状(疼痛时间>6个月或≤6个月)髋关节间及联合保留角(combined preserved angle,CPA)≥118.725°和CPA<118.725°髋关节间的生存率(以股骨头塌陷为终点)。选取组内手术及塌陷发生差异较大、具备研究价值的JIC C1分型,根据其坏死区在股骨头表面的位置,在CT重建侧位将其分成5个亚型,并提取坏死区轮廓线,匹配至标准股骨头模型上,对5个亚型的坏死情况进行热力图图像呈现。分析不同侧位亚型1、2、5年的股骨头塌陷和手术情况,并比较该型患者中CPA≥118.725°和CPA<118.725°髋关节间的生存率(以股骨头塌陷为终点),以及不同侧位亚型的生存率(分别以股骨头塌陷和手术为终点)。结果JIC C2型患髋1、2、5年股骨头塌陷率与手术率均明显高于其他分型(P<0.05);而C1型患髋塌陷率与手术率均高于A、B型(P<0.05)。不同JIC分型患髋的生存率差异有统计学意义(P<0.05),A、B、C1、C2型逐渐降低;无症状髋关节生存率明显高于有症状髋关节,CPA≥118.725°的髋关节生存率明显高于CPA<118.725°的髋关节,差异均有统计学意义(P<0.05)。对C1型髋关节坏死区域CT重建侧位进行进一步分型,1型12髋、2型20髋、3型9髋、4型9髋、5型7髋。随访5年时各亚型之间股骨头塌陷率及手术率比较差异均有统计学意义(P<0.05)。4、5型塌陷率及手术率均为0;3型塌陷率及手术率均最高;2型塌陷率高,但手术率低于3型;1型塌陷率高,但手术率均为0。JIC C1型中,CPA≥118.725°的髋关节生存率明显高于CPA<118.725°的髋关节(P<0.05)。以股骨头塌陷为终点的随访中,4、5型患髋生存率均为100%,1、2、3型生存率均为0,差异有统计学意义(P<0.05)。以手术为终点的随访中,1、4、5型生存率均为100%,3型为0,2型为60%,差异有统计学意义(P<0.05)。结论JIC A、B型可选择非手术治疗,C2型可手术保髋。通过CT侧位分型对C1型进行5个亚型分类,3型塌陷风险最高,4、5型塌陷和手术风险低,1型塌陷率高但手术风险低;2型塌陷率高,但手术率接近JIC C1型平均值,仍需开展进一步研究。

Objective To analyze the femoral head collapse and the operation of osteonecrosis of the femoral head(ONFH)in different Japanese Investigation Commitee(JIC)types,in order to summarize the prognostic rules of each type of ONFH,and explore the clinical significance of CT lateral subtypes based on reconstruction of necrotic area of C1 type and verify their clinical effect.Methods A total of 119 patients(155 hips)with ONFH between May 2004 and December 2016 were enrolled in the study.The total hips consisted of34 hips in type A,33 in type B,57 in type C1,and 31 in type C2,respectively.There was no significant difference in age,gender,affected side,or type of ONFH of the patients with differenct JIC types(P>0.05).The 1-,2-,and 5-year femoral head collapse and operation of different JIC types were analyzed,as wellas the survival rate(with femoral head collapse as the end point)of hip joint between different JIC types,hormonal/non-hormonal ONFH,asymptomatic and symptomatic(pain duration>6 months or≤6 months),and combined preserved angle(CPA)≥118.725°and CPA<118.725°.JIC types with significant dfferences in subgroup surgery and collapse and with research value were selected.According to the location of the necrotic area on the surface of the femoral head,the JIC classification was divided into 5 subtypes in the lateral CT reconstruction,and the contour line of the necrotic area was extracted and matched to the standard femoral head model,and the necrosis of the five subtypes was presented by thermography.The 1-,2-,and 5-year outcomes of femoral head collapse and operation in different lateral subtypes were analyzed,and the survival rates(with collapse of the femoral head as the end point)between CPA≥118.7250 and CPA<118.725°hip in patients with this subtype were compared,as well as the survival rates of different lateral subtypes(with collapse and surgery as the end points,respectively).Results The femoral head collapse rate and operation rate in the 1-,2-,and 5-year were significantly higher in patients with JIC C2 type than in patients with other hip types(P<0.05),while in patients with JIC C1 type than in patients with JIC types A and B(P<0.05).The survival rate of patients with different JIC types was significantly different(P<0.05),and the survival rate of patients with JIC types A,B,C1,and C2 decreased gradually.The survival rate of asymptomatic hip was significantly higher than that of symptomatic hip,and the survival rate of CPA≥118.725°was significantly higher than that of CPA<118.725°(P<0.05).The lateral CT reconstruction of type C1 hip necrosis area was selected for further classification,including type 1 in 12 hips,type 2 in 20 hips,type 3 in 9 hips,type 4 in 9 hips,and type 5 in 7 hips.There were significant differences in the femoral head collapse rate and the operation rate among the subtypes after 5 years of follow-up(P<0.05).The collapse rate and operation rate of types 4 and 5 were O;the collapse rate and operation rate of type 3 were the highest the collapse rate of type 2 was high,but the operation rate was lower than that of type 3;the collapse rate of type 1 was high,but the operation rate was 0.In JIC type C1 patients,the survival rate of the hip joint with CPA≥118.725°was significantly higher than that with CPA<118.725°(P<0.05).In the follow-up with femoral head collapse as the end point,the survival rates of types 4 and 5 were all 100%,while the survival rates of types 1,2,and 3 were all 0,and the difference was significant(P<0.05).The survival rate of types 1,4,and 5 was 100%,of type 3 was 0,and of type 2 was 60%,showing significant difference(P<0.05).Conclusion JIC types A and B can be treated by non-surgical treatment,while type C2 can be treated by surgical treatment with hip preservation.Type C1 was classified into 5 subtypes by CT lateral classification,type 3 has the highest risk of femoral head collapse,types 4 and 5 have low risk offemoral head collapse and operation,type I has high femoral head collapse rate but low risk of operation;type 2 has high collapse rate,but the operation rate is close to the average of JIC type Cl,which still needs to be further studied.