创伤性股骨头坏死MRI分型的制订及其与股骨头塌陷的相关性研究

Establishment of MRI classification for traumatic osteonecrosis of the femoral head and its correlation with femoral head collapse

目的:建立创伤性股骨头坏死(osteonecrosis of femoral head,ONFH)MRI分型,并初步探讨其与股骨头塌陷进展的相关性。方法:回顾性分析2000年1月至2019年12月于泉州市正骨医院关节中心就诊的73例(73髋)创伤性ONFH,男46例、女27例,年龄为(34.9±8.3)岁(范围19~55岁)。记录患者的骨折分型、复位质量、日本厚生省骨坏死研究会(Japanese Investigation Commite,JIC)分型等临床和影像学资料。采用2019年修订版国际骨坏死与骨循环协会(Association Research Circulation Osseous,ARCO)分期诊断标准评估创伤性ONFH疾病进展程度,将其中的ⅢA期、ⅢB期分别定义为轻度塌陷和进行性塌陷。建立MRI修复带(bone repair band,BRB)分型,并对创伤性ONFH进行划分,并采用Kappa检验分析BRB分型的观察者内及观察者间的一致性,Kaplan-Meier生存曲线与二分类变量Cox回归分析BRB分型与股骨头进行性塌陷的相关性。结果:73例随访(54.8±34.9)个月(范围24~165个月)。根据BRB分型,73例中1型浅表病灶28例(38%)、2型不确定病灶16例(22%)、3型广泛病灶29例(40%)。BRB分型的观察者间一致性Kappa值为0.798,观察者内一致性Kappa值为0.896,一致性高。末次随访时进展至ARCOⅢA期者中BRB分型为1型3例、2型4例、3型14例;进展至ARCOⅢB期者中BRB分型1型1例、2型1例、3型12例。BRB分型是创伤性ONFH进行性塌陷的独立危险因素[HR=13.957,95%CI(4.551,21.193),P<0.001]。以出现进行性塌陷(ⅢB期)为终点事件,2型出现不良预后的风险与1型的差异无统计学意义[HR=1.766,95%CI(0.465,6.702),P=0.403],3型出现不良预后的风险显著高于1型[HR=15.126,95%CI(4.708,48.592),P<0.001]。结论:BRB分型与创伤性ONFH的疾病进展密切相关,是预测进行性塌陷发生的独立危险因素;BRB分型有助于早期诊断后预测塌陷进展与治疗方案决策。

Objective To establish a classification system for the repair band in the subchondral bone origination point in MRI for traumatic osteonecrosis of the femoral head(ONFH)and preliminarily explore the correlation between this classification and the progression of femoral head collapse.Methods A retrospective analysis was conducted on 73 cases of traumatic ON-FH treated at the Quanzhou Orthopedic-traumatological hospital from January 2000 to December 2019.Among them,there were 46 males and 27 females with an average age of 34.9±8.3 years(range 19-55 years).Clinical and radiological data such as age,gender,side,fracture classification,reduction quality,JIC classification,and bone repair band(BRB)classification were recorded.The progression of traumatic ONFH was assessed using the ARCO staging system,with stages IIIA and IIIB defined as mild collapse and progressive collapse,respectively.The BRB classification was established based on MRI findings,and the inter-and intra-observer consistency of the BRB classification was analyzed using Kappa test.The correlation between the BRB classification and progressive femoral head collapse was analyzed using the Kaplan-Meier survival curve and binary variable Cox regression analysis.Results According to the BRB classification,73 cases were divided into type 1 with superficial lesion in 38.4%,type 2 with uncertain lesion in 21.9%,and type 3 with extensive lesion in 39.7%.The inter-observer consistency Kappa value for the BRB classification was 0.798,and the intra-observer consistency Kappa value was 0.896,indicating a high level of consistency.A follow-up of 73 cases(54.8±34.9 months,range 24-165 months)showed a significant correlation between the BRB classification and ARCO staging at the last follow-up(χ^(2)=37.556,P<0.001),with progression to stages IIIA and IIIB as follows:type 1 had 3 and 1 cases,type 2 had 4 and 1 cases,and type 3 had 14 and 12 cases,respectively.Using the occurrence of progressive collapse(stage IIIB)as the endpoint,the risk of progression to stage IIIB for type 2 was not statistically different from type 1[HR=1.766,95%CI(0.465,6.702),P=0.403];the risk of progression to stage IIIB for type 3 was significantly higher than for type 1[HR=15.126,95%CI(4.708,48.592),P<0.001].Conclusion The BRB classification is closely related to the progression of traumatic ONFH and is an independent risk factor for predicting the occurrence of progressive collapse;this classification is helpful for early diagnosis and predicting the progression of collapse and treatment plan decision-making.