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WordsSubchondralInsufficiencyFracture:軟骨下不全骨折OsteonecrosisoftheFemoralHead:股骨頭壞死Convex凸ncavity凹第1頁,共30頁。軟骨下不全骨折(Subchondralinsufficiencyfracture,簡稱SIFs)
1、軟骨下機(jī)能不全性骨折是非外傷性的一種骨折。2、最常見的病因:骨質(zhì)疏松,不常見的病因是骨質(zhì)軟化癥或骨不全癥、甲狀旁腺功能亢進(jìn)和類風(fēng)濕性關(guān)節(jié)炎等。3、發(fā)病原理:正常軟骨可忍受正常的生物機(jī)械應(yīng)力,當(dāng)由于上述病因變得軟弱時,可出現(xiàn)軟骨下骨折,并發(fā)展為軟骨下萎陷,為此需認(rèn)識此病作出早期診斷,多數(shù)患者經(jīng)保守治療后可自愈。
第2頁,共30頁。OBJECTIVEThepurposeofthisarticleistoverifythehypothesisthatosteonecrosisandsubchondralinsufficiencyfractureofthefemoralheadcanbedifferentiatedonthebasisoftheirappearanceonMRI.第3頁,共30頁。SUBJECTSANDMETHODS1BetweenMay1998andFebruary2009,wereviewed30consecutivehipsin30patients,60yearsoldorolderatthetimeofonsetofhippain,withradiologicevidenceofsubchondralcollapseofthefemoralheadandwithbothMRimagesandhistologicresultsavailable.第4頁,共30頁。SUBJECTSANDMETHODS2Thepatientsweredividedintotwogroupaccordingtotheshapeoflow-intensitybandsonT1-weightedimages.Thefirstgroupshowedconcavityofthearticularsurface,whichischaracteristicofosteonecrosis,andthesecondgroupshowedanirregularconvexityofthearticularsurface,whichischaracteristicofsubchondralinsufficiencyfracture.第5頁,共30頁。AInosteonecrosis,low-intensitybandissmooth,concavetoarticularsurface,andcircumscribesallofnecroticsegments.BInsubchondralinsufficiencyfracture,low-intensitybandisirregular,convextoarticularsurface,anddiscontinuous.第6頁,共30頁。RESULTSSixteenhips(53.3%)showedevidenceofosteonecrosis,and14(46.7%)showedevidenceofsubchondralinsufficiencyfracture,whichwasconsistentwiththecorrespondinghistopathologicdiagnoses.Inallcasesofosteonecrosis,thepatienthadahistoryofeithercorticosteroidintakeoralcoholabuse.Amongpatientswithsubchondralinsufficiencyfracture,theproportionofwomenwassignificantlyhigherthanthatamongpatientswithosteonecrosis.Acrescentsign(subchondralfracture)waspresentradiographicallyinabouthalfofallcasesinbothgroups.第7頁,共30頁。TABLE1:ClinicalCharacteristicsofPatientsWithOsteonecrosisor
SubchondralInsufficiencyFracture第8頁,共30頁。CONCLUSIONTheresultsofthepresentstudysuggestthattheshapeofthelow-intensitybandonMRIisusefulforthedifferentiatingsubchondralinsufficiencyfracturefromosteonecrosis.Inaddition,amongosteoporoticelderlywomenwithoutanyhistoryofcorticosteroidintakeoralcoholabuse,adiagnosisofsubchondralinsufficiencyfractureshouldbeconsidered.第9頁,共30頁。64-year-oldmanwithhistoryofalcoholabuseandosteonecrosis.A,Anteroposteriorradiographoflefthip(Singhindexofseverityofosteoporosis,gradeV)obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion(arrows).第10頁,共30頁。B,CoronalT1-weightedimage(TR/TE,470/15)showsdiffuselowsignalintensityinfemoralneckatlateralportionandintertrochantericarea.Low-intensitybandonT1-weightedimageisconcavetoarticularsurface(arrows).第11頁,共30頁?!熬€樣征”位于股骨頭頸前上部病灶周圍多呈空間錐形分布,錐尖指向股骨頭基底部或股骨頸。Glimcher認(rèn)為修復(fù)開始后,肉芽組織自股骨頸或股骨頭基底部向死骨區(qū)爬行。肉芽組織到達(dá)并吸收骨皮質(zhì)時,皮質(zhì)承載力減弱。在重力作用下自此皮質(zhì)薄弱區(qū)于松質(zhì)骨內(nèi)產(chǎn)生多條微骨折線,因應(yīng)力作用微骨折線多位于股骨頭前上部周圍。肉芽組織在微骨折處大量增生堆積、吸收壞死骨小梁并于外圍大量成骨,從而形成T2WI上的“雙線癥”。第12頁,共30頁。D,AxialsliceofT1-weightedimage(500/15)showsthatlow-intensitybandcircumscribesallofnecroticsegments(arrows).第13頁,共30頁。E,Cutsectionofresectedfemoralheadshowszonalpattern(necrotic,reparative,andviablezones).Subchondralfractureline(arrow)correspondingtocrescentsignonradiograph(A)isseen.第14頁,共30頁。新月征形成機(jī)制因皮質(zhì)斷裂塌陷時,關(guān)節(jié)軟骨在一段時間內(nèi)尚保持完整,形成軟骨下負(fù)壓。股骨頭體液內(nèi)氣體在負(fù)壓作用下溢出并進(jìn)入囊腔。第15頁,共30頁。第16頁,共30頁。F,Histopathologicappearanceofnecroticregion,whichshowsaccumulationofbonemarrowcelldebris,andbonetrabeculaewithemptylacunaebeneathfracturelineareseen.(HandE,×40)第17頁,共30頁。G,Thereisrepairtissueinreparativezone,includingvasculargranulationtissue,fibroustissue.(HandE,×20)第18頁,共30頁。Fig.3—75-year-oldwoman,withouthistoryofeithercorticosteroidintakeoralcoholabuse,withsubchondralinsufficiencyfracture.Anteroposteriorradiographoflefthip(Singhindexofseverityofosteoporosis,gradeV)obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion(arrows).第19頁,共30頁。Thefrequencyofthecrescentsigninthesubchondralinsufficiencyfracturegroupwassimilartothatinosteonecrosisgroupinthecurrentstudy,thusindicatingthatthecrescentsignisnotsufficienttodifferentiateosteonecrosisfromsubchondralinsufficiencyfracture.第20頁,共30頁。B,CoronalT1-weightedimage(TR/TE,470/25)showsdiffuselowsignalintensityinfemoralheadandneck.Low-intensitybandisparallelto
subchondralboneendplate(arrows).Thelow-intensitybandonT1-weightedimagesinsubchondralinsufficiencyfracturecorrespondshistologicallytothefracturelineandassociatedfracturerepairtissue.Therefore,theshapeofthelow-intensitybandgenerallytendstobeirregular,disconnected,andconvextothearticularsurface.第21頁,共30頁。D,AxialslicesofT1-weightedimage(500/15)showlow-intensitybandmainlyinanteriorregion,whichisinterruptedinmiddle(arrows).第22頁,共30頁。E,Fat-saturatedcontrast-enhancedMRI(fromimageshowninD)(605/14)inwhichpartofproximalportionbeyondlow-intensitybandshowscontrastenhancementindicatingperfusion(arrows).第23頁,共30頁。F,Cutsectionofresectedfemoralheadshowssubchondralfractureline(blackarrow)andwhitishlinearshapedareabeneatharticularcartilage(whitearrow).第24頁,共30頁。G,Bandregionhistopathologicallycorrespondstofracturecallus,reactivecartilage,andgranulationtissue.(HandE,×40)第25頁,共30頁。第26頁,共30頁。Limititions樣本量小對于軟骨下不全骨折早期表現(xiàn),如軟骨下水腫,由于在平片上未見異常,未被納入。僅4例進(jìn)行了增強(qiáng)MR檢查。第27頁,共30頁。真愛生命,拒絕酒精第28頁,共30頁。統(tǒng)計學(xué)方法StatisticalanalyseswereperformedusingFisher’sexact
probabilitytestwithregardtosex,ahis
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