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Article(id=1198200262063129055, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198200256912519683, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.0534.2023.1130, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1681228800000, receivedDateStr=2023-04-12, revisedDate=null, revisedDateStr=null, acceptedDate=1688918400000, acceptedDateStr=2023-07-10, onlineDate=1763602803960, onlineDateStr=2025-11-20, pubDate=1732723200000, pubDateStr=2024-11-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763602803960, onlineIssueDateStr=2025-11-20, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763602803960, creator=13701087609, updateTime=1763602803960, updator=13701087609, issue=Issue{id=1198200256912519683, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='11', pageStart='1221', pageEnd='1342', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763602802732, creator=13701087609, updateTime=1763603918291, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1198204935973204862, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198200256912519683, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1198204935973204863, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1198200256912519683, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1272, endPage=1280, ext={EN=ArticleExt(id=1198200262352536037, articleId=1198200262063129055, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Factors influencing early collapse progression of the femoral head after allogenic fibula grafting and their predictive value, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To explore the influential factors and predictive value of early femoral head collapse progression following allogeneic fibula grafting (AFG) surgery. Methods Clinical and radiological data of 68 patients (75 hips) with osteonecrosis of the femoral head (ONFH) who underwent AFG between January 2008 and December 2022 at the Orthopedics and Traumatology Department, Affiliated Hospital of Nanjing University of Chinese Medicine were retrospectively analyzed. Seventy-five hips were divided into stable (n=40) and progressive (n=35) groups based on the presence or absence of postoperative collapse progression. Age, gender, etiology, location of the lesion, Association Research Circulation Osseous (ARCO) stage, Japanese Committee of Osteonecrosis Investigation (JIC) classification, China-Japan Friendship Hospital (CJFH) classification, and Hounsfield units (HU) value of anterolateral sclerosis rim (ⅠSHU) were collected. Univariate and multivariate logistic regression analyses were used to identify the factors influencing early collapse progression after AFG. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of the identified factors influencing postoperative early collapse progression. Results Of the 75 hips, 35(46.7%) had postoperative collapse progression. Univariate logistic regression analysis showed that age, ARCO stage, JIC classification, and ⅠSHU were in fluencing factors for early femoral head collapse progression after AFG (P<0.05). Multivariate logistic regression analysis showed that ARCO stage ⅢA and JIC classification C2 were independent risk factors for early femoral head collapse progression after AFG, while ⅠSHU was identified as an independent protective factor (P<0.05). The ROC curve analysis showed that the sensitivities of ARCO stage, JIC classification, ⅠSHU, and the combined predictive model were 0.850, 0.725, 0.800, and 0.775, the specificities were 0.486, 0.657, 0.743, and 0.914, and the area under the ROC curve (AUC) were 0.668, 0.725, 0.811, and 0.896, respectively. Conclusions ⅠSHU is associated with early collapse progression after AFG in patients with ONFH. ARCO stage ⅢA, JIC classification C2, and ⅠSHU are independent factors influencing postoperative early collapse progression and have a certain predictive value.

, correspAuthors=Xin Liu, authorNote=null, correspAuthorsNote=
E-mail:
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目的 探讨同种异体腓骨植骨术(AFG)后早期股骨头发生塌陷进展的影响因素及其预测价值。方法 回顾性分析2008年1月－2022年12月在南京中医药大学附属医院接受AFG治疗的68例(75髋)股骨头坏死(ONFH)患者的临床和影像学资料。根据术后股骨头是否发生塌陷进展将75髋分为稳定组(n=40)与进展组(n=35)。收集患者的年龄、性别、病因、发病部位、国际骨循环协会(ARCO)分期、日本骨坏死调查委员会(JIC)分型、中日友好医院(CJFH)分型、前外侧柱硬化带HU值(ⅠSHU)等资料。采用单因素和多因素logistic回归分析AFG术后早期股骨头发生塌陷进展的影响因素，采用受试者工作特征(ROC)曲线分析各影响因素预测AFG术后早期股骨头塌陷进展的价值。结果 75髋中，术后股骨头发生塌陷进展35髋(46.7%)。单因素logistic回归分析结果显示，年龄、ARCO分期、JIC分型和ⅠSHU是AFG术后股骨头塌陷进展的影响因素(P<0.05)。多因素logistic回归分析结果显示，ARCO ⅢA分期、JIC C2分型是AFG术后早期股骨头塌陷进展的独立危险因素，ⅠSHU是AFG术后早期股骨头塌陷进展的独立保护因素(P<0.05)。ROC曲线分析结果显示，ARCO分期、JIC分型、ⅠSHU单项及联合预测AFG术后早期股骨头塌陷进展的敏感度为0.850、0.725、0.800、0.775，特异度为0.486、0.657、0.743、0.914，曲线下面积(AUC)为0.668、0.725、0.811、0.896。结论 ⅠSHU与术后早期股骨头塌陷进展存在相关性，ARCO ⅢA分期、JIC C2分型和ⅠSHU是AFG术后早期股骨头塌陷进展的独立影响因素并具有一定的预测价值。

, correspAuthors=刘锌, authorNote=null, correspAuthorsNote=
刘锌，E-mail：
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黄艺轩，硕士研究生，主要从事骨与关节的临床研究

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黄艺轩，硕士研究生，主要从事骨与关节的临床研究

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黄艺轩，硕士研究生，主要从事骨与关节的临床研究

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Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips[J]. J Bone Joint Surg Am, 1995, 77(5): 681-694., articleTitle=Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips, refAbstract=null), Reference(id=1198318995934904517, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, doi=null, pmid=null, pmcid=null, year=2020, volume=102, issue=7, pageStart=838, pageEnd=844, url=null, language=null, rfNumber=[29], rfOrder=28, authorNames=Chen L, Hong G, Hong Z, journalName=Bone Joint J, refType=null, unstructuredReference=Chen L, Hong G, Hong Z, et al. Optimizing indications of impacting bone allograft transplantation in osteonecrosis of the femoral head[J]. 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BMC Musculoskelet Disord, 2015, 16: 140., articleTitle=Should thorough debridement be used in fibular allograft with impaction bone grafting to treat femoral head necrosis: a biomechanical evaluation, refAbstract=null)], funds=[Fund(id=1198318992428466304, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, awardId=82074471, language=EN, fundingSource=General Program of National Natural Science Foundation of China(82074471), fundOrder=null, country=null), Fund(id=1198318992554295425, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, awardId=82074471, language=CN, fundingSource=国家自然科学基金面上项目(82074471), fundOrder=null, country=null), Fund(id=1198318992818536580, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, awardId=81804117, language=EN, fundingSource=Youth Fund of National Natural Science Foundation of China(81804117), fundOrder=null, country=null), Fund(id=1198318992940171398, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, awardId=81804117, language=CN, fundingSource=国家自然科学基金青年基金(81804117), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1198318985709192092, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, xref=null, ext=[AuthorCompanyExt(id=1198318985717580700, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, companyId=1198318985709192092, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=Orthopedics and Traumatology Department, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210029, China), AuthorCompanyExt(id=1198318985730163613, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, companyId=1198318985709192092, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=南京中医药大学附属医院骨伤科，江苏南京 210029)])], figs=[ArticleFig(id=1198318990079655998, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Fig.1, caption=Three-dimensional reconstruction of the proximal femur and sclerosis rim, figureFileSmall=0KCssbStoGiT7mYZus9vJQ==, figureFileBig=XjbZVGsW1NjBWPTlX5ONwg==, tableContent=null), ArticleFig(id=1198318990197096513, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=图1, caption=股骨近端及硬化带的三维模型重建

A. 初始股骨蒙版；B. 人工勾画后股骨蒙版；C. 股骨三维重建模型；D. 初始硬化带蒙版；E. 人工勾画后硬化带蒙版；F. 硬化带三维重建模型

, figureFileSmall=0KCssbStoGiT7mYZus9vJQ==, figureFileBig=XjbZVGsW1NjBWPTlX5ONwg==, tableContent=null), ArticleFig(id=1198318990348091462, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Fig.2, caption=Segmentation of the femoral head and sclerosis rim using a four-plane and nine-column system, figureFileSmall=msqycZ2OjEqsgrvuqZoYRQ==, figureFileBig=1+M3GgIdCybirsG1EmHyWw==, tableContent=null), ArticleFig(id=1198318990511669321, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=图2, caption=四面九柱体系与股骨头、硬化带分割

RP. 参考面；AP. 前侧面；PR. 后侧面；LP. 外侧面；MP. 内侧面；Ⅰ. 前外侧柱；Ⅱ. 中外侧柱；Ⅲ. 前中侧柱；ⅠS. 前外侧柱硬化带；ⅡS. 中外侧柱硬化带；ⅢS. 前中侧柱硬化带；A、B、C. 四面九柱体系冠状位、矢状位、水平位视图；D、E、F. 前外侧区三柱冠状位、矢状位、水平位视图；G、H、I. 前外侧区硬化带冠状位、矢状位、水平位视图

, figureFileSmall=msqycZ2OjEqsgrvuqZoYRQ==, figureFileBig=1+M3GgIdCybirsG1EmHyWw==, tableContent=null), ArticleFig(id=1198318990641692749, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Fig.3, caption=Measurement of HU value of anteromedial sclerosis rim, figureFileSmall=F9w6wDNaD9GrebqUpi245w==, figureFileBig=Z0Cm1b4NfXfBR3WwE/BSxw==, tableContent=null), ArticleFig(id=1198318990721384527, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=图3, caption=前中侧柱硬化带HU值测量

ⅢS. 前中侧柱硬化带；A. 硬化带蒙版；B. 分割ⅢS蒙版；C. 计算ⅢS蒙版平均HU值

, figureFileSmall=F9w6wDNaD9GrebqUpi245w==, figureFileBig=Z0Cm1b4NfXfBR3WwE/BSxw==, tableContent=null), ArticleFig(id=1198318990817853524, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Fig.4, caption=The concentric circular vertical measurement method and correspondence, figureFileSmall=KdSymMkrNqOaGHnpMJ34YA==, figureFileBig=wBpiSQalO7KhAjo1DOj0aQ==, tableContent=null), ArticleFig(id=1198318990943682647, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=图4, caption=同心圆垂直测量法测量股骨头塌陷程度及对应关系

A. 同心圆测量法，o为圆心，ab间距离为股骨头塌陷程度；B. 前外侧柱(Ⅰ)在蛙位的对应位置(红色区域)；C. 前外侧柱硬化带(ⅠS)在蛙位的对应位置(红色区域)

, figureFileSmall=KdSymMkrNqOaGHnpMJ34YA==, figureFileBig=wBpiSQalO7KhAjo1DOj0aQ==, tableContent=null), ArticleFig(id=1198318991052734555, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Fig.5, caption=ROC curve analysis the predictive value of ARCO staging, JIC classification, ⅠSHU, and the combined early collapse progression after AFG, figureFileSmall=nuP1LxybhBCJZGzyqj1zWw==, figureFileBig=lj2zVNPdsMYGCZfdiy8c8A==, tableContent=null), ArticleFig(id=1198318991145009247, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=图5, caption=ROC曲线分析ARCO分期、JIC分型、ⅠSHU单项及联合预测AFG术后早期股骨头塌陷进展的价值

ROC. 受试者工作特征；AUC. 曲线下面积；ARCO. 国际骨循环协会分期；JIC. 日本股骨头坏死调查协会分型；ⅠSHU. 前外侧柱硬化带HU值；AFG. 同种异体腓骨植骨术

, figureFileSmall=nuP1LxybhBCJZGzyqj1zWw==, figureFileBig=lj2zVNPdsMYGCZfdiy8c8A==, tableContent=null), ArticleFig(id=1198318991245672544, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Fig.6, caption=Preoperative influencing factors and postoperative femoral head collapse progression in typical cases of allogeneic fibular grafting surgery, figureFileSmall=HH2BOvwmoYmkViiBLWxffQ==, figureFileBig=/5hSYgmsxq8rjgoyVzbe3g==, tableContent=null), ArticleFig(id=1198318991342141537, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=图6, caption=同种异体腓骨植骨术典型病例的术前影响因素及术后股骨头塌陷进展情况

病例1：男，18岁，左髋疼痛6个月，诊断为激素性股骨头坏死，ARCO ⅢA期，JIC C1型，前外侧柱硬化带HU值(ⅠSHU)为771.3 HU，术后12个月股骨头塌陷进展1.5 mm。A、B. 术前左髋关节正位、蛙位X线平片；C、D. 术后12个月正位、蛙位X线平片。病例2，男，32岁，左髋疼痛1个月，诊断为特发性股骨头坏死，ARCO ⅢA期，JIC C2型，ⅠSHU为583.0 HU，术后12个月股骨头塌陷进展8.9 mm。E、F. 术前左髋关节正位、蛙位X线平片；G、H. 术后12个月正位、蛙位X线平片

, figureFileSmall=HH2BOvwmoYmkViiBLWxffQ==, figureFileBig=/5hSYgmsxq8rjgoyVzbe3g==, tableContent=null), ArticleFig(id=1198318991514108006, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Tab.1, caption=

Comparison of clinical and radiographic data between stable and progressive groups

, figureFileSmall=null, figureFileBig=null, tableContent=
项目稳定组(n=40)进展组(n=35)P
年龄[岁, M(Q1, Q3)]32.5(29.3, 43.0)50(37.0, 54.0)0.001
性别[例(%)]0.861
女11(27.5)9(25.7)
男29(72.5)26(74.3)
ONFH病因[例(%)]0.518
AONFH7(17.5)10(28.6)
SANFH15(37.5)11(31.4)
IONFH18(45.0)14(40.0)
位置[髋(%)]0.078
右侧17(42.5)22(62.9)
左侧23(57.5)13(37.1)
ARCO分期[髋(%)]0.002
Ⅱ期34(85.0)18(51.4)
ⅢA期6(15.0)17(48.6)
JIC分型[髋(%)]0.001
B型8(20.0)0
C1型21(52.5)12(34.3)
C2型11(27.5)23(65.7)
CJFH分型[髋(%)]0.583
C型1(2.5)1(2.9)
L1型11(27.5)5(14.3)
L2型22(55.0)23(65.7)
L3型6(15.0)6(17.1)
HU值(HU, $\bar{x}±s$)685.94±64.10642.53±50.470.223
ⅠSHU(HU, $\bar{x}±s$)683.77±78.28606.55±47.080.001
ⅡSHU(HU, $\bar{x}±s$)684.68±75.19629.08±54.690.111
ⅢSHU(HU, $\bar{x}±s$)681.19±64.19638.72±54.910.435
), ArticleFig(id=1198318991602188393, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=表1, caption=

稳定组与进展组临床和影像学资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
项目稳定组(n=40)进展组(n=35)P
年龄[岁, M(Q1, Q3)]32.5(29.3, 43.0)50(37.0, 54.0)0.001
性别[例(%)]0.861
女11(27.5)9(25.7)
男29(72.5)26(74.3)
ONFH病因[例(%)]0.518
AONFH7(17.5)10(28.6)
SANFH15(37.5)11(31.4)
IONFH18(45.0)14(40.0)
位置[髋(%)]0.078
右侧17(42.5)22(62.9)
左侧23(57.5)13(37.1)
ARCO分期[髋(%)]0.002
Ⅱ期34(85.0)18(51.4)
ⅢA期6(15.0)17(48.6)
JIC分型[髋(%)]0.001
B型8(20.0)0
C1型21(52.5)12(34.3)
C2型11(27.5)23(65.7)
CJFH分型[髋(%)]0.583
C型1(2.5)1(2.9)
L1型11(27.5)5(14.3)
L2型22(55.0)23(65.7)
L3型6(15.0)6(17.1)
HU值(HU, $\bar{x}±s$)685.94±64.10642.53±50.470.223
ⅠSHU(HU, $\bar{x}±s$)683.77±78.28606.55±47.080.001
ⅡSHU(HU, $\bar{x}±s$)684.68±75.19629.08±54.690.111
ⅢSHU(HU, $\bar{x}±s$)681.19±64.19638.72±54.910.435
), ArticleFig(id=1198318991698657388, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Tab.2, caption=

Univariate logistic regression analysis of factors affecting collapse progression after AFG

, figureFileSmall=null, figureFileBig=null, tableContent=
变量βSEWald χ2POR95%CI
年龄0.0760.02310.7100.0011.0791.031~1.130
ARCO分期(Ⅱ期 vs. ⅡA期)1.6770.2919.0630.0035.2521.796~15.951
JIC分型(B型 vs. C1型 vs. C2型)1.5840.44812.2080.0014.8762.026~11.737
ⅠSHU-0.0220.00614.6950.0010.9780.967~0.989
), ArticleFig(id=1198318991807709292, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=表2, caption=

AFG术后股骨头塌陷进展影响因素的单因素logistic回归分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量βSEWald χ2POR95%CI
年龄0.0760.02310.7100.0011.0791.031~1.130
ARCO分期(Ⅱ期 vs. ⅡA期)1.6770.2919.0630.0035.2521.796~15.951
JIC分型(B型 vs. C1型 vs. C2型)1.5840.44812.2080.0014.8762.026~11.737
ⅠSHU-0.0220.00614.6950.0010.9780.967~0.989
), ArticleFig(id=1198318991904178287, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Tab.3, caption=

Multivariate logistic regression analysis of factors influencing collapse progression after AFG

, figureFileSmall=null, figureFileBig=null, tableContent=
变量βSEWald χ2POR95%CI
年龄0.0380.0301.6460.1991.0390.980~1.100
ARCO分期(Ⅱ期 vs. ⅢA期)1.7160.7475.2780.0225.5651.287~24.064
JIC分型(B型 vs. C1型 vs. C2型)1.3570.5965.1950.0233.8861.209~12.488
ⅠSHU-0.0210.00710.2210.0010.9790.966~0.992
), ArticleFig(id=1198318991996452977, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=表3, caption=

AFG术后股骨头塌陷进展影响因素的多因素logistic回归分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量βSEWald χ2POR95%CI
年龄0.0380.0301.6460.1991.0390.980~1.100
ARCO分期(Ⅱ期 vs. ⅢA期)1.7160.7475.2780.0225.5651.287~24.064
JIC分型(B型 vs. C1型 vs. C2型)1.3570.5965.1950.0233.8861.209~12.488
ⅠSHU-0.0210.00710.2210.0010.9790.966~0.992
), ArticleFig(id=1198318992113893492, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=EN, label=Tab.4, caption=

Predictive value of factors influencing collapse progression after AFG based on ROC curve analysis

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变量截断值敏感度特异度约登指数AUC(95%CI)P
ARCO分期0.500期*0.8500.4860.3360.668(0.543~0.793)0.013
JIC分型2.500型*0.7250.6570.3820.725(0.611~0.840)0.001
ⅠSHU579.050 HU0.8000.7430.5430.811(0.713~0.908)0.001
ARCO+JIC+ⅠSHU0.7750.9140.6890.896(0.823~0.968)0.001
), ArticleFig(id=1198318992256499832, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1198200262063129055, language=CN, label=表4, caption=

ROC曲线分析各影响因素对AFG术后股骨头发生塌陷进展的预测价值

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变量截断值敏感度特异度约登指数AUC(95%CI)P
ARCO分期0.500期*0.8500.4860.3360.668(0.543~0.793)0.013
JIC分型2.500型*0.7250.6570.3820.725(0.611~0.840)0.001
ⅠSHU579.050 HU0.8000.7430.5430.811(0.713~0.908)0.001
ARCO+JIC+ⅠSHU0.7750.9140.6890.896(0.823~0.968)0.001
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同种异体腓骨植骨术后股骨头早期塌陷进展的影响因素及其预测价值
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黄艺轩 , 郭铭滨 , 麦健斌 , 袁鑫玮 , 席洪钟 , 宋伟 , 杜斌 , 刘锌 *
解放军医学杂志 | 临床研究 2024,49(11): 1272-1280
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解放军医学杂志 | 临床研究 2024, 49(11): 1272-1280
同种异体腓骨植骨术后股骨头早期塌陷进展的影响因素及其预测价值
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黄艺轩, 郭铭滨, 麦健斌, 袁鑫玮, 席洪钟, 宋伟, 杜斌, 刘锌*
作者信息
  • 南京中医药大学附属医院骨伤科，江苏南京 210029

    • 黄艺轩，硕士研究生，主要从事骨与关节的临床研究

通讯作者:

刘锌，E-mail：
Factors influencing early collapse progression of the femoral head after allogenic fibula grafting and their predictive value
Yi-Xuan Huang, Ming-Bin Guo, Jian-Bin Mai, Xin-Wei Yuan, Hong-Zhong Xi, Wei Song, Bin Du, Xin Liu*
Affiliations
  • Orthopedics and Traumatology Department, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210029, China
出版时间: 2024-11-28 doi: 10.11855/j.issn.0577-7402.0534.2023.1130
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摘要
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目的 探讨同种异体腓骨植骨术(AFG)后早期股骨头发生塌陷进展的影响因素及其预测价值。方法 回顾性分析2008年1月－2022年12月在南京中医药大学附属医院接受AFG治疗的68例(75髋)股骨头坏死(ONFH)患者的临床和影像学资料。根据术后股骨头是否发生塌陷进展将75髋分为稳定组(n=40)与进展组(n=35)。收集患者的年龄、性别、病因、发病部位、国际骨循环协会(ARCO)分期、日本骨坏死调查委员会(JIC)分型、中日友好医院(CJFH)分型、前外侧柱硬化带HU值(ⅠSHU)等资料。采用单因素和多因素logistic回归分析AFG术后早期股骨头发生塌陷进展的影响因素，采用受试者工作特征(ROC)曲线分析各影响因素预测AFG术后早期股骨头塌陷进展的价值。结果 75髋中，术后股骨头发生塌陷进展35髋(46.7%)。单因素logistic回归分析结果显示，年龄、ARCO分期、JIC分型和ⅠSHU是AFG术后股骨头塌陷进展的影响因素(P<0.05)。多因素logistic回归分析结果显示，ARCO ⅢA分期、JIC C2分型是AFG术后早期股骨头塌陷进展的独立危险因素，ⅠSHU是AFG术后早期股骨头塌陷进展的独立保护因素(P<0.05)。ROC曲线分析结果显示，ARCO分期、JIC分型、ⅠSHU单项及联合预测AFG术后早期股骨头塌陷进展的敏感度为0.850、0.725、0.800、0.775，特异度为0.486、0.657、0.743、0.914，曲线下面积(AUC)为0.668、0.725、0.811、0.896。结论 ⅠSHU与术后早期股骨头塌陷进展存在相关性，ARCO ⅢA分期、JIC C2分型和ⅠSHU是AFG术后早期股骨头塌陷进展的独立影响因素并具有一定的预测价值。

股骨头坏死  /  硬化带  /  异体腓骨植骨术  /  影响因素

Objective To explore the influential factors and predictive value of early femoral head collapse progression following allogeneic fibula grafting (AFG) surgery. Methods Clinical and radiological data of 68 patients (75 hips) with osteonecrosis of the femoral head (ONFH) who underwent AFG between January 2008 and December 2022 at the Orthopedics and Traumatology Department, Affiliated Hospital of Nanjing University of Chinese Medicine were retrospectively analyzed. Seventy-five hips were divided into stable (n=40) and progressive (n=35) groups based on the presence or absence of postoperative collapse progression. Age, gender, etiology, location of the lesion, Association Research Circulation Osseous (ARCO) stage, Japanese Committee of Osteonecrosis Investigation (JIC) classification, China-Japan Friendship Hospital (CJFH) classification, and Hounsfield units (HU) value of anterolateral sclerosis rim (ⅠSHU) were collected. Univariate and multivariate logistic regression analyses were used to identify the factors influencing early collapse progression after AFG. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of the identified factors influencing postoperative early collapse progression. Results Of the 75 hips, 35(46.7%) had postoperative collapse progression. Univariate logistic regression analysis showed that age, ARCO stage, JIC classification, and ⅠSHU were in fluencing factors for early femoral head collapse progression after AFG (P<0.05). Multivariate logistic regression analysis showed that ARCO stage ⅢA and JIC classification C2 were independent risk factors for early femoral head collapse progression after AFG, while ⅠSHU was identified as an independent protective factor (P<0.05). The ROC curve analysis showed that the sensitivities of ARCO stage, JIC classification, ⅠSHU, and the combined predictive model were 0.850, 0.725, 0.800, and 0.775, the specificities were 0.486, 0.657, 0.743, and 0.914, and the area under the ROC curve (AUC) were 0.668, 0.725, 0.811, and 0.896, respectively. Conclusions ⅠSHU is associated with early collapse progression after AFG in patients with ONFH. ARCO stage ⅢA, JIC classification C2, and ⅠSHU are independent factors influencing postoperative early collapse progression and have a certain predictive value.

femoral head osteonecrosis  /  sclerosis rim  /  allogeneic fibula grafting  /  influential factors
黄艺轩, 郭铭滨, 麦健斌, 袁鑫玮, 席洪钟, 宋伟, 杜斌, 刘锌. 同种异体腓骨植骨术后股骨头早期塌陷进展的影响因素及其预测价值. 解放军医学杂志, 2024 , 49 (11) : 1272 -1280 . DOI: 10.11855/j.issn.0577-7402.0534.2023.1130
Yi-Xuan Huang, Ming-Bin Guo, Jian-Bin Mai, Xin-Wei Yuan, Hong-Zhong Xi, Wei Song, Bin Du, Xin Liu. Factors influencing early collapse progression of the femoral head after allogenic fibula grafting and their predictive value[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (11) : 1272 -1280 . DOI: 10.11855/j.issn.0577-7402.0534.2023.1130
正文
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股骨头坏死(osteonecrosis of the femoral head，ONFH)是一种难治性、高致残性疾病，好发于中青年，给家庭和社会带来了巨大的经济负担[1]。在ONFH晚期进行全髋关节置换术是一种有效的干预[2]，但对于青年患者应尽可能避免过早进行全髋关节置换手术，否则在他们一生中将可能进行多次翻修手术，因此早期进行保髋手术干预非常必要。保髋手术的目的是通过提供足够的机械支撑以避免股骨头过早塌陷，同时恢复坏死区域内的血运。既往研究发现，同种异体腓骨植入术(allogenic fibula grafting，AFG)治疗ONFH取得了令人满意的疗效[3]，但存在术后股骨头过早塌陷的可能。因此，术前应分析不同影响因素以预测预后，从而指导临床决策。硬化带是ONFH患者在X线平片或CT检查中于坏死区与正常组织之间出现的不规则或条带状高密度影[4]。既往研究表明，软骨下骨硬化带在股骨头塌陷过程中可起到保护作用[5-8]。然而目前关于硬化带的特征与AFG术后股骨头塌陷关系的报道较少。为此，本研究探讨硬化带HU值(Hounsfield units，HU)与AFG术后早期股骨头塌陷的关系，并分析AFG术后早期股骨头塌陷进展的影响因素及其预测价值。
1 资料与方法
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1.1 研究对象
回顾性纳入2008年1月－2022年12月南京中医药大学附属医院收治的68例ONFH患者。纳入标准：(1)符合《成人股骨头坏死临床诊断与治疗指南(2019年版)》[9]中成人非创伤性ONFH诊断标准；(2)2019年国际骨循环协会(Association Research Circulation Osseous，ARCO)分期[10]Ⅱ、ⅢA期；(3)年龄18~60岁；(4)采用AFG行保髋手术。排除标准：(1)病程短或随访时间1年；(2)缺乏术前髋关节正位或蛙位X线平片，或缺乏术后随访影像学资料；(3)因成像体位不符合或其他原因导致成像不规范，影响相关数据的测量。本研究获南京中医药大学附属医院伦理委员会审批(2023NL-001-01)，免除患者知情同意。
1.2 临床资料收集
从电子病历和医院数据库获得临床和影像学资料，其中临床资料包括患者年龄、性别、发病部位、病因(酒精性、激素性或特发性)等；影像学资料包括术前双髋关节正位和蛙位X线平片、术前最近一次双髋关节CT图像、术后末次随访(术后第12个月)的双髋关节蛙位X线平片。由1名骨科医师A对术前正位X线平片进行评估，并根据ARCO分期[10]、日本骨坏死调查委员会(Japanese Committee of Osteonecrosis Investigation，JIC)分型[11]、中日友好医院(China-Japan Friendship Hospital，CJFH)分型[12]进行分类。所有双髋关节CT图像采集参数：管电压120~140 kV，管电流220~680 mA，层厚1~3 mm，重建矩阵512×512。
1.3 手术方法
患者取仰卧位，术侧抬高20°。股骨大转子下方做6~8 cm纵向切口暴露，于大转子下方1.5 cm处向坏死区中心钻入1枚直径2 mm克氏针至股骨头下0.5 cm进行定位。沿克氏针用动力髋的扩孔器钻出骨隧道至软骨下3~5 mm，根据干燥异体腓骨直径用定制型扩髓器扩大骨隧道，清除坏死灶，同时收集隧道内健康骨泥备用。用一长柄角度刮匙深入骨隧道到达坏死区内搔刮，以尽量清除死骨，注意保护前外侧柱骨质和硬化带，操作过程应避免穿破关节面。病灶清理完毕，充分冲洗骨隧道，经隧道填充松质骨粒，用不同直径及角度自制植骨棒适当改善或纠正股骨头轮廓，松质骨厚度5~10 mm，测量骨隧道深度，植入相应直径及长度的干燥异体腓骨。裁剪多余的皮质骨条紧贴腓骨打压在隧道口。
1.4 术后康复
术后3个月内所有患者禁止患肢负重，卧床进行下肢关节的主被动锻炼；术后3个月复查，根据X线平片复查情况，可拄双拐部分负重；术后6个月如骨植入物整合良好，可脱拐行走。
1.5 股骨头三维模型重建与分割
由1名骨科医师A完成以下步骤：(1)CT图像导入。打开Mimics软件(21.0版，Materialise，Leuven，Belgium)，将CT图像以DICOM格式导入。(2)重建三维图像。点击Segment栏目，选择New Mask指令，股骨Threshold选择在226~2566 HU；硬化带为520~2566 HU(图1A、D)。利用Edit Mask指令，在每个层面勾画股骨近端与硬化带的蒙版，其中硬化带定义为坏死区周围不规则或条带状高密度影，皮质骨和压力性骨小梁的高密度影应被去除(图1B、E)。利用Calculate Part指令重建股骨近端与硬化带的三维模型(图1C、F)。(3)三维图像的分区与分割。在已经提出的三维三柱体系[13]上进一步细化，建立两个平行于参考平面(reference plane，RP)的面：前平面(anterior plane，AP)和后平面(posterior plane，PP)，使用3D TOOLS栏目中With Plane指令将股骨头与硬化带在水平位平均分割为三部分；结合Liu等[13]提出的外侧面(lateral plane，LP)与内侧面(medial plane，MP)，构建一个新的四面九柱体系(图2A、B、C)。本研究将前外侧区域内的3个负重柱定义为感兴趣区(region of interest，ROI)，即前外侧柱(Ⅰ)、中外侧柱(Ⅱ)和前中侧柱(Ⅲ) (图2D、E、F)；3个感兴趣区域的硬化带分别命名为前外侧柱硬化带(ⅠS)、中外侧柱硬化带(ⅡS)和前中侧柱硬化带(ⅢS，图2G、H、I)。
1.6 不同三维分区HU值测量
在Segment栏目下选择Split Mask指令，按照不同三维分区在冠状面、矢状面、水平面上的显示位置，将硬化带蒙版分割，分别命名为ⅠS蒙版、ⅡS蒙版、ⅢS蒙版(图3A、B)。使用Mask Properties计算平均HU值并记录，分别为ⅠSHU、ⅡSHU和ⅢSHU(图3C)。
1.7 术后早期股骨头塌陷程度的随访及评估
术后3、6、9、12个月及以后1年1次进行门诊随访，随访截至2023年2月，每次随访均拍摄髋关节正位和蛙位X线平片。Kubo等[14]提出了同心圆垂直测量方法测量股骨头塌陷程度，髋关节蛙位X线平片能反映前外侧区的股骨头塌陷情况[15]，在此基础上本研究使用Auto CAD 2019(美国国立卫生研究院，Bethesda，MD，USA)测量术后第12个月的髋关节蛙位X线平片的股骨头塌陷程度(图4A)，测量方法和术后蛙位与Ⅰ柱和ⅠS的对应位置关系如图4B、C所示。具体方法：根据蛙位X线平片测量股骨头塌陷的程度，即股骨头中心拟合圆与股骨头实际边界在正中垂线上的差值。参考2019年ARCO分期[10]，根据术后股骨头塌陷程度分为塌陷≤2 mm组(稳定组，n=40)与塌陷2 mm组(进展组，n=35)。
1.8 AGF术后股骨头发生塌陷进展的影响因素及其预测价值分析
采用单因素和多因素logistic回归分析AGF术后股骨头发生塌陷进展的影响因素。采用受试者工作特征(receiver operating characteristic curve，ROC)曲线分析相关影响因素预测术后股骨头塌陷进展的价值。
1.9 硬化带HU值提取的一致性分析
为验证硬化带HU值提取的可重复性及再现性，采用SPSS 25.0软件进行分析。随机选取20例患者，由另一名骨科医师B进行一次图像分割并进行硬化带HU值提取，以计算组内相关系数(interclass correlation coefficient，ICC)。ICC0.75表示一致性良好，ICC0.4表示一致性较差。
1.10 统计学处理
使用SPSS 25.0软件进行统计分析。符合正态分布的计量资料以$\bar{x}±s$表示，组间比较采用两独立样本t检验；非正态分布的计量资料以M(Q1，Q3)表示，组间比较采用两独立样本秩和检验；计数资料以例(%)表示，组间比较采用χ2检验。不同病因ONFH的ⅠSHU的差异分析采用Kruskal-Wallis检验。采用R 4.2.1构建ROC曲线，计算曲线下面积(area under curve，AUC)，量化预测价值。P<0.05为差异有统计学意义。
2 结果
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2.1 两组临床和影像学资料比较
共纳入68例ONFH患者(75髋)，其中男51例(55髋)，女17例(20髋)，年龄(40.1±1.4)岁。75髋中，17髋由酒精引起，26髋由皮质激素引起，32髋无明确诱因。ARCO Ⅱ期52髋，ⅢA期23髋；JIC分型B型8髋，C1型33髋，C2型34髋；CJFH分型C型2髋，L1型16髋，L2型45髋，L3型12髋。AFG术后股骨头塌陷稳定40髋(股骨头塌陷≤2 mm，稳定组)，股骨头塌陷进展35髋(股骨头塌陷2 mm，进展组)，股骨头塌陷进展发生率为46.7%(35/75)。两组年龄、ARCO分期、JIC分型和ⅠSHU比较差异有统计学意义(P<0.05)，ONFH病因、位置、CJFH分型等其余变量差异无统计学意义(P>0.05，表1)。
2.2 影像学图像分割及特征提取一致性评价
骨科医师A与骨科医师B对图像分割并进行硬化带HU值提取的ICC为0.853，表明硬化带HU值提取具有良好的一致性，其重复性和再现性满足研究需要。
2.3 AFG术后股骨头塌陷进展影响因素的单因素logistic回归分析
单因素logistic回归分析结果显示，年龄、ARCO分期、JIC分型、ⅠSHU是AFG术后股骨头塌陷进展的影响因素(P<0.05)。年龄每增加1岁，术后股骨头塌陷进展的风险可增加0.079倍；ARCO分期每进展1期，术后股骨头塌陷进展的风险可增加4.252倍(P=0.003)；JIC分型每增加1个等级，术后股骨头塌陷进展的风险较上一分型增加3.876倍(P<0.001)；ⅠSHU每增加1单位，术后股骨头塌陷进展的风险降低2.2%(P<0.001) (表2)。
2.4 AFG术后股骨头塌陷进展影响因素的多因素logistic回归分析
以年龄、ARCO分期(Ⅱ期和ⅢA期分别赋值为0、1)、JIC分型(B型、C1型和C2型分别赋值为1、2、3)和ⅠSHU(股骨头塌陷稳定和塌陷进展分别赋值为0、1)为自变量，以术后早期股骨头是否发生塌陷进展为因变量进行多因素logistic回归分析，结果显示，ARCO ⅢA分期、JIC C2分型是AFG术后早期股骨头塌陷进展的独立危险因素，ⅠSHU是AFG术后早期股骨头塌陷进展的独立保护因素(P<0.05，表3)。
2.5 不同病因ONFH的ⅠSHU差异分析结果
Kruskal-Wallis检验结果显示，酒精性ONFH、皮质激素性ONFH和特发性ONFH之间的ⅠSHU差异无统计学意义(H=3.910，P=0.142)。
2.6 各影响因素预测AFG术后早期股骨头塌陷进展的价值
ROC曲线分析结果显示，ARCO分期、JIC分型、ⅠSHU的截断值依次为0.500期、2.500型、579.050 HU，ARCO分期、JIC分型、ⅠSHU单项及联合预测AFG术后早期股骨头塌陷进展的敏感度为0.850、0.725、0.800、0.775，特异度为0.486、0.657、0.743、0.914，曲线下面积(AUC)为0.668、0.725、0.811、0.896(图5、表4)。截至2023年2月，对75髋术后12个月的临床随访结果显示，术前ⅠSHU较高的髋AFG术后效果较好，股骨头发生塌陷较少(图6A-D)；术前ⅠSHU较低的患者术后股骨头塌陷容易进展(图6E-H)。
3 讨论
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既往研究中硬化带在ONFH病程中的作用一直存在争议。一方面，硬化带的形成可能阻碍血管向坏死区的生长，从而阻碍骨修复进程；此外，股骨头塌陷多发生在硬化带周围，可能与剪切应力有关[16-17]。另一方面，硬化带在ONFH塌陷的进程中能起到力学支撑作用，延缓股骨头塌陷的进展[5,7,18]。对于股骨头塌陷的不同报道结果，可能与硬化带的形态特征有关，因为形态特征上的差异会影响股骨头内的稳定性，从而不同程度影响塌陷的进程[6,19-20]。
然而目前研究发现，硬化带的特征多聚焦于主观的分型或仅在单一层面或部分层面对硬化带的特征进行定性描述，因此导致不同研究者提出的形态分型纷繁多样，致使研究结论之间存在差异，在临床上难以广泛推广应用。面对目前存在的问题，本研究基于Mimics软件利用髋关节CT数据中阈值的不同，完成对股骨头、硬化带等不同密度组织的三维重建，通过软件指令完成对不同区域特征的测量，得到能够定量的、客观反映硬化带特征的硬化带HU值，较好地解决了上述问题。此外，本研究一方面在Liu等[13]三维模型的基础上进行了优化，进一步细化了分区，并对前外侧区域的三柱进行研究，方便直接关注负重区的硬化带特征；另一方面为了更好地反映负重区的股骨头塌陷程度，本研究在术后蛙位X线平片上测量股骨头塌陷程度，采用这一影像学指标来客观评价术后临床疗效。
本研究结果表明，ⅠSHU是术后股骨头塌陷进展的独立保护因素，当ⅠSHU每增加1单位，术后股骨头塌陷进展风险降低2.2%。ⅠSHU与术后股骨头塌陷进展的关系可能通过以下机制解释：(1)有限元分析表明，股骨头应力集中在前外侧柱，前外侧柱是主要的支撑区域[21-22]，因此该区域的力学强度对于股骨头塌陷起到至关重要的作用。前外侧柱硬化带可能有助于提升该区域的力学强度。(2)HU值与骨密度呈线性相关[23]；骨密度高低能够反映硬化带在生物力学弹性模量的大小[24]。因此，随着HU值提高，骨质密度提高，弹性模量相应增加，可能增强了硬化带结构的力学强度，起到力学支撑的作用，对于预防术后骨修复初期过早塌陷、维持股骨头形态完整有重要意义[25]。该结果与Huang等[26]的研究结果一致，他们认为硬化带骨密度是ONFH塌陷的保护因素。但与之不同的是，他们的研究对象为未接受手术治疗的ONFH患者，其股骨头内部的力学稳定性不但没有恢复且可能随坏死范围的扩大进一步恶化；而通过AFG术式可重建股骨头的载荷传导路径，恢复股骨头内部的生物力学稳定性[27]。
除ⅠSHU外，传统的危险因素也在本研究结果中得到验证。既往研究表明，在出现软骨下骨塌陷时，保髋手术并不成功。Urbaniak等[28]报道了带血管腓骨移植术治疗ONFH，发现Steinberg Ⅲ期患者7年失败率为23%(5/22)，Steinberg Ⅳ期患者则高达43%(17/40)。Feng等[3]认为，ARCO Ⅱ期是同种异体腓骨移植术的适应证，当发生股骨头塌陷即进展为ARCO Ⅲ期时更适合带血管蒂大转子自体移植。与本研究结果一致：ARCO分期每向后进展1期，术后股骨头塌陷进展的风险可提升4.565倍(P=0.003)。JIC分型或病变的位置常被认为是影响治疗效果的重要因素，坏死区域范围累积到外侧柱时预后较差。Chen等[29]发现，B型和C1型患者行AFG的失败率低于6.9%(2/29)，而C2型患者的失败率为28.6%(10/35)。与本研究结果一致：JIC分型每增加1个等级，术后股骨头塌陷进展的风险较上一分型增加2.886倍(P<0.001)。
在临床实践中，AFG术中打通股骨头远端硬化带是必须的，主要作用：一方面能释放股骨头内的压力，重新恢复坏死区血供；另一方面为死骨清理、松质骨植骨和腓骨棒置入提供了通道。Zhou等[30]认为，AFG术中对于死骨的清理应该谨慎，清创范围在3/8~1/2坏死区域内相较彻底清创更能避免股骨头塌陷的进一步发生。但目前关于股骨头近端硬化带，尤其是前外侧负重区硬化带在术中如何处理尚未见报道。笔者认为，AFG术中应尽可能地保护前外侧柱和前外侧柱硬化带的完整性。
本研究存在以下局限性：(1)为单中心回顾性研究，引入了各种偏倚，包括选择偏倚、失访和数据缺失等；(2)保髋手术需要严格把握手术适应证，入选患者数量有限；(3)股骨头塌陷进展定义为在随访1年内发生塌陷或塌陷进展。因此，综合指标的预测性能应严格限制在术后早期。未来可通过构建有限元模型，从生物力学的角度进行大样本多中心的长期随访研究来验证该结果。
综上所述，本研究结果表明，ⅠSHU与AFG术后早期股骨头塌陷存在相关性。ARCO ⅢA分期、JIC C2分型是AFG术后早期股骨头塌陷进展的独立危险因素，ⅠSHU是AFG术后早期股骨头塌陷进展的独立保护因素。ARCO+JIC+ⅠSHU联合可能预测术后早期股骨头塌陷进展。
基金
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  • 国家自然科学基金面上项目(82074471)
  • 国家自然科学基金青年基金(81804117)
文献
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2024年第49卷第11期
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doi: 10.11855/j.issn.0577-7402.0534.2023.1130
  • 接收时间：2023-04-12
  • 首发时间：2025-11-20
  • 出版时间：2024-11-28
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  • 收稿日期：2023-04-12
  • 录用日期：2023-07-10
基金
General Program of National Natural Science Foundation of China(82074471)
国家自然科学基金面上项目(82074471)
Youth Fund of National Natural Science Foundation of China(81804117)
国家自然科学基金青年基金(81804117)
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    南京中医药大学附属医院骨伤科，江苏南京 210029

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刘锌，E-mail：
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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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