Chinese Journal of Tissue Engineering Research ›› 2019, Vol. 23 ›› Issue (16): 2516-2522.doi: 10.3969/j.issn.2095-4344.1148
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Role of bone status in anterolateral portion of femoral head in the progression of osteonecrosis of the femoral head
Wei Qiushi1, 2, Fang Bin2, Chen Zhenqiu2, He Mincong3, Chen Xiaojun3, Yang Fan3, Zhang Qingwen1, 2, He Wei1, 2
- 1Hip Preserving Ward of Third Department of Orthopedics, 2Third Department of Orthopedics, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510407, Guangdong Province, China; 3Guangzhou University of Chinese Medicine, Guangzhou 510405, Guangdong Province, China
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Online:2019-06-08Published:2019-06-08 -
Contact:He Wei, Chief physician, Professor, Doctoral supervisor, Hip Preserving Ward of Third Department of Orthopedics, Third Department of Orthopedics, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510407, Guangdong Province, China -
About author:Wei Qiushi, MD, Hip Preserving Ward of Third Department of Orthopedics, Third Department of Orthopedics, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510407, Guangdong Province, China -
Supported by:国家自然科学基金(81573996)，项目负责人：陈振秋|国家自然科学基金(81473697)，项目负责人：何伟|广东省科技计划项目(2016A020226028)
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Wei Qiushi, Fang Bin, Chen Zhenqiu, He Mincong, Chen Xiaojun, Yang Fan, Zhang Qingwen, He Wei. Role of bone status in anterolateral portion of femoral head in the progression of osteonecrosis of the femoral head[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(16): 2516-2522.
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Imageology evaluation MRI and radiographs were analyzed in consensus by two experienced orthopedic surgeons in the diagnosis and treatment for ONFH. By screening T1-weighted MRI images, the diagnosis of ONFH was identified on the basis of previously published criteria, and the stage of the disease and subclassifications were defined according to the ARCO staging system[18]. The extent of the necrotic lesion in MRI was graded from A to C, representing less than 15% (type A), 15%-30% (type B) and more than 30% femoral head involvement (type C). Although the value of the China-Japan Friendship Hospital classification of ONFH based on 3 pillars of the femoral head is higher in predicting the collapse risk[19], the disadvantage is that the missed diagnosis rate of collapse is existent (Figure 1). Based on this, FLL classification was proposed according to the site of the necrotic lesion on the anterolateral portion of the femoral head. Accordingly, the location of the necrotic lesion within the femoral head was described as posteromedial and central portions (type 1), part of the anterolateral portion (type 2), and the entire anterolateral portion (type 3), which account for 25%, 50%, and 25% of the head width, respectively (Figure 2). The collapse rate and the time to collapse in different types were assessed."
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Statistical analysis The data were analyzed using SPSS version 13.0 (SPSS Inc., USA). A P value of less than 0.05 was considered statistically significant. Chi-square and Fisher’s exact tests were used for statistical analysis. RESULTS Clinical characteristics of the subjects Based on the inclusion and exclusion criteria, eight hips from five patients were excluded because of previous hip surgery in one patient, recent trauma to the femoral neck in two patients, and developmental dysplasia of the hip in two patients. Finally, 87 patients (102 hips) were enrolled into the study, including 65 men and 22 women with an average age of (44.38±12.74) years (19-73 years). Fifteen patients had bilateral sides and 72 patients had unilateral side of ONFH. All patients were followed for 3 to 58 months. MRI and radiographic imaging On MRI, the size of the necrotic lesion in the femoral head was graded as type A in zero hip, type B in 9 hips and type C in 93 hips (Table 1). On anteroposterior X-ray images, collapsed femoral heads were observed in 46 of 102 (45.1 %) hips, which were assigned to two hips in type B and 44 hips in type C (Table 1). On FLL images, collapsed femoral heads were found in 57 of 102 (55.9 %) hips, which were classified as type B (n=3) and type C (n=54), respectively. In the 60 collapsed-hips, the number of the collapsed femoral heads was viewed on FLL X-ray films and was significantly higher than that of on anteroposterior X-ray films (P < 0.01). However, the time to collapse were lower on FLL X-ray films than that of on anteroposterior X-ray films (16.28±12.69) months versus (17.35±13.28) months), although the P value was greater than 0.05 (Figure 3). Fourteen (23.3 %) hips were only seen on FLL X-ray films but not on anteroposterior X-ray images. The three collapsed-hips (5.0%) were only detected on anteroposterior images, but not on FLL images (Table 1)."
Collapse rate In all 102 hips with ARCO stage II ONFH, the collapse rate in type 3 ONFH was significantly higher than that of in type 2 ONFH (P < 0.001),and the time to collapse was markedly shortened. No femoral head collapse was found in six hips with type 1 ONFH. In nine hips with ARCO stage II type B ONFH, there was a higher collapse rate in type 3 ONFH compared with type 2 lesions (100% vs. 20%), but this was not statistically significant because of the low number of patients. In 93 hips with ARCO stage II type C ONFH, the collapse rate for type 3 ONFH was significantly higher than compared with both type 1 and type 2 (Table 2). "
Only six hips were classified as type 1 at entry into the study. At the final examination, all these joints were still at ARCO stage II, the patients were free from symptoms (Figure 4). All 44 hips of type 2 were at stage II at the initial examination, 32 (72.7%) were still at stage II and 12 (27.3%) had collapsed of the femoral head during follow-up (Figure 5). The total incidence of collapse in all type 3 femoral heads, was 86.5% (45 to 52), 26 of these developed to stage III in three to 43 months (mean 21 months), and 19 of these having advanced to ARCO stage IV in three to 18 months (mean 11.5 months) after entry to the study (Figure 6)."
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