股骨頭壞死的影像學(xué)表現(xiàn)

MRIEvaluationofCollapsed

FemoralHeadsinPatients

60YearsOldorOlder:

DifferentiationofSubchondral

InsufficiencyFractureFrom

OsteonecrosisoftheFemoralHead1精選課件WordsSubchondralInsufficiencyFracture：軟骨下不全骨折OsteonecrosisoftheFemoralHead：股骨頭壞死Convex凸ncavity凹2精選課件軟骨下不全骨折（Subchondralinsufficiencyfracture,簡(jiǎn)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(shí)，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(shí)此病作出早期診斷，多數(shù)患者經(jīng)保守治療后可自愈。

3精選課件OBJECTIVEThepurposeofthisarticleistoverifythehypothesisthatosteonecrosisandsubchondralinsufficiencyfractureofthefemoralheadcanbedifferentiatedonthebasisoftheirappearanceonMRI.4精選課件SUBJECTSANDMETHODS1BetweenMay1998andFebruary2009,wereviewed30consecutivehipsin30patients,60yearsoldorolderatthetimeofonsetofhippain,withradiologicevidenceofsubchondralcollapseofthefemoralheadandwithbothMRimagesandhistologicresultsavailable.5精選課件SUBJECTSANDMETHODS2Thepatientsweredividedintotwogroupaccordingtotheshapeoflow-intensitybandsonT1-weightedimages.Thefirstgroupshowedconcavityofthearticularsurface,whichischaracteristicofosteonecrosis,andthesecondgroupshowedanirregularconvexityofthearticularsurface,whichischaracteristicofsubchondralinsufficiencyfracture.6精選課件AInosteonecrosis,low-intensitybandissmooth,concavetoarticularsurface,andcircumscribesallofnecroticsegments.BInsubchondralinsufficiencyfracture,low-intensitybandisirregular,convextoarticularsurface,anddiscontinuous.7精選課件RESULTSSixteenhips(53.3%)showedevidenceofosteonecrosis,and14(46.7%)showedevidenceofsubchondralinsufficiencyfracture,whichwasconsistentwiththecorrespondinghistopathologicdiagnoses.Inallcasesofosteonecrosis,thepatienthadahistoryofeithercorticosteroidintakeoralcoholabuse.Amongpatientswithsubchondralinsufficiencyfracture,theproportionofwomenwassignificantlyhigherthanthatamongpatientswithosteonecrosis.Acrescentsign(subchondralfracture)waspresentradiographicallyinabouthalfofallcasesinbothgroups.8精選課件TABLE1:ClinicalCharacteristicsofPatientsWithOsteonecrosisor

SubchondralInsufficiencyFracture9精選課件CONCLUSIONTheresultsofthepresentstudysuggestthattheshapeofthelow-intensitybandonMRIisusefulforthedifferentiatingsubchondralinsufficiencyfracturefromosteonecrosis.Inaddition,amongosteoporoticelderlywomenwithoutanyhistoryofcorticosteroidintakeoralcoholabuse,adiagnosisofsubchondralinsufficiencyfractureshouldbeconsidered.10精選課件64-year-oldmanwithhistoryofalcoholabuseandosteonecrosis.A,Anteroposteriorradiographoflefthip(Singhindexofseverityofosteoporosis,gradeV)obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion(arrows).11精選課件B,CoronalT1-weightedimage(TR/TE,470/15)showsdiffuselowsignalintensityinfemoralneckatlateralportionandintertrochantericarea.Low-intensitybandonT1-weightedimageisconcavetoarticularsurface(arrows).12精選課件“線樣征”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(shí),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”。13精選課件D,AxialsliceofT1-weightedimage(500/15)showsthatlow-intensitybandcircumscribesallofnecroticsegments(arrows).14精選課件E,Cutsectionofresectedfemoralheadshowszonalpattern(necrotic,reparative,andviablezones).Subchondralfractureline(arrow)correspondingtocrescentsignonradiograph(A)isseen.15精選課件新月征形成機(jī)制因皮質(zhì)斷裂塌陷時(shí),關(guān)節(jié)軟骨在一段時(shí)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。16精選課件17精選課件F,Histopathologicappearanceofnecroticregion,whichshowsaccumulationofbonemarrowcelldebris,andbonetrabeculaewithemptylacunaebeneathfracturelineareseen.(HandE,×40)18精選課件G,Thereisrepairtissueinreparativezone,includingvasculargranulationtissue,fibroustissue.(HandE,×20)19精選課件Fig.3—75-year-oldwoman,withouthistoryofeithercorticosteroidintakeoralcoholabuse,withsubchondralinsufficiencyfracture.Anteroposteriorradiographoflefthip(Singhindexofseverityofosteoporosis,gradeV)obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion(arrows).20精選課件Thefrequencyofthecrescentsigninthesubchondralinsufficiencyfracturegroupwassimilartothatinosteonecrosisgroupinthecurrentstudy,thusindicatingthatthecrescentsignisnotsufficienttodifferentiateosteonecrosisfromsubchondralinsufficiencyfracture.21精選課件B,CoronalT1-weightedimage(TR/TE,470/25)showsdiffuselowsignalintensityinfemoralheadandneck.Low-intensitybandisparallelto

subchondralboneendplate(arrows).Thelow-intensitybandonT1-weightedimagesinsubchondralinsufficiencyfracturecorrespondshistologicallytothefracturelineandassociatedfracturerepairtissue.Therefore,theshapeofthelow-intensitybandgenerallytendstobeirregular,disconnected,andconvextothearticularsurface.22精選課件D,AxialslicesofT1-weightedimage(500/15)showlow-intensitybandmainlyinanteriorregion,whichisinterruptedinmiddle(arrows).23精選課件E,Fat-saturatedcontrast-enhancedMRI(fromimageshowninD)(605/14)inwhichpartofproximalportionbeyondlow-intensitybandshowscontrastenhancementindicatingperfusion(arrows).24精選課件F,Cutsectionofresectedfemoralheadshowssubchondralfractureline(blackarrow)andwhitishlinearshapedareabeneatharticularcartilage(whitearrow).25精選課件G,Bandregionhistopathologicallycorrespondstofracturecallus,reactivecartilage,andgranulationtissue.(HandE,×40)26精選課件27精選課件Limititions樣本量小對(duì)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。28精選課件真愛生命，拒絕酒精29精選課件統(tǒng)計(jì)學(xué)方法StatisticalanalyseswereperformedusingFisher’sexact

probabilitytestwithr