股骨头坏死的影像学表现PPT课件.ppt

MRIEvaluationofCollapsedFemoralHeadsinPatients60YearsOldorOlder DifferentiationofSubchondralInsufficiencyFractureFromOsteonecrosisoftheFemoralHead 2011 4 17FromAJR 195 July2010 1 Words SubchondralInsufficiencyFracture 软骨下不全骨折OsteonecrosisoftheFemoralHead 股骨头坏死Convex凸ncavity凹 2 软骨下不全骨折 Subchondralinsufficiencyfracture 简称SIFs 1 软骨下机能不全性骨折是非外伤性的一种骨折 2 最常见的病因 骨质疏松 不常见的病因是骨质软化症或骨不全症 甲状旁腺功能亢进和类风湿性关节炎等 3 发病原理 正常软骨可忍受正常的生物机械应力 当由于上述病因变得软弱时 可出现软骨下骨折 并发展为软骨下萎陷 为此需认识此病作出早期诊断 多数患者经保守治疗后可自愈 3 OBJECTIVE ThepurposeofthisarticleistoverifythehypothesisthatosteonecrosisandsubchondralinsufficiencyfractureofthefemoralheadcanbedifferentiatedonthebasisoftheirappearanceonMRI 4 SUBJECTSANDMETHODS1 BetweenMay1998andFebruary2009 wereviewed30consecutivehipsin30patients 60yearsoldorolderatthetimeofonsetofhippain withradiologicevidenceofsubchondralcollapseofthefemoralheadandwithbothMRimagesandhistologicresultsavailable 5 SUBJECTSANDMETHODS2 Thepatientsweredividedintotwogroupaccordingtotheshapeoflow intensitybandsonT1 weightedimages Thefirstgroupshowedconcavityofthearticularsurface whichischaracteristicofosteonecrosis andthesecondgroupshowedanirregularconvexityofthearticularsurface whichischaracteristicofsubchondralinsufficiencyfracture 6 AInosteonecrosis low intensitybandissmooth concavetoarticularsurface andcircumscribesallofnecroticsegments BInsubchondralinsufficiencyfracture low intensitybandisirregular convextoarticularsurface anddiscontinuous 7 RESULTS Sixteenhips 53 3 showedevidenceofosteonecrosis and14 46 7 showedevidenceofsubchondralinsufficiencyfracture whichwasconsistentwiththecorrespondinghistopathologicdiagnoses Inallcasesofosteonecrosis thepatienthadahistoryofeithercorticosteroidintakeoralcoholabuse Amongpatientswithsubchondralinsufficiencyfracture theproportionofwomenwassignificantlyhigherthanthatamongpatientswithosteonecrosis Acrescentsign subchondralfracture waspresentradiographicallyinabouthalfofallcasesinbothgroups 8 TABLE1 ClinicalCharacteristicsofPatientsWithOsteonecrosisorSubchondralInsufficiencyFracture 9 CONCLUSION Theresultsofthepresentstudysuggestthattheshapeofthelow intensitybandonMRIisusefulforthedifferentiatingsubchondralinsufficiencyfracturefromosteonecrosis Inaddition amongosteoporoticelderlywomenwithoutanyhistoryofcorticosteroidintakeoralcoholabuse adiagnosisofsubchondralinsufficiencyfractureshouldbeconsidered 10 64 year oldmanwithhistoryofalcoholabuseandosteonecrosis A Anteroposteriorradiographoflefthip Singhindexofseverityofosteoporosis gradeV obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion arrows 11 B CoronalT1 weightedimage TR TE 470 15 showsdiffuselowsignalintensityinfemoralneckatlateralportionandintertrochantericarea Low intensitybandonT1 weightedimageisconcavetoarticularsurface arrows 12 线样征 位于股骨头颈前上部病灶周围多呈空间锥形分布 锥尖指向股骨头基底部或股骨颈 Glimcher认为修复开始后 肉芽组织自股骨颈或股骨头基底部向死骨区爬行 肉芽组织到达并吸收骨皮质时 皮质承载力减弱 在重力作用下自此皮质薄弱区于松质骨内产生多条微骨折线 因应力作用微骨折线多位于股骨头前上部周围 肉芽组织在微骨折处大量增生堆积 吸收坏死骨小梁并于外围大量成骨 从而形成T2WI上的 双线症 13 D AxialsliceofT1 weightedimage 500 15 showsthatlow intensitybandcircumscribesallofnecroticsegments arrows 14 E Cutsectionofresectedfemoralheadshowszonalpattern necrotic reparative andviablezones Subchondralfractureline arrow correspondingtocrescentsignonradiograph A isseen 15 新月征形成机制 因皮质断裂塌陷时 关节软骨在一段时间内尚保持完整 形成软骨下负压 股骨头体液内气体在负压作用下溢出并进入囊腔 16 2020 1 7 17 18 F Histopathologicappearanceofnecroticregion whichshowsaccumulationofbonemarrowcelldebris andbonetrabeculaewithemptylacunaebeneathfracturelineareseen HandE 40 19 G Thereisrepairtissueinreparativezone includingvasculargranulationtissue fibroustissue HandE 20 20 Fig 3 75 year oldwoman withouthistoryofeithercorticosteroidintakeoralcoholabuse withsubchondralinsufficiencyfracture Anteroposteriorradiographoflefthip Singhindexofseverityofosteoporosis gradeV obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion arrows 21 Thefrequencyofthecrescentsigninthesubchondralinsufficiencyfracturegroupwassimilartothatinosteonecrosisgroupinthecurrentstudy thusindicatingthatthecrescentsignisnotsufficienttodifferentiateosteonecrosisfromsubchondralinsufficiencyfracture 22 B CoronalT1 weightedimage TR TE 470 25 showsdiffuselowsignalintensityinfemoralheadandneck Low intensitybandisparalleltosubchondralboneendplate arrows Thelow intensitybandonT1 weightedimagesinsubchondralinsufficiencyfracturecorrespondshistologicallytothefracturelineandassociatedfracturerepairtissue Therefore theshapeofthelow intensitybandgenerallytendstobeirregular disconnected andconvextothearticularsurface 23 D AxialslicesofT1 weightedimage 500 15 showlow intensitybandmainlyinanteriorregion whichisinterruptedinmiddle arrows 24 E Fat saturatedcontrast enhancedMRI fromimageshowninD 605 14 inwhichpartofproximalportionbeyondlow intensitybandshowscontrastenhancementindicatingperfusion arrows 25 F Cutsectionofresectedfemoralheadshowssubchondralfractureline blackarrow andwhitishlinearshapedareabeneatharticularcartilage whitearrow 26 G Bandregionhistopathologicallycorrespondstofracturecallus reactivecartilage andgranulationtissue HandE 40 27 28 Limititions 样本量小对于软骨下不全骨折早期表现 如软骨下水肿 由于在平片上未见异常 未被纳入 仅4例进行了增强MR检查 29 真爱生命 拒绝酒精 30 统计学方法 StatisticalanalyseswereperformedusingFisher sexactprobabilitytestwithregardtosex ahistoryofcorticosteroidintakeoralcoholabuse andtheradiologicfindings i e demarcatingsclerosis crescentsign andvertebralcompressionfracture AgeandBMIofgroupsAandBwerecomparedusingtheunpairedStudent sttesttheSinghindexwascomparedusingtheMann WhitneyUtest StatisticalanalyseswereperformedusingStat