基于“3S”体系的股骨头坏死分型及其与中医体质的关系研究

发布时间：2018-05-25 20:50

本文选题：股骨头坏死 + 三柱结构　；参考：《中国中医科学院》2015年硕士论文

【摘要】：股骨头坏死(osteonecrosis of the femoral head,ONFH)是当今骨科领域常见、难治病之一,是由于多种原因导致股骨头血供不足,继而出现骨的活性成分(包括骨细胞、骨髓造血细胞和脂肪细胞)死亡的一种病理过程。据估计我国目前需要治疗的股骨头坏死患者约为500-750万,且每年新发病例约为15-30万人次。根据ONFH发病原因的不同,可将其分为创伤性和非创伤性两大类。其中非创伤性ONFH好发于中青年,且一旦发病,如未及时给予有效治疗,约有80%的患者将会在1-4年内进展为股骨头塌陷,最终将会发展为累及整个髋关节的严重毁损。此时,大多数患者不得不面临人工髋关节置换的结局。然而,目前临床中所应用的人工关节使用寿命有限,对于年轻患者而言,在一生中可能需要经历再次或多次人工关节翻修，，这样不仅给患者自身带来巨大的痛苦,也给家庭和社会带来了巨大的经济负担。而在股骨头坏死早期,根据股骨头坏死的分期分型特点,做出正确的预后判断,确立合理的治疗原则,并予以相应的治疗方法,从而预防股骨头坏死塌陷成为本病治疗的关键。因此,科学合理的股骨头坏死分期分型方法,对股骨头坏死的预后判断及指导临床诊治意义重大。目前,关于股骨头坏死分期分型方法有多种,但均存在着其自身的一定局限性,不能完全满足临床需要。结合前期文献研究及临床实践,我们发现ONFH的预后主要受到坏死范围(Size)、坏死部位(Site)和坏死后自身修复能力(Self-repairing)三方面因素的影响,我们称之为“3S”。而目前所现存的分期分型方法的制定或单从一方面因素考虑,或从两方面因素考虑,尚未有综合考虑三方面因素者。据此,本研究拟结合坏死范围(Size)、坏死部位(Site)、自身修复能力(Self-repairing),提出一种新的股骨头坏死分型体系,即基于“3S”体系的股骨头坏死分型---ABC分型方法,并分析其与中医体质的关系,为股骨头坏死塌陷预测及中西医诊治提供新方法、新思路。目的：1.基于股骨头骨小梁的生物力学分布特征,确定成人股骨头三柱结构的划分标准及具体划分方法。2.基于“3S”体系思想建立股骨头坏死ABC分型方法,为股骨头坏死预后及临床诊治方案的制定提供依据。3.通过分析中医体质与股骨头坏死灶三柱分布的关系,以探索中医体质对股骨头坏死范围、坏死部位的影响,为股骨头坏死的中医诊治提供新思路。方法：1.正常股骨头三柱结构的测算：选取50例(100髋)正常股骨头志愿者,拍摄双髋关节正位X线片,根据股骨头主要压力骨小梁的分布情况,完成三柱结构的划分,借助CAD软件完成股骨头外侧柱、中间柱及内侧柱的测算,并根据测算结果计算外侧柱：中间柱：内侧柱在股骨头最大横径上的比例,为三柱结构的划分提供科学依据。2.基于“3S”体系的股骨头坏死ABC分型方法的建立：在确立股骨头三柱结构划分的基础上,综合考虑坏死范围、部位、自身修复能力提出股骨头坏死的ABC分型方法。由中国中医科学院广安门医院骨科门诊收集132例223髋符合纳入和排除标准的股骨头坏死病例。选取CT或MRI冠状位坏死范围最大层面为三柱测量层面,CT坏死范围最大层面及其前后各1层共3个层面为近端硬化带比例测算层面借助CAD软件行三柱划分和近端硬化带比例的测算并比较ABC分型各型间股骨头坏死塌陷的差异。3.中医体质与股骨头坏死“三柱分布”关系的研究：由中国中医科学院广安门医院骨科门诊收集95例中医体质为阳虚质和(或)、湿热质和(或)、血瘀质的股骨头坏死病例,所有病例均行双髋关节CT或MRI扫描。选取冠状位坏死范围最大的层面,使用CAD软件行ABC分型,比较分析不同中医体质股骨头坏死患者累及股骨头柱数分布和累及坏死部位(即是否累及外侧柱)是否存在差异。结果：1.正常股骨头三柱测量情况：采用单样本K-S检验,内侧柱、中间柱、外侧柱及最大横径测量结果P值均0.05,均符合正态分布。股骨头最大横径53.50±3.12,外侧柱15.96+1.20,中间柱20.94±1.22,内侧柱16.60±1.08,三者所占股骨头宽度比例分别为0.31、0.39、0.30。不同性别组间正常股骨头外侧柱、中间柱及内侧柱长度及比例差异均无统计学意义,双侧检验结果P值均0.05。不同侧别组间正常股骨头外侧柱、中间柱及内侧柱长度及比例差异均无统计学意义,双侧检验结果P值均0.05。为方便临床应用,我们可以选择外侧柱：中间柱：内侧柱为3：4：3的比例在股骨头最大横径上进行划分。2.基于“3S”体系的股骨头坏死ABC分型结果：本组病例中A型占0.9%,其中AⅠ和AⅡ型各占0.45%；B型占9.4%,其中BⅠ和BⅡ型分别占3.1%、6.3%；C型占1.3%,其中CⅠ和CⅡ型分别占0.4%、0.9%；AB型占12.1%,其中ABⅠ和ABⅡ型分别占7.2%、4.9%；BC型占9.4%,其中BCⅠ和BCⅡ型分别占4.9%、4.5%；A-C型占66.8%,其中A-CⅠ和A-CⅡ型分别占53.8%、13.0%。ABC分型法中A型、B型、C型、AB型、BC型、A-C型的股骨头塌陷率分别为50%、9.5%、0、74.1%、52.4%、88.6%,差异有统计学意义(X12=77.775,P 1=0.000)。各型的股骨头坏死塌陷率排序为：A-C型AB型BC型A型B型C型。各亚型中AⅠ型、AⅡ型、BⅠ型、BⅡ型、CⅠ型、CⅡ型、ABⅠ型、ABⅡ型、BCⅠ型、BCⅡ型、A-CⅠ型及A-CⅡ型的股骨头塌陷率分别为100%、0、28.6%、0、0、0、100%、36.4%、81.8%、20.0%、100%、41.4%,差异有统计学意义(X22=170.939,P2＝0.000)。各亚型间两两比较：BⅠ型与BⅡ型差异有统计学意义(X2=4.833,P=0.028)：ABⅠ型与ABⅡ型差异有统计学意义(X2=16.483,P－0.000)：BCⅠ型与BCⅡ型差异有统计学意义(X2=8.625,P=0.003);A-CⅠ型与A-CⅡ型差异有统计学意义(X2=66.451,P=0.000)。股骨头坏死塌陷率排序为：A-CⅠ型、ABⅠ型、AⅠ型BCⅠ型A-CⅡ型ABⅡ型BⅠ型BCⅡ型AⅡ型、BⅡ型、CⅠ型、CⅡ型。3.中医体质与股骨头坏死“三柱分布”的关系研究：95例股骨头坏死病例中,阳虚质有38例(39.6%),湿热质18例(18.9%),血瘀质12例(12.6%),阳虚兼湿热质11例(11.6%),阳虚兼血瘀质10例(10.5%),湿热兼血瘀质6例(6.3%)。不同体质组间柱数分布差异有统计学意义,双侧检验结果χb 25.59,P＝0.02(0.05)：对三种单一偏颇体质进行检验,结果为χ2＝12.19,P=0.016(0.05)。单一偏颇体质中湿热质及阳虚质累及柱数为双柱或三柱,未出现累及单柱情况。血瘀质可累及单柱或三柱。将股骨头坏死不同中医体质累及柱数做两两比较分析结果为：阳虚质与血瘀质(P＝0.001)、湿热质与血瘀质(P＝0.01)、阳虚+湿热质与血瘀质(P＝0.04)比较差异有统计学意义,余各体质间比较差异无统计学意义。不同体质组间累及外侧柱差异无统计学意义,双侧检验结果χ2＝7.64,P＝0.18(0.05)(表4)。对三种单一偏颇体质进行检验,结果为χ26.53,P＝0.08(0.05)。结论：1.股骨头的外侧柱、中间柱及内侧柱在股骨头最大横径所占比例分别为0.31、0.39、0.30,即在股骨头冠状面上做两条垂线,将股骨头最大横径分为3：4：3三段,对应股骨头外侧柱、中间柱及内侧柱。2.股骨头坏死ABC分型方法综合了坏死范围(Size)、坏死部位(Site)、自身修复能力(Self-repairing)三个影响股骨头坏死预后的重要因素,是目前预测股骨头坏死塌陷较为系统的综合预测体系,该分型方法中,A-CⅠ型、ABⅠ型、AⅠ型、BCⅠ型的预后较差,AⅡ型、BⅡ型、CⅠ型、CⅡ型的预后较好。3.中医体质可能通过影响股骨头坏死范围而影响股骨头坏死预后,血瘀质者坏死范围较小,阳虚质及湿热质坏死范围较大,容易塌陷,预后较差,需在早期积极给予预防塌陷的治疗手段,调整改善体质,重以温阳利湿之法。
[Abstract]:Osteonecrosis of the femoral head (ONFH) is one of the common and difficult diseases in the field of Department of orthopedics today. It is a pathological process of the death of the active components of the bone (including bone cells, bone marrow hematopoietic cells and adipocytes) due to a variety of reasons, and it is estimated that the femur is currently in need of treatment in China. The number of head necrosis is about 500-750 million, and the new incidence is about 15-30 million people each year. According to the different causes of ONFH, it can be divided into two categories of traumatic and non traumatic. The non traumatic ONFH is good for the young and middle-aged, and if the disease is not given effective treatment, about 80% of the patients will advance to the femoral head within 1-4 years. The collapse will eventually develop into a serious damage to the entire hip joint. At this time, most patients have to face the outcome of artificial hip replacement. However, the life of the artificial joints used in the clinic is limited. For young patients, it may need to experience or refurbishment of artificial joints in their life, so that not only will it be necessary to undergo repeated or multiple artificial joint refurbishment in their life. It brings great pain to the patient itself and brings great economic burden to the family and society. In the early stage of the necrosis of the femoral head, the correct prognosis is made according to the classification of the necrosis of the femoral head, the rational treatment principle is established, and the corresponding treatment method is given so as to prevent the necrosis of the femoral head and become the treatment of this disease. Therefore, a scientific and rational method for the classification of femoral head necrosis is of great significance to the prognosis of the necrosis of the femoral head and to guide the clinical diagnosis and treatment. At present, there are a variety of methods for the classification of the necrosis of the femoral head, but all of them have their own limitations and can not fully meet the clinical needs. In practice, we found that the prognosis of ONFH is mainly affected by the three factors of necrosis (Size), necrotic site (Site) and post necrotic self repair (Self-repairing). We call it "3S". In view of the three factors, this study proposed a new type of femoral head necrosis classification system based on the necrosis area (Size), necrotic site (Site) and self repair ability (Self-repairing), that is, the type of ---ABC classification of femoral head necrosis based on the "3S" system, and to analyze the relationship with the constitution of traditional Chinese medicine, for the prediction of the collapse of the femoral head. New methods and new ideas for the diagnosis and treatment of Chinese and Western medicine. Objective: 1. based on the characteristics of the biomechanical distribution of the trabecular bone of the femoral head, the standard and specific classification method of the three column structure of the femoral head is determined by.2., based on the idea of "3S" system, the method of ABC typing for the necrosis of the femoral head is established for the prognosis of the femoral head necrosis and the formulation of the clinical diagnosis and treatment scheme. To explore the relationship between the constitution of Chinese medicine and the three column of the necrosis of the femoral head by analyzing the relationship between the constitution of the Chinese medicine and the three column of the necrosis of the femoral head in order to explore the influence of the constitution of the Chinese medicine on the necrosis of the femoral head and the necrotic parts of the femoral head, and to provide a new way of thinking for the diagnosis and treatment of the femoral head necrosis. Method: to measure the structure of the three column of the 1. normal femoral head: to select 50 cases (100 hips) of the normal femoral head volunteers and take the double. According to the distribution of the main pressure bone trabecula of the femoral head, the three column structure is divided according to the distribution of the main pressure bone trabecula of the femoral head. The calculation of the lateral column, the middle column and the inner column of the femoral head is completed with the help of CAD software, and the ratio of the lateral column to the maximum transverse diameter of the femur head is calculated according to the calculated results, which is divided into the division of the three column structure. .2. based on the "3S" system based on the ".2." system of femoral head necrosis of the method of the establishment: on the basis of the establishment of the three column structure of the femoral head, comprehensive consideration of the scope of necrosis, the location, the ability to repair the femoral head necrosis of the ABC typing method. From the Department of orthopedics in the Guanganmen Hospital of Chinese Academy of traditional Chinese medicine (Chinese Academy of Chinese Medicine) to collect 223 hip conforms. The maximum level of the CT or MRI coronal necrosis range was three column measurements, the maximum level of the CT necrosis range and the 1 layers before and after the 3 layers were measured by the proportion of the three column and the proximal hard zone with the CAD software and compared with the ABC typing. A study on the relationship between the.3. constitution and the three column distribution of necrosis of the femoral head: 95 cases of TCM Constitution were collected from the Department of orthopedics of the Department of orthopedics, Guanganmen Hospital of Chinese Academy of science of traditional Chinese medicine (Chinese Academy of Chinese Medicine). The largest level of the coronal necrosis, using the CAD software ABC typing, compared and analyzed whether there were differences in the number distribution of the femoral head and the necrotic parts involving the lateral column of the femoral head necrosis in different TCM Constitution. Results: 1. the measurement of the three columns of the normal femoral head: the single sample K-S test, the medial column, and the middle The P values of the column, the lateral column and the maximum transverse diameter were all 0.05. The maximum transverse diameter of the femoral head was 53.50 + 3.12, the lateral column 15.96+1.20, the middle column 20.94 + 1.22, the medial column 16.60 + 1.08. The width ratio of the femoral head in the three was the normal femoral head lateral column, the middle column and the inner column, respectively, and the length of the middle column and the inner column in the 0.31,0.39,0.30. groups. There was no statistical significance in the proportion difference. The P values of bilateral tests were all 0.05. in the lateral column of the normal femoral head, the length and proportion of the middle column and the inner column were not statistically significant. The P value of bilateral test results was 0.05. for the convenience of clinical application. We could choose the lateral column: the middle column: the ratio of the inner column to 3:4:3 was in the middle column. The maximum transverse diameter of the femoral head was divided into.2. based on the "3S" system based ABC typing of the femoral head necrosis: in this group, the A type accounted for 0.9%, of which A I and A II accounted for 9.4%, and B I and B II accounted for 3.1%, 6.3% and C type 1.3%, including C and C type 0.4%, 0.9% and 12.1%. 7.2%, 4.9%, and type BC accounted for 9.4%, of which BC I and BC II accounted for 4.9% and 4.5%, and A-C accounted for 66.8%, of which A-C I and A-C II were 53.8%, A, B, C, AB, BC type and 52.4%, 52.4%, 88.6%, respectively, were 50%, 9.5%, 52.4%, 88.6%, respectively. A-C type AB type BC type A B type C type, A type, A II, B type, B II, C I in each subtype, C type II, type I type, type I type, type I type, type I, type I and type II type of femoral head collapse were 100%, respectively, 36.4%, 81.8%, 20%, 100%, 41.4%. 0.939, P2 = 0). 22 comparison among subtypes: the difference between type B I and B type II has statistical significance (X2=4.833, P=0.028):AB type I and AB type II type differences (X2=16.483, P 0):BC I and BC type II have statistical significance. The rate of collapse of the femoral head necrosis was A-C I, AB I, type A I type BC I, type A-C II, AB II, B, type BC II, A II, B II, C, and the relationship between the three column distribution of the necrosis of the femoral head: 95 cases of necrosis of the femoral head, 38 cases (39.6%), 18 cases of damp heat (18.9%), and 12 cases of blood stasis (12.) 6%) 11 cases (11.6%) of Yang deficiency and humid heat, 10 cases of Yang deficiency and blood stasis (10.5%), 6 cases of damp heat and blood stasis (6.3%). The difference of column number distribution between different constitution groups was statistically significant, the results of bilateral test were B 25.59, and P = 0.02 (0.05): the result was chi chi 2 = 12.19, P=0.016 (0.05). The number of two columns or three columns was not involved in the column number. The blood stasis could be involved in single column or three column. The results of the 22 comparative analysis of the different TCM Constitution of the femoral head necrosis were as follows: Yang deficiency and blood stasis (P = 0.001), damp heat and blood stasis (P = 0.01), Yang deficiency + damp heat and blood stasis (P = 0.04). The difference was statistically significant. There was no statistical difference between the other physique. There was no statistical difference between the different physique groups involved in the lateral column, the results of bilateral tests were 2 = 7.64, P = 0.18 (0.05) (Table 4). Three kinds of single biased constitution were tested, the results were x 26.53, P = 0.08 (0.05). Conclusion: the lateral column, the middle column and the inside of 1. femoral head. The proportion of the lateral column of the femoral head in the largest transverse diameter of the femoral head is 0.31,0.39,0.30, that is to do two vertical lines on the coronal surface of the femoral head and divide the maximum transverse diameter of the femoral head into three segments. The ABC classification method for the lateral column of the femoral head, the middle column and the medial column.2. femoral head necrosis (Size), the necrotic site (Site), and the self repair ability of the femoral head are combined. (Self-repairing) the three important factors affecting the prognosis of avascular necrosis of the femoral head are the comprehensive prediction system for predicting the collapse of femoral head necrosis. In this method, the prognosis of A-C I, AB I, A I, BC I is poor, A II, B II, C I, and C II type, the prognosis of the.3. Chinese medicine may be affected by the necrosis of the femoral head. For the prognosis of the necrosis of the femoral head, the necrosis range of the blood stasis is small, the scope of the deficiency of Yang deficiency and the necrosis of heat and heat is larger, the collapse is easy and the prognosis is poor.
【学位授予单位】：中国中医科学院
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R681.8

【参考文献】