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1、MRIEvaluationofCollapsedFemoralHeadsinPatients60YearsOldorOlder DifferentiationofSubchondralInsufficiencyFractureFromOsteonecrosisoftheFemoralHead 2011 4 17FromAJR 195 July2010 Words SubchondralInsufficiencyFracture 软骨下不全骨折OsteonecrosisoftheFemoralHead 股骨头坏死Convex凸ncavity凹 软骨下不全骨折 Subchondralinsuffi
2、ciencyfracture 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 OBJECTIVE Thepurposeofthisarticleistoverifythehypothesisthatosteonecrosisandsubchondralinsufficiencyfractureofthefemoralh
3、eadcanbedifferentiatedonthebasisoftheirappearanceonMRI SUBJECTSANDMETHODS1 BetweenMay1998andFebruary2009 wereviewed30consecutivehipsin30patients 60yearsoldorolderatthetimeofonsetofhippain withradiologicevidenceofsubchondralcollapseofthefemoralheadandwithbothMRimagesandhistologicresultsavailable SUBJ
4、ECTSANDMETHODS2 Thepatientsweredividedintotwogroupaccordingtotheshapeoflow intensitybandsonT1 weightedimages Thefirstgroupshowedconcavityofthearticularsurface whichischaracteristicofosteonecrosis andthesecondgroupshowedanirregularconvexityofthearticularsurface whichischaracteristicofsubchondralinsuf
5、ficiencyfracture AInosteonecrosis low intensitybandissmooth concavetoarticularsurface andcircumscribesallofnecroticsegments BInsubchondralinsufficiencyfracture low intensitybandisirregular convextoarticularsurface anddiscontinuous RESULTS Sixteenhips 53 3 showedevidenceofosteonecrosis and14 46 7 sho
6、wedevidenceofsubchondralinsufficiencyfracture whichwasconsistentwiththecorrespondinghistopathologicdiagnoses Inallcasesofosteonecrosis thepatienthadahistoryofeithercorticosteroidintakeoralcoholabuse Amongpatientswithsubchondralinsufficiencyfracture theproportionofwomenwassignificantlyhigherthanthata
7、mongpatientswithosteonecrosis Acrescentsign subchondralfracture waspresentradiographicallyinabouthalfofallcasesinbothgroups TABLE1 ClinicalCharacteristicsofPatientsWithOsteonecrosisorSubchondralInsufficiencyFracture CONCLUSION Theresultsofthepresentstudysuggestthattheshapeofthelow intensitybandonMRI
8、isusefulforthedifferentiatingsubchondralinsufficiencyfracturefromosteonecrosis Inaddition amongosteoporoticelderlywomenwithoutanyhistoryofcorticosteroidintakeoralcoholabuse adiagnosisofsubchondralinsufficiencyfractureshouldbeconsidered 64 year oldmanwithhistoryofalcoholabuseandosteonecrosis A Antero
9、posteriorradiographoflefthip Singhindexofseverityofosteoporosis gradeV obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion arrows B CoronalT1 weightedimage TR TE 470 15 showsdiffuselowsignalintensityinfemoralneckatlateralportionandintertrochantericarea Low
10、intensitybandonT1 weightedimageisconcavetoarticularsurface arrows 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 D AxialsliceofT1 weightedimage 500 15
11、showsthatlow intensitybandcircumscribesallofnecroticsegments arrows E Cutsectionofresectedfemoralheadshowszonalpattern necrotic reparative andviablezones Subchondralfractureline arrow correspondingtocrescentsignonradiograph A isseen 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 F Hi
12、stopathologicappearanceofnecroticregion whichshowsaccumulationofbonemarrowcelldebris andbonetrabeculaewithemptylacunaebeneathfracturelineareseen HandE 40 G Thereisrepairtissueinreparativezone includingvasculargranulationtissue fibroustissue HandE 20 Fig 3 75 year oldwoman withouthistoryofeithercorti
13、costeroidintakeoralcoholabuse withsubchondralinsufficiencyfracture Anteroposteriorradiographoflefthip Singhindexofseverityofosteoporosis gradeV obtainedattimeofonsetofpainshowsbothcrescentsignandcollapseoffemoralheadatsuperolateralportion arrows Thefrequencyofthecrescentsigninthesubchondralinsuffici
14、encyfracturegroupwassimilartothatinosteonecrosisgroupinthecurrentstudy thusindicatingthatthecrescentsignisnotsufficienttodifferentiateosteonecrosisfromsubchondralinsufficiencyfracture B CoronalT1 weightedimage TR TE 470 25 showsdiffuselowsignalintensityinfemoralheadandneck Low intensitybandisparalle
15、ltosubchondralboneendplate arrows Thelow intensitybandonT1 weightedimagesinsubchondralinsufficiencyfracturecorrespondshistologicallytothefracturelineandassociatedfracturerepairtissue Therefore theshapeofthelow intensitybandgenerallytendstobeirregular disconnected andconvextothearticularsurface D Axi
16、alslicesofT1 weightedimage 500 15 showlow intensitybandmainlyinanteriorregion whichisinterruptedinmiddle arrows E Fat saturatedcontrast enhancedMRI fromimageshowninD 605 14 inwhichpartofproximalportionbeyondlow intensitybandshowscontrastenhancementindicatingperfusion arrows F Cutsectionofresectedfemoralheadshowssubchondralfractureline blackarrow andwhitishlinearshapedareabeneatharticularcartilage whitearrow G Bandregionhistopathologicallycorrespondstofracturecallus reactivecartilage andgranulati
