本文選題：股骨頭壞死 + 三柱結(jié)構(gòu)�。� 參考：《中國(guó)中醫(yī)科學(xué)院》2015年碩士論文

【摘要】：股骨頭壞死(osteonecrosis of the femoral head,ONFH)是當(dāng)今骨科領(lǐng)域常見、難治病之一,是由于多種原因?qū)е鹿晒穷^血供不足,繼而出現(xiàn)骨的活性成分(包括骨細(xì)胞、骨髓造血細(xì)胞和脂肪細(xì)胞)死亡的一種病理過(guò)程。據(jù)估計(jì)我國(guó)目前需要治療的股骨頭壞死患者約為500-750萬(wàn),且每年新發(fā)病例約為15-30萬(wàn)人次。根據(jù)ONFH發(fā)病原因的不同,可將其分為創(chuàng)傷性和非創(chuàng)傷性兩大類。其中非創(chuàng)傷性O(shè)NFH好發(fā)于中青年,且一旦發(fā)病,如未及時(shí)給予有效治療,約有80%的患者將會(huì)在1-4年內(nèi)進(jìn)展為股骨頭塌陷,最終將會(huì)發(fā)展為累及整個(gè)髖關(guān)節(jié)的嚴(yán)重毀損。此時(shí),大多數(shù)患者不得不面臨人工髖關(guān)節(jié)置換的結(jié)局。然而,目前臨床中所應(yīng)用的人工關(guān)節(jié)使用壽命有限,對(duì)于年輕患者而言,在一生中可能需要經(jīng)歷再次或多次人工關(guān)節(jié)翻修，，這樣不僅給患者自身帶來(lái)巨大的痛苦,也給家庭和社會(huì)帶來(lái)了巨大的經(jīng)濟(jì)負(fù)擔(dān)。而在股骨頭壞死早期,根據(jù)股骨頭壞死的分期分型特點(diǎn),做出正確的預(yù)后判斷,確立合理的治療原則,并予以相應(yīng)的治療方法,從而預(yù)防股骨頭壞死塌陷成為本病治療的關(guān)鍵。因此,科學(xué)合理的股骨頭壞死分期分型方法,對(duì)股骨頭壞死的預(yù)后判斷及指導(dǎo)臨床診治意義重大。目前,關(guān)于股骨頭壞死分期分型方法有多種,但均存在著其自身的一定局限性,不能完全滿足臨床需要。結(jié)合前期文獻(xiàn)研究及臨床實(shí)踐,我們發(fā)現(xiàn)ONFH的預(yù)后主要受到壞死范圍(Size)、壞死部位(Site)和壞死后自身修復(fù)能力(Self-repairing)三方面因素的影響,我們稱之為“3S”。而目前所現(xiàn)存的分期分型方法的制定或單從一方面因素考慮,或從兩方面因素考慮,尚未有綜合考慮三方面因素者。據(jù)此,本研究擬結(jié)合壞死范圍(Size)、壞死部位(Site)、自身修復(fù)能力(Self-repairing),提出一種新的股骨頭壞死分型體系,即基于“3S”體系的股骨頭壞死分型---ABC分型方法,并分析其與中醫(yī)體質(zhì)的關(guān)系,為股骨頭壞死塌陷預(yù)測(cè)及中西醫(yī)診治提供新方法、新思路。目的：1.基于股骨頭骨小梁的生物力學(xué)分布特征,確定成人股骨頭三柱結(jié)構(gòu)的劃分標(biāo)準(zhǔn)及具體劃分方法。2.基于“3S”體系思想建立股骨頭壞死ABC分型方法,為股骨頭壞死預(yù)后及臨床診治方案的制定提供依據(jù)。3.通過(guò)分析中醫(yī)體質(zhì)與股骨頭壞死灶三柱分布的關(guān)系,以探索中醫(yī)體質(zhì)對(duì)股骨頭壞死范圍、壞死部位的影響,為股骨頭壞死的中醫(yī)診治提供新思路。方法：1.正常股骨頭三柱結(jié)構(gòu)的測(cè)算：選取50例(100髖)正常股骨頭志愿者,拍攝雙髖關(guān)節(jié)正位X線片,根據(jù)股骨頭主要壓力骨小梁的分布情況,完成三柱結(jié)構(gòu)的劃分,借助CAD軟件完成股骨頭外側(cè)柱、中間柱及內(nèi)側(cè)柱的測(cè)算,并根據(jù)測(cè)算結(jié)果計(jì)算外側(cè)柱：中間柱：內(nèi)側(cè)柱在股骨頭最大橫徑上的比例,為三柱結(jié)構(gòu)的劃分提供科學(xué)依據(jù)。2.基于“3S”體系的股骨頭壞死ABC分型方法的建立：在確立股骨頭三柱結(jié)構(gòu)劃分的基礎(chǔ)上,綜合考慮壞死范圍、部位、自身修復(fù)能力提出股骨頭壞死的ABC分型方法。由中國(guó)中醫(yī)科學(xué)院廣安門醫(yī)院骨科門診收集132例223髖符合納入和排除標(biāo)準(zhǔn)的股骨頭壞死病例。選取CT或MRI冠狀位壞死范圍最大層面為三柱測(cè)量層面,CT壞死范圍最大層面及其前后各1層共3個(gè)層面為近端硬化帶比例測(cè)算層面借助CAD軟件行三柱劃分和近端硬化帶比例的測(cè)算并比較ABC分型各型間股骨頭壞死塌陷的差異。3.中醫(yī)體質(zhì)與股骨頭壞死“三柱分布”關(guān)系的研究：由中國(guó)中醫(yī)科學(xué)院廣安門醫(yī)院骨科門診收集95例中醫(yī)體質(zhì)為陽(yáng)虛質(zhì)和(或)、濕熱質(zhì)和(或)、血瘀質(zhì)的股骨頭壞死病例,所有病例均行雙髖關(guān)節(jié)CT或MRI掃描。選取冠狀位壞死范圍最大的層面,使用CAD軟件行ABC分型,比較分析不同中醫(yī)體質(zhì)股骨頭壞死患者累及股骨頭柱數(shù)分布和累及壞死部位(即是否累及外側(cè)柱)是否存在差異。結(jié)果：1.正常股骨頭三柱測(cè)量情況：采用單樣本K-S檢驗(yàn),內(nèi)側(cè)柱、中間柱、外側(cè)柱及最大橫徑測(cè)量結(jié)果P值均0.05,均符合正態(tài)分布。股骨頭最大橫徑53.50±3.12,外側(cè)柱15.96+1.20,中間柱20.94±1.22,內(nèi)側(cè)柱16.60±1.08,三者所占股骨頭寬度比例分別為0.31、0.39、0.30。不同性別組間正常股骨頭外側(cè)柱、中間柱及內(nèi)側(cè)柱長(zhǎng)度及比例差異均無(wú)統(tǒng)計(jì)學(xué)意義,雙側(cè)檢驗(yàn)結(jié)果P值均0.05。不同側(cè)別組間正常股骨頭外側(cè)柱、中間柱及內(nèi)側(cè)柱長(zhǎng)度及比例差異均無(wú)統(tǒng)計(jì)學(xué)意義,雙側(cè)檢驗(yàn)結(jié)果P值均0.05。為方便臨床應(yīng)用,我們可以選擇外側(cè)柱：中間柱：內(nèi)側(cè)柱為3：4：3的比例在股骨頭最大橫徑上進(jìn)行劃分。2.基于“3S”體系的股骨頭壞死ABC分型結(jié)果：本組病例中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型分別占3.1%、6.3%；C型占1.3%,其中CⅠ和CⅡ型分別占0.4%、0.9%；AB型占12.1%,其中ABⅠ和ABⅡ型分別占7.2%、4.9%；BC型占9.4%,其中BCⅠ和BCⅡ型分別占4.9%、4.5%；A-C型占66.8%,其中A-CⅠ和A-CⅡ型分別占53.8%、13.0%。ABC分型法中A型、B型、C型、AB型、BC型、A-C型的股骨頭塌陷率分別為50%、9.5%、0、74.1%、52.4%、88.6%,差異有統(tǒng)計(jì)學(xué)意義(X12=77.775,P 1=0.000)。各型的股骨頭壞死塌陷率排序?yàn)椋篈-C型AB型BC型A型B型C型。各亞型中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型的股骨頭塌陷率分別為100%、0、28.6%、0、0、0、100%、36.4%、81.8%、20.0%、100%、41.4%,差異有統(tǒng)計(jì)學(xué)意義(X22=170.939,P2＝0.000)。各亞型間兩兩比較：BⅠ型與BⅡ型差異有統(tǒng)計(jì)學(xué)意義(X2=4.833,P=0.028)：ABⅠ型與ABⅡ型差異有統(tǒng)計(jì)學(xué)意義(X2=16.483,P－0.000)：BCⅠ型與BCⅡ型差異有統(tǒng)計(jì)學(xué)意義(X2=8.625,P=0.003);A-CⅠ型與A-CⅡ型差異有統(tǒng)計(jì)學(xué)意義(X2=66.451,P=0.000)。股骨頭壞死塌陷率排序?yàn)椋篈-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.中醫(yī)體質(zhì)與股骨頭壞死“三柱分布”的關(guān)系研究：95例股骨頭壞死病例中,陽(yáng)虛質(zhì)有38例(39.6%),濕熱質(zhì)18例(18.9%),血瘀質(zhì)12例(12.6%),陽(yáng)虛兼濕熱質(zhì)11例(11.6%),陽(yáng)虛兼血瘀質(zhì)10例(10.5%),濕熱兼血瘀質(zhì)6例(6.3%)。不同體質(zhì)組間柱數(shù)分布差異有統(tǒng)計(jì)學(xué)意義,雙側(cè)檢驗(yàn)結(jié)果χb 25.59,P＝0.02(0.05)：對(duì)三種單一偏頗體質(zhì)進(jìn)行檢驗(yàn),結(jié)果為χ2＝12.19,P=0.016(0.05)。單一偏頗體質(zhì)中濕熱質(zhì)及陽(yáng)虛質(zhì)累及柱數(shù)為雙柱或三柱,未出現(xiàn)累及單柱情況。血瘀質(zhì)可累及單柱或三柱。將股骨頭壞死不同中醫(yī)體質(zhì)累及柱數(shù)做兩兩比較分析結(jié)果為：陽(yáng)虛質(zhì)與血瘀質(zhì)(P＝0.001)、濕熱質(zhì)與血瘀質(zhì)(P＝0.01)、陽(yáng)虛+濕熱質(zhì)與血瘀質(zhì)(P＝0.04)比較差異有統(tǒng)計(jì)學(xué)意義,余各體質(zhì)間比較差異無(wú)統(tǒng)計(jì)學(xué)意義。不同體質(zhì)組間累及外側(cè)柱差異無(wú)統(tǒng)計(jì)學(xué)意義,雙側(cè)檢驗(yàn)結(jié)果χ2＝7.64,P＝0.18(0.05)(表4)。對(duì)三種單一偏頗體質(zhì)進(jìn)行檢驗(yàn),結(jié)果為χ26.53,P＝0.08(0.05)。結(jié)論：1.股骨頭的外側(cè)柱、中間柱及內(nèi)側(cè)柱在股骨頭最大橫徑所占比例分別為0.31、0.39、0.30,即在股骨頭冠狀面上做兩條垂線,將股骨頭最大橫徑分為3：4：3三段,對(duì)應(yīng)股骨頭外側(cè)柱、中間柱及內(nèi)側(cè)柱。2.股骨頭壞死ABC分型方法綜合了壞死范圍(Size)、壞死部位(Site)、自身修復(fù)能力(Self-repairing)三個(gè)影響股骨頭壞死預(yù)后的重要因素,是目前預(yù)測(cè)股骨頭壞死塌陷較為系統(tǒng)的綜合預(yù)測(cè)體系,該分型方法中,A-CⅠ型、ABⅠ型、AⅠ型、BCⅠ型的預(yù)后較差,AⅡ型、BⅡ型、CⅠ型、CⅡ型的預(yù)后較好。3.中醫(yī)體質(zhì)可能通過(guò)影響股骨頭壞死范圍而影響股骨頭壞死預(yù)后,血瘀質(zhì)者壞死范圍較小,陽(yáng)虛質(zhì)及濕熱質(zhì)壞死范圍較大,容易塌陷,預(yù)后較差,需在早期積極給予預(yù)防塌陷的治療手段,調(diào)整改善體質(zhì),重以溫陽(yáng)利濕之法。
[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.
【學(xué)位授予單位】：中國(guó)中醫(yī)科學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R681.8

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