New Classification Of Osteonerosis Of The Femoral Head Based On The "3S" Systemin And It’s Relationship With Tcm Constituion

Osteonecrosis of the femoral head (ONFH) is a recalcitrant and common disease in the field of orthopedics, which caused by inadequate blood supply to the affected segment of the subchondral bone. Then it characterized by death of the osteocytes、the bone marrow and the adipocyte. It is estimated that there are 5 million to 7.5 million ONFH patients who need treating in our country. And the new cases are 150,000-300,000 annually. According to the different causes, ONFH is divided into two categories, including traumatic and non-traumatic ONFH. And non-traumatic ONFH offen occurs in young and middle-aged patients. Without proper treatment, about 80% of ONFH will develop to the collapse of the femoral head in 1 to 4 years and eventually develop into serious injuries involving the whole hip joint. At this time, most patients have to face the outcome of artificial hip replacement. Therefore, at the early stages, according to staging classification characteristics, formulating therapeutic principles and treatment methods to prevent femoral head collapse is essential. At present, the clinical application of artificial joint service life is limited. For young patients, it has to be repeated or repeatedly artificial joint renovation.So not only to the patients themselves a huge pain, but also to the family and society has brought a huge burden.So the scientific and reasonable staging classification method of ONFH is of great significance to guide the clinical diagnosis and treatment of the necrosis of the femoral head. There are plenty of methods to predict collapse of ONFH. However, all of them have their limitations and cannot fully meet the clinical needs.Combined with previous research and clinical practice, we found that the prognosis of ONFH is mainly affected by the necrotic size, necrosis site and the self-repairing capacity after necrosis. We call it "3S" And the existing staging method of the development or single factor from the one factor considerations, or from the two factor considerations, there are not considered the three factors.Therefore, this research is intend to establish a new classification system which is including the necrosis size, necrosis site and the self-repairing capacity. It is called "3S" system---ABC typing method. Then its relationship with traditional Chinese medicine the constitution will be explored. It can provide new methods for predicting the collapse of ONFH and new ideas for TCM treatment of ONFH.Objective:1. Based on the biomechanical distribution of the femoral head trabecular, to determine the standard structure of adult femoral head three column and concrete division method.2. Based on the "3S" system to establish the ABC typing method for the prognosis of ONFH and providing guidance basis for the formulating therapeutic principles and treatment scheme.3. To explore the effects of TCM Constitution on femoral head necrosis size, necrosis site. This can provide new ideas for TCM treatment of ONFH.Methods:1. The division of three column structures:50 volunteers (including 170 hips) were collected. Each one took dual hips anteroposterior X-ray. According to the distribution of stress bone trabecula, three column structures were divided by CAD software. The length of each column was calculated. Then according to the results, the ratio of the each column on the maximum transverse diameter was got. It can provide a scientific basis for the division of three column structure.2. To establish the ABC typing method based on the "3S" system:132 cases (including 223 hips) were collected from out-patient clinic of orthopedic of Guang’anmen hospital of China Academy of Chinese Medical Science. The maximum necrotic area level on coronal CT or MRI images was collected as the three column division level.There were three layers to measure the proximal sclerosis proportions, including the maximum necrotic area level on coronal CT images and the before and after levels. Using CAD software to divide three columns and estimate the proximal sclerosis proportions. The differences among ABC typings were analysed.3. Study on the relationship with TCM Constitution and "three column distribution": 95 cases that the TCM constitutions conformed to yang-deficiency and (or) dampness-heat (or) and blood-stasis constitutions were collected from out-patient clinic of orthopedic of Guang’anmen hospital of China Academy of Chinese Medical Science. Each case took CT or MRI examinations of the pelvis. all cases underwent CT scan of double hip joint. The maximum necrotic area level on coronal CT or MRI images was collected as the three column division level. Using CAD software to divide three columns. Analyzed the differences between TCM constitutionsof column numbers and the necrotic site (i.e., whether involving the lateral column).Results:1. The division of three column structures:All of the three colums were according with normal distribution (p>0.05). The femoral head maximum transverse diameter was 53.50±3.12mm. And the lengths oflateral.center and medial column on maximum transverse diameter were 15.96±1.20mm,20.94±1.22mm and16.60 ± 1.08mm. The ratios of them were 0.31,0.39 and0.30. Different genders and sides had no difference between the lengths of lateral,center and medial column on maximum transverse diameter(p>0.05). In clinical practice, we can choose 3:4:3.2. The results of the ABC typing method based on the "3S" system:Type-A accounted for 0.9%, with A Ⅰ and A Ⅱ type accounted for 0.45%; Type-B accounted for 9.4%, with B Ⅰ and B Ⅱ type accounted for 3.1%,6.3%; Type-C accounted for 1.3%, with C Ⅰ and C Ⅱ accounted for 0.4%,0.9%; Type-AB accounted for 12.1%, with AB Ⅰ and AB Ⅱ type accounted for 7.2%,4.9%; Type-BC accounted for 9.4%, with BC I and BC Ⅱ type accounted for 4.9%, 4.5%; Type-A-C accounted for 66.8%, with A-CI and A-C Ⅱ type accounted for 53.8%,13%. The femoral head collapse rates of type-A, type-B, type-C, type-AB, type- BC and type-A-C were 50%,9.5%,0,74.1%,52.4%,88.6%, and the difference was statistically significant (X2= 77.775, P=0.000). The subtypes femoral head collapse rates of type AⅠ,AⅡ,BⅠ,BⅡ,CⅠ,CⅡ,ABⅠ,ABⅡ, BCⅠ, BCⅡ, A-CⅠ and A-CⅡ were 100%,0,28.6%,0,0,0,100%,36.4%, 81.8%,20%,100%,41.4%. The difference was statistically significant (X2= 170.939, P=0.000). Femoral head collapse rate ranking: A-C>AB>BC>A>B>C; A-C Ⅰ, AB Ⅰ, AⅠ>BC Ⅰ>A-C Ⅱ>AB Ⅱ> BⅠ> BC Ⅱ>AⅡ, BⅡ,CⅠ,CⅡ. There were significant differences between BⅠ and BⅡ (X2=4.833, P=0.028), BⅠ and BⅡ (X2=4.833, P=0.028), AB Ⅰ and ABⅡ (X2=16.483, P=0.000),BCⅠ and BCⅡ (X2=8.625, P=0.003), A-CⅠ and A-C Ⅱ (X2=66.451, P=0.000)3. The relationship with TCM Constitution and "three column distribution":Among the 95 cases,38 cases (39.6%)were Yang-deficiency,18 cases (18.9%) were dampness-heat,12 cases (12.6%) were blood-stasis,11 cases (11.6%) were Yang-deficiency combined dampness-heat,10 cases (10.5%) were Yang-deficiency combined blood-stasis,6 cases (6.3%) were dampness-heat combined blood-stasis. There were significant differences between groups in different column numbers, χ2= 25.59, P= 0.02 (<0.05); There were also differences between the three kinds of single lopsided constitutions, χ2= 12.19, P= 0.016 (<0.05). Blood-stasis involved a single column or three columns..For each pairwise comparison, we found that blood-stasis constitution are different with yang-deficiency constitution (p=0.001), dampness-heat (p=0.01), Yang-deficiency combined dampness-heat (P= 0.04). The differences of necrotic site among different constitutions as no statistical significance χ2= 7.64, P= 0.18 (>0.05). There was also no difference between the three kinds of single lopsided constitutions, χ2=6.53, P=0.08(>0.05)Conclusions:1. The ratios of lateral, center and medial column on the maximum transverse diameter were 0.31,0.39and0.30. It means that two vertical lines on the coronal plane of femoral head divide the maximum transverse diameter into three parts, the ratio is 3:4:3.2. The ABC typing method combines the necrosis size, necrosis site and self-repairing three important factors. It is a systematic and comprehensive method to predicte the necrosis of the femoral head Type A-C Ⅰ, Type AB Ⅰ, Type A and Type BCⅠ have poor prognosis, while Type AⅡ,Type BⅡ, Type CI and Type C Ⅱ have good prognosis.3. The TCM constitution may affect the prognosis of ONFH by the necrosis size. Blood-stasis constitution has small necrosis size but the yang-deficiency and dampness-heat constitution has large necrosis size, which tend to collapse and need positive treatment in the early stage. The main therapeutic principles should reinforce the kidney and strengthen the spleen.