超声造影在股骨头坏死血流灌注中的应用价值

doi:10.3877/cma.j.issn.1672-6448.2021.03.011

目的

探讨超声造影在股骨头坏死患者股骨头软骨下骨血流灌注中的应用价值。

方法

收集2019年3月至9月广州中医药大学第一附属医院就诊的股骨头坏死患者共48例（80髋），经MRI检查确诊，根据国际骨微循环研究协会制定的分期标准，股骨头坏死侧共65髋，其中Ⅱ期共31髋（Ⅱ期组），Ⅲ期共34髋（Ⅲ期组）；对侧无坏死的正常侧共15髋（对照组）。行常规超声和超声造影检查，生成超声造影时间-强度曲线（TIC）并获得以下血流灌注参数：达峰时间（TTP）、峰值强度（PI）、平均越渡时间（MTT）、曲线上升支斜率（AS）、曲线下降支斜率（DS）。对3组参数的PI、MTT采用单因素方差分析，两两比较采用LSD-t检验，对TTP、AS、DS采用非参数检验，两两比较采用Kruskal-Wallis检验。以MRI为诊断金标准，选取3组间均有统计学意义的参数，绘制受试者操作特征（ROC）曲线，评价其诊断股骨头坏死的效能。

结果

Ⅱ期组与对照组比较，PI、AS均高于对照组［（27.46±5.60）dB vs（21.06±5.37）dB；（1.69±0.78）vs 0.61（0.24，0.88）］，MTT、TTP、DS均低于对照组［（51.99±16.63）s vs（68.65±17.46）s；8.10（7.32，10.20）s vs 13.26（10.36，18.60）s；（-0.18±0.09） vs （-0.08±0.05）］，差异均具有统计学意义（t=3.359，P=0.001；H=3.507，P=0.001；t=3.336，P=0.001；H=3.914，P＜0.001；H=3.608，P＜0.001）；III期组与对照组比较，PI、AS均高于对照组［（31.79±6.70）dB vs （21.06±5.37）dB；（2.40±1.00）vs 0.61（0.24，0.88）］，MTT、TTP、DS均低于对照组［（55.71±14.42）s vs （68.65±17.46）s；7.81（6.81，9.25）s vs 13.26（10.36，18.60）s］；（-0.22±0.09） vs （-0.08±.05）］，差异均具有统计学意义（t=5.713，P＜0.001；H=5.586，P＜0.001；t=2.629，P=0.010；H=4.612，P＜0.001；H=4.818，P＜0.001）；Ⅱ期组与Ⅲ期组比较，PI和AS均低于III期组［（27.46±5.60）dB vs （31.79±6.70）dB；（1.69±0.78）vs （2.40±1.00）］，差异具有统计学意义（t=2.876，P=0.005；H=2.532，P=0.034），MTT、TTP、DS比较差异无统计学意义（P＞0.05）。ROC曲线分析PI和AS的曲线下面积分别为0.848（P＜0.001）和0.916（P＜0.001）。

结论

超声造影可能为股骨头坏死Ⅱ期和Ⅲ期患者股骨头软骨下骨血流灌注的评估进行有效补充，可为临床股骨头坏死的分期诊断提供参考依据。

关键词: 超声造影, 股骨头坏死, 时间-强度曲线, 血流灌注

Objective

To evaluate the application value of contrast-enhanced ultrasound (CEUS) in evaluating blood perfusion of subchondral bone in patients with osteonecrosis of the femoral head.

Methods

Forty-eight patients (80 hips) with osteonecrosis of the femoral head at the First Affiliated Hospital of Guangzhou University of Chinese Medicine from March to September 2019 were collected. There were 65 hips with osteonecrosis of the femoral head, of which 31 hips were at ARCO stage II (stage II group) and 34 hips were at ARCO stage III (stage III group), and 15 normal hips (control group) by the staging criteria of the Association Research Circulation Osseous (ARCO). All subjects underwent ultrasound and CEUS examinations, and parameters including time to peak (TTP), peak intensity (PI), mean transit time (MTT), ascending slope (AS), and descending slope (DS) were quantitatively analyzed among the three groups. One-way ANOVA was used for comparing the PI and MTT of the three groups, and the LSD test was used for pairwise comparisons. The rank sum test was used for comparisons of TTP, AS, and DS among the three groups, and the Kruskal-Wallis test was used for pairwise comparisons. Taking MRI as the diagnostic gold standard, the operating characteristics (ROC) curves of the parameters were drawn to evaluate their performance for the diagnosis of femoral head necrosis.

Results

PI and AS values in the stage II group were significantly higher than those of the control group [(27.46±5.60) dB vs (21.06±5.37) dB, t=3.359, P=0.001; (1.69±0.78) vs 0.61(0.24, 0.88)], H=3.507, P=0.001], while MTT, TTP, and DS values in the stage II group were significantly lower than those of the control group [(51.99±16.63) s vs (68.65±17.46) s, t=3.336, P=0.001; 8.10 (7.32, 10.20) s vs 13.26 (10.36, 18.60) s, H=3.914, P＜0.001; (-0.18±0.09) vs (-0.08±0.05), H=3.608, P＜0.001]. PI and AS values in the stage III group were significantly higher than those of the control group [(31.79±6.70) dB vs (21.06±5.37) dB, t=5.713, P＜0.001; (2.4±1.00) vs 0.61 (0.24, 0.88), H=5.586, P＜0.001], while MTT, TTP, and DS values in the stage III group were significantly lower than those of the control group [(55.71±14.42) s vs (68.65±17.46) s, t=2.629, P=0.010; 7.81 (6.81, 9.25) vs 13.26 (10.36, 18.60) s, H=4.612, P＜0.001; (-0.22±0.09) vs (-0.08

±

0.05), H=4.818, P＜0.001]. PI and AS values in the stage II group were significantly lower than those of the stage III group [(27.46

±

5.60) dB vs (31.79

±

6.70) dB, t=2.876, P=0.005; (1.69

±

0.78) vs (2.40±1.00), H=2.532, P=0.034], but there was no significant difference in MTT, TTP, or DS between the two groups (P＞0.05). ROC curve analysis showed the AUC values of PI and AS were 0.848 (P＜0.001) and 0.916 (P＜0.001), respectively.

Conclusion

Contrast-enhanced ultrasound may be used as an effective supplement for the assessment of the blood perfusion of subchondral bone in patients with ARCO stage II and III osteonecrosis of the femoral head and can provide effective evidence for the diagnosis of osteonecrosis of the femoral head.

Key words: Contrast-enhanced ultrasound, Osteonecrosis of the femoral head, Time-intensity curve, Blood perfusion

图1 股骨头二维超声声像图、MRI图。图a、b、c为二维超声声像图，图d、e、f为MRI图，图a、d为对照组，图b、e为Ⅱ期组，图c、f为Ⅲ期组

图2 股骨头造影剂灌注过程。图a为推注造影剂约23 s时，造影剂微泡从头颈交界区向股骨头弥散灌注，图b为推注造影剂约33 s时，股骨头软骨下骨区造影剂灌注达高峰，图c为推注造影剂约62 s时，造影剂逐渐消退

图3 对照组（图a）、Ⅱ期组（图b）、Ⅲ期组（图c）时间-强度曲线图

表1 3组股骨头间时间-强度曲线相关参数比较

组别	髋关节数	TTP[s，M（Q_R）]	PI（dB， $x ¯$ ±ｓ）	MTT（ $x ¯$ ±ｓ）	AS[M（Q_R）， $x ¯$ ±ｓ）]	DS（ $x ¯$ ±ｓ）
对照组	15	13.26（10.36，18.60）	21.06±5.37	68.65±17.46	0.61（0.24，0.88）	-0.08±0.05
Ⅱ期组	31	8.10（7.32，10.20）^a	27.46±5.60^ab	51.99±16.63^a	1.69±0.78^ab	-0.18±0.09^a
Ⅲ期组	34	7.81（6.81，9.25）^a	31.79±6.70^a	55.71±14.42^a	2.40±1.00^a	-0.22±0.09^a
统计值		$χ$ ²=22.35	F=16.60	F=5.68	$χ$ ²=31.39	$χ$ ²=13.20
P值		＜0.001	＜0.001	0.005	＜0.001	＜0.001

表1 3组股骨头间时间-强度曲线相关参数比较

组别	髋关节数	TTP[s，M（Q_R）]	PI（dB， $x ¯$ ±ｓ）	MTT（ $x ¯$ ±ｓ）	AS[M（Q_R）， $x ¯$ ±ｓ）]	DS（ $x ¯$ ±ｓ）
对照组	15	13.26（10.36，18.60）	21.06±5.37	68.65±17.46	0.61（0.24，0.88）	-0.08±0.05
Ⅱ期组	31	8.10（7.32，10.20）^a	27.46±5.60^ab	51.99±16.63^a	1.69±0.78^ab	-0.18±0.09^a
Ⅲ期组	34	7.81（6.81，9.25）^a	31.79±6.70^a	55.71±14.42^a	2.40±1.00^a	-0.22±0.09^a
统计值		$χ$ ²=22.35	F=16.60	F=5.68	$χ$ ²=31.39	$χ$ ²=13.20
P值		＜0.001	＜0.001	0.005	＜0.001	＜0.001

图4 PI、AS鉴别诊断股骨头坏死的受试者操作特征曲线

1	Zhao D, Zhang F, Wang B, et al. Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version) [J]. J Orthop Translat, 2020, 21: 100‐110.
2	Petek D, Hannouche D, Suva D. Osteonecrosis of the femoral head:pathophysiology and current concepts of treatment [J]. EFORT Open Rev, 2019, 4(3): 85-97.
3	Löffler C, Sattler H, Uppenkamp M, et al. Contrast-enhanced ultrasound in coxitis [J]. Joint Bone Spine, 2016, 83(6): 669-674.
4	Li XZ, Song J, Sun ZX, et al. Diagnostic performance of contrast-enhanced ultrasound for pancreatic neoplasms: a systematic review and meta-analysis [J]. Dig Liver Dis, 2018, 50(2): 132-138.
5	Yoon BH, Mont MA, Koo KH, et al. The 2019 revised version of association research circulation osseous staging system of osteonecrosis of the femoral head [J]. J Arthroplasty, 2020, 35(4): 933-940.
6	魏秋实, 方斌, 陈镇秋, 等. 股骨头前外侧骨质状态在股骨头坏死塌陷进展中的作用(英文) [J]. 中国组织工程研究, 2019, 23(16): 2516-2522.
7	何伟. 如何把握股骨头坏死患者的保髋治疗时期 [J]. 中国骨与关节杂志, 2016, 5(2): 82-86.
8	魏秋实, 何伟, 张庆文, 等. 基于X线片建立股骨头坏死新分型体系的临床意义 [J/CD]. 中华关节外科杂志(电子版), 2018, 12(6): 849-856.
9	Zhao D, Qiu X, Wang B, et al. Epiphyseal arterial network and inferior retinacular artery seem critical to femoral head perfusion in adults with femoral neck fractures [J]. Clin Orthop Relat Res, 2017, 475(8): 2011-2023.
10	Qiu X, Cheng LL, Wang BJ, et al. Micro perfusion and quantitative analysis of the femoral head intraosseous artery [J]. Orthop Surg, 2018, 10(1): 69-74.
11	李秀芹. 超声造影定量参数与甲状腺乳头状癌组织中微血管密度、颈部淋巴结转移的关系 [J]. 临床与病理杂志, 2020, 40(1): 52-57.
12	Pitre-Champagnat S, Leguerney I, Bosq J, et al. Dynamic contrast-enhanced ultrasound parametric maps to evaluate intratumoral vascularization [J]. Invest Radiol, 2015, 50(4): 212-217.
13	刘春蕊, 黄鹏飞, 谢迎东, 等. 超声造影定性分析鉴别诊断甲状腺良恶性结节的价值 [J/CD]. 中华医学超声杂志(电子版), 2017, 14(3): 220-225.
14	郭瑞君. 肌肉骨骼超声进入崭新时代 [J/CD]. 中华医学超声杂志(电子版), 2015, 9(1): 3-5.
15	Kiyan W, Nakagawa Y, Ito A, et al. Ultrasound parameters for human osteoarthritic subchondral bone ex vivo: comparison with micro-computed tomography parameters [J]. Ultrasound Med Biol, 2018, 44(10): 2115-2130.
16	Aula AS, Töyräs J, Tiitu V, et al. Simultaneous ultrasound measurement of articular cartilage and subchondral bone [J]. Osteoarthritis Cartilage, 2010, 18(12): 1570-1576.
17	Geis S, Prantl L, Mueller S, et al. Quantitative assessment of bone microvascularization after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS) [J]. Ultraschall Med, 2013, 34(3): 272-279.
18	Sidhu PS, Cantisani V, Dietrich CF, et al. The EFSUMB guidelines and recommendations for the clinical practice of contrast-enhanced ultrasound (CEUS) in non-hepatic applications: update 2017 (long version) [J]. Ultraschall Med, 2018, 39(2): e2-e44.
19	Chen YY, Wu XS, Tian YY, et al. Evaluation of femoral head perfusion by contrast-enhanced ultrasound in a rabbit model of steroid-induced osteonecrosis [J]. J Ultrasound Med, 2020, 39(5): 987-995.
20	田媛媛, 赵萍, 孙淑玮, 等. 超声造影对兔股骨头坏死微循环灌注的定量研究 [J]. 中国超声医学杂志, 2020, 36(1): 76-79.
21	邱逦, 苏白海, 罗燕, 等. 股骨头缺血性坏死的超声表现及其临床意义 [J]. 中国医学影像技术, 2007, 23(11): 1697-1699.
22	孙淑玮, 赵萍, 陈钰仪, 等. 超声造影定量分析早期兔股骨头坏死的实验研究 [J]. 中国超声医学杂志, 2018, 34(11): 1038-1041.
23	牛宏珍, 勇强, 张蕾, 等. 超微血流显像与超声造影评价极低回声区斑块内新生血管分布的研究初探 [J]. 心肺血管病杂志, 2018, 37(12): 1046-1048, 1057.
24	陈雷雷, 何伟. 股骨头缺血性坏死相关生物力学研究进展 [J]. 中国骨伤, 2011, 24(2): 174-177.
25	Chan WP, Liu YJ, Huang GS, et al. Relationship of idiopathic osteonecrosis of the femoral head to perfusion changes in the proximal femur by dynamic contrast-enhanced MRI [J]. AJR Am J Roentgenol, 2011, 196(3): 637-643.

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Application value of contrast-enhanced ultrasound in evaluating blood perfusion with osteonecrosis of the femoral head

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Application value of contrast-enhanced ultrasound in evaluating blood perfusion with osteonecrosis of the femoral head