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武漢大學(xué)中南醫(yī)院

公立三甲綜合醫(yī)院

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疾?。? 股骨頭壞死
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股骨頭壞死科普知識(shí) 查看全部

股骨頭壞死早期能多走路嗎？不行股骨頭壞死是引起髖關(guān)節(jié)疼痛，活動(dòng)受限的常見(jiàn)原因，很多是因?yàn)榧に亍⑿锞?、外傷等原因造成的。股骨頭壞死早期很多人癥狀不明顯，有時(shí)候感覺(jué)坐著起來(lái)的幾步疼，然后接著走就不疼了。很多時(shí)候是休息的時(shí)候不疼，變換姿勢(shì)起身走路就有點(diǎn)疼，有時(shí)候還疼得有點(diǎn)明顯，但是再走就又不疼了。那么這樣是不是就可以多走？盡量站著，不坐下變換體位不就不疼了嗎？這樣理解是不對(duì)的！股骨頭壞死以后股骨頭因?yàn)橛袎乃溃晒穷^強(qiáng)度就會(huì)有下降。尤其是負(fù)重區(qū)的壞死，在負(fù)重情況下會(huì)引起股骨頭局部壓力增加，會(huì)加速股骨頭壞死的進(jìn)展。負(fù)重不是說(shuō)自己扛什么重東西，站立時(shí)候的體重壓在股骨頭上就是在增加股骨頭的負(fù)重了。所以這樣就可以理解，為什么股骨頭壞死早期，即使不疼或者疼痛不嚴(yán)重，醫(yī)生也是建議一定要扶拐保護(hù)。扶拐保護(hù)的目的就是盡量減輕體重對(duì)股骨頭的壓力，避免壞死的股骨頭由于局部壓力的增加，使得早期壞死治療的效果大打折扣。所以股骨頭壞死早期一定要重視，好好扶拐保護(hù)，減輕股骨頭負(fù)重，保護(hù)好自己的股骨頭
談?wù)劰晒穷^壞死（二）一、什么樣的外來(lái)因素會(huì)導(dǎo)致股骨頭壞死，也就是股骨頭內(nèi)骨細(xì)胞的非正常死亡激素、酒精和創(chuàng)傷（絕大數(shù)多是股骨頸骨折）是臨床觀察到的導(dǎo)致股骨頭壞死最常見(jiàn)的三大原因。教科書(shū)和文獻(xiàn)中還記載著一些少見(jiàn)的原因，如鐮狀細(xì)胞貧血、減壓?。ㄈ鐫撍w行等），但本人門(mén)診還沒(méi)有遇到過(guò)，也許是因?yàn)椴惶J(rèn)識(shí)的緣故。還有一些是自身免疫性疾病的患者，因?yàn)榇蠖嘟邮苓^(guò)糖皮質(zhì)激素的治療，所以也無(wú)法確定是自身免疫性疾病本身還是激素治療導(dǎo)致的股骨頭壞死。印象中，繼發(fā)股骨頭壞死的自身免疫病患者中，系統(tǒng)性紅斑狼瘡似乎是最多見(jiàn)的。除了這些有比較明確原因的患者，還有少部分股骨頭壞死患者則找不到目前已知的病因。激素是導(dǎo)致股骨頭壞死的第一大病因。由于激素在國(guó)內(nèi)使用的廣泛性，包括必要的和不必要的，尤其是在國(guó)內(nèi)各種不規(guī)范醫(yī)療還普遍存在的現(xiàn)狀下，激素性股骨頭壞死的數(shù)量在國(guó)內(nèi)非常之多，估算年度新增病例數(shù)達(dá)10余萬(wàn)例。激素性股骨頭壞死的患者人群中年輕人比例較高，十幾、二十幾歲的也有不少，這也給治療帶來(lái)了更大的挑戰(zhàn)。從股骨頭壞死這個(gè)疾病的角度來(lái)看，激素?zé)o疑是頭號(hào)殺手。但另一個(gè)事實(shí)也同樣存在，那就是從激素使用者的角度來(lái)看，大多數(shù)激素使用者并沒(méi)有發(fā)生股骨頭壞死。根據(jù)一些報(bào)道，激素使用后發(fā)生股骨頭壞死的概率大概是10-30%。因此，對(duì)于那些確實(shí)有必要使用激素治療的嚴(yán)重疾病，也不必因?yàn)楣晒穷^壞死這樣的并發(fā)癥而影響治療決策。自然，不必要的激素治療應(yīng)該避免。激素使用后是否發(fā)生股骨頭壞死，教科書(shū)和一些文獻(xiàn)通常認(rèn)為，與使用的劑量和時(shí)長(zhǎng)相關(guān)。但臨床確實(shí)也見(jiàn)到一些股骨頭壞死患者只有非常短暫的激素使用史,比如因?yàn)槭n麻疹或者發(fā)熱什么的。再結(jié)合很多長(zhǎng)時(shí)間、大劑量使用激素的患者并沒(méi)有發(fā)生股骨頭壞死的事實(shí)，因此我們推測(cè)激素使用與發(fā)生股骨頭壞死之間也可能存在的首先是一種“有”或“無(wú)”的關(guān)系，在“有”的群體里，才進(jìn)一步存在壞死嚴(yán)重程度和激素使用劑量的相關(guān)性。酒精大概是導(dǎo)致股骨頭壞死的第二大病因。酒精性股骨頭壞死的患病人群大多為中年男性，具有喝酒頻率高，劑量大，年頭長(zhǎng)的普遍特點(diǎn)。這一點(diǎn)與激素性股骨頭壞死有較大區(qū)別，酒精性股骨頭壞死與酒精攝入量之間存在更為明顯的劑量依賴(lài)關(guān)系，只有足夠劑量的酒精才可能導(dǎo)致股骨頭壞死的發(fā)生。飲酒者自然遠(yuǎn)遠(yuǎn)要多于激素使用者，因此雖然說(shuō)酒精是導(dǎo)致股骨頭壞死的第二大病因，但飲酒者發(fā)生股骨頭壞死還是一個(gè)很小概率的事件，具體的發(fā)生率難以統(tǒng)計(jì)，相比激素使用后10-30%的發(fā)生率，酒精攝入者的股骨頭壞死發(fā)生率應(yīng)該會(huì)小幾個(gè)數(shù)量級(jí)。對(duì)于長(zhǎng)期大量飲用酒精的人群，比股骨頭壞死發(fā)生率更高、危害程度更大的并發(fā)癥還有很多，比如神經(jīng)系統(tǒng)損害、消化系統(tǒng)損害等等。酒精愛(ài)好者當(dāng)然也不用太在意這些，因?yàn)楹染频哪康膹膩?lái)也不是為了健康。創(chuàng)傷是導(dǎo)致股骨頭壞死的另一重大原因。創(chuàng)傷性股骨頭壞死和酒精性股骨頭壞死的患者數(shù)量哪個(gè)更多，不太確定，可能與不同的地區(qū)、不同的醫(yī)療機(jī)構(gòu)有關(guān)。從本人門(mén)診接觸的患者來(lái)看，感覺(jué)兩者數(shù)量似乎差不多。創(chuàng)傷性股骨頭壞死的患者中，絕大多數(shù)是繼發(fā)于股骨頸骨折，其它比較少見(jiàn)的原始損傷類(lèi)型還包括股骨頭骨折、髖關(guān)節(jié)脫位和髖臼骨折、股骨粗隆部和股骨干骨折髓內(nèi)釘手術(shù)后。股骨頸骨折是一種常見(jiàn)骨折類(lèi)型，發(fā)生人數(shù)眾多，約占成人骨折總數(shù)的1.68%（據(jù)張英澤，臨床創(chuàng)傷骨科流行病學(xué)）。GBD（國(guó)際骨折聯(lián)盟）報(bào)告2019年全球新發(fā)骨折例數(shù)1.78億，據(jù)此估算股骨頸骨折的年發(fā)生例數(shù)，全球約300萬(wàn)，中國(guó)約60萬(wàn)。而且，股骨頸骨折多發(fā)生于老年人，由于國(guó)內(nèi)人口老齡化的加劇，股骨頸骨折的發(fā)生率還在持續(xù)快速增長(zhǎng)中。接骨、外固定或內(nèi)固定是骨折治療的常規(guī)方法，但是股骨頸骨折的內(nèi)固定治療幾乎是人體主要骨折中并發(fā)癥最多、治療結(jié)果最差的。也正因如此，人工關(guān)節(jié)置換已經(jīng)成為了老年人股骨頸骨折的首要治療方法。股骨頸骨折內(nèi)固定治療的并發(fā)癥主要有三個(gè)，一是比其它部位骨折更高的骨折不愈合的發(fā)生率；二是股骨頸短縮，即使骨折愈合了，很多也是股骨頸短縮后的愈合。股骨頸短縮的后果是肢體變短和臀中肌力矩變小，進(jìn)而導(dǎo)致步態(tài)異常、走路搖擺；三是股骨頭壞死，這是股骨頸骨折最麻煩而又最常見(jiàn)的并發(fā)癥，內(nèi)固定后股骨頭壞死的總體發(fā)生率約30%。股骨頸骨折后的股骨頭壞死還存在一個(gè)非常奇怪的臨床現(xiàn)象，那就是年輕患者的股骨頭壞死發(fā)生率要高于年長(zhǎng)患者，越年輕的股骨頸骨折患者發(fā)生股骨頭壞死的可能性越大。這與常識(shí)不符，與年輕患者骨折愈合能力更強(qiáng)的事實(shí)也不一致，但這又是臨床觀察到的確實(shí)現(xiàn)象，也是教科書(shū)里早就記載的。對(duì)于這個(gè)現(xiàn)象，目前還沒(méi)有一個(gè)具有足夠說(shuō)服力的解釋。按照年齡分布，大概有10%的股骨頸骨折患者年齡小于40歲，這還不包括14歲以下兒童。因?yàn)楣晒穷i骨折病例基數(shù)巨大，這10%的部分也是一個(gè)數(shù)量龐大的人群。對(duì)于這部分年輕股骨頸骨折患者，其繼發(fā)的股骨頭壞死是一個(gè)更加嚴(yán)重的臨床問(wèn)題乃至社會(huì)問(wèn)題，青少年移位型股骨頸骨折的股骨頭壞死發(fā)生率可高達(dá)40-50%，治療更是棘手，充滿(mǎn)挑戰(zhàn)。還有一類(lèi)少見(jiàn)、隱蔽且易于與股骨頭壞死混淆的損傷類(lèi)型，是股骨頭骨軟骨損傷。損傷當(dāng)時(shí)的常規(guī)X線(xiàn)片往往都是陰性表現(xiàn)，但是患者的疼痛很久都不能緩解。因?yàn)镸RI（磁共振）影像上的表現(xiàn)與股骨頭壞死非常相似，股骨頭骨軟骨損傷的患者常被認(rèn)作是股骨頭壞死而來(lái)就診。這種骨軟骨損傷更常見(jiàn)發(fā)生于距骨這個(gè)部位，也經(jīng)常被認(rèn)作是距骨骨壞死，這可能與我們的教科書(shū)對(duì)于骨軟骨損傷和骨壞死這兩個(gè)疾病的命名和闡述不夠清晰有關(guān)。這兩種疾病的性質(zhì)顯然是不一樣的，骨軟骨損傷實(shí)際是一種特殊類(lèi)型的骨折，由關(guān)節(jié)兩端的骨骼直接撞擊導(dǎo)致，骨折塊以軟骨為主體、帶少部分骨質(zhì)。（待續(xù)）
激素使用對(duì)股骨頭骨壞死發(fā)生和進(jìn)展的影響:一項(xiàng)全國(guó)性巢式病例對(duì)照研究（2024）激素使用對(duì)股骨頭骨壞死發(fā)生和進(jìn)展的影響:一項(xiàng)全國(guó)性巢式病例對(duì)照研究（2024）EffectofCorticosteroidUseontheOccurrenceandProgressionofOsteonecrosisoftheFemoralHead:ANationwideNestedCase-ControlStudy?KwonHM,HanM,LeeTS,JungI,SongJJ,YangHM,LeeJ,LeeSH,LeeYH,ParkKK.EffectofCorticosteroidUseontheOccurrenceandProgressionofOsteonecrosisoftheFemoralHead:ANationwideNestedCase-ControlStudy[J].JArthroplasty,2024轉(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/38830431/轉(zhuǎn)載文章的原鏈接2：https://www-clinicalkey-com-443.vpnm.ccmu.edu.cn/#!/content/journal/1-s2.0-S0883540324004595?AbstractBackgroundAlthoughitisverywellknownthatcorticosteroidscauseosteonecrosisofthefemoralhead(ONFH),itisunclearastowhichpatientsdevelopONFH.Additionally,therearenostudiesontheassociationbetweencorticosteroiduseandfemoralheadcollapseinONFHpatients.WeaimedtoinvestigatetheassociationbetweencorticosteroiduseandtheriskofONFHamongthegeneralpopulationandwhatfactorsaffectONFHoccurrence.Additionally,weaimedtodemonstratewhichfactorsaffectfemoralheadcollapseandtotalhiparthroplasty(THA)afterONFHoccurrence.雖然眾所周知，皮質(zhì)類(lèi)固醇會(huì)導(dǎo)致股骨頭骨壞死(ONFH)，但目前尚不清楚哪些患者會(huì)發(fā)生ONFH。此外，沒(méi)有關(guān)于皮質(zhì)類(lèi)固醇使用與ONFH患者股骨頭塌陷之間關(guān)系的研究。我們的目的是調(diào)查普通人群中皮質(zhì)類(lèi)固醇使用與ONFH風(fēng)險(xiǎn)之間的關(guān)系，以及影響ONFH發(fā)生的因素。此外，我們旨在證明哪些因素影響ONFH發(fā)生后股骨頭塌陷和全髖關(guān)節(jié)置換術(shù)(THA)。?MethodsAnationwide,nestedcase-controlstudywasconductedwithdatafromtheNationalHealthInsuranceServicePhysicalHealthExaminationCohort(2002to2019)intheRepublicofKorea.WedefinedONFH(N=3,500)usingdiagnosisandtreatmentcodes.PatientswhohadONFHwerematched1:5toformacontrolgroupbasedonthevariablesofbirthyear,sex,andfollow-upduration.Additionally,inpatientswhohaveONFH,welookedforriskfactorsforprogressiontoTHA.使用韓國(guó)國(guó)民健康保險(xiǎn)服務(wù)機(jī)構(gòu)身體健康檢查隊(duì)列(2002年至2019年)的數(shù)據(jù)進(jìn)行了一項(xiàng)全國(guó)性的巢式病例對(duì)照研究。我們使用診斷和治療代碼定義ONFH(N=3,500)。根據(jù)出生年份、性別、隨訪時(shí)間等變量對(duì)ONFH患者進(jìn)行1:5匹配，形成對(duì)照組。此外，在患有ONFH的患者中，我們尋找進(jìn)展為T(mén)HA的危險(xiǎn)因素。?ResultsComparedwiththecontrolgroup,ONFHpatientshadalowhouseholdincomeandhadmorediabetes,hypertension,dyslipidemia,andheavyalcoholuse(drinkingmorethan3to7drinksperweek).Systemiccorticosteroiduse(≥1,800mg)wassignificantlyassociatedwithanincreasedriskofONFHincidence.However,lipidprofiles,corticosteroidprescription,andcumulativedosesofcorticosteroiddidnotaffecttheprogressiontoTHA.與對(duì)照組相比，ONFH患者家庭收入較低，糖尿病、高血壓、血脂異常和重度飲酒(每周飲酒超過(guò)3至7天)的發(fā)生率更高。全身使用皮質(zhì)類(lèi)固醇(≥1800mg)與ONFH發(fā)生率增加顯著相關(guān)。然而，脂質(zhì)譜、皮質(zhì)類(lèi)固醇處方和皮質(zhì)類(lèi)固醇累積劑量對(duì)進(jìn)展到THA沒(méi)有影響。?ConclusionsTheONFHriskincreasedrapidlywhencumulativeprednisoloneusewas≥1,800mg.However,oralorhigh-doseintravenouscorticosteroiduseandcumulativedosedidnotaffecttheprognosisofONFH.SincetheoccurrenceandprognosisofONFHarecomplexandmultifactorialprocesses,furtherstudyisneeded.當(dāng)累積使用潑尼松龍≥1800mg時(shí)，ONFH風(fēng)險(xiǎn)迅速增加。然而，口服或大劑量靜脈注射皮質(zhì)類(lèi)固醇和累積劑量不影響股骨頭壞死的預(yù)后。由于股骨頭壞死的發(fā)生和預(yù)后是一個(gè)復(fù)雜的多因素過(guò)程，需要進(jìn)一步研究。?Osteonecrosisofthefemoralhead(ONFH)maycauseseverehippain,andcanultimatelyleadtocollapseofthefemoralheadandsubsequentrapiddestructionofthehipjointinrelativelyyoungpatients[1-3].Intractablepaincausedbyfemoralheadcollapseeventuallyleadstototalhiparthroplasty(THA)atayoungage[4,5].Althoughtrauma,theuseofcorticosteroid,andexcessivealcoholintakearewell-knownriskfactorsforONFH,theetiologyofONFHremainsmultifactorial,andnoconsensusexistsonthecommonpathophysiology[6-9].Impairedperfusionofbloodtobone,abnormalcellularreparativeprocesses,andgeneticpointmutationsarepresumedtoaffectONFHoccurrence,butithasnotyetbeenclarified[10-12].股骨頭壞死(Osteonecrosisoffemoralhead,ONFH)可引起嚴(yán)重的髖關(guān)節(jié)疼痛，在相對(duì)年輕的患者中，最終可導(dǎo)致股骨頭塌陷并隨后迅速破壞髖關(guān)節(jié)[1-3]。股骨頭塌陷引起的頑固性疼痛最終導(dǎo)致在年輕時(shí)進(jìn)行全髖關(guān)節(jié)置換術(shù)(THA)[4,5]。雖然創(chuàng)傷、皮質(zhì)類(lèi)固醇的使用和過(guò)量飲酒是眾所周知的ONFH的危險(xiǎn)因素，但ONFH的病因仍然是多因素的，對(duì)共同的病理生理尚未達(dá)成共識(shí)[6-9]。據(jù)推測(cè)，骨血流灌注受損、細(xì)胞修復(fù)過(guò)程異常以及基因點(diǎn)突變可能影響ONFH的發(fā)生，但尚未明確[10-12]。AlthoughitisverywellknownthatcorticosteroidscauseONFH,itisunclearastowhichpatientsdevelopONFH.Thereareseveralstudiesreportingthathigh-dosecorticosteroiduseof2grams(g)ormorewithin3monthsisassociatedwithONFHdevelopment[8,13-15].However,thesewerestudieswitharelativelysmallnumberofpatients,andthereareheterogeneitiesinpatientdemographicsandepidemiologicvariabilities.OnceONFHoccurs,theprognosisisknowntobepoor,andtherearestudiesstatingthatfemoralheadcollapseprogressesfromabout24.6to42.8%withnaturalevolutionwithin2years[16,17].Inparticular,whenfemoralheadcollapseoccurs,manypatientsoftenreceiveTHAatayoungage,sopredictingtheprognosisforfemoralheadcollapseisasimportantaspredictingtheoccurrenceofONFH.SeveralstudieshavedemonstratedthatfemoralheadcollapseinONFHpatientsisassociatedwithsize,volume,locationofnecroticlesions,andanatomicalparameters[1,2,18,19].However,therearenostudiesontheassociationbetweencorticosteroiduseandfemoralheadcollapseinONFHpatients.雖然眾所周知，皮質(zhì)類(lèi)固醇會(huì)引起ONFH，但尚不清楚哪些患者會(huì)發(fā)生ONFH。有幾項(xiàng)研究報(bào)道，在3個(gè)月內(nèi)使用2克或更多的高劑量皮質(zhì)類(lèi)固醇與ONFH的發(fā)生有關(guān)[8,13-15]。然而，這些研究的患者數(shù)量相對(duì)較少，并且在患者人口統(tǒng)計(jì)學(xué)和流行病學(xué)變異方面存在異質(zhì)性。一旦發(fā)生ONFH，預(yù)后很差，有研究表明股骨頭塌陷在2年內(nèi)自然演化，從24.6%發(fā)展到42.8%[16,17]。特別是股骨頭塌陷發(fā)生時(shí)，許多患者往往在年輕時(shí)接受THA，因此預(yù)測(cè)股骨頭塌陷的預(yù)后與預(yù)測(cè)ONFH的發(fā)生同樣重要。多項(xiàng)研究表明，ONFH患者股骨頭塌陷與壞死灶的大小、體積、位置和解剖學(xué)參數(shù)有關(guān)[1,2,18,19]。然而，目前還沒(méi)有關(guān)于ONFH患者使用皮質(zhì)類(lèi)固醇與股骨頭塌陷之間關(guān)系的研究。TheNationalHealthInsuranceService(NHIS)ofSouthKoreaisanationalinsurancecoverageservicethatcoversabout97%ofcitizensinSouthKorea,includingdemographicdataandaclaimdatabaseincludingdiagnosesandprescriptions[20].Additionally,theNHISoffershealthscreeningexaminationsforinsuredKoreansaged40yearsorolder,includingbasicbloodtests,smoking,drinking,andphysicalactivitiesusingself-reportedquestionnaires.BecausetheNationalHealthInsuranceService–NationalSampleCohort(NHIS-NSC)isahighlyrepresentativepopulation-basedcohortoftheentireKoreanpopulation,itcanbeusedasapopulation-based,nationwidestudyforepidemiologicresearchonvariousdiseases[20-22].韓國(guó)國(guó)民健康保險(xiǎn)服務(wù)(NationalHealthInsuranceService,NHIS)是一項(xiàng)覆蓋韓國(guó)約97%公民的國(guó)民保險(xiǎn)服務(wù)，包括人口統(tǒng)計(jì)數(shù)據(jù)和包括診斷和處方在內(nèi)的索賠數(shù)據(jù)庫(kù)[20]。此外，國(guó)民健康保險(xiǎn)制度還為40歲或40歲以上的參保韓國(guó)人提供健康檢查，包括基本的血液檢查、吸煙、飲酒和使用自我報(bào)告問(wèn)卷的體育活動(dòng)。由于國(guó)民健康保險(xiǎn)服務(wù)-國(guó)民樣本隊(duì)列(NationalHealthInsuranceService-NationalSampleCohort,NHIS-NSC)是韓國(guó)人口中極具代表性的基于人群的隊(duì)列，因此可以作為一項(xiàng)基于人群的全國(guó)性研究，用于各種疾病的流行病學(xué)研究[20-22]。Therefore,inthepresentstudy,weaimedtoinvestigatetheassociationbetweencorticosteroiduseandtheriskofONFHdevelopmentamongthewholegeneralpopulationandwhatfactorsaffectONFHdevelopmentusinganationwidelargesamplefromlongitudinalnestedcase-controldatainalong-termcohortstudy.Inaddition,weaimedtodemonstratewhichfactorsaffectTHAafterthedevelopmentofONFH.因此，在本研究中，我們旨在通過(guò)一項(xiàng)長(zhǎng)期隊(duì)列研究，在全國(guó)范圍內(nèi)采用縱向嵌套病例對(duì)照數(shù)據(jù)的大樣本，調(diào)查皮質(zhì)類(lèi)固醇使用與整個(gè)普通人群中ONFH發(fā)生風(fēng)險(xiǎn)之間的關(guān)系，以及影響ONFH發(fā)生的因素。此外，我們旨在證明哪些因素會(huì)影響ONFH發(fā)展后的THA。?MaterialsandMethodsStudyPopulationWeuseda2002to2019datasetfromtheNHISPhysicalHealthExaminationCohort(NHIS-NSC)2.0databaseintheRepublicofKorea[23].TheNHIS-NSC2.0databasewascomprisedofatotalof1,137,861participantswhowerestratifiedandrandomlysampledsuchthattheage,sex,region,healthinsurancetype,andhouseholdincomesofthesamplesremainedproportionaltothoseofthe2006Koreanpopulationof50million.Weexcluded223,474participantswhowerealreadyprescribedintravenous(IV)ororalcorticosteroidstoreducethebiasintheanalysisoftheeffectoftheprescribedcorticosteroiddoseonONFH.Fromtheremainingcohort,weexcluded241participantswhowerealreadydiagnosedwithONFHin2002toobtainthenewdevelopmentofONFH(washoutperiod).Therefore,theindexdatewasthedatethatthepatientwasdiagnosedwithONFH.Weincluded914,146participantsinthefinalanalysis.Theinformationinthedatasetincludedallinpatientandoutpatientmedicalclaimsdata,includingprescriptiondruguse,diagnosticandtreatmentcodes,primaryandsecondarydiagnosticcodes,andhealthexaminationdata.AlltheindividualsincludedintheNHIS-NSCwerefolloweduntil2019,unlesstherewasadeathordisqualificationforNationalHealthInsurance,suchasemigration.TheprotocolofthisstudywasapprovedbytheInstitutionalReviewBoardofourinstitution(4-2022-0304)andtheNHIS(NHIS-2022-2-232).我們使用了2002年至2019年的數(shù)據(jù)集，這些數(shù)據(jù)集來(lái)自韓國(guó)NHIS身體健康檢查隊(duì)列(NHIS-nsc)2.0數(shù)據(jù)庫(kù)[23]。國(guó)民健康保險(xiǎn)制度-國(guó)家安全保障制度2.0數(shù)據(jù)庫(kù)共包括1137861名參與者，這些參與者的年齡、性別、地區(qū)、健康保險(xiǎn)類(lèi)型和家庭收入與2006年韓國(guó)5000萬(wàn)人口的比例保持一致，并進(jìn)行了分層和隨機(jī)抽樣。我們排除了223,474名已經(jīng)靜脈注射或口服皮質(zhì)類(lèi)固醇的參與者，以減少處方皮質(zhì)類(lèi)固醇劑量對(duì)ONFH影響分析的偏倚。從剩余隊(duì)列中，我們排除了241名在2002年已經(jīng)診斷為ONFH的參與者，以獲得ONFH的新進(jìn)展(洗脫期)。因此，索引日期為患者被診斷為ONFH的日期。我們?cè)谧罱K分析中納入了914146名參與者。數(shù)據(jù)集中的信息包括所有住院和門(mén)診醫(yī)療索賠數(shù)據(jù)，包括處方藥使用、診斷和治療代碼、初級(jí)和二級(jí)診斷代碼以及健康檢查數(shù)據(jù)。納入國(guó)家健康保險(xiǎn)制度-國(guó)家安全保障制度的所有個(gè)人都被跟蹤到2019年，除非死亡或喪失參加國(guó)家健康保險(xiǎn)的資格，例如移民。本研究的方案經(jīng)我院機(jī)構(gòu)審查委員會(huì)(4-2022-0304)和NHIS(NHIS-2022-2-232)批準(zhǔn)。?CaseandControlSelectionWeusedtheInternationalStatisticalClassificationofDiseasesandRelatedHealthProblems,10thRevision(ICD-10)toidentifycasepatients.WedefinedONFH(N=3,500)usingthediagnosticcodeandtreatmentcodeICD-10codesforosteonecrosisofthefemur(SupplementaryTable1).Toavoidlengthbias,anestedcase-controlanalysiswasdesignedtoinvestigatetheeffectoftheprescribedcorticosteroiddoseonONFH.PatientswhohadONFHwerematched1:5toformacontrolgroupbasedonthevariablesofbirthyear,sex,andfollow-upduration.Identicalexclusioncriteriawereappliedtothecontrolgroup(N=12).Finally,casepatients(N=3,488)andcontrolpatients(N=17,440)werematchedbasedonsexandageattheindexdateandcompared(Figure1).我們使用國(guó)際疾病和相關(guān)健康問(wèn)題統(tǒng)計(jì)分類(lèi)第十次修訂版(ICD-10)來(lái)確定病例患者。我們使用股骨骨壞死的診斷代碼和治療代碼ICD-10來(lái)定義ONFH(N=3,500)(補(bǔ)充表1)。為避免長(zhǎng)度偏倚，設(shè)計(jì)了巢式病例對(duì)照分析，以調(diào)查處方皮質(zhì)類(lèi)固醇劑量對(duì)ONFH的影響。根據(jù)出生年份、性別、隨訪時(shí)間等變量對(duì)ONFH患者進(jìn)行1:5匹配，形成對(duì)照組。對(duì)照組(N=12)采用相同的排除標(biāo)準(zhǔn)。最后，根據(jù)索引日期的性別和年齡對(duì)病例患者(N=3,488)和對(duì)照患者(N=17,440)進(jìn)行匹配和比較(圖1)。??Fig.1Studyflow:selectionofparticipantsofcasesandmatchedcontrolsONFH,osteonecrosisoffemoralhead.??DefinitionofParametersFromthehealthexaminations,participantswereclassifiedinto4groupsbasedonthebodymassindex(BMI)accordingtotheWorldHealthOrganizationWesternPacificRegionguidelineandtheKoreanpracticalguidelineasfollows:low(<18.5),normal(18.5to23),overweight(23to25),andobese(>25).UnderlyingcomorbiditiesweredefinedbyatleastoneadmissionoroutpatienttreatmentupontheprimaryorfirstsecondarydiagnosisusingtheICD-10codeforthepastyear(hypertension:I10-I15,diabetesmellitus:E10-E14,dyslipidemia:E78).Thefrequencyofdrinkingalcoholwascategorizedas“non-alcoholuse”(drinkinglessthan1drinkperweek),“mildalcoholuse”(drinking1to2drinksperweek),or“heavyalcoholuse”(drinkingmorethan3to7drinksperweek).Smokingstatuswascategorizedasnonsmoker,pastsmoker,orcurrentsmoker.Afterovernightfasting,bloodsampleswereobtained,andserumhigh-densitylipoproteincholesterol,low-densitylipoprotein(LDL)cholesterol,andtriglyceride(TG)resultscouldbeobtained.根據(jù)健康檢查結(jié)果，根據(jù)世界衛(wèi)生組織西太平洋地區(qū)指南和韓國(guó)實(shí)踐指南，將參與者的身體質(zhì)量指數(shù)(BMI)分為4組:低(<18.5)、正常(18.5~23)、超重(23~25)和肥胖(>25)。潛在的合并癥是在過(guò)去一年中使用ICD-10代碼進(jìn)行原發(fā)性或首次繼發(fā)性診斷時(shí)至少進(jìn)行一次住院或門(mén)診治療(高血壓:I10-I15，糖尿病:E10-E14，血脂異常:E78)。飲酒頻率分為“不飲酒”(每周飲酒少于1杯)、“輕度飲酒”(每周飲酒1至2杯)或“重度飲酒”(每周飲酒超過(guò)3至7杯)。吸煙狀況分為不吸煙者、過(guò)去吸煙者和現(xiàn)在吸煙者。禁食過(guò)夜后采集血樣，得到血清高密度脂蛋白膽固醇、低密度脂蛋白膽固醇和甘油三酯(TG)結(jié)果。?SystemicCorticosteroidPrescriptionWedefinedsystemiccorticosteroidprescriptionsasoralcorticosteroidprescriptionsandIVcorticosteroidprescription.Systemiccorticosteroidusewasdefinedastheprescriptionofmedicationcodesduringadmissionsandoutpatientvisitsfrom2003totheindexdate(Table1).Bothgroupshadidenticalobservationperiods.Allcorticosteroidformulationswereconvertedintoadailydosebasedonprednisoneequivalentdoses[24](1mgprednisolone=4mghydrocortisone=0.8mgmethylprednisolone=0.8mgtriamcinolone=0.16mgbetamethasone=1.2mgdeflazacort),andwecalculatedcumulativedosesofexposureforcorticosteroidswiththesumofthedosesforalltheprescribeddays,whichwasexpressedasthecumulativedefineddailydose(cDDD)accordingtotheWorldHealthOrganizationdefinition.我們將系統(tǒng)性糖皮質(zhì)激素處方定義為口服糖皮質(zhì)激素處方和靜脈糖皮質(zhì)激素處方。系統(tǒng)性糖皮質(zhì)激素使用定義為從2003年到基線(xiàn)日期（見(jiàn)表1）的住院和門(mén)診就診期間的藥物代碼處方。兩組觀察期相同。將所有糖皮質(zhì)激素制劑轉(zhuǎn)換為基于潑尼松等效劑量（1毫克潑尼松龍等于4毫克氫化可的松等于0.8毫克甲基潑尼松龍等于0.8毫克曲安奈德等于0.16毫克倍他米松等于1.2毫克德夫氯喹）的每日劑量，并根據(jù)世界衛(wèi)生組織的定義計(jì)算糖皮質(zhì)激素的累積暴露劑量（累積定義每日劑量，cDDD），即將所有處方天數(shù)的劑量相加。?Table1PrescriptionDrugCodesandDosageofSystemicCorticosteroidBasedontheHealthInsuranceClaimsPaymentCodingSystem.Drug???????Code??????CorticosteroidandDosageOralcorticosteroids116401ATB???betamethasone0.5mg116501ATB???betamethasonesodiumphosphate0.5mg296900ATB???betamethasone0.25mg140801ATB???deflazacort6mg140802ATB???deflazacort30mg141901ATB???dexamethasone0.5mg141903ATB???dexamethasone0.75mg141904ATB???dexamethasone4mg170901ATB???hydrocortisone10mg170905ATB???hydrocortisone20mg170906ATB???hydrocortisone5mg193301ATB???methylprednisolone16mg193302ATB???methylprednisolone4mg193303ATB???methylprednisolone8mg193304ATB???methylprednisolone2mg193305ATB???methylprednisolone1mg217001ATB???prednisolone5mg243201ATB???triamcinolone1mg243202ATB???triamcinolone2mg243203ATB???triamcinolone4mgHigh-doseIVcorticosteroids?171201BIJ???????hydrocortisonesodiumsuccinate100mg171202BIJ?????hydrocortisonesodiumsuccinate250mg171203BIJ?????hydrocortisonesodiumsuccinate40mg193601BIJ?????methylprednisolonesodiumsuccinate125mg193602BIJ?????methylprednisolonesodiumsuccinate250mg193603BIJ?????methylprednisolonesodiumsuccinate40mgmethylprednisolonesodiumsuccinate500mg193604BIJ?????methylprednisolonesodiumsuccinate1000mg193605BIJ?????prednisolonesodiumsuccinate1000mg217301BIJ?????prednisolonesodiumsuccinate250mg217302BIJ???????SubgroupAnalysisATHAafteranONFHdiagnosiswasusedasasurrogateforfemoralheadcollapse.Therefore,wedividedallcasesinto2groups:agroupthatreceivedTHAandanothergroupthatdidnotreceiveTHAusingtreatmentcodes(N0711.N7020).Amongatotalof3,430patients,weexcluded70patientswhohadaTHAtreatmentcodepriortodiagnosis,1,175patientswhoreceivedTHAduringtheobservationperiod,and2,255patientswhodidnot.Wecomparedthe2groupsandanalyzedthemusingtheCoxproportionalhazardsmodel,whichfactorsaffectdiseaseprogressionleadingtoTHA(Figure2).診斷為ONFH后進(jìn)行THA作為股骨頭塌陷的替代。因此，我們使用治療代碼(N0711)將所有病例分為兩組:接受THA治療的組和未接受THA治療的組。N7020)。在總共3430例患者中，我們排除了70例在診斷前有THA治療代碼的患者，1175例在觀察期間接受THA治療的患者和2255例未接受THA治療的患者。我們對(duì)兩組患者進(jìn)行比較，并使用Cox比例風(fēng)險(xiǎn)模型進(jìn)行分析，分析影響THA病情進(jìn)展的因素(圖2)。??Fig.2Studyflow:comparisonofpatientswhoreceivedanddidnotreceivetotalhiparthroplastyafterdiagnosisONFH,osteonecrosisoffemoralhead;THA,totalhiparthroplasty.??DataAnalysisChi-squaredtestsforcategoricalvariableswereperformedtocomparethebaselinecharacteristicsbetweencaseandcontrolpatients.AconditionallogisticregressionanalysiswasperformedtoevaluatetheassociationbetweensystemiccorticosteroiduseandtheriskofONFH.Forsubgroupanalysis,weusedCoxproportionalhazardmodelstoestimateadjustedhazardratios(aHRs)and95%confidenceintervals(CIs).APvalue<.05wasconsideredsignificant.AllstatisticalanalyseswereperformedusingSASEnterpriseGuideversion7.1(SASInstitute,Cary,NorthCarolina).?ResultsDemographicDataforONFHCasesandMatchedControlsTable2showsthebaselinecharacteristicsofcasesandmatchedcontrols.The2groupshadevendistributionsinthematchingvariables,includingsexandbirthyear.Subjectswerepredominantlymen(61.1%),andthemostcommonagegroupwasthoseborninthe1950s(age63to72asof2022).Comparedwiththecontrolgroup,ONFHcasepatientshadlowhouseholdincomeandhadmorediabetes,hypertension,dyslipidemia,andheavyalcoholuse(drinkingmorethan3to7drinksperweek).Inaddition,thecasepatientshadnormalserumLDLlevels(<100mg/dL),butconversely,thereweremanycasesofhypertriglyceridemiawithserumTGlevelsof200mg/dLormore.??Table2BaselineCharacteristicofOsteonecrosisofFemoralHeadCasesandMatchedControls.totalN=20,928(%)?????CasesN=3,488(%)ControlsN=17,440(%)?????PSex????????????????????????Men12,792(61.1)?2,132(61.1)???10,660(61.1)?Women???8,136(38.9)???1,356(38.9)???6,780(38.9)???????Birthyear??????????????????????????????<1930????852(4.1)142(4.1)710(4.1)1930to1939?3,024(14.4)???504(14.4)??????2,520(14.4)?????1940to1949?4,074(19.5)???679(19.5)??????3,395(19.5)?????1950to1959?5,112(24.4)???852(24.4)??????4,260(24.4)?????1960to1969?3,786(18.1)???631(18.1)??????3,155(18.1)?????1970to1979?2,184(10.4)???364(10.4)??????1,820(10.4)?????1980to1989?1,080(5.2)?????180(5.2)900(5.2)1990to1999?558(2.7)93(2.7)??465(2.7)2000to2009?210(1.0)35(1.0)??175(1.0)2010to2019?48(0.2)??8(0.2)????40(0.2)??Age(atindexdate)55.2±16.9????55.2±16.9???????55.2±16.9????Householdincome????????????????????????Low4,535(21.7)???896(25.7)??????3,639(20.9)???????<.001Middle???6,500(31.0)???1,090(31.2)???5,410(31.0)???????High???????9,893(26.5)???1,502(43.1)???8,391(48.1)???????Comorbidities????????????????????????Hypertension?6,631(31.7)???1,301(37.3)???5,330(30.6)?????<.001Diabetesmellitus???4,567(21.8)???908(26.0)???????3,659(21.0)???<.001Dyslipidemia??5,555(26.5)???1,120(32.1)???4,435(25.4)?????<.001Frequencyofdrinkingalcohol??????????????????????????????<1d/wk??10,044(48.0)?1,613(46.2)???8,431(48.3)???????<.0011to2d/wk?????3,987(19.1)???560(16.1)??????3,427(19.7)?????3to7d/wk?????2,794(13.3)???621(17.8)??????2,173(12.5)?????Missing??4,103(19.6)???694(19.9)??????3,409(19.5)???????Smokingstatus?????????????????????????????Non-smoker???9,455(45.2)???1,539(44.1)???7,916(45.4)?????.199Ex-smoker?????2,865(13.7)???462(13.3)??????2,403(13.8)?????Currentsmoker??????4,488(21.4)???790(22.6)???????3,698(21.2)???Missing??4,120(19.7)???697(20.0)??????3,423(19.6)???????BMI,kg/m2??24.0±3.3??????23.9±3.4??????24.0±3.3??.547<18·5?????608(2.9)113(3.2)495(2.8).09018·5to22·9???6,126(29.3)???1,029(29.5)???5,097(29.2)?????23·0to24·9???4,239(20.3)???651(18.7)??????3,588(20.6)?????≥25·0?6,113(29.2)???1,049(30.1)???5,064(29.0)???????Missing??3,842(25.1)???646(18.5)??????3,196(18.3)???????HDL,mg/dL??54.2±20.5????55.2±22.7????54.0±20.0.015<40?2,113(10.1)???339(9.7)1,774(10.2%).03340to59??8,856(42.3)???1,411(40.5)???7,445(42.7%)??≥60???????4,700(22.5)???830(23.8)????3870(22.2%)???????Missing??5,259(25.1)???908(26.0)??????4,351(24.9%)??LDL,mg/dL???114.8±77.2??110.6±56.9??115.7±80.6<.001<100??????5,627(26.9)???1,045(30.0)???4,582(26.3)???????<.001100to159?????8,493(40.6)???1,297(37.2)???7,196(41.3)?????≥160?????1,528(7.3)?????234(6.7)1,294(7.4)?????Missing??5,280(25.2)???912(26.1)??????4,368(25.0)???????TG,mg/dL?????144.5±108.7154.8±125.0142.5±105.1??????<.001<150??????10,395(49.7)?1,651(47.3)???8,744(50.1)???????<.001150to199?????2,447(11.7)???390(11.2)??????2,057(11.8)?????≥200?????2,829(13.5)???540(15.5)??????2,289(13.1)???????Missing??5,257(25.1)???907(26.0)??????4,350(24.9)???????BMI,bodymassindex;HDL,highdensitylipoprotein;LDL,lowdensitylipoprotein;TG,triglyceride.??Table3showsthecomparisonofprescribedsystemiccorticosteroidsincasepatientsandcontrolpatients.Bothgroupshadidenticalobservationperiods(meanobservationperiodwas8.26years).Systemiccorticosteroidwasprescribedatleastoncemoreinthecasegroupthaninthecontrolgroup(71.8versus62.9%,P<.001).EvenwhenoralcorticosteroidsandIVcorticosteroidswerecompared,respectively,thenumberofcasesprescribedcorticosteroidsatleastoncewashigherinthepatientswhohadONFH(oralcorticosteroids:71.2versus62.4%,P<.001/IVcorticosteroids:10.7versus4.9%,P<.001).??Table3DifferenceinCorticosteroidUseBetweenCasesandMatchedControlsFrom2003UntilDiagnosis.TotalN=20,928(%)?????CasesN=3,488(%)ControlsN=17,440(%)?????PCorticosteroid(oralorhigh-doseIV)???????????????????????????Neveruse???????7,453(35.6)???983(28.2)??????6,470(37.1)?????<.001Everuse?13,475(64.4)?2,505(71.8)?10,970(62.9)???????Oralcorticosteroid????????????????????????Neveruse???????7,562(36.1)???1,004(18.8)???6,558(37.6)?????<.001Everuse?13,366(63.9)?2,484(71.2)?10,882(62.4)???????Neveruse???????7,562(36.1)???1,004(18.8)???6,558(37.6)?????<.001<180cDDDs??12,667(60.5)?2,192(62.8)???10,475(60.1)?????180to364cDDDs?397(1.9)146(4.2)251(1.4)365to729cDDDs?179(0.9)84(2.4)??95(0.5)??≥730cDDDs123(0.6)62(1.8)??61(0.4)??High-doseIVcorticosteroid??????????????????????????Neveruse???????19,703(94.2)?3,116(89.3)???16,587(95.1)?????<.001Everuse?1,225(5.8)?????372(10.7)??????853(4.9)Neveruse???????19,703(94.2)?3,116(89.3)???16,587(95.1)?????<.001<180cDDDs??988(4.7)266(7.6)722(4.1)180to364cDDDs?120(0.6)46(1.3)??74(0.4)??365to729cDDDs?77(0.4)??40(1.2)??37(0.2)??≥730cDDDs40(0.2)??20(0.6)??20(0.1)??cDDDs,cumulativedefineddailydoses(prednisolone10mg);IV,intravenous.??CumulativeCorticosteroidDoseandONFHDevelopmentConditionallogisticregressionanalysiswasperformedtoanalyzetheeffectofthecumulativedoseofsystemiccorticosteroidsfor1yearbeforediagnosisontheincidenceofONFH(Table4).SystemiccorticosteroidusewassignificantlyassociatedwithanincreasedriskofONFHincidencecomparedtothatofnonusers.Specifically,higherdosesoforalcorticosteroidwereassociatedwithincreasedriskofONFH(oddsratiosof1.61(95%CI1.47to1.78,P<.001),4.39(95%CI3.47to5.56,P<.001),6.42(95%CI4.65to8.87,P<.001),and5.44(95%CI3.65to8.13,P<.001)forpatientswhohavecorticosteroiduseof<180,180to365,365to720,and>720cDDDs(valuesconvertedtodailyprednisolone10mg),respectively.TheriskofONFHincreasedrapidlywhenthecDDDwas180ormore,thatis,whencumulativeprednisoloneusewas1,800mgormore.Inaddition,atrendtowardriskincreasewithcumulativedosesofIVcorticosteroidusewasshownwithadjustedoddsratio(AOR)of1.63(95%CI1.39to1.90,P<.001),2.34(95%CI1.57to3.49,P<.001),3.77(95%CI2.33to6.10,P<.001),and2.76(95%CI1.41to5.39,P=.003)forpatientswhohavecorticosteroiduseof<180,180to365,365to720,and>720cDDDs(valuesconvertedtodailyprednisolone10mg),respectively.??Table4AdjustedRiskofOsteonecrosisofFemoralHeadOccurrence.ConditionalLogisticRegressionAnalysisforONFHDevelopmentCrudeOR??????95%CI???P?????AdjustedOR??95%CI???????PHouseholdincome????????????????????????????????????????Low1.381.26to1.52???<.001?????1.381.25to1.51???????<.001Middle???1.131.03to1.23???.0071.131.03to1.23???????.008High???????1.00ref.?????????1.00ref.??Comorbidities???????????????????????????????????????Hypertension?1.471.35to1.60???<.001?????1.21???????1.06to1.37???.004Diabetesmellitus???1.381.26to1.51???<.001???????1.070.95to1.20???.289Dyslipidemia??1.471.35to1.60???<.001?????1.18???????1.04to1.34???.012Frequencyofdrinkingalcohol?????????????????????????????????????????????<1d/wk??1.00ref.?????????1.00ref.??1to2d/wk?????0.870.78to0.97???.0150.900.80to1.01.0713to7d/wk?????1.541.38to1.73???<.001?????1.54???????1.36to1.74???<.001Missing??1.080.97to1.20???.1801.120.59to2.14???????.731Smokingstatus?????????????????????????????????????????????Non–smoker??1.00ref.?????????1.00ref.??Ex–smoker?????1.010.89to1.15???.8670.930.82to1.07.314Currentsmoker??????1.131.01to1.26???.0321.01???????0.90to1.14???.855Missing??1.060.95to1.18???.2791.030.55to1.94???????.923BMI,kg/m2?????????????????????????????????????????<18·5?????1.130.91to1.41???.2621.150.92to1.44???????.23218·5to22·9???1.00ref.?????????1.00ref.??23·0to24·9???0.900.81to0.99???.0490.900.80to1.01.062≥25·0?1.020.93to1.13???.6280.990.89to1.09???????.784Missing??1.000.90to1.13???.9450.800.55to1.17???????.254HDL,mg/dL?????????????????????????????????????????<40?1.010.88to1.15???.9250.950.83to1.09???????.44740to59??1.00ref.?????????1.00ref.??≥60???????1.131.03to1.25???.0091.100.99to1.21???????.069Missing??1.121.01to1.23???.0312.910.14to60.46???????.490LDL,mg/dL??????????????????????????????????????????<100??????1.00ref.?????????1.00ref.??100to159?????0.790.72to0.86???<.001?????0.86???????0.78to0.94???.001≥160?????0.790.67to0.92???.0030.84071to0.98???????.031Missing??0.930.83to1.03???.1520.840.28to2.56???????.762TG,mg/dL????????????????????????????????????????????<150??????1.00ref.?????????1.00ref.??150to199?????1.010.89to1.14???.9170.990.88to1.13.970≥200?????1.261.13to1.40???<.001?????1.171.04to1.32.009Missing??1.121.01to1.23???.0250.460.03to7.70???????.585Medication????????????????????????????????????????????Steroid(oralorhigh–doseIV)?????????????????????????????????????????????Neveruse???????1.00ref.?????????1.00ref.??Everuse?1.751.59to1.92???<.001?????1.771.60to1.94<.001POsteroid?????????????????????????????????????????????Neveruse???????1.00ref.?????????1.00ref.??Everuse?1.731.57to1.90???<.001?????1.681.53to1.85<.001Neveruse???????1.00ref.?????????1.00ref.??<180cDDDs??1.631.49to1.79???<.001?????1.61???????1.47to1.78???<.001180to364cDDDs?4.983.96to6.25???<.001???????4.393.47to5.56???<.001365to729cDDDs?7.515.50to10.27?<.001???????6.424.65to8.87???<.001≥730cDDDs8.966.16to13.02?<.001?????5.44???????3.65to8.13???<.001High–doseIVsteroid????????????????????????????????????????????Neveruse???????1.00ref.?????????1.00ref.??Everuse?2.422.12to2.76???<.001?????2.201.92to2.51<.001Neveruse???????1.00ref.?????????1·00?????ref.??<180cDDDs??2.041.76to2.38???<.001?????1.63???????1.39to1.90???<.001180to364cDDDs?3.402.35to4.92???<.001???????2.341.57to3.49???<.001365to729cDDDs?5.863.74to9.18???<.001???????3.772.33to6.10???<.001≥730cDDDs5.232.81to9.73???<.001?????2.76???????1.41to5.39???.003BMI,bodymassindex;cDDDs,cumulativedefineddailydoses(prednisolone10mg);CI,confidenceinterval;HDL,highdensitylipoprotein;IV,intravenous;LDL,lowdensitylipoprotein;ONFH,osteonecrosisoffemoralhead;OR,oddsratio;PO,peroral;TG,triglyceride.??RiskFactorsforTHAinPatientswhoHaveONFHFortheONFHcasepatients,asubgroupanalysiswasperformedon1,175patientsintheTHAgroupand2,255patientsinthenon-THAgroupduringtheobservationperiod.Thefollow-updurationoftheTHAgroup(1,175patients)was1.03±2.25years,andthefollow-updurationofthenon-THAgroup(2,255patients)was7.93±5.15years.Table5showsthebaselinecharacteristicsofTHAcasesandnon-THAcases.IntheTHAgroup,therewasagreaterproportionofmen(63.9versus60.0%,P=.028),higherBMI(24.1versus23.8,P=.027),heavyalcoholuseofthosewhoconsumedalcoholmorethan3to7daysaweek(22.9versus15.2%,P<.001),currentsmokers(26.4versus20.8%,P<.001),andhigherTG(162.3mg/dLversus150.0,P≤.001).However,whentheeffectondiseaseprogressionwasanalyzedusingCoxproportionalhazardsmodelforsurvivalanalysisafterONFHdiagnosis,heavyalcoholuseandlongercorticosteroidusesweretheriskfactorsaffectingdiseaseprogression,anddiabeteswasafactorthatslowedprogression.Moreover,otherlipidprofilesaswellascorticosteroidsusedandcumulativedosesofcorticosteroidsdidnotaffecttheincidenceofTHA(Table6).Inaddition,whenthesurvivalanalysiswasperformedafterthediagnosisofONFHbydividingthepatientgroupintomalesandfemales,heavyalcoholuseinvolvingthosewhoconsumedalcoholmorethan3to7daysaweekincreasedtheriskofdiseaseprogressionafterONFHdiagnosisinmalesonly(aHR:1.38,95%CI1.16to1.65,P<.001),andaBMIof25orhigherinfemalesonlyincreasedtheriskofincidenceofTHAafterONFHdiagnosis(aHR:1.52,95%CI1.18to1.96,P<.001).??Table5Comparisonofthe2GroupsAccordingtoWhetherorNotTotalHipArthroplastywasPerformedDuringtheFollow-UpPeriodAfterOsteonecrosisofFemoralHeadDiagnosis.TotalN=3,430(%)??????THAafterDiagnosisN=1,175(%)?????NoTHAafterDiagnosisN=2,255(%)???????PSex????????????????????????Men2,104(61.3)???751(63.9)??????10,660(61.1)???????.028Women???1,326(38.7)???424(36.1)??????6,780(38.9)???????Birthyear??????????????????????????????<1930????141(4.1)16(1.4)??125(5.5)<.0011930to1939?492(14.3)??????153(13.0)??????339(15.0)?????1940to1949?665(19.4)??????246(20.9)??????419(18.6)?????1950to1959?837(24.4)??????344(29.3)??????493(21.9)?????1960to1969?621(18.1)??????229(19.5)??????392(17.4)?????1970to1979?359(10.5)??????118(10.0)??????241(10.4)?????1980to1989?180(5.3)56(4.8)??124(5.2)1990to1999?92(2.7)??13(1.1)??79(3.5)??2000to2009?35(1.0)??0(0.0)????35(1.6)??2010to2019?8(0.2)????0(0.0)????8(0.3)????Age(atindexdate)55.1±17.0????56.41±13.8???????54.6±18.4????.007Householdincome????????????????????????Low880(25.7)??????283(24.1)??????597(26.5)???????.008Middle???1,077(31.4)???409(34.8)??????668(29.6)???????High???????1,473(42.9)???483(41.1)??????990(43.9)???????Comorbidities????????????????????????Hypertension?1,269(37.0)???445(37.9)??????824(36.5)?????.466Diabetesmellitus???888(25.9)??????285(24.3)???????603(26.7)??????.125Dyslipidemia??1,095(31.9)???383(32.6)??????712(31.6)?????.568Frequencyofdrinkingalcohol??????????????????????????????<1d/wk??1,581(46.1)???504(42.9)??????1,077(47.8)???????<.0011to2d/wk?????549(16.0)??????207(17.6)??????342(15.2)?????3to7d/wk?????613(17.9)??????269(22.9)??????344(15.2)?????Missing??687(20.0)??????195(16.6)??????492(21.8)???????Smokingstatus?????????????????????????????Nonsmoker????1,507(43.9)???491(41.8)??????1,016(45.1)?????.199Ex-smoker?????454(13.2)??????180(15.3)??????274(12.2)?????Currentsmoker??????780(22.7)??????310(26.4)???????470(20.8)??????Missing??689(20.1)??????194(16.5)??????495(21.9)???????BMI,kg/m2???23.9±3.4??????24.1±3.4??????23.8±3.3??.027<18·5?????112(3.3)37(3.2)??75(3.3)??<.00118·5-22·9??????1,014(29.3)???355(30.2)??????659(29.2)?????23·0-24·9??????640(18.7)??????218(18.5)??????422(18.7)?????≥25·0?1,024(29.8)???388(33.0)??????636(28.2)???????Missing??640(18.7)??????177(15.1)??????463(20.5)???????HDL,mg/dL??55.3±22.9????55.7±16.0????55.1±26.1.015<40?331(9.6)110(9.4)221(9.8).03340-59?????1,379(40.2)???494(42.0)??????885(39.2)???????≥60???????822(24.0%)??322(27.4%)??500(22.2%)???????Missing??898(26.2%)??248(21.2%)??649(28.8%)???????LDL,mg/dL???110.6±57.1??111.4±80.9??110.1±37.0.668<100??????1,023(29.8%)378(32.2%)??645(28.6%)???????<.001100-159?1,277(37.2%)464(39.5%)??813(36.1%)???????≥160?????229(6.7%)????81(6.9%)??????148(6.5%)???????Missing??901(26.3%)??252(21.4%)??649(28.8%)???????TG,mg/dL?????154.5±125.1162.3±141.3150.0±114.5??????.024<150??????1,626(47.4%)576(19.0%)??1,050(46.6%)??<.001150-199?378(11.0%)???140(11.9%)???238(10.5%)???????≥200?????530(15.5%)??211(18.0%)???319(14.2%)???????Missing??896(26.1)??????248(21.1)??????648(28.7)???????Systemiccorticosteroid(Oralorhigh-doseIV)???????????????????????????Neveruse???????2,090(60.9)???710(60.4)??????1,380(61.2)?????.687Everuse?1,340(39.1)???465(39.6)??????875(38.8)???????Oralcorticosteroid????????????????????????Neveruse???????2,119(61.8)???718(61.1)??????1,401(62.1)?????.584Everuse?1,311(38.2)???457(38.9)??????854(37.9)???????.690Neveruse???????2,119(61.8)???718(61.1)??????1,401(62.1)?????<180cDDDs??1,240(36.1)???434(36.9)??????806(35.7)?????180-364cDDDs????47(1.4)??15(1.3)??32(1.4)??365-729cDDDs????21(0.6)??8(0.7)????13(0.6)??≥730cDDDs3(0.1)????0(0.0)????3(0.1)????High-doseIVcorticosteroid??????????????????????????Neveruse???????3,322(96.9)???1,142(97.2)???2,180(96.7)?????.471Everuse?108(3.1)33(2.8)??75(3.3)??.858Neveruse???????3,322(96.9)???1,142(97.2)???2,180(96.7)?????<180cDDDs??84(2.4)??26(2.2)??58(2.5)??180-364cDDDs????9(0.3)????2(0.2)????7(0.3)????365-729cDDDs????10(0.3)??4(0.3)????6(0.3)????≥730cDDDs5(0.1)????1(0.1)????4(0.2)????BMI,bodymassindex;cDDDs,cumulativedefineddailydoses(prednisolone10mg);CI,confidenceinterval;HDL,highdensitylipoprotein;IV,intravenous;LDL,lowdensitylipoprotein;ONFH,osteonecrosisoffemoralhead;OR,oddsratio;TG,triglyceride;THA,totalhiparthroplasty.??Table6AdjustedRiskofTotalHipArthroplastyofOsteonecrosisofFemoralHeadPatients.ConditionalLogisticRegressionAnalysisforONFHDevelopmentCrudeOR??????95%CI???P?????AdjustedOR??95%CI???????PSex????????????????????????????????????????Men1.00ref.?????????1.00ref.??Women???0.890.79to1.01???.0601.030.88to1.20???????.731Age?1.011.00to1.01???<.001?????1.011.01to1.02???????<.001Householdincome????????????????????????????????????????Low1.000.86to1.16???.9891.020.88to1.19???????.786Middle???1.201.05to1.37???.0081.211.06to1.38???????.006High???????1.00ref.?????????1.00ref.??Comorbidities???????????????????????????????????????Hypertension?1.120.99to1.26???.0581.100.91to1.32.340Diabetesmellitus???0.950.83to1.09???.4460.80???????0.68to0.96???.013Dyslipidemia??1.090.97to1.23???.1570.980.81to1.19.842Frequencyofdrinkingalcohol?????????????????????????????????????????????<1d/wk??1.00ref.?????????1.00ref.??1to2d/wk?????1.231.05to1.45???.0111.231.02to1.47.0263to7d/wk?????1.501.30to1.74???<.001?????1.38???????1.16to1.65???<.001Missing??0.900.76to1.06???.2043.120.80to12.23???????.103Smokingstatus?????????????????????????????????????????????Nonsmoker????1.00ref.?????????1.00ref.??Ex-smoker?????1.311.11to1.56???.0020.251.03to1.52.027Currentsmoker??????1.261.09to1.45???.0021.17???????0.98to1.41???.085Missing??0.860.73to1.02???.0850.400.10to1.64???????.203BMI,kg/m2?????????????????????????????????????????<18·5?????0.940.67to1.31???.6980.890.63to1.25???????.51018·5to22·9???1.00ref.?????????1.00ref.??23·0to24·9???0.940.80to1.12???.4940.950.80to1.12.519≥25·0?1.090.95to1.26???.2321.110.96to1.29???????.176Missing??0.770.65to0.93???.0051.040.61to1.77???????.880HDL,mg/dL?????????????????????????????????????????<40?0.930.76to1.15???.5170.910.74to1.12???????.37640to59??1.00ref.?????????1.00ref.??≥60???????1.130.98to1.30???.0941.161.01to1.34???????.043Missing??0.770.66to0.90???<.001?????0.320.03to3.11.325LDL,mg/dL??????????????????????????????????????????<100??????1.00ref.?????????1.00ref.??100to159?????0.970.84to1.11???.6140.990.86to1.13.844≥160?????0.930.73to1.18???.5610.960.75to1.23???????.728Missing??0.740.63to0.87???<.001?????5.091.59to16.28??????.006TG,mg/dL????????????????????????????????????????????<150??????1.00ref.?????????1.00ref.??150to199?????1.070.89to1.29???.4471.050.87to1.27.583≥200?????1.191.02to1.39???.0301.110.94to1.31???????.231Missing??0.780.67to0.91???.0010.490.07to3.60???????.485Medication????????????????????????????????????????????Steroid(oralorhigh–doseIV)?????????????????????????????????????????????Neveruse???????1.00ref.?????????1.00ref.??Everuse?1.090.97to1.22???.1721.070.95to1.21???????.268POsteroid?????????????????????????????????????????????Neveruse???????1.00ref.?????????1.00ref.??Everuse?1.090.97to1.23???.1341.070.95to1.21???????.268Neveruse???????1.00ref.?????????1.00ref.??<180cDDDs??1.090.97to1.23???.1421.080.95to1.21.247180to364cDDDs?1.100.66to1.83???.7161.22???????0.73to2.06???.449365to729cDDDs?1.280.64to2.58???.4821.62???????0.79to3.36???.191≥730cDDDs<0.001???<0.001to999.944<0.001???????<0.001to999.943High–doseIVsteroid????????????????????????????????????????????Neveruse???????1.00ref.?????????1.00ref.??Everuse?0.910.64to1.29???.5920.900.63to1.28???????.552Neveruse???????1.00ref.?????????1.00ref.??<180cDDDs??0.950.64to1.39???.7760.870.59to1.30.504180to364cDDDs?0.600.15to2.41???.4740.71???????0.17to2.87???.626365to729cDDDs?1.200.45to3.20???.7191.35???????0.50to3.64???.554≥730cDDDs0.480.07to3.38???.4580.540.07to4.01.545Steroiduseduration?????????????????????????????????????????????Neveruse???????1.00ref.?????????1.00ref.??<3mobeforediagnosis?1.601.45-1.76<.001???????1.621.47-1.78<.0013-6mobeforediagnosis3.863.22-4.63<.001???????3.913.25-4.70<.0016-12mobeforediagnosis??????5.284.16-6.71<.001???????5.234.10-6.67<.001>12mobeforediagnosis7.575.98-9.59<.001???????7.405.82-9.42<.001?查看原圖BMI,bodymassindex;cDDDs,cumulativedefineddailydoses(prednisolone10mg);CI,confidenceinterval;HDL,highdensitylipoprotein;IV,intravenous;LDL,lowdensitylipoprotein;ONFH,osteonecrosisoffemoralhead;OR,oddsratio;PO,peroral;TG,triglyceride;THA,totalhiparthroplasty.??DiscussionWeevaluated3,488ONFHcasesand17,440controlcaseswithmatchingvariablesincludingage,sex,andthetimeofthefollow-upata1:5ratiofromtheNHIS-NSC,includingthefollow-updatafrom2002to2019of1,137,861participantsinanationwidelongitudinalnestedcase-controlstudy.Wedemonstratedthatalowhouseholdincome,diabetes,hypertension,dyslipidemia,heavyalcoholicswhoconsumedalcoholmorethan3daysaweek,andserumTGlevelsof200mg/dLormorewereassociatedwiththedevelopmentofONFH.Inaddition,systemiccorticosteroidusewassignificantlyassociatedwithanincreasedriskofONFHincidencecomparedtothatofnonusers.Specifically,theriskofONFHincreasedrapidlywhenthecDDDswere180ormorecumulativedosesofcorticosteroiduse.WeanalyzedthefactorsaffectingtheprogressionofthediseasebycomparingpatientswhounderwentTHAwiththosewhodidnotundergoTHAduringthefollow-upperiodafterONFHdiagnosis.Men,whohadahigherBMI,heavyalcoholicswhoconsumedalcoholmorethan3daysaweek,currentsmokers,andserumTGlevelsof200mg/dLormorewereassociatedwithTHAafterONFHdiagnosis.However,afteradjustingforcompoundfactors,heavyalcoholicsweretheonlyfactoraffectingtheincidenceofTHAafterONFHdiagnosis,anditmaybeusedtocounselONFHpatients.Otherlipidprofiles,corticosteroidsused,andcumulativedosesofcorticosteroidsdidnotaffecttheincidenceofTHA.我們?cè)u(píng)估了3488例ONFH病例和17440例對(duì)照病例，匹配變量包括年齡、性別和隨訪時(shí)間，比例為1:5，來(lái)自NHIS-NSC，包括2002年至2019年全國(guó)縱向巢式病例對(duì)照研究中1137861名參與者的隨訪數(shù)據(jù)。研究表明，家庭收入低、糖尿病、高血壓、血脂異常、每周飲酒超過(guò)3天的重度酗酒者以及血清TG水平≥200mg/dL與ONFH的發(fā)生有關(guān)。此外，與不使用皮質(zhì)類(lèi)固醇的患者相比，全身性使用皮質(zhì)類(lèi)固醇與ONFH發(fā)生率增加顯著相關(guān)。特別是，當(dāng)皮質(zhì)類(lèi)固醇的累積使用劑量達(dá)到180或更高時(shí)，ONFH的風(fēng)險(xiǎn)迅速增加。我們通過(guò)比較ONFH診斷后隨訪期間接受THA和未接受THA的患者來(lái)分析影響疾病進(jìn)展的因素。BMI較高的男性、每周飲酒超過(guò)3天的重度酗酒者、當(dāng)前吸煙者、血清TG水平≥200mg/dL的男性在ONFH診斷后與THA相關(guān)。然而，在調(diào)整復(fù)合因素后，重度酗酒者是ONFH診斷后唯一影響THA發(fā)生率的因素，可用于指導(dǎo)ONFH患者。其他脂質(zhì)特征、使用的皮質(zhì)類(lèi)固醇和皮質(zhì)類(lèi)固醇的累積劑量對(duì)THA的發(fā)生率沒(méi)有影響。TherelationshipbetweencorticosteroiduseandONFHdevelopmenthasbeenrevealedinseveralstudies[8,25,26],andtherearealsosomestudiesthathavesuggestedspecificdosesanddurationsofcorticosteroiduse,suchastheassociationwiththedevelopmentofdiseasewhenusingmorethan2gwithin3months[27]orthemeancorticosteroiduseofpatientswhohaveONFHdevelopmentof3,314mg[28].Inthecurrentlargecohortstudyofthegeneralpopulation,weanalyzedvariousfactorsthatcanaffectthedevelopmentofONFH.Asinpreviousstudies,thecaseofcorticosteroiduseatleastonceandadditionalcumulativecorticosteroiddosewereassociatedwiththeincreasedriskofONFHdevelopment,andwhencumulativeprednisoloneusewas1,800mg(180cDDDs)ormore,theriskofONFHdevelopmentincreasedrapidly.Surely,thedevelopmentofONFHrelatedtocorticosteroiduseisthoughttobecausedbyacombinationofnotonlycorticosteroidusebutalsoseveralfactorssuchascomorbidities,alcohol,smoking,andgeneticfactors.Sincecorticosteroidtreatmentisoftenessentialformanydiseases,itisnecessarytobeawareofthecumulativedoseatwhichtheriskofONFHincreasesrapidlywhencontinuouscorticosteroidtreatmentisrequired.?一些研究已經(jīng)揭示了皮質(zhì)類(lèi)固醇的使用與ONFH發(fā)展之間的關(guān)系[8,25,26]，也有一些研究提出了皮質(zhì)類(lèi)固醇使用的特定劑量和持續(xù)時(shí)間，如在3個(gè)月內(nèi)使用超過(guò)2g與疾病發(fā)展的關(guān)系[27]，或ONFH發(fā)展患者的平均皮質(zhì)類(lèi)固醇使用量為3,314mg[28]。在目前針對(duì)普通人群的大型隊(duì)列研究中，我們分析了影響ONFH發(fā)展的各種因素。與之前的研究一樣，至少使用一次皮質(zhì)類(lèi)固醇和額外的皮質(zhì)類(lèi)固醇累積劑量與ONFH發(fā)展的風(fēng)險(xiǎn)增加有關(guān)，當(dāng)潑尼松龍累積使用1800毫克(180cDDDs)或更多時(shí)，ONFH發(fā)展的風(fēng)險(xiǎn)迅速增加。當(dāng)然，與皮質(zhì)類(lèi)固醇使用相關(guān)的ONFH的發(fā)展被認(rèn)為不僅是由皮質(zhì)類(lèi)固醇使用引起的，還包括合并癥、酒精、吸煙和遺傳因素等多種因素。由于皮質(zhì)類(lèi)固醇治療通常對(duì)許多疾病至關(guān)重要，因此有必要了解在需要持續(xù)皮質(zhì)類(lèi)固醇治療時(shí)ONFH風(fēng)險(xiǎn)迅速增加的累積劑量。Tothebestofourknowledge,nostudyhascomparedtheincidenceofONFHwithhigh-doseIVandoralcorticosteroidsatthesamecumulativedose.Inthepresentstudy,bothoralcorticosteroidandhigh-doseIVcorticosteroidsincreasedtheriskofdevelopingONFH,andwhencomparingtheoralandhigh-doseIVatthesamecumulativedose,oralcorticosteroidhadahigherrisk;totheAORsoforalcorticosteroidwere1.61(<180cDDDs),4.39(180to365cDDDs),6.42(365to720cDDDs),and5.44(>720cDDDs).TheAORsofhigh-doseIVcorticosteroidwere1.63(<180cDDDs),2.34(180to365cDDDs),3.77(365to720cDDDs),and2.76(>720cDDDs),respectively.Ingeneral,sincetheprednisolonepotencyoforalcorticosteroidsismuchlowerthanthatofhigh-doseIV,thedurationoforalcorticosteroidusewouldhavebeenlongerifthesamecumulativedosewasused.Montetal.reportedthatONFHoccurrencewasassociatedwithmeandailycorticosteroiddose,cumulativedose,andtreatmentduration[8].Ofcourse,ONFHoccurrenceswouldbeaffectedbygeneticsusceptibilityandexposuretovariousriskfactors,butinourstudy,weconfirmedthatmoreONFHoccurredinoralcorticosteroidswitharelativelysmalldailydoseatthesamecumulativedosecomparedtohigh-doseIVcorticosteroid,soitisassumedthatthelongertreatmentperiodofcorticosteroidisalsoassociatedwithdevelopingONFH.據(jù)我們所知，沒(méi)有研究比較相同累積劑量的高劑量靜脈注射和口服皮質(zhì)類(lèi)固醇對(duì)ONFH的發(fā)生率。在本研究中，口服皮質(zhì)類(lèi)固醇和高劑量靜脈注射皮質(zhì)類(lèi)固醇都增加了發(fā)生ONFH的風(fēng)險(xiǎn)，并且在相同累積劑量下，口服皮質(zhì)類(lèi)固醇與高劑量靜脈注射皮質(zhì)類(lèi)固醇相比，風(fēng)險(xiǎn)更高;口服皮質(zhì)類(lèi)固醇的AORs分別為1.61(<180cDDDs)、4.39(180~365cDDDs)、6.42(365~720cDDDs)和5.44(>720cDDDs)。高劑量靜脈注射皮質(zhì)類(lèi)固醇的AORs分別為1.63(<180cDDDs)、2.34(180~365cDDDs)、3.77(365~720cDDDs)和2.76(>720cDDDs)。一般來(lái)說(shuō)，由于口服皮質(zhì)類(lèi)固醇的強(qiáng)的松龍效力遠(yuǎn)低于高劑量靜脈注射，如果使用相同的累積劑量，口服皮質(zhì)類(lèi)固醇的使用時(shí)間會(huì)更長(zhǎng)。Mont等人報(bào)道ONFH的發(fā)生與皮質(zhì)類(lèi)固醇的平均每日劑量、累積劑量和治療時(shí)間有關(guān)[8]。當(dāng)然，ONFH的發(fā)生會(huì)受到遺傳易感性和暴露于各種危險(xiǎn)因素的影響，但在我們的研究中，我們證實(shí)在相同累積劑量下，相對(duì)于高劑量靜脈注射皮質(zhì)類(lèi)固醇，日劑量相對(duì)較小的口服皮質(zhì)類(lèi)固醇更易發(fā)生ONFH，因此我們假設(shè)皮質(zhì)類(lèi)固醇治療時(shí)間越長(zhǎng)也與ONFH的發(fā)生有關(guān)。ItiswellknownthatahigherTGlevel,orLDLcholesterol,isanimportantriskfactorforischemicheartdiseaseandstrokebyinhibitingbloodflow,andONFHispresumedtoberelatedtoinhibitionofbloodflowtothefemoralheadinasimilarmechanism[29].Similartopreviousstudies[7,30],higherTGwasariskfactorforONFHinourstudy.Inaddition,itwasconfirmedthatLDLatlessthan100mg/dLhasaprotectiveeffectontheoccurrenceofONFH.眾所周知，較高的TG或LDL膽固醇水平通過(guò)抑制血流是缺血性心臟病和中風(fēng)的重要危險(xiǎn)因素，而ONFH被認(rèn)為與股骨頭血流的抑制有類(lèi)似的機(jī)制[29]。與以往的研究相似[7,30]，在我們的研究中，高TG是ONFH的危險(xiǎn)因素。此外，還證實(shí)了低于100mg/dL的LDL對(duì)ONFH的發(fā)生有保護(hù)作用。SinceONFHoccurspredominantlyinyoungerpatientsandpreservationofthenativejointasmuchaspossibleistheprincipleoftreatment,thediseaseprogressionandprognosisareasimportantastheoccurrenceofthedisease.WeoftenseecasesofbilateralONFHdevelopmentwhereonesidehasfemoralcollapseandtheothersideremainsasymptomaticwithoutfemoralheadcollapse.Alternatively,somecaseswereasymptomaticwithoutfemoralheadcollapse,butreceivedTHA.ItisknownthattheprognosisafterONFHdevelopmentisinfluencedbyvariousfactors,anduntilnow,therehavebeenstudiesshowingthatradiologicfactorssuchasthesizeorlocationofnecrosisoracetabularanatomicalfactorshaveaneffect[1,19,31].Montetal.reportedthattheprevalenceoffemoralheadcollapsewas38%(106of282hips)inameta-analysisandvariedfrom17to73%dependingontheriskfactor[16].Inourstudy,34.3%ofpatientsunderwentTHA,anaverageof1.03±2.25yearsafterdiagnosis,similartothepreviousstudy.Althoughradiologicassessmentcouldnotbeperformed,casesthatmayhaveseengreaterphysicalloads,suchasmen,whohadahigherBMI,excessivedrinking,smoking,andahigherserumTGlevelover200mg/dL,wereassociatedwithdiseaseprogression.Inparticular,thefactorsthatincreasedtheriskofdiseaseprogressionweredifferentinmenandwomen.Wefoundthatcorticosteroidsprescribedornotandcumulativedosesofcorticosteroidswereunlikelytoaffectdiseaseprogression.由于ONFH主要發(fā)生在年輕患者中，治療原則是盡可能保留原有關(guān)節(jié)，因此疾病的進(jìn)展和預(yù)后與疾病的發(fā)生同樣重要。我們經(jīng)?？吹诫p側(cè)ONFH發(fā)展的病例，其中一側(cè)有股骨頭塌陷，另一側(cè)無(wú)股骨頭塌陷癥狀。另外，一些病例無(wú)股骨頭塌陷癥狀，但接受了THA。眾所周知，ONFH發(fā)生后的預(yù)后受多種因素影響，迄今已有研究表明，壞死的大小或位置等放射學(xué)因素或髖臼解剖因素對(duì)ONFH的預(yù)后有影響[1,19,31]。Mont等人在一項(xiàng)薈萃分析中報(bào)道，股骨頭塌陷的患病率為38%(282髖中的106髖)，根據(jù)危險(xiǎn)因素的不同，患病率從17%到73%不等[16]。在我們的研究中，34.3%的患者接受了THA，平均診斷后1.03±2.25年，與之前的研究相似。雖然無(wú)法進(jìn)行放射學(xué)評(píng)估，但可能出現(xiàn)較大身體負(fù)荷的病例，如男性，BMI較高，過(guò)度飲酒，吸煙，血清TG水平高于200mg/dL，與疾病進(jìn)展相關(guān)。特別是，增加疾病進(jìn)展風(fēng)險(xiǎn)的因素在男性和女性中是不同的。我們發(fā)現(xiàn)，開(kāi)具或不開(kāi)具皮質(zhì)類(lèi)固醇以及皮質(zhì)類(lèi)固醇的累積劑量不太可能影響疾病進(jìn)展。Ourstudyhasseveralpotentiallimitationsthatshouldbeaddressedinfurtherstudies.TheONFHwasassessedbyanoperationaldefinitionusingadiagnosiscode,notbyaradiologicevaluationsuchasanx-rayorMRI.However,theincidenceofONFHinthisstudywassimilartothatinapreviousAsiangeneralpopulationstudythatdefineditusinghipjointx-raysand/orMRI[32].BecauseanaccurateselectionofONFHpatientsmaynothavebeenmade,anestedcase-controlanalysisfromapopulation-basedcohortwasperformedtoincreasetheaccuracyoftheanalysis.Additionally,usingtheNHIS-NSCdatabase,prescriptionrecordsforcorticosteroidscouldbeaccessed.However,theactualintakeofcorticosteroidsinsubjectsmightbedifferentfromtheprescriptionrecords.Fortunately,severalstudieshaveshownagoodcorrelationbetweenprescriptionsandrealexposuretodrugs[33,34].Also,wecouldnotobtaininformationabouttraumaticONFH,whichmayhaveinfluencedtheresultsofthecurrentstudy.Inaddition,wecouldnotassessotherinterventionsthatcouldaffectdyslipidemia,microvascularbloodflow,andosteogenesis,suchastheuseoflipid-loweringmedication,aspirin,antiplatelets,andanticoagulantmedication.Thisshouldbeevaluatedinfuturestudies.Furthermore,ananalysisofmultiplecomorbiditiessuchasrheumaticdisease,sicklecelldisease,humanimmunodeficiencyvirus,organtransplantation,andsoonthatcouldaffecttheoccurrenceandprognosisofONFHwasnotperformed.Inparticular,sincetheprognosisofONFHisdifferentforeachdisease,subgroupanalysisaccordingtocomorbidityisabsolutelynecessaryforfuturestudies.Additionally,weanalyzedtheassociationbetweencumulativedoseofcorticosteroidanddiseaseprogressionafterONFHdiagnosisusingcDDD,andweconfirmedthatcumulativedoseofcorticosteroiddidnotaffectdiseaseprogression.However,sincethenumberofpatientswhohave180cDDDormorewassmall,additionalanalysiswithalargernumberofpatientsmaybeneededtoobtainmoreaccurateresults.我們的研究有幾個(gè)潛在的局限性，應(yīng)該在進(jìn)一步的研究中加以解決。ONFH通過(guò)使用診斷代碼的操作定義進(jìn)行評(píng)估，而不是通過(guò)x射線(xiàn)或MRI等放射學(xué)評(píng)估。然而，本研究中ONFH的發(fā)生率與先前的亞洲普通人群研究相似，該研究使用髖關(guān)節(jié)X光片和/或MRI來(lái)定義ONFH[32]。由于可能沒(méi)有對(duì)ONFH患者進(jìn)行準(zhǔn)確的選擇，因此進(jìn)行了基于人群的隊(duì)列嵌套病例對(duì)照分析，以提高分析的準(zhǔn)確性。此外，使用NHIS-NSC數(shù)據(jù)庫(kù)，可以訪問(wèn)皮質(zhì)類(lèi)固醇的處方記錄。然而，受試者的實(shí)際皮質(zhì)類(lèi)固醇攝入量可能與處方記錄不同。幸運(yùn)的是，有幾項(xiàng)研究表明，處方與實(shí)際接觸藥物之間存在良好的相關(guān)性[33,34]。此外，我們無(wú)法獲得有關(guān)創(chuàng)傷性O(shè)NFH的信息，這可能影響了當(dāng)前研究的結(jié)果。此外，我們無(wú)法評(píng)估其他可能影響血脂異常、微血管血流和成骨的干預(yù)措施，如使用降脂藥物、阿司匹林、抗血小板和抗凝藥物。這應(yīng)該在未來(lái)的研究中進(jìn)行評(píng)估。此外，對(duì)風(fēng)濕病、鐮狀細(xì)胞病、人類(lèi)免疫缺陷病毒、器官移植等可能影響ONFH發(fā)生和預(yù)后的多重合并癥未進(jìn)行分析。特別是，由于每種疾病的預(yù)后不同，因此根據(jù)合并癥進(jìn)行亞組分析對(duì)于未來(lái)的研究是絕對(duì)必要的。此外，我們分析了使用cDDD診斷ONFH后皮質(zhì)類(lèi)固醇累積劑量與疾病進(jìn)展之間的關(guān)系，我們證實(shí)皮質(zhì)類(lèi)固醇累積劑量不影響疾病進(jìn)展。然而，由于cDDD≥180的患者數(shù)量較少，因此可能需要對(duì)更多患者進(jìn)行額外分析，以獲得更準(zhǔn)確的結(jié)果。?ConclusionLowhouseholdincome,diabetes,hypertension,dyslipidemia,heavyalcoholicswhoconsumedalcoholmorethan3daysaweek,serumTGlevelsof200mg/dLormore,andoralorhigh-doseIVcorticosteroiduseareassociatedwithONFHdevelopment.Specifically,theriskofONFHincreasedrapidlywhencumulativeprednisoloneusewas1,800mgormore.However,oralorhigh-doseIVcorticosteroiduseandcumulativedosedidnotaffecttheprognosisofONFH.SincethedevelopmentandprognosisofONFHarecomplexandmultifactorialprocesses,furtherstudyisneeded.低收入家庭、糖尿病、高血壓、血脂異常、每周飲酒超過(guò)3天的重度酗酒者、血清TG水平≥200mg/dL、口服或高劑量靜脈注射皮質(zhì)類(lèi)固醇與ONFH的發(fā)生有關(guān)。具體來(lái)說(shuō)，當(dāng)累積使用強(qiáng)的松龍超過(guò)1800毫克時(shí)，ONFH的風(fēng)險(xiǎn)迅速增加。然而，口服或高劑量靜脈注射皮質(zhì)類(lèi)固醇和累積劑量對(duì)ONFH的預(yù)后沒(méi)有影響。由于ONFH的發(fā)展和預(yù)后是一個(gè)復(fù)雜的多因素過(guò)程，需要進(jìn)一步研究。