Development and evaluation of a 3D ensemble framework for automatic diagnosis of early osteonecrosis of the femoral head based on MRI: a multicenter diagnostic study

Miao Yang ^1* Fuchou Hsiang ² Chengfan Li ¹ Xiaoyi Chen ^3* Changqing Zhang ² Guangchen Sun ^4* Qiliang Lou ^4* Wenhui Zhu ^5* Hongtao Zhao ^5* Feng Liu ^6* Xuehai Ding ^1* Jun Xu ^2*

• ¹ Shanghai University, Shanghai, China
• ² Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, Shanghai Municipality, China
• ³ Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, Zhejiang Province, China
• ⁴ Jiashan First People's Hospital, Jiaxing, China
• ⁵ Sanmenxia Hospital of Traditional Chinese Medicine, Sanmenxia, Henan Province, China
• ⁶ Taixing Traditional Chinese Medicine Hospital, Guangzhou, Guangdong Province, China

Background: Efficient and reliable diagnosis of early osteonecrosis of the femoral head (ONFH) based on MRI is crucial for the formulation of clinical treatment plans. This study aimed to apply artificial intelligence (AI) to achieve automatic diagnosis and visualization of early ONFH, thereby improving the success rate of hip-preserving treatments.Method: This retrospective study constructed a multicenter dataset using MRI data of 381 femoral heads from 209 patients with ONFH collected from four institutions (including 239 early ONFH cases and 142 non-ONFH cases). The dataset was divided into training, validation, and internal and external test datasets. This study developed a 3D ensemble framework to automatically diagnose early osteonecrosis of the femoral head based on MRI and utilized 3D Grad-CAM to visualize its decision-making process. Finally, the diagnostic performance of the framework was experimentally evaluated on the MRI dataset and compared with the diagnostic results of three orthopedic surgeons.Results: On the internal test dataset, the 3D-ONFHNet framework achieved overall diagnostic performance with an accuracy of 93.83%, sensitivity of 89.44%, specificity of 95.56%, F1-score of 87.67%, and AUC of 95.41%. On the two external test datasets, the framework achieved overall diagnostic accuracies of 87.76% and 87.60%, respectively. Compared to three orthopedic surgeons, the diagnostic performance of the 3D-ONFHNet framework was comparable to that of senior orthopedic surgeons and superior to that of junior orthopedic surgeons.The framework proposed in this study can generate staging results for early ONFH and provide visualizations of internal signal changes within the femoral head. It assists orthopedic surgeons in screening for early ONFH on MRI in a clinical setting, facilitating preoperative planning and subsequent treatment strategies. This framework not only enhances diagnostic efficiency but also offers valuable diagnostic references for physicians.