股骨颈骨折后股骨头负重区及非负重区软骨下骨形态学研究及OPG/HIF蛋白的表达实验
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摘要
目的:通过对股骨颈骨折后股骨头负重区、非负重区软骨下骨的组织形态、微观形态学变化及免疫组化实验观察分析,为股骨颈骨折临床治疗提供实验依据。
方法:取36例股骨头标本,均为股骨颈骨折2周内手术的GardenⅢ、Ⅳ骨折,其中女性股骨头标本24例,年龄60-79岁,平均69.18±6.31 ,男性股骨头标本12例,年龄53-83岁,平均64.25±9.81。由股骨头上取出负重区及非负重区的软骨下骨两个部位的软骨下骨进行对照观察实验,分别进行苏木素-伊红染色,观察软骨下骨骨小梁形态的修复重建;扫描电镜方法观察两个不同区域的骨小梁及胶原纤维的微观形态;组化法,观察OPG和HIF两个因子在负重区、非负重区的不同表达。
结果:
1.大体形态学的观察:观察所有标本的纵剖面,可见股骨头负重区的软骨下有一条明显的出血带,呈鲜红色半弧形衬附于软骨帽下,非负重区较负重区充血不明显。
2.苏木素-伊红染色显示:股骨头负重区多数骨小梁断裂,骨小梁断端有大量成骨细胞增值,软骨下基质中破骨细胞较活跃,骨小梁断端可见大量毛细血管增生长入;非负重区也可见部分小梁断裂,但软骨下骨中破骨细胞不活跃,成骨细胞较负重区数量少,毛细血管数量少。
3.扫描电镜:股骨头负重区软骨下骨内部结构由柱状及板状骨小梁共同组成拱形结构。股骨颈骨折后其拱形结构已遭受不同程度的损伤。很多骨小梁被破坏,主要表现为柱状骨小梁断裂,使拱形结构的完整性明显减弱,骨小梁上出现有多处的微骨折。此外还可见骨小梁的显微骨痂样组织。该区部分骨小梁表面出现较重的吸收现象;非负重区的骨小梁多数为椭圆形或不规则形状,排列稀疏、其上散布的较小的吸收面和骨陷窝,骨小梁上的微骨折现象较负重区少。
4. OPG因子检测:负重区的骨小梁阳性表达明显,骨小梁修复明显,非负重区骨小梁基质中有表达,阳性表达较负重区弱。
5. HIF-1α因子的检测:负重区、非负重区均表达HIF-1α,但以前者明显,且集中在负重区的细胞浆和基质中。
结论:
1.老年股骨颈骨折后软骨下骨发生微骨折,负重区较非负重区明显加重。这种微骨折可能是后期继发头坏死塌陷原因之一。
2.软骨下骨微骨折早期即有骨组织修复重建发生。
3.股骨颈骨折内固定术后可早期活动,但应避免负重,以利于软骨下骨微骨折修复。
4.对高龄股骨颈骨折患者行人工关节置换是优先选择之一。
Objective:This research text studied the different changes of organizational morphology and micro-morphology on the sending down fishbone cartilage from weight-bearing area and non-weight-bearing area after femoral neck fracture on human. For femoral neck fracture and provide experimental basis for clinical treatment..
Method:Specimens are from 36 cases of femoral head, which are operated within 2 weeks after femoral neck fracture and the GardenⅢⅣ.In those, 24 cases are from women and age from 60-79 years (the average 69.18±6.31 years ) ,12 cases are from male and age from 53-83 years(average 64.25±9.81 years).In order to compare sending down fishbone cartilage from weight-bearing area of femoral head to that one from the non-weight-bearing area , We apply hematoxylin-eosine stain to survey the recovery and re-establishment about morphology of bone trabecula on sending down fishbone cartilage; use scanning electron microscope to observe the micro-morphous of bone trabecula and collagenous fibers on the different areas; adopt immunohistochemical staining method to definite the difference about OPG and HIF on weight-bearing area and non-weight-bearing area.
Results:
1.morphological observation: Observation of the longitudinal profile of all samples, there is a hemorrhagic belt, which is bright red semi-curved lining attached to the cartilage cap , on the weight-bearing area of femoral head. It is not obvious on the non-weight-bearing area .
2.Hematoxylin-eosine stain showed: The majority of trabecular bone is fracture on the weight-bearing area of femoral head.There is substantial osteoblasts in ends, osteoclasts is active under the cartilage matrix, and a lot of capillaries have growed into in ends . Part of trabecular is fracture on non-weight-bearing area, but the osteoclasts is inactive on subchondral bone , the number of osteoblasts and capillaries are less than the number of weight-bearing area.
3. Scanning electron microscope: The internal structure of subchondral bone is composed of the column and the plate trabecular bone in femoral head,which is arch formed structure. After femoral neck fracture ,the arched structure has suffered damage to varying degrees. A lot of trabecular bone is damaged, cylindrical trabecular bone is fracture, so that the integrity of the arch structure apparently disappeared,and many of the micro-fracture can be seen on Trabecular bone. In addition, microstructure callus-like tissue is visible of trabecular bone. There is seriously absorbed on trabecular bone surface area. Trabecular bone are mostly oval or irregular shape, with sparse, and its spread on the absorption surface and bone lacuna on Non-weight-bearing.
4.OPG factor detected: There is obviously about positive expression and repair of trabecular bone on weight-bearing area.It is also have postive expression on the matrix of non-weight-bearing areas ,but that is less than the weight-bearing area.
5.HIF-1αfactor Detected: There is the expression of HIF-1αon weight-bearing areas and non-weight-bearing area ,but the further is obviously,forthmore the positive cells were seen in the cytoplasm of cells and stromal on weight-bearing areas.
Conclusion:
1. The subchondral micro-fractures occurred after the elderly femoral neck fracture, and it is seriously in weight-bearing area than those in non-weight-bearing areas.This micro-fracture may be one of the reasons for the post-secondary necrosis collapse.
2. Bone tissue repair and reconstruction have taken place in the early stage of subchondral bone micro-fractures.
3. After internal fixation of femoral neck fracture,it may be early mobilization , but should avoid weight-bearing in order to facilitate micro-fracture of subchondral bone repaired.
4.It is preferred to total hip replacement for femoral neck fracture in elderly patients.
方法:取36例股骨头标本,均为股骨颈骨折2周内手术的GardenⅢ、Ⅳ骨折,其中女性股骨头标本24例,年龄60-79岁,平均69.18±6.31 ,男性股骨头标本12例,年龄53-83岁,平均64.25±9.81。由股骨头上取出负重区及非负重区的软骨下骨两个部位的软骨下骨进行对照观察实验,分别进行苏木素-伊红染色,观察软骨下骨骨小梁形态的修复重建;扫描电镜方法观察两个不同区域的骨小梁及胶原纤维的微观形态;组化法,观察OPG和HIF两个因子在负重区、非负重区的不同表达。
结果:
1.大体形态学的观察:观察所有标本的纵剖面,可见股骨头负重区的软骨下有一条明显的出血带,呈鲜红色半弧形衬附于软骨帽下,非负重区较负重区充血不明显。
2.苏木素-伊红染色显示:股骨头负重区多数骨小梁断裂,骨小梁断端有大量成骨细胞增值,软骨下基质中破骨细胞较活跃,骨小梁断端可见大量毛细血管增生长入;非负重区也可见部分小梁断裂,但软骨下骨中破骨细胞不活跃,成骨细胞较负重区数量少,毛细血管数量少。
3.扫描电镜:股骨头负重区软骨下骨内部结构由柱状及板状骨小梁共同组成拱形结构。股骨颈骨折后其拱形结构已遭受不同程度的损伤。很多骨小梁被破坏,主要表现为柱状骨小梁断裂,使拱形结构的完整性明显减弱,骨小梁上出现有多处的微骨折。此外还可见骨小梁的显微骨痂样组织。该区部分骨小梁表面出现较重的吸收现象;非负重区的骨小梁多数为椭圆形或不规则形状,排列稀疏、其上散布的较小的吸收面和骨陷窝,骨小梁上的微骨折现象较负重区少。
4. OPG因子检测:负重区的骨小梁阳性表达明显,骨小梁修复明显,非负重区骨小梁基质中有表达,阳性表达较负重区弱。
5. HIF-1α因子的检测:负重区、非负重区均表达HIF-1α,但以前者明显,且集中在负重区的细胞浆和基质中。
结论:
1.老年股骨颈骨折后软骨下骨发生微骨折,负重区较非负重区明显加重。这种微骨折可能是后期继发头坏死塌陷原因之一。
2.软骨下骨微骨折早期即有骨组织修复重建发生。
3.股骨颈骨折内固定术后可早期活动,但应避免负重,以利于软骨下骨微骨折修复。
4.对高龄股骨颈骨折患者行人工关节置换是优先选择之一。
Objective:This research text studied the different changes of organizational morphology and micro-morphology on the sending down fishbone cartilage from weight-bearing area and non-weight-bearing area after femoral neck fracture on human. For femoral neck fracture and provide experimental basis for clinical treatment..
Method:Specimens are from 36 cases of femoral head, which are operated within 2 weeks after femoral neck fracture and the GardenⅢⅣ.In those, 24 cases are from women and age from 60-79 years (the average 69.18±6.31 years ) ,12 cases are from male and age from 53-83 years(average 64.25±9.81 years).In order to compare sending down fishbone cartilage from weight-bearing area of femoral head to that one from the non-weight-bearing area , We apply hematoxylin-eosine stain to survey the recovery and re-establishment about morphology of bone trabecula on sending down fishbone cartilage; use scanning electron microscope to observe the micro-morphous of bone trabecula and collagenous fibers on the different areas; adopt immunohistochemical staining method to definite the difference about OPG and HIF on weight-bearing area and non-weight-bearing area.
Results:
1.morphological observation: Observation of the longitudinal profile of all samples, there is a hemorrhagic belt, which is bright red semi-curved lining attached to the cartilage cap , on the weight-bearing area of femoral head. It is not obvious on the non-weight-bearing area .
2.Hematoxylin-eosine stain showed: The majority of trabecular bone is fracture on the weight-bearing area of femoral head.There is substantial osteoblasts in ends, osteoclasts is active under the cartilage matrix, and a lot of capillaries have growed into in ends . Part of trabecular is fracture on non-weight-bearing area, but the osteoclasts is inactive on subchondral bone , the number of osteoblasts and capillaries are less than the number of weight-bearing area.
3. Scanning electron microscope: The internal structure of subchondral bone is composed of the column and the plate trabecular bone in femoral head,which is arch formed structure. After femoral neck fracture ,the arched structure has suffered damage to varying degrees. A lot of trabecular bone is damaged, cylindrical trabecular bone is fracture, so that the integrity of the arch structure apparently disappeared,and many of the micro-fracture can be seen on Trabecular bone. In addition, microstructure callus-like tissue is visible of trabecular bone. There is seriously absorbed on trabecular bone surface area. Trabecular bone are mostly oval or irregular shape, with sparse, and its spread on the absorption surface and bone lacuna on Non-weight-bearing.
4.OPG factor detected: There is obviously about positive expression and repair of trabecular bone on weight-bearing area.It is also have postive expression on the matrix of non-weight-bearing areas ,but that is less than the weight-bearing area.
5.HIF-1αfactor Detected: There is the expression of HIF-1αon weight-bearing areas and non-weight-bearing area ,but the further is obviously,forthmore the positive cells were seen in the cytoplasm of cells and stromal on weight-bearing areas.
Conclusion:
1. The subchondral micro-fractures occurred after the elderly femoral neck fracture, and it is seriously in weight-bearing area than those in non-weight-bearing areas.This micro-fracture may be one of the reasons for the post-secondary necrosis collapse.
2. Bone tissue repair and reconstruction have taken place in the early stage of subchondral bone micro-fractures.
3. After internal fixation of femoral neck fracture,it may be early mobilization , but should avoid weight-bearing in order to facilitate micro-fracture of subchondral bone repaired.
4.It is preferred to total hip replacement for femoral neck fracture in elderly patients.
引文
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1.Haidukewych GJ,Rothwell WS,Jacofsky DJ, et al. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am 2004,86-A(8):1711-1176
2.Galla M, Lobenhoffer P.The minimally-invasive screw osteosynthesis of the medial femoral neck fracture in the very old. A prospective clinical study. Unfallchirurg. 2004,107(5):381-387
3.Healy WL,Iorio R.Total hip arthroplasty: optimal treatment for displaced femoral neck fractures in elderly patients. Clin Orthop Relat Res 2004,429: 43-48
4.Gardner MJ,Lorich DG,Lane JM.Osteoporotic femoral neck fractures: management and current controversies. Instr Course Lect.2004, 53:427-439
5.Shuqiang M,Kunzheng W,Zhichao T,et al. Outcome of non-operauve management in GardenⅠfemeral neck fractures. Injury.2006,37(10): 974-978
6.Probo R,Ward R. Internal fixation of femoral neck fractures.J Am Acad Orthop Surg.2006:14(9):565-571
7.Georgescu N,Alexa O,Stratan L.Displaced femoral neck fractures: internal fixation or arthroplasty?Rev Med Chir Soc Med 2001: 105(4) 763-768
8.BhandariM, Devereaux P, Tornetta P3rd,et al.Operative management of displaced femoral neck fractures in elderly patients,An international survey[J].J Bone Joint Surg(Am),2005,87(9): 2122-2130.
9.Kadakia A,Langkamer VG.Cancellous screw fixation of undisplaced femoral neck fractures in over 70 years.Injury Extra,2007,38(4):146-147
10.Stannard JP,HarrisHW,Volgas DA,et al.Functional outcome of patients with femoral head fractures associated with hip dislocations.Clin Orthop ReletRes,2000 (377): 44-56
11.Estrada LS,VolgasDA,Stannard JP,et al.Fixation failure in femoral neck fractured. Clin Orthop Relat Res,2002,399(6): 110-118
12.Bosch U,SchreiberT,Krettek C.Reduction and fixation ofdisplaced intracapsular fractures of proximal femur.Clin Orthop RelatRes, 2002,399(6):59-71
13.胡孔足,卜海富.空心螺纹钉治疗股骨颈骨折的滑动加压原理.临床骨科杂志,2004,(74):370-372
14.Toh EM,SahniV,Acharya A,et al.Management of intracapsular femoral neck fractures in the elderly; is it time to rethink our strategy?.Injury,2004,35(2):125-129
15.Mjorud J,Skaro O,Solhaug JH,et al.A randomised study in all cervical hip fractures osteosynthesis with Hansson hook-pins versusAO-screws in 199 consecutive patients followed for two years.Injury,2006,37(8):768-777
16.Nikolopoulos KE,Papadakis SA,Kateros KF,et al.Long-term outcome of patients with avascular necrosis,after internal fixation of femoral neck fractures.Injury,2003,34(7):525-528
17郝敏,李美才,刘安庆.股骨颈骨折导针靶向定位装置的研制与临床初步应用.中国骨与关节损伤杂志,2005,20(8):521
18.曹立,沈惠良,雍宜民.空心钉治疗老年股骨颈骨折中远期疗效观察.中国骨与关节损伤杂志,2005,20(10):658
19.王以进,王方麟。骨科生物力学。北京:人民军医出版社,1989;272
20.杨述华.骨坏死学.北京:人民军医出版社,2002:33
21.Messmer P,Soklie P,Matter P.Femoral neck fracture and femoral head neerosis. Helv Chir Acta,1993,59(5-6):993-997
22.Mirdad T. Fracture of the neck of the Children:an experienee at the Aseer Central Hospital,Abha,Saudi Arabia.Injury, 2002,33(9):823-827
23.Bombaci H,Cente1 T,Babay A,et al.Evaluation of complications of femoral neck fractures in children operated on at least 24 hours after initial trauma.Acta Orthop Traumatol Turc,2006,40(1):6-14
24.方大标,王秋根,张秋林,等.医源性因素对DHS治疗髋部骨折疗效的影响.中华创伤骨科杂志,2004,6(5):525-528
25.Lu-Yao GL,Keller RB,Littenberg B,et al.Outcomes after displaced fractures of the femoral neck.A meta-analysis of one hundred and sixpublished reports.J Bone Joint Surg (Am),1994,76(1):15-25
26.Alberts KA,Jervaeus J.Factors predisposing to healing complications after internal fixation of femoral neck fraeture:a stepwise logistic regression analysis.Clin Orthop Relat Res,1990, 257:129-133
27.Hernefalk L,Messner K.Invitro femoral stiffness after femoral neck osteotomy and osteosynthesis with defined surgical errors.J orthop Trauma,1996,10(6):426
28.李子荣,张念非,史振才,等.股骨头坏死塌陷的预测与治疗方法的选择.中华骨科杂志,2003,23:193-196
29.潘显明,胡修德,谭映军,等.82例青壮年股骨颈骨折治疗的评价.中华创伤杂志,2000,16(3):145-147
30.Maeda S,Kita A,Fujii G,et al.Avascular necrosis associated with fractures of the femoral neck in children:histological evaluation of core biopsies of the femoral head.Injury,2003,34(4):283-286
31.张永飞,张义修.股骨颈骨折术后股骨头坏死的力学因素.骨与关节损伤杂志,2001,16(4):270-272