Objective To investigate cl inical therapeutic effect on early stage femoral head necrosis managed with allogeneic cortical bone cage support combining with autologous cancellous bone grafting through core decompression tunnel, and to discuss its effect on preventing femoral head collapse and influence factors. Methods From January 2002 to December2005, 40 patients (42 hips) with femoral head necrosis underwent core decompression and an allogeneic threaded cortical bone supporting cage which was loaded with autologous cancellous bone inside. There were 26 males and 14 females, aging 27-45 years (mean 35.6 years). The disease course was 6-28 months (mean 18.3 months). All the cases underwent X-ray, CT and MRI examination to confirm the diagnosis and necrosis area. Twelve hips were at Ficat stage I, 29 hip at stage II, and 1 hips at stage III. Harris hip score system was used to evaluate the hip function pre- and post-operatively. X-ray films were taken regularly after operation. Results All the wound healed by first intention without any compl ications such as infection, fracture, nerve and vascular injury, and deep vein thrombosis. Thirty-six patients (38 hips) were followed up for 24-58 months with an average of 38 months. All the patients had different degrees of improvement in cl inical symptoms. According to Harris hip score system, the Harris score was 63.1 ± 6.4 before operation and 82.3 ± 16.5 at the last follow-up, showing significant difference (P lt; 0.001). The results were excellent in 24 hips, good in 11 hips, fair in 2 hips and poor in 1 hips. The X-ray films showed femoral head repairing and no advancement of osteonecrosis and collapsing in 23 patients (24 hips) 24 months after operation. Conclusion Allogeneic cortical bone cage support combining with autologous cancellous bone grafting is suitable for managing early stagefemoral head necrosis and its short- and middle-term effect is satisfactory.
Objective To evaluate the mid-term outcome of impacting bone graft and strut graft in treating osteonecrosis of the femoral head (ONFH) and to compare the effects of fibular autograft and allograft for strut graft. Methods From August 2004 to December 2004, 40 cases (58 hips) of ONFH were treated with impacting bone graft and nonvascular fibular autograft (autograft group) or allograft (allograft group). In the autograft group, 20 cases (27 hips) included 17 males (23 hips) and 3 females (4 hips) with an average age of 41 years (22-53 years); 22 hips were at stage II and 5 hips at stageIII according to the classification system of Association Research Circulation Osseous (ARCO). In the allograft group, 20 cases (31 hips) included 17 males (25 hips) and 3 cases females (6 hips) with an average age of 40 years (18-55 years); 23 hips were at stage II and 8 hips at stage III according to the classification system of ARCO. The outcome was evaluated both cl inically by Harris hip score (HHS) and radiologically by X-rays. The related compl ications were recorded. The end-point of observation was determined when further salvage operation or total hip arthroplasty was needed. Results All cases were followed up for 36-40 months (mean 37.5 months), 25 hips (92.6%) preserved femoral heads in autograft group and 28 hips (90.3%) in allograft group. Harris score in autograft and allograft groups was increased significantly from 70.82 ± 8.26 and 69.94 ± 9.59 before operation to 86.36 ± 6.27 and 87.45 ± 7.03 at the last follow-up, respectively, indicating a significant difference between before and after operation in two groups (P lt; 0.05), but no significant difference between two groups (Pgt;0.05). The radiological results showed that 17 hips (63.0%) in autograft group and 21 hips (67.8%) in allograft group improved or had no further collapse; and 20 hips (74.1%) in autograft group and 22 hips (71.0%) in allograft group were in good repair, indicating no significant difference between two groups (P gt; 0.05). The postoperative compl ication occurred after weight-bearing walk in the autograft group and during wound heal ing stage in the allograft group. Conclusion For selected cases of femur head necrosis, the treatment with modified impacting bone graft and strut graft has a satisfactory mid-term outcome. The results of fibular autograft and fibular allograft had no significant difference.
Objective To investigate the expression levels of osteoprotegerin (OPG) and receptor activator of nuclear factor kappa B l igand (RANKL) mRNAs in BMSCs in patients suffering glucocorticoid-induced necrosis of the femoral head (GNFH), and to discuss the relationshi p between OPG/RANKL system and GNFH. Methods The bone tissue and BMSCs of femoral head were collected from 35 patients suffering GNFH (experimental group) and from 21 patients suffering fracture of femoral neck (control group). The ratio of men to women was 4 ∶ 3 in two groups, aged 41 to 70 years (mean 55.34years in the experimental group and mean 55.33 years in the control group). The patients of experimental group received over 3 weeks’ glucocorticoid treatment or more than 1 week’s high-dose glucocorticoid therapy in recent 2 years, but patients of the control group did not receive more than 1 week’s hormone therapy. In 2 groups, the microstructure of bone tissue of femoral head was detected by HE staining. The BMSCs were isolated and cultured by adherent-wall method; the expression levels of OPG and RANKL mRNAs were examined by real-time quantitative polymerase chain reaction and the ratio of OPG mRNA to RANKL mRNA was caculated. Results Bone trabeculae and bone units were replaced by interrupted bone fragments, which were surrounded by inflammation and granulation tissue and few osteocytes were seen in bone lacunae in the experimental group. In control group, bone trabeculae and bone units were made by complete lamellar bone which surrounded blood vessels and osteocytes were seen in lacunae. The expression levels of OPG mRNA in the experimental group (0.37 ± 0.12) was significantly lower than that in the control group (0.47 ± 0.13), and the levels of RANKL mRNA in the experimental group (1.12 ± 0.39) was significantly higher than that in the control group (0.84 ± 0.24), showing statistically significant difference (P lt; 0.05). The ratio of OPG mRNA to RANKL mRNA in the experimental group (0.37 ± 0.17) was significantly lower than that in the control group (0.61 ± 0.26, P lt; 0.05). Conclusion The GNFH may be related to the expression levels of OPG mRNA and RANKL mRNA in BMSCs.
Objective To evaluate sex determining region of the Y (Sry) as a engrafting track of the transplanted BMSCs survival and new bone formation in the osteonecrosis of the femoral head (ONFH) of rabbit. Methods Fortynine 4-5-month-old New Zealand White rabbits were included, weighing 2.0-2.5 kg, 48 females and 1 male. BMSCs of the rabbits were isolated by density gradient separation method, the third passage cells were marked by 1, 1’-dioctadecyl-3, 3, 3’, 3’-tetramethyl indocarbocyanine perchlorate (DiI) and the concentration of cell suspension was 2.5 × 108/ mL. The animal model of ONFH were establ ished with 48 female rabbits by injecting l iquid nitrogen, and femoral head was not dislocated.The animal model were divided into 3 groups, 16 rabbits in each group. Group A only establ ished animal model as control. Autologous BMSCs (4 μL) marked by DiI was transplanted in the ONFH models of the group B. Allogenic BMSCs (4 μL) marked by DiI was transplanted in ONFH models of the group C. The femoral head were observed by X-ray, HE staining and Masson staining, and the regenerating trabecular volume percentages was determined at 2, 4, 6 and 8 weeks after operation respectively. The examples of the heart, lung, l iver, spleen and kidney were obtained. The transplanted BMSCs were traced by fluorescence microscope, the Sry gene expression was detected by PCR for cells survival. Results All rabbits survived till the end of experiment. The X-ray showed gradual necrosis in the femoral head of group A. HE and Masson staining results indicated that compared with the group A, the recovery condition of the necrotic femoral head in the groups B and C was better. At each time of groups B and C, the regenerating trabecular volume percentages were higher than that of the group A significantly (P lt; 0.01). There was no significant difference between groups B and C (P gt; 0.05). The cells marked by DiI were not founded in the tissues of the heart, lung, l iver, spleen and kidney in groups B and C at each time. PCR showed that the expression of Sry gene were not observed at the heart, lung, l iver, spleen and kidney of three groups at each time. The expression of Sry gene was clearly identified in the femoral head of all 16 rabbits in the group C at each time point. Conclusion Allografting of BMSCs transplanted into the femoral head can survive and induce new bone formation without redistribution.
Objective To explore the relationship between alcohol induced osteonecrosis of the femoral head (ONFH) and the single nucleotide polymorphisms (SNP) of methylene tetrahydrofolate reductase (MTHFR) 677 C/T. Methods From July 2005 to May 2008, eighty-nine male patients with alcohol induced ONFH were selected as the patient group, aged from 24 to58 years old (mean 44.3 years old). The time of drinking was about 17 years, 375 mL/day. The imaging evidence showed ONFH with no other history associated to ONFH. Seventy-seven male healthy adults were selected as the control group, aged from 23 to 52 years old (mean 42.7 years old). The time of drinking was about 14 years, 335 mL/day. The imaging evidence showed no ONFH. The 2 mL blood sample was acquired from every subject. DNA was purified from leucocyte at first, then was ampl icated by PCR, the product of PCR was sequenced at last. The SNP of MTHFR 677 C/T was analyzed with SPSS 12.0 software package. Results The TT genotype and T allele frequencies of MTHFR 677 C/T were 27.2% and 52.0% (P gt; 0.05) in the control group, and the distribution of genotype was consistent with Hardy-Weinberg equil ibrium. The genotype frequencies of CC, CT and TT were 23.4% (18 cases), 49.4% (38 cases) and 27.2% (21 cases) in the control group, were 14.6% (13 cases), 36.0% (32 cases) and 49.4% (44 cases) in the patient group; showing statistically significant differences (P lt; 0.05). The allele frequencies of C and T were 48.0% (74) and 52.0% (80) in the control group, and were 32.6% (58) and 67.4% (120) in the patient group; showing statistically significant differences (P lt; 0.05). The frequencies of C, T alleles and TT genotype were higher in the patient group than in the control group, showing statistically significant differences (P lt; 0.05). The odds ratios were 0.523, 1.914 and 2.607, respectively; the 95% confidence interval were 0.335-0.816, 1.226-2.987, 1.359-5.001, respectively. Conclusion The relationship may exist between the SNP of MTHFR 677 C/T and alcohol induced ONFH.
【Abstract】 Objective To establ ish a animal model of osteonecrosis of femoral head in canine l ike human.Methods The thermal field of canine’s femoral head was three-dimensionally analyzed with fluent 6.2 software so that the best cryosurgery patent could be designed to maximize the osteonecrosis and minimize extra surgery trauma with the cryosurgery system invented by Shanghai Jiaotong University. Liquid nitrogen was pressurized to 0.5 MPa, poured into femoral head for 6.5 minutes, rewarming to 2 for 5 minutes and then repoured into it again for another 6.5 minutes. Ten three-foot canines were conducted as the animal models of osteonecrosis of femoral head according to the method above. At the end of followup,the results were reviewed by radiologic and pathologic check. Two dogs were conducted as control group. Results In the experimental group, one of the ten canines was testified to occur osteonecrosis of femoral head after one week pathologically, cell death and vessel breakage of cavitas medullaris in the femoral head was obvious under microscope; in other nine canines beingstill under follow-up, five with three-month follow-up at least progressed to the collapse of femoral head l ike human (Ficat III). In control group, no osteonecrosis was found. Conclusion Cryosurgery for osteonecrosis of the femoral head in three-foot canine model may become a method to establ ish the animal model of osteonecrosis of femoral head l ike human.
【Abstract】 Objective To investigate both incidence and mechanism attributing to steroid-associated osteonecrosisof femoral head(ONFH) using an experimental protocol with a single low-dose l i popolysaccharide (LPS) injection andsubsequently three injections of high-dose methylprednisolone (MPS). Methods Twenty-five New Zealand white rabbits with body weight of (3.0 ± 0.3) kg were divided randomly into 2 groups. In treatment group, 19 rabbits received one intravenous injection of LPS (10 μg/kg); 24 hours later, three injections of 20 mg/kg of MPS were given intramuscularly at an interval of 24 hours. Additional 6 rabbits which received normal sal ine injection at the same time point were used as controls(control group). The blood samples were collected for hematological examinations before and after LPS injection, MRI was performed on bilateral hip six weeks after last MPS injection, meanwhile, bone marrow was aspirated from femoral head region to evaluate stem cell’s activity. Bilateral femoral heads were harvested to make histopathology examination. Results All animals survived throughout the experiment period except one death on the second day after LPS injection. In the histopathological examinationfor the femoral head, ONFH+ was observed in 16 rabbits (88.9%), and the lesions were mainly in the metaphysis. In ONFH+ rabbits, micro vessels fibrous thrombosis and extravascular marrow fat cell size increasing were found around necrotic bone; The femoral heads of control group had no changes. MRI accurate ratio was 93.8% (15/16). Compared to basel ine, a significant decrease in ratio of tissue plasminogen activator/plasminogen activator inhibitor 1 and activated partial thromboplatin time, and a significant increase in ratio of low-density l ipoprotein/high-density l ipoprotein were only found in ONFH+ rabbits (P lt; 0.05). Meanwhile there was a significant decrease in the number of CFU-F (8.50 ± 9.63) compared with the control (70.17 ± 7.78, P lt; 0.05). Conclusion A single low-dose LPS injection and subsequent three injections of high-dose MPS is effective on building steroid-associated ONFH model, coagulation and l ipometabol ism abnormal ity, activity degeneration of stem cell may be the key factors of ONFH.
【Abstract】 Objective To approach the possibil ity of combination of simvastatin and BMSCs transplantation forsteroid-associated osteonecrosis of femoral head. Methods The BMSCs harvested from 24 rabbits were prepared for cell suspension at a concentration of 1 × 107/mL, and combined with gelatin sponge. Seventy New Zealand white rabbits received one intravenous injection of l ipopolysaccharide (10 μg/ kg). After 24 hours, three injections of 20 mg/kg of methylprednisolone were given intramuscularly at a time interval of 24 hours. Forty-eight rabbits diagnosed as having femoral head necrosis by MRI were divided into 4 groups randomly, group A: no treatment; group B: only decompression; group C: decompression and BMSCs transplantation; and group D: simvastatin drench (10 mg/kg.d) decompression and BMSCs transplantation. The general information of animals were recorded; after 4 and 8 weeks of operation, 6 rabbits of each group were chosen randomly to do MRI scan, and femoral heads were harvested to do histopathology and scanning electron microscope examination. Results After 8 weeks, rabbits became more active than before treatment, and walking way became normal gradually in groups C and D. Fourweeks after operation, the MRI low signal region of all groups had no obvious changes, but 8 weeks later, the necrosis signal region of group A magnified while it reduced obviously in group D. Histopathological observation: 4 weeks after operation, diffuse presence of empty lacunae and pyknotic nuclei of osteocytes were found in the trabeculae, and few newborn micrangium could been seen in group A; lots of empty lacunae and a small quantity of newborn micrangium could been found in group B; and large amounts of osteoblats and newborn micrangium were found around the necrosis regions in groups C and D. The positive ratio of empty lacunae and microvessel density in group D were 19.30 ± 1.52 and 7.08 ± 1.09, showing significant difference compared with other groups (P lt; 0.05). After 8 weeks of treatment, the bone trabecula collapsed in many regions in group A; there was fibra callus formation along the decompression channel in group B; few empty lacunae was in the bone trabecular, but the shape of marrow cavity was not normal in group C; and it showed almost normal appearance in group D. The positive ratio of empty lacunae and microvessel density in group D were 11.31 ± 1.28 and 12.37 ± 1.32, showing significant differences compared with other groups (P lt; 0.05), meanwhile, showing significant difference compared with that of 4 weeks after operation(P lt; 0.05). Scanning electron microscope: 8 weeks after operation, the bone trabecula collapsed in many regions, and few osteoblasts could be found on the surface, a great quantity of fat cells cumulated in the bone marrow in group A; cracked bone trabecula could be found occasionally in group B; the density of bone trabecula was lower than the normal in group C; and the shape of the marrow avity and thedensity of bone trabecula were similar to the normal in group D. Conclusion Simvastatin can promote the differentiation of osteocyte and vascular endothel ial cell from MSCs, the combination of simvastatin and marrow stem cells transplantation for the treatment of steroid-associated osteonecrosis of femoral head have good appl ication prospects.
【Abstract】 Objective To measure the changes of bone mineral density and bone micro-architecture of thefemoral head that harvested from the three-foot bearing ethanol destroyed canine model for osteonecrosis of femoral head, and discuss the influences of local injection of ethanol and biomechanical loading to the structural properties of the femoral head. Methods Twenty-four Beagles were divided randomly into four-foot bearing canines and three-foot bearing canines. One fore-l imb was fixed randomly in three-foot bearing canines. Osteonecrosis was induced in all experimental animals by local injection of 5 mL pure ethanol into one side of the femoral head. The hind l imbs injected with NS were acted as control group, that of three-foot canines injected with ethanol were acted as three-foot canine group, and that of four-foot canines injected with ethanol were acted as four-foot canine group. The contralateral femoral head was injected into equal amount of NS. Animals were sacrificed at the time intervals of 1, 3, 6, and 12 weeks after the injection of ethanol. Quantitative microcomputedtomography was used to characterize changes in bone micro-architecture and bone mineral density of femoralhead. Results The clear three-dimensional model of trabecular bone of necrotic femoral head were obtained. There were no significant differences among 3 groups according to the time l ine by 1 week after ethanol injection(P gt; 0.05). At 3 weeks after injection of ethanol, in three-foot canine group and four-foot canine group, the volume of BMC, BMD, BVF, and BS/BV increased gradually as the distance to the drill ing canal increased. There were significant differences between 3 regions (P lt; 0.05). At 6 weeks, in three-foot canine group and four-foot canine group, the volume of BMC, BMD,BVF, and Tb.N of region I and II decreased significantly compared with region III (P lt; 0.05). At 12 weeks, there are no differences among 3 groups (P gt; 0.05). There were significant decreases in BMD values, BVF, BS/BV, Tb.N, Tb.Sp and Tb.Th after the injection of pure ethanol. And, the changes were more and more obvious by the time l ine. These changes were differentiable at 3 weeks after injection of ethanol, and became obvious at 6 weeks. These changes were more obvious at the part that near the injection canal. The changes in threefoot canine group were more obvious than that in four-foot canine group. Conclusion Resorption of necrotic compact bone trabecular may weaken the structural properties of the femoral head. Moreover, remodel ing and repairing process of necrotic bone trabecular may be hampered by constant biomechanical loading that presented in three-foot bearing canines, and thereby further weaken the structural properties of the femoral head. Biomechanical loading may be one of the critical reasons that lead to the collapse of femoral head.
【Abstract】 Objective To explore the correlation between pain grading, stage of necrosis and bone marrow edema(BME) in nontraumatic osteonecrosis of femoral head (NONFH) so as to strengthen understandings about cl inical significance of BME in NONFH. Methods From October 2004 to October 2006, 97 patients (149 hips) with NONFH were treated. There were 68 males and 29 femals with an average age of 38.8 years (19-62 years). The disease course was from 20 days to 4 years. BME was identified grade 0 to grade 2 according to MRI. Based on grading scale of pain, pain grading were divided into no pain (grade 0), mild pain (grade 1) and moderate or severe pain (grade 2). According to Association Research Circulation Osseous staging system, NONFH were divided into I-IV stages. The incidence rate of BME in each pain grading and stages of necrosis was analyzed respectively. Contingency table analyses and rank sum tests were used to compare the difference of pain grading and stages of necrosis among these groups. Results The total incidence rate of BME was 73.15% (109/149), the incidence rateswere 84.38% in pain groups (108 /128) and 94.12% in the grade 2 (32/34). Pain grading correlated with BME rating (P lt; 0.001).The results of rank sum tests for several independent samples showed significant difference in BME among pain groups(P lt; 0.001). With the advance of pain scale, the mean rank of BME increased gradually(28.19 for grade 0, 78.94 for grade 1 and 96.12 for grade 2). BME was more commonly and clearly seen in stage Ⅱ(77.05%)and stage Ⅲ(82.81%)of NONFH. Stage I-III of NONFH correlated with BME rating (P lt; 0.001). The results of rank sum tests showed significant difference in BME rating among three stages (P lt; 0.001). With the advance of disease, the rank of BME rating increased gradually (39.07 for grade 0, 60.16 for grade 1 and 86.15 for grade 2 ). Conclusion BME is a sign that is accompanied with NONFH. The probabil ity and extent of BME correlated well with the pain and stage of NONFH.The condition of BME can be used as a index for the appraisal of advancement of disease and the judgment of treatment result.