【作者】 张俊；

【导师】 李康华； 胡建中；

【作者基本信息】 中南大学 ， 外科学， 2009， 博士

【摘要】 前交叉韧带(anterior curciate ligament,ACL)损伤是临床上的常见运动损伤,严重影响膝关节稳定性。是继发膝关节软骨退变的原因之一。然而,ACL损伤是否对髌骨也产生影响,目前尚未见文献报道。本研究采用生物力学测定的方法,观察ACL完全断裂和部分断裂对髌骨上、下极,髌骨内、外侧应变的影响;并用组织学方法,观察ACL完全断裂后髌骨组织病理改变,同时检测IL-1β及MMP-13的表达,以了解其继发髌骨病变中的作用机制,为ACL损伤是否对髌骨产生影响提供理论依据。第一章前交叉韧带功能性分束的生物力学研究目的探讨前交叉韧带功能性分束为后续研究奠定基础。方法6具新鲜成人正常膝关节标本,取ACL胫骨止点前方两侧、股骨止点后方两侧作为应变测量点,分别对应:前内侧区纤维束(前内侧束)、前外侧区纤维束(前外侧束)、后内侧区纤维束(后内侧束)、后外侧区纤维束(后外侧束)。在800N轴向载荷下,测试膝关节0°、30°、60°、90°状态下ACL各纤维束应变,采用样本聚类方法进行功能性分束。结果1、膝关节0°位,ACL后外侧束、前外侧束应变均大于后内侧束、前内侧束应变,均有显著性差异,均P＜0.05;后外侧束与前外侧束应变无显著性差异,P＞0.05;后内侧束与前内侧束应变无显著性差异,P＞0.05。30°位和90°位,ACL后内侧束、前内侧束应变均大于后外侧束、前外侧束应变,均有显著性差异,均P＜0.05;后内侧束与前内侧束应变无显著性差异,P＞0.05;后外侧束与前外侧束应变无显著性差异,P＞0.05。60°位,应变大小依次为:后内侧束、前内侧束、后外侧束、前外侧束,束间应变比较均有显著性差异,均P＜0.05。2、前内侧束与后内侧束应变变化一致,依序0°、30°、60°、90°逐渐增大,均有显著性差异,均P＜0.05;前外侧束应变在膝0°、30°、60°、90°均无显著性差异,均P＞0.05。后外侧束应变在膝关节60°位大于0°、30°、90°,均有显著性差异,均P＜0.05;0°与90°应变无显著性差异,P＞0.05;0°、90°应变均大于30°,差异均有显著性,均P＜0.05。3、聚类分析:后外侧束与前外侧束归为一类,后内侧束与前内侧束归为一类。结论ACL后外侧区纤维束和前外侧区纤维束应变在膝0°位大于后内侧区纤维束和前内侧区纤维束,30°、60°、90°小于后内侧区纤维束和前内侧区纤维束应变,说明后外侧区纤维束和前外侧区纤维束主要维持膝关节伸直稳定性,后内侧区纤维束和前内侧区纤维束主要维持膝关节屈曲稳定性,结合聚类结果,可将ACL分为前内、后外两功能性纤维束。第二章前交叉韧带断裂对髌骨生物力学影响的实验研究目的探讨ACL完全断裂和部分断裂对髌骨的生物力学影响。方法新鲜成人尸体膝关节标本10具,依ACL完整(10具)、AMB切断(5具)、PLB切断(5具)和ACL完全切断(10具)分别在膝关节0°、30°、60°、90°位轴向加载200～800N,测量髌骨上、下极,髌骨内、外侧关节面的应变并对数据进行统计分析。结果1.ACL完整组:①膝关节0°位,髌骨上下极、髌骨内外侧应变值均为最小,均无统计学差异,P＞0.05。②膝关节屈曲30°位时,髌骨下极为压应变,髌骨上极为拉应变,应变绝对值随载荷增加而增加;60°位时,髌骨上、下极均为拉应变,90°位时,髌骨上极为压应变,髌骨下极为拉应变,应变绝对值随载荷增加而增加;各角度间应变均有统计学差异,P＜0.05。③30°、60°、90°位时,髌骨内、外侧均为压应变,应变绝对值随载荷增加而增加,各角度间应变值均有统计学差异,P＜0.05,髌骨内侧与外侧应变值间无统计学差异,P＞0.05。2.AMB切断组:①膝关节0°位,髌骨上下极、髌骨内外侧应变值均为最小,均无统计学差异,P＞0.05。②膝关节屈曲30°位时,髌骨上极下极为均压应变,髌骨上极应变绝对值随载荷增加而增加,髌骨下极应变绝对值随载荷增加而减小;60°位时,髌骨上极为压应变,髌骨下极为拉应变,应变绝对值均随载荷增加而增加。90°位时,髌骨上极为压应变,髌骨下极为拉应变,应变绝对值随载荷增加而增加;各角度间应变均有统计学差异,P＜0.05。③30°、60°、90°位时,髌骨内、外侧均为压应变,应变绝对值随载荷增加而减小,各角度间应变值均有统计学差异,P＜0.05,髌骨内侧与外侧应变值间有统计学差异,P＜0.05。3.PLB切断组:①膝关节0°位,髌骨上下极、髌骨内外侧应变值均为最小,均无统计学差异,P＞0.05。②膝关节屈曲30°位时,髌骨上极为拉应变,下极为压应变,髌骨上、下极应变绝对值随载荷增加而增加,髌骨下极应变绝对值随载荷增加先增加后减小;60°位时,髌骨上极为压应变,髌骨下极为拉应变,应变绝对值均随载荷增加而增加。90°位时,髌骨上极为压应变,髌骨下极为拉应变,应变绝对值随载荷增加而增加;各角度间应变均有统计学差异,P＜0.05。③30°、60°、90°位时,髌骨内、外侧均为压应变,30°时应变绝对值随载荷增加先增加后减小,60°、90°时应变绝对值随载荷增加而减小,各角度间应变值均有统计学差异,P＜0.05。髌骨内侧与外侧应变值间有统计学差异,P＜0.05。4.ACL切断组:①膝关节0°位,髌骨上下极、髌骨内外侧应变值均为最小,均无统计学差异,P＞0.05。②膝关节屈曲30°、60°、90°位时,髌骨下极为拉应变,髌骨上极为压应变,应变绝对值随载荷增加而增加;各角度间应变均有统计学差异,P＜0.05。③30°、60°、90°位时,髌骨内、外侧均为压应变,应变绝对值随载荷增加而减小,各角度间应变值均有统计学差异,P＜0.05,髌骨内侧与外侧应变值间有统计学差异,P＜0.05。结论1、ACL完全切断,在不同载荷和角度下,对髌骨各部的应变均有影响。2、AMB切断在膝关节屈曲30°、60°、90°位各载荷下可引起髌骨各部生物力学改变。3、PLB切断在膝关节0°位及30°200N、400N载荷下对髌骨各部应变无影响。4、ACL完全断裂,髌骨外侧应变高于髌骨内侧应变,其意义尚需进一步探讨。第三章前交叉韧带断裂对髌骨软骨组织学的影响目的通过观察兔膝关节ACL断裂后髌骨软骨组织结构的变化及IL-1β、MMP-13的表达,了解前交叉韧带断裂对髌骨组织学的影响。方法48只雄性家兔随机分为四组,实验侧行后腿单侧ACL切断,自身对照。造模后于第1、3、6、8周各随机处死12只。观察各时间点髌骨软骨组织结构HE染色与IL-1β、MMP-13表达的变化。结果1.大体观察:随着ACL断裂时间的推移,髌骨软骨逐渐出现色泽改变、光泽减退、表面磨损甚至软骨表面的溃疡。2.HE染色:自第三周开始出现软骨表面及软骨细胞排列的异常。Mankin评分实验组随时间推移而增高,各实验组间比较均有显著性差异,均P＜0.01;第1周实验组与对照组比较无显著性差异,P＞0.05,其他各实验组均大于对照组,差异均具有显著性,均P＜0.01。3.IL-1β表达情况:第1、3、6、8周实验组均高于正常对照组,均有显著性差异,均P＜0.05。实验组第1周低于3、6、8周,均有显著性差异,均P＜0.05;第6周表达高于第3、8周,均有显著性差异,均P＜0.01;第8周表达高于第3周,有显著性差异,P＜0.01。正常对照组各周间比较均无显著性差异,均P＞0.05。4.MMP-13表达情况:第1、3、6、8周实验组均高于正常对照组,均有显著性差异,均P＜0.01。实验组第1周低于第3、6、8周,均有显著性差异,均P＜0.01;第6周表达高于第3、8周,均有显著性差异,均P＜0.01;第8周表达与第3周比较无显著性差异,P＞0.05。正常对照组各周间比较均无显著性差异,均P＞0.05。结论1、证实ACL断裂可引起髌骨软骨退变。2、ACL断裂后IL-1β、MMP-13表达增高提示IL-1β、MMP-13可能参与了ACL断裂后髌骨软骨的退变过程。更多还原

【Abstract】 The injuries of Anterior Curciate Ligament are very common in sport injuries.The injuries mainly effect the stabilization of knee joint,it also is the reason of the degeneration of cartilage in knee joint after ACL injury.However,the ACL injury did effect the patella or not is unknown, there is few literature report it too.This research intend to use biomechanic method observe the biomechanic change of patella after ACL complete rupture or incomplete rupture,further more,use histological methods to observe the pathological change of patella after ACL complete rupture,detect the expression of IL-1β、MMP-13. Through the reaserch to investigate the effect mechanism of pathological changes in patella after ACL rupture,provide the theory evidence of pathological changes in patella after ACL rupture.Chapter1 The biomechanical study of ACL bundles’ functional classificationObjective:To investigate the biomechanical function of the ACL bundles for subsequent research.Methods:6 fresh cadaveric knees from adult human beings were used. Selected the bilateral anterior part of the ACL tibial insertion and the bilateral posterior part of the ACL femoral insertion as the measure parts correspond to:anteromedial area fiber bundle(anteromedial bundle)、anterolateral area fiber bundle(anterolateral bundle)、posteromedial area bundle(posteromedial bundle) and posterolateral area bundle (posterolateral bundle).The strain on the ACL bundles was measured when the knees were applied with 800N axial loading force in 0°、30°、60°、90°positions.The bundles were functional classified by cluster analysis.Results:1.In 0°position,the strain on the posterolateral and anterolateral bundles was significantly larger than the posteromedial and anteromedial bundles(P＜0.05),There were no significant diference between the posterolateral and anterolateral bundles(P＞0.05) and so did the posteromedial and anteromedial bundles(P＞0.05);In 30°and 90°position,the strain on the posteromedial and anteromedial bundles was significantly larger than the posterolateral and anterolateral bundles (P＜0.05),There were no significant difference between the posteromedial and anteromedial bundles(P＞0.05) and so did the posterolateral and anterolateral bundles(P＞0.05);In 60°position,the strain on the posteromedial bundle was the largest,and then the anteromedial、posterolateral、anterolateral bundle,the differences among bundles were all significant(P＜0.05).2.The strain on the posteromedial and anteromedial bundles was increased by degrees when the knee flexed 0°、30°、60°、90°,and all the difference were significant (P＜0.01);There were no significant changes of the strain on the anterolateral bundle among different angles(P＞0.05).The strain on the posterolateral bundle in 60°position was larger than 0°、30°、90°positions,the differences were significant(P＜0.05);The strain in 30°position was significantly smaller than 0°and 90°positions (P＜0.05),but the difference of strain between 0°and 90°positions was not significant(P＞0.05).3.Cluster analysis classfied the anteromedial bundle and the posteromedial bundle as one class and the anterolateral and posterolateral bundles as the other class.Conclusion:Compared with the posteromedial area and anteromedial area fiber bundles,the strain on the posterolateral area and anterolateral area fiber bundles was significantly larger in 0°position and smaller in 30°、60°、90°positions,means the posterolateral area and anterolateral area fiber bundles mainly maintain stability of the knee in extended positions,the posteromedial area and anteromedial area fiber bundles mainly maintain stability of the knee in flexed positions.Combined with the cluster analysis results,ACL may be classified into the anteromedial functional fiber bundle and the posterolateral functional fiber bundle. Chapter 2 The biomechanical influence of ACL rupture on the patellaObjective:To investigate the biomechanical influences of partial and total ACL rupture on the patella.Methods:10 fresh cadaveric knees from adult human beings were divided into ACL intact group(10 samples)、AMB broken group(5 samples)、PLB broken group(5 samples)and ACL total broken group(10 samples).The knees were applied with 200N～800N axial loading force when they flexed 0°、30°、60°、90°.The strain on the patella was measured and analysed.Results:1.In ACL intact group:①In 0°position,the strain of all 4 test place of patellar were the smallest,and the differences among the parts were not significant(P＞0.05).②In 30°positions,the inferior of patellar was compressive strain,the superior of patellar was tensile strain,the absolute value of strain was increased with the load increased.In 60°positions,the strain of inferior and superior of patellar were tensile strain, the absolute value of strain was increased with the load increased.In 90°positions,the superior of patellar was compressive strain,the inferior of patellar was tensile strain,the absolute value of strain was increased with the load increased.The differences among the parts were all significant(P＜0.05).③In 30°、60°、90°positions,the medial and lateral of patellar were compressive strain,the absolute value of strain was increased with the load increased.The differences among the parts were all significant(P＜0.05).There were no significant differences among the medial and lateral of patellar(P＞0.05).2.In AMB broken group:①In 0°position,the strain of all 4 test place of patellar were the smallest,and the differences among the parts were not significant(P＞0.05).②In 30°positions,the strain of inferior and superior of patellar were compressive strain,the absolute value of strain on the superior of patellar was increased with the load increased.The absolute value of strain on the inferior of patellar was decreased with the load increased.In 60°positions,the superior of patellar was compressive strain,the inferior of patellar was tensile strain,and the absolute value of strain was increased with the load increased.In 90°positions,the superior of patellar was compressive strain,the inferior of patellar was tensile strain,and the absolute value of strain was increased with the load increased.The differences among the parts were all significant(P＜0.05).③In 30°、60°、90°positions,the medial and lateral of patellar were compressive strain,the absolute value of strain was decreased with the load increased. The differences among the parts were all significant(P＜0.05).There were significant differences among the medial and lateral of patellar (P＜0.05).3.In PLB broken group:①In 0°position,the strain of all 4 test place of patellar were the smallest,and the differences among the parts were not significant(P＞0.05).②In 30°positions,the strain of superior of patellar were tensile strain,the inferior of patellar was compressive strain,the absolute value of strain on the superior of patellar was increased with the load increased.The absolute value of strain on the inferior of patellar was increased in first,and then decreased with the load increased.In 60°positions,the superior of patellar was compressive strain,the inferior of patellar was tensile strain, the absolute value of strain was increased with the load increased.In 90°positions,the superior of patellar was compressive strain,the inferior of patellar was tensile strain,and the absolute value of strain was increased with the load increased.The differences among the parts were all significant(P＜0.05).③In 30°、60°、90°positions,the medial and lateral of patellar were compressive strain,In 30°positions,the absolute value of strain was increased in first,then decreased with the load increased. In 60°、90°positions,the absolute value of strain was decreased with the load increased.The differences among the parts were all significant (P＜0.05).There were significant differences among the medial and lateral of patellar(P＜0.05).4.In ACL total broken group:①In 0°position,the strain of all 4 test place of patellar were the smallest,and the differences among the parts were not significant(P＞0.05).②In 30°、60°、90°positions,the inferior of patellar was tensile strain,the superior of patellar was compressive strain,the absolute value of strain was increased with the load increased.The differences among the parts were all significant(P＜0.05).③In 30°、60°、90°positions,the medial and lateral of patellar were compressive strain,the absolute value of strain was decreased with the load increased.The differences among the parts were all significant(P＜0.05).There were significant differences among the medial and lateral of patellar(P＜0.05).Conclusion:1.ACL total rupture may cause abnormal load on the patellar in all the positions.2.AMB rupture may cause abnormal load on the patellar in 30°、60°、90°positions.3.PLB rupture not cause abnormal biomechanical change on patella in 0°position and 200N、400N loaded in 30°position.4.ACL total rupture can cause the strain of lateral of patellar was larger than medial of patellar,which need to be further explored. Chapter 3 The histological influence of ACL rupture on the patellar cartilageObjective:To investigate the tissue construction changes and IL-1、MMP-13 express in the patellar cartilage,to further explore the influence of ACL rupture on the patellar cartilage.Methods:48 male rabbits were randomly divided into four groups,and all were under one side posterior leg ACL cut and the opposite side as the control.HE staining and immunohistochemical methods were used. Tissue construction and IL-1β、MMP-13 expression changes of the lateral tibial plateau cartilage were observed 1、3、6、8 weeks later.Results:1.Gross observation:As the time lasted,the patellar cartilage had the color changed、the gloss decreased、the surface abrased and even had ulcer on the cartilage.2.Routine HE staining:There are abnormal cartilage surface and cell disposition after 3 weeks.The Mankin scores in experimental groups increased as the time lasted,the differences among the groups were all significant(P＜0.01);there was no significant difference between 1-week group and control group(P＞0.05),the Mankin scores in the other experimental groups were significantly higher than that in control group(P＜0.01).3.IL-1βexpression:All the experimental groups had higher IL-1βexpression than that in control groups(P＜0.01).In experimental groups,IL-1βexpressed significantly lower in 1-week group than that in 3、6、8-week groups(p＜0.05);In 6-week group,IL-1βexpressed higher than that in 3-week group and 8-week group(P＜0.01).IL-1βexpressed higher in 8-week group than that in 3-week group(P＜0.01).There were no signifigant differences among the control groups(P＞0.05).4.MMP-13 expression:All the experimental groups had higher IL-1βexpression than that in control groups(P＜0.01).In experimental groups,MMP-13 expressed significantly lower in 1-week group than that in 3、6、8-week groups (p＜0.01);In 6-week group,MMP-13 expressed higher than that in 3-week group and 8-week group(P＜0.01).There was no significant difference between 3-week group and 8-week group(P＞0.05).There were no signifigant differences among the control groups(P＞0.05).Conclusion:1.The reaserch confirmed ACL rupture may cause cartilage degeneration on the patellar cartilage.2.The increased IL-1βand MMP-13 expression suggest that IL-1β、MMP-13 may participate in cartilage degeneration on the patellar after ACL rupture.更多还原