【作者】 周锦颢；

【导师】 李康华； 雷光华；

【作者基本信息】 中南大学 ， 骨科学， 2009， 博士

【摘要】 前交叉韧带(anterior cruciate ligament,ACL)是维护膝关节稳定的重要结构,具有限制胫骨前移和旋转的作用。ACL损伤常继发关节软骨和半月板的损伤,后期可导致膝关节退变。目前对ACL的研究多集中在ACL完全断裂后对关节软骨退变的影响以及ACL功能的重建,而ACL损伤后对股骨外髁生物力学和组织学影响的研究鲜有报道。本研究采用生物力学测定的方法,观察ACL完全断裂或部分断裂对股骨外髁前部、中部及后部应变的影响,采用组织学方法,观察ACL完全断裂后股骨外髁组织学改变,同时,检测IL-1β、MMP13的表达,以了解其在股骨外髁软骨退变中的作用机制,为ACL损伤继发股骨外髁损伤提供理论依据。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的功能性分束,为ACL损伤重建提供理论依据。方法新鲜正常成人膝关节标本6具,根据ACL在膝关节中的位置将ACL分为: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)。在膝关节标本上施加800N轴向载荷,分别测试膝关节0°、30°、60°、90°位ACL各纤维束应变。比较各束应变的差异,采用聚类分析方法进行分类。结果1.膝关节0°位,ACL后外侧束和前外侧束应变大于后内侧束和前内侧束应变,有显著性差异,P＜0.01;前内侧束与后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;膝关节30°、90°位,ACL前内侧束和后内侧束应变大于后外侧束和前外侧束应变,有显著性差异,P＜0.05;前内侧束与后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;膝关节60°位,ACL后内侧束应变最大,其后依次为前内侧束、后外侧束和前外侧束,各束间比较均具有显著性差异,均P＜0.05。2、前内侧束与后内侧束应变变化一致,依序膝关节0°、30°、60°、90°位逐渐增大,均有显著性差异,均p＜0.05;前外侧束应变在膝关节0°、30°、60°、90°均无显著性差异,均p＞0.05。后外侧束应变膝60°位大于0°、30°、90°位,均有显著性差异,均p＜0.05;0°位与90°位应变无显著性差异,均p＞0.05;0°、90°应变均大于30°,均有显著性差异,均p＜0.05。3、聚类分析:后外侧束与前外侧束聚为一类,后内侧束与前内侧束聚为一类。结论随膝关节不同屈伸角度ACL内部各纤维束张力不等,且在膝关节0°—90°屈伸过程中ACL始终处于有张力状态。膝关节0°位,后外侧区纤维束和前外侧区纤维束应变大于后内侧区纤维束和前内侧区纤维束,膝关节30°、60°、90°位,后内侧区纤维束和前内侧区纤维束应变大于后外侧区纤维束和前外侧区纤维束应变,提示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。ACL可分为内侧束和外侧束两功能束,根据两束在ACL胫骨止点一前一后的解剖特点,两束分别定义为前内侧束和后外侧束。第二章前交叉韧带断裂对股骨外髁生物力学特性的影响目的探讨ACL断裂对股骨外髁生物力学的影响,为ACL断裂继发股骨外髁损伤的早期诊治提供理论依据。方法新鲜正常成人膝关节标本10具作为ACL完整组,在200N、400N、600N、800N载荷下,测试膝关节0°、30°、60°、90°位股骨外髁应变,测试完毕后随机将标本造模成前内侧束(AMB)切断组和后外侧束(PLB)切断组,各5具,在上述条件下测试应变,最后再将10具标本的ACL完全切断(全断组)进行测试。结果1.膝关节0°位,200N和400N载荷下,股骨外髁前部、中部、后部的应变在PLB切断组与ACL全断组、ACL完整组与AMB切断组之间均无显著性差异,均P＞0.05;600N、800N载荷下,股骨外髁前部、后部的应变在各实验组间均有显著性差异,均P＜0.05,股骨外髁前部应变值表现为全断组＞PLB切断组＞AMB切断组＞完整组,股骨外髁后部应变值表现为完整组＞AMB切断组＞PLB切断组＞全断组;600N、800N载荷下,股骨外髁中部应变在各实验组间无显著性差异,均P＞0.05,应变值表现为全断组＞PLB切断组＞AMB切断组＞完整组。2.膝关节30°位,200N和400N载荷下,股骨外髁前部、中部、后部的应变在ACL完整组与PLB切断组、AMB切断组与ACL全断组之间无显著性差异,均P＞0.05;600N、800N载荷下各实验组间均有显著性差异,均P＜0.05,相同载荷下应变值表现为全断组＞AMB切断组＞PLB切断组＞完整组。3.膝关节60°位,200N和400N、600N、800N载荷下,股骨外髁前部、中部、后部的应变各实验组间均有显著性差异,均P＜0.05;相同载荷下应变值表现为全断组＞AMB切断组＞PLB切断组＞完整组。4.膝关节90°位,在200N、400N、600N、800N载荷下,股骨外髁前部、中部、后部的应变各实验组间均有显著差异,均P＜0.05;股骨外髁前部应变均表现为完整组＞PLB切断组＞AMB切断组＞全断组,股骨外髁中部、后部应变均表现为全断组＞AMB切断组＞PLB切断组＞完整组。结论1、ACL完全断裂对股骨外髁前部、中部和后部的应变均有影响;2、膝关节0°位,PLB断裂对股骨外髁前部、后部的应变均有影响;3、膝关节30°、60°、90°位,AMB断裂对股骨外髁前部、中部、后部的应变均有影响。第三章前交叉韧带断裂后股骨外髁退变的组织学研究目的探讨ACL断裂对股骨外髁组织学的影响。方法48只家兔后侧膝关节配对为实验侧和对照侧,实验侧行ACL切断造模,造模后分别在第1、3、6、8周随机处死12只,行股骨外髁大体观察,并进行HE染色,免疫组化检测IL-1β、MMP13表达。结果1.大体观察:随时间延长,实验组股骨外髁软骨出现色泽改变,呈灰黄色,软骨表面光泽减退,不平整,有磨损甚至溃疡。2.组织学观察:从第三周开始出现软骨表面及软骨细胞排列异常,Mankin评分实验组随时间推移而增大;第一周实验组与对照组无显著性差异,P＞0.05,第3、6、8周实验组大于对照组,有显著性差异,均P＜0.01。3.IL-1β表达:实验组第3周、第6周均高于第1周和第8周,均有显著性差异,均P＜0.05;实验组第8周高于第1周,有显著性差异,P＜0.05;实验组第3周和第6周无显著性差异,P＞0.05;实验组第1,3,6,8周IL-1β表达均高于相应时间点的对照组,均有显著性差异,均P＜0.05。4.MMP13表达:实验组第3周、第6周高于第1周、第8周,均有显著性差异,均P＜0.05;实验组第8周高于第1周,有显著性差异,P＜0.05:第3周和第6周无显著性差异,P＞0.05;实验组第1,3,6,8周MMP13表达均高于相应时间点的对照组,均有显著性差异,均P＜0.05。结论1、ACL断裂可引起股骨外髁软骨组织退变;2、IL-1β、MMP-13在ACL断裂股骨外髁退变中的表达呈先增高后降低的变化规律;3、IL-1β、MMP13表达增高提示IL-1β、MMP13可能是ACL断裂继发股骨外髁退变的因素之一。更多还原

【Abstract】 The anterior cruciate ligament（ACL） is a stable structure whose main role is controlling the antedisplacement of tibial and regulating the rotation of tibial.ACL deficiency always results in the secondary injuries of articular cartilage and meniscus,followed by the severe degeneration of the knee joint in the end.For the sake of preventing the development of osteoarthrosis and the injury of femoral lateral condyle,it is important to understand the histological and biomechanics mechanism of the effect on femoral lateral condyle,which directly relates to the early diagnosis, clinical decision and appraisement of ACL injury.At present,the researching about the effect of ACL injury mostly concentrates on the degeneration of articular cartilage and reconstruction of ACL after complete rupture of ACL,and few on the effect on biomechanics and histology of lateral condyle.In this study,straining changes of the anterior part,middle part and posterior part on the lateral condyle caused by ACL injury were analyzed by way of biomechanics approach,as well as histological evaluation of cartilage in femoral lateral condyle and expression of IL-1βand MMP13 in cartilage,which provides theoretical evidence for the formation of the secondary injury of the femoral lateral condyle following the ACL injury. Chapter 1 The biomechanical study of ACL bundles’ functional classificationObjective:To investigate the functional bundle division of the ACL, to provide the theoretical evidence for ACL reconstruction.Method:In this experiment the specimens were 6 normal knee joints of adult male.The bilateral areas in front of the ACL tibial insertion and the bilateral areas at the back of the ACL femoral insertion were chosen as the four straingauge point,which correspond to anteromedial bundle, anterolateral bundle,posteromedial bundle and posterolateral bundle respectively.The strain of each bundle under the load of 800N were measured when the knee joint position at 0°、30°、60°、90°angle respectively,followed by the cluster analysis to explore the functional division of the ACL.Results:1.①When the knee located at 0°,the strain of ACL anterolateral bundle and posterolateral bundle were bigger than anteromedial and posteromedial bundle,p＜0.01.However,there were no significant difference between the anterolateral bundle and posterolateral bundle,as well the anteromedial and posteromedial bundle,p＞0.05.②When the knee located at both 30°and 90°,the strain of ACL anteromedial bundle and posteromedial bundle were bigger than anterolateral and posterolateral bundle,p＜0.05.However,there were no significant difference between the anterolateral bundle and posterolateral bundle,as well the anteromedial and posteromedial bundle,p＞0.05.③When the knee located at 60°,the strain of each bundle were ordered from maximum to minimum as follows:posteromedial bundle, anteromedial bundle,posterolateral bundle and anterolateral bundle. There were significant difference among the four bundles,p＜0.05.2.①The strain of the anteromedial bundle coincided with the strain of the posteromedial bundle.Ranking from maximum to minimum,the strain of these two bundles at different knee positions were 90°,60°, 30°,0°.There were significant difference among the four bundles, p＜0.05.②For the strain of the anterolateral bundle,there were no significant difference at the knee positions,p＞0.05.③The strain of the posterolateral bundle reached its peak at the position angle at 60°, p＜0.05;its bottom at the position of 30°,p＜0.05;position angle at 0°and 90°respectively,for the strain of the posterolateral bundle,both of them were moderate and there was no significant difference between them,p＞0.05.3.Cluster analysis:The anteromedial bundle and the posteromedial bundle can be regarded as the same kind of bunch by way of cluster analysis.And so do the anterolateral bundle and the posterolateral bundle.Conclusion:When the knee at the position angle at 0°,the strain of the anterolateral bundle and the posterolateral bundle were bigger than the medial ones.However,when the knee at the other bended positions, the strain of the anteromedial bundle and the posteromedial bundle were bigger the lateral ones.Therefore,we could draw a conclusion that the lateral bundles maintain the stability mainly when the knee straightens and the medial ones mainly keep the stable when the knee flexes. Combined with the cluster analysis,the ACL can be regarded as two functional bundles:the anteromedial bundle and the posterolateral bundle. Chapter 2 The biomechanical influence of ACL ruptures on the femoral lateral condyleObjective:To investigate the biomechanical influences of ACL rupture on the femoral lateral condyle and provide theoretic evidence for early ACL repair.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（5samples） 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 femoral lateral condyle was measured in different loading force along with the position angles.Result:1.In 0°position,under the load of 200N and 400N,for the straining of the anterior part,middle part and posterior part on the femoral lateral condyle,there were no significant difference between PLB rupture group and ACL complete rupture group,as well as complete ACL group and AMB rupture group,P＞0.05;under the loads of 600N and 800N,there was significant difference between the anterior part and posterior part on the femoral lateral condyle,P＜0.05,while the straining of middle part on the femoral lateral condyle showed no significant difference among all the groups under the loads of 600N and 800N,P＞0.05;under the same load and angle of flexion,the correlation of the absolute value of straining in every group of the anterior part and middle part on the femoral lateral condyle increased as follows:ACL complete rupture group＞PLB rupture group＞AMB rupture group＞ complete ACL group.But the posterior part on the femoral lateral condyle increased as follows:complete ACL group＞AMB rupture group＞PLB rupture group＞ACL complete rupture group.2.In 30°position,under the load of 200N and 400N,for the straining of the anterior part,middle part and posterior part on the femoral femoral lateral condyle,there were no significant difference between AMB rupture group and ACL complete rupture group,as well as complete ACL group and PLB rupture group,P＞0.05;under the load of 600N and 800N,there were significant differences among the four groups.Under the same load and angle of flexion,the correlation of the value of straining in each group increased as the follows:ACL complete rupture group＞AMB rupture group＞PLB rupture group＞complete ACL group.3.In 60°position,under the load of 200N and 400N and 600N and 800N,for the straining of the anterior part and middle part and posterior part on the femoral lateral condyle,there were significant difference among four groups,P＜0.05;under the same load and angle of flexion, the correlation of the value of straining in each group increased as the follows:ACL complete rupture group＞AMB rupture group＞PLB rupture group＞complete ACL group.4.In 90°position,under the load of 200N and 400N and 600N and 800N,for the straining of the anterior part and middle part and posterior part on the femoral lateral condyle,there were significant difference among four groups,P＜0.05.under the same load and angle of flexion, the correlation of the value of straining in each group of the anterior part on the femoral lateral condyle increased as follows:ACL complete group＞PLB rupture group＞AMB rupture group＞complete rupture group. while each group of middle part and posterior part on the femoral lateral condyle increased as follows:ACL complete rupture group＞AMB rupture group＞PLB rupture group＞complete ACL group.Conclusion:ACL total rupture may cause abnormal straining on the femoral lateral condyle.The AMB rupture showed the various straining of the anterior part,middle part and posterior part on the femoral lateral condyle at 30°and 60°and 90°of flexion.The PLB rupture showed the various straining of the anterior part and posterior part on the femoral lateral condyle at 0°of flexion. Chapter 3 Study on the histological influence of ACL rupture on the femoral lateral condyleObjective:To explore the histological variety of femoral lateral condyle followed by rupture of ACL.Method:Lateral meniscus of 48 rabbits were matched as experiment side and control side,ACL rupture used for experiment side.At the 1st, 3rd,6th and 8th week,12 rabbits were executed randomly,followed by naked-eye observation of lateral meniscus and by way of HE staining,as well immunohistochemistry staining to detect the expression of IL-1βand MMP13.Result:1.Gross observation:with longer time,the lateral condyle cartilage had the color changed、the gloss decreased、the surface abrased and even had different depth ulcer on the cartilage.2.Histological observation:3^rd week late,in the experiment side, fibrous degeneration of cartilage surface layer occurred,along with middle layer rupture,chaotic arrangement of chondrocyte,irregular tidal line with blood capillary and more clustered chondrocytes.For the Mankin scores,there was significant difference between the experiment side and control side,P＜0.05.3.In experiment side,IL-1βexpressed significantly higher in 3^rd week,6^th week than that in 1^st week,8^th week respectively,p＜0.05,in which IL-1βexpressed higher in 8^th week than that in 1^st week,P＜0.05; there was no significant difference between 3^rd week and 6^th week.While compared to control side,in 1^st,3^rd,6^th and 8^th week respectively,there were more higher IL-1βexpression respectively,P＜0.05. 4.In experiment side,MMP-13 expressed significantly higher in 3^rd week,6^th week than that in 1^st week,8^th week respectively,p＜0.05,in which MMP-13 expressed higher in 8^th week than that in 1^st week, P＜0.05;there was no significant difference between 3^rd week and 6^th week.While compared to control side,in 1^st,3^rd,6^th and 8^th week respectively,there were more higher MMP-13 expression respectively, P＜0.05.Conclusion:ACL rupture may cause cartilage degeneration on the femoral lateral condyle.A regularity of expression of IL-1βand MMP13 show the increasing expression in primal stage and decreasing in late stage after ACL rupture.The increased IL-1βand MMP-13 expression suggest that IL-1β、MMP-13 may participate in cartilage degeneration on the femoral lateral condyle after ACL rupture.更多还原