【作者】 何锐；

【导师】 杨柳；

【作者基本信息】 第三军医大学 ， 外科学， 2008， 硕士

【摘要】 膝关节髌内侧滑膜皱襞(Medial Plica,MP)是膝关节腔内的正常的滑膜结构,来源于胚胎时期间叶组织,在胚胎发育期间吸收不完全形成。[1]MP是存在于膝关节中的正常结构,同时又可能由于异常增生、损伤等原因形成病理性髌内侧滑膜皱襞。[2,3]众多学者对于病理性和生理性的髌内侧滑膜皱襞的界定尚存争议。在髌内侧滑膜皱襞的病理学研究中发现病变滑膜皱襞的主要病理变化是慢性机械性磨损和纤维化,滑膜组织的肥大,炎症细胞的浸润,血管壁的增厚等表现镜检发现较少。[1]。这些病理学征象并非为特征性的。Richmond、McGinty报道镜检正常的患者中40%切除髌内侧滑模皱襞后症状缓解,同时临床症状明显的髌内侧滑膜皱襞综合征(mediopatellar plica syndrome,MPS)患者切除髌内侧滑膜皱襞之后手术效果良好的患者中,病检出现纤维化表现的占15-66%,炎症表现占33%[4-6]。因此,膝关节髌内侧滑膜皱襞中病理学结构需要进一步的研究以揭示生理和病理性皱襞之间的真正差异。膝关节髌内侧滑膜皱襞综合征是导致髌股关节疼痛(Patellofemoral Pain,PFP)的重要病因[7,8]。存在于髌股关节(Patellofemoral Joint,PFJ)复杂生物力学机制中的滑膜皱襞的解剖结构和生理机能目前尚缺乏进一步的研究。既往研究认为MPS导致髌股关节疼痛的病因通常是由于MP反复摩擦导致膝关节内的软骨损伤。[9]在临床中我们发现,即使在没有明显软骨缺损的情况下,部分MPS患者仍然存在膝前疼痛等表现。薄的滑膜皱襞同样能够导致症状的产生;宽的、紧张的、厚的滑膜皱襞可能无明显症状。有研究发现:膝关节滑膜中神经分布的上升和神经肽的作用是导致疼痛产生重要的物质基础。[10]因此我们推测在髌内侧滑膜皱襞外观和症状之间没有直接的联系,病因存在于髌内侧滑膜皱襞神经解剖结构之中,需要对髌内侧滑膜皱襞病理结构进行更加深入的探讨。针对上述问题,本研究运用膝关节镜技术和免疫组化染色技术研究滑膜皱襞病理组织中神经解剖结构变化。通过膝关节镜获取髌内侧滑膜皱襞标本,观察蛋白基因产物9.5(protein gene product,PGP9.5)、P物质(substance P,SP)在膝关节髌内侧滑膜皱襞中的分布,观察在滑膜皱襞中神经解剖结构的分布规律、变化趋势,并通过半定量分析比较空白对照组、阳性对照组、实验组3组患者髌内侧滑膜皱襞中神经纤维密度的差异性,试证实髌内侧滑膜皱襞中神经纤维分布增多、与痛觉产生和传导密切相关的P物质表达增多是导致髌股关节疼痛的重要物质结构基础。目的:通过免疫组化染色,采用半定量方法统计神经纤维的数量,观察研究膝关节MPS患者滑膜皱襞病理组织中神经解剖结构的变化趋势,分布规律;研究与痛觉产生和传导相关的神经纤维与膝前疼痛之间的相关关系。主要内容:①膝关节镜下采集2007年5月至2007年7月20例膝关节MPS患者的髌内侧滑膜皱襞进行PGP9.5、SP染色分析,采用酶标链霉亲和素-生物素方法(Labelled streptavidin-biotin,LsAB)和免疫荧光法显色技术,在双盲原则下半定量分析神经纤维分布区域密度、分布规律,为大样本的临床滑膜皱襞样本标准化取样提供理论指导。②按照标准化取样方法、随机双盲原则,膝关节镜下采集无髌股关节疼痛空白组、实验组和阳性对照组、3组共51例患者的髌内侧滑膜皱襞和髌上滑膜皱襞标本,详细纪录患者术前体格检查和疼痛部位与程度,术前进行视觉类比标度疼痛评分(Visual analog scale,VAS),冰冻切片后行PGP9.5、SP免疫荧光染色并行半定量分析,计算神经纤维分布密度;③对数据进行统计,分析在髌上、髌内侧滑膜皱襞中PGP9.5、SP表达的差异;空白组、实验组、阳性对照组组间髌内侧滑膜皱襞PGP9.5、SP表达的差异;对患者VAS膝关节疼痛评分与髌内侧滑膜皱襞PGP9.5、SP神经分布密度进行相关性分析,探讨髌内侧滑膜皱襞中神经解剖结构与疼痛之间的相互关系。研究结果:1、膝关节髌内侧滑膜皱襞中存在神经纤维的分布,病理性的髌内滑膜皱襞中,神经结构主要呈游离神经纤维、神经纤维束、血管周围神经网络三种主要的形态存在。走行与血管相伴,主要分布于血管周围区域。2、髌内侧滑膜皱襞中神经纤维分布区域以皱襞基底部为主,分布在基底部的神经纤维数明显高于游离缘区域;在游离缘区域的边缘,结缔组织中血管成分减少,伴行神经纤维减少。从解剖结构和生物力学的角度上考虑,髌内侧滑膜皱襞基底部区域是产生疼痛的高危区域。3、髌内侧滑膜皱襞综合征患者髌内侧滑膜皱襞中PGP9.5染色阳性神经纤维密度(单位:纤维/cm2)为295.10+90.41,髌上滑膜皱襞神经纤维密度118.70+70.70;髌内侧滑膜皱襞神经纤维密度明显高于髌上滑膜皱襞,差异具有统计学意义;髌内侧滑膜皱襞综合征患者髌内侧滑膜皱襞中SP染色阳性与痛觉传导紧密相关的神经纤维密度为261.72+79.39,髌上滑膜皱襞神经纤维密度88.21+66.76,髌内侧滑膜皱襞神经纤维密度明显高于髌上滑膜皱襞,差异具有统计学意义。4、实验组患者髌内侧滑膜皱襞PGP9.5神经纤维密度为299.14+86.58、阳性对照组密度为291.06+96.17,均明显高于空白组37.65+22.91;实验组患者髌内侧滑膜皱襞SP神经纤维密度为255.44+87.91、阳性对照组密度为268.00+71.60,均明显高于空白组23.23+18.41。5、阳性对照组患者髌内侧滑膜皱襞中PGP9.5染色神经纤维密度与实验组患者无明显统计学差异;SP染色神经纤维密度和实验组无统计学差异;6、实验组和阳性对照组VAS疼痛评分差异无显著统计学意义;7、在神经分布密度与疼痛程度的相关关系研究中,PGP9.5染色阳性神经纤维分布密度与疼痛程度具有明显正相关关系。SP神经纤维分布密度与疼痛程度具有明确正相关关系。结论:在引起髌股关节疼痛的病理性髌内侧滑膜皱襞中,神经分布增多,神经纤维的密度增高,在滑膜皱襞基底部区域尤为明显;其中,表达与疼痛的产生和传导密切相关的SP的感觉神经纤维明显增多。神经纤维分布增高区域与临床上疼痛位点一致。病理性髌内侧滑膜皱襞中神经纤维分布密度的高低和患者疼痛程度呈明显正相关关系。髌内侧滑膜皱襞中神经纤维,尤其是表达SP的伤害性疼痛感觉神经纤维是疼痛发生的重要神经病理学基础;是髌内侧滑膜皱襞综合征发病机制中的重要环节。更多还原

【Abstract】 Medial plicais the normal synovial membrane structure in knee. A mesenchymal tissue or un chondrified blastema fills the space between the distal femoral and the proximal tibial epiphyses resorbs uncompletely in areas to between the femoral epiphysis and the patella to form the mediopatellar plica. The medial plicacommonly is presented as a normal finding of the knee, as well as a lesion, an ailment, a pathologic condition, or a hypertrophy.Many authors focus on the definition of medial plica as either normal or abnormal.Histologic study of medial plicaconfirms mechanical and chronic conflict with pathologic changes as deep fibrosis and abrasion of the superficial synovial layer. Such as infiltration of inflammatory cells and hypertrophy of a synovitis, thickening of vessels walls are inconstant.But these signs are not characteristic. Richmond and McGinty reported 40% of the patients with good results after plica resection had a normal pathology examination; Klein and Hanspal reported that 15-66% of the patients felt obviously patellfemoral pain ,which had good results after plica resection,found plica fibrosis ,33% found abnormal findings with inflammation.It is necessary to do more research to demonsrate the real difference between normal and abnormal mediopatellar plica.The mediopatellar plica syndrome almost resut patellfemoral pain.The anatomy and fuction need further more research.Some authors reported that medial plicaassociated lesion of cartilage result pain.But we found that some patients felt pain even though their patellfemoral cartilage had no lesion. Thin medial plicae can in fact be symptomatic, and the patient’s complaints relieved by excision. Wide, tense, and thick plicae may be totally asymptomatic, as there is no strict relationship between the aspect of the plica and the possible symptoms.Neuro-immunohistology suggest that innervation of synovial membrane upgoing in the patients who felt anterior knee pain.We presume that the innervation of medial plicae response for the anterior knee pain. The study focus on the neurotomia of plica by using neuron-immunology.Obtaining medial plicae by knee arthroscope.,Two indirect immunohistological techniques were employed for the semiquantitative analysis of protein gene product(PGP9.5)、substance P(SP).Compare the density of innervation among the three groups by paired t-test、one -way analysis of variance (ANOVA) and Student-Newman-Keuls Test (SNK).Evaluate the correlation between the density of innervation and the scores of VAS by Wilcoxon rank sum test and Spearman correlation analysis.The results were as followed:①The innervation in medial plicae do exist,there are three type of nerve fiber: free fiber、perivascular neural network around the blood vassel、nerve fiber bundle.②The density of nerve fiber in the basilar part is higher than edge area.Decide the basilar part to be the test site.③The density of nerve fiber of medial plicae is higher than superior plica.④The density of nervefiber of the medial plicasyndrome patients is higher than negative control group.⑤There is positive correlation between the density of nerve fiber and pain level.Main conclusions included: Medial plica syndrome is an important reason for Patellfemoral pain syndrome.Innervation upgoing and density of nerve fiber upgrade in medial plica syndrome patients,substance P are significantly correlated with pain.更多还原