【作者】 李国军；

【导师】 李康华； 朱勇；

【作者基本信息】 中南大学 ， 外科学， 2009， 博士

【摘要】 前交叉韧带(anterior cruciate ligament,ACL)的主要作用是控制胫骨的前移和旋转,也参与膝内外翻的调节。半月板是膝关节的重要组成部分,具有吸收震荡、传递负荷、维持膝关节稳定等重要功能。随着MRI、关节镜手术等诊疗水平的提高,越来越多的ACL损伤得到早期诊断和治疗。同时发现,ACL损伤常继发关节软骨退变;然而ACL损伤是否影响外侧半月板,目前研究甚少。本研究拟采用生物力学测定的方法,观察ACL完全断裂和部分断裂对外侧半月板各部位应变的影响;并运用组织学方法,观察ACL完全断裂后外侧半月板组织形态学的变化,同时检测IL-1β、MMP13的表达,以了解其在外侧半月板退变中的作用机制;测量ACL完全或部分断裂后外侧半月板的周缘性移位及其程度,为ACL损伤是否对外侧半月板产生影响提供理论依据。第一章前交叉韧带断裂对外侧半月板生物力学特性的影响目的探讨ACL断裂对外侧半月板生物力学的影响。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°位外侧半月板前角、体部和后角的应变,测试完毕后随机将标本造模成前内侧束(AMB)断裂组和后外侧束(PLB)断裂组,各5具,在上述条件下测试,最后再将10具标本的ACL完全切断进行测试。结果1.膝关节0°位,在200N、400N载荷下,前角、体部、后角的应变在PLB切断组和ACL全断组、ACL完整组和AMB切断组之间无显著性差异,P＞0.05;在600N、800N载荷下各实验组之间有显著性差异,P＜0.05,前角和体部应变绝对值表现为全断组＞PLB切断组＞AMB切断组＞完整组,后角应变绝对值表现为全断组＜PLB切断组＜AMB切断组＜完整组。2.膝关节30°位,在200N、400N载荷下,前角、体部、后角的应变在ACL完整组和PLB切断组、AMB切断组和ACL全断组之间无显著性差异,P＞0.05;在600N、800N载荷下各实验组之间有显著性差异,P＜0.05,应变绝对值表现为全断组＞AMB切断组＞PLB切断组＞完整组。3.膝关节60°、90°位,相同载荷下各实验组应变之间有显著差异,P＜0.05,应变绝对值表现为全断组＞AMB切断组＞PLB切断组＞完整组。结论1.ACL完全断裂,对外侧半月板前角、体部和后角的应变均有影响。2.在200N和400N载荷下,AMB切断在膝关节0°位和PLB切断在膝关节屈曲30°位对外侧半月板前角、体部和后角的应变均无影响。3.在600N和800N载荷下,AMB切断在膝关节0°位和PLB切断在屈膝30°、60°、90°位对外侧半月板前角、体部和后角的应变均有影响。4.在各实验载荷下,AMB切断在屈膝30°、60°、90°位和PLB切断在膝0°位对外侧半月板前角、体部和后角的应变均有影响。第二章前交叉韧带断裂后外侧半月板退变的组织学研究目的探讨ACL断裂对外侧半月板组织学的影响。方法48只家兔膝关节配对为实验侧和对照侧,实验侧行ACL切断造模,造模后第1、3、6、8周各随机处死12只,行外侧半月板大体观察,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,实验组外侧半月板出现磨损,甚至撕裂,呈黄色,弹性差。2.组织学观察,随时间延长,半月板表面不平整,组织疏松,胶原纤维排列紊乱,炎性细胞浸润,间质水肿,软骨细胞变性减少。各实验组和对照组组织学退变评分均有显著性差异,P＜0.05。3.实验组IL-1β、MMP13表达均高于对照组,有显著性差异,P＜0.05。4.实验组IL-1β表达阳性率第3周高于第1周和第8周,有显著性差异,P＜0.05;实验组第6周高于第1周和第8周,有显著性差异,P＜0.05;实验组第8周IL-1β表达阳性率高于第1周,有显著性差异,P＜0.05;实验组第3周和第6周IL-1β表达阳性率无显著性差异,P＞0.05。6.实验组MMP13阳性表达率第3周高于第1周、第8周,均有显著性差异,P＜0.05;实验组MMP13阳性表达率第6周高于第8周和第1周,有显著性差异,P＜0.05;实验组MMP13阳性表达率第1周和第8周,有显著性差异,P＜0.05;实验组MMP13阳性表达率第3周和第6周无显著性差异,P＞0.05。结论1.ACL断裂可引起外侧半月板组织退变。2.IL-1β、MMP13在ACL断裂膝关节外侧半月板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可能是继发外侧半月板退变的因素之一。4.首次制定了半月板退变组织学评分标准。第三章前交叉韧带断裂对外侧半月板周缘性移位影响的研究目的探讨ACL断裂对外侧半月板周缘性移位的影响以及断裂程度与周缘性移位程度之间的关系。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,测量膝关节0°、30°、60°、90°位外侧半月板周缘性位移,测量完毕后随机将标本造模成前内侧束(AMB)断裂组和后外侧束(PLB)断裂组,各5具,在上述条件下测量,最后再将10具标本的ACL完全切断作为全断组进行测量。结果1.ACL完整时的外侧半月板移位分布在0.5～2.7mm。2.膝关节屈曲0°,在200N、400N、600N载荷下,全断组和PLB切断组、完整组和AMB切断组外侧半月板移位无显著性差异,P＞0.05;完整组和PLB切断组、全断组和完整组、AMB切断组和PLB切断组外侧半月板移位均有显著性差异,P＜0.05;在800N载荷下,各组外侧半月板移位均有显著性差异,P＜0.05。3.膝关节屈曲30°、60°,在200N、400N载荷下,完整组和PLB切断组、AMB切断组和全断组外侧半月板移位均无显著性差异,P＞0.05,其余各组间外侧半月板移位均有显著性差异,P＜0.05;在600N、800N载荷下各组间外侧半月板移位均有显著性差异,P＜0.05。4.膝关节屈曲90°,在200N载荷下,完整组和PLB切断组、AMB切断组和全断组外侧半月板移位均无显著性差异,P＞0.05,其余各组间外侧半月板移位均有显著性差异,P＜0.05;在400N、600N、800N载荷下各组间外侧半月板移位均有显著性差异,P＜0.05。结论1.外侧半月板生理性移位范围为0.5～2.7mm。2.AMB断裂后外侧半月板在膝关节屈曲时移位明显增大。3.PLB断裂后外侧半月板在膝关节伸直时移位明显增大。4.ACL完全断裂后外侧半月板在膝关节屈曲、伸直时移位均明显增大。5.ACL损伤后外侧半月板移位明显,提示ACL损伤是外侧半月板退变的原因之一。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 as well as the varus and valgus of knee joint partly.The role of the lateral meniscus which is an important ingredient of the knee is shock absorption and stress transmission and stabilization of the knee joint.With the development of MRI and arthroscope,early diagnosis and treatment of ACL injury turns to be easily achieved,meanwhile,it is found that the secondary injury of ACL deficiency always occurs in articular cartilage,but it is little known whether deficiency of ACL effects on the lateral meniscus.In this study,straining changes in several sites of lateral meniscus caused by ACL injury is observed through biomechanics approach;histological changes of meniscus and expression of IL-1βand MMP13 in meniscus are observed so as to investigate the function of IL-1βand MMP13 in degeneration of lateral meniscus;circumferentia displacement of lateral meniscus after ACL injury is measured,so as to provide theoretical evidence whether deficiency of ACL effects on the lateral meniscus. ChapterⅠThe Effect of ACL Rupture on the Biomechanics of Lateral MeniscusOBJECTIVE The effect of ACL injury on all locations of lateral meniscus by measuring biomechanics is observed so as to explore the mechanism of lateral meniscus injury after ACL rupture.METHOD The straining of lateral meniscus anterior horn, caudomedial part and posterior horn in all fresh normal adult knee joint specimens including 10 specimens of complete ACL,5 of anteriomedialis bundle（AMB） rupture,5 of post-lateral bundle rupture and 10 of complete rupture ACL are tested when the knee joints loaded 200N,400N,600N and 800N at 0°,30°,60°and 90°of flexion.RESULT 1.The straining of lateral meniscus anterior horn, caudomedial part and posterior horn shows no significant difference between PLB rupture group and ACL complete rupture group,complete ACL group and AMB rupture group under the load of 200N and 400N at 0°of flexion,P＞0.05;significant difference is showed among all the groups under the loads of 600N and 800N at 0°of flexion,P＜0.05; under the same load and angle of flexion,the correlation of the absolute value of straining in every group of lateral meniscus anterior horn and caudomedial part increases in this way of ACL complete rupture group＞PLB rupture group＞AMB rupture group＞complete ACL group,and of posterior horn increases in this way of ACL complete rupture group＜PLB rupture group＜AMB rupture group＜complete ACL group. 2.The straining of lateral meniscus anterior horn,caudomedial part and posterior horn shows no significant difference between AMB rupture group and ACL complete rupture group,complete ACL group and PLB rupture group under the loads of 200N and 400N at 30°of flexion,P＞0.05;significant difference is showed among all the groups under the load of 600N and 800N at 30°of flexion,P＜0.05;under the same load and angle of flexion,the correlation of the absolute value of straining in every group increases in this way of ACL complete rupture group＞AMB rupture group＞PLB rupture group＞complete ACL group.3.There is significant difference among all the groups under the load of 200N,400N,600N and 800N at 60°and 90°of flexion,P＜0.05.under the same load and angle of flexion,the correlation of the absolute value of straining in every group increases in this way of ACL complete rupture group＞AMB rupture group＞PLB rupture group＞complete ACL group.CONCLUSION 1.ACL complete rupture is likely to cause abnormal straining in all regions of lateral meniscus under different load and angle of flexion.2.Under the load of 200N and 400N,AMB rupture at 0°of flexion and PLB rupture at 30°of flexion cause no effect on the straining in all regions of lateral meniscus.3.Under the load of 600N and 800N,AMB rupture at 0°of flexion and PLB rupture at 30°,60°and 90°of flexion cause apparently effect on the straining in all regions of lateral meniscus.4.Abnormal straining in all regions of lateral meniscus can be caused by PLB rupture at 0°of flexion and AMB rupture at 30°,60°and 90°of flexion under different load.ChapterⅡThe Research of Histology about Degeneration of Lateral Meniscus after Rupture of ACLOBJECTIVE Study the effect on lateral meniscus which was caused by rupture of ACL.METHOD Lateral meniscus of 48 rabbits matched mode pairs both in experiment side which ACL were transacted and control side,at the 1^st,3^rd,6^th and 8^th week,execute 12 rabbits randomly,then to observe lateral meniscus in general and through HE staining and immunohistochemistry staining,detect the expression of IL-1βand MMP13.RESULT 1.The observation in general showed that along with the increase of the time lateral meniscus of experiment group gradually wore,even ruptured,presenting yellow and bad elasticity.2.Along with the increase of the time the observation of histology shows uneven surface of meniscus,loose tissue,disorder of collagen fibers,infiltration of inflammatory cell,interstitial edema and deformation of intracytoplasm mitochondrion in the chondrocytes.Histological evaluation of the degeneration in fibrocartilage of meniscus in both groups:The scores at the 1^st,3^rd,6^th and 8^th week were higher in the experimental group than those in the control group,showing significant difference,P＜0.05; the scores of experimental group at the 6^th and 8^th week was higher than that at the 1^st and 3^rd week,showing significant difference,P＜0.05,but there is no significant difference between the 1^st and 3^rd week,P＞0.05.3.At the 1^st,3^rd,6^thand 9^th week,expression of IL-1βand MMP13 is higher in experimental group than that in control group,showing significant difference,P＜0.05.4.In experimental group,expression of IL-1βis higher at the 3^rd than that at 1^st and 8^th week,showing significant difference,P＜0.05,expression of IL-1βis higher at the 6^th week than that at 1^st and 8^th week,showing significant difference,P＜0.05,expression of IL-1βis higher at the 8^th week than that at 1^st week,showing significant difference,P＜0.05,but there is no significant difference between the 3^rd and 6^th week.5.In experimental group, expression of MMP13 is higher at the 3^rd week than that at 1^st and 8^th week,showing significant difference,P＜0.05,expression of MMP13 is higher at the 6^th week than that at 1^st and 8th week,showing significant difference,P＜0.05,expression of MMP13 is higher at the 8^th week than that at 1^st week,showing significant difference,P＜0.05,but there is no significant difference between the 3^rd and 6^thweek,P＞0.05.CONCLUSION 1.Rupture of ACL could cause the degeneration of lateral meniscus.2.A regularity of expression of IL-1βand MMP13 is displayed that the expression is increasing in primal stage and decreasing in advanced stage after rupture of ACL 3.The high expression of IL-1βand MMP13 hints that IL-1βand MMP13 maybe a promotional factor which causes the degeneration of lateral meniscus.4.The histological evaluation criterion of degeneration of meniscus was made first time.ChapterⅢThe Effect of ACL Rupture on the Circumferential Displacement of Lateral MeniscusOBJECTIVE To explore the effect of ACL rupture on lateral meniscus circumferentia displacement and the correlation between the degree of ACL rupture and circumferentia displacement.METHOD The circumferentia displacement of lateral meniscus in all fresh normal adult knee joint specimens including 10 specimens of complete ACL,5 of anteriomedialis bundle（AMB） rupture,5 of post-lateral bundle rupture（PLB） and 10 of complete rupture ACL are tested when the knee joints loaded 200N,400N,600Nand 800N at 0°, 30°,60°and 90°of flexion. RESULT 1.The limit of circumferentia displacement of lateral meniscus is distributed between 0.5～2.7mm in complete ACL group.2. At 0°of flexion and under the loads of 200N,400N and 600N,the circumferentia displacement of lateral meniscus between ACL complete rupture group and PLB rupture group,complete ACL group and AMB rupture group shows no significant difference,P＞0.05;significant difference is displayed between complete ACL group and PLB rupture group,ACL complete rupture group and complete ACL group,AMB rupture group and PLB rupture group,P＜0.05;there is significant difference among each group under the load of 800N at 0°of flexion,P＜0.05.3.Under the loads of 200N and 400N,the circumferentia displacement of lateral meniscus between complete ACL group and PLB rupture group,ACL complete rupture group and AMB rupture group shows no significant difference at 30°and 60°of flexion,P＞0.05,and that among the other groups shows significant difference,P＜0.05;Under the loads of 600N and 800N,the circumferentia displacement among every group shows significant difference at 30°and 60°of flexion,P＜0.05.4.Under the loads of 200N,the circumferentia displacement of lateral meniscus between complete ACL group and PLB rupture group, ACL complete rupture group and AMB rupture group shows no significant difference at 90°of flexion,P＞0.05,and that among the other groups shows significant difference,P＜0.05;Under the loads of 200N,600N and 800N,the circumferentia displacement among every group shows significant difference at 90°of flexion,P＜0.05.CONCLUSION 1.The physiological circumferentia displacement of lateral meniscus is between 0.5mm and 2.7mm.2.The circumferentia displacement of lateral meniscus in AMB rupture group at flexed position of the knee joint becomes bigger than that in complete ACL group.3.The circumferentia displacement of lateral meniscus in PLB rupture group at straight position of the knee joint becomes bigger than that in complete ACL group.4.The circumferentia displacement of lateral meniscus becomes big at all position of the knee joint when the ACL is ruptured completely.5.The abnormal circumferentia displacement of lateral meniscus after ACL rupture hints that ACL rupture maybe a factor which causes the degeneration of lateral meniscus.更多还原