| BackgroundOsteonecrosis of the femoral head(ONFH)occurs in young and middle-aged people with a high rate of disability and an increasing incidence year by year.Step-by-step and individual treatment has become an important consensus in the diagnosis and treatment of the disease.The extension of staging and classification system provides an important reference for achieving the above goals.Type L2 and type L3 ONFH of China-Japan Friendship Hospital Classification(CJFH Classification)are the difficulties in hip preservation precedures.Rotational osteotomy of the base of the femoral neck can transfer the necrotic lateral column to the non-weight-bearing area of the hip joint,to prevent further collapse of the femoral head.The long-term application of Bushen Huoxue Decoction recorded in Dacheng of Shangke combined hip-conserving surgery in the treatment of intermediate and advanced ONFH has achieved good clinical effect.Rotational osteotomy on the base of femoral neck combined with Bushen Huoxue decoction provides a new method for the treatment of ONFH.Purpose1.To evaluate the short-term clinical efficacy of virtual reality-assisted rotational osteotomy on the base of the femoral neck in combination with Bushen Huoxue Decoction to treat type L2 and type L3 ONFH of CJFH classification.2.To provide direct evidences for the treatment of ONFH by rotational osteotomy on the base of the femoral neck,type L2 and type L3 ONFH specimens produced by artificial joint replacements were studied through Micro-CT and pathological methods.The similarities and differences of the lateral column,middle column,and medial column of type L2 and type L3 ONFH specimens in trabecular bone and other bone microstructures and apoptosis phenotypes were analysised.3.To explore the potential mechanisms of Bushen Huoxue Decoction in the treatment of ONFH.The effects of the serum containing Bushen Huoxue Decoction on the proliferation,osteogenic differentiation and paracrine functions of bone marrow mesenchymal stem cells were studied in vitro..Methods1.Patients in the trial group who underwent rotational osteotomy on the base of the femoral neck combined with Bushen Huoxue Decoction and patients in the control group who underwent rotational osteotomy of the base on the femoral neck were followed up and evaluated before treatment and at 3,6 and 12 months after treatment in terms of X-ray hip preservation efficacy evaluation and Harris score.2.To study type L2 and type L3 ONFH specimens produced by artificial joint replacements.Micro-CT was used to segment the three-column structure of the femoral head three-dimensionally in the first.Parameters including BV/TV,BS/BV,Tb.Sp,Tb.Th,Tb.N of lateral columns,middle columns,and medial columns were analysied.The similarities and differences between three columns of the femoral head in bone mass and trabecular bone structure related parameters were comparied.Specimens were incised by oscillating saws after Micro-CT studies,specimens were made into paraffin slices,HE staining and apoptosis-related immunohistochemical staining were performed.The similarities and differences of the apoptotic phenotypes of lateral columns,middle columns,and medial columns of type L2 and type L3 ONFH specimens were evaluated by comparing the rates of empty bone lacunae and positive immunohistochemical staining.3.In vitro intervention of BMSCs in SD rats with the drug-containing serum of Bushen Huoxue Decoction,the effect of Bushen Huoxue Decoction on osteogenic differentiation of BMSCs was assessed under osteogenic induction conditions after screening the optimal administration concentration by CCK8 method;the effect of the drug-containing serum of Bushen Huoxue Decoction on the paracrine secretion of cytokines such as SDF-1α,TGFp1 and VEGF was also assessed under conditioned culture.Results1.The control group had a slightly higher score on the evaluation of efficacy of X-ray hip preservation at 3 months after treatment,6 months after treatment and 12 months after treatment than the trial group,but the difference between them was not statistically significant(P>0.05).2.In the trial group and the control group,the Harris scores at 3,6 and 12 months after surgery improved compared with the preoperative scores.The trial group improved compared with the control Harris score at 3 and 6 months after surgery,and there was a statistical difference between the two groups(p<0.05).The Harris score of test group still improved compared with the control group at 12 months after surgery,but there was no statistical difference between the two groups(p>0.05).3.In the type L2 ONFH specimens,there were statistically significant differences between the lateral and medial columns and the middle column in terms of BV/TV,Tb.Th,Tb.Sp and Tb.N(p<0.05),whereas in the type L3 ONFH specimens,there were no statistically significant differences between the three columns in terms of bone parameters such as BS/BV,BV/TV,Tb.Th,Tb.Sp and Tb.N(p>0.05).4.In type L2 and type L3 ONFH specimens,the empty bone lacuna rates were slightly higher in the lateral column than in the medial and middle columns,but the differences between the three columns were not statistically significant(p>0.05).Conclusion1.Rotational osteotomy on the base of the femoral neck can prevent further collapse of the femoral head and has been observed to be effective in the treatment of ONFH in the short term.The combination of Bushen Huoxue Decoction can increase the functional recovery of patients after surgery,which has good application and research prospects.2.In type L2 ONFH specimens,the femoral head has a better trabecular structure in medial column and middle column then lateral column,and rotational osteotomy on the base of the femoral neck can help patients rebuild a lateral column with better trabecular structure and more bone mass.In contrast,in type L3 ONFH specimens,the trabecular structure of the medial and middle columns of the femoral head is extensively damaged,there were no differences between three columns in trabecular structures.Rotational osteotomy on the base of the femoral neck may not help to reconstruct a better lateral column than the original one,therefore the use of rotational osteotomy on the base of the femoral neck for hip preservation intervention in young type L3 patients should be carefully considered.3.The empty bone lacuna rates in the "three-column structure" of both type L2 and L3 ONFH femoral head specimens were above 85%,but there were no statistically significant differences between the three columns,although the destruction of trabeculae in the medial and middle columns were less than the lateral column in type L2 ONFH.This suggested that at the end-stage of osteonecrosis of the femoral head,the common pathological process is related to osteocyte apoptosis,and this process may occurred earlier than the destruction of trabecular structures.4.Bushen Huoxue Decoction may be involved in the repair process of femoral head necrosis by promoting the proliferation of BMSCs,increasing the expression and paracrine secretion of SDF-1α,TGFβ1 and VEGF in BMSCs.At the same time,the Bushen Huoxue Decoction may has the effect of promoting osteogenic differentiation of BMSCs,which in turn exerts a therapeutic effect on ONFH. |
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