Study on bone microstructure and pathology of type L2 and L3 osteonecrosis of the femoral head specimens classified by China-Japan Friendship Hospital classification based on “three-columns structure”_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

GAO Runzi ¹ , XIA Xiawei ² , LIU Jinzhu ² , YUAN Zhaofeng ² , HUAN Dawei ² ,  SHEN Jirong ²

1. Department of Orthopedics and Traumatology, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210029, P. R. China;
2. Department of Orthopedics and Traumatology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing Jiangsu, 210001, P. R. China;

Corresponding?author：

SHEN Jirong, Email: joint66118@sina.com

Keywords：

Osteonecrosis of the femoral head; China Japan Friendship Hospital classification; Micro-CT; pathology

DOI：

10.7507/1002-1892.202203108

Video：

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Objective To analyze the similarities and differences of bone microstructure and apoptosis phenotype of lateral column, middle column, and medial column in type L2 and L3 osteonecrosis of the femoral head (ONFH) specimens classified by China-Japan Friendship Hospital (CJFH) classification, so as to carry out a quantitative study of ONFH “three-columns structure theory” and to provide research support for the treatment of ONFH by rotational osteotomy through the base of femoral neck. Methods Discarded femoral head specimens from 16 patients (16 hips) with CJFH type L2 and L3 ONFH undergone total hip arthroplasty between April 2020 and February 2021 were selected as the research objects. First, the “three-column structure” of the femoral head was three-dimensionally segmented by Micro-CT, and the bone volume to total volume (BV/TV), bone surface area to bone volume ratio (BS/BV), trabecular spacing/separation (Tb.Sp), trabecular thickness (Tb.Th), and trabecular number (Tb.N) in the lateral column, middle column, and medial column were analyzed to compare the similarities and differences of parameters related to bone mass and trabecular structure among the three columns. Then, the specimens were cut with a oscillating saw and made into paraffin sections for HE staining and immunohistochemical staining of B-cell lymphoma-2 (Bcl-2) and Bcl-2 associated X protein (Bax). The differences of apoptosis phenotype between the three columns of ONFH samples of CJFH type L2 and L3 were evaluated by comparing the rate of empty lacunae and the rate of positive cells of immunohistochemical staining. Results There were significant differences in BV/TV, Tb.Th, and Tb.N among the three columns of CJFH type L2 ONFH femoral head (P<0.05), with the largest in the medial column and the smallest in the lateral column; BS/BV and Tb.Sp of the lateral column were significantly greater than those of the medial column and middle column (P<0.05), no significant difference was found between the middle column and medial column (P>0.05). There was no significant difference in the bone parameters between the three columns of the CJFH type L3 ONFH femoral head (P>0.05). There was no significant difference in the rate of empty lacunae between the three columns of the CJFH type L2 and L3 ONFH femoral head (P>0.05). Immunohistochemical staining showed that a large number of tissue sections were detached, and only a small amount of non-specific staining was found in the sections without detachment, so the positive cell rate could not be calculated. Conclusion The middle and medial columns of the CJFH type L2 ONFH has better trabecular structures than the lateral column, and there is no significant difference in trabecular structures among the three columns of the CJFH type L3 ONFH.

Citation： GAO Runzi, XIA Xiawei, LIU Jinzhu, YUAN Zhaofeng, HUAN Dawei, SHEN Jirong. Study on bone microstructure and pathology of type L2 and L3 osteonecrosis of the femoral head specimens classified by China-Japan Friendship Hospital classification based on “three-columns structure”. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(8): 1003-1010. doi: 10.7507/1002-1892.202203108 Copy

1.	中國醫師協會骨科醫師分會骨循環與骨壞死專業委員會, 中華醫學會骨科分會骨顯微修復學組, 國際骨循環學會中國區. 中國成人股骨頭壞死臨床診療指南(2020). 中華骨科雜志, 2020, 40(20): 1365-1376.
2.	Zhao DW, Yu M, Hu K, et al. Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the chinese population: Results from a nationally representative survey. Chin Med J (Engl), 2015, 128(21): 2843-2850.
3.	夏天衛, 魏偉, 張超, 等. 基于中日友好醫院分型的股骨頭壞死階梯化保髖治療經驗總結. 中國修復重建外科雜志, 2020, 34(1): 10-15.
4.	Weinstein RS, Nicholas RW, Manolagas SC. Apoptosis of osteocytes in glucocorticoid-induced osteonecrosis of the hip. J Clin Endocrinol Metab, 2000, 85(8): 2907-2912.
5.	Bai R, Feng W, Liu WL, et al. Roles of osteocyte apoptosis in steroid-induced avascular necrosis of the femoral head. Genet Mol Res, 2016, 15(1). doi: 10.4238/gmr.15017529.
6.	Gao Y, Zhu H, Wang Q, et al. Inhibition of PERK signaling prevents against glucocorticoid-induced endotheliocyte apoptosis and osteonecrosis of the femoral head. Int J Biol Sci, 2020, 16(4): 543-552.
7.	Wang C, Meng H, Wang Y, et al. Analysis of early stage osteonecrosis of the human femoral head and the mechanism of femoral head collapse. Int J Biol Sci, 2018, 14(2): 156-164.
8.	Houdek MT, Wyles CC, Packard BD, et al. Decreased osteogenic activity of mesenchymal stem cells in patients with corticosteroid-induced osteonecrosis of the femoral head. J Arthroplasty, 2016, 31(4): 893-898.
9.	Ding P, Zhang W, Tan Q, et al. Impairment of circulating endothelial progenitor cells (EPCs) in patients with glucocorticoid-induced avascular necrosis of the femoral head and changes of EPCs after glucocorticoid treatment in vitro. J Orthop Surg Res, 2019, 14(1): 226. doi: 10.1186/s13018-019-1279-6.
10.	Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res, 1978, (130): 191-201.
11.	Sugioka Y, Hotokebuchi T, Tsutsui H. Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results. Clin Orthop Relat Res, 1992, (277): 111-120.
12.	Dean MT, Cabanela ME. Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. J Bone Joint Surg (Br), 1993, 75(4): 597-601.
13.	肖凱, 羅殿中, 程徽, 等. 股骨頸基底部旋轉截骨術治療早期股骨頭壞死的臨床療效. 中華骨科雜志, 2018, 38(7): 425-432.
14.	崢睿, 馬劍雄, 趙興文, 等. 基于高分辨X線及Micro-CT的距骨內骨小梁空間結構研究. 中華醫學雜志, 2021, 101(37): 2982-2987.
15.	高潤子, 夏天衛, 環大維, 等. 虛擬現實技術輔助下經股骨頸基底部旋轉截骨術治療股骨頭壞死11例. 中國中醫骨傷科雜志, 2021, 29(5): 51-55.
16.	芮仞, 婁悅, 張先姚, 等. 細胞凋亡在激素性股骨頭壞死發病機制中的研究進展. 山西中醫學院學報, 2019, 20(1): 65-69.
17.	孫飛, 彭昊. 激素性股骨頭壞死病理機制中細胞凋亡的研究進展. 骨科, 2022, 13(1): 86-91.

1. 中國醫師協會骨科醫師分會骨循環與骨壞死專業委員會, 中華醫學會骨科分會骨顯微修復學組, 國際骨循環學會中國區. 中國成人股骨頭壞死臨床診療指南(2020). 中華骨科雜志, 2020, 40(20): 1365-1376.
2. Zhao DW, Yu M, Hu K, et al. Prevalence of nontraumatic osteonecrosis of the femoral head and its associated risk factors in the chinese population: Results from a nationally representative survey. Chin Med J (Engl), 2015, 128(21): 2843-2850.
3. 夏天衛, 魏偉, 張超, 等. 基于中日友好醫院分型的股骨頭壞死階梯化保髖治療經驗總結. 中國修復重建外科雜志, 2020, 34(1): 10-15.
4. Weinstein RS, Nicholas RW, Manolagas SC. Apoptosis of osteocytes in glucocorticoid-induced osteonecrosis of the hip. J Clin Endocrinol Metab, 2000, 85(8): 2907-2912.
5. Bai R, Feng W, Liu WL, et al. Roles of osteocyte apoptosis in steroid-induced avascular necrosis of the femoral head. Genet Mol Res, 2016, 15(1). doi: 10.4238/gmr.15017529.
6. Gao Y, Zhu H, Wang Q, et al. Inhibition of PERK signaling prevents against glucocorticoid-induced endotheliocyte apoptosis and osteonecrosis of the femoral head. Int J Biol Sci, 2020, 16(4): 543-552.
7. Wang C, Meng H, Wang Y, et al. Analysis of early stage osteonecrosis of the human femoral head and the mechanism of femoral head collapse. Int J Biol Sci, 2018, 14(2): 156-164.
8. Houdek MT, Wyles CC, Packard BD, et al. Decreased osteogenic activity of mesenchymal stem cells in patients with corticosteroid-induced osteonecrosis of the femoral head. J Arthroplasty, 2016, 31(4): 893-898.
9. Ding P, Zhang W, Tan Q, et al. Impairment of circulating endothelial progenitor cells (EPCs) in patients with glucocorticoid-induced avascular necrosis of the femoral head and changes of EPCs after glucocorticoid treatment in vitro. J Orthop Surg Res, 2019, 14(1): 226. doi: 10.1186/s13018-019-1279-6.
10. Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res, 1978, (130): 191-201.
11. Sugioka Y, Hotokebuchi T, Tsutsui H. Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results. Clin Orthop Relat Res, 1992, (277): 111-120.
12. Dean MT, Cabanela ME. Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. J Bone Joint Surg (Br), 1993, 75(4): 597-601.
13. 肖凱, 羅殿中, 程徽, 等. 股骨頸基底部旋轉截骨術治療早期股骨頭壞死的臨床療效. 中華骨科雜志, 2018, 38(7): 425-432.
14. 崢睿, 馬劍雄, 趙興文, 等. 基于高分辨X線及Micro-CT的距骨內骨小梁空間結構研究. 中華醫學雜志, 2021, 101(37): 2982-2987.
15. 高潤子, 夏天衛, 環大維, 等. 虛擬現實技術輔助下經股骨頸基底部旋轉截骨術治療股骨頭壞死11例. 中國中醫骨傷科雜志, 2021, 29(5): 51-55.
16. 芮仞, 婁悅, 張先姚, 等. 細胞凋亡在激素性股骨頭壞死發病機制中的研究進展. 山西中醫學院學報, 2019, 20(1): 65-69.
17. 孫飛, 彭昊. 激素性股骨頭壞死病理機制中細胞凋亡的研究進展. 骨科, 2022, 13(1): 86-91.

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Chinese Journal of Reparative and Reconstructive Surgery

Study on bone microstructure and pathology of type L2 and L3 osteonecrosis of the femoral head specimens classified by China-Japan Friendship Hospital classification based on “three-columns structure”

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