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.	中国医师协会骨科医师分会骨循环与骨坏死专业委员会, 中华医学会骨科分会骨显微修复学组, 国际骨循环学会中国区. 中国成人股骨头坏死临床诊疗指南(2020). 中华骨科杂志, 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.	夏天卫, 魏伟, 张超, 等. 基于中日友好医院分型的股骨头坏死阶梯化保髋治疗经验总结. 中国修复重建外科杂志, 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.	肖凯, 罗殿中, 程徽, 等. 股骨颈基底部旋转截骨术治疗早期股骨头坏死的临床疗效. 中华骨科杂志, 2018, 38(7): 425-432.
14.	峥睿, 马剑雄, 赵兴文, 等. 基于高分辨X线及Micro-CT的距骨内骨小梁空间结构研究. 中华医学杂志, 2021, 101(37): 2982-2987.
15.	高润子, 夏天卫, 环大维, 等. 虚拟现实技术辅助下经股骨颈基底部旋转截骨术治疗股骨头坏死11例. 中国中医骨伤科杂志, 2021, 29(5): 51-55.
16.	芮仞, 娄悦, 张先姚, 等. 细胞凋亡在激素性股骨头坏死发病机制中的研究进展. 山西中医学院学报, 2019, 20(1): 65-69.
17.	孙飞, 彭昊. 激素性股骨头坏死病理机制中细胞凋亡的研究进展. 骨科, 2022, 13(1): 86-91.

1. 中国医师协会骨科医师分会骨循环与骨坏死专业委员会, 中华医学会骨科分会骨显微修复学组, 国际骨循环学会中国区. 中国成人股骨头坏死临床诊疗指南(2020). 中华骨科杂志, 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. 夏天卫, 魏伟, 张超, 等. 基于中日友好医院分型的股骨头坏死阶梯化保髋治疗经验总结. 中国修复重建外科杂志, 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. 肖凯, 罗殿中, 程徽, 等. 股骨颈基底部旋转截骨术治疗早期股骨头坏死的临床疗效. 中华骨科杂志, 2018, 38(7): 425-432.
14. 峥睿, 马剑雄, 赵兴文, 等. 基于高分辨X线及Micro-CT的距骨内骨小梁空间结构研究. 中华医学杂志, 2021, 101(37): 2982-2987.
15. 高润子, 夏天卫, 环大维, 等. 虚拟现实技术辅助下经股骨颈基底部旋转截骨术治疗股骨头坏死11例. 中国中医骨伤科杂志, 2021, 29(5): 51-55.
16. 芮仞, 娄悦, 张先姚, 等. 细胞凋亡在激素性股骨头坏死发病机制中的研究进展. 山西中医学院学报, 2019, 20(1): 65-69.
17. 孙飞, 彭昊. 激素性股骨头坏死病理机制中细胞凋亡的研究进展. 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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