03-이기석/68-79

Size: px

Start display at page:

Download "03-이기석/68-79"

자옥 사
5 years ago
Views:

1 = Abstract = Effect of Curettage and DBM-CaSO4 Graft for the Treatment of Ischemic Necrosis of the Capital Femoral Epiphysis in Immature Pigs Ki Seok Lee, M.D., Sun-Yong Kim, M.D., In Ho Choi, M.D.* Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Korea Department of Orthopaedic Surgery, Seoul National University, College of Medicine, Seoul, Korea* Purpose: The purpose of this study was to determine the effect of curettage and DBM complex graft as a new treatment modality for LCP disease using piglet capital femoral epiphysis ischemic necrosis model. Materials and Methods: Five to six weeks old piglets were used for the experiment. Ischemic necrosis of the capital femoral epiphysis was surgically induced by cervical ligation on both sides. Three weeks following ischemic insult, the left hip joint was approached medially. About 15% of the necrotic capital femoral epiphysis was curetted through a window which was opened at medial cervical cortex, then, demineralized bone matrix complex was engrafted. The right femoral heads served as controls. Piglets were sacrificed three, six, nine, and twelve weeks following were harvested for histologic examination. Results: In control group, photomicrographs of specimens showed central necrosis and fibrovascular invasion in capital femoral necrosis at three weeks after ischemic insult. Six, nine, and twelve weeks following ischemic insult, fibrovascular invasion advanced without noticeable new bone formation and collapse of femoral head progressed. At twelve weeks, definite coxa plana developed. In curettage and DBM complex graft group, there was evident new bone formation observed in the site of DBM complex graft. At three weeks, new bone formation along with fibrovascular invasion was observed around the engrafted DBM complex mainly in the cervical metaphyseal area. At six and nine weeks, new bone formation progressed into the engrafted DBM complex in the cervical metaphysis and around the engrafted DBM complex in the capital femoral epiphysis. At twelve weeks, new bone along with new cartilage formation was observed in the capital femoral epiphysis. Conclusion: In conclusion, curettage and DBM complex graft is thought to be an effective treatment modality that promote regeneration of ischemic necrosis of capital femoral epiphysis. Key Words: Legg-Calve -Perthes disease, Ischemic necrosis, Capital femoral epiphysis, Curettage, Demineralized bone matrix (DBM)

4 Table 1. Number of piglet s femoral heads used in the study. Harvest time* Experimental group Curettage & DBM graft (N=21) Control group Simple observation (N=24) 3 weeks weeks weeks weeks 6 6 *From curettage & DBM graft.

5 Fig. 1. Photomicrographs of femur head of each groups stained with Hematoxylin and Eosin at original scale. In control (simple observation) group, collapse of femoral head progressed with time, resulted in coxa plana deformity. In experimental (DBM+CaSO4 graft) group, partial disruption of metaphyseal physis reflects the passage of previous curettage & DBM complex graft. New bone formation at the site of engrafted DBM complex was observed, but femoral head collapsed with time.

7 Fig. 2. Photomicrographs of femur head of each groups stained with Hematoxylin and Eosin at low magnification ( 20). At the top of the figure is a schematic drawing of the center of the secondary ossification center corresponding to the coronal sections of figures in the table. In control (simple observation) group, necrotic tissues are absorbed and replaced by fibrous tissue without new bone formation. In experimental (DBM+CaSO4 graft) group, active new bone formation at the site of graft is observed nine weeks after graft procedure.

Fig. 3. Photomicrographs of femur head of experimental (DBM+CaSO4 graft) group stained with Hematoxylin & Eosin and Masson s Trichrome at high magnification ( 40).

8 Fig. 3. Photomicrographs of femur head of experimental (DBM+CaSO4 graft) group stained with Hematoxylin & Eosin and Masson s Trichrome at high magnification ( 40). At the top of the figure is a schematic drawing of the site of engrafted DBM complex in the secondary ossification center corresponding to the coronal sections of figures in the table. Until 6 weeks after DBM complex graft, there is no active new bone formation observed around the engrafted DBM complex in the secondary ossification center. At nine weeks after DBM complex graft, fibrous tissue and early stage of endochondral bone mixed with fibrous tissues were observe (black arrow). At twelve weeks after DBM complex graft, new bone growth as indicated by osteocytes forming cement lines on Masson s Trichrome staining sections (white arrows).

11 REFERENCES 1) Waldenstrom H: The first stages of coxa plana. J Bone Joint Surg Am. 1938;20: ) Lloyd-Roberts GC, Catterall A, Salamon PB: A controlled study of the indications for and the results of femoral osteotomy in Perthes disease. J Bone Joint Surg Br. 1976;58: ) Eyre-Brook Al: Osteochondritis deformans coxae juvernilis, or Perthes disease: the results of treatment by traction in recumbency. Br J Surg 1936;24:166 4) Harrison MH, Menon MP: Legg-Calve -Perthes disease. The value of roentgenographic measurement in clinical practice with special reference to the broomstick plaster method. J Bone Joint Surg Am. 1966;48:

12 5) Joseph B, Mulpuri K, Varghese G: Perthes disease in the adolescent. J Bone Joint Surg Br. 2001;83: ) Kim HK, Su PH, Qiu YS: Histopathologic changes in growth-plate cartilage following ischemic necrosis of the capital femoral epiphysis. An experimental investigation in immature pigs. J Bone Joint Surg Am. 2001;83: ) Lavigne M, Kalhor M, Beck M, Ganz R, Leunig M: Distribution of vascular foramina around the femoral head and neck junction: relevance for conservative intracapsular procedures of the hip. Orthop Clin North Am. 2005;36: ) Kim HK, Su PH: Development of flattening and apparent fragmentation following ischemic necrosis of the capital femoral epiphysis in a piglet model. J Bone Joint Surg Am. 2002;84: ) Herring JA, Neustadt JB, Williams JJ, et al.: The lateral pillar classification of Legg-Calve- Perthes disease. J Pediatr Orthop 1992;12: ) Mont MA, Jones LC, Elias JJ, et al.: Strutautografting with and without osteogenic protein-1: a preliminary study of a canine femoral head defect model. J Bone Joint Surg Am. 2001;83: ) Mont MA, Einhorn TA, Sponseller PD, Hungerford DS: The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head. J Bone Joint Surg Br. 1998;80: ) Wells L, Hosalkar HS, Crawford EA, Agrawal N, Goebel J, Dormans JP: Thorough debridement under endoscopic visualization with bone grafting and stabilization for femoral head osteonecrosis in children. J Pediatr Orthop. 2009;29: ) Urist MR, Sato K, Brownell AG, et al.: Human bone morphogenetic protein (hbmp). Proc Soc Exp Biol Med. 1983;173: ) Colnot C, Romero DM, Huang S, Helms JA: Mechanisms of action of demineralized bone matrix in the repair of cortical bone defects. Clin Orthop Relat Res. 2005;435: ) Gao J, Knaack D, Goldberg VM, Caplan AI: Osteochondral defect repair by demineralized cortical bone matrix. Clin Orthop Relat Res. 2004;427 Suppl:S ) Turner TM, Urban RM, Hall DJ, et al.: Osseous healing using injectable calcium sulfatebased putty for the delivery of demineralized bone matrix and cancellous bone chips. Orthopedics. 2003;26(5 Suppl):s ) Ballock RT, O Keefe RJ: The biology of the growth plate. J Bone Joint Surg Am. 2003;85: ) Stulberg SD, Cooperman DR, Wallensten R: The natural history of Legg-Calve -Perthes disease. J Bone Joint Surg Am Sep;63(7):

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding