骨内血管解剖方法及骨内血管分布的临床意义初步研究

Preliminary investigation on the dissected methods of intraosseous vasculature and the clinical significances of intraosse-ous vascularity

目的新鲜骨标本脱钙后影像定位血管孔道,根据孔道走向行骨内血管的解剖学研究,初步探索骨内血管解剖方法及其临床意义。方法取材来源包括膝关节车祸截肢新鲜标本7例,膝关节以上肿瘤截肢新鲜标本9例及一般尸体解剖标本44例(来自24具尸体);其中男22例(55%),女18例(45%);左膝28例(46.7%),右膝32例(53.3%);6~15岁10例(来自8位供体),15~85岁50例(来自32位供体)。以胫骨近端为例,解剖进入本研究团队发现并命名的"胫骨髁间隆突孔"的膝中静脉分支。取得新鲜膝关节标本后,先行血管造影观察连续的骨外骨内血管。去除骨皮质,在4℃福尔马林溶液中浸泡7 d,再使用EDTA脱钙剂浸泡30 d,隔日更换脱钙剂。行CT薄层扫描后三维重建,标注血管骨性孔道,根据血管骨内孔道走向进行解剖。解剖过程使用眼科手术显微器械精细操作,直观展示解剖结果,与造影成像对比,并使用组织切片验证。同时使用第2组标本行强酸脱钙剂脱钙,行效果对比。评价两种脱钙解剖方法的优劣、特定血管孔道在骨内的分布及普遍性,使用此方法可解剖出的骨内血管直径。以骨内血管解剖学研究为基础,对相关骨肿瘤及骨骺损伤病例行病因、复发及传播机制临床分析,改进治疗方案。结果解剖出膝中静脉分支经关节腔进入胫骨髁间隆突,经骨骺(儿童)或骨端(成人)穿越成人骺线或儿童将闭合骺板进入干骺端的血管分支。进入髁间隆突孔血管外径1.2 mm,进入骨内逐渐变细并继续分支,穿越骺线或将闭合骺板的细小分支外径0.3 mm,再向远端逐渐分化成毛细血管,难以直接解剖出。组织切片验证结果证实为骨内血管。对比使用强酸脱钙剂脱钙后的标本血管明显溶解,光学显微镜下只看到少量残存上皮细胞。以骨内血管解剖学研究为基础,对部分相关骨肿瘤及骨骺损伤病例行治疗方案改进,取得满意效果。结论对于外径≥0.3 mm的骨内血管,根据孔道走向行骨内血管可实现理想的直观解剖。

Objective The vasculature and canal were located using radiography after the fresh osseous specimens were decalcified,after which the anatomic investigation of intraosseous vasculature was conducted based on the orientation of the canals.Methods To investigate the basic dissected methods for intraosseous vasculature and the related clinical significance.Methods The materials were obtained from seven fresh knee joint specimens from patients with amputation due to car accidents,nine fresh knee joint specimens from patients with amputation due to oncological radical surgery,and 44 knee joint specimens from 24 cadavers.Among them,22 were males(55%)and 18 were females(45%),28 were left knees(46.7%)and 32 were right knees(53.3%).10 were aged from 16-90 years old(from 8 donors)and 50 were aged from 15-85 years old(from 32 donors).The tributaries of middle genicular vein which penetrate into the proximal tibial epiphysis and metaphysis via our previously discovered and denominated"foramen of tibial intercondylar eminence(FTIE)"were dissected as an example.After obtaining the fresh knee joint specimen,angiography was performed to observe the continuous extraosseous and intraosseous blood vessels.The first group of specimens with the removal of cortical bone was reserved in formalin solution at 4℃ for 7 d,sequentially immersed in Ethylene Diamine Tetraacetic Acid(EDTA),the decalcification agent,for 30 d with replacement for each two days.Based on the CT scanning and three-dimensional reconstruction,the orientation of bony canal which enclosed the vasculature was exposed to guide the anatomic incision.The exquisite dissection was achieved with the help of ophthalmological microsurgical instruments.The anatomical dissection were intuitively observed,compared with the angiographic images,and verified by histological examinations.The second group of samples was decalcified with strong acid as another strategy,and the comparison between different groups was conducted.To estimate the advantages and disadvantages of the two decalcification and dissection methods,and the distribution and universality of specific intraosseous vasculatures and canals,the methods can be utilized to dissect the diameter of the intraosseous vessels.Based on the anatomical study of intraosseous vasculature,the mechanisms including etiology,recurrence and spread of bone tumors and epiphyseal injuries were analyzed to improve the therapeutic regimen.Results The intraosseous tributaries of middle genicular vein which penetrate into the tibial intercondylar eminence from the articular cavity were dissected,these vessels extended to the tibial metaphysis from epiphysis through the epiphyseal line or senescent physes.The diameter of the vessel entering the FTIE was 1.2 mm,and the intraosseous vessels divided into several tinier tributaries with the diameter of 0.3 mm to cross the epiphyseal line or closed physeal plate and differentiated into capillaries in the distal regions,therefore was difficult to dissect directly.The histological examinations confirmed the authenticity of intraosseous vessels.Compared with the samples decalcified with strong acid,the blood vessels were obviously dissolved,and only a few residual epithelial cells were observed under the light microscope.Based on the anatomical study of intraosseous vessels,the treatment protocols for some related bone tumors and epiphyseal injuries were modified and satisfactory results were achieved.Conclusion The methods can realize the ideal direct dissection for the intraosseous blood vessels with the outer diameter greater than or equal to 0.3 mm.