【作者】 刘玉新；

【导师】 蔡锦方；

【作者基本信息】 第二军医大学 ， 外科学， 2008， 博士

【摘要】 一研究背景骨髓炎骨缺损(Osteomyelitic bone defection,OBD)对于病人来说是相当痛苦的,其治疗对于医生来说也是非常棘手的,有很多患有此病的患者最后不得不截肢。其治疗主要是抗感染和骨缺损的修复,近年来,出现了大量有关转移局部带血供肌瓣(Muscleflap with vessel pedicle,MFVP)修复骨缺损的报道,也有转移以腺病毒为载体表达的骨形态发生蛋白-2(Adenovirus Recombined Human Bone Morphogenetic Protein-2,Ad-rhBMP-2)基因诱导肌细胞成骨的报道,但尚未发现有关于转移肌瓣骨化过程及转移Ad-rhBMP-2基因修复OBD的报道。我们应用显微外科技术,转移局部带血管蒂肌瓣骨化修复OBD,并联合应用基因技术,缩短肌瓣骨化修复OBD时间,提出治疗OBD有效的新方法。二实验目的观察、比较两种治疗方案诱导肌瓣骨化修复OBD的效果。①应用显微外科技术,转移MFVP填充清创术后的OBD,保证肌瓣的血供。②联合应用显微外科技术与基因技术,转移MFVP填充清创术后的OBD,并转移Ad-rhBMP-2基因至肌瓣。三实验方法(一)大鼠OBD模型制备:向胫骨上段骨缺损腔内塞入蘸有3×10~6CFU金葡菌0.3 ml的纱布及注射5%鱼肝油酸钠(Sodium Morrhuate SM)注射液(含有2%苯甲醇),以骨蜡封闭骨面,14天后,造成骨髓炎骨缺损模型。(二)治疗OBD1分组:将120只Wistar大鼠OBD模型随机分为3组,每组40只:第1组,对照组;第2组,肌瓣组;第3组,复合转移Ad-rhBMP-2组。2清创:清除不健康的软组织及坏死的骨组织,保留感染骨质,钻通封闭的髓腔。3实验过程:第1组:膝下愿切口进入,适当延长,清创后,缝合创口。第2组:取膝下切口,局部清创。更换手套及操作器械,自腹股沟中点向上方做“S”形切口,长约4cm,应用显微外科技术,自股动脉起始处找到向上走行的腹壁浅血管神经束,保留肌肉深层,游离血管神经蒂,宽4-5mm,及以腹壁浅血管、神经为蒂的肌瓣(Muscle flap with epigastria superficialis vessel pedicle,MFSAVP),并在与股动脉神经束交界处切断神经束。上下口之间做皮下潜行隧道,将肌瓣经隧道穿至下方的清创口,将肌瓣填充残腔,缝合创口。第3组:第一步:清创及转移肌瓣,同第2组;第二步:在肌瓣上分3点局部注射Ad-rhBMP-2,注意不损害肌瓣血供,缝合创口。4术后处理:3天内给予肌肉注射盐酸罂粟碱预防血管痉挛,按(10mg/kg/d),肌肉注射注射用头孢呋辛(按100mg/kg/d)抗感染知道伤口愈合。并分别在术后7、14、28、42、56天时,测量肛温、检验白细胞分析,以断髓法处死8只大鼠,观察大鼠肌瓣,检查胫骨CR,光镜下观察肌瓣组织病理切片,观测成骨情况。四实验结果(一)模型体重、肛温、局部表现、CR及光镜下所见病理图片示:7天时,骨髓炎急性期,7天后,症状逐渐缓解,14天时,骨髓炎转为慢性期,制造出OBD模型。(二)治疗第1组伤口愈合时间,比第2、3组时间长。第1组,术后56天时,残腔变小为原来体积的1/2,瘢痕填充缺损腔。第2组:术后56天时,肌瓣骨化,修复OBD。第3组,术后42天时,肌瓣骨化,修复OBD。五结论(一)将蘸有3×10~6CFU金黄色葡萄球菌的棉条植入Wistar大鼠胫骨上段骨缺损腔内,并腔内注射5%鱼肝油酸钠,骨蜡封闭,可以造成OBD模型。(二)将蘸有3×10~6CFU金黄色葡萄球菌的棉条植入Wistar大鼠胫骨上段骨缺损腔内,并腔内注射5%鱼肝油酸钠,骨蜡封闭,7天时,骨髓炎处于急性期;经过应用抗生素7天,骨髓炎转为慢性。(三)骨髓炎骨缺损区骨质直径(d),骨缺损面积(m),当m＞d×1.5d时,骨髓炎骨缺损很难自愈。(四)转移局部带血管蒂肌瓣,肌瓣可以骨化修复骨髓炎骨缺损。(五)Ⅳ途径转移5×10~8PFU/ml滴度的Ad-rhBMP-2诱导肌瓣骨化过程中,无明显排异反应。(六)Ⅳ途径转移Ad-rhBMP-2至肌瓣,可以诱导肌瓣骨化修复骨髓炎骨缺损。(七)当转移带血管蒂肌瓣修复骨髓炎骨缺损时,Ad-rhBMP-2可以缩短肌瓣骨化时间。更多还原

【Abstract】 一BackgroundOsteomyelitic bone defection(OBD) is very suffering to patients and formidable to doctors.Many patients with the OBDs have to receive amputation.The therapis for the OBD are anti-infection and repair bone defection(BD).These years,there are many articles about repairing the BD by Muscle flap with vessel pedicle(MFVP) and inducing muscle cells to bone cells by Ad-rhBMP-2.There was no article about the course of muscle flap ossification and transferring Ad-rhBMP-2 for curing the OBD.My study is to cure the OBD by the ossification of the MFVP,then transferring Ad-rhBMP-2 accelerating inducing muscle flap ossification.Provide a new effect therapy for the CO.二ObjectiveEvaluate and compare the therapy effect of the two ways:①using the technology of microsurgery transferring the MFVP,②combining the technology of microsurgery transferring the MFVP to OBD with geneⅣtransferring the Ad-rhBMP-2 to MFVP.三Method(一) Make OBD modals of the Wistar rats.We put a carbasus with 0.3 ml Staphylococcus aureus(SA)(3×106CFU) and injected 5%SM in the bone defection,and covered by bone wax.14 days later,we got the modals.(二) The treatment of OBD1 GroupingThe 120 Wistar rats modals were meanly divided into 3 groups randomly.The 1st group:Control group.The 2nd group:Muscle flap group.The 3rd group:with transferring Ad-rhBMP-2 group.2 DebridingMorbid soft tissue and necrotic bone were debrided until we can see the normal hemodiapedesis and infected bone was remained.The containing cavum medulla was penetrated by high speed electrical drill. 3 OperationsThe 1st group:we had not any proposal after debriding.The 2nd group:Before debriding,We did an incision about 4cm from inguina on, finding the superficial abdominal vessel and take the adaptive MFSAVP through a latent tunnel to fill the OBD,then sutured skin.The 3rd group:The 1st step was transferring muscle flap.It is the same as the 2nd group.The 2nd step was that we injected Ad-rhBMP-2 in the muscle flap from 4 points, and then sutured skin.4 Post-operation treatmentsViewed the rats condition of all over the body and vulnus timedly everyday.Muscle injection the Papaverine(10mg/kg/d) avoids artery spasm in 3 days and the Cefuroxime (100mg/kg/d) for anti-infection until intention.We executed 8 rats respectively at 7,14,28, 42,56day after theoperation to get the appearance of local tissue condition,the rectal temperature,the leuk-analysis,the tibias DR and pathological section for evaluating the course of ossification.四Result(一) ModalTemperature,lencocyte count,weight,CR and pathological section under light microscope showed at the 7 day after modal making,it is acute osteomyelitis stage,and 14 day after modal making,it is chronic osteomyelitis stage,so we got the modal.(二) TherapyThe intention time of the 1 st group was longer than that of the 2nd and 3rd.The 1st group:56 days later,bone defection is clear with its verge smooth and bone density higher while its area diminished to 1/2 of it was.The 2nd group at the 56 day and the 3rd group at the 42 day after operation:the OBDs were repaired by the ossification of the muscle flap.五Conclusion(一) The Wistar rats tibia acute osteomyelitic bone defection modal was made by injecting Staphylococcus aureus(3×10~6CFU),sodium morrhuate(5%) in bone defection then which was covered by absorbing film 7 days later.(二) The acute stage of osteomyelitis turned to chronic stage after 7 days effective antibiotic therapy.(三) The letter "d" means the diameter of the bone which the OBD occurred.The letter "m" means the OBD area.The natural cure is impossible if m＞d×2d.(四) muscle flap ossification repair OBD after transferred to it with vessel pedicle.(五) There is no obvious rejection during the ossification course sinceⅣtransferring Ad-rhBMP-2(5×10~8PFU/ml) in muscle flap byⅣway.(六) Transferring Ad-rhBMP-2 in muscle flap byⅣway,induce it ossification to repair the OBD.(七) Ad-rhBMP-2 shorten the time of ossification when use the muscle flap with vessel pedicle repairing the OBD.更多还原