【作者】 王飞；

【导师】 张桂生； 朱晓光；

【作者基本信息】 河北医科大学 ， 外科学， 2008， 硕士

【摘要】 目的:肌腱损伤在骨科临床工作中极其常见,特别是屈指肌腱,其术后愈合与粘连问题的解决一直是个难题。虽然尽力恢复其连续性,保持修复、吻合处平整、光滑,但绝大多数患者都须经过长时间的固定及二期肌腱松解来进一步恢复其功能,且功能恢复的程度仍不理想。多年来,人们对肌腱解剖、生理、病理及愈合过程进行了大量的临床及实验研究,探索了许多促进肌腱愈合和预防粘连的方法,取得了一定的成果,但是始终没有一种效果确切而且操作简单、成本低廉的方法能够在临床普遍推广。碱性成纤维细胞生长因子(bFGF),是肝素结合型生长因子家族中的成员之一,是由146个氨基酸组成的多肽。已有研究证实,外源性bFGF既能促进肌腱愈合也加剧粘连程度,关键在于选择什么样的途径或方法能够扬长避短。这成为目前国内外研究的重点。本试验通过将静脉留置针置于肌腱断端间,早期持续注入适量bFGF,干预肌腱的愈合过程。从组织学角度观察其对肌腱内源性愈合的影响,以及比较愈合与粘连的进程。旨在为肌腱损伤后加速肌腱愈合的进程,使之适于早期功能锻炼提供理论依据。方法:健康雄性莱亨鸡78只,随机分成3组。氯胺酮肌肉注射麻醉成功后,稳妥固定于操作台上,右膝关节以远常规清洗、消毒、铺巾。于第3趾近节与中节“┏┓”形切开皮肤分离皮下组织,打开A2-A4滑车之间的鞘管。制备趾深屈肌腱横断模型。A组近侧端肌腱内纵行放置静脉留置针,开口于断端,以备断端间给药。B组鞘管内放置静脉留置针,以备鞘管内给药。C组原位缝合肌腱、自然愈合。三组均采用6-0无创伤缝合线行改良Kessler缝合,间断缝合修复鞘管。术后各组均用石膏固定鸡爪成拳击手套状,各组动物回笼饲养,自由活动。抗生素应用3天,预防感染。自术后24小时起经留置针应用5.0ng/ml的bFGF,A组2μl/次、B组5μl/次。每12小时一次,连续8次,拔除留置针。于术后2、3、4、6周各组分别取6只鸡,局麻下逐层解剖。行大体观察,HE、Masson组织染色观察,图像分析,术后4周各组加取两趾行扫描和透射电镜观察,对各组数据进行统计学分析。结果:大体观察:术后2周,各组半透明胶冻样物存在于断端间及周围,B组肌腱断端周围广泛粘连,微红色、较疏松的组织填充于腱鞘与肌腱之间,质脆;A、C两组粘连程度相似较B组轻,B组断端胶胨样物质与A组相似,颜色较C组暗,坚韧度也强于C组。术后3周,吻合处梭形膨大的颜色有所加深,弹性增强,质较韧,粘连明显加重,B组粘连范围较大,钝性分离较难,断端连接牢固,肌腱滑动受限;A、C组仅梭形膨大处粘连,钝性分离较B组容易;各组断端胶胨样物质颜色更浑浊,坚韧度增强,C组相对较差。术后4周,B组肌腱致密粘连,粘连带与3周时相似,须锐性分离。腱断端被较牢固的纤维组织连接,暗灰色,质韧,弹性好;A、C组肌腱粘连范围相似,愈合情况A组明显好于C组。术后6周,肌腱粘连程度A、C两组相似,较B组肌腱粘连程度轻。A、B组愈合质量相似,较C组好。组织学观察:A、B两组断端愈合情况表现相似。A、C两组腱周围粘连情况接近。术后2周,A组肌腱实质内成纤维细胞增生非常活跃,可见大量新生胶原纤维和增生的毛细血管,明显多于腱周。B组腱实质内成纤维细胞及胶原纤维排列含量较A组稍差,腱周大量肉芽组织增生。C组成纤维细胞数量和新生胶原纤维量较少,排列紊乱,可见少量炎性细胞浸润。术后3周,A组肌腱断端由大量新生的形态和排列较规则的成纤维细胞和胶原纤维所连接。腱周和腱实质内细胞数量增加。毛细血管数量较前有所减少。B组腱实质与腱周的成纤维细胞及胶原纤维含量丰富,新生的胶原纤维和成纤维细胞连接断端,胶原纤维排列较A组稍紊乱。C组大量成纤维细胞增生较活跃,新生胶原纤维粗大、不均匀、排列较紊乱,纵横交错较严重。毛细血管明显增生。术后4周,A、B组肌腱断端愈合情况均较好,成纤维细胞增生旺盛,向腱细胞分化。胶原纤维均匀,排列规则。C组较差。B组粘连最重。术后6周A组愈合情况最好,可见断端的胶原纤维基本融入腱实质,界限不明显。毛细血管少见;B组腱内情况与A组接近,但肌腱与周围组织的粘连严重;C组实质内成纤维细胞较多,腱细胞明显较A、B组少,且分化稍不成熟。断端胶原纤维丰富、不均匀、呈波浪状、排列趋于规则,自断端向腱实质过度明显。图像分析结果:术后各周腱实质内成纤维细胞数量和胶原纤维含量A组与B组之间差异无统计学意义P>0.05 A、B组与C组之间差异有统计学意义,量都大于C组,P<0.05;腱周A组与C组之间差异无统计学意义P>0.05;A、C组与B组之间差异有统计学意义P<0.05。结论:损伤肌腱内纵行留置纤细的留置针,于肌腱断端处早期滴注5.0ng/ml的外源性bFGF,可以有效的促进肌腱内源性愈合,且不增加肌腱与周围组织的粘连程度,加快了肌腱的愈合过程,为进行早期功能锻炼提供了组织学依据。此方法操作简单,用药方便,效果确切,且成本低廉不增加患者负担。为临床肌腱损伤的修复提供新的思路。更多还原

【Abstract】 Objective: We often see injury of tendon in clinical orthopae- dics especially flexor tendons injury. It has always been a difficult problom in healing and adhesion after operating. Doctors try to recover its continuous, keep recovering, try to solve the injured smooth, but it always takes most of the patients a lot of time for external fixation, and recover the function with secondary tendonlysis, but we cannot always get efficacy well. For many years, people do a lot of experimental research on anatomy, physiological, pathological and the process of the healing. They explored many good ways to promote the healing of tendons and prevention adhesion. They have made some achievement. However, we still cannot find a good way, and a cheaper way to develop in clinical.bFGF is a member of heparin binding growth factor family. It consists of 146 amino acid residues, and is a polypeptide. Studies have shown that exogenous bFGF not only can promote the healing of tendons, but also can facilitate the formation of tendon adhesion. It is a very important that choose the proper way so as to developing merits, avoiding weakness. It has been the main point to study at home and abroad. So far, we do the experiment to make the venous indwelling trocar to break end. We continus injecting a little bFGF early time, intervent the process of the healing of tendon. To investigate the effect of bFGF influences on intrinsic healing of flexor tendons within synoviail sheath from histological observation, and compared the processes of healing and adhesion. To provide theoretical foundation that promote the process of healing of tendon after injuring, make it fits for early stage dirigation.Methods: We used 78 healthy male leghorns, divided leg- horn into 3 groups randomly, each chicken was anaesthesiaed with Ketamine intramuscular injection, and then fixed on the operating board . The right foot was disinfected routily. Cut the skin of proximal phalanx and midplate of the third dactly as "┏┓" shape separates the tela subcutanea, cuts open the sheath tube between the A2-A4 pulley. After the model of the deep toe flexor tendon breaking cross had been made, proximal longitudinal near group A put the venous indwelling needle, opened at the break end, in order to put the medicine in it. Within flexor sheath on group B put the venous indwelling needle, in order to put medicine in flexor sheath, suture in situ on the original of group C, make it normal healing. With 6-0 non-injured suture line, using the method of Modified Kessler suture technique after the tendon had been severed. Then with 7-0 non-injured suture line to suture the sheath, use the plaster to fix chicken’s foot as boxing gloves. After operation, the chicken is raised in the cage free-running, using the antibiotics for 3 days to prevent infection, injected 5.0ng/ml of bFGF after opration 24 hours, 2ul for group A once a time, 5ul for group B once a time, twelve hours once, go on for 8 times, then pull the indwelling needle out after 12 hours of the last one. 2,3,4,6 weeks after the operation, six toes of leghorns in every group were dissected layer-by-layer in local anesthetic. The conditions of tendon healing and adhesion were observed. Every section was used for HE staining, Masson’s staining, and the conditions of tendon were observed under light microscope, the function of cells was observed under transmission electron microscope (TEM) and scanning electron microscope (SEM).The picture analysis of the sections was dealt with cell parameter analysis system. Put the data into computer to statistical analysis.Result: Gross appearance: Two weeks after operating, translucent colloidal of each group exists in the break end and the around. The tendon break end in group B was wider adhesion, a bit red, more looser, connective tissue filled in between the tendon sheath and tendon, it is crisp. The adhesion of A and C is a little lighter than group B, the substance of colloudal in group B is similar to group A, it is a little darker than group C in color, the toughness is stronger than group C; Three weeks after operating, the color of the shuttle-shape connection is darker and less crisp, the adhesion was more seriously, the scope of adhesion in group B is wider, and the blunt seperation is harder than before, the break end connected stronger and the tendon gliding movement passively is limited. In group A and C, only the shuttle-shape connection adhered, the blunt seperation was easier than group B; The color of break end colloidal in every group was more epinepheloser, the toughness is more stranger, but group C is weaker. Four weeks after operating, the pyknotic tendon adhesion were formed in group B, the adhesion band was the same as that before one week, and mast be divided by sharp separation. The break end was connected firmly by fibrous tissues, gray in color, pliable but strong, and elasticity was good. Adhension between A and C was very similar, but it is clear that the quality of healing of group A was better than group C. Six weeks after operating, the degree of adhension of group A and C were similar, more lighter than group B, the quality of healing of group A and group B were similar, and it was better than group C.Hisological observation: The break end between group A and group B are similar, the adhension group A and group C was nearly the same. Two weeks after operating, the fibrolasts in tendon group A proliferate very activity so we can find new collagen fibers and hyperplasia of capillaries, obviously more than peri-tendon, he fibrolasts in tendon and collagen fibers in group B is weaken than group A, and granulation tissues were growing. The granulation tissues around tendon, the number of cells and collagen fibers in group C became less, he range of the cells was in group C was in disorder, so we can see only a few inflammatory cells infiltrated in group C. Three weeks after operating, the break end in group A was collagen fibers, the cells between sheath and parenchyma less than before, and the capillaries less than before too. The fibrolasts and collagen fibers in parenchyma and sheath of group B were abundant. The break end was linked by collagen fibers and fibroblasts, the range of collagen fibers was little in disorder than group A. A lot of fibroblasts in group C proliferate lively, and the new collagen fibers the range was in disorder, crassitude, inhomogeneous, capillaries proliferate obviously. Four weeks after operation, the tendon break end in group A and B healed both well, the fibroblasts proliferate vigorously differentiation into tenocytes, collagen fibers were well distributed, the range was in regular. Group C is a little worse. The adhesion in group B was the most serious.Six weeks after operation, the quality of healing of group A was the best, the collagen fibers break end were melted in parenchyma of tendon, the border wasn’t obvious, capillaries less. The condition of parenchyma in group B was approximate to group A, but the adhesion was more serious; In group C, fibrolasts proliferat vigorously, but tenocytes were less than group A and B clearly, and the differentiation was immature. The collagen fibers proliferate was abundant inhomogeneous, and the arrangement trend to regular but was waves in arrangement. It was abviously that collagen fibers transit from the break end to parenchyma of tendon.The result of image analysis: On the total area of fibroblast and the amount of collagen fiber in most of weeks after operation, there was not statistically significant difference between group A and group B, P>0.05; but between group A、B and group C was statistically significant difference, P<0.05. However, on the total area of fibroblast and the amount of collagen fiber in peri-tendon there was statistically significant difference between group A、C and group B, P<0.05. But between group A and group C wad not statistically significant difference, P>0.05.Conclusion: The method that put the venous indwelling needle in longitudinal proximal near, and put 5.0ng/ml bFGF early in the break end of tendon can promote the process of healing of tendon. It won’t promote the level of adhesion between tendon and tissue around the tendon, so that it provides the proof of histology to early stage dirigation. The method is very simple, and the price that the patient can afford is cheap We can apply chemicals conveniently, and may achieve definite results. It provides a new way to recover the tendon damnifi- cation in clinic.更多还原