【作者】 张志敏；

【导师】 刘建； 吴尧平；

【作者基本信息】 第四军医大学 ， 外科学， 2008， 硕士

【摘要】 研究背景鞘管区术后肌腱粘连是肌腱损伤后常见问题,是手外科尚未解决的难题之一,迄今为止,仍无有效的解决方法。肌腱粘连是指肌腱损伤修复过程中周围组织的增生和侵入,造成肌腱运动功能障碍。虽然目前治疗肌腱粘连的方法有多种,但其治疗效果并不显著。近年来,细胞因子TGFβ逐渐受到国内外学者的关注。TGFβ是一个25 000同源二聚体,它通过促使成纤维细胞和巨噬细胞的募集、促进血管的生成、刺激胶原的产生、下调基质金属蛋白酶的活性和增加基质金属蛋白酶抑制剂的活性而发挥作用,是一个在急性炎症及伤口愈合中起重要作用的细胞因子,它的过分表达可导致过度的瘢痕增生和纤维化[1-2]。实验证实:在TGFβ的亚型中,TGFβ₁与胶原形成关系最为密切。通过利用TGFβ₁拮抗剂来抑制肌腱周围TGFβ₁的生物活性,从而抑制肌腱周围瘢痕的过度形成,已成为目前研究的热点。本实验我们研究TGFβ₁中和抗体预防肌腱粘连的可能性及对肌腱愈合后生物力学的影响.考虑到TGFβ₁抗体在局部代谢快,作用不持久的问题,决定将TGFβ₁抗体与生物蛋白胶复合应用于局部,在局部发挥其的缓释作用,旨在找到一种效果较为理想的抗粘连药。目的1.研究TGF-β₁抗体复合生物蛋白胶预防鞘管区屈肌腱粘连的作用。2.研究肌腱损伤局部应用TGFβ₁抗体复合生物蛋白胶后,对其愈合后功能有无影响。方法本实验将成年雄性来亨（Leghorn）鸡72只随机平均分为4组,每组18只。左足第3、4趾趾深屈肌腱横断,四股交叉缝合肌腱,鞘管未缝合。按鞘管区给药分为4组:A组TGF-β₁Ab、B组FG、C组TGF-β₁Ab+FG、D组生理盐水。仅术中注入一次药物,术后1、3、8周处死取材。实验一形态学观察:在术后1、3、8周,每组各取6只鸡,将其第4趾制成冰冻切片,分别行大体观察和组织学观察。实验二生物力学测定:在术后1、3、8周,每组各取6只鸡,利用特制模具对其第3趾分别行肌腱滑动距离、模拟主动屈曲度及屈曲功测定;待上述测定结束后再将标本制成末节趾骨-趾深屈肌腱复合体,行最大抗断裂载荷测定。结果实验一形态学观察:1.大体观察:术后1、3、8周肌腱粘连程度分级A组与B组无统计学差异（P>0.05）, C组与其余3组比较有统计学差异（P<0.05）。2.组织学观测:术后3、8周A、B、D组胶原纤维排列紊乱,C组胶原纤维排列较其余三组整齐。实验二生物力学测定:1.肌腱滑动距离比值:术后3周,各组肌腱滑动距离比值分别为0.45±0.05、0.40±0.10、0.79±0.09、0.25±0.07;术后8周,各组肌腱滑动距离比值分别为0.45±0.07、0.43±0.08、0.80±0.09、0.29±0.05。术后3、8周,C组与其余三组比较差异均有统计学意义（P<0.05）。2.模拟主动屈曲度比值:术后3周,各组模拟主动屈曲度比值分别为0.61±0.02、0.67±0.03、0.91±0.03、0.53±0.04;术后8周,模拟主动屈曲度比值分别为0.61±0.02、0.63±0.03、0.92±0.03、0.53±0.03。术后3、8周,C组与其余三组比较差异均有统计学意义（P<0.05）。3.屈曲功:术后3周,各组屈曲功分别为18.0±0.77度/N、17.8±1.13度/N、27.6±1.73度/N、15.6±1.27度/N;屈曲功分别为18.3±0.84度/N、15.3±0.75度/N、27.9±1.24度/N、18.6±0.80度/N。术后3、8周,C组与其余三组比较差异均有统计学意义（P<0.05）。4.最大抗断裂载荷:术后3周,各组最大抗断裂载荷分别为14.2±1.9 N、15.2±2.2N、16.0±2.2N、14.7±2.7N;术后8周,各组最大抗断裂载荷分别为51.9±3.0N,51.4±1.44N,53.3±1.3N,52.3±2.2N。术后3、8周,各组间差异均无统计学意义（P>0.05）。结论1. TGFβ₁抗体复合生物蛋白胶可以有效预防术后肌腱粘连;2.肌腱损伤局部应用TGF-β₁抗体复合生物蛋白胶后,肌腱的正常愈合进程及愈后功能不受影响。更多还原

【Abstract】 BeckgroundThe tendon adhesion post-operation in the sheathing canal area is a common and tough problem after tendon injury and there is no effective resolvent so far. tendon adhesion is proliferation and intrusion of periphery tissue during the process of wound healing, and induces the motor dysfunction of tendon. The therapeutic efficacy of clinical treatments of suppressing tendon adhesion is not significant.Nowadays the transforming growth factor TGFβhas received much more schola -stic attention. TGFβis a 25 000 homodimer, and has various functions includeing promoting the aggregation of fibroblast and macrophage, enhancing the angiogenesis, stimulating the production of collagenous, down-regulating the matrix metalloprotein -ase and up-regulating the matrix metalloproteinase inhibitor. TGFβis a important cytokine in acute inflammation and wound healing and the over express -ion can induce the scar hyperplasy and fibrosis[1-2]. It is confirmed that inhibiting the biologi -cal activity of TGFβ₁ around the tendon by TGFβ₁ inhibitor become a hot spot.In our experiments we studied the possibilities of preventing the tendon adhesion and the influence on tendon healing of TGFβ₁ antibody. Concerning about the fast region metabolism and low effectiveness of TGFβ₁, the compound of transforming growth factor-β₁ antibody and fibrin glue （TGFβ₁ Ab + FG） was investigated in order to delaying TGFβ₁ antibody release and find a therapeutic way to solve the tendon adhesion.Purpose1. To explore the preventing influences of the compound of transforming growth factor-β₁ antibody and fibrin glue （TGFβ₁ Ab + FG） on prevention of peritendinous adhesive formation.2. To study the effects of applying the compound of TGFβ₁ Ab + FG in region on the function o f healed tendon .MethodsSeventy-two Leghorn chickens were randomly divided into 4 groups （group s A , B ,C and D） , 18 chickens for each group, and the long flexor tendons of the 3rd and 4th toes in zoneⅡof 72 leghorn chickens were transversed and sutured with The 4-strand Cruciate repair technique to make defect models. In group A , TGFβ₁ antibody was applied at repair site.In group B, FG was applied at repair site. In group C, The TGF-β₁Ab and FG 0.2 ml compound was applied at repair site. In group D, normal sodium was applied at repair site. At 1, 3 and 8 weeks after operation, the chickens tendons in each group were harvested.The first part of our study was to observe the morphological influences of the compound of TGFβ₁ Ab + FG on tendon repair. After 1, 3 and 8 weeks post operation, the tendons of 6 chickens in each group were harvested. And the 4th toes were made into frozen section for morphological and histological evaluation. The second part of our study was to detect the biomechanical influences of the compound of TGFβ₁ Ab + FG on tendon repair. After 1, 3 and 8 weeks post operation, the tendons of 6 chickens in each group were harvested. And the 3rd toes were obtained for biomechanical test including the gliding excursion,the simulated active flexion and the work of flexion. After all the tests above ,the specimens of each group were made into the compound of phalanx ungula and flexor digitorum profundus muscle to test the tendon anastomosis breaking strength.ResultsFirstly, the results of morphological observation.1. The gross observation showed that the differences of grading of tendon adhesion were not significant among groups A , B, and D（P > 0. 05）, but in group C, the differences were significant between A , B, and D after 3 and 8 weeks postoperation （P < 0. 05）.2. Histological observation showed that collagen fibers of group A, B and D were in a great disorder, but were well-formed in group C.Secondly, the results of biomechanical tests.1. The gliding excursion ratio of the tendons in group A , B, C and D were 0.45±0.05、0.40±0.10、0.79±0.09、0.25±0.07 respectively after 3 weeks postoperation; the same ratio of the tendons were 0.45±0.07、0.43±0.08、0.80±0.09、0.29±0.05 respectively after 8 weeks. Compared with other three groups, the group C had significant differences after 3 and 8 weeks （P < 0. 05）.2. The simulated active flexion ratio were 0.61±0.02、0.67±0.03、0.91±0.03、0.53±0.04 respectively after 3 weeks postoperation; the same ratio of the tendons were 0.61±0.02、0.63±0.03、0.92±0.03、0.53±0.03 respectively after 8 weeks. Compared with other three groups, the group C had significant differences after 3 and 8 weeks （P < 0. 05）.3. The work of flexion were18.0±0.77D/N、17.8±1.13D/N、27.6±1.73D/N、15.6±1.27 D/N respectively after 3 weeks postoperation, and were 18.3±0.84D/N、15.3±0.75 D/N、27.9±1.24 D/N、18.6±0.80D/N respectively after 8 weeks. Compared with other three groups, the group C had significant differences after 3 and 8 weeks （P < 0. 05）.4. Tendon anastomosis breaking strength were14.2±1.9N,15.2±2.2N,16.0±2.2N, 14.7±2.7N respectively after 3 weeks postoperation, and were 51.9±3.0N, 51.4±1.44 N, 53.3±1.3N, 52.3±2.2N respectively after 8 weeks. There were no significant differences among the 4 groups after 3 and 8 weeks （P > 0.05）.Conclusion1. The compound of TGFβ₁ antibody with FG could significantly prohibit the formation of fibrous adhesions .2. Applying the compound of TGFβ₁ antibody with FG after tendon injury did not interfere with the healing process.更多还原