Chinese Journal of Tissue Engineering Research ›› 2014, Vol. 18 ›› Issue (46): 7515-7519.doi: 10.3969/j.issn.2095-4344.2014.46.027
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Gao Jun1, Wang Wei1, Na Lei1, Jiang Hong-tao1, Liu Shi-bo2, Wang Pei2
Revised:
2014-10-11
Online:
2014-11-12
Published:
2014-11-12
Contact:
Wang Pei, Master, Associate professor, Department of Hand and Foot Surgery, Affiliated Hospital of Chengde Medical University, Chengde 067000, Hebei Province, China
About author:
Gao Jun, Studying for master’s degree, Chengde Medical University, Chengde 067000, Hebei Province, China
CLC Number:
Gao Jun, Wang Wei, Na Lei, Jiang Hong-tao, Liu Shi-bo, Wang Pei. Tendon adhesion prevention: status and progress[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(46): 7515-7519.
2.1 手术修复方法在肌腱粘连预防方面的应用 黄克[6]提出肌腱的手术修复应符合以下的3项原则:①能够最大限度的恢复肌腱表面光滑度。②对肌腱断端血运不产生影响。③要有一定的扩展度。 肌腱吻合方法在防止肌腱粘连方面也起着非常重要的作用,肌腱吻合方法较多(图1),如Tsuge缝合、KH缝合、8字缝合、Kleinert缝合、Becker缝合、编织、Kessler缝合、改良Kessler缝合、Lee缝合等。束状肌腱吻合临床上常用改良Kessler缝合[7]。Tang法的拉伸强度、韧度、负荷、断裂功耗最高[8]。扁平状的肌腱多采用多个“8”字缝合方法[9]。国内外学者通过实验对几种方法进行比较,发现改良Kessler在预防术后肌腱粘连方面效果良 好[10-11]。 长期以来腱鞘损伤后是否进行修复一直存在争议,以往对于腱鞘的处理原则是切除或者不予修复。Keyser等[12]主张不修复腱鞘以保证移植肌腱的成活。随着对肌腱愈合机制及腱鞘作用的认识,杨志明等[13]认为腱鞘的完整对肌腱的修复尤为重要,具有不可替代的作用。陆奎元等[14]也认为腱鞘可以为肌腱提供屏障作用及滑动支持结构,提出肌腱与腱鞘应当同时修复。近年来,学者们普遍认为进行腱鞘及腱周膜的修复有利于减少肌腱的粘连。汤锦波[15]通过临床实验研究,用自体腱鞘移植修复腱周缺损,提出对于以往的治疗效果较差的肌腱损伤可以通过重建腱周组织减少肌腱粘连。很多学者提倡用显微修复的方法修复肌腱、腱鞘及腱周膜。如吴景明等[16]通过实验提出:显微修复肌腱及腱周组织可以减轻术后肌腱的粘连。王忠,薛宏斌[17]通过临床试验得出结论,认为肌腱修复术中给予一期显微缝合腱旁组织,能更好的保护肌腱的血运,促进减轻肌腱粘连。"
2.2 药物在肌腱粘连预防中的应用 临床试验表明,很多药物都具有减轻局部肌腱粘连的功效,常用的药物有:类固醇皮质激素、非类固醇类抗炎药、去纤维蛋白类、抑制胶原合成类、抑制胶原交联药、中药(川芎嗪、当归及丹参注射液、红花黄色素等)。郭明珂等[18]提出:应用5-氟尿嘧啶是可以有效减轻肌腱粘连[19]。宋根套等[20]证实丝裂霉素C有防止肌腱粘连的作用。葛廷云,李 雪[21]应用几丁糖防治术后肌腱粘连,指出几顶糖具有良好的预防肌腱粘连的效果。林浩东等[22]证实糜蛋白酶可以防止肌腱粘连。 目前药物薄膜受到了国内外学者的青睐,它既可以通过薄膜的屏障作用来预防肌腱粘连,还可以通过所载药物的药理作用影响肌腱的愈合机制,达到减轻粘连的目 的[23-27]。 2.3 细胞因子在肌腱粘连预防中的作用 近年来,应用细胞因子防治肌腱粘连已成为一种可行的途径。如张志敏 等[28]用来亨鸡制备实验模型,得出转化生长因子β1 AB复合FG能有效的预防肌腱修复术后粘连且不影响肌腱的正常愈合。谢志新等[29]通过动物实验得出结论,认为Synoviolin基因修饰滑膜细胞,可以使使无滑膜肌腱滑膜化,在提高肌腱愈合质量的同时有效的防治肌腱粘连。王继宏等[30]提出应用表皮生长因子与胶原膜联用促进肌腱内源性愈合且防止外源性愈合,具有防止肌腱粘连的作用。熊雁,张正治[31]提出核心蛋白聚糖能显著减少屈肌腱损伤修复术后粘连,且能调节胶原纤维的形成,促进肌腱愈合。Molloy和Mi等[32]对类胰岛素生长因子、血小板源性生长因子等进行基因转移研究,证明其起到了改善肌腱愈合的效果。 2.4 阻隔材料在肌腱粘连预防中的应用 使用阻隔材料作为鞘膜替代品,可以有效的减轻肌腱的外源性愈合从而减少肌腱粘连。现有的阻隔材料包括生物材料、合成材料和假性鞘膜。 2.4.1 生物材料 目前采用的生物材料有:动静脉血管、腱周组织、软骨、人胎羊膜、阔筋膜、硬脊膜等,学者们以上述材料修复腱周缺损或包绕到肌腱缝合段,起到了减轻肌腱粘连的作用。 2.4.2 合成材料 许多合成材料曾被作为腱鞘替代品用以预防肌腱的外源性愈合从而预防肌腱粘连,如银片,硅管等的。但由于其通透性及组织相容性差,不但容易阻断肌腱的营养,而且可以导致肌腱断端严重的炎性反应从而导致肌腱坏死,因而未能真正的应用于临床。章国庆等[33]利用金箔来预防屈肌腱粘连,通过观察对比肌腱的滑动功能发现,金箔组的效果明显的优于单纯肌腱修复组,且金箔组不会对肌腱的正常愈合产生影响,是较理想的防粘连材料。 2.4.3 假性鞘膜 Hunter等[34]通过实验研究和临床实践均已证明将Silastic棒放置在屈指肌腱的缺损位置,经过4-8周可以生成假性鞘膜(环绕Silastic棒一周的环形管状结构),然后再进行肌腱移植。因假性鞘膜的结构与正常的腱鞘相似,从而起到减轻肌腱粘连的作用。 2.5 物理疗法 超声波治疗,音频电治疗,氦氖激光照射等都对减轻肌腱粘连起到了效果。田德虎等[35]将透明质酸钠与分米波照射在预防肌腱粘连方面做了比较,结果得出透明质酸钠和分米波在防止术后肌腱粘连方面均起到了良好的作用。 2.6 术后康复治疗 Durbert[36]认为肌腱修复术后早期进行主动功能锻炼可以达到增强肌腱的内源性愈合,减轻肌腱粘连的作用。Savage等[37]认为肌腱术后早期活动不但有助于血管再生及肌腱的愈合,还可以起到增加肌腱强度,促进肌腱愈合后塑形的效果。目前大多数学者认同术后早期主被动锻炼可减轻肌腱粘连的观点。早期进行保护性的被动活动可以预防肌腱粘连的机制可能为:①机械作用。肌腱的反复滑动打断了肌腱缝合段与周围组织的接触,抑制了肌腱的外源性愈合。②迅速重建肌腱的有关功能。应力的改变,肌腱的滑动,诱导肌腱本身的肌腱外膜细胞发生分化,抑制炎性细胞浸润肌腱。③增殖期的腱鞘细胞向肌腱方向生长,覆盖了肌腱外膜,早期活动可以阻止腱鞘细胞过多的向肌腱缝合段生长,从而起到阻断二者之间粘连的作用。"
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