深低温冷冻同种异体骨修复骨缺损的临床应用

采用－８０℃深低温冷冻同种异体骨植骨治疗缺损３２例。四肢良性肿瘤１７例，恶性肿瘤２例，创伤性骨缺损６例，重建椎体６例，重建跟重１例，异体骨加自体骨移植１８例，单纯异体骨１４例，大块异体骨移植１４例。Ｘ线片显示移植骨与宿主骨愈合良好，认为深低温冷冻同种异体骨是一种较理想的骨缺损修复材料。     

复合骨移植在下肢骨肿瘤保肢治疗中的应用

目的探讨复合骨移植在下肢骨肿瘤保肢术中重建骨缺损的手术原理及效果。方法应用携带监测皮岛吻合血管的自体腓骨与深低温冷冻大段同种异体骨复合移植，重建下肢骨肿瘤切除后的长段骨缺损12例。其中，骨肉瘤6例，恶性纤维组织细胞瘤1例，骨纤维结构不良2例，骨巨细胞瘤3例。结果12例经术后8～38个月随访，1例死于肺转移，2例带瘤存活，9例无瘤存活。术后功能优良率达75％。10例术后3个月内X线示骨端骨性愈合，2例内固定失败重新外固定后骨性愈合，所有均在9个月内能完全负重行走。结论携带监测皮岛吻合血管的自体腓骨与深低温冷冻大段同种异体骨复合移植，适用于下肢骨肿瘤保肢术中的长段骨缺损的修复，具有自体活骨移植和异体骨移植的双重优点。     

影响同种异体骨移植愈合的相关因素

现代冷冻保存技术和免疫学的进展 ,同种异体骨作为常用的骨移植替代材料广泛应用于各种原因引起骨缺损的修复和重建治疗。同种异体骨的免疫原性和制备、保存过程对其生物活性的干扰 ,严重影响同种异体骨与宿主的愈合和整合 (ｉｎｃｏｒｐｏｒａｔｉｏｎ) ,长期临床随访结果发现 ,骨不连和骨折的发生率达 16 %～17% [1、2 ] ,影响临床治疗效果。本文从同种异体骨的愈合机制、制备、保存和免疫学等方面 ,分析影响同种异体骨移植愈合的各种相关因素 ,以期提高临床应用同种异体骨移植修复骨缺损的治疗效果。1　影响同种异体骨与宿主愈合的因素目…     

骨肿瘤

20061286 复合骨移植在下肢骨肿瘤保肢治疗中的应用／王建炜…∥中华显微外科杂志．-2005，28（4）．-309-311 应用携带监测皮岛吻合血管的自体腓骨与深低温冷冻大段同种异体骨复合移植，重建下肢骨肿瘤切除后的长段骨缺损12例。其中，骨肉瘤6例，恶性纤维组织细胞瘤1例，骨纤维结构不良2例，骨巨细胞瘤3例。结果：12例经术后8～38个月随访，1例死于肺转移，2例带瘤存活，9例无瘤存活。术后功能优良率达75％。10例术后3个月内X线示骨端骨性愈合，2例内固定失败重新外固定后骨性愈合，所有均在9个月内能完全负重行走。结论；携带监测皮岛吻合血管的自体腓骨与深低温冷冻大段同种异体骨复合移植，适用于下肢骨肿瘤保肢术中的长段骨缺损的修复，具有自体活骨移植和异体骨移植的双重优点。图3参6     

新鲜和深低温冷冻同种异体骨软骨移植长期转归实验研究

[目的]观察和比较新鲜和深低温冷冻同种异体骨软骨移植后的长期转归情况,为同种异体骨软骨移植治疗关节软骨缺损进一步提供理论基础。[方法]建立兔膝关节软骨缺损模型,行新鲜和深低温冷冻同种异体骨软骨移植。在术后12个月和18个月,骨软骨移植物取材进行关节软骨蛋白多糖、软骨细胞活性检测和软骨细胞超微结构观察。[结果]新鲜和冷冻骨软骨移植物中蛋白多糖阿尔新蓝染色强度和存活软骨细胞比率术后均下降,且在各时间点新鲜移植组的结果优于冷冻移植组,有统计学差异(P0.05)。超微结构显示软骨细胞退行性改变。[结论]新鲜和深低温冷冻同种异体骨软骨在移植术后较长时间均出现严重退变,冷冻骨软骨移植物退变较严重,其作为关节软骨缺损治疗方法目前是不可行的。     

同种异体骨移植生物学

同种异体骨移植生物学孙磊综述胡蕴玉，宁志杰审校同种异体骨是临床上常用的替代自体骨移植材料，但同种异体骨移植可诱发宿主产生免疫排异反应，且目前临床上多采用经冷冻、冻干或化学处理的同种异体骨，其细胞成份多已坏死，因此同种异体骨移植在与宿主愈合过程中的表现...     

自体与同种异体骨移植修复四肢长骨骨缺损的对比研究

目的比较自体与同种异体骨移植修复四肢长骨骨缺损的临床效果。方法回顾性分析132例异体骨和97例自体骨修复重建四肢长骨骨缺损患者的临床治疗资料,比较两种方法愈合时间、骨性愈合评分（按Jorgenson标准）、并发症发生率及植骨失败率。结果异体骨重建组132例,4例因感染致植骨失败需行病灶清除灌洗加自体骨移植,10例发生局部排斥反应,其余118例患者术后骨缺损获得良好修复,愈合时间（17．6±1．9）周。骨性愈合评分2．7±0．5。自体骨重建组97例,9例出现供区疼痛、切口感染及局部皮肤麻木等供区并发症,骨缺损均获得良好修复,愈合时间（17．4±23）周,骨性愈合评分2．84±0.3。两组之间在愈合时间、并发症发生率以及愈合评分方面的差异无统计学意义（P〉0．05）;在植骨失败率方面的差异有统计学意义（P〈0．05）。结论运用同种异体骨和自体骨移植重建四肢长骨骨缺损,均能获得满意结果且疗效相似。异体骨移植术后感染致植骨失败以及排斥反应发生率较高,而自体骨移植则多表现为供区的并发症。     

应用异体骨及皮瓣移植修复小腿骨和皮肤缺损

目的报道应用同种异体骨及皮瓣移植修复小腿骨缺损并皮肤缺损的临床效果。方法采用深低温冷冻的异体胫骨移植，可调式支架外固定，带骨膜的皮瓣修复小腿骨缺损并皮肤缺损39例。结果35例皮瓣全部成活，4例皮瓣远端部分坏死，经二次皮瓣修复，创面愈合，术后X线复查，移植的异体骨对位对线好。术后1个多月有骨痂生长，术后6周可带外固定支架行走，术后8个月可拆支架行走。结论应用异体骨及采用带骨膜的复合皮瓣移植修复，加速骨的愈合，缩短疗程，可恢复行走功能。     

自固化磷酸钙复合BMP及同种异体骨修复兔股骨大段骨缺损

[目的] 观察一种新型自固化磷酸钙（CPC）复合BMP与同种异体骨修复兔股骨节段性骨缺损的效果，为临床复合应用大段同种异体骨移植提供参考。[方法] 54只新西兰大白兔随机分成3组，于一侧股骨中上段造成2cm长皮质骨缺损模型，分别进行：A组复合BMP与CPC的新鲜冷冻同种异体骨移植；B组单纯新鲜冷冻同种异体骨移植；C组自体大段骨移植。移植骨均用直径3mm三棱髓内针固定。于术后4、8、12周，进行影像学、组织学检查，对比各组移植骨愈合过程与修复效果。[结果] CPC复合BMP大段同种异体骨移植早期骨修复效果优于单纯异体骨移植（P〈0．01），与自体骨移植修复效果相似，至12周3组均达骨性愈合，以A组及C组骨修复塑形较好。CPC复合BMP组骨痂量较多，分布于移植骨与宿主骨结合部及移植骨周围，形成皮质骨外骨桥，并较早在异体骨外表面形成破骨与成骨，异体骨内哈佛氏管扩大，衬垫细胞、成骨细胞、破骨细胞及血细胞较其它组多。CPC随着新骨的形成及改建塑形逐步缓慢降解。[结论] CPC复合BMP对大段同种异体骨移植的愈合及替代有增强和促进作用。     

冷冻异体骨移植治疗骨肿瘤切除后骨缺损

目的探讨冷冻异体骨移植在治疗骨肿瘤切除后骨缺损中的作用。方法1992年3月至2002年9月应用深低温保存同种异体骨治疗骨肿瘤切除后骨缺损164例患者,其中男性90例,女性74例,年龄12～65岁,平均20岁。疾病种类以骨巨细胞瘤和骨肉瘤为主。外科治疗以Enneking外科分期标准为原则。主要发病部位为股骨上端、股骨下端、胫骨上端及胫骨上端及肱骨上端。异体骨均为北京骨科创伤研究所骨库提供。重建方式为1／2关节移植术95例,1／4关节移植术15例,人工关节．异体骨复合物12例,大块骨移植23例,骨干节段移植15例,骨盆骨移植4例。结果所有患者均获得随访,平均随访时间47个月。治疗满意率74．4％（122／164）,复发率12．8％（21／164）,感染率11．0％（18／164）,骨端不愈合23．2％（38／164）,内固定折断6．7％（11／164）,关节不稳定7．9％（13／164）,异体骨骨折6．7％（11／164）,死亡6．1％（10／164）,最终保肢率91．5％（150／164）。结论深低温保存异体骨降低了异体骨的免疫原性,具有与自体骨近似的骨传导性及骨诱导性,可保留韧带附丽以供软组织重建应用。但异体骨移植具有较高并发症,只有在移植骨与宿主完全愈合后,方可发挥作用。     

同种异体骨复合人工关节置换治疗骨肿瘤

目的：探讨分析同种异体同关节复合人工假体移植治疗骨肿瘤的临床应用及疗效。方法：对应用同种异体骨关节复合人工假体移植治疗骨肿瘤12例进行临床回顾分析。其中髋关节周围7例，膝关节周围3例，肩关节周围（肱骨近端）2例，病变性质；骨巨细胞瘤6例，皮质旁骨肉瘤2例，软骨肉瘤2例，转移性腺癌2例，均行肿瘤切除及异体骨关节复合人工假体移植。结果：本组12例病人手术均顺利，肿瘤获彻底切除，平均随访时间2．5年（1－5年），伤口均一期愈合无1例感染，关节功能按Mankin标准评定，优良率为91．6％，结论：同种异体骨关节复合人工假体移植是修复骨肿瘤的有效手段。     

带血管骨移植在四肢骨肿瘤治疗中的应用

目的临床观察带血管骨移植修复四肢骨肿瘤瘤段切除后骨缺损的治疗价值。方法对４８例不同类型的骨肿瘤行局部彻底切刮除,或骨膜外瘤段切除后所致的骨缺损分别采用带血管蒂髂骨瓣转位移植６例,游离移植３例;带血管胫骨瓣游离移植１例;带血管蒂腓骨瓣同侧顺逆行转位移植９例,游离腓骨移植２２例,双腓骨瓣组合移植４例,腓骨皮瓣游离移植３例进行修复治疗。结果移植骨与主骨均获得愈合,时间为２５～４２个月,平均３５个月。并经０５～１２年（平均４７年）的随访,４５例治愈,;３例复发,复发的３例病人中２例为骨肉瘤,１例为动脉瘤样骨囊肿恶性变,最终行了截肢术。结论证明带血管骨移植用于修复病变广泛的良性骨肿瘤或低变恶性骨肿瘤瘤段切除后的骨缺损疗效可靠,恶性肿瘤者较差。     

Bone stock reconstruction for huge bone loss using allograft-bones,bone marrow,and teriparatide in an infected total knee arthroplasty

Bone stock reconstruction using allograft-bones, bone marrow (BM), and teriparatide (TPTD) is reported. Huge and extensive bone losses occurred in the medullary cavity of the femur and tibia of a 55-year-old female rheumatoid arthritis patient with severe osteoporosis after debridement of her infected total knee arthroplasty. Because of the risks of unstable prosthetic fixation and intra-operation fracture, we first reconstructed the bone stock. Chipped allograft bones mixed with BM were implanted in the bone defects, and TPTD was administrated for the osteoporosis therapy. Good bone formation was found by computed tomography after 4 months. Bone turnover markers and bone mineral density (BMD) were increased at 6 months. We confirmed good bone formation at the re-implantation surgery. The newly formed bone harvested during the re-implantation surgery showed active osteoblast-like lining cells. TPTD is known to enhance allograft bone union, mesenchymal stem cell differentiation into osteoblasts, and BMD. This tissue engineering-based technique might be improved by the various effects of TPTD. This method without any laboratory cell culture might be a good option for bone stock reconstruction surgery in ordinary hospitals.     

肢体大块骨缺损的大段同种异种骨关节移植

作者为３５例四肢恶性肿瘤切除后的骨缺损患者进行了大段同种异体骨移植重建，其中男性２３例，女性１２例。股骨下端和胫骨上端占６８．５％。骨肉瘤占４０％。所有病例均经术前、术后化疗。植骨材料来源于该院综合骨库。作者强调充分的术前准备，仔细选择匹配移植骨段，手术中注意设计骨膜油套和软组织袖套以利于骨愈合。本组病例随访５个月￣１０年，平均３年，其中无病存活者２５例，死亡６例，带病存活４例。部分患者于术后２年     

Osteoarticular and Total Elbow Allograft Reconstruction With Severe Bone Loss

Osteoarticular allograft reconstruction is an option in patients with massive periarticular elbow bone loss secondary to tumor surgery or trauma. Our consecutive series consisted of 18 patients with tumors and one patient with trauma. Reconstruction consisted of 16 hemiarticular allografts and three total elbow osteoarticular allografts; patients had a minimum followup of 2 years (mean, 9.9 years; range, 2-12 years). For patients who had hemiarticular allografts, 14 of 16 were able to return to their preoperative level of occupational function, with one patient experiencing failure of the allograft from infection. For the three patients who had total elbow allograft reconstructions, all had degenerative changes develop after surgery and two of the allografts failed. Complications occurred in six of 19 patients. Hemiarticular elbow allograft reconstruction is useful for limb salvage with massive bone loss. Total elbow allograft reconstructions have a high failure rate in the mid-term. LEVEL OF EVIDENCE: Level IV, therapeutic study.     

同种异体骨移植的研究进展

同种异体骨移植是目前临床广泛使用于治疗各种骨缺损和促进脊柱融合的方法。根据处理方式的不同,同种异体骨可以分为：新鲜异体骨、深冻骨、冷冻干燥骨（fresh frozen allograft, FFA）和脱钙骨基质（demineralized bone matrix, DBM）。同种异体骨与新鲜的自体骨的愈合机制有着本质不同,其主要依靠“爬行替代”实现与宿主骨的融合,因此愈合速度慢、愈合质量差,容易发生骨不连和移植骨骨折,故存在较高的失败率。而复合生长因子、复合间充质干细胞以及红骨髓等方法可以提高异体骨愈合的速度。利用组织工程的原理与方法,采用复合移植的方法使异体骨得到活化,是今后异体骨移植研究与应用的发展方向。     

皮肤与骨骼复合缺损的修复

目的 探讨显微外科修复肢体骨与皮肤复合缺损的技术和效果。方法 39例肢体骨与皮肤复合缺损患者接受显微外科手术修复:游离移植背阔肌肌皮瓣,而后髂骨植骨4例,移植髂骨皮瓣7例,移植腓骨皮瓣6例,组合移植背阔肌肌皮瓣与游离腓骨20例,组合移植双侧背阔肌肌皮瓣与游离腓骨2例。结果 移植组织完全成活30例,9例移植的(肌)皮瓣远端皮肤发生局部浅表坏死,经换药后愈合。移植骨术后12～18周与宿主骨牢固连接。平均随访3年6个月,修复肢体均恢复有用功能。14例12岁以下儿童,修复后下肢生长正常,未发生肢体不等长现象。结论 严格手术指征,准确操作,酌情选择不同皮瓣与骨复合组织移植的显微外科修复是治疗骨与皮肤缺损的有效手段。     

Vascularized fibula transplantation in orthopedic oncology. Personal experience and review of the literature

Primary malignant bone tumors can be treated predominantly with limb salvage. After resection of large articular segments adjacent to the dia- or metaphysis of long bones modular endoprosthetic devices are most commonly used for reconstruction. In case non-vascularized corticocancellous bone is transplanted in order to bridge extensive bone defects, the risk of pseudarthrosis and fracture of the donor bone is significantly higher in comparison to a free vascularized transplant. From 1988 until 1999 we treated 20 patients with extensive bone defects after resection of tumors affecting the upper and lower extremity using a vascularized fibular graft. In this retrospective analysis we collected the data focusing on bone integration and functional outcome. The graft union was classified according to the standards of the "International Symposium of Limb Salvage". Evaluation of the functional outcome was quantified using the Enneking-score. The stabilisation of the transplant was obtained exclusively by plate fixation in the upper extremity. In 10 in a total of 12 patients the reconstruction using a vascularized fibula transfer was reinforced with an allograft in the lower extremity. The functional evaluation score reached 73% of normal function at the last follow-up. After 18 months the radiographic evaluation of graft union was "excellent" in 75%, "good" in 11%, "fair" in 6% and "poor" in 9% according to the criteria of the ISOLS. Main complications were graft fracture in of 15% and pseudarthrosis in 14.3%. Reconstruction of extensive bone defects using free vascularized fibula grafts are a demanding operative procedure. The procedure combines a biologic form of reconstruction with a legitimate expectation of good long term outcome and a relatively low rate of complications.     

Rekonstruktion von Segmentdefekten der langen Röhrenknochen

Surgery of malignant tumors and the subsequent outcome after treatment of complicated fracture situations of long bones often result in major bone defects. In addition to bridging of defects and stabilization with allogenic implants, defect reconstruction by callus distraction with segment transport and vascularized free fibula transfer are the procedures of choice for defect reconstruction in long bones. The heterogeneity of the causes of large bone defects and specific comorbidities of the patients require a differentiated approach. The indications and characteristics of the various surgical approaches and current developments in procedures for reconstruction of large defects in long bones are presented.