肌腱缺损治疗的研究进展

肌腱缺损治疗的研究重点在于获得理想的移植材料.目前临床应用的肌腱移植材料主要有以下几类:自体肌腱、同种异体肌腱、人工肌腱和组织工程化肌腱,但均存在各自不足.笔者就肌腱移植的研究现状及进展作一综述.     

组织工程在创伤修复中的应用

创伤修复涉及到自体、同种异体组织移植及人工材料替代。上世纪80年代中期出现的组织工程学,为创伤修复提供了新的方向,即用活的细胞接种在可降解支架材料上,经体外培养后植入体内,修复组织缺损,重建功能。本文根据最新文献,介绍了组织工程的主要基础研究成果及临床应用的经验。     

关节软骨修复材料研究进展

软骨缺损修复特别是大面积软骨缺损修复目前仍然是骨关节外科医生及骨科研究学者的难题.本文针对目前软骨修复材料的基础科学作一个较系统的回顾及总结,并将软骨修复材料分为三大类:(1)自体软骨转移;(2)异体骨软骨移植;(3)组织工程材料.在此基础上对临床软骨缺损修复提供一种理论上的选择,提出针对临床应用的软骨缺损修复解决方案和未来软骨修复研究的发展方向.     

常用膜性脱细胞基质的制备

因外伤、肿瘤、感染等原因所致的组织缺损十分常见,针对不同的缺损修复方法众多,但至今仍无一种最为理想的方法。缺损修复经历了由最初异体、异种材料到自体组织移植再向生物替代材料移植转变,已期在获得满意修复效果的同时减少自体组织的损伤。近年来,随着细胞生物学和组织工程技术的发展,一种新兴的修复材料一脱细胞基质逐渐兴起并在临床得到应用,并形成了一些比较成熟的应对组织的脱细胞技术。     

穿支皮瓣在大面积软组织缺损创面修复中的应用研究进展

【摘要】 大面积软组织缺损多由直接或间接暴力伤所致， 常伴有大血管、 肌腱、 神经以及骨骼等深部组织外露甚至损毁， 一旦修复不及时或修复不当可导致机体局部功能障碍、 畸形等而影响患者的生活质量。 近年来，随着显微外科技术以及皮瓣外科技术的不断发展， 以传统游离皮瓣移植技术为基础发展而来的穿支皮瓣移植在大面积软组织缺损创面的修复中得到了广泛应用， 并取得了较好的临床疗效。 本文主要对穿支皮瓣在大面积软组织缺损创面修复中的应用研究进展进行综述， 以期进一步指导穿支皮瓣的临床应用。     

应用足背分叶皮瓣携带趾伸肌腱移植修复多手指皮肤合并肌腱组织缺损

目的探讨应用足背分叶皮瓣携带趾伸肌腱移植同期修复多手指皮肤合并肌腱组织缺损的临床效果。方法 2011年5月~2013年10月治疗12例(27指)多手指皮肤合并伸、屈肌腱缺损患者。根据伤指创面大小、形状设计以足背血管为主干的跗内侧、第一跖背、跗外侧血管为分支构成的足内侧、第1跖背、足外侧三叶或以第一跖背、跗外侧血管为分支构成的第1跖背、足外侧双叶皮瓣移植,切取皮瓣同时携带趾伸肌腱,一次性修复2~3指的皮肤合并1指或2指的屈、伸肌腱缺损。结果移植皮瓣全部成活。其中3例发生动脉危象,2例经静脉使用抗血管痉挛药物后皮瓣成活,1例经血管探查,切除血栓段血管,重新吻合动脉后皮瓣成活。12例经8~19个月随访,皮瓣外形和质地良好,18指屈伸功能正常,5指屈曲轻度受限,伸直正常,4指屈曲有较明显受限,伸直轻微受限。供皮瓣和肌腱足无明显瘢痕挛缩,行走正常。结论应用足背分叶皮瓣携带趾伸肌腱游离移植方法,一次手术能修复多个手指皮肤合并肌腱缺损,皮瓣外形和质地良好,手指获得良好的功能恢复,是修复多手指皮肤合并腱肌组织缺损的有效方法。     

周围神经组织工程研究

周围神经缺损目前主要采用自体神经移植的方法修复。但自体神经移植会造成供体功能丧失 ,且修复长度受限 ,大小难以匹配 ,可能形成神经瘤等。随着生命科学、材料学以及相关物理、化学学科的发展 ,周围神经组织工程为神经缺损的修复提供供体成为可能 ,其核心是建立由生物材料和种子细胞构成的三维空间复合体。笔者就生物材料和种子细胞两方面作一综述。一、生物材料1.生物材料的研究 :已被应用于修复神经的材料有血管、膜管、变性肌肉[1 ]等天然生物活性材料。这些材料虽具与机体极好的相容性 ,但在缺血后存在管壁塌陷、再生不良、瘢痕组织增…     

培养自体软骨细胞移植修复软骨缺损的分子生物学基础

创伤等原因所致的关节软骨缺损可引起患者疼痛,并导致滑膜炎和关节变性等,而软骨组织的自身修复能力又很差,缺损往往不能自行修复。目前临床上修复关节软骨缺损主要是自体软骨植入及软骨代用品植入,效果均不理想。近期研究表明,培养自体软骨细胞移植治疗软骨缺损取得了满意的疗效,这种方法还可在培养软骨细胞增殖和再分化的过程中调节基因表达[1]。笔者就自体软骨细胞移植治疗软骨缺损的分子生物学基础进行综述。一、关节软骨的分子生物学组成关节软骨(也称透明软骨)是覆盖在运动关节骨末端的一层质地坚韧的半透明组织,在膝关节厚度为1～5ｍ…     

船员四肢创伤性软组织缺损43例的显微外科治疗

目的　报告应用显微外科皮瓣修复船员四肢软组织缺损的临床疗效。方法　应用 14种皮瓣、肌皮瓣及骨皮瓣 ,其中躯干部 4种 18块 ,下肢 5种 10块 ,上肢 5种 16块 ,通过游离移植或带蒂转位方法 ,修复四肢因严重创伤所致软组织缺损、肌腱及骨外露或缺损。结果　移植的组织共 44块 ,其中成活 42块 ,坏死 2块 ,成活率 95 .5 %。经 3个月～ 5年 (平均 11个月 )随访 ,皮瓣成活良好 ,所有修复的肢体保留和恢复了功能。结论　采用皮瓣、肌皮瓣修复四肢软组织缺损见效快 ,疗效好 ,能取得良好临床效果     

吻合血管皮瓣移植修复前臂和手部复杂性软组织缺损

目的探讨吻合血管皮瓣移植修复前臂和手部复杂软组织缺损的临床效果。方法对17例前臂和手部复杂软组织缺损采用股前外侧皮瓣、胸脐皮瓣、小腿内侧与股前外侧皮瓣的串联皮瓣游离移植修复创面。创面面积11 cm×8 cm～26 cm×9 cm,皮瓣切取面积13 cm×9 cm～27 cm×10 cm。结果移植皮瓣全部成活;8例皮瓣臃肿,需再次手术整形;4例骨缺损在皮瓣成活后半年施行自体髂骨植骨钢板内固定,骨折愈合,前臂的旋转功能和手部功能恢复满意;3例肌腱缺损者术后3～5个月用健侧掌长肌腱或手屈指浅肌腱移植修复,手部功能获得部分恢复;2例尺、桡动脉严重损伤,合并重度皮肤肌肉组织缺损者手部功能获得部分恢复,其余患者前臂旋转功能和手部功能恢复满意。结论吻合血管皮瓣移植能有效地修复前臂和手部复杂软组织缺损,控制创面感染,有助于骨折愈合和手部功能的恢复。     

肌腱移植材料与组织工程化肌腱移植技术

本文综述肌腱移植材料的研究进展,并对组织工程化肌腱移植技术取得的成果进行总结,如种子细胞、细胞外基质材料的应用研究等。指出有利于细胞生长与粘附的生物材料的研制必将推动组织工程化肌腱的研究。     

Effects of training, immobilization and remobilization on tendons

Since a tendon is a living tissue, it is not a surprise that tendon shows the capacity to adapt its structure and mechanical properties to the functional demands of the entire muscle-tendon unit. However, compared with muscle, the experimental knowledge of the effects of strength or endurance-type training on tendon tissue is scarce and clinical human experiments are completely lacking (1). Research should, however, be able to improve the true understanding of the biomechanical, functional, morphological and biochemical changes that occur in tendons due to training and physical activity, since understanding of the basic physiology of a tissue is the key to understanding its pathological processes (1,2). Compared with muscle tissue, the metabolic turnover of tendon tissue is many times slower due to poorer vascularity and circulation (1, 3). The adaptive responses of tendons to training are therefore also slower than those in muscles, but they may finally be considerable if the time frame is long enough (3, 4).     

骨组织工程研究现状与趋势

骨组织工程是目前的研究热点,作者从组织工程研究的主要构成要素,即种子细胞、细胞载体支架、组织构建三个方面对骨组织工程研究的现状和存在的挑战进行了回顾和展望,旨在分析当前研究成果与骨组织工程的最终临床应用之间的差距,为尽快缩短这一距离提供可行的设想。     

Tissue engineering for tendon repair

Tissue engineering aims to induce tissue self-regeneration in vivo or to produce a functional tissue replacement in vitro to be then implanted in the body. To produce a viable and functional tendon, a uniaxially orientated collagen type I matrix has to be generated. Biochemical and physical factors can potentially alter both the production and the organisation of this matrix, and their combination in a dose- and time-dependent manner is probably the key to in vitro engineered tendons. This review discusses the role of these different factors affecting tenocyte growth in a three-dimensional environment in vivo and in vitro, and underlines the future challenge of tendon tissue engineering.     

应用股前外侧皮瓣修复手背软组织和指伸肌腱缺损

目的 探讨股前外侧皮瓣修复手背软组织和指伸肌腱缺损的临床应用.方法 对17例手背软组织和指伸肌腱缺损患者行急诊清创、负压封闭引流(VSD)覆盖创面,7～10天后应用股前外侧皮瓣移植修复创面,同时将缺损指伸肌腱近、远端分别与阔筋膜编织缝合.Ⅱ期将阔筋膜修成肌腱形状并行手指功能锻炼.结果 17例皮瓣移植术后完全成活,Ⅱ期手...     

Reconstruction of chronic achilles tendon rupture with the use of interposed tissue between the stumps

BACKGROUND: The gap between the tendon stumps in chronic Achilles tendon rupture has reportedly been filled with interposed scar tissue. In the authors' clinical experience, this interposed tissue is often thick and resists tension, so they considered it was possible to use the interposed tissue for reconstruction of Achilles tendon rupture. HYPOTHESIS: Scar tissue interposed between the tendon stumps has the capacity to form tendon-like repair tissue in patients with chronic Achilles tendon rupture. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Six patients with chronic rupture of the Achilles tendon underwent tendon reconstruction with the use of interposed tissue between the stumps. The average time from the primary injury to surgery was 22 weeks (range, 9 to 30 weeks). Preoperative magnetic resonance imaging (MRI), histology of the interposed tissue, and clinical results were evaluated. The average postoperative follow-up period was 31 months (range, 24 to 43 months). RESULTS: Preoperative T2-weighted MRI in all cases revealed that chronically ruptured Achilles tendons were thickened and fusiform-shaped with diffuse intratendinous high-signal alterations throughout. Longitudinal high-signal bands were seen throughout the tendon, except at the musculotendinous junction and insertion on the calcaneus. Histologically, scar tissue interposed between the tendon stumps consisted of dense collagen fibers, and degenerative changes were not seen. After surgery, no patient had difficulty in walking or stair climbing, and all were able to perform a single-limb toe raise. The mean preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were 88.2 and 98.3 points, respectively; the difference was statistically significant (P = .0277). CONCLUSION: Interposed tissue between the tendon stumps is suitable for repair of chronic Achilles tendon rupture if preoperative MRI shows a thickened fusiform-shaped Achilles tendon with diffuse intratendinous high-signal alterations throughout.     

Tendon tissue sampling

Mechanical load is regarded as the most important etiologic factor in cumulative trauma disorders affecting human tendons. At present there is limited knowledge concerning adaptation and the influence of training on human tendon tissue and the time process of developing a chronic tendon disorder. Tendon tissue samples and data concerning tendon pathology and repair have been derived from biopsies removed during surgery for rupture or pain conditions and from autopsy material. The ultrasound-guided percutaneous core biopsy technique provides the possibility to obtain tendon tissue from human Achilles and patellar tendon with limited discomfort for the individual. The specimens can be used for diagnostic purposes or for research and have the potential to highlight novel knowledge in, for example, the early stages of painful human tendon disorders. The fact that the procedure is invasive is a limitation. Autopsy material has limitations regarding poor information on case history, post mortem alterations and legal regulations on the use of tissue for medical purposes. The inflammatory process quickly affects ruptured tendons. The subcutaneous tendons that sustain a rupture are commonly characterized by degenerative alterations. Many tendon ruptures are treated with surgery, facilitating easy access to biopsy material. In summary, tendon tissue sampling in humans has obvious limitations. The recently described use of the core biopsy technique in human tendon research and diagnosis gives potential for new knowledge concerning human tendon adaptation, repair and disease.     

Platelet-rich plasma in tendon-related disorders: results and indications

Purpose

Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied.

Methods

A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies.

Results

The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative).

Conclusion

Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders.

Level of evidence

Systematic review of level I–IV trials, Level IV.

     

One-stage treatment of deep infection following repair of Achilles tendon rupture with flexor hallucis longus transfer

We present one-stage treatment of deep infection following repair of Achilles tendon rupture using flexor hallucis longus transfer. Flexor hallucis longus was used not only to connect the defect in Achillles tendon, but also to control the soft tissue infection with its abundant blood supply, simultaneously. The clinical results for the two patients in this report were excellent without major complication.     

Gene expression and matrix turnover in overused and damaged tendons

Chronic, painful conditions affecting tendons, frequently known as tendinopathy, are very common types of sporting injury. The tendon extracellular matrix is substantially altered in tendinopathy, and these changes are thought to precede and underlie the clinical condition. The tendon cell response to repeated minor injuries or "overuse" is thought to be a major factor in the development of tendinopathy. Changes in matrix turnover may also be effected by the cellular response to physical load, altering the balance of matrix turnover and changing the structure and composition of the tendon. Matrix turnover is relatively high in tendons exposed to high mechanical demands, such as the supraspinatus and Achilles, and this is thought to represent either a repair or tissue maintenance function. Metalloproteinases are a large family of enzymes capable of degrading all of the tendon matrix components, and these are thought to play a major role in the degradation of matrix during development, adaptation and repair. It is proposed that some metalloproteinase enzymes are required for the health of the tendon, and others may be damaging, leading to degeneration of the tissue. Further research is required to investigate how these enzyme activities are regulated in tendon and altered in tendinopathy. A profile of all the metalloproteinases expressed and active in healthy and degenerate tendon is required and may lead to the development of new drug therapies for these common and debilitating sports injuries.