高分子纤维素预防肌腱粘连的实验研究

目的 比较高分子纤维素与不同防粘连物质在预防肌腱粘连中的作用。方法 以鸡趾为动物模型，将肌腱切断缝合后分别于局部应用高分子纤维素膏剂、生物膜、透明质酸及生理盐水，术后于不同时间行肉眼观察、生物力学及组织学检测。结果 三种物质均有一定的粘连预防作用，其中以高分子纤维素膏剂效果最佳。结论 局部应用高分子纤维素是预防肌腱粘连的较理想方法。     

Preventive effects of a turnover flexor tendon sheath flap on adhesion formation after flexor profundus tendon injury: an experimental study.

This study aims to investigate the effects of a proximally-based turnover sheath flap obtained from the tendon sheath on the prevention of adhesion formation in the legs of the chickens whose tendons and sheaths have been injured. The chickens were categorised into 4 groups. Group 1 was chosen as the sham group. In Group 2, a defective area of 0.3 x0.5 cm was created across the sheath, without damaging the tendon. The healthy profundus tendons of the chickens in Group 3 were cut and repaired. Afterwards, a defective area of 0.3 x 0.5 cm was created across the tendon sheath. In Group 4, the healthy profundus tendons were cut and repaired. Then, a defective area of 0.3 x 0.5 cm was created over the reconstructed tendon. This defective area was finally covered with a proximally-based turnover sheath flap of the size 0.4 x 1 cm, which was raised from the distal part of the sheath. The toes were immobilised for 3 weeks before the chickens were sacrificed. Histopathological and biomechanical analyses showed adhesion in the repaired tendons in Group 3, in which movement restriction was shown by biomechanical analyses. The present study showed that covering the defective sheath that was created over the repaired tendon with a proximally-based turnover tendon sheath flap prevented peritendinous adhesion.     

The role of human-derived fibrin sealant in the reduction of postoperative flexor tendon adhesion formation in rabbits

This study assessed the role of a novel fibrin sealant (Vivostat in adhesion reduction after flexor tendon surgery. The deep flexor tendons of the 2nd and 4th digits of the left paw of 20 rabbits were exposed and a standard partial injury was performed on each. The rabbits were randomized to either immediate post-injury treatment with Vivostat or no treatment. In each case active movement of the 2nd digit was prevented while the 4th digit was allowed to move normally. The two groups were assessed at 14 days for adhesion formation with a tensiometer. The right paw acted as the unoperated control. Results showed that there was no significant difference in the force needed to remove the tendon from its sheath when comparing the two Vivostat((R))-treated groups to the unoperated controls. There was, however, a highly significant difference in this force between the non-Vivostat-treated groups and the unoperated controls. This suggests a beneficial effect of Vivostat in reducing post surgical tendon adhesion formation.     

Effects of human amniotic fluid on peritendinous adhesion formation and tendon healing after flexor tendon surgery in rabbits

The effect of the topical application of human amniotic fluid (HAF) on peritendinous adhesion formation and tendon healing was investigated in 32 New Zealand adult rabbits. The long flexor tendons of the digits of each hind paw were completely divided and repaired with a modified Kessler technique. The rabbits were randomly divided into 4 experimental groups according to the type of repair used: sheath excision, sheath excision and local HAF application, sheath repair, and sheath repair and local HAF application. The extent of adhesions and the healing status of the tendons were macroscopically and histologically evaluated at 12 weeks. Tensile strength of the repaired tendons was measured biomechanically at 20 weeks. The least adhesion and the best healing were observed in tendons treated with sheath repair and HAF application. Tendons treated with HAF had significantly higher tensile load values. Topical application of HAF immediately after tenorrhaphy is significantly effective in preventing peritendinous adhesion formation without impairment of tendon healing in this rabbit model.     

Sodium hyaluronate as an adjunct in adhesion prevention after flexor tendon surgery in rabbits.

Topical application of sodium-hyaluronate (NaHe) has been proposed to decrease the formation of adhesions after tendon surgery, but reports published thus far have been contradictory. A new test instrument capable of simultaneous registration of tensile load, tendon excursion, and joint motion was therefore developed and used to evaluate the effect of locally administered NaHe of different concentrations and molecular weights on the outcome after tenorrhaphy of rabbit hindlimb flexor tendons. Immediately after tenorrhaphy, NaHe or saline solution was deposited into the tendon sheath. The functional characteristics of the digits were evaluated 15 days after surgery. NaHe with a concentration of 19 mg/ml and a molecular weight of 6 x 10(6) significantly limited the strength of the adhesions formed without impairment of tensile strength. These results suggest that the efficacy of NaHe is affected by both the concentration and the molecular weight of the NaHe preparation used.     

川芎嗪注射液对实验性屈肌腱粘连的影响

本实验观察了川芎嗪注射液对鸡屈深肌腱粘连模型的影响，并与具有抗组织粘连作用的二甲基硅油及生理盐水进行对照。结果显示：川芎嗪与硅油组的损伤肌腱滑动功能好且粘连面积小，与盐水组比较有显著性差异（Ｐ＜０．０５，Ｐ＜０．０１）。而在肌腱的修复方面，川芎嗪又明显优于硅油组。表明：在损伤肌腱的鞘管内局部运用川芎嗪注射液既可减轻其腱周粘连，又不影响肌腱自身的愈合过程。     

Mixture of hyaluronic acid and phospholipid prevents adhesion formation on the injured flexor tendon in rabbits.

Dipalmitoyl phosphatidylcholine, a highly surface-active polar lipid, has been implicated as a potential boundary lubricant for synovial joints. We examined the effects of dipalmitoyl phosphatidylcholine on the flexor tendon and its protective effect against postoperative adhesion in two experimental steps. First, the flexor digitorum fibularis and the distal pulley of rabbits were set for a friction test. The test was performed with saline solution, sodium hyaluronate, or a mixture of dipalmitoyl phosphatidylcholine and sodium hyaluronate as the lubricant. The friction coefficient was significantly lower with the mixture of dipalmitoyl phosphatidylcholine and sodium hyaluronate than with saline solution or sodium hyaluronate. We concluded that the decreased friction coefficient indicates that dipalmitoyl phosphatidylcholine could complement the boundary-lubricating ability of the tendon. In the second experiment, we used an experimental adhesion model of the flexor digitorum fibularis in the rabbit. During the operation, either saline solution, sodium hyaluronate, or a mixture of dipalmitoyl phosphatidylcholine and sodium hyaluronate was injected into the tendon sheath. The specimen was sent to another tester, and the work required to tear off the adhesion was measured. The work required was significantly greater for the tendons that had been injected with saline solution than for those given injections of dipalmitoyl phosphatidylcholine and sodium hyaluronate. Our findings suggest that dipalmitoyl phosphatidylcholine plays an important role in the boundary lubrication of the tendon and that after tendon injury, the administration of a mixture of dipalmitoyl phosphatidylcholine and sodium hyaluronate may improve tendon lubrication and prevent adhesion formation.     

Reconstruction of flexor tendon pulley with expanded polytetrafluoroethylene (E-PTFE). An experimental study in rabbits

Gore-Tex (expanded Polytetrafluoroethylene, E-PTFE) was used to replace the distal pulleys on the proximal phalanges of 20 rabbits. Morphology and function of the reconstructed pulleys were evaluated at 12-20 weeks. The breaking strength of the E-PTFE pulley equalled that of a normal pulley. Range of motion, tendon excursion, and force of flexion were no different from those of normal pulleys. No adhesions between flexor tendons and synovial tendon sheaths or the E-PTFE pulleys could be detected. No adverse tissue reactions were seen. Fibroblast-like cells from the surrounding tissues had grown into the membrane. In other experiments, where the pulleys had been either removed or detached, local fibrosis and adhesions were seen, and the deep flexor tendons had ruptured. The results of the present study indicate that E-PTFE can be used as a biosynthetic replacement for damaged pulleys.     

屈指肌腱损伤修复后早期生物力学性能的变化

目的以改良Kessler法和Tsuge法修复鸡趾深屈肌腱,观察术后早期肌腱生物力学性能的变化特点,并探讨两种缝合方法修复屈指肌腱损伤后早期主动或被动功能锻炼的可行性。方法取42只三黄鸡,随机分成两组,每组21只(42趾)。选用改良Kessler法和Tsuge法修复鸡右足第二、四趾趾深屈肌腱,分别于术后即刻、1、4、7、10、14、21d取材,进行生物力学测试,检测肌腱的拉伸断裂负荷、拉伸断裂伸长率。结果改良Kessler法拉伸断裂负荷在术后10d～两周降到最低,3周时恢复到即刻水平;Tsuge法在术后10d降至最低,2周后开始恢复,3周时尚未恢复到即刻水平;Tsuge法的拉伸断裂负荷在术后即刻和1d较改良Kessler法高,差异有非常显著性(P<0.01)。改良Kessler法拉伸断裂伸长率在术后1周逐渐下降,Tsuge法在术后4d逐渐下降,两者均在术后3周达到最低点,两种缝合方法之间不同时间点差异均无显著性。结论Tsuge法较高的力学特性术后丢失快,恢复慢;改良Kessler法的力学特性仅在术后10d有显著降低,2周后即可恢复。     

A comparative study of different methods of tendon lengthening: an experimental study in rabbits

Three different techniques of tendon lengthening--Z-lengthening, intramuscular lengthening, and tenotomy--were studied in rabbits. The cut tendon ends were marked with radioopaque sutures. The repair process was similar with all three techniques, with healing being completed by 6 weeks. With intramuscular lengthening, the gap distance remained constant throughout the experiment, whether immobilization was used or not. Thus, immobilization is not necessary with this technique. In contrast, with tenotomy the gap distance increased significantly when immobilization was not used. However, with immobilization the distance remained constant throughout the experiment. Immobilization is necessary after tenotomy to prevent undue lengthening of the tendon.     

肌腱缝合后鞘内置入法预防Ⅱ区屈肌腱粘连的实验研究

目的 探讨一种屈肌腱修复新方法即腱缝合后鞘内置入法，并观察其在鸡Ⅱ区屈肌腱损伤修复中的疗效，揭示其预防屈肌腱术后粘连机理，为临床应用提供依据。方法 选用健康白色纯种Leghorn鸡40只，以第三趾趾深屈肌腱屈曲型损伤为实验模型，随机分组，左右足配对设计，一侧为实验组，用腱缝合后鞘内置入法修复肌腱；另一侧为对照组，切开腱鞘修复肌腱，缝合腱鞘。分别于术后1、2、4、8周进行大体观察、组织学观察、生物力学测定。结果 1周后大体观察、肌腱滑动距离，实验组与对照组间无显著性统计学意义。2、4、8周后大体观察粘连情况、肌腱滑动距离、各是关节屈曲角度、组织学观察结果，两组间有显著性差异，4周后腱及鞘缝合口间距与肌腱粘连带宽度比，两组间均有显著性差异。结论 腱缝合后鞘内置入法在Ⅱ区屈肌腱修复中能有效减轻肌腱术后粘连，尤其是致密粘连的形成，在提高肌腱术后功能上优于单纯腱鞘闭合，可以适用于临床。     

Adhesions from flexor tendon surgery: an animal study comparing surgical techniques

Intraoperative and postoperative hemorrhage has long been considered a cause of tendon adhesion and, thus, scarring and poor surgical results. To prevent such problems bipolar coagulators are commonly used during surgery to help achieve hemostasis. Surgical lasers also have been reported to help limit bleeding and scar formation. Very little is known regarding the relationship between hemorrhage and/or direct tendon tissue effects and tendon adhesions with the use of these modalities. We compared 3 different surgical techniques (meticulous sharp scalpel dissection, scalpel dissection plus bipolar coagulation, and CO(2) laser dissection) and used chicken flexor tendons to biomechanically and histologically assess the amount of adhesion formation after each procedure. Our findings show that bipolar coagulation and CO(2) laser application are both associated with significantly increased adhesion formation in tendon surgery compared with sharp dissection alone and that the meticulous, conventional sharp dissection technique is the best method to control adhesion formation. These conclusions have relevance to clinical tendon surgery.     

Biomechanical analyses of the human flexor tendon adhesion models in the hand: A cadaveric study

Patients with longstanding trigger finger may develop flexion contracture at the proximal interphalangeal (PIP) joint that persists even after division of the A1 pulley. The purpose of this study was to explore the hypothesis that flexion deformity of the PIP joint in advanced trigger finger is caused by severe adhesion between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Ten freshly frozen cadaveric hands were used in the experiments. After preparation of the extrinsic flexor, extrinsic extensor, and intrinsic muscle tendons, we applied weights to the flexor tendons and minimal tension to the extrinsic extensor and intrinsic muscle tendons. We then measured the initial flexion angles of the metacarpophalangeal (MCP) and PIP joints. Next, we measured the flexion angles of the MCP and PIP joints as increasing tension was applied to the extrinsic extensor and intrinsic muscle tendons, respectively. We repeated these experiments after constructing flexor tendon adhesion model. The initial flexion angles of the MCP and PIP joints were greater in the adhesion model, as were the average tensions required for full extension of these joints. Our results suggest that adhesion between two flexor tendons contributes to progression of flexion deformity in the PIP joint. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:717–725, 2015.     

Advances in the biology of zone II flexor tendon healing and adhesion formation

There has been dramatic improvement in the results of zone II tendon surgery in the last three decades. This improvement was brought, to a great extent, by the better understanding of the mechanisms of tendon healing. This article provides an overview of the mechanism of intrasynovial tendon healing, the role and origin of fibroblasts, and the effects of extracellular components and various growth factors on tendon healing. It also sheds light on the incidence and significance of tendon adhesions. An account of the ultrastructure of the synovial sheath is presented.     

透明质酸钠在防治屈肌腱粘连中的临床研究

目的阐明透明质酸钠（ｓｏｄｉｕｍｈｙａｌｕｒｏｎａｔｅｐｒｏｄｕｃｔ，ＳＨＰ）防止肌腱粘连的作用。方法一期修复鞘管区屈肌腱损伤２８例４６条肌腱，术中用套圈缝合法缝接肌腱后，在肌腱鞘管内置入透明质酸钠０．５～１．０ｍｌ，缝合皮肤。术后２４小时开始行功能锻炼。另选２０例４１条损伤肌腱用同样方法修复，但不用透明质酸钠作对照。结果两组经过平均１年２个月的随访，按ＴＡＭ法评定疗效，透明质酸钠组随访的４３根肌腱，疗效优良者３８根，优良率为８８．４％，显著高于对照组的６５．７％（Ｐ＜０．０５）。结论透明质酸钠具有促进肌腱愈合，防止或减轻术后粘连，改善肌腱滑动的作用。     

An experimental model for the study of canine flexor tendon adhesions

An experimental model for the study of canine flexor tendon adhesions was designed using a standardized crush-abrasion injury, meticulous sheath closure, and three-week limb immobilization. Ten animals in the experimental protocol were evaluated for visible adhesion formation. With use of a flexor tendon adhesion rating scale, consistent adhesion formation was documented with an average score of 10.4 +/- 2.1 (range, 0 to 12). Five additional animals had biomechanical testing. Applying an increasing load to the proximally divided profundus tendon (0 to 10 Newtons), it was found that the angle of distal interphalangeal joint motion and the displacement of the toe were significantly decreased, and the work generated significantly increased in the experimental versus control digits (p less than 0.05). The consistent production of visible adhesions thus correlates with biomechanical impairments in toe motion and work. The study of agents aimed at diminishing flexor tendon adhesions will thus be facilitated by this reliable model. Systemic or intrasheath administration of agents will be possible.     

Tendon healing in vivo: effect of mannose-6-phosphate on flexor tendon adhesion formation

The purpose of this study was to investigate the preventive effect of mannose-6-phosphate on flexor tendon adhesion formation. From a total of 84 adult New Zealand White rabbits, 36 were randomly divided into 2 groups, the normal saline group and the mannose-6-phosphate group, after anastomosis of the flexor tendons. Tendons were harvested at 4 weeks, and biomechanics testing was conducted. The other 48 rabbits were randomly divided into 2 groups, the normal saline group and the mannose-6-phosphate group, after anastomosis of the flexor tendons, and tendons were harvested at 7, 14, 28, and 56 days and analyzed by in situ hybridization to determine the mRNA expression of transforming growth factor (TGF)-β1 and collagen I. The results of biomechanics testing indicated that mannose-6-phosphate can effectively prevent flexor tendon adhesion formation after anastomonsis. The in situ hybridization examination revealed that TGF-β1 and collagen I mRNA expression in the mannose-6-phosphate group was lower than that in the normal saline group at each time point. Mannose-6-phosphate can effectively inhibit the function of TGF-β1 and prevent adhesion formation after flexor tendon injury.