【作者】 范启申； 周祥吉； 张开刚； 张锴； 张树明；

【Author】 Fan Qishen,Zhou Xiangji,Zhang Kaigang,Zhang Kai,et al.Department of Orthopaedics,89 Hospital of PLA,Weifang,Shandong,China 261021

【机构】 解放军第89医院全军创伤骨科研究所；

【摘要】 [目的]研究长骨大段骨缺损修复的方法。[方法]如上图1股骨大段缺损较常见,其修复方法也较困难。由于缺损骨粗,自体骨无类似皮质骨移植修复;用自体松质骨移植修复,缺乏支撑力,用骨量大,植入骨易吸收;用异体骨移植修复,易产生排斥反应,感染机会多,愈合时间长,失败率高;用人工骨替代修复,由于缺乏适宜材料,且排斥反应及骨愈合等问题未能解决,应取慎重态度;用组织工程培育的骨修复,目前还不能实现。有用吻合血管腓骨移植修复的报道,但单腓骨移植由于腓骨细易折断,O’Brien等采用了双腓骨移植的方法,但由于骨膜的相隔,两段或双根腓骨很难愈合在一起。我们自1992年开始进行吻合血管骨膜内双腓骨组合移植实验研究(图2、3):健康新西兰大白兔72只,随机分为3组。制成胫骨中上段骨与骨膜缺损10.0mm。A组:单腓骨移植组;B组:骨膜外双腓骨组合移植组;C组:骨膜内双腓骨组合移植组:该方法是从双侧取带腓动脉腓骨或从单侧取带腓动脉腓骨截成双段,将双腓骨或双段腓骨的前内侧骨膜从中央纵行切开并向两侧剥离至骨嵴,显露出前内在侧骨皮,将双腓骨.或.双段腓骨折叠,使其前内侧面骨皮质相对,将相对缘游离的骨膜纵行缝合,使其组合为一个骨膜包裹的粗骨。双腓骨断端钢丝固定。于组合的新骨一端相连的腓血管袢,制成"U"形,勿呈锐角。用制成的骨移植体修复粗骨缺损。吻合腓血管。采用上述3种方式进行腓骨移植,术后2、4、8、12、16周分别拍摄X线片及测定血清碱性磷酸酶(ALP)、骨钙素(BGP)、骨密度,并行组织学和生物力学检查。按C组术式临床应用34例:其中男27例,女7例,年龄14～48岁(平均23.5岁)。骨缺损部位:股骨干8例,胫骨干26例。骨缺损的长度:7～25cm。按上述实验方法进行手术,移植双腓骨段长度10～27cm。单侧取带腓血管的腓骨截成双段28例,双侧取带腓血管的腓骨6例,所截取的双腓骨段要比骨缺损长2cm以上。如为双侧取腓骨,将双腓骨的腓血管一断端进行吻合,使成为类似带腓血管的单侧腓骨的双段。随访访6个月～8年,其中27例随访4年以上,术后疗效良好。[结果]X线片显示,与A、B组比较,C组骨痂增加明显,骨小梁排列整齐,移植腓骨明显增粗。术后2、4、8、12、16周,血清ALP、血清BGP及骨密度C组均比A、B组高(P<0.01)。组织学检查C组较A、B组骨痂形成及成熟早,骨小梁排列整齐,双腓骨形成一体。成骨量C组高于A、B组。生物力学测试,移植骨平均最大载荷、最大扭距及剪切应力,C组均大于A、B组(P<0.05或0.01)。34例随访4年以上者,X线片示:23例6～8个月后骨性愈合,11例1年后骨性愈合。骨性愈合后,去掉石膏外固定,开始进行关节功能锻炼。4年以上的27例患者,X线片示移植腓骨增粗。其中6例骨纤维结构不良,肿瘤切除后骨缺损的长度:15～22cm,移植双腓骨段长度17～24cm,随访6～11年,未有在移植骨上再发生肿瘤,仅1例股骨干于正常骨干远段发生了病灶,但移植骨段仍未发生病灶,骨移植体愈合好。5例由于多次手术,长期石膏外固定,膝关节伸屈功能受限,患者拒绝进行膝关节松解治疗,致使膝关节伸屈功能未能恢复。供区在切取腓骨时,于外踝上用1螺丝钉将腓骨固定于胫骨上,故取腓骨后踝关节稳定,伸屈正常,功能恢复满意。移植骨未发生再骨折。[结论]采用有血运的骨膜内双腓骨或双段腓骨组合成粗骨类似负重骨,支撑力强,愈合快,随着时间推移,移植骨再增粗,使骨缺损完全得到修复,恢复正常生理功能,是修复长段负重骨缺损的理想方法。更多还原

【Abstract】 [Objective]To study the effect of operation on transplanted fibula healing,which repaired long and thick bone defects by two fibula compound transplanation under periosteum with vascular loop. [Methods]72 healthy rabbits were divided randomly into three groups.Group A is the mono-fibular transplanation group,group B,the double fibular transplanation extra-periosteum and group C,the double fibular transplanation under-periosteum.Animal models of 10mm tibial defects were established and three operation patterns were performed.the serum were obtained to determine the level of ALP and BGP bone and mineral density and biomechanic index and X-rays at 2,4,8,12,16 weeks.The condition of the bone healing and contour were observed.The 34 cases of clinal apliation with the fashion of group C.[Results]The X -ray showed that the area of the external callus were larger in C groups than that in A,B and the bone trabecula were in order,the fibula showed significant bone hypertrophy,the serum ALP,BGP and mineral density level were higher in C group than that in A,B.The difference has statistical significance(P<0.05).Compared with quantitative analysis of histological examination showed that the bone trabecula were in order,the two fibula were healed in one and the fibular medullary cavity were recanalized.The volume of new bone were higher in the groups C than that in A,B.The biomechanical index of the average maximal load,torque,shearing stress of the transplanted bone in C group were all larger than those in A,B group.The difference had statistical significance(P<0.01).All 34 bone defects were healed,and fracture was not occurred in transplantation bone.[Conclusions]The two compound fibula with vascular loop under periosteum used to repair long、thick and burnden bone defects is a satisfactory method in the clinic.更多还原