不同材质内植物混合使用对骨折愈合的影响
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摘要
背景:不锈钢和钛合金作为在骨科手术中应用最多的2种内植物材料,在临床应用中常不可避免的相互混搭接触,但有关内固定联合应用对周围组织干扰情及骨折愈合影响的研究较少。目的:观察评价不同材质内植物(不锈钢、钛合金)单纯及混合使用对骨折周围组织炎性反应及骨愈合的影响。方法:取24只新西兰大白兔(包头医学院第一附属医院骨科动物实验室提供),截骨制作胫骨骨折模型,随机分4组干预,每组6只:A组以不锈钢接骨板及不锈钢螺钉内固定,B组以不锈钢接骨板及钛钉内固定,C组以钛接骨板及钛钉内固定,D组以钛接骨板及不锈钢螺钉内固定。术后6,12周,取出实验胫骨标本,进行X射线和组织学检查。结果与结论:①苏木精-伊红染色:术后6周,各组内植物周围标本均有中等量的炎性细胞浸润,以淋巴细胞为主,伴有少量中性粒细胞,可见毛细血管及纤维细胞;术后12周,各组标本淋巴细胞数量减少,偶可见巨噬细胞和中性粒细胞,接骨板表面纤维膜厚度较术后6周时明显减小;术后不同时间点各组间差异不明显;②X射线检查:术后6周,各组骨折复位良好,内固定物在位,仍可见骨折线,但已模糊,骨折线及内植物周围未见明显骨痂形成,各组间差异不明显;术后12周,各组骨折线已不可见,内固定在位,因内固定遮挡,骨痂未能满意显示;去除内固定后,沿内固定边缘可见骨痂形成,原骨折断端亦有明显骨痂形成,各组间差异不明显;③结果表明:在动物实验中,混合使用不同材质(不锈钢及钛)内植物进行骨折内固定,不会引起严重炎性反应,不影响骨折愈合速度。
BACKGROUND: As the two most commonly used implant materials in orthopedic surgery, stainless steel and titanium alloy, are inevitably to contact with each other in clinical application. But the effect of the combined application of internal fixation on peripheral tissue disturbance and fracture healing is rarely reported.OBJECTIVE: To observe and evaluate the effects of simple and mixed use of different materials of implants(stainless steel and titanium alloy) on inflammatory response and bone healing in the surrounding tissues of fractures.METHODS: Twenty-four New Zealand white rabbits(provided by the Animal Lab of the First Affiliated Hospital of Baotou Medical College of Inner Mongolia University of Science & Technology) were selected to establish the model of tibial fracture. The rabbit models were randomly divided into four groups, and underwent internal fixation with stainless steel plate and screw(group A), stainless steel plate and titanium screw(group B), titanium plate and screw(group C), or titanium plate and stainless screw(group D). The tibia specimens were removed at 6 and 12 weeks after surgery for X-ray and histological examinations.RESULTS AND CONCLUSION:(1) Hematoxylin-eosin staining: at 6 weeks after surgery, all the specimens around the plants in each group had medium amount of inflammatory cell infiltration, with abundant lymphocytes, few neutrophils, and visible capillaries and fibrous cells. At 12 weeks after surgery, the number of lymphocytes in each group was decreased, with occasional macrophages and neutrophils. The thickness of the fibrous membrane on the surface of the bone plate was decreased significantly compared with that at 6 weeks after surgery. There was no significant difference between groups at different time points after surgery.(2) X-ray results: at 6 weeks after surgery, the fracture reduction was good in each group, the position of internal fixators was good, and the fracture line was blurred. No obvious callus formation was observed on the fracture line and around the implant, and no significant difference was found among groups. At 12 weeks after surgery, the fracture lines in each group disappeared. The internal fixators were in good position, and the callus could not be revealed well due to internal fixator covering. After removal of internal fixators, callus formation was observed along the edge of fixed part, and obvious callus formation was observed at the fracture end of the original fracture. There was no significant difference among groups.(3) These results indicate that in animal experiments, the internal fixation of fracture with different materials(stainless steel and titanium) implants cannot cause severe inflammatory reaction and makes no effect on the speed of fracture healing.
BACKGROUND: As the two most commonly used implant materials in orthopedic surgery, stainless steel and titanium alloy, are inevitably to contact with each other in clinical application. But the effect of the combined application of internal fixation on peripheral tissue disturbance and fracture healing is rarely reported.OBJECTIVE: To observe and evaluate the effects of simple and mixed use of different materials of implants(stainless steel and titanium alloy) on inflammatory response and bone healing in the surrounding tissues of fractures.METHODS: Twenty-four New Zealand white rabbits(provided by the Animal Lab of the First Affiliated Hospital of Baotou Medical College of Inner Mongolia University of Science & Technology) were selected to establish the model of tibial fracture. The rabbit models were randomly divided into four groups, and underwent internal fixation with stainless steel plate and screw(group A), stainless steel plate and titanium screw(group B), titanium plate and screw(group C), or titanium plate and stainless screw(group D). The tibia specimens were removed at 6 and 12 weeks after surgery for X-ray and histological examinations.RESULTS AND CONCLUSION:(1) Hematoxylin-eosin staining: at 6 weeks after surgery, all the specimens around the plants in each group had medium amount of inflammatory cell infiltration, with abundant lymphocytes, few neutrophils, and visible capillaries and fibrous cells. At 12 weeks after surgery, the number of lymphocytes in each group was decreased, with occasional macrophages and neutrophils. The thickness of the fibrous membrane on the surface of the bone plate was decreased significantly compared with that at 6 weeks after surgery. There was no significant difference between groups at different time points after surgery.(2) X-ray results: at 6 weeks after surgery, the fracture reduction was good in each group, the position of internal fixators was good, and the fracture line was blurred. No obvious callus formation was observed on the fracture line and around the implant, and no significant difference was found among groups. At 12 weeks after surgery, the fracture lines in each group disappeared. The internal fixators were in good position, and the callus could not be revealed well due to internal fixator covering. After removal of internal fixators, callus formation was observed along the edge of fixed part, and obvious callus formation was observed at the fracture end of the original fracture. There was no significant difference among groups.(3) These results indicate that in animal experiments, the internal fixation of fracture with different materials(stainless steel and titanium) implants cannot cause severe inflammatory reaction and makes no effect on the speed of fracture healing.
引文
[1]Hayes JS,Richards RG.The use of titanium and stainless steel in fracture fixation.Expert Rev Med Devices.2010;7(6):843-853.
[2]Brown SA,Mayor MB.The biocompatibility of materials for internal fixation of fractures.J Biomed Mater Res.1978;12(1):67-82.
[3]周耀,王佳,竺智雄.不同内固定材料治疗三踝骨折效果分析[J].中国医药导报,2014,35(17):61-64.
[4]Uhthoff HK,Bardos DI,Liskova-Kiar M.The advantages of titanium alloy over stainless steel plates for the internal fixation of fractures.An experimental study in dogs.J Bone Joint Surg Br.1981;63-B(3):427-484.
[5]Brown SA,Simpson JP.Crevice and fretting corrosion of stainlesssteel plates and screws.J Biomed Mater Res.1981;15(6):867-878.
[6]Disegi JA,Eschbach L.Stainless steel in bone surgery.Injury.2000;31:D2-D6.
[7]Ganesh VK,Ramakrishna K,Ghista DN.Biomechanics of bone-fracture fixation by stiffness-graded plates in comparison with stainless-steel plates.Biomed Eng Online.2005;4:46.
[8]Martola M,Lindqvist C,H?nninen H,et al.Fracture of titanium plates used for mandibular reconstruction following ablative tumor surgery.J Biomed Mater Res B Appl Biomater.2007;80(2):345-352.
[9]Cho JH.Percutaneous cannulated screws with tension band wiring technique in patella fractures.Knee Surg Relat Res.2013;25(4):215-219.
[10]Carpenter JE,Kasman RA,Patel N,et al.Biomechanical evaluation of current patella fracture fixation techniques.J Orthop Trauma.1997;11(5):351-356.
[11]Leung PC,Mak KH,Lee SY.Percutaneous tension band wiring:a new method of internal fixation for mildly displaced patella fracture.JTrauma.1983;23(1):62-64.
[12]Lhotka C,Szekeres T,Steffan I,et al.Four-year study of cobalt and chromium blood levels in patients managed with two different metal-on-metal total hip replacements.J Orthop Res.2003;21(2):189-195.
[13]李铁军,丁中伟,何强.钛合金内固定材料严重电解反应1例[J].河北北方学院学报(医学版),2010,27(3):49-50.
[14]胥少汀,葛宝丰,徐印坎.实用骨科学[M].3版.北京:人民军医出版社,2005:356-357.
[15]Rüedi Th,Perren SM,Pohler O,et al.[Titanium,steel and their combination in bone surgery].Langenbecks Arch Chir.1975;Suppl:395-398.
[16]W?chter R,Stoll P.[Can steel screws be combined with titanium plates?Hard polishing technique and SEM in animal experiments].Dtsch Z Mund Kiefer Gesichtschir.1991;15(4):275-284.
[17]Richard M,Einhorn TA.The biology of fracture healing.Injury.2011;42(6):551-555.
[18]郭庆勇,张毅,买买提·黑牙斯丁,等.小动物骨折的诊断与治疗[J].新疆畜牧业,2010,26(5):50-53.
[19]John D.Wrought 18%chromium-14%nickel-2.5%molybdenum stainless steel implant material.AO ASIF Materials Technical Commission,1998.
[20]Barbosa MA.Corrosion mechanisms of metallic biomaterials.Barbosa,MA Porto:Elsevier Science Publishers BV,1991:227-258.
[21]Griffin CD,Buchanan RA,Lemons JE.In vitro electrochemical corrosion study of coupled surgical implant materials.J Biomed Mater Res.1983;17(3):489-500.
[22]Brown SA,Merritt K.Fretting corrosion of plates and screws:an in vitro test method.Corrosion and Degradation of Implant Materials:Second Symposium.ASTM International,1985.
[23]Serhan H,Slivka M,Albert T,et al.Is galvanic corrosion between titanium alloy and stainless steel spinal implants a clinical concern?Spine J.2004;4(4):379-387.
[24]Venugopalan R,Lucas LC.Evaluation of restorative and implant alloys galvanically coupled to titanium.Dent Mater.1998;14(3):165-172.
[25]H?l PJ,M?lster A,Gjerdet NR.Should the galvanic combination of titanium and stainless steel surgical implants be avoided?Injury.2008;39(2):161-169.
[26]Acevedo D,Loy BN,Lee B,et al.Mixing implants of differing metallic composition in the treatment of upper-extremity fractures.Orthopedics.2013;36(9):e1175-1179.
[27]陈欣,黄亚娟,田谦,等.钛合金与不锈钢内固定材料置入修复脊柱结核的生物相容性[J].中国组织工程研究,2015,19(30):4860-4864.
[28]Textor M,Caroline Sittig C,Frauchiger V,et al.Properties and biological significance of natural oxide films on titanium and its alloys.Titanium in medicine.Springer,Berlin,Heidelberg,2001:171-230.
[29]侯金健,高强强,安晓婷.国内外高温钛合金研究及应用的最新发展[J].热加工工艺,2014,43(10):11-15.
[30]Ghaith el-S,Hodgson S,Sharp M.Laser surface alloying of 316Lstainless steel coated with a bioactive hydroxyapatite-titanium oxide composite.J Mater Sci Mater Med.2015;26(2):83.
[31]Banaszkiewicz PA.Metallic wear in failed titanium-alloy total hip replacements:A histological and quantitative analysis.Classic Papers in Orthopaedics.Springer,London,2014:97-100.
[32]Leopold SS,Berger RA,Patterson L,et al.Serum titanium level for diagnosis of a failed,metal-backed patellar component.JArthroplasty.2000;15(7):938-943.
[2]Brown SA,Mayor MB.The biocompatibility of materials for internal fixation of fractures.J Biomed Mater Res.1978;12(1):67-82.
[3]周耀,王佳,竺智雄.不同内固定材料治疗三踝骨折效果分析[J].中国医药导报,2014,35(17):61-64.
[4]Uhthoff HK,Bardos DI,Liskova-Kiar M.The advantages of titanium alloy over stainless steel plates for the internal fixation of fractures.An experimental study in dogs.J Bone Joint Surg Br.1981;63-B(3):427-484.
[5]Brown SA,Simpson JP.Crevice and fretting corrosion of stainlesssteel plates and screws.J Biomed Mater Res.1981;15(6):867-878.
[6]Disegi JA,Eschbach L.Stainless steel in bone surgery.Injury.2000;31:D2-D6.
[7]Ganesh VK,Ramakrishna K,Ghista DN.Biomechanics of bone-fracture fixation by stiffness-graded plates in comparison with stainless-steel plates.Biomed Eng Online.2005;4:46.
[8]Martola M,Lindqvist C,H?nninen H,et al.Fracture of titanium plates used for mandibular reconstruction following ablative tumor surgery.J Biomed Mater Res B Appl Biomater.2007;80(2):345-352.
[9]Cho JH.Percutaneous cannulated screws with tension band wiring technique in patella fractures.Knee Surg Relat Res.2013;25(4):215-219.
[10]Carpenter JE,Kasman RA,Patel N,et al.Biomechanical evaluation of current patella fracture fixation techniques.J Orthop Trauma.1997;11(5):351-356.
[11]Leung PC,Mak KH,Lee SY.Percutaneous tension band wiring:a new method of internal fixation for mildly displaced patella fracture.JTrauma.1983;23(1):62-64.
[12]Lhotka C,Szekeres T,Steffan I,et al.Four-year study of cobalt and chromium blood levels in patients managed with two different metal-on-metal total hip replacements.J Orthop Res.2003;21(2):189-195.
[13]李铁军,丁中伟,何强.钛合金内固定材料严重电解反应1例[J].河北北方学院学报(医学版),2010,27(3):49-50.
[14]胥少汀,葛宝丰,徐印坎.实用骨科学[M].3版.北京:人民军医出版社,2005:356-357.
[15]Rüedi Th,Perren SM,Pohler O,et al.[Titanium,steel and their combination in bone surgery].Langenbecks Arch Chir.1975;Suppl:395-398.
[16]W?chter R,Stoll P.[Can steel screws be combined with titanium plates?Hard polishing technique and SEM in animal experiments].Dtsch Z Mund Kiefer Gesichtschir.1991;15(4):275-284.
[17]Richard M,Einhorn TA.The biology of fracture healing.Injury.2011;42(6):551-555.
[18]郭庆勇,张毅,买买提·黑牙斯丁,等.小动物骨折的诊断与治疗[J].新疆畜牧业,2010,26(5):50-53.
[19]John D.Wrought 18%chromium-14%nickel-2.5%molybdenum stainless steel implant material.AO ASIF Materials Technical Commission,1998.
[20]Barbosa MA.Corrosion mechanisms of metallic biomaterials.Barbosa,MA Porto:Elsevier Science Publishers BV,1991:227-258.
[21]Griffin CD,Buchanan RA,Lemons JE.In vitro electrochemical corrosion study of coupled surgical implant materials.J Biomed Mater Res.1983;17(3):489-500.
[22]Brown SA,Merritt K.Fretting corrosion of plates and screws:an in vitro test method.Corrosion and Degradation of Implant Materials:Second Symposium.ASTM International,1985.
[23]Serhan H,Slivka M,Albert T,et al.Is galvanic corrosion between titanium alloy and stainless steel spinal implants a clinical concern?Spine J.2004;4(4):379-387.
[24]Venugopalan R,Lucas LC.Evaluation of restorative and implant alloys galvanically coupled to titanium.Dent Mater.1998;14(3):165-172.
[25]H?l PJ,M?lster A,Gjerdet NR.Should the galvanic combination of titanium and stainless steel surgical implants be avoided?Injury.2008;39(2):161-169.
[26]Acevedo D,Loy BN,Lee B,et al.Mixing implants of differing metallic composition in the treatment of upper-extremity fractures.Orthopedics.2013;36(9):e1175-1179.
[27]陈欣,黄亚娟,田谦,等.钛合金与不锈钢内固定材料置入修复脊柱结核的生物相容性[J].中国组织工程研究,2015,19(30):4860-4864.
[28]Textor M,Caroline Sittig C,Frauchiger V,et al.Properties and biological significance of natural oxide films on titanium and its alloys.Titanium in medicine.Springer,Berlin,Heidelberg,2001:171-230.
[29]侯金健,高强强,安晓婷.国内外高温钛合金研究及应用的最新发展[J].热加工工艺,2014,43(10):11-15.
[30]Ghaith el-S,Hodgson S,Sharp M.Laser surface alloying of 316Lstainless steel coated with a bioactive hydroxyapatite-titanium oxide composite.J Mater Sci Mater Med.2015;26(2):83.
[31]Banaszkiewicz PA.Metallic wear in failed titanium-alloy total hip replacements:A histological and quantitative analysis.Classic Papers in Orthopaedics.Springer,London,2014:97-100.
[32]Leopold SS,Berger RA,Patterson L,et al.Serum titanium level for diagnosis of a failed,metal-backed patellar component.JArthroplasty.2000;15(7):938-943.