自体多孔骨瓣回植修补颅骨缺损的实验研究
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摘要
目的：颅骨修补材料很多，但迄今还没有一种材料能在塑形、抗冲击、抗压力、隔温、防磁等方面完全替代颅骨。因此有人用自体颅骨瓣在皮下埋藏隔期回植，但病人在骨瓣埋藏和取出时需经受两次手术的痛苦，同时埋藏的骨瓣易吸收变小。也有人将骨瓣放入骨库中进行深冷冻，需要时取回复温后使用，但这种方法需要冷冻设备，限制了其推广应用。颅脑外伤或脑肿瘤手术，为了降低颅内压，往往需行去骨瓣减压术而造成颅骨缺损。那这部分病人的骨瓣往往是完整的，丢弃十分可惜。二期采取目前流行的钛合金网进行修补，价格昂贵，生理曲度不够完美。如果采用自体多孔骨瓣进行修复成功，方法简单，省钱又兼顾美观。我们的临床研究已证实此方法可行，且取得显著的疗效。本实验研究在于探索颅骨缺损生物性修复的可行性，拟通过受区骨支架的病理学研究，确定离体自体多孔骨瓣能否做为理想的颅骨缺损修复支架材料。
方法：实验动物为新西兰大白兔，制作颅骨缺损模型，将取出的颅骨用高速颅钻钻成多孔骨瓣，经高温煮沸30分钟后原位回植，分别在2周、4周、8周和12周时处死取材进行组织学检查、电镜检查和免疫组化检查。
结果：二．大体形态：2周时仍为死骨，尚未有纤维结缔组织长人；
4周己经有纤维结缔组织覆盖，骨瓣已建立血运；8周时硬膜表面有结
缔组织长入死骨：u周己有新生骨，形成骨性愈合。空自对照组观察
12周均未见成骨现象，缺损处以纤维结缔组织填充。2．组织学检查：
正常颅骨结构可见板状骨和骨髓腔。煮沸30分钟后骨板中的陷窝细胞
死亡，骨髓腔破坏，植人2周后，可见己有纤维结缔组织及血管长入
骨孔内；植入4周时可见纤维结缔组织及血管长入，可见骨岛：植入8
周时可见部分死骨复活，形成新的骨髓腔：植入u周时新生骨增殖活
跃，形成许多骨小梁，骨髓腔再通。3．骨形态发生蛋白 出）免疫组
化检查：高温灭活的自体多孔骨瓣的骨基质呈弱阳性。骨膜、硬膜及
纤维结缔组织中未分化的间质细胞呈阳性，新生骨中成骨细胞呈强阳
性。4．电镜检查：正常骨结构：内外骨板和骨髓腔内的骨小梁：煮沸
30分钟后可见：内外骨板和骨小梁依然存在；植入12周时交接面可见
骨性愈合。
结论：高温灭活后的骨瓣由有机物和钙盐构成的骨架尚未被破坏，
具备天然的传导性骨再生条件，而且在不加外源性骨生长因子的情况
下，灭活后的自体骨瓣尚残留BMP，能刺激骨膜和硬膜未分化的间质细
胞转化为成骨细胞，植入骨瓣经周围正常骨及骨膜的成骨作用，逐渐爬
行替代而复活，经过骨俪改造塑形，可以恢复正常颅骨的结构。因此，
自体多孔骨瓣是颅骨缺损修复理想的支架材料。
Objective: Many skull repairing materials are available, but as far as now none can completely substitute skull as of the aspects of plastic, anti-impact, resistance, heat prevention and antimagnetism, etc. Therefore somebody used the autogenous skull flap to be buried subcutaneously and then transplant back to the patient after a period. But when burying and taking out the skull flap the patient has to undergo pains of twice operations, and the buried flap is easy to be absorbed to become contracted. Somebody else preserves the flap in the bone bank to be deeply frozen, and when in need take out to recover the temperature. But the need for freezing devices limited its popularization. During the operations for trauma of skull and brain or operations of brain tumor, in order to depress the intracranial pressure, the bone flap has to be removed and thus skull damage results.
The bone flaps of these patients are usually intact, and throwing away will be very pitiful. Repairing by the currently popular titanium alloy in the second stage is too expensive and the physiological curve is not perfect. But repairing by autogenous porous flap is very easy, cost-effective and beautiful. Our clinic studies have confirmed that this method is applicable and have achieved remarkable effects. In order to explore the feasibility of the biological repair of skull defect, this study has carried out a pathological study on the bone frame of the receptor zone, to determine whether the isolated autogenous dead bone flap can be used as an ideal repair material for skull defect.
Method: New Zealand large white rabbits were taken to make skull defect model. The extracted skull was made into porous flaps by high-speed skull drill. After being seethed for 30 minutes they were transplanted back to the original place. The material was taken out 2, 4, 8 and 12 weeks later respectively for histological, electronic microscope and immunological histochemical tests.
Results: l.General shape: After 2 it was still dead bone, no flbrotic or connective tissues grew; after 4 it was covered by some fibrotic and connective tissues, blood supply was already constructed; after 8 weeks in the dural surface some connective tissues grew into the dead bone; after 12 there was new bone to form bony healing. Observation for 12 weeks on the blank control group found no osteogenesis, and the defected area was filled
with fibrotic tissues. 2.Histological tests: The tabular bone and marrow cavity can be seen in the normal skull structures. After being seethed for 30 minutes the lacunar cells in the osseous lamella were dead and the marrow cavity was destroyed. Two weeks after transplantation, some fibrotic and connective tissues as well as blood vessels has grown into the bone foramens; four weeks after transplantation, the fibrotic and connective tissues as well as blood vessels has grown and the bone island was visible; eight weeks after transplantation the dead bone revived and new marrow cavity was formed; 12 weeks after transplantation proliferation of the new bone was active and many bone trabecula were formed and the marrow cavity was connected again. S.Immunological histochemical tests of BMP: the bone matrix of the isolated autogenous porous skull flap that was inactivated by high temperature was slightly positive. The non-differential interstitial cells of the periosteum, dura and fibrotic connective tissues were positive, the osteoblast of the new bone were strongly positive. 4.Electronic microscope test: normal bone structure: internal and outer osseous lamella, bone trabecula in the marrow cavity; after being seethed for 30 minutes: internal and outer osseous lamella, and bone trabecula still existed; 12 weeks after transplantation in the interface the bony healing could be seen. Conclusion: After inactivated by high temperature the flap's bone frame which is formed by organic substances and calcium salts was not destroyed, and they have the natural regeneration conditions of conductive bones. And
in the condition o
方法：实验动物为新西兰大白兔，制作颅骨缺损模型，将取出的颅骨用高速颅钻钻成多孔骨瓣，经高温煮沸30分钟后原位回植，分别在2周、4周、8周和12周时处死取材进行组织学检查、电镜检查和免疫组化检查。
结果：二．大体形态：2周时仍为死骨，尚未有纤维结缔组织长人；
4周己经有纤维结缔组织覆盖，骨瓣已建立血运；8周时硬膜表面有结
缔组织长入死骨：u周己有新生骨，形成骨性愈合。空自对照组观察
12周均未见成骨现象，缺损处以纤维结缔组织填充。2．组织学检查：
正常颅骨结构可见板状骨和骨髓腔。煮沸30分钟后骨板中的陷窝细胞
死亡，骨髓腔破坏，植人2周后，可见己有纤维结缔组织及血管长入
骨孔内；植入4周时可见纤维结缔组织及血管长入，可见骨岛：植入8
周时可见部分死骨复活，形成新的骨髓腔：植入u周时新生骨增殖活
跃，形成许多骨小梁，骨髓腔再通。3．骨形态发生蛋白 出）免疫组
化检查：高温灭活的自体多孔骨瓣的骨基质呈弱阳性。骨膜、硬膜及
纤维结缔组织中未分化的间质细胞呈阳性，新生骨中成骨细胞呈强阳
性。4．电镜检查：正常骨结构：内外骨板和骨髓腔内的骨小梁：煮沸
30分钟后可见：内外骨板和骨小梁依然存在；植入12周时交接面可见
骨性愈合。
结论：高温灭活后的骨瓣由有机物和钙盐构成的骨架尚未被破坏，
具备天然的传导性骨再生条件，而且在不加外源性骨生长因子的情况
下，灭活后的自体骨瓣尚残留BMP，能刺激骨膜和硬膜未分化的间质细
胞转化为成骨细胞，植入骨瓣经周围正常骨及骨膜的成骨作用，逐渐爬
行替代而复活，经过骨俪改造塑形，可以恢复正常颅骨的结构。因此，
自体多孔骨瓣是颅骨缺损修复理想的支架材料。
Objective: Many skull repairing materials are available, but as far as now none can completely substitute skull as of the aspects of plastic, anti-impact, resistance, heat prevention and antimagnetism, etc. Therefore somebody used the autogenous skull flap to be buried subcutaneously and then transplant back to the patient after a period. But when burying and taking out the skull flap the patient has to undergo pains of twice operations, and the buried flap is easy to be absorbed to become contracted. Somebody else preserves the flap in the bone bank to be deeply frozen, and when in need take out to recover the temperature. But the need for freezing devices limited its popularization. During the operations for trauma of skull and brain or operations of brain tumor, in order to depress the intracranial pressure, the bone flap has to be removed and thus skull damage results.
The bone flaps of these patients are usually intact, and throwing away will be very pitiful. Repairing by the currently popular titanium alloy in the second stage is too expensive and the physiological curve is not perfect. But repairing by autogenous porous flap is very easy, cost-effective and beautiful. Our clinic studies have confirmed that this method is applicable and have achieved remarkable effects. In order to explore the feasibility of the biological repair of skull defect, this study has carried out a pathological study on the bone frame of the receptor zone, to determine whether the isolated autogenous dead bone flap can be used as an ideal repair material for skull defect.
Method: New Zealand large white rabbits were taken to make skull defect model. The extracted skull was made into porous flaps by high-speed skull drill. After being seethed for 30 minutes they were transplanted back to the original place. The material was taken out 2, 4, 8 and 12 weeks later respectively for histological, electronic microscope and immunological histochemical tests.
Results: l.General shape: After 2 it was still dead bone, no flbrotic or connective tissues grew; after 4 it was covered by some fibrotic and connective tissues, blood supply was already constructed; after 8 weeks in the dural surface some connective tissues grew into the dead bone; after 12 there was new bone to form bony healing. Observation for 12 weeks on the blank control group found no osteogenesis, and the defected area was filled
with fibrotic tissues. 2.Histological tests: The tabular bone and marrow cavity can be seen in the normal skull structures. After being seethed for 30 minutes the lacunar cells in the osseous lamella were dead and the marrow cavity was destroyed. Two weeks after transplantation, some fibrotic and connective tissues as well as blood vessels has grown into the bone foramens; four weeks after transplantation, the fibrotic and connective tissues as well as blood vessels has grown and the bone island was visible; eight weeks after transplantation the dead bone revived and new marrow cavity was formed; 12 weeks after transplantation proliferation of the new bone was active and many bone trabecula were formed and the marrow cavity was connected again. S.Immunological histochemical tests of BMP: the bone matrix of the isolated autogenous porous skull flap that was inactivated by high temperature was slightly positive. The non-differential interstitial cells of the periosteum, dura and fibrotic connective tissues were positive, the osteoblast of the new bone were strongly positive. 4.Electronic microscope test: normal bone structure: internal and outer osseous lamella, bone trabecula in the marrow cavity; after being seethed for 30 minutes: internal and outer osseous lamella, and bone trabecula still existed; 12 weeks after transplantation in the interface the bony healing could be seen. Conclusion: After inactivated by high temperature the flap's bone frame which is formed by organic substances and calcium salts was not destroyed, and they have the natural regeneration conditions of conductive bones. And
in the condition o
引文
1．郑少钦，杨应明，郑丰任等 颅脑外伤术后颅骨缺损修复临床研究《中国急救医学》 2001年2月第21(2)：83
2. Dodde R 2nd, Yavuzer R, Bier UC et. al. Spontaneous bone healing in the rabbit. J Craniofac Surg. 2000 Jul;11(4):346-9.
3．杨应明等．改良覆盖法颅骨成形术《中国医学文苑》 第一版，云南，云南科技出版社．1997；7：156
4．毛天球，陈富林，杨维东等 骨组织工程及支架材料的研究《解放军医学杂志》 2001年4月第26(4)：235-7．
5. Yang LJ, Jin Y. Immunohistochemical observations on bone morphogenetic protein in normal and abnormal conditions. Clin Orthop. 1990 Aug; (257):249-56.
6. Nakase T, Nomura S, Yoshikawa H et. al. Transient and localized expression of bone morphogenetic protein 4 messenger RNA during fracture healing. J Bone Miner Res. 1994 May;9(5):651-9.
7. Grundel RE, Chapman MW, Yee T et. al. Autogeneic bone marrow and porous biphasic calcium phosphate ceramic for segmental bone defects in the canine ulna. Clin Orthop. 1991 May;(266):244-58.
2. Dodde R 2nd, Yavuzer R, Bier UC et. al. Spontaneous bone healing in the rabbit. J Craniofac Surg. 2000 Jul;11(4):346-9.
3．杨应明等．改良覆盖法颅骨成形术《中国医学文苑》 第一版，云南，云南科技出版社．1997；7：156
4．毛天球，陈富林，杨维东等 骨组织工程及支架材料的研究《解放军医学杂志》 2001年4月第26(4)：235-7．
5. Yang LJ, Jin Y. Immunohistochemical observations on bone morphogenetic protein in normal and abnormal conditions. Clin Orthop. 1990 Aug; (257):249-56.
6. Nakase T, Nomura S, Yoshikawa H et. al. Transient and localized expression of bone morphogenetic protein 4 messenger RNA during fracture healing. J Bone Miner Res. 1994 May;9(5):651-9.
7. Grundel RE, Chapman MW, Yee T et. al. Autogeneic bone marrow and porous biphasic calcium phosphate ceramic for segmental bone defects in the canine ulna. Clin Orthop. 1991 May;(266):244-58.