同种异体肌腱移植膝关节交叉韧带重建的动物实验与临床应用研究
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摘要
第一部分
同种异体肌腱移植膝关节交叉韧带重建的动物实验研究
背景
同种异体肌腱移植重建膝关节交叉韧带是近十年来的热门课题,国内外有一定数量的临床论文发表。应用同种异体肌腱重建膝关节交叉韧带,因不需要从患者取自体肌腱而造成取腱的损害,而受到学术界的关注。不同于取自体肌腱的现取现用,异体肌腱是在特定条件下保存了一定时间的植入材料,故对其临床应用需要动物实验的研究基础。有关的动物实验论文较少,国内尚无动物实验研究报告发表。同种异体肌腱移植重建膝关节交叉韧带,有以下几点备受关注:(1)同种异体肌腱的生物力学强度,经过冰冻和冷藏后其生物学强度是否有所损失,能否达到临床手术的需要。在制备和解冻异体肌腱过程中,哪些环节可能会导致胶原纤维崩解而影响肌腱的生物学强度,如何有效地保护肌腱。(2)同种异体肌腱植入体内后是否存在免疫排斥反应,引发手术后的关节渗液、发热、甚至感染等毒副作用。(3)同种异体肌腱移植后其愈合修复过程与自体肌腱移植有无差异。
开展同种异体肌腱移植重建膝关节交叉韧带的动物实验研究,是建立人类同种异体肌腱库的前期基础工作,其结果和数据对于调整和改进同种异体肌腱的制备技术,对于应用同种异体肌腱重建膝关节交叉韧带临床治疗过程中正确掌握肌腱保存、运输、溶冻等重要环节技术,提供重要的实验数据和理论依据。同时,肌腱愈合过程的研究是制定临床治疗过程中的手术方案、康复方案的重要参考。动物实验研究是系统开发和研究人类同种异体肌腱库必不可少的工作。
目的
1、观察同种异体肌腱制备环节对肌腱的生物力学强度、组织形态学的影响,研究制备同种异体肌腱的工艺程序。
2、观察同种异体肌腱植入动物体内后机体的免疫学变化。
3、研究同种异肌腱重建交叉韧带后的组织愈合过程,通过与自体肌腱移植比较,探讨用同种异体肌腱替代自体肌腱重建膝关节交叉韧带的理论基础。
方法
1、手术模型用新西兰大白兔1/2BPTB移植,切开重建膝关节前交叉韧带。
2、移植肌腱的制备方法无菌切取1/2BPTB,先经无菌生理盐水漂洗2～3次,然后在保护液(10%小牛血清+MEM溶液)中浸泡10～15分钟,以湿纱布拭去表面多余的水分,再放入冻存管中。-80℃深低温冷冻方法:先将冻存管置于4℃中平衡半小时,再置于-20℃冰箱中4小时,最后置于可控深低温冰箱中逐步降温至-80℃保存。程序冷冻液氮保存方法:将冻存管放入程序冷冻仪(CBS2100,USA)中,按设定好的冷冻程序先以1℃/min的速度降至4℃,平衡0.5h,再以0.5℃/min的速度降至-80℃,然后以1℃/min的速度降至-180℃,最后置于液氮储存罐中保存。移植肌腱的解冻方法:将取出的异体腱置于40℃生理盐水中融化15分钟,当肌腱恢复弹性后,再置于庆大霉素溶液(4万U/100ml)漂洗5～10分钟,再经生理盐水漂洗后即可使用。
3、不同冻存方法对髌腱移植物的影响实验取12只大白兔双侧膝关节1/2骨-髌腱-骨复合体(BPTB)共48条,将所取BPTB再随机分为3组,即-80℃深低温保存2周组、程序冷冻液氮保存2周组和新鲜未冷冻组,各组随机选取8条BPTB行生物力学测试,6条行细胞活性检验,2条行形态学观察。
4、移植实验用1/2BPTB同种异体肌腱的制备取16只大白兔1/2BPTB共64条,分别经-80℃深低温保存2周和程序冷冻液氮保存2周备异体移植用。
5、BPTB移植重建膝关节交叉韧带实验48只大白兔随机分为3组,即-80℃深低温保存异体移植组、程序冷冻液氮保存异体移植组和自体移植组(对照组)。分别于移植后3周和8周观察淋巴细胞毒性、细胞活性、移植物强度和组织形态学变化。
结果
1、自体肌腱移植和两种冻存方法处理的异体肌腱移植后都会经历大致相似的组织学变化过程,初期大量新生成纤维细胞及毛细血管增生并侵入移植腱,移植腱的胶原组织逐渐坏死并被新生的胶原所替代,其修复随时间的推移而趋向成熟,最终演变为排列整齐呈波浪型的胶原纤维束。
2、经-80℃和液氮两种深低温保存方法处理后,髌腱的最大载荷无明显下降,细胞活性均得到了较好的保存,程序冷冻液氮保存组更优。
3、移植后的全过程均未表现明显的排斥反应,且免疫反应随时间的推移而下降。
4、移植后3周,程序冷冻液氮保存组和-80℃深低温保存组相比最大载荷无差异,细胞活性较优,术后8周,程序冷冻液氮保存组移植物的最大载荷和细胞活性均优于-80℃深低温保存组。
结论
1、-80℃深低温保存法和程序冷冻液氮保存法均可有效地用于保存同种异体腱,而程序冷冻液氮保存法更优。
2、-80℃深低温保存法和程序冷冻液氮保存法处理的同种异体腱移植术后无明显淋巴细胞素作用,需要在人体内进一步验证有无排斥反应或关节刺激反应。
3、同种异体肌腱移植重建膝关节交叉韧带后其韧带愈合过程接近于自体肌腱,但较自体肌腱慢。
第二部分
同种异体肌腱移植关节镜下膝关节交叉韧带重建的临床观察
背景
膝关节是人体最大和最重要的下肢承重和运动关节,在运动过程中所产生的应力和剪力,大部分被膝部肌肉收缩所产生的力量所吸收,部分由关节韧带、关节纤维囊等静力稳定结构吸收。在运动过程中,膝关节遭受巨大外力,超过动力稳定的代偿能力时,韧带将承受超极限的负荷而发生撕裂和损伤。而韧带损伤后,静力和动力结构和功能失去平衡,导致膝关节运动时的不稳定。
交叉韧带损伤是一种常见的膝关节损伤,是引起膝关节不稳的重要因素之一,交叉韧带损伤可导致关节疼痛及关节不稳,后期常引起关节松弛、关节退行性改变以及继发的半月板损伤和关节软骨破坏,严重者可导致关节病废。交叉韧带损伤常见于运动伤和交通事故伤,随着现代竞技体育的发展和高速车辆交通事故的增多,膝关节交叉韧带的损伤也逐渐增加,其损伤后的治疗成为骨科医生及运动医学专家关注的重要问题。
对于因交叉韧带实质部的损伤引起的膝关节不稳定,用肌腱替代物植入重建膝关节的韧带结构和功能是临床上十分有效的治疗方法,关节镜微创技术的应用使膝关节交叉韧带重建手术创伤小、治疗效果好,从而得到广泛的医患认可。
自体肌腱移植最早用于交叉韧带重建手术,常用的移植肌腱是中1/3髌腱带骨块(Bone-Patellar tengdon-Bone,BPTB)和腘绳肌腱(Semitendinosus+Gracilis,ST+Gr)。BPTB切取后约有20-40%的患者发生膝前区疼痛、弹响、跪地困难等膝前区症状,采用改良式双横切口技术仍有约10%的膝前区症状。切取ST+Gr后则损失屈膝肌力约20%,持续1年-1年半后始可恢复。采用自体肌腱移植存在不同程度地对患膝造成新的损害,特别是在多韧带损伤时,自体肌腱的取材受到较大的限制。
同种异体肌腱移植重建膝关节交叉韧带手术后,经历与自体肌腱相似的韧带修复过程,可以用于替代自体肌腱以避免取自体肌腱时对已受伤的膝关节造成新的创伤,并且其选材不受限制,能满足严重的多韧带损伤的重建材料需要。但同种异体肌腱不同于自体材料的现取现用,而是经过了体外的冰冻、保存、解冻等多个环节,其植入人体安全性和临床治疗结果需要观察和总结。
开展同种异体肌腱移植重建膝关节交叉韧带的临床治疗工作,需要高质量符合手术植入标准的肌腱供应来源。尽管国外现已形成具有一定规模的同种异体肌腱库,但由于准入制度等原因目前阶段尚无法向我国提供产品,亦无法向我国提供标准化的同种异体肌腱制备程序。本课题总结国外的相关资料和经验,结合动物实验所得到的数据,研究建立人类同种异体肌腱库的技术和方法,并制定了供体选择、取材、包装、冷冻、解冻等相关的工艺流程以及管理制度。
同种异体肌腱可提供不同于自体肌腱的移植材料,如1/2BPTB(自体为1/3髌腱)、1/2股四头肌腱(自体为1/3股四头肌腱),而胫骨前后肌腱、腓骨长短肌腱及跟腱则是无法从自体割取的。移植材料不同,其手术方法亦存在差异。本课题尚对前后交叉韧带重建的手术方法进行探索。
目的
1、研究和改进建立人类同种异体肌腱制作的技术方法和操作规程,建立腱库管理的相关制度,为本课题临床膝关节交叉韧带重建手术提供符合要求的同种异体肌腱。
2、根据同种异体肌腱的特点,探讨特定的关节镜下重建手术方式。
3、通过临床应用,观察同种异体肌腱植入人体的安全性,通过临床随访分析,总结同种异体肌腱移植重建膝关节前年交叉韧带临床治疗效果。
方法
1、同种异体肌腱库的建立(1)供体选择健康捐献者及创伤截肢术后的肢体。(2)供体筛选①年龄供者年龄原则上无严格限制,本课题所选供体均为20～45岁男性。②排除全身的急慢性感染、血液传播性疾病、恶性肿瘤特别是骨骼肌肉系统肿瘤等。③血样检查包括HIVAb)、乙肝病毒检测、丙肝病毒(HCV)抗体检测、梅毒快速血浆反应素试验(RPR)、血液细菌培养等。(3)取材在离体或死亡后2小时内取材为最佳,特殊情况可延长到12小时。在手术台无菌条件下取腱,经无菌生理盐水漂洗2-3次后,浸泡在保护液(10%小牛血清+MEM溶液)中10～15分钟,三层无菌塑料封装袋中。(4)冷冻用程序冷冻仪逐步降温到-180℃,然后置于液氮罐中(-196℃)保存,10天后即可使用。(5)腱库管理①标签和说明移植材料制备后,依据其组织来源、部位、制备方法、灭菌方法等,正确地冠以名称,标明材料的编号、大小、体积、数量,标明制备时间和使用的有效期限,并标明注意事项和贮存条件,开启方法和使用方法。②建立各种记录制度严格建立各种操作记录制度,包括供体的筛选、组织获取、材料制备、发放等各种操作过程的记录。③专人监控复核发放登记。
2、经关节镜膝关节前交叉韧带重建治疗组(1)应用1/2BPTB移植单束重建ACL 27例、应用胫骨前后肌腱及腓骨长短肌腱双束重建ACL 15例。全部采用关节镜微创技术按照等长点的原则进行重建,BPTB两端骨块均用钛钉或可吸收界面镙钉固定,双束重建股骨骨道端用内置钢板固定,胫骨骨道端用可吸收界面镙钉固定。(2)术后按照统一的康复程序进行功能训练。(3)疗效果观察指标膝关节伸屈活动幅度,与术前相同的Lysholm评分、Lachman试验、轴移试验、前抽屉试验以及患者主观评价。(4)观察伤口愈合情况、关节肿胀或积液情况、有无感染发生等。
3、经关节镜膝关节后交叉韧带重建治疗组(1)应用跟腱双束重建后交叉韧带21例,全部采用关节镜微创技术按照等长点的原则进行重建,胫骨骨道移植腱骨块用钛钉或可吸收界面镙钉固定,股骨骨道用可吸收界面镙钉固定。(2)术后按照统一的康复程序进行功能训练。(3)疗效果观察指标膝关节伸屈活动幅度,与术前相同的Larson评分、Lysholm评分、Lachman试验、后抽屉试验以及患者主观评价。(4)观察伤口愈合情况、关节肿胀或积液情况、有无感染发生等。
结果
1、本组手术所用的肌腱,采用40℃盐水15分种解冻技术,所有肌腱外观色泽新鲜、骨块强度虽有降低但能达到内固定要求。术中对移植腱多点细菌培养均为阴性。
2、本组所有手术无一例发生切口或关节腔感染,部分病例早期有轻度到中度的关节肿胀或积液,一般经过1～3个月可消退。
3、前交叉韧带重建的42个膝关节中,有37例得到随访,平均随访时间1年2个月(6个月～2年3个月)。随访指标包括与术前相同的Lysholm评分、Lachman试验及前抽屉试验以及患者主观评价。末次随访结果:Lysholm评分由术前(58.2±6.3)分提高至术后(92.1±4.8)分。所有患者的膝关节活动范围基本恢复到与对侧相同。患者自我评价,满意25个膝,比较满意10个膝,尚可2个膝。无一例接受二次修正手术。
4、后交叉韧带双束重建的21个膝关节中,有18膝得到随访,平均随访11个月(6个月～1年9个月)。随访指标包括与术前相同的Larson评分、Lysholm评分、反向Lachman试验及后抽屉试验物理检查以及患者主观评价。末次随访结果:Larson评分法功能评估术前平均59(37～72)分,术后平均92(85～98)分,Lysholm评分法功能评估术前平均56(39～76)分,术后平均91(81～99)分。Larson评分平均提高33分,Lysholm评分平均提高35分。所有患膝术前后抽屉试验(PDT)及反向Lachman试验均阳性,术后仅2例后抽屉试验弱阳性,1例反向Lachman试验弱阳性。患者自我评价,满意11例,比较满意6例,尚可1例。
结论
1、本腱库所制备同种异体肌腱安全、可靠,经临床应用验证,无细菌污染,植入体内后无明显刺激及炎症反应。
2、同种异体肌腱移植经关节镜膝关节前后交叉韧带重建技术,创伤小、治疗效果好,对因交叉韧带损伤引起的关节不稳定有显著的临床治疗效果。
PART ONE
The animal experiments of knee cruciate ligament reconstruction with allogenous tendon grafts
Background
Reconstruction of the knee joint cruciate ligament using tendon allografts is the hot topic in recent decades.A certain amount of clinical papers have been published at home and abroad.This method attracts more attention mainly due to no harm of the knee joint in harvesting grafts.Reconstructing cruciate ligament with allografts must be supported by animal experiments as the allograft are the materials preserved in certain condition for a period of time and this kind of allograft is not the'same as autogenous tendon.Animal experiments are less and no papers have been published in china.Reconstruction of the knee joint cruciate ligament by tendon allograft receives much concern as follows:(1)Whether the biomechanical strength of tendon allografts is changed after frozen and cold storage? Which factor could lead to disintegration of collagen fibers and then reduce the biomechanical strength of tendon allograft in the freezing and thawing process of the tendon? How to protect the tendon effectively?(2) Whether immunological rejection is initiated by tendon allograft?(3) Whether there are differences in reparation and healing of the cruciate ligaments between tendon allograft and autograft?
The animal study of tendon allograft transplantation is a fundamental work for establishment of human tendon allograft bank.Moreover,the results of animal experiments will provide crucial data and theoretical basis for adjustment and improvement of tendon allograft preparation technology.In addition,the healing process in the animals will supply important references for operation and rehabilitation schemes in clinical application.
Objective
(1) To study the process of tendon allograft preparation,and to investigate the effects of tendon allograft preparation on the biomechanical strength and histomorphology of the tendon.
(2) To observe the immunological changes of cruciate ligament after tendon allograft transplantation.
(3) To investigate the tendon healing process of the cruciate ligament after tendon allograft transplantation and to provide theoretical basis of tendon allograft by comparison with autograft.
Methods
(1) Operation model Discission and Reconstruction of the anterior crucial ligament by transplantation of New Zealand white rabbits 1/2BPTB.
(2) Tendon preparation method 1/2BPTB were detached and washed three times with 0.9%normal sodium and soaked in protective solution(10%calf serum + MEM) for 10-15 min,then,were placed in frozen stock tube.①Deep- frozen(-80℃)Method The tube were put in 4℃for 30 min,then in -20℃for 4 h,and then were transferred to a deep-frozen refrigerator gradually down to -80℃.②Programmable freezing and liquid nitrogen store method The tube were placed in a programmable freezer (CBS2100,USA) lower to 4℃at a speed of 1℃/min,then lower to -80℃at a speed of 1℃/min,finally lower to -180℃at the speed of 1℃/min according to the programmed procedure.The tube was stored in -180℃for further investigation.③Tendon thawing method The tendon allografts were put in 0.9%normal sodium (40℃) for 15 min,then were placed in gentamicin solution(400U/ml) and washed for 5-10 min when its elasticity recovering.The tendon could be transplanted after rinsing with 0.9%normal sodium.
(3) Effects of different cryopreservative methods on patellar tendon allograft 48 1/2 BPTBs were detached from 12 white rabbits.The BPTBs were randomly divided into -80℃deep-frozen group,programmable freezing and liquid nitrogen store group and control group.In every group,8 BPTBs were detected with biomechanical test,6 BPTBs with cell viability analysis,and 2 BPTBs with morphological observation.
(4) Preparation of 1/2BPTB for transplantation 64 1/2 BPTBs were detached from 16 white rabbits,then,were preserved with -80℃deep-frozen method or liquid nitrogen, respectively,for 2 weeks for further transplantation.
(5) The experiments of reconstruction of the knee joint cruciate ligament by BPTB transplantation 48 white rabbits were randomly divided into -80℃deep-frozen group, programmable freezing and liquid nitrogen store group and control group.Cytotoxic effect,cell viability analysis,biomechanical strength of grafts and morphological changes were detected after 3 and 8 weeks of transplantation.
Results
(1) The histological changes of tendon with different cryopreservative methods were much similar.At early stage,a lot of fibroblasts and proliferating capillaries invaded into the transplanted tendon,collagen tissue were damaged and replaced by neonatal collagen gradually.Finally,the neonatal collagen line up in order and form undee collagen fibers bundles.
(2) In comparision with control group,the peak loads of patellar tendon and cell viability preserved by different cryopreservative methods were not obviously impaired. However,programmable freezing and liquid nitrogen store group could achieve better performance.
(3) There was no obvious immunologic rejection of the tendon transplantation in the whole process,and the immunological response was reduced with time passing.
(4) 3 weeks after transplantation,there was no differences in peak load between -80℃deep-frozen group and programmable freezing and liquid nitrogen store group.8 weeks after transplantation,the peak load and cell activity in programmable freezing and liquid nitrogen store group is superior to -80℃deep-frozen group.
Conclusions
(1) -80℃deep-frozen method and programmable freezing and liquid nitrogen store method can effectively preserve tendon allografts,and the latter has better effects.
(2) The cytotoxic effect caused by the transplantation of the tendon stored with -80℃deep-frozen method and programmable freezing and liquid nitrogen store method were unconspicuous.However,the reject reaction and stimulus response of the joint need to be verification in human.
(3) The healing process of cruciate ligaments of knee joint after tendon allograft transplantation was similar with but slower than that of autograft transplantation.
PART Two
The clinical observation of the Cruciate ligaments reconstruction by allogenic tendon transplantation under arthroscope
Background
Knee is lower extremity weight-bearing and athletics joint.It is the most important and complex joint.The muscles round the knee absorb most stress and shear force which motion caused.While the articular ligament and fibrous capsule absorb little.During motion process,knee subject prodigious power.If it is bigger than its stabilization power,the ligament will be teared.The overbalance of static and dynamic structure caused by teared ligament lead to the instability of the knee during motion process.
Since traffic accident and overexercise more and more,Cruciate ligament lesion increase together.Cruciate ligament lesion is frequent in knee injury which result to knee ache and unsteadiness,then arthrochalasis,retrogression,and meniscus and cartilage injury,some even irreversible joint damage.So it is important for orthopedist and athletic expert to treat the injury.
It is effective using surrogate reconstructing the cruciate construction and function to treat the cruciate lesion.Arthroscope technology proved to be good way in reconstruction of cruciate ligament because less operation wound and better therapeutic efficacy.
Auto tendon transplantation is original in cruciate ligament reconstruction,the most are Bone-Patellar tendon-Bone(BPTB) and Semitendon & Graces (ST+Gr).When BPTB was removed,anterior area pain of knee,clicking and difficult to kneel occurred(20%-40%).Even reforming 2 transsection was used,the symptom is 10%.It lost 20%muscle force aider ST+Gr was incised,and it take 1-1.5 years for the injury to recovery.We can conclude that the auto tendons transplantation is limit because it cause to new injury of the knee,especially in multiligament injury.
The recovery process of allogenic tendon after transplantation is same to auto tendon.It avoid the new injury of auto tendon transplantation.The material is unlimited and satisfied mutiligament reconstruction after injury.However,the safety and clinical therapeutic result of allogenic tendon transplantation need to be proved since the tendon through exosomatic freezing,conservation,and defrosting process and so on.
The operation of Cruciate ligaments reconstruction by allogenic tendon transplantation needs high quality tendon resource coincidence to operation standard. Some other countries and nations have aUogenic tendon warehouse,but we can not use those,and we do not know the standard process of allogenic tendon making.This title invest the technology and approach of establishing human allogenic tendon warehouse and formulate flow-sheet and supervising system after concluded correlated document and experience combinating the animal test data.
The allogenic tendon is different to auto on material,such as 1/2BPTB,1/3 quadriceps femoris tendon.It is can not be obtained of tibialis anterior and posterior tendon,long and short peroneal tendons and achilles tendon.The operation is different duo to different transplantation materials.This title also investigate the operation ways.
Objective
1.investigating and improving the making manufacture technology and manipulate process of human allogenic tendon,establish the institution of administering tendon warehouse.Providing the coincident allogenic tendons for clinical reconstruction operations of cruciate ligaments.
2.Approaching specific operation way under arthroscope according to different allogenic tendons.
3.Observing the safety after allogenic tendon transplantation in human body through the analyses of clinical follow-up,concluding the clinical therapeutic efficacy of reconstructing anterior cruciate ligament by allogenic tendon.
Materials and methods
1.to establish the allogenic tendon warehouse.
(1) selection donor:well and active donor and extremity after traumatic amputation.
(2) bolting donor:1) age,20-25 years old males.2) exclude the donors with infection,blood transmissible disease and malignant tumor especially bone and muscle system.3) Blood analysis.Including HBV,HCV,RPR,HIV-Ab and blood bacterial culture and so on.(3) To draw the material:drawing the material in 2 hours aider the material was donated,some maybe prolong to 12 Hs.We draw the tendons on operation table under asepsis condition,then wash it 2-2 times by SPSS,dishing in safety fluid(calf serum and men solution) 10-15 minutes,and capsulating in asepsis plastic pouchs.(4) Freezing:the temperature cooling to -180℃step by step by freezing machine,then restored it in nitrogen canister.We can use the tendon 10 days later.(5) Administering the tendon warehouse:1)label and illustration.After preparing the transplantation materials,we titled them,labeled the number,size,volume,quant, preparation time,expiry data and announcements,stock condition,open and use ways according to its source,position,preparative method and sterilization way.2) To establish the institution of record and manipulation,including bolting donors,obtaining, preparing and distributing the materials.3) Monitoring the record by special messenger.
2.The group of anterior cruciate ligament reconstruction under arthroscope.(1) 27 patients by 1/2BPTB,15 by double tendon of tibialis anterior and posterior tendon, long and short peroneal tendons and achilles tendon.The reconstruction was operated all under arthroscope according to isometric rules.The BPTB were fixed by Ti screw or absorption interface screw.Double tendon was fixed by introfix plate at femur and absorption interface screw at tibia.(2) unified rehabilitation procedure after operation. (3) The indexes of result:the range extension and flexion,Lysholm score,Lachman test,pivot shift test,anterior drawer test,and subjective evaluation the same to before operation.(4) observing the wound condition,arthrocele,fluidify and infection and so on.
3.The group of posterior cruciate ligament reconstruction under arthroscope.(1) 21 patients by double achilles tendon,the operation rules and ways is the same to the 2~(nd) group.The rehabilitation and indexes is the same to the 2~(nd) group except for the posterior drawer test.
Results
1.The tendons which was defrosted 15 minutes in 40℃SPSS looks fresh with enough strength however lower than normal.The bacterial culture of poly-point is negative in operation.
2.All the patients have no infection after operation,however,some with gently or medium arthrocele and fluidify,but the syndrome extinct 1-3 months later.
3.37 of 42 anterior cruciate ligament reconstruction patients was follow-up mean 1 year and 2 months(6months-2years and 3 months).the follow up indexes is the same to anterior operations.Lysholm score increased from 58.2±6.3 to 92.1±4.8.the motion range is the same to the other knee.25 Patients were satisfied.10 were improved,2 had advcanticement.Objective check with KT2000 showed that -2～4mm,compared to normal.All the patients had not receive the revisional operation.
4.18 of 21 posterior cruciate ligament reconstruction patients was follow-up mean 11 months(6months-1years and 9 months).the follow up indexes is the same to anterior operations.Larson score increased from 59(37～72) to 92(85～98).Lyscholm score increase from 56(39-76) to 91(81-99).The increase mean ranges are 33 by Larson score and 35 Lyscholm score.The PDT and Lzchman test are all positive while they are all negative except 2 weakly positive by PDT and 1 by Lachman test after operations.11 Patients were satisfied.6 were improved,1 had advcanticement.
Conclusions
1.Clinical using proved that the allogenic tendon our preparing are safety without any bacterial contamination and reflex of irritation and infection when they were transplanted in human body.
2.The Cruciate ligaments reconstruction by allogenic tendon transplantation under arthroscope with less operation injuery have good clinical therapeutic efficacy to treat joint unstable due to cruciate ligament lesion.
同种异体肌腱移植膝关节交叉韧带重建的动物实验研究
背景
同种异体肌腱移植重建膝关节交叉韧带是近十年来的热门课题,国内外有一定数量的临床论文发表。应用同种异体肌腱重建膝关节交叉韧带,因不需要从患者取自体肌腱而造成取腱的损害,而受到学术界的关注。不同于取自体肌腱的现取现用,异体肌腱是在特定条件下保存了一定时间的植入材料,故对其临床应用需要动物实验的研究基础。有关的动物实验论文较少,国内尚无动物实验研究报告发表。同种异体肌腱移植重建膝关节交叉韧带,有以下几点备受关注:(1)同种异体肌腱的生物力学强度,经过冰冻和冷藏后其生物学强度是否有所损失,能否达到临床手术的需要。在制备和解冻异体肌腱过程中,哪些环节可能会导致胶原纤维崩解而影响肌腱的生物学强度,如何有效地保护肌腱。(2)同种异体肌腱植入体内后是否存在免疫排斥反应,引发手术后的关节渗液、发热、甚至感染等毒副作用。(3)同种异体肌腱移植后其愈合修复过程与自体肌腱移植有无差异。
开展同种异体肌腱移植重建膝关节交叉韧带的动物实验研究,是建立人类同种异体肌腱库的前期基础工作,其结果和数据对于调整和改进同种异体肌腱的制备技术,对于应用同种异体肌腱重建膝关节交叉韧带临床治疗过程中正确掌握肌腱保存、运输、溶冻等重要环节技术,提供重要的实验数据和理论依据。同时,肌腱愈合过程的研究是制定临床治疗过程中的手术方案、康复方案的重要参考。动物实验研究是系统开发和研究人类同种异体肌腱库必不可少的工作。
目的
1、观察同种异体肌腱制备环节对肌腱的生物力学强度、组织形态学的影响,研究制备同种异体肌腱的工艺程序。
2、观察同种异体肌腱植入动物体内后机体的免疫学变化。
3、研究同种异肌腱重建交叉韧带后的组织愈合过程,通过与自体肌腱移植比较,探讨用同种异体肌腱替代自体肌腱重建膝关节交叉韧带的理论基础。
方法
1、手术模型用新西兰大白兔1/2BPTB移植,切开重建膝关节前交叉韧带。
2、移植肌腱的制备方法无菌切取1/2BPTB,先经无菌生理盐水漂洗2～3次,然后在保护液(10%小牛血清+MEM溶液)中浸泡10～15分钟,以湿纱布拭去表面多余的水分,再放入冻存管中。-80℃深低温冷冻方法:先将冻存管置于4℃中平衡半小时,再置于-20℃冰箱中4小时,最后置于可控深低温冰箱中逐步降温至-80℃保存。程序冷冻液氮保存方法:将冻存管放入程序冷冻仪(CBS2100,USA)中,按设定好的冷冻程序先以1℃/min的速度降至4℃,平衡0.5h,再以0.5℃/min的速度降至-80℃,然后以1℃/min的速度降至-180℃,最后置于液氮储存罐中保存。移植肌腱的解冻方法:将取出的异体腱置于40℃生理盐水中融化15分钟,当肌腱恢复弹性后,再置于庆大霉素溶液(4万U/100ml)漂洗5～10分钟,再经生理盐水漂洗后即可使用。
3、不同冻存方法对髌腱移植物的影响实验取12只大白兔双侧膝关节1/2骨-髌腱-骨复合体(BPTB)共48条,将所取BPTB再随机分为3组,即-80℃深低温保存2周组、程序冷冻液氮保存2周组和新鲜未冷冻组,各组随机选取8条BPTB行生物力学测试,6条行细胞活性检验,2条行形态学观察。
4、移植实验用1/2BPTB同种异体肌腱的制备取16只大白兔1/2BPTB共64条,分别经-80℃深低温保存2周和程序冷冻液氮保存2周备异体移植用。
5、BPTB移植重建膝关节交叉韧带实验48只大白兔随机分为3组,即-80℃深低温保存异体移植组、程序冷冻液氮保存异体移植组和自体移植组(对照组)。分别于移植后3周和8周观察淋巴细胞毒性、细胞活性、移植物强度和组织形态学变化。
结果
1、自体肌腱移植和两种冻存方法处理的异体肌腱移植后都会经历大致相似的组织学变化过程,初期大量新生成纤维细胞及毛细血管增生并侵入移植腱,移植腱的胶原组织逐渐坏死并被新生的胶原所替代,其修复随时间的推移而趋向成熟,最终演变为排列整齐呈波浪型的胶原纤维束。
2、经-80℃和液氮两种深低温保存方法处理后,髌腱的最大载荷无明显下降,细胞活性均得到了较好的保存,程序冷冻液氮保存组更优。
3、移植后的全过程均未表现明显的排斥反应,且免疫反应随时间的推移而下降。
4、移植后3周,程序冷冻液氮保存组和-80℃深低温保存组相比最大载荷无差异,细胞活性较优,术后8周,程序冷冻液氮保存组移植物的最大载荷和细胞活性均优于-80℃深低温保存组。
结论
1、-80℃深低温保存法和程序冷冻液氮保存法均可有效地用于保存同种异体腱,而程序冷冻液氮保存法更优。
2、-80℃深低温保存法和程序冷冻液氮保存法处理的同种异体腱移植术后无明显淋巴细胞素作用,需要在人体内进一步验证有无排斥反应或关节刺激反应。
3、同种异体肌腱移植重建膝关节交叉韧带后其韧带愈合过程接近于自体肌腱,但较自体肌腱慢。
第二部分
同种异体肌腱移植关节镜下膝关节交叉韧带重建的临床观察
背景
膝关节是人体最大和最重要的下肢承重和运动关节,在运动过程中所产生的应力和剪力,大部分被膝部肌肉收缩所产生的力量所吸收,部分由关节韧带、关节纤维囊等静力稳定结构吸收。在运动过程中,膝关节遭受巨大外力,超过动力稳定的代偿能力时,韧带将承受超极限的负荷而发生撕裂和损伤。而韧带损伤后,静力和动力结构和功能失去平衡,导致膝关节运动时的不稳定。
交叉韧带损伤是一种常见的膝关节损伤,是引起膝关节不稳的重要因素之一,交叉韧带损伤可导致关节疼痛及关节不稳,后期常引起关节松弛、关节退行性改变以及继发的半月板损伤和关节软骨破坏,严重者可导致关节病废。交叉韧带损伤常见于运动伤和交通事故伤,随着现代竞技体育的发展和高速车辆交通事故的增多,膝关节交叉韧带的损伤也逐渐增加,其损伤后的治疗成为骨科医生及运动医学专家关注的重要问题。
对于因交叉韧带实质部的损伤引起的膝关节不稳定,用肌腱替代物植入重建膝关节的韧带结构和功能是临床上十分有效的治疗方法,关节镜微创技术的应用使膝关节交叉韧带重建手术创伤小、治疗效果好,从而得到广泛的医患认可。
自体肌腱移植最早用于交叉韧带重建手术,常用的移植肌腱是中1/3髌腱带骨块(Bone-Patellar tengdon-Bone,BPTB)和腘绳肌腱(Semitendinosus+Gracilis,ST+Gr)。BPTB切取后约有20-40%的患者发生膝前区疼痛、弹响、跪地困难等膝前区症状,采用改良式双横切口技术仍有约10%的膝前区症状。切取ST+Gr后则损失屈膝肌力约20%,持续1年-1年半后始可恢复。采用自体肌腱移植存在不同程度地对患膝造成新的损害,特别是在多韧带损伤时,自体肌腱的取材受到较大的限制。
同种异体肌腱移植重建膝关节交叉韧带手术后,经历与自体肌腱相似的韧带修复过程,可以用于替代自体肌腱以避免取自体肌腱时对已受伤的膝关节造成新的创伤,并且其选材不受限制,能满足严重的多韧带损伤的重建材料需要。但同种异体肌腱不同于自体材料的现取现用,而是经过了体外的冰冻、保存、解冻等多个环节,其植入人体安全性和临床治疗结果需要观察和总结。
开展同种异体肌腱移植重建膝关节交叉韧带的临床治疗工作,需要高质量符合手术植入标准的肌腱供应来源。尽管国外现已形成具有一定规模的同种异体肌腱库,但由于准入制度等原因目前阶段尚无法向我国提供产品,亦无法向我国提供标准化的同种异体肌腱制备程序。本课题总结国外的相关资料和经验,结合动物实验所得到的数据,研究建立人类同种异体肌腱库的技术和方法,并制定了供体选择、取材、包装、冷冻、解冻等相关的工艺流程以及管理制度。
同种异体肌腱可提供不同于自体肌腱的移植材料,如1/2BPTB(自体为1/3髌腱)、1/2股四头肌腱(自体为1/3股四头肌腱),而胫骨前后肌腱、腓骨长短肌腱及跟腱则是无法从自体割取的。移植材料不同,其手术方法亦存在差异。本课题尚对前后交叉韧带重建的手术方法进行探索。
目的
1、研究和改进建立人类同种异体肌腱制作的技术方法和操作规程,建立腱库管理的相关制度,为本课题临床膝关节交叉韧带重建手术提供符合要求的同种异体肌腱。
2、根据同种异体肌腱的特点,探讨特定的关节镜下重建手术方式。
3、通过临床应用,观察同种异体肌腱植入人体的安全性,通过临床随访分析,总结同种异体肌腱移植重建膝关节前年交叉韧带临床治疗效果。
方法
1、同种异体肌腱库的建立(1)供体选择健康捐献者及创伤截肢术后的肢体。(2)供体筛选①年龄供者年龄原则上无严格限制,本课题所选供体均为20～45岁男性。②排除全身的急慢性感染、血液传播性疾病、恶性肿瘤特别是骨骼肌肉系统肿瘤等。③血样检查包括HIVAb)、乙肝病毒检测、丙肝病毒(HCV)抗体检测、梅毒快速血浆反应素试验(RPR)、血液细菌培养等。(3)取材在离体或死亡后2小时内取材为最佳,特殊情况可延长到12小时。在手术台无菌条件下取腱,经无菌生理盐水漂洗2-3次后,浸泡在保护液(10%小牛血清+MEM溶液)中10～15分钟,三层无菌塑料封装袋中。(4)冷冻用程序冷冻仪逐步降温到-180℃,然后置于液氮罐中(-196℃)保存,10天后即可使用。(5)腱库管理①标签和说明移植材料制备后,依据其组织来源、部位、制备方法、灭菌方法等,正确地冠以名称,标明材料的编号、大小、体积、数量,标明制备时间和使用的有效期限,并标明注意事项和贮存条件,开启方法和使用方法。②建立各种记录制度严格建立各种操作记录制度,包括供体的筛选、组织获取、材料制备、发放等各种操作过程的记录。③专人监控复核发放登记。
2、经关节镜膝关节前交叉韧带重建治疗组(1)应用1/2BPTB移植单束重建ACL 27例、应用胫骨前后肌腱及腓骨长短肌腱双束重建ACL 15例。全部采用关节镜微创技术按照等长点的原则进行重建,BPTB两端骨块均用钛钉或可吸收界面镙钉固定,双束重建股骨骨道端用内置钢板固定,胫骨骨道端用可吸收界面镙钉固定。(2)术后按照统一的康复程序进行功能训练。(3)疗效果观察指标膝关节伸屈活动幅度,与术前相同的Lysholm评分、Lachman试验、轴移试验、前抽屉试验以及患者主观评价。(4)观察伤口愈合情况、关节肿胀或积液情况、有无感染发生等。
3、经关节镜膝关节后交叉韧带重建治疗组(1)应用跟腱双束重建后交叉韧带21例,全部采用关节镜微创技术按照等长点的原则进行重建,胫骨骨道移植腱骨块用钛钉或可吸收界面镙钉固定,股骨骨道用可吸收界面镙钉固定。(2)术后按照统一的康复程序进行功能训练。(3)疗效果观察指标膝关节伸屈活动幅度,与术前相同的Larson评分、Lysholm评分、Lachman试验、后抽屉试验以及患者主观评价。(4)观察伤口愈合情况、关节肿胀或积液情况、有无感染发生等。
结果
1、本组手术所用的肌腱,采用40℃盐水15分种解冻技术,所有肌腱外观色泽新鲜、骨块强度虽有降低但能达到内固定要求。术中对移植腱多点细菌培养均为阴性。
2、本组所有手术无一例发生切口或关节腔感染,部分病例早期有轻度到中度的关节肿胀或积液,一般经过1～3个月可消退。
3、前交叉韧带重建的42个膝关节中,有37例得到随访,平均随访时间1年2个月(6个月～2年3个月)。随访指标包括与术前相同的Lysholm评分、Lachman试验及前抽屉试验以及患者主观评价。末次随访结果:Lysholm评分由术前(58.2±6.3)分提高至术后(92.1±4.8)分。所有患者的膝关节活动范围基本恢复到与对侧相同。患者自我评价,满意25个膝,比较满意10个膝,尚可2个膝。无一例接受二次修正手术。
4、后交叉韧带双束重建的21个膝关节中,有18膝得到随访,平均随访11个月(6个月～1年9个月)。随访指标包括与术前相同的Larson评分、Lysholm评分、反向Lachman试验及后抽屉试验物理检查以及患者主观评价。末次随访结果:Larson评分法功能评估术前平均59(37～72)分,术后平均92(85～98)分,Lysholm评分法功能评估术前平均56(39～76)分,术后平均91(81～99)分。Larson评分平均提高33分,Lysholm评分平均提高35分。所有患膝术前后抽屉试验(PDT)及反向Lachman试验均阳性,术后仅2例后抽屉试验弱阳性,1例反向Lachman试验弱阳性。患者自我评价,满意11例,比较满意6例,尚可1例。
结论
1、本腱库所制备同种异体肌腱安全、可靠,经临床应用验证,无细菌污染,植入体内后无明显刺激及炎症反应。
2、同种异体肌腱移植经关节镜膝关节前后交叉韧带重建技术,创伤小、治疗效果好,对因交叉韧带损伤引起的关节不稳定有显著的临床治疗效果。
PART ONE
The animal experiments of knee cruciate ligament reconstruction with allogenous tendon grafts
Background
Reconstruction of the knee joint cruciate ligament using tendon allografts is the hot topic in recent decades.A certain amount of clinical papers have been published at home and abroad.This method attracts more attention mainly due to no harm of the knee joint in harvesting grafts.Reconstructing cruciate ligament with allografts must be supported by animal experiments as the allograft are the materials preserved in certain condition for a period of time and this kind of allograft is not the'same as autogenous tendon.Animal experiments are less and no papers have been published in china.Reconstruction of the knee joint cruciate ligament by tendon allograft receives much concern as follows:(1)Whether the biomechanical strength of tendon allografts is changed after frozen and cold storage? Which factor could lead to disintegration of collagen fibers and then reduce the biomechanical strength of tendon allograft in the freezing and thawing process of the tendon? How to protect the tendon effectively?(2) Whether immunological rejection is initiated by tendon allograft?(3) Whether there are differences in reparation and healing of the cruciate ligaments between tendon allograft and autograft?
The animal study of tendon allograft transplantation is a fundamental work for establishment of human tendon allograft bank.Moreover,the results of animal experiments will provide crucial data and theoretical basis for adjustment and improvement of tendon allograft preparation technology.In addition,the healing process in the animals will supply important references for operation and rehabilitation schemes in clinical application.
Objective
(1) To study the process of tendon allograft preparation,and to investigate the effects of tendon allograft preparation on the biomechanical strength and histomorphology of the tendon.
(2) To observe the immunological changes of cruciate ligament after tendon allograft transplantation.
(3) To investigate the tendon healing process of the cruciate ligament after tendon allograft transplantation and to provide theoretical basis of tendon allograft by comparison with autograft.
Methods
(1) Operation model Discission and Reconstruction of the anterior crucial ligament by transplantation of New Zealand white rabbits 1/2BPTB.
(2) Tendon preparation method 1/2BPTB were detached and washed three times with 0.9%normal sodium and soaked in protective solution(10%calf serum + MEM) for 10-15 min,then,were placed in frozen stock tube.①Deep- frozen(-80℃)Method The tube were put in 4℃for 30 min,then in -20℃for 4 h,and then were transferred to a deep-frozen refrigerator gradually down to -80℃.②Programmable freezing and liquid nitrogen store method The tube were placed in a programmable freezer (CBS2100,USA) lower to 4℃at a speed of 1℃/min,then lower to -80℃at a speed of 1℃/min,finally lower to -180℃at the speed of 1℃/min according to the programmed procedure.The tube was stored in -180℃for further investigation.③Tendon thawing method The tendon allografts were put in 0.9%normal sodium (40℃) for 15 min,then were placed in gentamicin solution(400U/ml) and washed for 5-10 min when its elasticity recovering.The tendon could be transplanted after rinsing with 0.9%normal sodium.
(3) Effects of different cryopreservative methods on patellar tendon allograft 48 1/2 BPTBs were detached from 12 white rabbits.The BPTBs were randomly divided into -80℃deep-frozen group,programmable freezing and liquid nitrogen store group and control group.In every group,8 BPTBs were detected with biomechanical test,6 BPTBs with cell viability analysis,and 2 BPTBs with morphological observation.
(4) Preparation of 1/2BPTB for transplantation 64 1/2 BPTBs were detached from 16 white rabbits,then,were preserved with -80℃deep-frozen method or liquid nitrogen, respectively,for 2 weeks for further transplantation.
(5) The experiments of reconstruction of the knee joint cruciate ligament by BPTB transplantation 48 white rabbits were randomly divided into -80℃deep-frozen group, programmable freezing and liquid nitrogen store group and control group.Cytotoxic effect,cell viability analysis,biomechanical strength of grafts and morphological changes were detected after 3 and 8 weeks of transplantation.
Results
(1) The histological changes of tendon with different cryopreservative methods were much similar.At early stage,a lot of fibroblasts and proliferating capillaries invaded into the transplanted tendon,collagen tissue were damaged and replaced by neonatal collagen gradually.Finally,the neonatal collagen line up in order and form undee collagen fibers bundles.
(2) In comparision with control group,the peak loads of patellar tendon and cell viability preserved by different cryopreservative methods were not obviously impaired. However,programmable freezing and liquid nitrogen store group could achieve better performance.
(3) There was no obvious immunologic rejection of the tendon transplantation in the whole process,and the immunological response was reduced with time passing.
(4) 3 weeks after transplantation,there was no differences in peak load between -80℃deep-frozen group and programmable freezing and liquid nitrogen store group.8 weeks after transplantation,the peak load and cell activity in programmable freezing and liquid nitrogen store group is superior to -80℃deep-frozen group.
Conclusions
(1) -80℃deep-frozen method and programmable freezing and liquid nitrogen store method can effectively preserve tendon allografts,and the latter has better effects.
(2) The cytotoxic effect caused by the transplantation of the tendon stored with -80℃deep-frozen method and programmable freezing and liquid nitrogen store method were unconspicuous.However,the reject reaction and stimulus response of the joint need to be verification in human.
(3) The healing process of cruciate ligaments of knee joint after tendon allograft transplantation was similar with but slower than that of autograft transplantation.
PART Two
The clinical observation of the Cruciate ligaments reconstruction by allogenic tendon transplantation under arthroscope
Background
Knee is lower extremity weight-bearing and athletics joint.It is the most important and complex joint.The muscles round the knee absorb most stress and shear force which motion caused.While the articular ligament and fibrous capsule absorb little.During motion process,knee subject prodigious power.If it is bigger than its stabilization power,the ligament will be teared.The overbalance of static and dynamic structure caused by teared ligament lead to the instability of the knee during motion process.
Since traffic accident and overexercise more and more,Cruciate ligament lesion increase together.Cruciate ligament lesion is frequent in knee injury which result to knee ache and unsteadiness,then arthrochalasis,retrogression,and meniscus and cartilage injury,some even irreversible joint damage.So it is important for orthopedist and athletic expert to treat the injury.
It is effective using surrogate reconstructing the cruciate construction and function to treat the cruciate lesion.Arthroscope technology proved to be good way in reconstruction of cruciate ligament because less operation wound and better therapeutic efficacy.
Auto tendon transplantation is original in cruciate ligament reconstruction,the most are Bone-Patellar tendon-Bone(BPTB) and Semitendon & Graces (ST+Gr).When BPTB was removed,anterior area pain of knee,clicking and difficult to kneel occurred(20%-40%).Even reforming 2 transsection was used,the symptom is 10%.It lost 20%muscle force aider ST+Gr was incised,and it take 1-1.5 years for the injury to recovery.We can conclude that the auto tendons transplantation is limit because it cause to new injury of the knee,especially in multiligament injury.
The recovery process of allogenic tendon after transplantation is same to auto tendon.It avoid the new injury of auto tendon transplantation.The material is unlimited and satisfied mutiligament reconstruction after injury.However,the safety and clinical therapeutic result of allogenic tendon transplantation need to be proved since the tendon through exosomatic freezing,conservation,and defrosting process and so on.
The operation of Cruciate ligaments reconstruction by allogenic tendon transplantation needs high quality tendon resource coincidence to operation standard. Some other countries and nations have aUogenic tendon warehouse,but we can not use those,and we do not know the standard process of allogenic tendon making.This title invest the technology and approach of establishing human allogenic tendon warehouse and formulate flow-sheet and supervising system after concluded correlated document and experience combinating the animal test data.
The allogenic tendon is different to auto on material,such as 1/2BPTB,1/3 quadriceps femoris tendon.It is can not be obtained of tibialis anterior and posterior tendon,long and short peroneal tendons and achilles tendon.The operation is different duo to different transplantation materials.This title also investigate the operation ways.
Objective
1.investigating and improving the making manufacture technology and manipulate process of human allogenic tendon,establish the institution of administering tendon warehouse.Providing the coincident allogenic tendons for clinical reconstruction operations of cruciate ligaments.
2.Approaching specific operation way under arthroscope according to different allogenic tendons.
3.Observing the safety after allogenic tendon transplantation in human body through the analyses of clinical follow-up,concluding the clinical therapeutic efficacy of reconstructing anterior cruciate ligament by allogenic tendon.
Materials and methods
1.to establish the allogenic tendon warehouse.
(1) selection donor:well and active donor and extremity after traumatic amputation.
(2) bolting donor:1) age,20-25 years old males.2) exclude the donors with infection,blood transmissible disease and malignant tumor especially bone and muscle system.3) Blood analysis.Including HBV,HCV,RPR,HIV-Ab and blood bacterial culture and so on.(3) To draw the material:drawing the material in 2 hours aider the material was donated,some maybe prolong to 12 Hs.We draw the tendons on operation table under asepsis condition,then wash it 2-2 times by SPSS,dishing in safety fluid(calf serum and men solution) 10-15 minutes,and capsulating in asepsis plastic pouchs.(4) Freezing:the temperature cooling to -180℃step by step by freezing machine,then restored it in nitrogen canister.We can use the tendon 10 days later.(5) Administering the tendon warehouse:1)label and illustration.After preparing the transplantation materials,we titled them,labeled the number,size,volume,quant, preparation time,expiry data and announcements,stock condition,open and use ways according to its source,position,preparative method and sterilization way.2) To establish the institution of record and manipulation,including bolting donors,obtaining, preparing and distributing the materials.3) Monitoring the record by special messenger.
2.The group of anterior cruciate ligament reconstruction under arthroscope.(1) 27 patients by 1/2BPTB,15 by double tendon of tibialis anterior and posterior tendon, long and short peroneal tendons and achilles tendon.The reconstruction was operated all under arthroscope according to isometric rules.The BPTB were fixed by Ti screw or absorption interface screw.Double tendon was fixed by introfix plate at femur and absorption interface screw at tibia.(2) unified rehabilitation procedure after operation. (3) The indexes of result:the range extension and flexion,Lysholm score,Lachman test,pivot shift test,anterior drawer test,and subjective evaluation the same to before operation.(4) observing the wound condition,arthrocele,fluidify and infection and so on.
3.The group of posterior cruciate ligament reconstruction under arthroscope.(1) 21 patients by double achilles tendon,the operation rules and ways is the same to the 2~(nd) group.The rehabilitation and indexes is the same to the 2~(nd) group except for the posterior drawer test.
Results
1.The tendons which was defrosted 15 minutes in 40℃SPSS looks fresh with enough strength however lower than normal.The bacterial culture of poly-point is negative in operation.
2.All the patients have no infection after operation,however,some with gently or medium arthrocele and fluidify,but the syndrome extinct 1-3 months later.
3.37 of 42 anterior cruciate ligament reconstruction patients was follow-up mean 1 year and 2 months(6months-2years and 3 months).the follow up indexes is the same to anterior operations.Lysholm score increased from 58.2±6.3 to 92.1±4.8.the motion range is the same to the other knee.25 Patients were satisfied.10 were improved,2 had advcanticement.Objective check with KT2000 showed that -2～4mm,compared to normal.All the patients had not receive the revisional operation.
4.18 of 21 posterior cruciate ligament reconstruction patients was follow-up mean 11 months(6months-1years and 9 months).the follow up indexes is the same to anterior operations.Larson score increased from 59(37～72) to 92(85～98).Lyscholm score increase from 56(39-76) to 91(81-99).The increase mean ranges are 33 by Larson score and 35 Lyscholm score.The PDT and Lzchman test are all positive while they are all negative except 2 weakly positive by PDT and 1 by Lachman test after operations.11 Patients were satisfied.6 were improved,1 had advcanticement.
Conclusions
1.Clinical using proved that the allogenic tendon our preparing are safety without any bacterial contamination and reflex of irritation and infection when they were transplanted in human body.
2.The Cruciate ligaments reconstruction by allogenic tendon transplantation under arthroscope with less operation injuery have good clinical therapeutic efficacy to treat joint unstable due to cruciate ligament lesion.
引文
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4.李靖扬,艾合买提·玉素甫,等.普通低温与深低温处理的同种异体跟腱移植的免疫学实验研究.新疆医科大学学报.2006,2:141-144.
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