丹参酮ⅡA治疗肌腱粘连的动物实验及临床研究

发布时间：2018-08-31 15:04

【摘要】：研究背景:肌腱粘连是指肌腱损伤修复过程中周围组织的增生和侵入,造成肌腱运动功能障碍。外伤术后肌腱粘连是肌腱损伤后常见问题之一,迄今为止仍无有效的解决方法,仍大概有30～40%的病人术后有关节活动度不佳,手功能受限等并发症[1]。我们希望通过深入肌腱粘连机制的研究来解决这一问题。肌腱粘连发生的原因可能为机械性和化学性的损伤。损伤诱发间质细胞和肥大细胞释放多种活性物质,使组织产生炎性反应,毛细血管通透性增加,大量浆液渗出。这些渗出物如不能被分解吸收,则促使纤维蛋白积聚,继而发生纤维细胞浸润和新生毛细血管的长入,最后形成纤维粘连[2]。目前认为肌腱的愈合由内、外两种修复机制完成。内源性修复机制指通过肌腱细胞增生修复损伤肌腱;外源性修复机制指通过腱周组织增生,纤维母细胞,炎症细胞的增生修复损伤肌腱。肌腱自身的强度主要取决于内源性修复机制;而外源性修复则主要形成粘连[3,4]。由于炎性反应导致局部组织渗出增多,炎性后的机化后更加重肌腱的粘连,这就是肌腱外源性修复容易广泛粘连的主要问题[5]。TGF-β1/Smad3是创伤修复过程中的重要信号通路。TGF-β1是各种损伤后组织发生病理性纤维化的因素之一。目前实验发现在肌腱损伤时TGF-β1可刺激腱细胞DNA合成,促进腱细胞增殖参与肌腱的修复,促使成纤维细胞和巨噬细胞的募集、血管的生成、刺激胶原的产生[6]。丹参酮ⅡA,TanshinoneⅡA,为唇形科鼠尾草属植物丹参(Salviamiltior-rhizabunge)的有效成份具有抗菌、消炎、扩张血管、抗血小板凝集等作用来治疗冠心病等心血管疾病[7-9]。我们研究TSA是否可以有效的防止肌腱粘连和其可能作用机制,包括微小RNA(miRNA)及通过TGF-β/Smad信号通路的蛋白表达,并且进一步验证并运用于临床。本研究的成功实施将为肌腱功能修复提供了新的理论和途径。第一部分丹参酮ⅡA治疗肌腱粘连的动物实验研究背景:肌腱表面和腱鞘之间的肌腱粘连是一种常见的临床问题。虽然骨科修复技术和康复治疗进步使肌腱粘连得到一定的改善,但仍然无法彻底根治。丹参酮ⅡA(TSA)是因为它的抗炎活性作为主要功能活性的植物化学物质之一。我们用丹参酮ⅡA(TSA)在大鼠的跟腱损伤模型中来防止肌腱粘连的和通过TGF-β/Smad信号通路研究可能的作用机制,包括微RNA(miRNA)的表达和蛋白质表达。方法:建立SD大鼠的跟腱损伤模型,肌腱损伤处通过改良Kessler的技术缝合,随机分为TSA和对照组。肌腱断端用TSA进行干预,并用生理盐水作为对照。6周后对肌腱组织进行大体观察和组织学评价。我们通过显微镜观察,大体观察肌腱的粘连情况,根据瘢痕量来评价胶原纤维的重塑的程度。通过实时PCR检测microRNA的表达和通过western blotting来检测蛋白表达。结果:根据肌腱粘连的评价标准,发现TSA组比对照组粘连形成少。两组中均未观察到肌腱断裂或局部感染的情况。TSA组中肌腱组织中的胶原纤维的含量降低,与对照组相比有显著的统计学差异,P=0.0004。在TSA组中在修复肌腱组织中进行检测 miRNA 的检测包括的 miR-155,miR-29b,miR-21,miR-133B 和 let7 的表达,仅观察到miR-29b的表达比对照组有增高,P0.0001,有显著的统计学差异。western blotting来检测TSA组中TGF-β1和p-Smad3蛋白的表达低于对照组。结论:在大鼠粘连模型中使用TSA可能是防止肌腱粘连的有效方法。第二部分丹参酮ⅡA治疗肌腱粘连的临床研究背景:手外伤容易造成术后掌指关节粘连和关节活动受限。特别是创伤术后掌指关节僵硬的患者,由于掌指关节的活动度对手指功能影响较大,所以如何恢复手部掌指粘连患者术后手部功能及提高生活质量具有重要意义。2015年9月～2016年3月,我们对80例掌指关节粘连的病人进行临床研究,随机双盲分成两组。现通过回顾分析患者临床资料,讨论丹参酮ⅡA(TSA)防治掌指关节粘连的临床疗效。目的:探讨丹参防治创伤后掌指关节粘连的临床疗效。方法:2015年9月～2016年3月,对80例掌指关节粘连的病人进行研究。随机双盲分成两组,TSA组40例和空白组40例。男58例,女22例;年龄20～55岁,平均38岁。其中拇指掌指关节16例,示指24例,环指22例,中指11例,小指7例。致伤原因:机器伤33例,运动伤21例,车祸伤17例,刀砍伤9例。治疗前、治疗后3个月和6个月进行影像学评估,功能评定采用手部关节活动度TAM系统评价法(total active movement,TAM),日常生活手功能评定采用Michigan手功能评价(Michigan Hand Outcome Questionnaire,MHQ),评分数据采用独立样本t检验。结果:患者术后切口均Ⅰ期愈合,术后均无内固定松动、断裂,骨折不愈合等并发症。患者均获随访,随访6个月时TAM评分丹参组优27例,良10例,可3例,差0例,优良率93%;空白组优15例,良16例,可9例,差0例,优良率78%,组间比较差异有统计学意义(P0.05);MHQ评分丹参组60.0±14.2分,空白组50.1±15.7分。组间比较差异有统计学意义(t=2.96,P0.05)。结论:运用丹参酮ⅡA可以减少术后掌指关节粘连程度,临床疗效满意。第三部分丹参酮ⅡA联合Swanson人工关节置换治疗严重掌指关节粘连的初期疗效研究Swanson人工关节最初并用于近端指间关节(proximal interphalangeal joint,PIP)和掌指关节(metacarpophalangealjoint,MCP)的关节置换。既往研究主要集中在Swanson人工关节置换治疗类风湿MCP关节的临床疗效[10-12]。对于创伤后掌指关节僵硬患者的治疗缺乏系统的临床研究。考虑到目前创伤后重度掌指关节粘连及僵硬的患者临床疗效不佳,我们选择使用丹参酮ⅡA联合Swanson人工关节置换来解决这个问题。评估其近期临床疗效和患者的主观评价。目的:探讨丹参酮ⅡA联合Swanson人工关节置治疗创伤后重度掌指关节粘连及僵硬患者的初期疗效。方法:从2014年9月至2015年7月在就诊的属于创伤后重度掌指关节粘连及僵硬患者,使用丹参酮ⅡA联合Swanson人工关节置换治疗掌指关节严重粘连僵硬患者的回顾性研究。其中男3例,女1例。示指为2例,中指为1例,同时涉及示指和中指1例。掌指关节离断3人,掌指关机挤压伤1人。患者平均年龄为52.15±2.6岁(范围41岁～67岁)。数据统计包括术前和术后6个月的评分(握力,关节活动范围,Sollerman 手功能测定和 Michigan 手功能评价(Michigan Hand Outcome Questionnaire,MHQ)"。结果:随访时间为术后6个月。握力较术前显著增加(术前4.2±2.2公斤,术后6.7±2.8公斤,P=0.027)。关节运动度范围已显著增加(术前24.6±9.0度,术后47.0±10.7度,P0.001)。Sollerman评分显示前和操作后,无统计学显著差异。MHQ总得分较术前显著增加(术前50±15,术后57±15,P=0.002)。功能方面,日常生活,外观和满病人满意度等术后评分也显著增加了。然而日常工作和疼痛的术后评分没有改善。所有患者对术后外观,自身满意度改善。结论:丹参酮ⅡA联合Swanson人工关节置换可明显改善掌指关节僵硬患者的运动范围。患者手部美观性功能及都得到了提高。今后的长期随访将有助于更好地确定该方法的功效。我们建议外伤后掌指关节僵硬患者可以选择丹参酮ⅡA联合Swanson人工关节置换这个手术方式。
[Abstract]:BACKGROUND: Tendon adhesion refers to the proliferation and invasion of surrounding tissues during tendon repair, resulting in tendon dysfunction. Postoperative tendon adhesion is one of the common problems after tendon injury. Up to now, there is no effective solution to this problem. There are still about 30-40% patients with poor joint mobility and limited hand function. Complications [1]. We hope to solve this problem through in-depth study of the mechanism of tendon adhesion. The causes of tendon adhesion may be mechanical and chemical injuries. Injury induces the release of a variety of active substances in stromal cells and mast cells, resulting in inflammation of tissues, increased capillary permeability, and massive serous exudation. If the exudate can not be absorbed, it will promote the accumulation of fibrin, then the infiltration of fibrocytes and the growth of new capillaries, and finally the formation of fiber adhesion [2]. The strength of the tendon itself mainly depends on the endogenous repair mechanism, whereas the exogenous repair mainly forms adhesion [3,4]. Because of the inflammation reaction, the local tissue exudates more, and the inflammation after the mechanization of tendon adhesion, this is the muscle. TGF-beta 1 is one of the important signaling pathways in the process of wound repair. TGF-beta 1 is one of the factors causing pathological fibrosis after various injuries. Promote the recruitment of fibroblasts and macrophages, angiogenesis, stimulation of collagen production [6].Tanshinone II A, Tanshinone II A, an effective ingredient of Salvia miltior-rhizabunge, has the effects of antibacterial, anti-inflammatory, vasodilation, anti-platelet aggregation and other cardiovascular diseases [7-9]. To investigate whether TSA can effectively prevent tendon adhesion and its possible mechanisms, including the expression of microRNA (microRNA) and protein via TGF-beta/Smad signaling pathway, and further validate and apply to clinical practice. The successful implementation of this study will provide a new theory and approach for tendon functional repair. Background: Tendon adhesion between the tendon sheath and the tendon surface is a common clinical problem. Although advances in orthopaedic repair and rehabilitation have improved tendon adhesion to some extent, it is still not completely cured. Tanshinone II A (TSA) is a plant whose anti-inflammatory activity is the main functional activity. One of the chemicals. We used tanshinone II A (TSA) to prevent tendon adhesion in the rat Achilles tendon injury model and investigated possible mechanisms of action, including microRNA (microRNA) expression and protein expression, through the TGF-beta/Smad signaling pathway. METHODS: SD rat Achilles tendon injury model was established. The tendon injury site was modified by Kessler's technique suture. After 6 weeks, the tendon tissue was observed and histologically evaluated. We observed the tendon adhesion by microscope and evaluated the degree of collagen remodeling by scar size. MicroRNA was detected by real-time PCR. Results: According to the evaluation criteria of tendon adhesion, there were fewer adhesion formation in TSA group than in control group. No tendon rupture or local infection was observed in both groups. In TSA group, the expression of microRNAs including microRNAs-155, microRNAs-29b, microRNAs-21, microRNAs-133B and let7 was detected in repaired tendon tissues. The expression of microRNAs-29b was significantly higher than that in control group (P 0.0001). The expression of TGF-beta 1 and p-Smad3 protein in TSA group was lower than that in control group. Conclusion: TSA may be an effective method to prevent tendon adhesion in rat adhesions model. Part 2: Clinical research background of tanshinone II A in the treatment of tendon adhesion: Hand trauma is liable to cause postoperative metacarpophalangeal joint adhesion and limitation of joint movement, especially in patients with metacarpophalangeal joint stiffness after trauma due to the mobility of metacarpophalangeal joint. From September 2015 to March 2016, 80 patients with metacarpophalangeal joint adhesion were randomly divided into two groups. The clinical data of the patients were analyzed retrospectively to discuss tanshinone II A (Tanshinone II A). Objective: To investigate the clinical effect of Salvia miltiorrhiza on the prevention and treatment of metacarpophalangeal joint adhesion after trauma. Methods: 80 patients with metacarpophalangeal joint adhesion were studied from September 2015 to March 2016. They were randomly divided into two groups, 40 cases in TSA group and 40 cases in blank group. There were 16 cases of metacarpophalangeal joint, 24 cases of index finger, 22 cases of ring finger, 11 cases of middle finger and 7 cases of small finger. Michigan Hand Outcome Questionnaire (MHQ) and independent sample t test were used to evaluate the hand function. Results: All the incisions healed in the first stage, and there were no complications such as loosening of internal fixation, rupture and nonunion. All the patients were followed up. The TAM score of Danshen group was excellent in 27 cases and good in 10 cases. There were 3 cases, fair 3 cases, poor 0 cases, excellent and good rate 93%; the blank group 15 cases, good 16 cases, fair 9 cases, poor 0 cases, excellent and good rate 78%. There was significant difference between the two groups (P 0.05); MHQ score of Danshen group 60.0 (+ 14.2), blank group 50.1 (+ 15.7). There was significant difference between the two groups (t = 2.96, P 0.05). Conclusion: Tanshinone II A can reduce postoperative metacarpophalangeal joint adhesion. The third part is the preliminary study of Tanshinone II A combined with Swanson artificial joint replacement in the treatment of severe metacarpophalangeal joint adhesion. Swanson artificial joint was initially used in proximal interphalangeal joint (PIP) and metacarpophalangeal joint (MCP). There is no systematic clinical study on the treatment of metacarpophalangeal joint stiffness after trauma. Considering the poor clinical efficacy of severe metacarpophalangeal joint adhesion and stiffness after trauma, we choose tanshinone II A combined with Swanson artificial joint. Objective: To investigate the initial efficacy of tanshinone II A combined with Swanson arthroplasty in the treatment of severe metacarpophalangeal joint adhesion and stiffness after trauma. A retrospective study of patients with severe adhesion and stiffness of metacarpophalangeal joints treated with tanshinone II A combined with Swanson arthroplasty was conducted. There were 3 males and 1 females. The index finger was 2 cases, the middle finger was 1 case, and the index finger and the middle finger were 1 case. Data included preoperative and postoperative scores (grip strength, range of motion, Sollerman hand function, and Michigan Hand Outcome Questionnaire, MHQ). "Results: Follow-up time was 6 months after surgery. Grip strength increased significantly (4.2 The range of motion of the joints was significantly increased (24.6 [9.0], 47.0 [10.7], P 0.001). Sollerman score showed no significant difference between before and after operation. The total score of MHQ was significantly increased (50 [15], 57 [15], P = 0.002) compared with that before operation. Conclusion: Tanshinone II A combined with Swanson arthroplasty can significantly improve the range of motion in patients with metacarpophalangeal joint stiffness. The aesthetic function of the hand and the postoperative scores of the patients have been improved. Long-term follow-up will be helpful. We suggest that patients with traumatic metacarpophalangeal joint stiffness may choose tanshinone II A combined with Swanson arthroplasty.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R686.1

【相似文献】