肋软骨切取术后胸廓畸形预防方法的生物力学研究

发布时间：2018-01-19 05:34

本文关键词： 切取肋软骨胸廓畸形再植动物模型生物力学　出处：《北京协和医学院》2017年博士论文　论文类型：学位论文

【摘要】：研究背景自体肋软骨是整形外科常用的支架填充材料,广泛用于耳、鼻和颌面部整形。耳再造手术所需软骨量较大,患者年龄较小,术后胸廓畸形发生率较高,因此广受医患双方的关注。为改善肋软骨切取术后供区形态,Kawanabe等提出了改良肋软骨切取法,并宣称术后供区完全无畸形。但是,尽管有学者完全按照Kawanabe的方法切取肋软骨,术后半年仍会出现明显的胸廓畸形,且生长发育期儿童尤为明显。因此,探索预防肋软骨切取术后胸廓畸形的方法仍是目前临床上研究的热点。根据文献报道,生物力学因素可能是引起胸廓畸形的重要原因之一。但是,目前研究主要关注于软骨组织的再生,而生物力学方面的研究较少。从生物力学角度对不同的干预措施进行研究将有助于为肋软骨切取术后胸廓畸形的预防提供新的思路和方法。研究目的1.建立肋软骨缺损修复的动物模型。评估不同的方式(回植软骨碎块、回植软骨条、不回植软骨)处理对肋软骨切取术后早期肋软骨缺损修复段形态和组织结构的影响。2.评估不同的方式(回植软骨碎块、回植软骨条、不回植软骨)处理对肋软骨切取术后早期缺损修复段生物力学特性的影响。3.评估肋软骨切取术后半年内通过坚持佩戴弹性胸带限制呼吸幅度,是否能够降低肋软骨切取术后胸廓畸形的发生率。研究方法1.新西兰大白兔12只,随机分为两组。于双侧第5、6肋分别切取长15mm肋软骨,保留供区软骨膜完整并缝合关闭软骨膜腔。左右两侧分别以不回植软骨/回植软骨碎块(第5肋)、回植软骨条/回植软骨碎块(第6肋)处理。回植量约为原软骨量的1/4。回植软骨碎块/软骨条的直径约为0.5mm。术后16周、24周分两批处死动物取材。测量比较修复段的外观形态和组织结构。2.采用三点弯曲试验对缺损修复段的生物力学进行评估。比较不同处理方法对缺损修复段生物力学性能的影响。3.通过病史采集和体格检查,对肋软骨切取术后1年左右来院接受耳再造第三期手术的患者的胸廓形态进行评估。按术后半年内是否坚持佩戴胸带分别统计患者胸廓畸形发生率并进行比较。研究结果1.建立了肋软骨缺损修复的动物模型。术后16、24周,同一水平(第5或第6肋)缺损修复段的平均宽度在左右两侧均无显著差异(P0.05)。而同侧、同一水平的缺损修复段术后24周较术后16周宽度窄,两者差异具有统计学显著性(P0.05)。供区新生组织以纤维组织为主,未见透明软骨再生。不同方式处理的缺损修复段的组织结构存在明显差异。2.术后16、24周,各缺损修复段的弹性模量均显著低于正常软骨。未回植软骨的修复段弯曲弹性模量显著高于回植软骨碎块的修复段;回植软骨条的修复段弯曲弹性模量显著高于回植软骨碎块的修复段(P0.05)。在应力应变关系和应力松弛方面,未回植软骨的修复段优于回植软骨碎块的修复段,但不及回植软骨条的修复段。3.共38名患者符合条件进入研究。按要求坚持佩戴胸带半年的患者术后胸廓畸形的发生率(64.7%)低于未按要求佩戴胸带的患者(95.2%)。两者差异具有统计学显著性(P=0.031)。研究结论1.肋软骨切取术后早期(半年内),肋软骨缺损处主要以纤维组织修复。纤维组织随时间而成熟萎缩。回植的自体肋软骨能够成活,但无法证明其能诱导透明软骨再生。按原肋软骨体积的1/4回植自体软骨,缺损修复段尺寸与是否回植软骨或回植软骨的形态无关。但是,是否回植和回植不同形状的自体软骨对修复段组织结构有明显影响,可能是造成生物力学性能差异的原因。2.肋软骨切取术后早期(半年内),肋软骨缺损修复段的生物力学性能显著低于正常软骨,但随时间会逐渐提高。回植自体软骨碎块(原体积的1/4)无助于提高供区的生物力学性能。回植自体软骨条(原体积的1/4)虽不能达到正常肋软骨的生物力学性能,但明显优于未回植和回植软骨碎块组。3.坚持佩戴弹性胸带适当限制呼吸幅度,通过减小呼吸肌和胸腔负压对供区段的牵拉力,能够降低肋软骨切取术后胸廓畸形的发生率。
[Abstract]:The research background of autogenous rib cartilage stent is plastic surgery commonly used filler material, widely used in ear, nose and facial plastic surgery. Ear reconstruction surgery required a large amount of cartilage, patients with younger age, higher incidence of postoperative chest deformity, so popular with both doctors and patients concerned. For cutting area form postoperatively for the improvement of costal cartilage Kawanabe, put forward a modified rib cartilage cut method, and declared that the donor site after surgery without deformity. However, although some scholars completely according to the method of Kawanabe cut costal cartilage, after half a year still obvious chest deformity, and the growth and development of children is particularly obvious. Therefore, to explore the focus of prevention of costal cartilage is the current clinical research methods of chest deformity were cut. According to the literatures, the biomechanical factors may be one of the important causes of thoracic deformity. However, current research is mainly focused on the regeneration of cartilage, The biomechanical research less. From the angle of biomechanics of different intervention measures for research will be helpful for the costal cartilage incision chest deformity prevention to provide new ideas and methods for research purposes. 1. to establish the animal model of rib cartilage defect repair. Evaluation of different ways (backgrafting cartilage fragments, backgrafting cartilage, cartilage) cut back with different ways to assess the impact section morphology and histological structure of early rib cartilage defect repair.2. after surgery of the rib cartilage (backgrafting cartilage fragments, backgrafting cartilage, no cartilage replantation) cut after surgery treatment effect of biomechanical characteristics of early repair of defect assessment.3. the first half of the costal cartilage after operation through the chest with a stick to wearing elastic limit of respiratory rate of the rib cartilage, can reduce the incidence of rib cartilage incision chest deformity. Methods: 1. 12 New Zealand rabbits were randomly. Divided into two groups. In the bilateral 5,6 ribs were harvested for 15mm long costal cartilage, reserved for cartilage membrane integrity and closure of the cartilage membrane cavity. Both sides were in replantation replantation / cartilage cartilage fragments (fifth rib), backgrafting cartilage / backgrafting cartilage fragments (sixth ribs). Replantation is about the original amount of cartilage 1/4. backgrafting cartilage cartilage fragments / a diameter of about 16 weeks after 0.5mm., 24 weeks, two batches were collected. Animal morphology and microstructure of the.2. measurement repair section by three point bending test of biomechanics of defect segments are evaluated. Comparing method some biomechanical properties of different repair defects affect.3. by history and physical examination, the costal cartilage for 1 years after surgery or to the hospital for chest ear reconstruction of the third stage were evaluated. According to postoperative half year whether to insist on wearing a chest belt were measured Patients with thoracic deformity rate were compared. Results 1. established an animal model of rib cartilage defect repair. After 16,24 weeks, the same level (fifth or sixth ribs) the average width of defect repair section on the left and right sides showed no significant difference (P0.05). And the same side of the same level, defect repair section 16 weeks after surgery 24 weeks after surgery is narrow, the difference was statistically significant (P0.05). The donor tissue mainly by fibrous tissue, no regeneration of hyaline cartilage. The organizational structure of different treatment defect segments of 16,24 weeks significantly after.2., the elastic modulus of each segment were defect repair was significantly lower than that of normal cartilage. Not to repair cartilage graft segment flexural modulus was significantly higher than that of repair segment replantation of cartilage fragments; replantation repair section bending elastic modulus of cartilage was significantly higher than that of the repair segment replantation of cartilage fragments (P0.05). The stress and strain The relationship between stress and relaxation, repair without replantation of cartilage repair section is better than that of the replantation of cartilage fragments, but less than the period of replantation of cartilage repair.3. a total of 38 eligible patients entered the study. According to the requirements of the first half of the stick to wearing chest strap in patients with thoracic malformations (64.7%) according to the below asked to wear a chest belt of patients (95.2%). The difference was statistically significant (P=0.031). Conclusion: 1. costal cartilage for early postoperative (six months), rib cartilage defects mainly by fibrous tissue. The fibrous tissue with time and mature atrophy. Autologous costal cartilage graft in the back can survive, but not that which can induce hyaline cartilage regeneration. According to the original cartilage volume of 1/4 implant autologous cartilage defect repair segment size has nothing to do with the replantation of cartilage or backgrafting cartilage morphology. However, whether autologous cartilage replantation and replantation of different shapes on the repair section There is obvious influence of organizational structure, may be caused by the difference of.2. biomechanical properties of costal cartilage for early postoperative (six months), the biomechanical properties of rib cartilage defect repair segment was significantly lower than that of the normal cartilage, but over time will gradually improve. Replantation of autologous cartilage fragments (original volume 1/4) can not improve the biomechanical properties for area. Replantation of autogenous cartilage (the original volume 1/4) biomechanical properties cannot attain normal cartilage, but not significantly better than the replantation and replantation of cartilage fragments.3. insist on wearing elastic chest strap appropriate to limit the amplitude of respiration, by reducing respiratory muscle tension and pleural pressure on Supply section, can occur to reduce the rate of rib cartilage incision chest deformity.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R622

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