改良肌腱缝合技术预防屈肌腱粘连的临床研究

发布时间：2018-06-04 02:06

本文选题：肌腱损伤 + 肌腱粘连　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:屈肌腱损伤在临床中十分常见,修复术后的肌腱粘连是肌腱损伤术后最常见的并发症之一,屈肌腱修复术后肌腱粘连更是手外科亟待解决的难题之一。血液供应、淋巴液参与是营养肌腱的两种主要形式。内源性愈合机制和外源性愈合机制是肌腱愈合的两种主要形式,肌腱愈合中这两种形式同时存在。内源性愈合占主导时粘连发生较少,外源性愈合占主导时粘连发生较多。因此,促进内源性愈合机制是预防粘连的关键。现在普遍认为早期功能锻炼可以促进内源性愈合机制从而预防肌腱粘连,这就要求缝合方法需不断改进以期拥有足够高的生物力学强度能够满足早期功能锻炼的要求。按照缝线对肌腱的作用方式不同,肌腱缝合方法可以分为锁式缝合方法和抓握式缝合方法。相较于抓握式缝合方法,锁式缝合方法的抗拉力强度更大,可以满足修复术后早期功能锻炼的需要。我们提出了一种新型锁式肌腱缝合方法。经过生物力学实验已经得出结论,其抗拉力强度和抗间隙形成能力大于手指在无阻力主动屈曲时的最大张力,能够满足早期主动功能锻炼的需要。本研究组将ZM缝合法结合3-0TICRON聚酯缝合线运用于临床,术后辅助早期主动功能锻炼,旨在观察评估ZM缝合法通过早期主动功能锻炼在预防肌腱粘连中的临床效果,以期指导临床,为解决预防肌腱粘连这一难题提供一种新方法。方法:自2016年4月至2017年1月,研究者筛选出就诊于我院的符合纳入标准的33例41指Ⅰ、Ⅱ、Ⅲ区指屈肌腱损伤患者,其中伴有神经血管损伤者9例。致伤原因:切割伤22例,电锯伤11例。其中拇指为6指,示指为10指,中指为9指,环指为9指,小指为7指。指深指浅屈肌腱全部断裂指数为28指,指深屈肌腱断裂为6指,指浅屈肌腱断裂为7指。所有患者均为急诊病人,全部一期缝合修复,指深浅屈肌腱均断裂时全部缝合修复。从受伤至手术时间为2-4小时左右。手术中修整肌腱断端后,应用美国泰龙泰科聚酯缝合线(3-0TICRON聚酯缝合线)行ZM肌腱中心缝合法修复,修复过程严格按照ZM中心缝合法的要求进行缝合。中心缝合完毕后以5-0PROLENE缝合线在肌腱吻合口处进行连续周边缝合。术后均给予腕关节中立位,掌指关节屈曲60度,指间关节伸直位(图7-8),石膏均固定4周。术后均常规给予对症治疗,术后24-48h时即拆除绷带,放开指间关节,只固定腕关节和掌指关节。指导患者进行早期功能锻炼,方法为:早中晚各2-3组,每组被动屈曲主动伸直活动3-5次,减少因关节僵硬带来的阻力,主动屈曲2次。主动屈曲应缓慢适度,以感到有阻力时为止,被动屈曲则应充分,以手指掌侧面接触手掌为止。术后2周左右,适当减少早期功能锻炼的次数,避免主动屈伸手指活动。术后12-14天拆线,于术后2周、4周、8周、12周时随访病人,记录患指活动度,并使用国际通用的TAM评价系统标准评价优良率,并计算优良率。结果:32例患者伤口一期愈合,仅有1例患者出现伤口渗液,红肿现象等炎症反应,后经过伤口换药、抗炎治疗,伤口愈合。但并未对最终结果产生影响。33例患者均获得随访,随访率达到100%。术后1月优良率为42.3%,术后2月优良率97.0%,术后3月优良率100%,且未发生术后并发症,无一例肌腱再次断裂患者。结论:33例肌腱损伤患者术后无一例肌腱二次断裂证明了临床应用ZM肌腱缝合法结合3-0TICRON聚酯缝合线可以满足早期主动功能锻炼的需要。且术后3个月优良率达到100%。证实了ZM缝合法结合3-0TICRON聚酯缝合线修复断裂指屈肌腱安全可靠,可以满足早期主动功能锻炼的需求,是修复断裂屈肌腱的优选方法之一。
[Abstract]:Objective: flexor tendon injury is very common in clinic. Tendon adhesion after repair is one of the most common complications after tendon injury. Tendon adhesion after flexor tendon repair is one of the difficult problems to be solved in hand surgery. Blood supply, lymph involvement is the two main form of nourishment tendon. Endogenous healing mechanism and exogenous mechanism Healing mechanism is the two main form of tendon healing. These two forms exist simultaneously in tendon healing. Endogenous healing is dominated by less adhesion and exogenous healing is dominant when the adhesion occurs more. Therefore, promoting endogenous healing mechanism is the key to prevent adhesion. It is now widely believed that early functional exercise can promote endogenous origin. The mechanism of sexual union prevents tendon adhesion, which requires that the suture method should be continuously improved to meet the requirements of early functional exercise with a high enough biomechanical strength. The action of the tendon to the tendon is different according to the suture. The tendon suture method can be divided into the lock suture method and the grasping suture method. A new method of locking tendon suture is proposed. A new method of locking tendon suture is proposed. Through biomechanical experiments, we have concluded that the tensile strength and the ability to resist the gap are greater than the maximum tension of the finger without resistance and active flexion. To meet the needs of early active functional exercise, the study group used the ZM suture method combined with the 3-0TICRON polyester suture to carry out the clinical and adjuvant early active functional exercises. The purpose of this study was to evaluate the clinical effects of ZM suture in the prevention of tendon adhesion through early active functional exercise, so as to guide the clinical and prevent the adhesion of tendon. A new method was provided for this problem. Methods: from April 2016 to January 2017, the researchers screened 33 cases of 41 fingers I, II, III and 9 cases of flexor tendon injury in our hospital, including 9 cases of neurovascular injury. The cause of injury was 22 cases of cutting and 11 cases of electric saw injury. Among them, the thumb was 6 fingers and the finger finger was 10 fingers. 9 finger, 9 ring finger and 7 finger. Finger deep flexor tendon rupture index is 28 fingers, finger deep flexor tendon rupture to 6 fingers, finger flexor tendon rupture to 7 fingers. All patients are emergency patients, all one period suture repair is repaired. The operation time is 2-4 hours from injury to operation time of 2-4 hours. After the repair of the broken end of the tendon, the ZM tendon suture was repaired by the tyon Tyco polyester suture (3-0TICRON polyester suture). The repair process was sutured strictly according to the requirements of the ZM center suture. After the central suture, the suture of the tendon was sutured at the tendon anastomosis with the 5-0PROLENE suture. All the wrist joints were given after the operation. In the neutral position, the flexion of the metacarpophalangeal joint was 60 degrees, the interphalangeal joint was extended (Figure 7-8) and the plaster was fixed for 4 weeks. After the operation, all the patients were routinely treated with symptomatic treatment. After 24-48h, the bandages were removed, the interphalangeal joints were removed, the wrist joint and the metacarpophalangeal joints were fixed only. The patients were instructed to perform early functional exercise, the method was the passive flexion extension of each group in each group. Activity 3-5 times, reduce the resistance caused by joint stiffness and 2 times of active flexion. Active flexion should be slow and moderate, so that the passive flexion should be sufficient to contact the palm side of the hand so far. 2 weeks after the operation, the number of early functional exercises should be reduced, and the active flexion and extension of the fingers are avoided. 12-14 days after the operation, the line is disassembled. The patients were followed up for 2 weeks, 4 weeks, 8 weeks and 12 weeks, and the patients were followed up to record the activity of the affected finger, and the excellent rate was evaluated by the international general TAM evaluation system standard. Results: the wounds healed in 32 cases, only 1 cases had inflammatory reaction such as wound leakage, redness and swelling, and then wound dressing, anti-inflammatory treatment, wound healing. .33 patients were followed up without effect on the final results. The good rate was 42.3% in January after 100%. operation, 97% in January after operation, 100% in March after operation, and no postoperative complications and no one case of tendon rupture. Conclusion: no one case of tendon rupture in 33 cases of tendon injury proved to be clinical. The combination of ZM tendon suture and 3-0TICRON polyester suture can meet the needs of early active functional exercise, and the excellent rate of 3 months after operation proves that ZM suture combined with 3-0TICRON polyester suture is safe and reliable for repairing flexor tendon, and it can meet the needs of early active function forging, and it is the best choice for repairing flexor tendon. One of the methods.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.2

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