可吸收医用膜在手肌腱损伤一期修复中应用

可吸收医用膜在手肌腱损伤一期修复中应用 可吸收医用膜在手肌腱损伤一期修复中应 用 [摘要] 目的:观察可吸收医用膜在手肌腱损伤一期修复中的疗效。方法,126例,285条,肌腱损伤患者为治疗组,均一期采用改良Kessler法缝接肌腱,并用可吸收医用膜包裹,术后早期循序渐进康复锻炼。对照组120例,282条肌腱损伤,予一期改良Kessler法缝接肌腱,术后早期康复锻炼。结果,随访3,24个月,按TAM法评定疗效,治疗组优59例,良52例,可10例,差5例,优良率为88.10%,对照组优45例,良50例,可12例,差13例,优良率为79.17%,两组比较差异有统计学意义,P,0.05,。结论,修复肌腱损伤应仔细清创,无创操作、良好肌腱吻合技术加可吸收医用膜的应用及早期功能锻炼是肌腱功能恢复的关键。 ,关键词, 手, 肌腱损伤, 可吸收医用膜, 缝合技术, 功能锻炼 ,中图分类号, R641 ,文献标识码, A ,文章编号, 1671-7562,2011,01-0062-03 doi:10.3969/j.issn.1671-7562.2011.01.省略 1 One-stage repair of hand tendon injuries by DIKFIM, a report of 126 cases CHENG Qing, LIU Li-bo, LI Jun-yao ,Department of Emergency, Wuhan General Hospital of Guangzhou Command, Wuhan 430070, China, [Abstract] Objective: To investigate the therapeutic effects of one-stage repair of hand tendon injuries by DIKFIM. Methods, 126 patients with,285 tendons, hand injuries were enrolled, 86 male and 40 female, aging from 5 to 60 years, with an average of 31.6 years. Forty-two patients were cut by glasses, 44 by knife, 28 patients by saw and 12 patients got crushed. The flexor tendon injuries,98 cases 182 tendons, in this study consisted of 11 cases,12 tendons, of ? zone, 37 cases,63 tendons, of ? zone, 26 cases,47 tendons, of ? zone, 10 cases,26 tendons, of ? zone and 14 cases,34 tendons, of ? zone. The extensor tendon injuries were 28 cases,103 tendons,. Seventy-two patients complicated with injuries of blood vessel and nerve, and 55 patients also hand fingers fractures. All the patients were treated with modified Kessler method to repair tendon and given DIKFIM at one-stage,and were given early rehabilitation step by step. 2 In the control group of 120 patients with,282 tendons, hand injuries, 78 patients were male and 42 patients were female, aging from 8 to 62 years, with an average of 33.2 years. Fifty patients were cut by glasses, 38 by knife, 22 patients saw, and 10 patients crushed. The flexor tendon injuries,88 cases 180 tendons, consisted of 14 cases,14 tendons, of ? zone, 35 cases,64 tendons, of ? zone, 20 cases,44 tendons, of ? zone, 10 cases,22 tendons, of ? zone and 9 cases,36 tendons, of ? zone. The extensor tendon injuries were 32 cases,102 tendons,. Sixty-eight patients complicated with injuries of blood vessel and nerve, and 50 patients also hand fingers fractures. All the patients were treated with modified Kessler method to repair their tendons, and were given early rehabilitation. Results, After the treatment, 126 patients were followed up from 3 to 24 months. According to TAM standard,59 patients recovered excellently, 52 well, 10 moderately fine and 5 failed, curative rate being 88.10%,P,0.05, compared with the control group,. In control group, 45 patients got an excellent result, 50 good, 12 fair and 13 bad, curative rate 79.17%. Conclusion, Microsurgical one-stage tendon repair should 3 be applied. Early rehabilitation, microsurgery repair and DIKFILM are important in preventing tendon adhesion. [Key words] hand, tendon injury, DIKFILM, suture techniques, rehabilitation 手部肌腱损伤在手外伤中十分常见,但由于常常缺乏正规、有效的治疗,手术后肌腱的粘连与断裂,特别是屈肌腱的粘连与断裂,严重影响手功能的恢复,1,。近年来,随着显微外科技术的发展以及防粘连技术的应用,手外伤后肌腱损伤的治疗取得了长足的发展。自2007年2月至2008年12月,我们应用显微外科技术,采用改良Kessler缝合法加局部应用可吸收医用膜,DIKFILM,成都迪康,国食药监械准字第3640459号,一期修复126例285条肌腱,经随访疗效满意,并与同期120例282条肌腱修复病例进行对照,现将结果报道如下。 1 临床资料 1.1 一般资料 126例,285条,手肌腱损伤患者为治疗组,其中男86 4 例,女40例,平均年龄31.6岁,5,60岁,,致伤原因,玻璃割伤42例,刀砍伤44例,电锯伤28例,挤压伤12例,屈肌腱损伤98例182条,?区11例12条,?区37例63条,?区26例47条,?区10例26条,?区14例34条,,伸肌腱损伤28例103条,合并血管神经损伤72例,合并骨折55例。选择一般资料与治疗组无统计学差异的120例,282条,手肌腱损伤患者设为对照组,其中男78例,女42例,平均年龄33.2岁,8,62岁,,玻璃割伤50例,刀砍伤38例,电锯伤22例,挤压伤10例,屈肌腱损伤88例180条,?区14例14条,?区35例64条,?区20例44条,?区10例22条,V区9例36条,,伸肌腱损伤32例102条,合并血管神经损伤68例,合并骨折50例。 1.2 治疗方法 1.2.1 手术方法 臂丛或局部麻醉下,上气囊止血带,先彻底清创,解剖出血管、神经、肌腱的断端,用注射针头分别贯穿鞘管固定肌腱远近端在无张力状态下操作。断腱清创,锐器切割伤断腱整齐者可不修剪断端,腱断端不整齐者用锐剪修齐。肌腱缝合方法,以3-0无创带针肌腱缝合线,在4,6倍手术放大镜下用改良Kessler方法吻合肌腱,然后用8-0无损伤线绕腱周作连续内翻缝合。仔细地修复断裂的腱鞘,在非鞘管区则缝合腱外膜。创面彻底止血后,于肌腱吻合处,选择合适规格或用剪刀剪成需要形状和大小,贴敷 5 并包裹DIKFILM。术中如有骨折先予交叉克氏针固定,合并神经血管损伤,用8-0无损伤线修复。术后用短臂石膏托固定。对照组治疗方法相同,仅不贴敷包裹DIKFILM。 1.2.2 康复锻炼 肌腱修复术后第3天即开始由医生指导作轻度被动活动,早晚各1次,第3周开始活动量增大,可作较大被动活动及轻度主动活动,第4周时去除外固定,积极进行主被动活动。 1.3 结果 按手部肌腱疗效评定法TAM作疗效评定。优,患指功能正常,良,TAM大于健侧85%,可,TAM为健侧的75%,85%,差,TAM小于健侧的75%。 随访时间3,24个月,平均8.2个月。治疗组126例中,优59例,良52例,可10例,差5例,优良率为88.10%,对照组120例中,优45例,良50例,可12例,差13例,优良率为79.17%。两组优良率经χ[WTBZ]2检验,P,0.05,差异有统计学意义。 2 讨 论 手部肌腱损伤多为开放性,以切割伤最为常见,多合并神经血管损伤和骨折。肌腱新鲜断裂后,解剖层次清晰,容易解剖出断端,修复较易,如果肌腱断裂未及时修复,时间越长,断端回缩越多,缝合的难度也随之增加。因此,对肌腱的新鲜损伤,应积极进行早期彻底的清创、止血,既可以 6 防止感染,还有利于减轻术后广泛的瘢痕形成,有效防止术后粘连及再断裂。要严格执行无创操作原则,应用显微外科技术,使用显微器械,尽量避免和减少对损伤肌腱血供的影响,为肌腱的内源性愈合提供保障。同时术中避免用血管钳在腱鞘内重复盲目夹持,以免损伤滑膜内衬,导致粘连发生,2,。 修复方法是影响疗效的重要因素,而缝合肌腱的最佳方式目前尚存争议,3,。我们体会,使用改良Kessler法加吻合口周边连续内翻缝合,缝线略偏掌侧,针边距8,10 mm为宜。临床已经证实改良Kessler法为较好的肌腱缝合方法,出针点的边距与抗张力成正比例关系,且以10 mm为最佳,再加之吻合口的连续内翻缝合,减少对肌腱腱鞘及腱周组织的损伤,同时牢固的缝线将肌腱内部腱纤维扣紧达到两断端牢固相交,缝线平滑、无外翻膨大,抗拉力及抗张力强度大,可减少术后粘连。 DIKFILM由聚乳酸,PDLLA,制成,通过膜的物理隔离作用,隔离时间1,3个月,,将术后易粘连组织界面分开,达到防止组织粘连的作用。聚乳酸DIKFILM是以高分子量聚-DL乳酸为基本成分,4,,它的主要特点如下,,1, 具有良好的生物相容性,对组织无刺激,,2, 具有良好的机械性能,质地柔软贴附性好,,3, 具有良好的通透性,能保证营养物质的正常交换,,4, 具有可吸收性,能在体内完 7 全降解为乳酸单体,终经三羧酸循环形成二氧化碳和水,无毒性。其防止组织粘连的机制,5,主要是通过膜的物理隔离作用将组织分开形成自然屏障,防止成纤维细胞的入侵,最终在组织间形成一层纤维结缔组织膜。该膜在术后成纤维细胞胶原纤维分泌最旺盛的前3周内能完整存在,3周后开始降解,体内维持隔离作用1个月左右,3个月左右完全降解吸收,即可以长时间停留在体内渡过机体瘢痕生成的时间。该膜生物相容性好,对组织无不良刺激,在体内可完全降解吸收,无须二次手术取出,同时其质地柔软,伸展性好,使用简单,植入体内不影响术后功能锻炼,术中可选择合适规格或裁剪成需要形状和大小,并可使用可吸收线缝合固定。我们的临床研究表明,手外伤肌腱手术中应用DIKFILM具有预防术后粘连的作用,其效果显著。 早期进行康复训练是恢复肌腱功能的重要措施。渐进的保护性被动活动一方面能使肌腱在活动过程中内在压力呈弛张性变化,利于吸收和排出滑液,从而促进滑液对肌腱的营养,激发肌腱内源性愈合力,促进肌腱修复,另一方面使肌腱外源性愈合形成的粘连减少,由于牵拉作用可使新形成的腱组织及血管按张力线排列,增加腱张力并能使新形成的结缔组织得到塑形,符合肌腱的生物力学需要。因此,早期系统康复治疗对取得良好疗效十分重要。 ,参考文献, 8 ,1, JONES M E. 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