本文關(guān)鍵詞： 切取肋軟骨 胸廓畸形 再植 動(dòng)物模型 生物力學(xué)　出處：《北京協(xié)和醫(yī)學(xué)院》2017年博士論文　論文類型：學(xué)位論文

【摘要】：研究背景自體肋軟骨是整形外科常用的支架填充材料,廣泛用于耳、鼻和頜面部整形。耳再造手術(shù)所需軟骨量較大,患者年齡較小,術(shù)后胸廓畸形發(fā)生率較高,因此廣受醫(yī)患雙方的關(guān)注。為改善肋軟骨切取術(shù)后供區(qū)形態(tài),Kawanabe等提出了改良肋軟骨切取法,并宣稱術(shù)后供區(qū)完全無(wú)畸形。但是,盡管有學(xué)者完全按照Kawanabe的方法切取肋軟骨,術(shù)后半年仍會(huì)出現(xiàn)明顯的胸廓畸形,且生長(zhǎng)發(fā)育期兒童尤為明顯。因此,探索預(yù)防肋軟骨切取術(shù)后胸廓畸形的方法仍是目前臨床上研究的熱點(diǎn)。根據(jù)文獻(xiàn)報(bào)道,生物力學(xué)因素可能是引起胸廓畸形的重要原因之一。但是,目前研究主要關(guān)注于軟骨組織的再生,而生物力學(xué)方面的研究較少。從生物力學(xué)角度對(duì)不同的干預(yù)措施進(jìn)行研究將有助于為肋軟骨切取術(shù)后胸廓畸形的預(yù)防提供新的思路和方法。研究目的1.建立肋軟骨缺損修復(fù)的動(dòng)物模型。評(píng)估不同的方式(回植軟骨碎塊、回植軟骨條、不回植軟骨)處理對(duì)肋軟骨切取術(shù)后早期肋軟骨缺損修復(fù)段形態(tài)和組織結(jié)構(gòu)的影響。2.評(píng)估不同的方式(回植軟骨碎塊、回植軟骨條、不回植軟骨)處理對(duì)肋軟骨切取術(shù)后早期缺損修復(fù)段生物力學(xué)特性的影響。3.評(píng)估肋軟骨切取術(shù)后半年內(nèi)通過(guò)堅(jiān)持佩戴彈性胸帶限制呼吸幅度,是否能夠降低肋軟骨切取術(shù)后胸廓畸形的發(fā)生率。研究方法1.新西蘭大白兔12只,隨機(jī)分為兩組。于雙側(cè)第5、6肋分別切取長(zhǎng)15mm肋軟骨,保留供區(qū)軟骨膜完整并縫合關(guān)閉軟骨膜腔。左右兩側(cè)分別以不回植軟骨/回植軟骨碎塊(第5肋)、回植軟骨條/回植軟骨碎塊(第6肋)處理�；刂擦考s為原軟骨量的1/4�；刂曹浌撬閴K/軟骨條的直徑約為0.5mm。術(shù)后16周、24周分兩批處死動(dòng)物取材。測(cè)量比較修復(fù)段的外觀形態(tài)和組織結(jié)構(gòu)。2.采用三點(diǎn)彎曲試驗(yàn)對(duì)缺損修復(fù)段的生物力學(xué)進(jìn)行評(píng)估。比較不同處理方法對(duì)缺損修復(fù)段生物力學(xué)性能的影響。3.通過(guò)病史采集和體格檢查,對(duì)肋軟骨切取術(shù)后1年左右來(lái)院接受耳再造第三期手術(shù)的患者的胸廓形態(tài)進(jìn)行評(píng)估。按術(shù)后半年內(nèi)是否堅(jiān)持佩戴胸帶分別統(tǒng)計(jì)患者胸廓畸形發(fā)生率并進(jìn)行比較。研究結(jié)果1.建立了肋軟骨缺損修復(fù)的動(dòng)物模型。術(shù)后16、24周,同一水平(第5或第6肋)缺損修復(fù)段的平均寬度在左右兩側(cè)均無(wú)顯著差異(P0.05)。而同側(cè)、同一水平的缺損修復(fù)段術(shù)后24周較術(shù)后16周寬度窄,兩者差異具有統(tǒng)計(jì)學(xué)顯著性(P0.05)。供區(qū)新生組織以纖維組織為主,未見(jiàn)透明軟骨再生。不同方式處理的缺損修復(fù)段的組織結(jié)構(gòu)存在明顯差異。2.術(shù)后16、24周,各缺損修復(fù)段的彈性模量均顯著低于正常軟骨。未回植軟骨的修復(fù)段彎曲彈性模量顯著高于回植軟骨碎塊的修復(fù)段;回植軟骨條的修復(fù)段彎曲彈性模量顯著高于回植軟骨碎塊的修復(fù)段(P0.05)。在應(yīng)力應(yīng)變關(guān)系和應(yīng)力松弛方面,未回植軟骨的修復(fù)段優(yōu)于回植軟骨碎塊的修復(fù)段,但不及回植軟骨條的修復(fù)段。3.共38名患者符合條件進(jìn)入研究。按要求堅(jiān)持佩戴胸帶半年的患者術(shù)后胸廓畸形的發(fā)生率(64.7%)低于未按要求佩戴胸帶的患者(95.2%)。兩者差異具有統(tǒng)計(jì)學(xué)顯著性(P=0.031)。研究結(jié)論1.肋軟骨切取術(shù)后早期(半年內(nèi)),肋軟骨缺損處主要以纖維組織修復(fù)。纖維組織隨時(shí)間而成熟萎縮�；刂驳淖泽w肋軟骨能夠成活,但無(wú)法證明其能誘導(dǎo)透明軟骨再生。按原肋軟骨體積的1/4回植自體軟骨,缺損修復(fù)段尺寸與是否回植軟骨或回植軟骨的形態(tài)無(wú)關(guān)。但是,是否回植和回植不同形狀的自體軟骨對(duì)修復(fù)段組織結(jié)構(gòu)有明顯影響,可能是造成生物力學(xué)性能差異的原因。2.肋軟骨切取術(shù)后早期(半年內(nèi)),肋軟骨缺損修復(fù)段的生物力學(xué)性能顯著低于正常軟骨,但隨時(shí)間會(huì)逐漸提高�；刂沧泽w軟骨碎塊(原體積的1/4)無(wú)助于提高供區(qū)的生物力學(xué)性能。回植自體軟骨條(原體積的1/4)雖不能達(dá)到正常肋軟骨的生物力學(xué)性能,但明顯優(yōu)于未回植和回植軟骨碎塊組。3.堅(jiān)持佩戴彈性胸帶適當(dāng)限制呼吸幅度,通過(guò)減小呼吸肌和胸腔負(fù)壓對(duì)供區(qū)段的牽拉力,能夠降低肋軟骨切取術(shù)后胸廓畸形的發(fā)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.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R622

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