本文選題：肋軟骨 + 實(shí)驗(yàn)動(dòng)物模型　； 參考：《第二軍醫(yī)大學(xué)》2015年博士論文

【摘要】：【研究背景】軟骨組織在整形外科是一種重要移植材料,尤其在鼻整形、耳再造等手術(shù)中更是一種不可或缺的重要材料。傳統(tǒng)的軟骨移植是取整塊狀軟骨,根據(jù)需要雕刻和拼接成一定形狀后再移植體內(nèi)。整塊狀軟骨存在翹曲的問題,嚴(yán)重的翹曲有時(shí)不得不再次修整,因而影響手術(shù)的最終效果。為了克服整塊軟骨容易翹曲的問題,顆粒軟骨應(yīng)運(yùn)而生,所謂顆粒軟骨是由整塊狀軟骨切成的0.5-2m m之間的顆粒。早在60多年前就曾出現(xiàn)過顆粒軟骨應(yīng)用于臨床的報(bào)道,它被用于顱骨缺損修復(fù)和頜面凹陷的填充,還可以金屬模具預(yù)構(gòu)顆粒軟骨支架用于耳再造及股骨頭再造,均取得較好效果,但隨后因造價(jià)及感染等原因被硅膠、聚乙烯、聚四氟乙烯等人工材料所取代。人工材料因可隨意塑形、可大量制造、避免供區(qū)損傷等優(yōu)勢曾經(jīng)大量使用,但隨后暴露出感染、排異、外露等問題,這讓作為自體材料的顆粒軟骨再次獲得外科醫(yī)生的親睞。近10多年來顆粒軟骨再次得到廣泛應(yīng)用,應(yīng)用形式除單純軟骨顆粒注射填充外,更常見的是以氧化纖維素膜、自體筋膜或脫細(xì)胞真皮支架(Allo Derm)包裹成“沙袋”狀結(jié)構(gòu)后用于移植,也有以纖維蛋白膠粘結(jié)后使用。顆粒軟骨是一種接近理想的移植材料,跟整塊狀軟骨相比,顆粒軟骨具有來源豐富、容易制備、易于塑形、不易翹曲等優(yōu)點(diǎn);相對人工材料,顆粒軟骨完全來源于自體,沒有排異反應(yīng),而且感染和外露均較少。顆粒軟骨雖然具有諸多優(yōu)點(diǎn),但若想得到更廣泛應(yīng)用,還存在以下問題:1、顆粒軟骨移植物的力學(xué)強(qiáng)度能否滿足臨床需要?在植入初期顆粒軟骨是沒有力學(xué)強(qiáng)度的,而植入后期顆粒軟骨移植物力學(xué)強(qiáng)度的變化至今尚不明了。2、早期以金屬模具塑造顆粒軟骨支架的方法因造價(jià)高昂、操作復(fù)雜和感染率高等問題被棄用,而人工材料的發(fā)展卻為模具材料提供更多的選擇,這些人工材料能否作為模具來構(gòu)建特定形狀的顆粒軟骨移植體?3、現(xiàn)有取肋軟骨手術(shù)的創(chuàng)傷仍然較大,并且軟骨顆粒的制備過程也較繁瑣�！灸康摹拷⑼美哕浌墙馄始吧锪W(xué)的實(shí)驗(yàn)?zāi)Ｐ汀Ｒ愿叻肿硬牧献鳛槟＞?構(gòu)建特定形狀的顆粒軟骨移植體。檢測所構(gòu)建顆粒軟骨移植體的力學(xué)性能,觀察顆粒軟骨移植體力學(xué)性能在不同移植時(shí)間、不同模具材料的差異及與正常肋軟骨的比較。另外,為解決現(xiàn)有取肋軟骨手術(shù)會(huì)在胸部留下較大疤痕的問題,探討經(jīng)微創(chuàng)切口切取顆粒軟骨的可行性�！痉椒ā�(1)對新西蘭大白兔進(jìn)行解剖,觀察胸廓及肋骨、肋軟骨的結(jié)構(gòu)和排列,測量剝離軟骨膜后單根肋軟骨的長度及橫徑;對第4至第7肋軟骨進(jìn)行壓縮測試和拉伸測試,得到正常新西蘭大白兔的肋軟骨的壓縮和拉伸破壞強(qiáng)度、應(yīng)力-應(yīng)變曲線及彈性模量等參數(shù)。(2)以電紡絲技術(shù)制備聚乳酸-聚羥基乙酸(PLGA)可吸收模具,以冷凍粉碎熱壓技術(shù)制備高密度聚乙烯(HDPE)不可吸收模具。壓縮實(shí)驗(yàn)組選取新西蘭大白兔12只,手術(shù)方法相同,分別切取雙側(cè)第6、7、8肋軟骨,其中雙側(cè)7肋切為4段,3段回植,1段送力學(xué)測試;剩余肋軟骨全部切成顆粒,分別填充于可吸收及不可吸收模具后回植體內(nèi)。拉伸實(shí)驗(yàn)組的動(dòng)物數(shù)量及手術(shù)方法與壓縮實(shí)驗(yàn)組相同。分別于術(shù)后1月、3月、6月取材,對不同樣本分別做壓縮及拉伸實(shí)驗(yàn)。所取樣本送組織學(xué)檢查。(3)通過對現(xiàn)有旋切器械的觀察和比對,以計(jì)算機(jī)輔助設(shè)計(jì)軟件Auto CAD構(gòu)建數(shù)字化旋切刀頭模型,通過金屬3D打印得到旋切刀頭,配合管狀刀身、套管、動(dòng)力裝置組裝成電動(dòng)肋軟骨旋切器,在離體豬軟骨、尸體及家豬上驗(yàn)證旋切器的工作方式,比較不同旋切刀頭的切削效率。將切取的軟骨碎屑及刀片切取的顆粒軟骨以II型膠原酶消化分離出軟骨細(xì)胞,對軟骨細(xì)胞作臺盼藍(lán)染色計(jì)數(shù)�！窘Y(jié)果】(1)兔擁有與人類類似的胸腔結(jié)構(gòu)及肋軟骨分布,多數(shù)兔與人類一樣擁有12對肋骨,12.5%有13對肋骨;其中第1-7肋通過軟骨直接與胸骨相連,稱為實(shí)肋,第8-10腫軟骨不直接與胸骨相連,而是通過韌帶在內(nèi)側(cè)相連并指向劍突,稱為虛肋,第11-13肋游離在腹壁中,稱為浮肋。肋軟骨長度從第1肋至第7肋逐漸增加,而從第8肋至第13肋逐漸減少。實(shí)肋的橫徑明顯比虛肋及浮肋的大,實(shí)肋中第1肋較其肋軟骨均粗,其余實(shí)肋粗細(xì)基本相同。正常兔肋軟骨抗壓強(qiáng)度平均12.73±1.06MPa,彈性模量平均27.64±1.88Mpa,極限應(yīng)變平均63.77%±2.67%;抗拉強(qiáng)度平均3.78±0.48Mpa,彈性模量平均25.94±4.09Mpa,極限應(yīng)變19.79%±2.38%。(2)以可吸收模具及不可吸收模具成功構(gòu)建顆粒軟骨移植物,軟骨顆粒可在模具內(nèi)結(jié)合成一個(gè)整體,其中可吸收模具在術(shù)后3月時(shí)已完全吸收。正常軟骨段及顆粒軟骨移植物的重量均有所增加,其中顆粒軟骨移植物的增加幅度更大;PL GA模具術(shù)后1月時(shí)有明顯溶脹,重量增加超過1倍。在壓縮實(shí)驗(yàn)組,術(shù)后1月、3月、6月可吸收模具顆粒軟骨(ADC)的壓縮彈性模量為6.63±1.20MPa、8.00±1.94MPa、10.50±1.82MPa,同期不可吸收模具顆粒軟骨(NDC)壓縮彈性模量為5.07±1.00MPa、10.61±1.80MPa、13.11±2.59MPa,同期ADC與NDC的壓縮彈性模量相比無統(tǒng)計(jì)學(xué)差異(p0.05),但均明顯小于術(shù)前正常軟骨段的壓縮彈性模量28.14±1.96MPa。正常軟骨段術(shù)后壓縮模量隨時(shí)間延長呈增加趨勢,1月、3月、6月時(shí)壓縮彈性模量分別為29.11±3.00MPa、32.45±2.79MPa、32.70±2.56MPa。在拉伸實(shí)驗(yàn)組,術(shù)后1月、3月、6月ADC抗拉強(qiáng)度分別為0.41±0.06Mpa、0.91±0.25MPa、1.24±0.11MPa,同期NDC的抗拉強(qiáng)度為0.15±0.05MPa、0.85±0.18MPa、1.09±0.10MP。6月ADC的抗拉強(qiáng)度大于NDC,這種差別具有統(tǒng)計(jì)學(xué)意義(p0.05)。組織學(xué)檢查顯示軟骨顆粒被大量纖維組織包裹粘結(jié),其膠原含量隨移植時(shí)間延長而減少,并且跟整塊狀軟骨相比炎性反應(yīng)更強(qiáng)。顆粒軟骨邊緣可見少量的新生軟骨。(3)在五種旋切刀頭中優(yōu)選出切削效率最高的橢圓面雙直刃側(cè)面開刃的刀頭,成功研制肋軟骨旋切器。經(jīng)小切口驗(yàn)證微創(chuàng)旋切軟骨技術(shù)可行,在手柄或電機(jī)帶動(dòng)下,可在肋軟骨表面旋轉(zhuǎn)切取螺旋片狀軟骨碎片。該技術(shù)裝置已申請國家發(fā)明專利,申請?zhí)?201510023304.4,已通過初審,待實(shí)質(zhì)性審查。通過該旋切刀切取的軟骨碎片,其細(xì)胞活率與以刀片切取的顆粒軟骨細(xì)胞活力相比沒有統(tǒng)計(jì)學(xué)差異�！窘Y(jié)論】本研究結(jié)果首次構(gòu)建兔肋軟骨解剖及生物力學(xué)模型,并以可吸收和不可吸模具構(gòu)建顆粒軟骨移植體,同時(shí)測試其力學(xué)強(qiáng)度。初期顆粒軟骨移植體的強(qiáng)度較弱,隨移植時(shí)間延長會(huì)逐漸增加,并且其抗壓性能要明顯優(yōu)于抗拉性能,表明顆粒軟骨目前僅可用于強(qiáng)度要求不高的移植部位,在組織缺損部位作為有一定強(qiáng)度的填充材料。借助Auto CAD及快速成形技術(shù),試制成旋切刀頭,以此為基礎(chǔ)組裝成旋切器,分別在尸體及家豬體內(nèi)成功切取肋軟骨碎片,驗(yàn)證了經(jīng)微創(chuàng)切口直接切取碎軟骨技術(shù)的可行性。
[Abstract]:[background] cartilage tissue is an important transplant material in plastic surgery, especially in the surgery of rhinoplasty and ear reconstruction. The traditional cartilage transplantation is a piece of cartilage, which is carved and spliced into a certain shape and replanted in a certain shape. The problem of the warpage is the problem of the whole cartilage. Heavy warp sometimes has to be repaired again, thus affecting the final effect of the operation. In order to overcome the problem that the whole cartilage is easy to warp, the granular cartilage comes into being, the so-called granular cartilage is a particle between the 0.5-2m m cut by the whole cartilage. It has been reported that the granular cartilage has been applied to the clinic more than 60 years ago. The repair of skull defects and the filling of the maxillofacial depression can also make the metal die prefabricated granular cartilage scaffold for the ear reconstruction and the femoral head reconstruction, which have achieved good results, but they are then replaced by artificial materials such as silica gel, polyethylene and polytetrafluoroethylene because of the cost and infection. The advantages of injury and other advantages have been used extensively, but then infection, rejection and exposure have been exposed. This makes the granular cartilage of the autogenous material get the attention of the surgeon again. In the past 10 years, the granular cartilage has been widely used. The fascia or acellular dermal scaffold (Allo Derm) is used as a "sandbag" structure and is used for transplantation. It is also used with fibrin glue. Granular cartilage is an ideal material for transplantation. Compared with the bulk cartilage, granular cartilage has the advantages of rich source, easy preparation, easy to shape and not warp easily; relative artificial material, Granular cartilage is completely derived from autologous, no rejection, and less infection and exposure. Although granular cartilage has many advantages, but if it is to be more widely used, there are still some problems: 1, the mechanical strength of granular cartilage grafts can meet the clinical needs? In the early stage of implantation, the granular cartilage is not mechanical strength, and implantation The changes in the mechanical strength of the late granular cartilage grafts are still unknown.2. The early method of molding the granular cartilage scaffold with metal molds was abandoned because of its high cost, complex operation and high infection rate, while the development of artificial materials provided more choices for mould materials. The shape of granular cartilage graft? 3, the trauma of the existing costal cartilage surgery is still large, and the preparation of cartilage granules is more complicated. [Objective] to establish an experimental model of the anatomy and biomechanics of the rabbit costal cartilage. The mechanical properties of the implant were observed, and the physical properties of the grafted cartilage were observed at different time of transplantation, the difference of the different mold materials and the comparison with the normal costal cartilage. In addition, to solve the problem that the existing costal cartilage surgery would leave a large scar on the chest, the feasibility of cutting the granular cartilage through the minimally invasive incision was discussed. [method] (1) new West The Landa rabbit was dissected to observe the structure and arrangement of the chest and ribs, the costal cartilage, and measure the length and transverse diameter of the single rib cartilage after the exfoliation of the cartilage membrane. The compression and tensile strength of the costal cartilage of the normal New Zealand white rabbits, the stress strain curve and the modulus of elasticity were obtained by compression test and tensile test of the fourth to seventh rib cartilage. (2) the preparation of poly (lactic acid polyglycolic acid) (PLGA) absorbable mould with electrospinning technology, and the preparation of high density polyethylene (HDPE) non absorbable mould with freezing crushing hot pressing technology. The experimental group selected 12 New Zealand white rabbits with the same operation methods, respectively, and cut bilateral 6,7,8 costal cartilage respectively, of which the bilateral 7 ribs were cut into 4 segments, 3 segments replanted, 1 The residual costal cartilage was completely cut into particles and filled in the absorbable and non absorbable moulds. The number of animals in the experimental group and the method of operation were the same as those in the compression experimental group. The samples were collected in January, March and June respectively. The compression and tensile tests were performed on the different samples respectively. (3 ) through the observation and comparison of the existing rotary cutting instruments, the computer aided design software Auto CAD is used to construct the digital rotary cutting tool head model, the rotary cutting tool head is obtained through the metal 3D printing, and the tube body, the casing and the power device are assembled into the electric rib cutter, and the working mode of the rotary cutter is verified in the pig cartilage, the corpse and the domestic pig. The cutting efficiency of different rotary cutting knives was compared. The cartilage cells were separated by II collagenase digestion and the cartilage cells were digested by II collagenase, and the cartilage cells were counted by trypan blue staining. [results] (results) rabbits had similar thoracic cavity structure and rib cartilage distribution, most rabbits had 12 pairs of ribs like humans, 12.5% There are 13 pairs of ribs; of which the 1-7 rib is connected directly with the sternum through the cartilage, which is called the real rib. The 8-10 swollen cartilage is not connected directly with the sternum, but is connected by the ligament on the inside and pointing to the sword process. It is called the virtual ribs. The 11-13 rib is free in the abdominal wall and is called the floating ribs. The length of the rib cartilage increases from the first ribs to the seventh ribs, and from the eighth ribs to the thirteenth ribs. The transverse diameter of the real rib is obviously larger than that of the virtual rib and the floating ribs. The first ribs in the real rib are thicker than the costal cartilage, and the rest of the rib are basically the same. The average compressive strength of the normal rabbit costal cartilage is 12.73 + 1.06MPa, the modulus of elasticity is 27.64 + 1.88Mpa, the average of the ultimate strain is 63.77% + 2.67%, the average tensile strength is 3.78 0.48Mpa, and the modulus of elasticity is 25.94 + 4. .09Mpa, the ultimate strain 19.79% + 2.38%. (2) can be successfully constructed with the absorbable die and the non absorbable die. The cartilage particles can be synthesized in the mold. The absorbable die is fully absorbed in March. The weight of the normal cartilage and the granular cartilage graft is increased, among which the grained cartilage is transplanted. The increase of the substance was greater; the PL GA mold was swelling in January, and the weight increased by more than 1 times. In the compression experimental group, the compression modulus of the absorbable die granular cartilage (ADC) was 6.63 + 1.20MPa, 8 + 1.94MPa and 10.50 + 1.82MPa in June, March and June. The compression modulus of the non absorbable die granular cartilage (NDC) was 5.07 + 1.00M at the same time. Pa, 10.61 + 1.80MPa, 13.11 + 2.59MPa, the compression modulus of ADC and NDC had no statistical difference at the same time (P0.05), but it was significantly less than the compression modulus of normal cartilage segment before operation 28.14 + 1.96MPa. normal cartilage segments increased with time. In January, March, and June, the compression modulus was 29.11 + 3.00MPa, respectively. The tensile strength of 32.45 + 2.79MPa and 32.70 + 2.56MPa. in the tensile test group was 0.41 + 0.06Mpa, 0.91 + 0.25MPa and 1.24 + 0.11MPa in June, March and June. The tensile strength of NDC was 0.15 + 0.05MPa, 0.85 + 0.18MPa, and 1.09 + 0.10MP.6 month ADC was greater than NDC, and the difference was statistically significant. Histological examination showed that The cartilage particles were wrapped and bonded by a large number of fibrous tissue, and the collagen content decreased with the prolongation of the transplantation time, and the inflammatory reaction was stronger compared with the bulk cartilage. A small amount of new cartilage was seen on the edge of the granular cartilage. (3) a knife with the highest cutting efficiency with the highest cutting efficiency on the side of the ellipsoid and two straight edges was selected, and the ribs were successfully developed. The technique of minimally invasive circumflex cartilage is proved to be feasible by a small incision and can be rotated on the surface of the rib cartilage by the handle or motor. The technical device has applied for a national patent for invention. The application number: 201510023304.4, it has been examined in the first instance, to be examined in a real quality. There was no statistical difference between the viability of the cells and the vitality of the granular cartilaginous cells taken by the blade. [Conclusion] the results of this study were the first to construct the anatomical and biomechanical models of the rabbit costal cartilage, and to construct the grafted body with absorbable and non absorbable molds and test their mechanical strength at the same time. The strength of the initial granular cartilage graft is weak. The prolongation of the transplantation time will increase gradually, and its compression performance is obviously superior to the tensile property. It shows that the granular cartilage can only be used in the grafts with low strength and is used as a filling material in the tissue defect. With the help of Auto CAD and rapid forming technology, a spin cutting tool is made, which is based on the rotation cutting. The rib cartilage fragments were successfully cut out in cadavers and pigs, which verified the feasibility of directly cutting the cartilage by minimally invasive incision.

【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R622

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