带蒂筋膜瓣包裹复合自体红骨髓的组织工程骨修复四肢低毒力感染性骨缺损

Repair of low virulence bacteria limb bone defect with uncellular tissue-engineered complexes of autolegous red bone marrow wrapped by facial flap with vessels

目的研究带蒂筋膜瓣包裹复合自体红骨髓组织工程骨体修复四肢低毒力感染性大段骨缺损的效果，为临床应用提供依据。方法本组四肢低毒力感染性骨缺损38例，取自体红骨髓（autologousredboneIIIaITOW，ARBM）与含骨形态发生蛋白（bonemorphogeneticprotein，BMP）的骨诱导活性材料（osteoinduetiveabsorbingmaterial，OAM）复合成组织工程骨，在骨缺损邻近制备一个带有无名血管蒂所属毛细血管网的筋膜瓣，使其包裹组织工程骨并充填骨缺损。18例采用病灶清除加复合ARBM的组织工程骨植入（A组），20例采用病灶清除加带蒂筋膜瓣包裹复合ARBM的组织工程骨植入（B组），术后3，6，12，18个月时血常规、超敏c一反应蛋白（CRP）监测炎性反应，x线观察骨缺损修复情况，部分患者作组织学和细菌学检查。结果A组术后平均6个月时5例出现感染，经细菌学培养阳性且与术前相同，（14．0±0．5）个月时，10例组织学显示原病变区骨断端之间仍有纤维结缔组织相连，其中4例病损区为炎性纤维肉芽组织充填且有少许死骨形成及细菌学检查阳性；B组术后无感染出现，16例组织学显示原筋膜瓣形成类似骨膜样组织，原病变区成熟骨结构形成，无炎性细胞浸润，细菌培养均为阴性；其余7例外固定架（A组3例，B组4例）（12．2±0．3）个月时骨性连接、结构稳定取出，未作组织学和细菌学检查。术后各时相点无论是血常规量化总分还是超敏CRP量化总分以及x线量化评分对比，B组明显大于A组（P〈0．05）。结论带蒂筋膜瓣包裹复合ARBM的组织工程骨是目前I期修复感染性骨缺损切实可行的较好方法，在抗感染的同时缩短骨缺损修复时间，显著提高成骨的质和量。

Objective To study the effect of the uncellular tissue engineering complexes of auto- legous red bone marrow wrapped by facial flap with vessels in repair of large segment bone defect infected with low virulence bacteria so as to provide evidence for the clinical application. Methods The study included 38 cases of limb bone defect infected with low virulence bacteria after trauma. Autologous red bone marrow （ARBM） was taken to prepare uncelluar tissue-engineered complexes with osteoinductive absorbing material （OAM） containing bone morphogenetic protein （BMP）. A facial flap with capillary network originating from an anonymous vessel adjacent to the bone defect was prepared to wrgo the tissue-engineered bone and fill the bone defect. Pathological focus clearance and tissue-engineered complexes compounded with ARBM implantation were performed in 18 cases （Group A） and pathological focus clearance and tissue-engineered complexes of autolegous red bone marrow wrapped by facial flap with ves- sels implantation in the other 20 cases （Group B）. The blood routine and supersensitive CRP were exam- ined to monitor the inflammation reaction; X-ray was used to observe the bone defect repair; histology and bacteriology examinations were performed in partial cases at 3,6,12,18 months after operation. Results Six months after operation, 5 cases of Group A were infected and the bacteria cultivation was as positive as that before the operation. The histological observation at （ 14.0 ±0.5 ） months after operation showed that fibrous connective tissues between the bone fracture ends existed in the pathological area in 10 cases, of whom four cases were filled with irfflammatory fibrous granulation tissues and few dead bones in the pathological area, and the bacterial examination was positive. There was no infection in Group B after op- eration. The histological observation manifested periosteum like tissues formation from the primary facial flap, mature bone structure formation in the primary pathological area and non-inflammatory infiltration in 16 cases and the bacteria cultivation was negative in these cases. The external fixation frame was taken out （12.2±0.3 ）months after operation because the synostosis appeared and the structure was stable in the other seven cases including three cases in Group A and four in Group B and the histological and bacte- rial examination were not performed. At each time point after operation, not only the blood routine but al- so the supersensitive CRP and the X-ray quantification grade of Group B were significantly more than those of Group A （ P 〈 0.05 ）. Conclusions The uncellular tissue-engineered complexes of autolegous red bone marrow wrapped by facial flap with vessels is a feasible method for repairing the infected bone defect by first intention, since it can resist infection, obviously promote the bone recovery and advance the quali- ty and quantity of osteanagenesis.