Gelberman R H, Khabie V, Cahill C J
Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston.
J Bone Joint Surg Am. 1991 Jul;73(6):868-81.
The role of revascularization in the nutritional support of repair of the flexor tendons is not completely understood. To explore the extent to which intrasynovial flexor tendons revascularize after transection and suture, a vascular injection study was carried out in a canine model. The tendons to the second and fifth digits of the forepaw in twelve adult mongrel dogs were transected and repaired. There were twenty-four experimental tendons and twenty-four normal tendons. The limb was placed in a polyurethane shoulder-spica cast, and the paw was treated with immediate protected passive mobilization. At three, seven, ten, seventeen, and twenty-eight days, the animals were killed and the major arteries supplying both the paw that had been operated on (left) and the contralateral normal paw (right) were injected with 200 milliliters of India ink. Segments of repaired and normal tendons were then clarified by a modified Spalteholz technique. The normal tendons demonstrated a well developed mesotenon that provided vascularization of the proximal portion of the flexor digitorum profundus tendon. A consistent three-cubic-millimeter avascular intrasynovial portion of tendon was noted. Distally, vessels arose from the vinculum breve, supplying the terminal twenty millimeters of tendon substance. In the experimental tendons, longitudinal and transverse clarified sections showed consistent revascularization of the site of repair by proximal vessels in the absence of ingrowth of peripheral adhesions. Vessels in the epitenon progressively extended for a distance of ten millimeters, through normally avascular regions, to reach the site of repair by the seventeenth postoperative day. Intratendinous vessels about the site of repair consistently originated from surface vessels, rather than from extensions of pre-existing intratendinous vessels. New vessels penetrated all areas, including the normally avascular volar segments of tendon, irrespective of previous topical zones of avascularity. Proximal vascular plexi were characterized by large tortuous vessels with frequent circuitous branches. More distal vessels had a longitudinally oriented, feathery appearance.
血管再通在屈肌腱修复营养支持中的作用尚未完全明确。为探究滑膜内屈肌腱横断缝合后再血管化的程度，在犬模型上进行了一项血管注射研究。将12只成年杂种犬前爪的第二和第五指肌腱横断并修复。有24条实验肌腱和24条正常肌腱。肢体置于聚氨酯肩人字石膏中，爪子立即进行保护性被动活动。在术后3天、7天、10天、17天和28天，处死动物，向手术侧（左侧）爪子和对侧正常爪子的主要供血动脉注射200毫升印度墨水。然后通过改良的斯帕尔托霍尔茨技术对修复和正常肌腱段进行透明处理。正常肌腱显示出发育良好的腱系膜，为指深屈肌腱近端提供血管化。注意到肌腱滑膜内有一个3立方毫米的无血管区。在远端，血管来自短腱纽，为肌腱末端20毫米提供血供。在实验肌腱中，纵向和横向透明切片显示，在没有外周粘连长入的情况下，近端血管对修复部位进行了持续的再血管化。术后第17天，腱外膜血管逐渐延伸10毫米，穿过正常无血管区域，到达修复部位。修复部位周围的肌腱内血管始终起源于表面血管，而非先前存在的肌腱内血管的延伸。新血管穿透所有区域，包括肌腱通常无血管的掌侧段，而不考虑先前的无血管局部区域。近端血管丛的特点是有大的迂曲血管，有频繁的迂回分支。更远端的血管呈纵向排列，外观呈羽毛状。
