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骨折愈合:骨折愈合被理解为一系列引人入胜的物理和生物相互作用的结果。第一部分。整合30年AO研究观察结果的尝试。

Fracture healing: fracture healing understood as the result of a fascinating cascade of physical and biological interactions. Part I. An Attempt to Integrate Observations from 30 Years AO Research.

作者信息

Perren S M

机构信息

AO Research Institute Davos, Switzerland.

出版信息

Acta Chir Orthop Traumatol Cech. 2014;81(6):355-64.

Abstract

The choice of best procedure in fracture treatment relies on a proper understanding of tissue reactions to the prevailing mechanical and biological conditions. Investing time and effort is rewarding as it opens up access to a fascinating world and improves fracture treatment based on logical decision making. An intact bony skeleton enables mechanical functions of the human body such as locomotion. This function of the bone is made possible by its stiffness and strength, which allows bone to carry load without undergoing major deformation while remaining intact even under heavy loads. The shortcoming of bone as a strong and stiff material is its brittleness. Its brittleness prevents bone from bridging a fracture under unstable conditions. In spontaneous healing or healing under flxible fiation, a cascade of repair tissues stabilizes the fracture and allows for solid bony union. Excessive load fractures the bone. Disrupted bone loses its stiffness. Loss of stiffness and, consequently, loss of skeletal support disables the function of the limb. fracture healing is a ubiquitous and spontaneous process which restores stiffness as a prerequisite for mechanical function. Restoration of mechanical integrity requires that bone bridges and/or remodels the fracture site. If there is high initial tissue deformation (strain) at the fracture site, bone as a brittle material cannot bridge the gap. In spontaneous healing or healing under flxible fiation a cascade of consecutive phases of tissue differentiation are required to overcome this shortcoming of bone. The cascade increases tissue stiffness at the expense of tolerance to deformation until a low value of interfragmental strain is reached that then allows bone to form a solid bridge. The cascade of differentiation is impressive as a "reasonable" process with a goal. Therefore, bone healing is often considered as a rational process where the repair tissues are expected "to think and to act in order to achieve". we propose the observation of bone reactions without assuming that these reactions are guided by goal-oriented intelligence because the latter is non-existent. Observing the unexpected without having a preconceived opinion is a precondition for new insight. This approach avoids being misled into projecting one's own thinking into tissues that react without goal orientation. fracture healing is a repair process which requires induction and must be enabled. To get a feel for the problem we will fist address the mechanical properties of bone as the prerequisites for its mechanical functions. Then we will discuss which conditions induce and which enable the repair process. The following paper addresses a fascinating interplay between physical and biological processes that enable fractured bone to bridge solidly and remodel to regain its "pre-fracture" function and structure. no one of the different treatment modalities or healing patterns is best on its own. for a given situation the goal is to recover the function of the bone, limb and patient early and permanently by choosing the optimal procedure and implant. Understanding bone reactions permits a rational choice and replaces subjective predilection and monomania. The stability of the fiation and the blood supply are priority considerations, which must often be weighed against each other.

摘要

骨折治疗中最佳治疗方法的选择依赖于对组织在当前力学和生物学条件下反应的正确理解。投入时间和精力是值得的,因为这能让人进入一个迷人的领域,并基于合理决策改进骨折治疗。完整的骨骼实现人体的力学功能,如运动。骨骼的这种功能得益于其刚度和强度,这使得骨骼能够承受负荷而不发生重大变形,即使在重负荷下也能保持完整。骨骼作为一种坚硬且刚性的材料,其缺点是脆性。其脆性使骨骼在不稳定条件下无法跨越骨折处。在自然愈合或柔性固定下愈合时,一系列修复组织会稳定骨折并实现坚实的骨愈合。过度负荷会导致骨折。骨折的骨骼失去其刚度。刚度的丧失以及随之而来的骨骼支撑的丧失会使肢体功能丧失。骨折愈合是一个普遍且自发的过程,它恢复刚度作为力学功能的先决条件。恢复力学完整性要求骨骼在骨折部位形成骨桥和/或进行重塑。如果骨折部位初始组织变形(应变)较高,作为脆性材料的骨骼无法跨越间隙。在自然愈合或柔性固定下愈合时,需要一系列连续的组织分化阶段来克服骨骼的这一缺点。这个过程以牺牲变形耐受性为代价增加组织刚度,直到达到较低的骨折间应变值,此时骨骼才能形成坚实的骨桥。这种分化过程作为一个有目标的“合理”过程令人印象深刻。因此,骨愈合通常被认为是一个理性的过程,人们期望修复组织“为了实现目标而思考和行动”。我们建议观察骨反应时不要假定这些反应是由目标导向的智能引导的,因为后者并不存在。在没有先入之见的情况下观察意外情况是获得新见解的前提。这种方法避免被误导,将自己的思维投射到无目标导向反应的组织中。骨折愈合是一个需要诱导且必须具备条件才能发生的修复过程。为了了解这个问题,我们首先将探讨骨骼的力学性能,这是其力学功能的先决条件。然后我们将讨论哪些条件诱导以及哪些条件使修复过程得以发生。以下文章阐述了物理和生物学过程之间迷人的相互作用,这些过程使骨折的骨骼能够牢固地形成骨桥并进行重塑,以恢复其“骨折前”的功能和结构。没有一种不同的治疗方式或愈合模式本身是最好的。对于给定的情况,目标是通过选择最佳的治疗方法和植入物,尽早并永久地恢复骨骼、肢体和患者的功能。了解骨反应有助于做出合理选择,取代主观偏好和偏执。固定的稳定性和血供是优先考虑的因素,它们常常需要相互权衡。

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