微创医学

目的探讨胫骨横向骨搬移术（TTT）促进重度糖尿病足创面愈合的作用机制。方法选择重度糖尿病足患者61例，观察手术前后创面愈合情况。受经费及患者依从性限制，分别随机挑选Wagner分级3级、4级、5级各4例患者，于术前及术后1个月对其创面边缘愈合组织行免疫组化检测，并观察手术前后CD86、CD163、CD31、血管内皮生长因子（VEGF）阳性细胞计数变化，以CD86、CD163单克隆抗体分别标记M1、M2型巨噬细胞，应用Image Pro Plus 6.0软件统计阳性细胞数，计算M1/M2值，并观察术前、术后1个月创面边缘组织HE染色情况。术前、术后1个月行足部血管造影检查观察足部血管变化。结果61例患者创面全部愈合,愈合时间1～12（3.83±2.31）个月，创面愈合过程基本按炎症期、增殖期和重塑期3个阶段发展。免疫组化结果显示，术后1个月，CD86、CD163阳性细胞较术前减少，VEGF、CD31阳性细胞较术前增加；术后1个月M1、M2型巨噬细胞计数较术前减少，M1/M2较术前降低（均P＜0.05）。术前HE染色发现组织残缺，未见皮肤附属器，术后新生皮肤组织结构完整,可见腺体样结构和胶原沉积。足部血管造影检查发现术前微血管少，术后微血管增多。结论TTT可显著促进重度糖尿病足创面再生愈合，可能与降低巨噬细胞M1/M2值，抑制创面炎症,促进微血管再生增多有关。

ObjectiveTo explore the effect mechanism of tibial transverse transport (TTT) for the promotion of wound healing of severe diabetic foot. MethodsA total of 61 patients with severe diabetic foot were selected, and the states of wound healing before and after operation were observed. Due to the financial constraints and compliance limitation of patients, 4 patients in each case, whose Wagner classification was in grade 3, 4, and 5, respectively, were randomly enrolled. Immuno-histochemistry detection was conducted to tissues of wound peripheral healing in patients before and a month after operation, and the changes of positive cells counts of CD86, CD163, CD31, and vascular endothelial growth factor (VEGF) were observed. M1 and M2 macrophages were labeled with monoclonal antibody of CD86 and CD163, respectively, the Image Pro Plus 6.0 Software was employed to count positive cells counts, and to calculate the ratio of M1 to M2, as well as the states of HE staining of peripheral tissues of wound were observed before and a month after operation. The changes of the foot blood vessels were observed by conducting foot angiography before and a month after operation. ResultsAll wounds of 61 patients were healed, with the healing time of 1 to 12 (3.83±2.31) months, and there were 3 stages of the developments of wound healing processes based on inflammatory stage, proliferating stage, and remodeling stage. The immunohistochemical results revealed that compared to before operation, positive cells of CD86 and CD163 reduced, whereas positive cells of VEGF and CD31 increased a month after operation; furthermore, the counts of M1 and M2 macrophages reduced, and the ratio of M1/M2 decreased a month after operation as compared with before operation (all P＜0.05). The preoperative HE staining implied incomplete tissues, no skin appendage, complete new skin tissues structure after operation, and glandular structure and collagen deposition. Foot angiography revealed that microvasculars reduced before operation, whereas increased after operation. ConclusionTTT can significantly promote wound regeneration and healing of severe diabetic foot, which may be associated with the decrease of the ratio of macrophage M1/M2, the inhibition of wound inflammation, and the promotion of regeneration and increase of microvasculars.