| BACKGROUND Diabetic foot is a very serious complication during the development of diabetes mellitus.The incidence of diabetes in China is about 10.6% now.About 25% of DM patients will suffer from foot infection,ulcers and gangrene in the course of disease development.At present,the existing methods of medical and surgical treatment are not good,and diabetic foot patients often have to amputate their limbs to prevent further development and deterioration of the condition.At the same time,the recurrence rate of diabetic foot is high.In some developing countries with low and middle income,diabetic foot patients are often faced with the situation of prolonged wound healing,increased medical expenses and even life-threatening.Tibial transverse transport is based on the Ilizarov technique "tension-stress" law for the treatment of chronic ischemic disease of the lower extremities,first applied to severe diabetic foot patients to promote wound healing and reduce the risk of amputation,and have got good results.The wound healing was in a short time.However,the mechanism for promoting wound healing is still not clear.Macrophages are important cells involved in inflammatory response.They can be transformed into cell subsets that express different phenotypes and functions of cells under different environmental factors,which is called macrophage polarization.Macrophages are mainly polarized into two types of macrophages,M1 and M2.The former can secrete various pro-inflammatory factors during the inflammatory phase to kill pathogenic microorganisms and control infection,but at the same time can cause damage to normal tissue.The latter can secrete a variety of anti-inflammatory and growth factors during the inflammatory proliferation phase to regulate immune response and promote repair of tissue damage.As a specific stem cell of skin tissue,epidermal stem cells not only maintain the normal metabolism of the skin,but also play a key role in the occurrence,repair,and reconstruction of skin tissue and skin adnexa.It promotes the proliferation and differentiation of epidermal stem cells,and makes the wound surface from anatomical repair to functional repair.We think that due to the persistent existence of pathogenic microorganism,the macrophage polarization in the wound of severe diabetic foot is unbalanced.Macrophages are mainly polarized into M1 macrophages,while M2 type macrophages are relatively deficient.At the same time,the function of epidermal stem cells is inhibited,so the wound healing is prolonged.Tibial transverse transport can promote the reconstruction of macrophage polarization balance,promote macrophages to transform into M2 macrophages,make the function of epidermal stem cells recovered,and make the wound healed.METHOD 1.A total of 136 patients with severe diabetic foot who were treated with tibial transverse transport at the Department of Osteoarthritis at the First Affiliated Hospital of Guangxi Medical University from July 2014 to June 2017 were collected.The basic data(age,sex,Wagner classification,duration of diabetes,duration of diabetic foot,etc.),the average time of wound healing,the amputation rate,the recurrence rate within 1 years and 3 years were counted,and the effect of tibial transverse transport for severe diabetic foot was initially evaluated.At the same time,there were 33 patients with systemic infection symptoms,compared their wound healing time with the patients without systemic infection symptoms.2.Patients were asked to agree to take the tissue at the edge of the healed wound at 1 month after operation to make a tissue section.After HE staining,it was observed under a microscope to see if it had skin tissue structure characteristics,a total of 10 cases.3.Patients were asked for consent and tissue sections were made on the edge of the wound surface before and after operation.Immunohistochemical techniques were used to label M1 macrophages with CD86 monoclonal antibody and M2 type macrophages with CD163 monoclonal antibody.After the dyeing,Image pro plus6.0 software was used to collect and analyze the pixels in the image,and the ratio of M1/M2 was calculated.There were 10 cases in the preoperative group and 1 month after the operation.4.Immunohistochemical technique was used to label epidermal stem cells with CK19 monoclonal antibody and detect the distribution of Ki-67 positive cells and CK19 positive cells before and after operation.There were 5 cases in the preoperative group and 1 month after the operation.RESULTS 1.Of the 136 patients with severe diabetic foot,6 were amputated due to poor postoperative wound healing,and the amputation rate was 4.4%;10 patients had ulcer recurrence within 1 year after wound healing,and 12 patients had ulcer recurrence within 3 years.The recurrence rates within one year and three years were 7.7% and 9.2% respectively.The average wound healing time was(3.8±2.4)months;The mean wound healing time was(5.3±2.7)months in patients with systemic infection symptoms,and(3.3±2.1)months in uncomplicated systemic infections.The difference was statistically significant(P<0.05).2.The striae and a linear scar were observed at the site of wound healing.After the tissue was stained with HE,the epidermis and dermis were observed under the microscope.3.The mean value of M1/M2 in the preoperative group was 4.072±0.502.The mean value of M1/M2 in the first month after operation was 3.098±0.548.The independent sample t test performed with SPSS 22.0 indicated that the difference was statistically significant(P<0.05).4.The preoperative Ki-67 positive cells were mainly concentrated in the epidermal basal cells with only one or two layers.Ki-67 positive cells thickened at the basal layer of the epidermis and also scattered distributions in the dermis after operation.The CK19-positive cells were mainly found in the dermis and distributed in tubular or lumps.The postoperative CK19-positive cells were more than those in preoperation.CONCLUSION 1.Tibial transverse transport can shorten the time for the healing of diabetic foot wounds and reduce the amputation rate and recurrence rate.2.The basic characteristics of skin tissue can be observed under general and HE staining after wound healing.It can be preliminarily proved that the operation of tibial transverse transport promotes the regeneration of skin tissue in severe diabetic foot wounds.3.Tibial transverse transport promotes the macrophage polarization to M2 macrophages,reconstructs the balance of macrophages polarization,and make the function of epidermal stem cells recovered,so the ulcers in severe diabetic foot wounds can be healed. |
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