胫骨横向骨搬移技术结合前列地尔治疗糖尿病足溃疡的临床研究

Tibial transverse bone movement combined with alprostadil in treatment of diabetic foot ulcer:a clinical study

目的探讨胫骨横向骨搬移微血管再生技术结合前列地尔治疗糖尿病足溃疡的临床疗效。方法对2018年6月至2019年12月利用胫骨横向骨搬移技术结合前列地尔治疗的18例糖尿病足溃疡患者(治疗组)进行回顾性分析,并与同期单纯利用胫骨横向骨搬移技术的18例糖尿病足溃疡患者(对照组)进行比较。所有患者入院后给予监测、控制血糖、抗感染、纠正低蛋白血症等对症支持治疗;对照组术中于患侧胫骨中段内侧面上做一范围约1.5 cm×6.5 cm骨窗,安置专用横向外固定牵引架,同时行患足清创术,术后第5天开始缓慢横向搬移骨窗(1 mm/d);治疗组手术方法及骨搬移方案同对照组,术后第1天开始将2 ml前列地尔注射液加入0.9%氯化钠注射液10 ml中混合均匀,缓慢静脉滴注,1次/d,10 d为1个疗程,共3个疗程。观察2组创面愈合时间,术前、术后3个月踝肱指数(ABI)及密歇根神经体征评分(MNSI)。结果2组患者均获随访,平均随访14.6个月。对照组中1例WagnerⅣ级和1例Ⅴ级患者创面未愈合,最终截肢,其余患者创面均得到愈合,平均愈合时间为(34±6)d,治疗组创面均得到愈合,平均愈合时间为(31±6)d;对照组ABI由术前(0.61±0.19)升至术后3个月(0.84±0.15),MNSI由术前(5.9±1.3)降至术后3个月(4.7±1.4),治疗组ABI由术前(0.58±0.24)升至术后3个月(0.95±0.16),MNSI由术前(5.9±1.3)降至术后3个月(4.1±1.4)。2组创面愈合时间比较差异有统计学意义,2组术后3个月ABI及MNSI较术前差异均有统计学意义,治疗组优于对照组,差异有统计学意义(P<0.05)。结论胫骨横向骨搬移微血管网再生技术可以重建糖尿病足患者小腿以下微血管网,促进周围血管及周围神经恢复,具有手术简便、疗效确切,保肢成功率高的优点,而前列地尔可改善下肢血液供应及神经营养,促进创面修复,二者结合可产生协同效应,是治疗糖尿病足溃疡的理想方法之一。

Objective To investigate the clinical efficacy of tibial transverse bone movement microvascular mesh regeneration combined with alprostadil in the treatment of diabetic foot ulcer.Methods The clinical data of 18 patients with diabetic foot ulceration(treatment group),who were treated with tibial transverse bone movement and alprostadil between June 2018 and December 2019,were retrospectively analyzed,and compared with those from a contemporary cohort of 18 patients with diabetic foot ulceration(control group)underwent tibial transverse bone movement alone.After admission,all patients were given symptomatic and supportive treatments such as monitoring,blood glucose control,anti-infection,and correction of hypoproteinemia.In the control group,a 1.5 cm×6.5 cm bone window was made on the medial surface of the middle tibia on the affected side,and a specific lateral external fixation traction frame was placed.At the same time,the affected foot was treated with debridement,and the bone window was slowly moved laterally at 5 d after the operation(1 mm/d).The surgical method and bone movement protocol in the treatment group were the same as those in the control group.At 1 d after the operation,2 ml of alprostadil injection was added into 10 ml of normal saline and mixed well for slow irrigation in the treatment group,once/d,10 d a course,with a total of 3 courses.The time to wound healing,and ankle brachial index(ABI)and Michigan neuropathy screening instruments(MNSI)scores at baseline and at 3 months after the operation in the two groups were examined.Results Both groups were followed up for an average of 14.6 months.In the control group,a case of WagnerⅣand a case of WagnerⅤlevel without healing finally received amputation,and the wounds in the remaining patients were healed,with an average time to healing of(34±6)d.The wounds in the treatment group were all healed,with an average time to healing of(31±6)d.In the control group,ABI increased from(0.61±0.19)at baseline to(0.84±0.15)at 3 months after operation,and MNSI decreased from(5.9±1.3)at baseline to(4.7±1.4)at 3 months after operation.In the treatment group,ABI increased from(0.58±0.24)at baseline to(0.95±0.16)at 3 months after operation,and MNSI decreased from preoperative(5.9±1.3)at baseline to(4.1±1.4)at 3 months after operation.There were statistically significant differences in the time to wound healing between the two groups.There were statistically significant differences in the ABI and MNSI at 3 months after the operation compared with those at baseline.The ABI and MNSI in the treatment group were better than those in the control group,with statistically significant differences.Conclusion Tibial transverse bone movement microvascular mesh regeneration may rebuild the vasoganglion in lower limbs of patients with diabetic foot disorders,and promote the recovery of surrounding vessels and peripheral nerve function.It has the advantages of simple operation,adequate curative effect,and high success rate of limb salvage.Alprostadil improves blood supply and neuronutrition of lower limbs,and promotes wound healing.The combination of the two may produce a synergistic effect,which is one of the ideal methods for the treatment of diabetic foot ulcers.