糖尿病足湿性坏疽膝下一期两阶段截肢术探讨

Treatment of diabetic foot with wet gangrene by simplified two-stage below-knee amputation

目的 分析糖尿病足湿性坏疽膝下截肢术术后感染率及治疗方案。方法 回顾性分析 19例Wagner 4期和 34例Wagner 5期糖尿病足湿性坏疽病例 ,Wagner 4期中 8例行一期两阶段手术 (术后一期关闭切口中部皮肤及筋膜层 ,两侧敞开引流 ,3～ 5d后关闭切口 ) ;11例行一期手术 (一期关闭切口 ) ;Wagner 5期病例中 ,12例行一期两阶段手术、15例行一期手术、7例行二期手术 (一期踝关节开放截肢 ,二期近端膝下截肢 )。结果 Wagner 4期患者 ,一期两阶段和一期手术组发生术后感染率分别为 12 .5 %(1/ 8例 )和 2 7%(3/ 11例 )差异无显著性 (P >0 .0 5 )。Wagner 5期患者 ,一期两阶段和一期手术组手术后感染率分别为 2 5 %(3/ 12例 )和6 0 %(9/ 15例 )差异有显著性 (P <0 .0 5 ) ;二期手术组术后感染率为 14.3%(1/ 7例 ) ,与一期两阶段手术组比较差异无显著性 (P >0 .0 5 )。结论 晚期糖尿病足湿性坏疽行一期两阶段膝下截肢术是一个可选择的手术方法。

Objective To assess the frequency of infection after different procedure of below-knee amputation (BKA) for unsalvageable diabetic foot with wet gangrene. Methods The frequency of infection after BKA in 53 cases of unsalvageable diabetic foot with wet gangrene was analysed. Before amputation, we pricked the patient's thigh with a 20 gauge needle and assessed the rate of bleeding, then sequentially pricked the patient's foot, ankle, and calf and compared the bleeding with the control to assess the vasculariration at the area of amputation and to determine the level of amputation when the patients were under anesthesia. There were 19 cases in Wagner 4, of whom 8 cases were given simplified two-stage BKA(The first stage was the standard below-knee amputation with a long posterior flap in which the fascia and skin were closed in the central portion with the medial and lateral portions of the wound left open for drainage. The second stage was delayed until closure of the opened wounds 3 to 5 days after the first stage.), and the others 11 cases were given one-stage BKA (a definitive standard below-knee amputation). There were 34 cases in Wagner 5, of whom 12 cases were given simplified two-stage BKA , 15 cases were given with one-stage BKA, and the other 7 cases were given two-stage BKA(be treated with open amputation just above or through the ankle, once the sepsis was cleared, a definitive BKA was performed.). Results In Wagner 4, One of The 8 patients (12.5%) in simplified two-stage group had infection after BKA vs 3 of 11 patients (27.3%) in one-stage group (P>0.05). In Wagner 5, 3 of 12 patients (25%) had infection in simplified two-stage group, vs 9 of 15 patients (60%) in one-stage group (P <0.05), and one of 7 patients (14.3%) in two-stage group (P>0.05). Conclusion For unsalvageable diabetic foot with wet gangrene, the simplified two-stage operation as an optional method can reduce the frequency of infection after BKA if the vasculariration at the area of amputation is good.(Shanghai Med J, 2002,25∶224-226)