骨搬移后对合端植骨内固定治疗下肢大段骨缺损的临床研究

Clinical study of bone transport combined with bone graft and internal fixation at the docking site in the treatment of large segmental bone defect in lower limb

目的 探讨伊利扎罗夫（Ilizarov）骨搬移技术联合对合端植骨内固定治疗下肢大段骨缺损的可行性及临床疗效。方法 2011年8月至2016年12月,手术治疗下肢骨缺损患者30例,采用前瞻性随机对照研究,按随机数字表分为单纯骨搬移技术治疗组（单纯骨搬移组）和骨搬移技术联合对合端植骨内固定治疗组（联合骨搬移组）。单纯骨搬移组15例,男10例,女5例;平均年龄（34.4±4.6）岁;骨缺损,股骨2例,胫骨13例;骨缺损长度（6.2±2.4）cm。联合骨搬移组15例,男12例,女3例;平均年龄（33.8±5.2）岁;骨缺损,股骨1例,胫骨14例;骨缺损长度（6.5±2.2）cm。比较两组术前纽约特种外科医院（hospital for special surgery,HSS）膝关节功能评分、术前Baird-Jackson踝关节功能评分、术后骨折愈合时间、骨愈合指数、外固定时间、外固定指数、术后Ilizarov技术研究与应用学会（ASAMI）骨及下肢功能评价及并发症发生率等。结果 30例患者均获得随访,单纯骨搬移组随访时间9~24个月,平均16.2个月;联合骨搬移组随访时间10~24个月,平均16.4个月。单纯骨搬移组和联合骨搬移组外固定时间分别为（17.6±5.4）个月和（8.4±2.1）个月,骨折愈合时间分别为（11.2±3.1）个月和（7.2±2.1）个月,骨愈合指数分别为（42.4±4.6） d/cm和（21.1±2.7） d/cm,以上各指标两组比较差异均有统计学意义（t=3.210,1.233,2.023; 均P〈0.05）。单纯骨搬移组和骨搬移联合组外固定指数分别为（32.4±2.1d/cm）和（32.1±2.5d/cm）,两组比较差异无统计学意义（t=0.812,P=0.884）。ASAMI骨愈合评价：单纯骨搬移组优6例,良6例,可 2例,差1例,优良率为80%（12/15）;联合骨搬移组优8例,良6例,可1例,优良率为93.3%（14/15）;两组比较差异有统计学意义（χ2=10.6,P=0.032）。下肢功能评价：单纯骨搬移组优5例,良5例,可4例,差1例,优良率为66.7%（10/15）;联合骨搬移组优6例,良7例,可2,优良率为86.7%（13/15）,两组比较差异有统计学意义（χ2=14.4,P=0.026）。结论 单纯骨搬移技术及骨搬移联合对合端植骨内固定对治疗下肢大段骨缺损疗效均满意,但骨搬移联合对合端植骨内固定的骨愈合时间更短,骨愈合率更高,并发症更少,功能评分更佳。

Objective To explore the feasibility and clinical value of Ilizarov bone transport technique combined with bone graft and internal fixation at the docking site in the treatment of large segmental bone defect of the lower limbs. Methods Thirty patients with large lower limbs bone defects were prospectively divided into two groups according to the random number table： pure bone transport group （Ilizarov bone transport technique alone, n=15, 10 males and 5 females, average age 34.4±4.6 years old, 2 cases bone defect of femur, 13 cases tibia, and the length of bone defect 6.2±2.4 cm）, and combined bone transport group （Ilizarov bone transport technique with bone graft and internal fixation at the docking site, n=15, 12 males and 3 females with the average age of 33.8±5.2 years, 1 case of bone defect and 14 tibia, and the length of bone defect 6.5±2.2 cm）. The preoperative hospital for special surgery （HSS） knee functional scores, Baird-Jackson ankle function scores, external fixation time, external fixation index, bone union time, bone union index, postoperative ASAMI scores and incidence of complications were compared between the two groups. Results All patients were followed up for 9 to 24 months （mean 16.2 months）. Pure bone transport group was followed up for 9 to 24 months （mean 16.2 months）, and combined bone transport group was 10 to 24 months （mean 16.4 months）. In pure bone transport group, the external fixation time was 17.6±5.4 months, and the bone union time was 11.2±3.1 months with the average bone union index 42.4±4.6 d/cm. While in combined bone transport group, the external fixation time of group B was 8.4±2.1 months, and the bone union time was 7.2±2.1 months with the average bone union index 21.1±2.7 d/cm. The external fixation index of pure bone transport group was 32.4±2.1 d/cm, while in combined bone transport group it was 32.1±2.5 d/cm, and there was no significant difference between these two groups（t=0.812,P=0.884）. According to the bone and function score of the ASAMI, in pure bone transport group, bone healing： excellent 6 cases, good 6 cases, fair 2 cases, poor 1 case, excellent rate was 80%. While in combined bone transport group： excellent in 8 cases, good 6 cases, fair 1 case, excellent rate was 93.3%. The difference between the two groups was statistically significant （χ2=10.6, P=0.032）. The lower limb function in pure bone transport group： excellent in 5 cases, good in 5, fair in 4, poor in 1, excellent rate was 66.7%; while in combined bone transport group： excellent in 6 cases, good in 7, fair in 2, excellent rate was 86.7%. There was also a significant difference in the incidence of complications between the two groups. Conclusion Both the pure Ilizarov bone transport technique and the Ilizarov technique with bone graft and internal fixation at the docking site could satisfactorily treat the large bone defect and shortening of the lower limb. But the latter technique had shorter healing time, higher healing rates, better limb function and fewer complications.