骨搬移技术治疗下肢长骨干慢性骨髓炎伴骨缺损术后骨性愈合不良的原因分析及对策

Causes and strategies for postoperative bone nonunion after bone transport of lower limb bone of chronic osteomyelitis with bone defect

目的:探讨骨搬移技术治疗下肢长骨干慢性骨髓炎伴骨缺损术后出现骨性愈合不良的原因及其相应对策。方法:回顾性分析2012年6月至2015年12月采用骨搬移技术治疗的38例下肢长骨干慢性骨髓炎伴骨缺损患者的临床资料,男23例,女15例;年龄20~56岁,平均36.5岁;股骨5例,胫骨33例;受伤至骨搬移时间2~19个月,平均7.4个月;骨缺损长度4~12 cm,平均7.3 cm;术后均经过1周"待机期"开始骨搬移,搬移方向由近端向远端30例,由远端向近端3例,双向搬移5例;并及时调整力线及骨搬移速度,患者坚持负重。定期随访,拍摄X线片,观察是否存在搬移间隙矿化成骨不良,对合端不愈合以及再发骨折等并发症;并采用Paley评分标准进行临床评价。结果:38例获得随访,时间12~36个月,平均23.1个月。骨髓炎无复发,但出现多种骨性愈合不良相关的并发症,其中骨搬移过程中发生搬移间隙矿化成骨不良3例,对合端不愈合17例,发生搬移间隙骨折5例,尚未拆除外固定架时发生骨折1例,拆除外固定架后发生骨折4例。带架时间9~27个月,平均16.3个月;外固定指数为1.7~2.7个月/cm,平均2.24个月/cm;根据Paley评分标准评定疗效:骨性结果优12例,良16例,中3例,差7例;功能结果优14例,良18例,中3例,差3例。结论:骨搬移技术有效解决了长骨干骨髓炎伴大段骨缺损的临床难题,但治疗周期长,对预后的影响因素多。因此,应严格适应证选择,同时应细致操作,全程监控,及时随访,并积极指导患者相应的预防策略,以期得到更满意的临床疗效。

Objective：To explore causes and strategies for postoperative bone nonunion after bone transport of lower limb bone of chronic osteomyelitis with bone defect. Methods：From June 2012 to December 2015,clinical data of 38 patients with lower limb bone of chronic osteomyelitis with bone defect were retrospectively analyzed,including 23 males and 15 females aged from 20 to 56 years old with an average of 36.5 years old; 5 cases occurred on 5 femoral osteomyelitis and 33 cases were tibial;the time from injury to bone transport ranged from 2 to 19 months with an average of 7.4 months; the distance of bone defect ranged from 4 to 12 cm with an average of 7.3 cm. Bone transport were performed at 1 week later after operations,and transport directions were from near end to far end for 30 cases,from far end to near end for 3 cases and bidirectional transport for another 5 cases. The alignment and transport speed were adjusted and weight bearing was encouraged. Regular follow up was performed and X ray films were taken to observe complications such as poor mineralization in transport gaps,nonunion of docking sites,and recurrent fracture. Paley scoring was used to evaluate clinical effects. Results：All patients were followed up for 12 to 36 months with an average of 23.1 months. No recurrence of osteomyelitis,but multiple complications associated with poor bony healing occurred. In the process of bone transport,3 cases occurred poor mineralization in transport gaps,17 cases occurred ununion of docking sites,5 cases suffered fracture gap,1 case occurred fracture without remove of external fixation,and 4 cases occurred facture after remove of external fixation. The time of taken fixation ranged from 9 to 27 months with an average of 16.3 months; index of external fixation ranged from 1.7 to 2.7 months/cm with an average of 2.24 months/cm. According to Paley＇s scoring,bony results showed 12 cases excellent,16 good,3 moderate and 7 poor;and functional results showed 14 cases excellent,18 good,3 moderate and 3 poor. Conclusion：Bone transport technique could effectively solve clinical problems of long bone osteomyelitis with bone defect. However,long treatment period influence prognosis. Therefore,indications should be chosen strict,and operations should be precise and accurate,also monitored across whole process and followed up in time. Doctors should be actively guide corresponding prevention strategies.