诱导膜技术的手术失误和并发症:44例感染性骨缺损治疗分析

Surgical errors and complications due to induced membrane technique: an analysis of 44 cases of infected bone defects

背景:临床中发现,诱导膜包裹植骨治疗感染性骨缺损的并发症发生率较高。目的:探讨如何减少诱导膜包裹植骨技术的手术失误和并发症。方法:回顾分析44例应用诱导膜包裹植骨技术治疗感染性骨缺损患者的临床资料,其中男29例,女15例,年龄14-69岁,随访时间15-51个月,观察骨水泥填塞物成型方式、制作质量、诱导膜形成质量、负载抗生素浓度、切口愈合、骨愈合、并发症和临近关节活动度恢复等情况。结果与结论:(1)填塞物体内成型23例,体外成型21例;骨水泥填塞物制作质量优14例,良17例,差13例;诱导膜完整22例,少许缺损13例,较多缺损9例;负载低度浓度万古霉素19例,负载中度浓度万古霉素25例;导致诱导膜缺损者为填塞物制作质量差,形成的诱导膜无法包裹植骨材料(13例),以及填塞物体内成型致填塞物与断端连接过紧,需用暴力咬除致诱导膜损伤性缺损(9例);(2)临床愈合时间3-16个月,平均5.9个月;患者应用诱导膜技术至骨愈合平均手术次数2.4次;(3)共11例发生并发症,其中8例是发生在诱导膜技术应用前2年;第一阶段术后并发症3例,包括1例切口裂开、表浅感染,1例深部感染,1例皮瓣部分坏死;第二阶段术后并发症8例,包括2例骨不愈合、5例感染复发、1例畸形愈合;(4)末次随访,临近关节活动度恢复优24例、良11例、可7例、差2例,优良率80%;(5)结果表明诱导膜技术是治疗感染性骨缺损的有效方法,但存在学习曲线,术者应掌握手术技巧,尤其是填塞物制作技巧,才能避免手术失误、减少并发症和提高治疗效果。

BACKGROUND： There is a high incidence of complications in the treatment of infected bone defects by wrapped bone grafting using induced membrane. OBJECTIVE： To investigate how to reduce the surgical errors and complications of induced membrane technique. METHODS： Clinical data from 44 patients with infected bone defect treated with induced membrane technique were retrospectively analyzed. There were 29 males and 15 females, aged 14-69 years old. All patients were followed up for 15-51 months postoperatively. Forming way and quality of bone cement spacer, quality of induced membrane formed, concentration of antibiotics loaded, healing of incision and bony defect, complication and mobility of adjacent joints were observed. RESULTS AND CONCLUSION： （1） Bone cement spacer formed in vivo in 23 cases and in vitro in 21 cases. The quality of spacer formed was excellent in 14 cases, good in 17 cases, and poor in 13 cases. The induced membrane was of integrity in 22 cases, had small defects in 13 cases and had large defects in 9 cases. Concentration of vancomycin was low in 19 cases and moderate in 25 cases. Defects in the induced membrane were caused by small size of induced membrane formed which could not completely wrap the graft material in 13 cases and by the difficult removal due to the tight connection between the spacer and the broken end in 9 cases. （2） The clinical healing time was 3-16 months with an average of 5.9 months. The average frequency of operations using induced membrane technique until bone healing was 2.4 times. （3） There were 11 cases of complications, of which 8 cases were noted at 2 years prior to the use of induced membrane technique, 3 cases in thefirst stage （1 of incision disruption and superficial infection, 1 of deep infection, and 1 of flap necrosis, and 8 cases in the second stage （2 of nonunion, 5 of recurrence of infection, and 1 of malunion）. （4） The range of movement of adjacent joints at the last follow-up was excellent in 24 cases, good in 11 cases, fair in 7 cases and poor in 2 cases, with the excellent and good rate of 80%. These findings indicate that the induced membrane technique is an effective method for infected bone defects. However, the presence of a learning curve is prone to cause surgical errors. Surgeons should master the surgical skills, especially the skills of spacer making, so as to avoid surgical errors, reduce complications and improve the effectiveness of treatment.