骨搬移治疗胫骨创伤性慢性骨髓炎的效果观察及术后对合端不愈合原因分析

Observation of therapeutic effects of bone transport for traumatic chronic tibial osteomyelitis and causes analysis of postoperative nonunion at the docking sites

目的观察骨搬移治疗胫骨创伤性慢性骨髓炎的临床效果,探讨术后对合端骨不愈合的原因及处理方法。方法回顾性分析2013年1月至2016年12月洛阳正骨医院收治的62例行Ilizarov骨搬移手术的创伤性胫骨慢性骨髓炎患者的临床资料。其中开放性胫骨骨折43例、闭合性骨折19例,均为Cierny-MaderⅣ型胫骨创伤性骨髓炎。根据Paley骨愈合标准评定疗效,记录骨折对合端不愈合的发生原因及处理措施。结果患者获随访15～40个月,平均随访时间24.3个月。骨块搬移距离4.3～10.8 cm(平均7.6 cm);胫骨近端截骨55例、远端截骨7例。随访期间对合端自然骨性愈合35例、不愈合27例,骨不愈合发生率44%。不愈合原因包括对合端骨质硬化13例,对位不良、接触面积较少7例,骨折端骨质吸收萎缩4例,软组织嵌顿2例,感染复发1例;3例经"手风琴"技术、19例经髂骨植骨、4例经原位植骨等相应处理后愈合,1例因护理不当,原窦道口处再次溃破渗出脓液,经病灶清除、载万古霉素硫酸钙填充、髂骨植骨治疗后愈合。末次随访Paley骨愈合标准评定优良率84%(52/62)。结论骨搬移手术具有微创、固定可靠、安全有效的特点,是治疗创伤性胫骨慢性骨髓炎的较好选择。但术后对合端不愈合发生率较高,其原因主要为轴线偏移、软组织嵌顿、骨折端硬化、缺乏应力刺激、感染复发及其他全身因素;可采用"手风琴"技术、植骨等相应措施进行处理。

Objective To investigate the clinical effects of bone transport for traumatic chronic osteomyelitis （TCO） of the tibia, and to discuss the causes and treatment of postoperative docking site nonunion.Methods Clinical data of 62 tibial TCO patients who underwent Ilizarov bone transport from January 2013 to December 2016 in Luoyang Orthopaedics Hospital were retrospectively analyzed. All of them were Cierny-Mader type Ⅳ tibial TCO, with open tibial fracture in 43 and closed fracture in 19 cases. Therapeutic effect was evaluated by Paley evaluation criteria of bone healing, the causes and treatment measures of postoperative docking site nonunion were recorded. Results All patients were followed up for 15 to 40 months with an average of 24.3 months. The removal distance of bone mass was 4.3 to 10.8 cm （average, 7.6 cm）. Proximal humerus osteotomy was performed in 55 patients, while distal osteotomy was performed in 7 patients. During the follow-up, natural bone healing was found in 35 patients, while nonunion at the docking site occurred in 27 patients, with the nonunion incidence of 44%. Causes of nonunion included bone hardening at the docking site （13 cases）, poor line position and deficient contact area （7 cases）, bone absorption and atrophy at the docking site （4 cases）, soft tissue incarceration （2 cases）, and infection recurrence （1 case）. Among 27 patients, 26 were healed by ＂accordion＂ technique （3 cases）, iliac bone grafting （19 cases）, and in situ bone grafting （4 cases）. Due to improper nursing care, sinus ostium was broken again in 1 patient. After focus lesion clearance, filling with vancomycin and illiac bone grafting, the patient was healed. At the latest follow-up, the excellent and good rate was 84% （52/62） according to Paley evaluation criteria. Conclusions Bone transport is a good choice for tibial TCO with the advantages of minimally invasive procedure, reliable fixation, as well as safe and effective operation. But the incidence of postoperative nonunion at the docking site is relative high, mainly due to axis deviation, soft tissue incarceration, fracture end hardening, lack of stress stimulation, infection recurrence and other systemic factors. Corresponding measurement such as ＂accordion＂ technique, bone grafting should be recomended.