骨搬移后对合端延迟愈合、不愈合的机制研究与规范化临床应用技术

Mechanism of delayed union and nonunion of the docking site after bone transport and standardized clinical application technology

背景:骨搬移技术是治疗大段骨缺失的常用技术之一,但治疗过程中对合端延迟愈合、不愈合发生率较高,亟待解决。目的:针对目前四肢长骨骨搬移后对合端延迟愈合、不愈合的研究报道进行综述,明确目前的治疗方法、存在的问题及下一步研究方向。方法:检索2009年1月至2019年12月PubMed、中国知网及万方医学网数据库中关于骨搬移、对合端/对接点的相关文献,英文检索词为"docking site""bone transport""distraction osteogenesis",中文检索词为对合端、对接点、骨搬移和牵拉成骨。结果与结论:①骨搬移是治疗四肢长骨大段骨缺损尤其是合并感染情况时的金标准,对合端延迟愈合、不愈合是该技术的并发症之一,文献报道其发生率为73%,总体呈较高水平;②导致对合端延迟愈合、不愈合的原因众多,包括对位不良接触面积减小、间隙内软组织嵌顿、血液供应差等;③预防以注意术前评估、术中精确操作、术后定期复查,早期干预为主,针对其治疗方法以断端切新+植骨的手术方法为主,此外衍生出了关节镜下断端清理+植骨修复、联合钢板、髓内针等内固定及非手术治疗等方法,并可辅助体外震波治疗、电磁场刺激、高压氧疗法和基因治疗等手段;③"手风琴"技术是保守治疗的方法之一,具有创伤小、费用低、无需植骨等优点,可单独应用于对合端不愈合的治疗,然而已报道的"手风琴"操作方案不一,病例较少,且机制尚不明确,限制了该技术的进一步推广;④今后应进一步扩大临床应用研究范围并深入基础研究该技术的作用机制,优化统一操作方案,使其得到进一步推广应用。

BACKGROUND:Bone transport technology is one of the commonly used technologies for the treatment of large bone loss.However,the delayed union and nonunion rate of the docking site during the treatment is high and needs to be solved urgently.OBJECTIVE:To summarize the current reports on delayed union and nonunion of the docking site after limb bone transport,to clarify the current treatment methods,existing problems and future research directions.METHODS:The PubMed,CNKI,and Wanfang Med Online Database were searched for relevant literatures on bone transport and docking site published from January 2009 to December 2019.The English and Chinese search key words were“docking site,bone transport,distraction osteogenesis”.RESULTS AND CONCLUSION:(1)Bone transport is the gold standard for the treatment of long bone defects in the limbs,especially in the case with infection.Delayed union and nonunion of the docking site are the common complications.The incidence rate in the literature is 73%,at a high level overall.(2)There are many reasons that lead to delayed union and nonunion of the docking site,including reduction of the area of contact,incarceration of soft tissue in the gap,and poor blood supply.(3)Prevention should focus on preoperative evaluation,precise operation,regular postoperative review,and early intervention.The treatment method is mainly based on incision and bone grafting.In addition,surgery under arthroscopy,combined fixation with plates,intramedullary pins,and non-surgical treatment are derived.It can assist extracorporeal shock wave therapy,electromagnetic field stimulation,hyperbaric oxygen therapy,and gene therapy.(3)“Accordion”technique is one of the conservative treatment methods.It has the advantages of fewer traumas,low cost,and no bone grafting.However,the“accordion”technique schemes are different;there are few cases reported;and the mechanism is not clear,which limits the further promotion of the technology.(4)In the future,the clinical research should be further expanded,and the mechanism of the technology should be studied in depth.The unified operation scheme should be optimized to further promote the“accordion”technique application.