Ilizarov跖骨延长治疗糖尿病足溃疡并跖骨头慢性骨髓炎

Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head

目的探讨清创后一期Ilizarov跖骨延长治疗糖尿病足溃疡并跖骨头慢性骨髓炎的临床疗效。方法2015年1月—2018年10月,应用清创后一期Ilizarov跖骨延长治疗糖尿病足溃疡并跖骨头慢性骨髓炎患者8例(9足、11个部位)。其中男3例(4足、5个部位),女5例(5足、6个部位);年龄44~65岁,平均57.5岁。糖尿病足分级:Wagner 3级6例(7足)、4级2例(2足)。左足4例,右足3例;双足1例。慢性骨髓炎病程1~5年,平均3.1年。骨髓炎部位:第1跖骨头3足,第3跖骨头1足,第4跖骨头1足,第5跖骨头6足。其中2例为同一足合并2个部位慢性骨髓炎。记录跖骨延长长度及时间、佩戴外固定架时间,计算外固定架带架指数;观察足部溃疡及骨延长段愈合情况,记录愈合时间,计算骨延长段愈合指数。末次随访时,按照美国矫形足踝协会(AOFAS)评分标准评定足部功能。结果患者术后获随访9~26个月,平均15.0个月。除骨延长期间发生针道感染外,治疗期间均无皮肤坏死以及血管、神经损伤等并发症发生。跖骨延长长度12~35 mm,平均20.5 mm;跖骨延长时间21~84 d,平均57.8 d。佩戴外固定架时间10.4~21.1周,平均14.6周;外固定架带架指数为42.9~59.2 d/cm,平均54.3 d/cm。患者足部溃疡均愈合,愈合时间19~70 d,平均30.5 d;随访期间溃疡均无复发。X线片复查示骨延长段均达骨性愈合,愈合指数为37~51 d/cm,平均42.5 d/cm。末次随访时,踝关节AOFAS评分为87~95分,平均91.7分;获优5足、良4足,优良率100%。结论清创后按照Ilizarov张力-应力法则行一期跖骨延长,能促进糖尿病足溃疡愈合、重建跖骨长度、保留跖骨负重功能,是治疗糖尿病足溃疡并跖骨头慢性骨髓炎的一种有效方法。

Objective To explore the effectiveness of the first-stage debridement and Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head.Methods Between January 2015 and October 2018,8 cases(9 feet,11 sites)of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head were treated by first-stage debridement and Ilizarov metatarsal bone lengthening.There were 3 males(4 feet,5 sites)and 5 females(5 feet,6 sites),with an average age of 57.5 years(range,44-65 years).According to diabetic foot Wagner grade,6 cases(7 feet)were grade 3 and 2 cases(2 feet)were grade 4.The chronic osteomyelitis located at left foot in 4 cases,right foot in 3 cases,and bilateral feet in 1 case.The duration of chronic osteomyelitis was 1-5 years(mean,3.1 years).The chronic osteomyelitis site was the 1 st metatarsal head in 3 feet,the 3 rd metatarsal head in 1 foot,the 4 th metatarsal head in 1 foot,and the 5th metatarsal head in 6 feet.Two patients had chronic osteomyelitis at 2 sites on 1 foot.The length of lengthened metatarsal bone,lengthening time,and the time of wearing external fixation frame were recorded,and the external fixation frame index was calculated.The healing conditions of foot ulcer and lengthening bone segment were observed,the healing time was recorded,and the healing index of lengthening bone was calculated.The ankle function was evaluated according to the American Orthopedic Foot and Ankle Society(AOFAS)score criteria.Results All patients were followed up 9-26 months with an average of 15.0 months.Except pin tract infection during the bone lengthening period,there was no complications such as skin necrosis and vascular or nerve injury occurred during treatment.The length of lengthened metatarsal bone was 12-35 mm with an average of 20.5 mm;the metatarsal bone lengthening time were 21-84 days with an average of 57.8 days.The average time of wearing external fixation frame was 14.6 weeks(range,10.4-21.1 weeks)and the external fixation frame index was54.3 days/cm(range,42.9-59.2 days/cm).The ulcer wound healed with an average healing time of 30.5 days(range,19-70 days)and no ulcer recurrence was observed during follow-up.Bone healing was obtained in all bone lengthening segments,and the average healing index was 42.5 days/cm(range,37-51 days/cm).The average AOFAS score was91.7(range,87-95);5 feet were excellent and 4 feet were good.The excellent and good rate was 100%.Conclusion The metatarsal bone lengthening under Ilizarov law of tension-stress after debridement can promote diabetic foot ulcers healing and reconstructing the length of metatarsal to retain the function of metatarsal load and avoid amputation.This is an effective method for the treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head.