改良诱导膜技术结合带蒂(肌)皮瓣治疗糖尿病患者胫骨慢性骨髓炎

Modified induced membrane technique and pedicled skin(myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes

目的探讨改良诱导膜技术结合带蒂(肌)皮瓣治疗糖尿病患者胫骨慢性骨髓炎的疗效。方法回顾分析2017年1月—2019年3月,收治并符合选择标准的22例合并胫骨慢性骨髓炎的糖尿病患者临床资料。男15例,女7例;年龄44~65岁,平均52岁。糖尿病病程3~12年,平均6.1年。骨髓炎病程4个月~7年,平均3.3年;Cierny-Mader分型:Ⅲ型9例,Ⅳ型13例。细菌培养显示单一细菌感染21例,混合细菌感染1例。术前下肢动脉彩色多普勒超声及CT血管造影检查证实胫前、胫后动脉通畅无闭塞。第1阶段治疗首先彻底清创,病灶清除后骨缺损长4~9 cm,平均5.6 cm;软组织缺损范围5 cm×2 cm~10 cm×7 cm。采用抗生素骨水泥分别填塞骨与软组织缺损区域;7~10 d后取出骨水泥填塞物,另取抗生素骨水泥填塞骨缺损区域,同时行带蒂(肌)皮瓣修复创面。待7~12周炎症指标均恢复正常时行第2阶段治疗,即采用自体髂骨或联合人工骨植骨修复缺损。观察创面及骨缺损愈合情况以及并发症发生情况,记录治疗成功例数,评价皮瓣疗效满意度及患肢功能。结果术后3例发生皮瓣边缘局部表皮坏死,创面延期愈合;其余19例皮瓣均顺利成活,创面Ⅰ期愈合。供区植皮均成活,切口Ⅰ期愈合。患者均获随访,随访时间13~28个月,平均20个月。术后12个月内2例感染复发,再次采用改良诱导膜技术治疗后骨缺损愈合;骨缺损愈合率达100%,愈合时间6~10个月,平均8.9个月;感染控制率和治疗成功率均为90.9%(20/22)。术后12个月,参照张浩等制定的皮瓣疗效满意度评分标准疗效均为满意;患肢功能按Johner-Wruhs邻近关节功能评定方法获优13例、良7例、可2例,优良率为90.9%。结论无血管闭塞的糖尿病患者发生胫骨慢性骨髓炎时,采用改良诱导膜技术结合带蒂(肌)皮瓣能修复骨与软组织缺损同时控制感染,早中期疗效良好。

Objective To investigate the effectiveness of modified induced membrane technique and pedicled skin(myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes. Methods A clinical data of 22 diabetic patients with chronic tibial osteomyelitis between January 2017 and March 2019 was retrospectively analyzed.There were 15 males and 7 females with an average age of 52 years(range, 44-65 years). The course of diabetes was 3-12 years(mean, 6.1 years). The course of chronic osteomyelitis was 4 months to 7 years(mean, 3.3 years). The chronic osteomyelitis was rated as type Ⅲ in 9 cases and as type Ⅳ in 13 cases according to the Cierny-Mader classification criteria. Bacterial culture showed 21 cases of single bacterial infection and 1 case of mixed bacterial infection. Preoperative color Doppler ultrasound and CT angiography confirmed that the anterior and posterior tibial arteries were unobstructed.In the first stage of treatment, the bone and soft tissue defects were filled with antibiotic bone cement after the lesion was thoroughly debrided;the length of bone defect was 4-9 cm(mean, 5.6 cm), and the size of soft tissue defect was 5 cm×2 cm to 10 cm×7 cm. After 7-10 days, the bone cement was removed and a new antibiotic bone cement was filled into the bone defect. Meanwhile, the pedicled skin(myocutaneous) flap was performed to repair the wound. After 7-12 weeks, the inflammatory indexes returned to normal, autogenous iliac bone or combined with artificial bone was used to repair the bone defect in the second stage of treatment. The wound healing, bone defect healing, complications, and the number of successful treatments were recorded. The satisfaction of the skin flap efficacy and the function of the affected limb were evaluated. Results Local necrosis of the skin flap occurred in 3 cases after operation, leading to delayed healing of the wound;the other 19 flaps survived successfully, leading to primary healing of the wound. The skin grafts survived completely and the incisions healed by first intention. All cases were followed up 13-28 months with an average of 20 months. The infection recurred in 2 cases within 12 months after operation, and the bone defects healed after treated by modified induced membrane technique. The bone defect healing rate was 100%;the bone healing time was 6-10 months,with an average of 8.9 months;the infection control rate and successful treatment rate were 90.9%(20/22) and 90.9%(20/22), respectively. At 12 months after operation, according to the satisfaction evaluation standard of skin flap efficacy formulated by ZHANG Hao et al., all were satisfied. According to Johner-Wruhs adjacent joint function method, the limb function recovery was excellent in 13 cases, good in 7 cases, and fair in 2 cases, with an excellent and good rate of 90.9%.Conclusion For the treatment of chronic tibial osteomyelitis in patients with diabetes without vascular occlusion, the modified induced membrane technique and pedicled skin(myocutaneous) flap can repair bone and soft tissue defects, and control the infection at the same time, the short-and medium-term effectiveness are good.