胫骨骨膜侧向牵张术治疗下肢慢性缺血性疾病

Preliminary study of lateral tibia periosteum distraction for the treatment of chronic ischemic diseases of lower limbs

目的探讨胫骨骨膜侧向牵张术治疗糖尿病足和脉管炎足的疗效。方法回顾性分析2019年6月至2020年5月采用胫骨骨膜侧向牵张术治疗并获得随访的13例(16足)患者资料,男9例(12足),女4例(4足);年龄39~77岁,平均66岁;左足7例,右足9例;5例为糖尿病足,1例为糖尿病足合并动脉硬化闭塞症,2例为血栓闭塞性脉管炎,5例为动脉硬化闭塞症。术中将胫骨骨膜切开并置入牵张装置,其中3例双足溃疡者胫骨骨膜牵张器安置于较为严重的一侧。术后第3天起开始牵张骨膜,速度约0.75 mm/d,调整时限为2周,2周后手术取出牵张装置。评价术后足部毛细血管充盈和创面恢复情况,对手术前、后的足部皮温、疼痛视觉模拟评分(visual analogue scale,VAS)、足末梢血氧饱和度进行统计学分析,同时采用CT血管造影(CT angiography,CTA)观察双下肢血管情况。结果术后13例患者均获得随访,随访时间2~12周,平均3.85周;术前13例患者VAS评分为(5.31±1.84)分(范围2~9分),术后2周为(2.46±1.39)分(范围1~6分),两者比较差异有统计学意义(t=6.124,P<0.001)。术前1例患足血氧饱和度未测出,其余12例为87.83%±14.83%(范围50%~98%),术后2周为92.33%±7.91%(范围75%~99%),两者比较差异无统计学意义(t=1.124,P=0.285)。术前10例患者足部皮温为(35.68±0.85)℃(范围34.00~36.60℃),术后为(36.23±0.46)℃(范围35.50~36.90℃),两者比较差异有统计学意义(t=3.197,P=0.008)。术后2周毛细血管充盈试验示毛细血管充盈反应较术前明显改善。所有患者均于术前行CTA检测,11例患者术后2周取出牵张装置后复查CTA,与术前CTA相比手术侧肢体可见明显的新生血管显影。除1例血栓闭塞性脉管炎患者(患足疼痛为主,无创面症状)外,其余12例患者中2例因合并心衰或肾衰而致创面未愈合、另外10例于术后1个月创面明显好转。结论胫骨骨膜侧向牵张术可用于治疗下肢慢性缺血性疾病,术后疗效满意。

Objective To investigate the effect of lateral tibial periosteum distraction on diabetic foot and vasculitis foot.Methods A retrospective analysis of 13 patients(16 feet)who received lateral tibial periosteal distraction between June 2019 and May 2020 were included in the study.9 males and 4 females;aged 39-77 years(average 66 years);left foot 7 cases,right foot 9 cases.5 cases were patients with diabetic foot,1 case was diabetic foot with arteriosclerosis obliterans,2 cases were thromboembolic vasculitis,and 5 cases were arteriosclerosis obliterans.The tibial periosteum was dissected and a distraction device was placed.In the 3 patients with foot ulcers,tibial periosteum distraction devices were placed on the severer side.The periosteal distraction began on the third day after surgery,about 0.75 mm/d,the adjustment was done usually in two weeks.Two weeks later,the stretch plate was removed surgically.The followings were evaluated:visual analogue scale(VAS)pain score,foot peripheral oxygen saturation,foot capillary filling test,lower extremity arterial CT angiography(CTA),etc.Results All 13 patients were followed up for 2-12 weeks,with an average of 3.85 weeks.VAS pain score:the average pain score of 13 patients with preoperative foot pain was 5.31±1.84(range,2-9)points,and 2 weeks after surgery,the average value was 2.46±1.39(range,1-6)points with statistical significance(t=6.124,P<0.001);peripheral foot oxygen saturation:the average preoperative blood oxygen saturation of 12 patients was 87.83%±14.83%(range,50%-98%),1 patient was not detected before surgery,and 2 weeks after operation,the average blood oxygen saturation was 92.33%±7.91%(range,75%-99%).There was no significant difference between them(t=1.124,P=0.285).The foot skin temperature of 10 patients was 35.68±0.85℃(range,34.00-36.60℃)before surgery and 36.23±0.46℃(range,35.50-36.90℃)after surgery,and the difference was statistically significant(t=3.197,P=0.008).Capillary filling test:2 weeks after operation,the capillary filling response was significantly improved.All 13 patients had improved CTA of both lower extremity arteries before operation,and 11 patients had CTA taken back after two weeks of operation.Compared with preoperative CTA,new vascular network was found in the operation limb.In addition to 1 patient with thromboangiitis obliterans(mainly suffering from foot pain,no wound symptoms),2 of 12 patients with heart failure,renal failure and other basic diseases did not heal,and the wounds of the other 10 patients had improved significantly 1 month later.Conclusion Lateral tibia periosteum distraction can be used to treat chronic ischemic diseases of lower extremities with satisfactory postoperative results.