骨膜牵张技术用于糖尿病足治疗的理论基础及临床结果验证

Periosteum distraction for the treatment of diabetic foot ulcer:theoretical basis and clinical verification

背景:骨膜牵张也具有促进成骨和微血管生成作用,但能否用于治疗糖尿病足目前尚未明确。目的:对骨膜牵张促进骨和血管再生的研究进展进行综述,以明确该技术用于糖尿病足治疗的理论基础,并介绍其在治疗糖尿病足中的初步应用。方法:计算机检索万方医学网、中国知网、PubMed及Elsevier数据库收录的相关文献,中文检索词为:“牵张成组织技术、牵张成骨、胫骨横向骨搬移与糖尿病足、骨膜牵张、骨膜牵张成骨、骨膜牵张与糖尿病足”;英文检索词为“Distraction histogenesis,Distraction osteogenesis,Tibia transverse transport and diabetic foot,Periosteal distraction osteogenesis,Periosteal distraction and diabetic foot”。最终纳入42篇文献进行综述分析。结果与结论:①基于Ilizarov张力-应力法则或牵张成组织原理,牵张成骨技术已用于治疗骨缺损、骨不连等疾病,而牵张成骨伴随的成血管原理催生了胫骨横向骨搬移技术,该技术已经成功应用于治疗包括糖尿病足在内的下肢难愈性溃疡,取得良好的治疗效果。②研究发现对骨膜进行持续、稳定、缓慢的牵张可以促进骨和血管再生,即骨膜牵张成骨和成血管现象,该现象的机制可能与骨膜的结构和成分有关。③目前关于骨膜牵张的研究主要聚焦于其成骨功能,且主要停留在动物实验阶段而极少用于人体。与胫骨横向骨搬移促进血管再生从而用于治疗糖尿病足类似,骨膜牵张促进血管再生也可能用于治疗糖尿病足,此即骨膜牵张用于治疗糖尿病足的理论基础。④该课题组已初步将骨膜牵张用于临床治疗糖尿病足,且治疗效果良好,该文章通过展示用于骨膜搬移的器械、手术方法及典型病例。初步结果显示,由于骨膜牵张技术不需要截骨,手术操作要比胫骨横向骨搬移更加简单,手术时间更短;因为骨膜牵张技术缺少对胫骨钻孔和骨搬移的操作,缺乏对胫骨髓腔的“开窗减压”作用及骨组织的搬移,可能促血管生成和创面愈合的效果要弱于胫骨横向骨搬。未来还需对骨膜牵张促进骨和血管再生的具体机制以及手术适应证及禁忌证等进一步研究。

BACKGROUND:Pe riosteal distraction has been found to stimulate osteogenesis and angiogenesis;however,whether this technique can be used for the treatment of diabetic foot remains unclear.OBJECTIVE:To review the research progress of periosteal distraction in the promotion of osteogenesis and neovascularization,to clarify the theoretical basis of this technique for the treatment of diabetic foot,and to introduce its preliminary application in the treatment of diabetic foot.METHODS:Literature retrieval was conducted using computer in WanFang,CNKI,PubMed and Elsevier databases using the keywords of "distraction histogenesis,distra ction osteogenesis,ti bia transverse transport and diabetic foot,periosteal distra ction osteogenesis,periosteal distra ction and diabetic foot" in Chinese and English.Finally,42 articles were included for analysis.RESULTS AND CONCLUSION:Based on Ilizarov’s law of tension-stress or the principle of distraction histogenesis,distraction osteogenesis has been used to treat bone defects,nonunion and other orthopedic diseases.The angiogenesis accompanying distraction osteogenesis gave birth to the technique of tibial transve rse transfer,which has been successfully applied to refractory lower extremity ulcers including diabetic foot.Also based on the principle of distraction histogenesis,studies have found that a continuous,stable and slow distraction of the periosteum can promote bone and vascular regeneration,that is,the phenomenon of periosteal distra ction osteogenesis and angiogenesis.The mechanism of this phenomenon may be related to the structure and composition of the periosteum.However,the current research on periosteal distraction mainly focuses on its osteogenic function in animal experiments but hardly in humans.Like tibial transve rse transfer to promote angiogenesis for the treatment of diabetic foot,periosteal distraction angiogenesis may also be used to treat diabetic foot,which is the theo retical basis of periosteal distraction for the treatment of diabetic foot.Our preliminary clinical study has shown that this technique is effective in the treatment of diabetic foot.Periosteal distraction is simpler and shorter than the lateral tibial bone transfer because it does not require osteotomy.The periosteal distraction technique lacks the manipulation of tibial drilling and bone transfer and lacks the "fenestration decompression" of the bone marrow cavity.So,the periosteal distra ction technique may be inferior to the lateral bone transfer of the tibia in terms of promoting angiogenesis and wound healing.In the future,the indications,contraindications,and specific mechanism of periosteal distraction still need to be explored.