一期骨搬运及二期包裹式植骨术治疗儿童先天性胫骨假关节手术后大段骨缺损的疗效探讨

Efficacy of one-stage bone transport and two-stage wrapped bone grafting in the treatment of large bone defect after congenital tibial pseudoarthroplasty in children

目的评估一期骨搬运、二期包裹式植骨术治疗儿童先天性胫骨假关节手术后大段骨缺损的临床效果。方法对湖南省儿童医院骨科自2016年1月至2018年12月期间采取一期骨搬运、二期包裹式植骨术治疗的先天性胫骨假关节手术后大段骨缺损患儿进行随访分析。所有患儿均一期行胫骨骨搬运术,胫骨延长速度为每日0.5 mm,每2周复查1次,监测骨痂情况适时调整延长速度。延长过程中加强膝、踝关节功能锻炼,配合使用胫骨延长辅助支具。待胫骨假关节断端对合后,行二期胫骨假关节切除、包裹式植骨术。胫骨假关节和延长段均初步愈合后,拆除外固定器。记录骨搬运长度、骨搬运时间、搬运段骨愈合时间、愈合指数、外固定器固定时间以及并发症情况。采用SPSS 20.0软件进行数据的统计分析。结果共6例患儿纳入研究,其中男4例,女2例,年龄(7.5±3.1)岁,均获满意随访,平均随访时间62个月。6例均分两期完成手术,骨搬运总长度(6.7±2.8)cm,骨搬运时间(138.7±58.1)d,搬运段骨愈合时间(328.7±103.4)d,骨搬运段愈合指数(46.7±12.8)d/cm,外固定器固定总时间(275.0±74.3)d。所有患儿胫骨延长段及胫骨假关节均获得骨性愈合。术后发生针道感染3例(3/6),经口服头孢克肟抗感染治愈;髓内棒尾端自足底脱出1例(1/6),予再次手术将髓内棒向胫骨近端推进,稳定延长段;延长段提前愈合1例(1/6);截骨段成角1例(1/6),行外固定器调整后胫骨力线改善。无一例发生血管神经损伤或骨髓炎。末次随访时,1例(1/6)患侧胫骨短缩4 cm,其余患儿胫骨短缩均小于1 cm。随访过程中无胫骨延长段及胫骨假关节段再骨折发生。结论对于儿童先天性胫骨假关节手术后大段骨缺损,一期骨搬运及二期包裹式植骨术尽管延长段愈合指数大,外固定时间长,但愈合率高,是一种较好的治疗方法。

Objective To evaluate the clinical effects of one-stage bone transport and two-stagewrapped bone grafting in the treatment of large bone defect after congenital tibial pseudoarthroplasty in children.Methods A retrospective analysis was performed on the cases of large bone defect after pseudoarthroplasty in children,who was treated with one-stage bone transport and two-stagewrapped bone grafting.One-stage tibial bone transport was performed in all cases with follow-up at every 2 weeks,the rate of lengthening of the tibia was 0.5 mm/day,and the transport speed was adjusted according to the quality of the callus.During the lengthening process,function exercises were strengthened for knee and ankle joint,and tibial lengthening fixator was used to prevent contractures.After the fracture ends of tibial pseudoarthrosis ends were aligned,the two-stage stage surgery of tibial pseudoarthrosis excision and wrapped bone grafting was performed.The external fixator was removed after initial healing of tibial pseudoarthrosis and transported segment.The length and healing time of bone transport,healing index,external fixation time and complications were recorded.SPSS20.0 was used to analyze the data.Results A total of 6 patients with an average age of(7.5±3.1)years were enrolled in this study,including 4 males and 2 females.All patients were followed up satisfactorily with an average of 62 months.The total bone transport length was(6.7±2.8)cm,and the bone transport time was(138.7±58.1)days.The bone healing time was(328.7±103.4)days and the bone transport healing index was(46.7±12.8)d/cm.The duration of external fixator use was(275.0±74.3)days.3 cases(50%)had pin tract infection and were cured by oral Cefixime.The end of the intramedullary rod was detached from the plantar of the foot in 1 case(16.7%),which was solved by pushing the intramedullary rod upward to the proximal tibia by surgery.In one case(16.7%),the transported segment of tibia was healed in advance.Angulation of osteotomy segment was found in 1 case(16.7%),which was treated by adjusting external fixator.None of vascular nerve injury or osteomyelitis was observed.At the end-point follow-up,4 cm shortening of tibia was occurred in 1 patient and less than 1 cm in other cases.During the follow up,neither further fracture of the elongated segment nor the tibial pseudo-articular segment was observed.Conclusion In children with large bone defects after congenital tibial pseudarthrosis surgery,one-stage bone transport and two-stage wrapped bone grafting is a preferable method with a high healing rate despite the high healing index and the long external fixation time.