3D打印量化植骨辅助Masquelet技术二阶段治疗Gustilo ⅢB、ⅢC型胫腓骨骨折长段骨缺损的疗效

Masquelet technique with 3D-printed quantitative bone implants for the treatment of long-segment bone defect following Gustilo type ⅢB and ⅢC tibial fractures

目的探讨3D打印量化植骨辅助Masquelet技术二阶段治疗Gustilo ⅢB、ⅢC型胫腓骨骨折长段骨缺损的疗效。方法采用回顾性病例系列研究分析2015年7月至2020年12月无锡市第九人民医院收治的26例Gustilo ⅢB、ⅢC型胫腓骨骨折长段骨缺损患者临床资料,其中男20例,女6例;年龄19~63岁[(46.5±4.5)岁]。Gustilo分型:ⅢB 23例,ⅢC 3例。一阶段所有患者急诊彻底清创、胫骨断端摘除所有游离骨块,恢复长度及力线同时外固定,遗留创面负压封闭引流(VSD)覆盖。伤后第2~7天,外固定拆除更换为内固定,骨缺损区骨水泥填塞,游离皮瓣覆盖创面。胫骨骨缺损长度5~14 cm[(6.3±0.4)cm]。胫骨缺损体积12.2~73.1 cm3[(33.6±9.2)cm3]。二阶段(伤后第6~19周),胫骨骨缺损区取出骨水泥后自体骨植骨,植骨术前利用数字化技术精确计算骨缺损体积,设计等体积髂骨取骨区域并3D打印截骨导板,术中根据截骨导板取骨后植骨。记录一次性髂骨取骨成功率、取骨所需时间、出血量。术后1 d、1个月及末次随访时采用视觉模拟评分(VAS)评估取骨区疼痛程度。观察伤口愈合、并发症、骨愈合情况。植骨术前及末次随访时根据健康调查简表(SF⁃36)[包括躯体健康总得分(PCS)、心理健康总得分(MCS)]评价生活质量。结果患者均获随访13~53个月[(32.3±12.5)个月]。患者均一次性取骨成功。取骨所需时间为15~30 min[(21.0±2.5)min]。出血量为50~120 m[l(62.3±29.0)ml]。术后1 d VAS为1~4分[(1.2±0.9)分],高于术后1个月及末次随访的(0.0±0.0)分(P均<0.01)。25例术后伤口愈合良好,1例植骨后出现伤口浅表感染,换药处理后愈合。1例植骨3个月后骨感染,重复Masquelet技术一、二阶段治疗后获得骨愈合。2例髂骨供区出现皮神经损伤症状。植骨愈合时间为4~7个月[(5.8±0.8)个月]。末次随访时SF⁃36中PCS为(73.6±12.8)分,MCS为(83.6±13.2)分,显著高于植骨术前的(46.8±0.5)分、(60.7±2.0)分(P均<0.01)。结论3D打印量化植骨辅助Masquelet二阶段治疗Gustilo ⅢB、ⅢC型胫腓骨骨折长段骨缺损可缩短取骨所需时间、减轻疼痛、减少并发症、促进骨愈合及功能恢复。

Objective To investigate the efficacy of 3D-printed quantitative bone implants assisting second-stage Masquelet technique for the treatment of long-segment bone defect following Gustilo type ⅢB and ⅢC tibial fractures.Methods A retrospective case series analysis was made on 26 patients with long-segment bone defect following Gustilo type ⅢB and ⅢC tibial fractures treated in Wuxi Ninth People's Hospital from July 2015 to December 2020,including 20 males and 6 females;aged 19-63 years[(46.5±4.5)years].Gustilo classification was type ⅢB in 23 patients and type ⅢC in 3.In the first stage,all patients had thoroughly emergent debridement,removal of all free bone pieces,restoration of the length and force line plus externally fixion,and vacuum sealing drainage(VSD)of the residual wound.After 2-7 days,the external fixation was removed and replaced by internal fixation,with the bone cement filling in the defect area and the free flap covering the wound.The length of tibial bone defect was 5-14 cm[(6.3±0.4)cm],and the tibial defect volume was 12.2-73.1 cm3[(33.6±9.2)cm3].In the second stage(6-19 weeks after injury),the bone cement was removed,followed by autologous bone grafting.Prior to bone grafting,digital technology was used to accurately calculate the bone defect volume,and an equal volume of bone harvesting area was designe to produce the 3D printed osteotomy template.Bone grafting was conducted after bone removal according to the osteotomy template during operation.The success rate of one-time iliac bone extraction,bone harvesting time,and bleeding volume were recorded.Pain in the bone extraction area was evaluated by visual analogue score(VAS)at 1 day and 1 month after operation and at the last follow-up.Wound healing,complications,and bone healing were observed.Life quality was evaluated by health survey brief form(SF-36)including scores of physical component summary(PCS)and mental component summary(MCS)before bone grafting and at the last follow-up.Results All the patients were followed up for 13-53 months[(32.3±12.5)months].One-time iliac bone extraction was successful in all the patients.Bone harvesting time was 15-30 minutes[(21.0±2.5)minutes].The bleeding volume was 50-120 ml[(62.3±29.0)ml].The VAS was 1-4 points[(1.2±0.9)points]at 1 day after operation,higher than these(0.0±0.0)points at 1 month after operation and at the last follow-up(all P<0.01).Totally,25 patients obtained wound healing after operation,except for 1 patient with superficial wound infection after bone grafting that was healed by dressing change.There was 1 patient with bone infection after 3 months of bone grafting that was healed by repeated surgery with Masquelet technique in the first and second stage.Besides,2 patients had symptoms of cutaneous nerve injury in the iliac donor area.The time of bone healing was 4-7 months[(5.8±0.8)months].The scores of PCS and MCS in SF-36 at the last follow-up were(73.6±12.8)points and(83.6±13.2)points,significantly higher than those before bone grafting[(46.8±0.5)points,(60.7±2.0)points](all P<0.01).Conclusion Second-stage Masquelet technique with 3D printed quantitative bone implants for the treatment of long-segment bone defect following Gustilo type ⅢB and ⅢC tibial fractures is associated with shortened bone harvesting time,attenuated pain,reduced complications,accelerated bone healing and improved function.