腓肠神经营养皮瓣结合载抗生素硫酸钙混合自体髂骨植骨治疗慢性跟骨骨髓炎的疗效

Therapeutic effect of sural neurocutaneous flap combined with antibiotic-impregnated calcium sulfate and autologous iliac bone graft of chronic calcaneal osteomyelitis

目的分析腓肠神经营养皮瓣结合载抗生素硫酸钙混合自体髂骨植骨治疗慢性跟骨骨髓炎的治疗效果。方法回顾性分析2013年4月—2020年1月西安交通大学附属红会医院收治的采用腓肠神经营养皮瓣结合载抗生素硫酸钙混合自体髂骨植骨治疗的29例慢性跟骨骨髓炎患者的临床资料, 其中男性19例, 女性10例;年龄为(45.38 ± 12.85) 岁, 范围为22~67岁;病程为(16.00 ± 6.96)个月, 范围为6~36个月;皮肤缺损面积为(41.9 ±15.9) cm~2, 范围为11.8~86.8 cm~2。患者致伤原因:高处坠落18例, 车祸6例, 重物碾压3例, 其余2例分别为机器绞伤和锐器刺伤。记录患者术前及术后2、4、8周及6个月的炎性指标[白细胞计数(WBC)、红细胞沉降率(ESR)、降钙素原(PCT)、C反应蛋白(CRP)]及骨愈合时间, 随访时观察皮瓣质地、成活及足部功能恢复情况, 并记录并发症发生情况。采用美国足踝外科协会(AOFAS)踝-后足评分标准评价手术前后足跟部功能恢复情况。计量资料以均数±标准差(±s)表示, 组间比较采用t检验;手术前后不同时间点的WBC、ESR、PCT、CRP比较采用重复测量的方差分析, 两两比较采用LSD-t检验。结果 29例患者均随访(14.51 ± 6.10)个月, 范围为6~30个月。所有皮瓣最终成活, 未见磨损、溃烂及皮肤高突情况, 均可正常穿鞋行走。28例患者一期骨性愈合, 时间为(5.87±2.07)个月, 范围为3~12个月。术后各时间点炎性指标较术前均降低(P<0.05)。术后6个月与术后8周各指标比较, 差异无统计学意义(P>0.05), 其余时间点差异均有统计学意义(P<0.05)。AOFAS的踝-后足评分:术前为(55.37 ± 8.07)分, 术后6个月为(83.44 ± 7.93)分, 差异均有统计学意义(P<0.05)。足部功能恢复情况:29例患者中, 优12例, 良15例, 可2例, 优良率为93.1%(27/29)。1例患者术后1个月复发, 予以扩创后再次植入载抗生素硫酸钙混合自体髂骨后愈合, 再无复发。并发症总发生率为31.0%, 但后期均未对患者生活造成明显影响, 所有患者均回归正常生活及工作。结论采用腓肠神经营养皮瓣结合载抗生素硫酸钙混合自体髂骨植骨治疗慢性跟骨骨髓炎可有效控制感染, 重建跟骨及软组织结构, 促进患肢功能恢复, 最终提高患者的生活质量。

Objective To analyze the therapeutic effect of sural neurocutaneous flap combined with antibiotic-impregnated calcium sulfate and autogenous iliac bone graft of chronic calcaneal osteomyelitis.Methods A retrospective analysis was peformed in 29 patients with chronic calcaneal osteomyelitis treated with sural neurocutaneous flap combined with antibiotic-impregnated calcium sulfate and autogenous iliac bone graft in the Xi′an Honghui Hospital Affiliated to Xi′an Jiaotong University from April 2013 to January 2020.There were 19 males and 10 females,with the age of(45.38±12.85)years,ranged from 22 to 67 years.The course of disease was(16.00±6.96)months,ranged from 6 to 36 months.The skin defect area was(41.9±15.9)cm^(2),ranged from 11.8 to 86.8 cm^(2).The causes of injury:18 cases of high fall,6 cases of traffic accidents,3 cases of heavy rolling,the remaining 2 cases were machine strangulation and sharp stab wounds.The inflammatory markers[white blood cell(WBC),erythrocyte sedimentation rate(ESR),procalcitonin(PCT),C reactive protein(CRP)]and bone healing time were recorded before operation,2,4,8 weeks and 6 months after operation.During the follow-up period,the flap texture,survival were observed,and the ankle-posterior foot function recovery was evaluated by the American Association of Foot and Ankle Surgery(AOFAS)score were observed before and after the operation,and the incidence of complications were recorded.The measurement data were expressed as mean±standard deviation(±s),and the t-test was used for inter-group comparison;the levels of WBC,ESR,PCT and CRP at different time points before and after operation were compared by repeated measurement ANOVA,and the LSD t-test was used for pairwise comparison.Results All the 29 patients were followed up for(14.51±6.10)months,ranged from 6 to 30 months.All the flaps survived without abrasion,ulceration,or skin protrusion,and all patients could walk normally with shoes.There were 28 cases of stage I bone healing,with an average of(5.87±2.07)months,ranged from 3 to 12 months.The inflammatory indexes was significantly decreased at different time points after operation(P<0.05).There was no significant difference between 6 months and 8 weeks after operation(P>0.05),while there was significant difference at other time points(P<0.05).The ankle-posterior foot score of AOFAS at 6 months after treatment was significantly higher than that before treatment(83.44±7.93 vs 55.37±8.07),the differences was statistically significant(P<0.05).The clinical efficacy of foot function recovery was excellent in 12 cases,good in 15 cases and fair in 2 cases among 29 patients.The excellent and good rate was 93.1%(27/29).One patient recurred 1 month after operation and was re-implanted with antibiotic-loaded calcium sulfate mixed autogenous iliac bone after debridement,no recurrence was found.The total complication rate was 31.0%,but there was no significant impact on the patient's life in the later period.All patients returned to daily life and work.Conclusion The treatment of chronic calcaneal osteomyelitis with sural neurocutaneous flap combined with antibiotic-impregnated calcium sulfate and autogenous iliac bone graft can effectively control infection,reconstruct calcaneal and soft tissue structure,promote functional recovery of affected limb,and ultimately improve the patient′s quality of life.