截骨移位治疗下肢长骨慢性骨髓炎伴骨缺损

目的 分析截骨移位治疗下肢长骨干慢性骨髓炎伴骨缺损术后非骨性愈合常见并发症的原因,并探讨相应对策.方法 回顾性分析2012年6月至2015年12月应用截骨移位治疗38例下肢长骨干慢性骨髓炎伴骨缺损患者的临床资料.男23例,女15例;年龄20~56岁,平均36.5岁.股骨5例、胫骨33例;受伤至截骨移位时间2~19个月,平均7.42个月;骨缺损长度4~12cm,平均7.3cm;术后均经过1周'待机期'开始截骨移位,移位方向由近端向远端30例,由远端向近端3例,双向移位5例;并及时调整力线及截骨移位速度,患者坚持负重.结果 38例患者随访12~36个月,平均23.1个月,骨髓炎无复发.钉道感染27例,其中伴周围软组织广泛蜂窝织炎2例;根据VAS评分进行疼痛评估,其中6例存在难以忍受的剧烈疼痛;肢体肿胀致外固定架对软组织造成压迫10例;邻近关节活动受限较术前加重5例.带架时间9~27个月,平均16.3个月;外固定指数为1.7~2.7个月/cm,平均2.24个月/cm;根据Paley等提出的评分标准评定疗效:优14例、良18例、中3例、差3例,优良率为84.2%.结论 截骨移位有效解决了长骨干骨髓炎伴大段骨缺损的临床难题,但因其具有较多的并发症,且治疗周期长,对患者依从性要求高,从而在一定程度上限制了临床应用.因此,选择手术适应证应慎重,术中操作应细致精准,治疗过程中应全程监控,及时随访,并积极指导患者相应的预防策略,以期得到更满意的临床疗效.

Objective To analyze the causes of non bony union related complications after the operations of bone transport technique in the treatment of lower long bone chronic osteomyelitis with bone defects,and to explore the corresponding countermeasures. Methods From June 2012 to December 2015,bone transport technique was used to treat 38 chronic osteomyelitis of lower limbs long bones patients with bone defect. They were 23 males and 15 females,aged from 20 to 56 years(average,36.5 years),with 5 femoral osteomyelitis and 33 tibial ones. The time from injury to bone transport was from 2 to 19 months,averaged 7.42 months. The bone defect of these patients averaged 7.3cm,ranging from 4 to 12cm. Bone transport started 1 week later after the operations,and the transport directions were from near-end to far-end with 30 cases,from far-end to near-end with 3 cases and bidirectional transport with another 5 cases. The alignment and transport speed were adjusted and weight-bearing was encouraged in patients. Results The 38 cases were followed up for 12 to 36 months(average,23.1 months)postoperation. No recurrence of osteomyelitis. In the process of bone transport,there were 27 cases with pin-tract infection,contained 2 of them combined with extensive soft tissue cellulitis. According to VAS pain evaluation criteria,there were 6 cases with severe pain. Because of the swelling limbs,soft tissues were compressed by external fixator in 10 cases. Adjacent joints activity limitation aggravated before operation in 5 cases. They wore the external fixators for 9 to 27 months(average,16.3 months). External fixation index was from 1.7month/cm to 2.7 month/cm(average,2.24 month/cm). According to Paley’s evaluation criteria,functional results:14 cases were excellent,18 good,3 moderate and 3 poor,with a good to excellent rate of 84.2%. Conclusion Bone transport technique can effectively solve the clinical problems of long bone osteomyelitis with bone defect. However,because of its complications,long treatment period, and high compliance of patients,the technique is limited in clinical application. Therefore,in order to obtain more satisfactory clinical effect,surgical indications should be carefully chosen. Operations should be precise and accurate. It also should be monitored across the whole process and followed up in time. Doctors should actively guide the corresponding prevention strategies.