胫骨横向骨搬移结合负压引流治疗糖尿病足溃疡的临床疗效分析
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摘要
目的 :探讨胫骨横向骨搬移微血管网再生技术结合封闭负压引流治疗伴溃疡形成的糖尿病足的临床疗效。方法:对2015年11月至2016年12月采用胫骨横向骨搬移结合负压引流治疗的19例伴溃疡形成的糖尿病足的临床资料进行回顾性分析,男15例,女4例;年龄42~82岁,平均(64.57±7.14)岁;糖尿病平均病程(14.62±6.19)年;左足12例,右足7例;溃疡面积2 cm×3 cm~8 cm×6 cm;按照Texas分类法进行分类,所有病例为D期,其中2级3例,3级10例,4级6例。手术前后测量踝肱指数及密歇根神经体征评分(MNSI)评价患足周围血管和周围神经功能恢复情况,术后复查血管造影或血管彩超。结果:19例患者中17例术后获得随访,时间3~13个月,平均6.9个月。17例患足创面均得到愈合;术后3个月踝肱指数由术前的0.51±0.20升至0.93±0.18,差异有统计学意义(t=13.63,P=0.000);术后3个月的MNSI为5.76±1.44,优于术前的4.06±1.36,差异有统计学意义(t=7.31,P=0.000)。术后复查血管造影或血管彩超显示患足微血管网再生满意,患足功能达到正常运动和日常生活需要。结论:胫骨横向骨搬移微血管网再生技术可以重建患肢小腿以下微血管网,促进周围血管及周围神经恢复,结合封闭负压引流可促进创面愈合,具有手术简便、疗效确切,保肢成功率高的优点,是治疗糖尿病足溃疡的理想方法之一。
Objective:To investigate clinical effect of transverse tibial bone transport micro vessels regeneration technology combined with vacuum drainage in treating diabetic foot ulcer. Methods:From November 2015 and December 2016,clinical data of 19 diabetic foot ulcer patients treated with transverse tibial bone transport micro vessels regeneration technology combined with vacuum drainage were retrospective analyzed,including 15 males and 4 females aged from 42 to 82 years old with an average of(64.57±7.14) years old;the courses of diabetic ranged was(14.62±6.19) years;12 cases on the left side and 7 cases on the right side;the area of ulcer ranged from 2 cm ×3 cm to 8 cm ×6 cm. All patients were stage D according to Texas classification,3 cases were grade 2,10 cases were grade 3 and 6 cases were grade 4. Ankle brachial index and Michigan Neuropathy Screening Instrument(MNSI) were used to evaluate recovery of peripheral vessel and nerve before and after operation,the result of angiography and vascular ultrasound were also compared after operation. Results:Seventeen of 19 patients were followed up from 3 to 13 months with an average of 6.9 months. Seventeen patients ' surface wound were healed. Ankle brachial index was increased from(0.51±0.20) before operation to(0.93±0.18) at 3 months after operation,and had significant difference(t=13.63,P=0.000);MNSI was increased from(4.06±1.36) before operation to(5.76±1.44) at 3 months after operation,and differences were statistically significant(t=7.31,P=0.000). Postoperative angiography and vascular ultrasound showed satisfied regeneration of micro vessel and affected foot achieved normal movement and daily life. Conclusion:Transverse tibial bone transport micro vessels regeneration technology could reconstruct micro vessel under lower affected limb,promote recovery of peripheral vessel and nerve,while with vacuum drainage could promote wound healing,has advantages of simple operation,obvious clinical effect,and high success rate of limb salvage,and is one of ideal treatment for diabetic foot ulcer.
Objective:To investigate clinical effect of transverse tibial bone transport micro vessels regeneration technology combined with vacuum drainage in treating diabetic foot ulcer. Methods:From November 2015 and December 2016,clinical data of 19 diabetic foot ulcer patients treated with transverse tibial bone transport micro vessels regeneration technology combined with vacuum drainage were retrospective analyzed,including 15 males and 4 females aged from 42 to 82 years old with an average of(64.57±7.14) years old;the courses of diabetic ranged was(14.62±6.19) years;12 cases on the left side and 7 cases on the right side;the area of ulcer ranged from 2 cm ×3 cm to 8 cm ×6 cm. All patients were stage D according to Texas classification,3 cases were grade 2,10 cases were grade 3 and 6 cases were grade 4. Ankle brachial index and Michigan Neuropathy Screening Instrument(MNSI) were used to evaluate recovery of peripheral vessel and nerve before and after operation,the result of angiography and vascular ultrasound were also compared after operation. Results:Seventeen of 19 patients were followed up from 3 to 13 months with an average of 6.9 months. Seventeen patients ' surface wound were healed. Ankle brachial index was increased from(0.51±0.20) before operation to(0.93±0.18) at 3 months after operation,and had significant difference(t=13.63,P=0.000);MNSI was increased from(4.06±1.36) before operation to(5.76±1.44) at 3 months after operation,and differences were statistically significant(t=7.31,P=0.000). Postoperative angiography and vascular ultrasound showed satisfied regeneration of micro vessel and affected foot achieved normal movement and daily life. Conclusion:Transverse tibial bone transport micro vessels regeneration technology could reconstruct micro vessel under lower affected limb,promote recovery of peripheral vessel and nerve,while with vacuum drainage could promote wound healing,has advantages of simple operation,obvious clinical effect,and high success rate of limb salvage,and is one of ideal treatment for diabetic foot ulcer.
引文
[1]Xu Z,Ran X.Diabetic foot care in China:challenges and strategy[J].Lancet Diabetes Endocrinol,2016,4(4):297-298.
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[3]班绎娟,王爱红,许樟荣.富血小板凝胶治疗难愈性糖尿病足溃疡的随机对照研究[J].中华糖尿病杂志,2015,7(5):306-310.BAN YJ,WANG AH,XU ZR.A randomized controlled study of platelet rich gel in treatment of refractory diabetic foot ulcer[J].Zhonghua Tang Niao Bing Za Zhi,2015,7(5):306-310.Chinese.
[4]魏巍,徐尔理,李岚,等.高压氧联合前列地尔治疗糖尿病足临床疗效分析[J].中华航海医学与高气压医学杂志,2013,20(2):104-106.WEI W,XU EL,LI L,et al.Clinical study on the effect of hyper鄄baric oxygen combined with liposomal alprostadil in the treatment of diabetic foot[J].Zhonghua Hang Hai Yi Xue Yu Gao Qi Ya Yi Xue Za Zhi,2013,20(2):104-106.Chinese.
[5]FejfarováV,JirkovskáA,Petkov V,et al.Has been changed num鄄bers and characteristics of patients with major amputations indicat鄄ed for the diabetic foot in our department during last decade[J].Vnitr Lek,2016,62(12):969-975.
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[7]Hellekson K.IDSA releases guidelines on the diagnosis and treat鄄ment of diabetie foot infections[J].Am Fam Physician,2005,71(7):1429-1433.
[8]Lavery LA,Armstrong DG,Harkless LB.Classification of diabetic foot wounds[J].J Foot Ankle Surg,1996,35(6):528-531.
[9]Mete T,Aydin Y,Saka M,et al.Comparison of efficiencies of michigan neuropathy screening instrument,neurothesiometer,and electromyography for diagnosis of diabetic neuropathy[J].Int J En鄄docrinol,2013,2013(11):821745.
[10]冉兴无,郑月宏.加强多学科协作,提高糖尿病缺血性足溃疡的治愈率[J].中华糖尿病杂志,2016,8(7):385-387.RAN XW,ZHENG YH.Strengthening multidisciplinary collabo鄄ration to improve the cure rate of diabetic ischemic foot ulcer[J].Zhonghua Tang Niao Bing Za Zhi,2016,8(7):385-387.Chinese.
[11]中国医疗保健国际交流促进会糖尿病足病分会.中国糖尿病足诊治指南[J].中华医学杂志,2017,97(4):251-258.Diabetic foot branch of China medical care international exchange association.Guidelines for the diagnosis and treatment of diabetic foot in China[J].Zhonghua Yi Xue Za Zhi,2017,97(4):251-258.Chinese.
[12]赵波,贺西京,李晟.糖尿病足截肢(趾)32例临床分析[J].中国骨伤,2008,21(7):546-547.ZHAO B,HE XJ,LI S.Clinical analysis of 32 cases of diabetic foot amputation(apodization)[J].Zhongguo Gu Shang/China J Orthop Trauma,2008,21(7):546-547.Chinese with abstract in English.
[13]王灿,果磊,李晶,等.糖尿病足溃疡外科修复的临床分析[J].中华内分泌外科杂志,2013,7(6):458-462.WANG C,GUO L,LI J,et al.surgical treatment for diabetic foot ulcers[J].Zhonghua Nei Fen Mi Wai Ke Za Zhi,2013,7(6):458-462.Chinese.
[14]Ilizarov GA.The tension stress effect on the genesis and growth of tissues.Part I.Theinfluence of stability of fixation and soft tissue preservation[J].Clin Orthop Relat Res,1989,(238):249-281.
[15]曲龙,王爱林,汤福刚.胫骨横向搬移血管再生术治疗血栓闭塞性脉管炎[J].中华医学杂志,2001,81(10):622-624.QU L,WANG AL,TANG FG.The therapy of transverse tibial bone transport and vesselregeneration operation on thromboangitis obliterans[J].Zhonghua Yi Xue Za Zhi,2001,81(10):622-624.Chinese.
[16]冼呈,赵劲民,苏伟,等.外固定架骨搬移系统修复糖尿病足:功能与影像学评价[J].中国组织工程研究,2015,19(46):7539-7544.XIAN C,ZHAO JM,SU W,et al.Ilizarov bone transport for repair of diabetic foot:a functional and imaging evaluation[J].Zhongguo Zu Zhi Gong Cheng Yan Jiu,2015,19(46):7539-7544.Chinese.
[17]Fleisehmann W,Streeker W,Bombeli M,et al.vacuum sealing as treatment of soft tissue damage in open fraetures[J].Unfallchirurg,1993,96(9):455-492.
[18]杨少玲,孙蕾蕾,胡丽叶,等.创面负压治疗对糖尿病足创面肉芽组织碱性成纤维细胞生长因子的影响[J].中华糖尿病杂志,2016,8(2):103-107.YANG SL,SUN LL,HU LY,et al.Impact of negative pressure wound therapy on basic fibroblast growth factor in human dia鄄betic foot wounds[J].Zhonghua Tang Niao Bing Za Zhi,2016,8(2):103-107.Chinese.
[19]Izzo V,Meloni M,Giurato L,et al.The effectiveness of negative pressure therapy in diabetic foot ulcers with elevated protease ac鄄tivity:A case series[J].Adv Wound Care(New Rochelle),2017,6(1):38-42.
[20]郭志民,上官天丞,张萌,等.骨搬移治疗胫骨骨缺损相关并发症的防治[J].中国骨伤,2016,29(8):756-760.GUO ZM,SHANGGUAN TC,ZHANG M,et al.Pevention and treatment of the related complication of tibial fratures bone defect by bone transport[J].Zhongguo Gu Shang/China J Orthop Trau鄄ma,2016,29(8):756-760.Chinese with abstract in English.
[21]柏松,骆立晖,吴春云,等.下肢骨折外固定器固定术后发生针孔感染的危险因素分析[J].中国骨伤,2016,29(2):154-156.BAI S,LUO LH,WU CY,et al.Risk factors of pinhole infection in the fractured lower limbs after external fixation:a case control study[J].Zhongguo Gu Shang/China J Orthop Trauma,2016,29(2):154-156.Chinese with abstract in English.
[22]Laakso M,Honkasalo M,Kiiski J,et al.Re organizing inpatient care saves legs in patients with diabetic foot infections[J].Diabetes Res Clin Pract,2017,125(1):39-46.
[23]Vatankhah N,Jahangiri Y,Landry GJ,et al.Effect of systemic in鄄sulin treatment on diabetic wound healing[J].Wound Repair Re鄄gen,2017,25(2):288-291.
[2]Jiang Y,Wang X,Xia L,et al.A cohort study of diabetic patients and diabetic foot ulceration patients in china[J].Wound Repair Regen,2015,23(2):222-230.
[3]班绎娟,王爱红,许樟荣.富血小板凝胶治疗难愈性糖尿病足溃疡的随机对照研究[J].中华糖尿病杂志,2015,7(5):306-310.BAN YJ,WANG AH,XU ZR.A randomized controlled study of platelet rich gel in treatment of refractory diabetic foot ulcer[J].Zhonghua Tang Niao Bing Za Zhi,2015,7(5):306-310.Chinese.
[4]魏巍,徐尔理,李岚,等.高压氧联合前列地尔治疗糖尿病足临床疗效分析[J].中华航海医学与高气压医学杂志,2013,20(2):104-106.WEI W,XU EL,LI L,et al.Clinical study on the effect of hyper鄄baric oxygen combined with liposomal alprostadil in the treatment of diabetic foot[J].Zhonghua Hang Hai Yi Xue Yu Gao Qi Ya Yi Xue Za Zhi,2013,20(2):104-106.Chinese.
[5]FejfarováV,JirkovskáA,Petkov V,et al.Has been changed num鄄bers and characteristics of patients with major amputations indicat鄄ed for the diabetic foot in our department during last decade[J].Vnitr Lek,2016,62(12):969-975.
[6]Apelqvist J,Bakker K,van Houtum WH,et al.International con鄄sensus and practical guidelines on the management and the preven鄄tion of the diabetic foot.International Working Group on the Dia鄄betic Foot[J].Diabetes Metab Res Rev,2000,16 Suppl 1:S84-92.
[7]Hellekson K.IDSA releases guidelines on the diagnosis and treat鄄ment of diabetie foot infections[J].Am Fam Physician,2005,71(7):1429-1433.
[8]Lavery LA,Armstrong DG,Harkless LB.Classification of diabetic foot wounds[J].J Foot Ankle Surg,1996,35(6):528-531.
[9]Mete T,Aydin Y,Saka M,et al.Comparison of efficiencies of michigan neuropathy screening instrument,neurothesiometer,and electromyography for diagnosis of diabetic neuropathy[J].Int J En鄄docrinol,2013,2013(11):821745.
[10]冉兴无,郑月宏.加强多学科协作,提高糖尿病缺血性足溃疡的治愈率[J].中华糖尿病杂志,2016,8(7):385-387.RAN XW,ZHENG YH.Strengthening multidisciplinary collabo鄄ration to improve the cure rate of diabetic ischemic foot ulcer[J].Zhonghua Tang Niao Bing Za Zhi,2016,8(7):385-387.Chinese.
[11]中国医疗保健国际交流促进会糖尿病足病分会.中国糖尿病足诊治指南[J].中华医学杂志,2017,97(4):251-258.Diabetic foot branch of China medical care international exchange association.Guidelines for the diagnosis and treatment of diabetic foot in China[J].Zhonghua Yi Xue Za Zhi,2017,97(4):251-258.Chinese.
[12]赵波,贺西京,李晟.糖尿病足截肢(趾)32例临床分析[J].中国骨伤,2008,21(7):546-547.ZHAO B,HE XJ,LI S.Clinical analysis of 32 cases of diabetic foot amputation(apodization)[J].Zhongguo Gu Shang/China J Orthop Trauma,2008,21(7):546-547.Chinese with abstract in English.
[13]王灿,果磊,李晶,等.糖尿病足溃疡外科修复的临床分析[J].中华内分泌外科杂志,2013,7(6):458-462.WANG C,GUO L,LI J,et al.surgical treatment for diabetic foot ulcers[J].Zhonghua Nei Fen Mi Wai Ke Za Zhi,2013,7(6):458-462.Chinese.
[14]Ilizarov GA.The tension stress effect on the genesis and growth of tissues.Part I.Theinfluence of stability of fixation and soft tissue preservation[J].Clin Orthop Relat Res,1989,(238):249-281.
[15]曲龙,王爱林,汤福刚.胫骨横向搬移血管再生术治疗血栓闭塞性脉管炎[J].中华医学杂志,2001,81(10):622-624.QU L,WANG AL,TANG FG.The therapy of transverse tibial bone transport and vesselregeneration operation on thromboangitis obliterans[J].Zhonghua Yi Xue Za Zhi,2001,81(10):622-624.Chinese.
[16]冼呈,赵劲民,苏伟,等.外固定架骨搬移系统修复糖尿病足:功能与影像学评价[J].中国组织工程研究,2015,19(46):7539-7544.XIAN C,ZHAO JM,SU W,et al.Ilizarov bone transport for repair of diabetic foot:a functional and imaging evaluation[J].Zhongguo Zu Zhi Gong Cheng Yan Jiu,2015,19(46):7539-7544.Chinese.
[17]Fleisehmann W,Streeker W,Bombeli M,et al.vacuum sealing as treatment of soft tissue damage in open fraetures[J].Unfallchirurg,1993,96(9):455-492.
[18]杨少玲,孙蕾蕾,胡丽叶,等.创面负压治疗对糖尿病足创面肉芽组织碱性成纤维细胞生长因子的影响[J].中华糖尿病杂志,2016,8(2):103-107.YANG SL,SUN LL,HU LY,et al.Impact of negative pressure wound therapy on basic fibroblast growth factor in human dia鄄betic foot wounds[J].Zhonghua Tang Niao Bing Za Zhi,2016,8(2):103-107.Chinese.
[19]Izzo V,Meloni M,Giurato L,et al.The effectiveness of negative pressure therapy in diabetic foot ulcers with elevated protease ac鄄tivity:A case series[J].Adv Wound Care(New Rochelle),2017,6(1):38-42.
[20]郭志民,上官天丞,张萌,等.骨搬移治疗胫骨骨缺损相关并发症的防治[J].中国骨伤,2016,29(8):756-760.GUO ZM,SHANGGUAN TC,ZHANG M,et al.Pevention and treatment of the related complication of tibial fratures bone defect by bone transport[J].Zhongguo Gu Shang/China J Orthop Trau鄄ma,2016,29(8):756-760.Chinese with abstract in English.
[21]柏松,骆立晖,吴春云,等.下肢骨折外固定器固定术后发生针孔感染的危险因素分析[J].中国骨伤,2016,29(2):154-156.BAI S,LUO LH,WU CY,et al.Risk factors of pinhole infection in the fractured lower limbs after external fixation:a case control study[J].Zhongguo Gu Shang/China J Orthop Trauma,2016,29(2):154-156.Chinese with abstract in English.
[22]Laakso M,Honkasalo M,Kiiski J,et al.Re organizing inpatient care saves legs in patients with diabetic foot infections[J].Diabetes Res Clin Pract,2017,125(1):39-46.
[23]Vatankhah N,Jahangiri Y,Landry GJ,et al.Effect of systemic in鄄sulin treatment on diabetic wound healing[J].Wound Repair Re鄄gen,2017,25(2):288-291.
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