婴幼儿骨骺骨髓炎三种不同治疗方式对预后影响的分析研究
发布时间：2018-07-25 07:45
【摘要】：骨骺骨髓炎是一种骨骺的感染性疾病,而且几乎只见于婴幼儿,这是因为在骺板发育成熟之前,骨骺与干骺端之间有血管通道存在,当骺板成熟以后则成为阻挡感染扩散的防御屏障。该疾病可造成骨骺早闭、骨坏死缺损、关节畸形、肢体不等长、患肢功能障碍等不良后果,目前各医院对婴幼儿骨骺骨髓炎的诊治经验不均衡,手术方式较为单一,对手术本身造成的骨骺损伤尚未有明确的认识,如果患儿出现骨骺早闭,致残率极高,因此总结手术经验,对比该手术方式对预后的影响,并降低致残率显得至关重要。目前手术方式多为骨骺及干骺端减张、单纯冲洗引流。骨骺及干骺端减张术是使用电钻及克氏针对骨骺或干骺端行钻孔减张,之后在关节内置入引流管,术后进行持续的灌洗引流,单纯冲洗引流术中不对骨骺或干骺端进行钻孔减张,通过此课题的研究分析,对在临床工作中及时明确诊断以及选择何种手术方式,有一定的指导意义。目的:分析骨骺骨髓炎的三种不同治疗方式,并对患儿进行随访调查,分析该治疗方式对预后的影响。方法:选取确诊为骨骺骨髓炎的患儿作为研究对象,年龄2月~2岁,病灶部位为肱骨近端骨骺、股骨头骨骺、股骨远端骨骺及胫骨近端骨骺,血常规显示白细胞及血沉、C反应蛋白均高于正常值,均有病变部位红肿、关节疼痛、活动受限,X线或MRI检查均有骨骺区被破坏,其中行关节切开冲洗引流+骨骺及干骺端钻孔减张术30例(A组)、行单纯关节冲洗引流术30例(B组)、未行手术治疗30例(C组),由于部分病例失随访以及数据测量不健全,最终每组病例21例,其中各含肩关节8例、髋关节7例、膝关节6例。根据患儿所行的手术方式进行分组,并选取未行手术治疗的病例入组,进行回顾性分析及随访,术后每周复查血常规、血沉、C反应蛋白连续复查3周正常后,改为每个月复查1次,重点复查X线及MRI,并对比骨骺有无进一步破坏或骨骺生长情况,3个月随访患儿肢体长度及关节功能恢复情况,6个月随访有无复发及肢体畸形的出现,通过分析检查健侧与患侧的肢体长度、关节最大活动度(rom)的变化(肩关节、髋关节、膝关节)、x线及mri的影像学变化(破坏范围、骨质密度、周围软组织情况),对行不同治疗方式的患儿,进行对比分析该三种治疗方式对预后的影响。结果:行关节切开冲洗引流+骨骺及干骺端钻孔减张术的患儿中,术后拔除引流管时间7~14天,住院时间14~25天。3个月之后随诊:累及肱骨近端骨骺的8例患儿肩关节最大活动度:外展145°~160°,前屈93°~113°、后伸39°~61°;累及股骨头骨骺的7例患儿髋关节最大活动度:屈曲141°~159°,外展71°~84°,内收36°~53°;累及胫骨近端的6例患儿膝关节最大活动度159°。6个月之后随诊:累及肱骨近端骨骺的8例患儿肩关节最大活动度:外展157°~185°,前屈112°~136°、后伸71°~91°;累及股骨头骨骺的7例患儿髋关节最大活动度:屈曲109°~142°,外展75°~89°,内收38°~59°;累及胫骨近端的6例患儿膝关节最大活动度161°。行关节冲洗引流的患儿中,术后拔除引流管时间15~19天,住院26~34天。3个月之后随诊:累及肱骨近端骨骺的8例患儿肩关节最大活动度:外展132°~153°,前屈89°~111°、后伸48°~61°;累及股骨头骨骺的7例患儿髋关节最大活动度:屈曲101°~116°,外展69°~85°,内收31°~49°;累及胫骨近端的6例患儿膝关节最大活动度149°。6个月之后随诊:累及肱骨近端骨骺的8例患儿肩关节最大活动度:外展139°~156°,前屈102°~118°、后伸48°~62°;累及股骨头骨骺的7例患儿髋关节最大活动度:屈曲101°~126°,外展74°~94°,内收31°~51°;累及胫骨近端的6例患儿膝关节最大活动度153°。未行手术治疗的患儿,住院时间31~40天。3个月之后随诊:累及肱骨近端骨骺的8例患儿肩关节最大活动度:外展132°~142°,前屈68°~91°、后伸46°~52°;累及股骨头骨骺的7例患儿髋关节最大活动度:屈曲67°~83°,外展67°~70°,内收28°~32°;累及胫骨近端的6例患儿膝关节最大活动度143°。6个月之后随诊:累及肱骨近端骨骺的8例患儿肩关节最大活动度:外展134°~156°,前屈81°~91°、后伸47°~56°;累及股骨头骨骺的7例患儿髋关节最大活动度:屈曲76°~92°,外展60°~76°,内收33°~42°;累及胫骨近端的6例患儿膝关节最大活动度148°。行关节切开冲洗引流+骨骺及干骺端钻孔减张术可以有效的减轻干骺端张力、充分的引流、刺激干骺端血运恢复,患儿住院时间及术后拔管时间明显缩短,术后长期随诊差异性显著,肩关节、髋关节及膝关节功能恢复的程度好于单纯行切开引流术的患儿和未行手术治疗的患儿。结论:对于行切开引流+干骺端钻孔减张术的患儿引流管拔除时间以及平均住院时间均有所缩短,可以有效的减少患儿家庭的经济负担,增加病房床位周转率;对于术后3个月之后以及6个月之后的随访结果,行切开引流+干骺端钻孔减张术的患儿各关节功能活动范围的恢复以及影像学表现的恢复情况均好于单纯行切开引流术的患儿和未行手术治疗的患儿,可以降低该疾病的致残率,提高患儿术后生活质量。
[Abstract]:Epiphyseal osteomyelitis is an infectious disease of the epiphysis and almost only in infants. This is because there is a vascular channel between the epiphysis and metaphysis before the epiphyseal matures. When the epiphyseal plate is mature, it becomes a defensive barrier to prevent the spread of infection. The experience of the diagnosis and treatment of the epiphyseal osteomyelitis in all hospitals is not balanced, the operation mode is relatively simple, and the epiphyseal damage caused by the operation is not clear. If the epiphysis is closed and the rate of disability is very high, the surgical experience is summed up and the prognosis is compared. It is very important to influence and reduce the rate of disability. At present, the surgical methods are epiphysis and epiphyseal reduction, simple irrigation and drainage. Epiphyseal and epiphyseal decompression is the use of electric drill and Kirschner's epiphysis or epiphysis to reduce the tension, then the drainage tube is inserted into the joint in the joint. To reduce the tension of the epiphysis or epiphysis, through the research and analysis of this topic, it has a certain guiding significance for the timely and clear diagnosis and selection of the mode of operation in clinical work. Objective: to analyze three different treatments of osteomyelitis of epiphysis and to investigate the effect of the treatment on the prognosis. The children who were diagnosed as epiphysis osteomyelitis were selected as the study object. The age was ~2 years old in February. The location of the lesion was proximal epiphysis of the humerus, the epiphysis of the femoral head, the epiphysis of the distal femur and the epiphysis of the tibia. The blood routine showed leukocyte and erythrocyte sedimentation, and the C reaction protein was higher than the normal value. There were red and swelling of the lesion, joint pain, limited activity, X-ray or MRI examination. The epiphyseal area was destroyed, of which 30 cases (group A) were performed joint incision, drainage, epiphysis and epiphyseal reduction, 30 cases (group B) with simple joint irrigation and drainage (group B), 30 cases (group C) without surgical treatment (group C). Due to some cases of lost follow-up and unsound data measurement, there were 8 cases of shoulder joints, 7 cases of hip joint, and knee joint. 6 cases of joint were divided into groups according to the operation mode of the children, and the cases in which the patients were not treated were selected for retrospective analysis and follow-up. After the reexamination of blood routine, erythrocyte sedimentation rate, C reactivity protein for 3 weeks after the operation, 1 times a month was rechecked, and the X-ray and the epiphysis were further examined and compared with the epiphysis to further damage or epiphysis. The length of limb and the recovery of joint function of the children were followed up for 3 months. There were no recurrence and limb deformity in 6 months. The changes of ROM (shoulder joint, hip joint, knee joint), X-ray and MRI (destruction range, bone density, surrounding) were examined by analysis of the limb length of the side and the affected side. The effects of the three treatments on the prognosis were compared and analyzed in children with different treatments. Results: in children with joint incision, drainage, epiphysis and epiphyseal reduction, the time of removal of drainage tube was 7~14 days after operation, and 8 cases involving the proximal epiphysis of the humerus were followed up to 8 cases after.3 months of hospitalization. The maximum activity of shoulder joint in children: abduction 145 ~160 degrees, flexion 93 ~113 degrees, and extension 39 degree ~61 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: flexion 141 degree ~159 degrees, abduction 71 ~84 degrees, 36 degree ~53 degrees, and the follow-up of the maximum knee joint activity of the proximal tibia for 159 degree.6 months after: the proximal epiphysis involving the humerus The maximum activity of shoulder joint in 8 children: abduction 157 ~185 degrees, anterior flexion 112 ~136 degrees, and extension 71 degree ~91 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: flexion 109 degree ~142 degrees, abduction 75 [~89], 38 degree ~59 degrees, and 161 degrees of the knee joint in 6 cases involving the proximal tibia. Extraction of drainage tube time 15~19 days, 26~34 days after.3 months of hospitalization, after.3 months of hospitalization: the maximum activity of the shoulder joint involving the proximal epiphysis of the humerus: the abduction of 132 degree ~153 degrees, the flexion 89 [89] ~111, and the extension 48 degrees ~61 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: flexor 101 [degree], 69 degree ~85 DEG, and 31 degree degrees; tiring tibial tibial The maximum activity of the knee joint in 6 cases of the proximal end was followed by 149.6 months. The maximum activity of the shoulder joint in 8 cases involving the proximal epiphysis of the humerus: abduction 139 [139], 102 degrees ~118 degrees, and 48 degree ~62 degrees; 7 children involved in the epiphysis of the femoral head: flexion 101 [~126], abduction 74 [~94], and 31 [degree]; involvement of 31 [degree]; involvement of 31 [degree]; involvement of 31 degrees. The maximum activity of the knee joint was 153 degrees in 6 cases of proximal tibial. The hospitalization time was 31~40 days.3 months later: the maximum activity of the shoulder joint in 8 cases involving the proximal epiphysis of the humerus: abduction 132 [~142], 68 degrees ~91 degrees, and 7 cases of femoral head epiphysis: the maximum hip joint activity: flexion 67 degree ~83 degrees, abduction 67 ~70 degrees, 28 degree ~32 degrees; the maximum activity of knee joint in 6 cases involving the proximal tibia was followed by 143 degree.6 months. The maximum activity of shoulder joint in 8 cases involving the proximal epiphysis of the humerus: the abduction 134 [~156], the anterior flexion 81 degree, and the 47 degree ~56 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: Flexion 76 ~92 degrees, abduction 60 ~76 degrees, 33 degree ~42 degrees, and the maximum knee joint activity of 6 cases involving the proximal tibia of 148 degrees. Joint incision and drainage, epiphysis and epiphyseal reduction can effectively reduce the epiphyseal tension, full drainage, stimulate the recovery of the metaphysis blood, the time of hospitalization and postoperative extubation time of the children are obviously shrinking. Short, significant difference in postoperative long-term follow-up, shoulder joint, hip and knee joint function recovery is better than that of children with simple incision and drainage and children who are not operated on. Conclusion: the removal of drainage tube time and average length of hospitalization in children with incision and metaphyseal drilling reduction can be effectively reduced. The economic burden of the family was reduced and the bed turnover rate was increased; for 3 months after the operation and the follow-up of 6 months after the operation, the recovery of the range of functional activities of the joints and the recovery of the imaging manifestations were better than those of the children who were treated with simple incision and drainage. Surgical treatment of children can reduce the disability rate of the disease and improve the quality of life of children.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.8
本文编号：2143121
[Abstract]:Epiphyseal osteomyelitis is an infectious disease of the epiphysis and almost only in infants. This is because there is a vascular channel between the epiphysis and metaphysis before the epiphyseal matures. When the epiphyseal plate is mature, it becomes a defensive barrier to prevent the spread of infection. The experience of the diagnosis and treatment of the epiphyseal osteomyelitis in all hospitals is not balanced, the operation mode is relatively simple, and the epiphyseal damage caused by the operation is not clear. If the epiphysis is closed and the rate of disability is very high, the surgical experience is summed up and the prognosis is compared. It is very important to influence and reduce the rate of disability. At present, the surgical methods are epiphysis and epiphyseal reduction, simple irrigation and drainage. Epiphyseal and epiphyseal decompression is the use of electric drill and Kirschner's epiphysis or epiphysis to reduce the tension, then the drainage tube is inserted into the joint in the joint. To reduce the tension of the epiphysis or epiphysis, through the research and analysis of this topic, it has a certain guiding significance for the timely and clear diagnosis and selection of the mode of operation in clinical work. Objective: to analyze three different treatments of osteomyelitis of epiphysis and to investigate the effect of the treatment on the prognosis. The children who were diagnosed as epiphysis osteomyelitis were selected as the study object. The age was ~2 years old in February. The location of the lesion was proximal epiphysis of the humerus, the epiphysis of the femoral head, the epiphysis of the distal femur and the epiphysis of the tibia. The blood routine showed leukocyte and erythrocyte sedimentation, and the C reaction protein was higher than the normal value. There were red and swelling of the lesion, joint pain, limited activity, X-ray or MRI examination. The epiphyseal area was destroyed, of which 30 cases (group A) were performed joint incision, drainage, epiphysis and epiphyseal reduction, 30 cases (group B) with simple joint irrigation and drainage (group B), 30 cases (group C) without surgical treatment (group C). Due to some cases of lost follow-up and unsound data measurement, there were 8 cases of shoulder joints, 7 cases of hip joint, and knee joint. 6 cases of joint were divided into groups according to the operation mode of the children, and the cases in which the patients were not treated were selected for retrospective analysis and follow-up. After the reexamination of blood routine, erythrocyte sedimentation rate, C reactivity protein for 3 weeks after the operation, 1 times a month was rechecked, and the X-ray and the epiphysis were further examined and compared with the epiphysis to further damage or epiphysis. The length of limb and the recovery of joint function of the children were followed up for 3 months. There were no recurrence and limb deformity in 6 months. The changes of ROM (shoulder joint, hip joint, knee joint), X-ray and MRI (destruction range, bone density, surrounding) were examined by analysis of the limb length of the side and the affected side. The effects of the three treatments on the prognosis were compared and analyzed in children with different treatments. Results: in children with joint incision, drainage, epiphysis and epiphyseal reduction, the time of removal of drainage tube was 7~14 days after operation, and 8 cases involving the proximal epiphysis of the humerus were followed up to 8 cases after.3 months of hospitalization. The maximum activity of shoulder joint in children: abduction 145 ~160 degrees, flexion 93 ~113 degrees, and extension 39 degree ~61 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: flexion 141 degree ~159 degrees, abduction 71 ~84 degrees, 36 degree ~53 degrees, and the follow-up of the maximum knee joint activity of the proximal tibia for 159 degree.6 months after: the proximal epiphysis involving the humerus The maximum activity of shoulder joint in 8 children: abduction 157 ~185 degrees, anterior flexion 112 ~136 degrees, and extension 71 degree ~91 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: flexion 109 degree ~142 degrees, abduction 75 [~89], 38 degree ~59 degrees, and 161 degrees of the knee joint in 6 cases involving the proximal tibia. Extraction of drainage tube time 15~19 days, 26~34 days after.3 months of hospitalization, after.3 months of hospitalization: the maximum activity of the shoulder joint involving the proximal epiphysis of the humerus: the abduction of 132 degree ~153 degrees, the flexion 89 [89] ~111, and the extension 48 degrees ~61 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: flexor 101 [degree], 69 degree ~85 DEG, and 31 degree degrees; tiring tibial tibial The maximum activity of the knee joint in 6 cases of the proximal end was followed by 149.6 months. The maximum activity of the shoulder joint in 8 cases involving the proximal epiphysis of the humerus: abduction 139 [139], 102 degrees ~118 degrees, and 48 degree ~62 degrees; 7 children involved in the epiphysis of the femoral head: flexion 101 [~126], abduction 74 [~94], and 31 [degree]; involvement of 31 [degree]; involvement of 31 [degree]; involvement of 31 degrees. The maximum activity of the knee joint was 153 degrees in 6 cases of proximal tibial. The hospitalization time was 31~40 days.3 months later: the maximum activity of the shoulder joint in 8 cases involving the proximal epiphysis of the humerus: abduction 132 [~142], 68 degrees ~91 degrees, and 7 cases of femoral head epiphysis: the maximum hip joint activity: flexion 67 degree ~83 degrees, abduction 67 ~70 degrees, 28 degree ~32 degrees; the maximum activity of knee joint in 6 cases involving the proximal tibia was followed by 143 degree.6 months. The maximum activity of shoulder joint in 8 cases involving the proximal epiphysis of the humerus: the abduction 134 [~156], the anterior flexion 81 degree, and the 47 degree ~56 degrees; the maximum hip joint activity of 7 cases involving the epiphysis of the femoral head: Flexion 76 ~92 degrees, abduction 60 ~76 degrees, 33 degree ~42 degrees, and the maximum knee joint activity of 6 cases involving the proximal tibia of 148 degrees. Joint incision and drainage, epiphysis and epiphyseal reduction can effectively reduce the epiphyseal tension, full drainage, stimulate the recovery of the metaphysis blood, the time of hospitalization and postoperative extubation time of the children are obviously shrinking. Short, significant difference in postoperative long-term follow-up, shoulder joint, hip and knee joint function recovery is better than that of children with simple incision and drainage and children who are not operated on. Conclusion: the removal of drainage tube time and average length of hospitalization in children with incision and metaphyseal drilling reduction can be effectively reduced. The economic burden of the family was reduced and the bed turnover rate was increased; for 3 months after the operation and the follow-up of 6 months after the operation, the recovery of the range of functional activities of the joints and the recovery of the imaging manifestations were better than those of the children who were treated with simple incision and drainage. Surgical treatment of children can reduce the disability rate of the disease and improve the quality of life of children.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.8
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