抗生素骨水泥被覆的锁定钢板在下肢慢性骨髓炎治疗中的临床运用

发布时间：2018-03-21 05:32

本文选题：骨髓炎　切入点：骨缺损　出处：《第三军医大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究背景长骨慢性骨髓炎的治疗一直是骨科领域的重大难题,彻底清创是实现感染控制的基本前提,也是慢性骨髓炎的治疗要点,但这可能会导致难以治疗的大段感染性骨缺损。目前,最常用于大段感染性骨缺损修复的技术主要包括:骨延长技术及自体带血管骨移植技术,传统的骨延长技术存在钉道感染、断钉、肌肉挛缩、邻近关节僵硬等并发症。自体带血管骨移植技术需要显微外科操作,而且存在取骨处并发症,术后还可能发生应力性骨折及骨不连。近年来,膜诱导技术被广泛用于长骨骨缺损的修复。该技术是一种重建骨缺损的两期手术治疗方法。Ⅰ期手术包括彻底清创后稳定骨端,并使用聚甲基丙烯酸甲酯(PMMA)骨水泥植入骨缺损部位,诱导假膜形成;Ⅱ期手术包括取出骨水泥并在假膜内植骨。外固定架是传统膜诱导技术Ⅰ期清创术中最常用的固定方式。但外固定架有其固有的局限性,存在稳定性差、钉道感染、佩戴困难等缺点,而使用传统内固定装置往往会导致感染难以控制。近年来抗生素骨水泥被覆的内固定装置在骨感染的治疗中取得了良好的疗效,因此我中心对传统的膜诱导技术进行了改进,使用抗生素骨水泥被覆的锁定钢板作为膜诱导技术Ⅰ期清创术中的固定方式。研究目的1.评估抗生素骨水泥被覆的锁定钢板作为膜诱导技术Ⅰ期清创术中固定方式对治疗过程及临床疗效的影响,并与其它固定方式相比较。2.探讨在膜诱导技术中使用抗生素骨水泥被覆锁定钢板的前提条件、最佳适应症以及缺点。研究方法采用回顾性分析2015年3月—2016年3月采用膜诱导技术治疗的下肢慢性骨髓炎患者85例。其中男72例,女13例,年龄10~66岁,平均36.4岁。其中股骨57例,胫骨28例。骨感染持续时间平均在2.2年(0.25~30年)。其中创伤后骨髓炎共73例,血源性骨髓炎共12例。有8例患者入院时患肢存在红肿热痛症状。患者在接受膜诱导技术治疗之前,患肢平均接受2.65次手术治疗(0~8次)。入院时患肢使用的固定方式包括内固定钢板19例,髓内钉13例,外固定架21例。56例患者入院时患肢存在窦道,其中24例患者窦道分泌物细菌培养结果为阳性。所有患者在Ⅰ期清创术中均使用抗生素骨水泥被覆的锁定钢板作为骨缺损断端的稳定方式。术后动态观察患者白细胞计数(WBC)、C-反应蛋白(CRP)、红细胞沉降率(ESR)、患肢临床表现(窦道形成及红肿热痛)及X线片。研究结果Ⅰ期术中组织细菌培养阳性的患者共有56例。Ⅰ期清创手术造成的骨缺损平均在7.3cm,(4~18cm)。有45例患者使用直型锁定钢板,有16例患者使用解剖型锁定钢板,有24例患者使用重建锁定钢板。Ⅰ期术后有68例患者伤口达到甲级愈合,17例患者伤口达到乙级愈合。Ⅰ期术中有4例胫骨骨髓炎患者通过实施局部皮瓣转位技术闭合伤口。Ⅰ期术后共有5例患者出现感染复发,Ⅱ期术后共有2例患者出现感染复发,总感染复发率在8.25%。这些患者在接受进一步治疗后感染得到控制,并在随访期间无感染复发表现。所有患者植骨在Ⅱ期术后平均5.7月(4.5~6.5月)取得影像学愈合,随访过程中均可见植骨逐渐融合及皮质化。研究结论我们认为在膜诱导技术治疗下肢长骨慢性骨髓炎时,抗生素骨水泥被覆的锁定钢板作为内固定方式可以用于Ⅰ期清创手术。相比外固定架,该装置能为患者提供更多的舒适度,而且不会增加感染复发率,对移植骨的愈合也没有明显影响。相比抗生素骨水泥覆盖的髓内钉,该装置适用范围更广,制作、放置与取出过程更简单,对髓腔结构影响更小。相对普通钢板,锁定钢板特殊的角稳定性使其更适用于慢性骨髓炎的治疗。
[Abstract]:Study on the treatment of chronic osteomyelitis of long bone background is a major problem in the field of Department of orthopedics, thorough debridement is a basic prerequisite for infection control, but also the key points of the treatment of chronic osteomyelitis, but it may lead to some difficult to treat infected bone defects. At present, the most commonly used in large segmental infected bone defect repair technology including: bone lengthening and bone autograft, traditional bone lengthening technique has broken nails, nail infection, muscle contracture, adjacent joint stiffness and other complications. Bone autograft technique requires microsurgical operation, and the existence of donor site complications, may also occur stress fracture and nonunion of bone surgery after the induction. In recent years, membrane technology is widely used in repairing bone defect. The technique is a kind of two surgical methods in the treatment of bone defect reconstruction. One-stage surgery included debridement stable bone end, And the use of polymethylmethacrylate (PMMA) bone cement implantation bone defect site, induced by the second stage surgery including pseudomembrane formation; remove bone cement and bone graft in the internal fixator is pseudomembrane. Traditional membrane induced stage debridement of the most commonly used fixed. But external fixation has its inherent limitations, existence and stability poor wear nail infection. Disadvantages of difficulty, but using traditional internal fixation device will often lead to infection is difficult to control. In recent years, antibiotic bone cement coated internal fixation device in the treatment of bone infection in achieved good effect, so I center on traditional film induction technology was improved and the use of antibiotics in bone locking plate cement coated membrane technology as induced by I-stage debridement and fixation operation. The locking plate objective 1. assessment of antibiotic bone cement coated membrane as induction stage debridement fixed operation Influence on the course of treatment and clinical curative effect, and compared with other fixed.2. on condition of induced used in the technique of antibiotic bone cement coated locking plate in the film, the best indications and disadvantages. Methods a retrospective analysis from March 2015 to March 2016 85 patients with chronic osteomyelitis of lower extremity treated cases induced by the film. Male 72 cases, female 13 cases, age 10~66 years old, average 36.4 years old. Among them 57 cases of femur and tibia bone infection in 28 cases. The average duration of 2.2 years (0.25~30 years). Among them there were 73 cases of post-traumatic osteomyelitis, bone marrow blood inflammation in 12 cases. There were 8 patients with limb swelling there heat pain symptoms. Patients before receiving treatment induced membrane technology, the average limb treated 2.65 surgery (0~8). At the time of admission with fixed limb use include internal fixation in 19 cases, 13 cases of intramedullary nail and external fixation in 21 cases of.56 patients On admission patients with sinus tract, including 24 cases of patients with sinus tract bacterial culture results were positive. All patients with stable and clear locking plate antibiotic bone cement coating was used during surgery as a bone defect ends in one stage. The dynamic observation of white blood cell count after surgery (WBC), C- reactive protein (CRP), erythrocyte sedimentation rate (ESR), limb clinical manifestations (sinus formation and swelling and heat pain) and X-ray. The results of intraoperative tissue bacterial culture positive patients. There were 56 cases of one-stage debridement of bone defects caused by an average of 7.3cm (4~, 18cm) in 45 cases. Patients with a straight locking plate, 16 cases of patients with anatomical locking plate, 24 cases of patients with one-stage reconstruction of locking plate. 68 cases of postoperative wound healing reached, 17 patients with wound healing. B to stage I in 4 cases of tibial osteomyelitis patients through the implementation of Council Department of flap closure wound. Stage I after a total of 5 patients had recurrence of infection, phase II after a total of 2 patients had recurrence of infection, the total infection recurrence rate in 8.25%. infection was controlled in these patients for further treatment, and no infection during the follow-up period. All patients are complex: bone graft in phase II after an average of 5.7 months (4.5~6.5 months) achieved radiographic union, during follow-up showed bone graft fusion and gradually. The conclusion of the study we believe that cortical induction treatment of lower extremity chronic osteomyelitis in film, antibiotic bone cement coated locking plate as internal fixation can be used for one-stage debridement surgery. Compared with external fixation, the device can provide patients with more comfort, and will not increase the recurrence rate of infection, healing of the bone graft has no significant effects. Compared with antibiotic bone cement covered intramedullary nail, the It has wider application scope, simpler manufacture and placement, and less influence on medullary cavity structure. Compared with ordinary steel plate, the special angle stability of locking plate makes it more suitable for the treatment of chronic osteomyelitis.

【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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