摘要
目的:探讨采用Ilizarov技术行胫骨横向搬移术治疗糖尿病足溃疡的临床疗效。方法 :自2013年7月至2017年3月,采用Ilizarov胫骨横向搬移术治疗20例糖尿病足溃疡患者,男14例,女6例;年龄46～61(51.6±6.8)岁。Wagner分级:3级5例,4级15例。手术前后观察并记录截肢平面、溃疡愈合情况、创面愈合时间、VAS疼痛评分、患足皮温,CTA观察血管再通及血管网重建情况。结果:20例患者均进行了随访,时间12～58个月,平均22.4个月,所有患者足部溃疡顺利愈合,时间6～18(13.2±3.7)周,坏死及截肢平面没有上移,患足疼痛明显缓解,VAS评分由术前的5.6±0.8降低至术后1年的0.9±0.4,差异有统计学意义(t=-26.55,P<0.05);患足皮温由治疗前的(27.9±1.1)℃提高至术后1年的(30.9±1.1)℃(t=-5.98,P<0.05)。CTA可见术前闭塞的血管再通,微血管数量明显增加,足部血管网重建。结论:Ilizarov胫骨横向搬移术能促进足部血管的再生、微血管网的再通或重建,从而改善糖尿病足患者的血液循环,促进溃疡的愈合,适合以微血管病变为主的糖尿病足患者。对于主干大动脉严重狭窄或闭塞的患者应当慎重或配合介入等血管再通技术联合应用。
Objective:To explore Ilizarov technique in treating diabetic foot ulcers with transverse tibial bone movement.Methods:From July 2013 to March 2017,20 patients with diabetic foot ulcers were treated by transverse tibial bone movement,including 14 males and 6 females aged from 46 years to 61 years with an average of(51.6 ±6.8) years old. According to Wagner's criteria,5 patients were Grade Ⅲ and 15 patients were Grade Ⅳ. Amputation level,ulcer healing time,VAS score,foot skin temperature before and after operation,vascular recanalization or reconstruction were observed by CTA of affected limb. Results:Twenty patients followed up from 12 to 58 months with an average of 22.4 months. Foot ulcers were healed from6 to 18 weeks with an average of(13.2±3.7) weeks. There was no upper movement in the level of necrosis and amputation,and pain was relieved. VAS score was decreased from 5.6±0.8 before operation to 0.9±0.4 after operation at 1 year; skin temperature was increased from(27.9±1.1)℃ before operation to(30.9±1.1)℃ after operation at 1 year. CTA indicated vessel occluded artery was dredged,and the number of micro vessel was increased,and vasoganglion of foot was reconstructed. Conclusion:Transverse tibial bone movement by Ilizarov technique could promote angiogenesis,reconstructive of vasoganglion to improve blood circulation of diabetic patients with foot ulcers,promote healing of ulcers,so it is suitable for diabetic patients with foot ulcers occurred on microangiopathy. For patients with severe stenosis or occlusion of trunk artery should be used carefully or combination with interventional therapy.
引文
[1]Ziegler Graham K,Mackenzie EJ,Ephraim PL,et al.Estimating the prevalence of limb loss in the United States:2005 to 2050[J].Arch Phys Med Rehabil,2008,89(3):422-429.
[2]Beaney AJ,Nunney I,Gooday C,et al.Factors determining the risk of diabetes foot amputations A retrospective analysis of a tertiary diabetes foot care service[J].Diabetes Res Clin Pract,2016,114:69-74
[3]Chan P,Stuart W,Hinchliffe R.New reporting standards are required to assess the impact of vascular intervention on patients with diabetic foot ulceration[J].Eur J Vasc Endovasc Surg,2015,50(2):139-140.
[4]Mammoto A,Connr KM,Mammoto T,et al.A mechanosensitive transcriptional mechanism that controls angiogenesis[J].Nature,2011,457(7233):1103-1108.
[5]Dattilo PB,Casserly IP.Critical limb ischemia:endovascular strategies for limb salvage[J].Prog Cardiovasc Dis,2011,54(1):47-60.
[6]花奇凯,秦泗河,赵良军,等.Ilizarov技术胫骨横向骨搬移术治疗糖尿病足[J].中国矫形外科杂志,2017,25(2):303-307.HUA QK,QIN SH,ZHAO LJ,et al.Transverse tibial bone transport by Ilizarov technique for treatment of diabetic foot[J].Zhongguo Jiao Xing Wai Ke Za Zhi,2017,25(2):303-307.Chinese.
[7]严广斌.视觉模拟评分法[J].中华关节外科杂志,2014,8(2):34.YAN GB.Visual analogue scale[J].Zhonghua Guan Jie Wai Ke Za Zhi,2014,8(2):34.Chinese.
[8]Prompers L,Huijberts M,Apelqvist J,et al.High prevalence of ischaemia,infection and serious comorbidity in patients with dia betic foot disease in Europe.Baseline results from the Eurodiale study[J].Diabetologia,2007,50(1):18-25.
[9]Fossaceca R,Guzzardi G,Cerini P,et al.Endovascular treatment of diabetic foot in a selected population of patients with below the knee disease:is the angiosome model effective[J].Cardiovasc Intervent Radiol,2013,36(3):637-644.
[10]臧建成,秦泗河.从Wolff定律和Ilizarov张力-应力法则到骨科自然重建理念[J].中国骨伤,2013,26(4):287-290.ZANG JC,QIN SH.From Wolff law,Ilizarov technology to natural reconstruction theory[J].Zhongguo Gu Shang/China J Orthop Trauma,2013,26(4):287-290.Chinese with abstract in English.
[11]汪涛,赵珺,梅家才.WIFi分级用于预测糖尿病足合并周围血管病变病人下肢血管再通后伤口愈合效果研究[J].中国实用外科杂志,2016,36(12):1293-1297.WANG T,ZHAO J,MEI JC,et al.Clinical application of WIFi classification system on the wound healing of diabetic foot patients with lower limb ischemia after lower limbs re vascularization[J].Zhongguo Shi Yong Wai Ke Za Zhi,2016,36(12):1293-1297.Chinese.
