应用Ilizarov技术治疗骨髓炎出现复杂软组织问题的处理技巧探讨
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摘要
目的总结应用Ilizarov技术治疗骨髓炎中出现复杂软组织问题的多种处理技巧。方法回顾分析2015年1月—2017年6月收治的应用Ilizarov技术治疗骨髓炎过程中出现复杂软组织问题的31例患者临床资料。男23例,女8例;年龄14~67岁,平均37.8岁。为创伤后慢性骨髓炎,病程12 d~16个月,平均6.3个月。入院前手术次数2~8次,平均3.8次。其中行骨搬移后出现软组织嵌插29例,马蹄足、跟骨骨髓炎并足底部皮肤大面积感染缺损1例,胫骨开放骨折术后感染软组织缺损大于骨缺损骨外露1例。软组织缺损范围为4.5 cm×4.0 cm~16.5 cm×8.5 cm。软组织嵌插通过皮下植入克氏针缓慢弹性回缩后纠正,软组织缺损则通过缓慢牵拉逐步解决。结果患者术后均获随访,随访时间6~24个月,平均11.5个月。术后创面均获Ⅰ期愈合,未二期行皮肤移植、皮瓣移位修复等。1例马蹄足并足底皮肤缺损患者,行马蹄足牵拉矫形后逐步皮肤牵拉,未行二期缝合,行走3个月后未见皮肤破溃,感觉较正常稍减退。1例软组织横向牵拉患者创面完全覆盖,无骨质外露,局部软组织未见明显色素沉着,感觉较正常稍减退,皮肤弹性较正常差,颜色、温度无明显异常。29例应用克氏针弹力纠正皮肤凹陷患者均未出现严重针眼反应;其中6例克氏针出现弹性回缩至皮下割破皮肤;1例足底皮肤牵拉患者出现2次针眼大量渗出,局部皮肤色红现象,其中被迫更换牵引针1次,停止牵拉1周、加强换药并应用抗生素1次,症状缓解;1例横向牵拉患者出现3次针眼反应(感染),调整牵拉装置及对症处理后好转并完成治疗。结论对于骨髓炎中出现的大多数复杂软组织问题,利用Ilizarov技术早期有效干预,可便捷、经济、有效地解决,为临床提供了新的治疗思路及方法。
Objective To discuss skills for the treatment of complex soft tissue problems in osteomyelitis using Ilizarov techniques. Methods The clinical data of 31 patients with complex soft tissue problems during the treatment of osteomyelitis with Ilizarov technique between January 2015 and June 2017 were retrospectively analyzed. There were23 males and 8 females, with an age of 14-67 years(mean, 37.8 years). All the patients were post-traumatic chronic osteomyelitis, the disease duration was 12 days to 16 months(mean, 6.3 months). They went through 2-8 times surgeries(mean, 3.8 times). There were 29 cases of soft tissue insertion after bone grafting; 1 case of strephopodia and calcaneal osteomyelitis with plantar skin infection defect; 1 case of the open tibial fracture postoperative infection, the skin defect of infection was more than that of bone defect. The soft tissue defect area was 4.5 cm×4.0 cm to 16.5 cm×8.5 cm. Soft tissue depression and insertion was corrected by subcutaneous insertion of Kirschner wire after slow elastic retraction. Soft tissue defects were gradually resolved through slow traction. Results All patients were followed up 6-24 months(mean, 11.5 months). All wounds healed by first intention, and skin graft and flap repair were not performed in the two stage. One case of strephopodia and calcaneal osteomyelitis with plantar skin infection defect was treated with slow skin traction, no secondary suture was performed; no skin ulceration was found after walking for 3 months, and the feeling was slightly lower than normal. One case of soft tissue transverse traction wound completely covered, with no bone exposure and no obvious pigmentation of local soft tissue, the feeling was slightly lower than normal, the skin elasticity was worse than normal, and the color, temperature had no obvious abnormalities. There was no severe needle eye reactions in 29 patients with skin depressions corrected by Kirschner wire. Six cases of Kirschner wire showed elastic retraction and lacerate skin;1 case of plantar skin traction had 2 times of exudation of the needle eye and local skin reddish phenomenon; the symptoms relieved when the traction needle was changed once, the traction was stopped for 1 week, the dressing was changed and antibiotics were used once. One patient with transverse traction had 3 times of pin-eye infection, and the treatment was completed after adjusting the traction device and symptomatic treatment. Conclusion For most of the complex soft tissue problems in osteomyelitis, early and effective intervention with Ilizarov technique can be easily,economically, and effectively solved, which provides a new way for clinical treatment.
Objective To discuss skills for the treatment of complex soft tissue problems in osteomyelitis using Ilizarov techniques. Methods The clinical data of 31 patients with complex soft tissue problems during the treatment of osteomyelitis with Ilizarov technique between January 2015 and June 2017 were retrospectively analyzed. There were23 males and 8 females, with an age of 14-67 years(mean, 37.8 years). All the patients were post-traumatic chronic osteomyelitis, the disease duration was 12 days to 16 months(mean, 6.3 months). They went through 2-8 times surgeries(mean, 3.8 times). There were 29 cases of soft tissue insertion after bone grafting; 1 case of strephopodia and calcaneal osteomyelitis with plantar skin infection defect; 1 case of the open tibial fracture postoperative infection, the skin defect of infection was more than that of bone defect. The soft tissue defect area was 4.5 cm×4.0 cm to 16.5 cm×8.5 cm. Soft tissue depression and insertion was corrected by subcutaneous insertion of Kirschner wire after slow elastic retraction. Soft tissue defects were gradually resolved through slow traction. Results All patients were followed up 6-24 months(mean, 11.5 months). All wounds healed by first intention, and skin graft and flap repair were not performed in the two stage. One case of strephopodia and calcaneal osteomyelitis with plantar skin infection defect was treated with slow skin traction, no secondary suture was performed; no skin ulceration was found after walking for 3 months, and the feeling was slightly lower than normal. One case of soft tissue transverse traction wound completely covered, with no bone exposure and no obvious pigmentation of local soft tissue, the feeling was slightly lower than normal, the skin elasticity was worse than normal, and the color, temperature had no obvious abnormalities. There was no severe needle eye reactions in 29 patients with skin depressions corrected by Kirschner wire. Six cases of Kirschner wire showed elastic retraction and lacerate skin;1 case of plantar skin traction had 2 times of exudation of the needle eye and local skin reddish phenomenon; the symptoms relieved when the traction needle was changed once, the traction was stopped for 1 week, the dressing was changed and antibiotics were used once. One patient with transverse traction had 3 times of pin-eye infection, and the treatment was completed after adjusting the traction device and symptomatic treatment. Conclusion For most of the complex soft tissue problems in osteomyelitis, early and effective intervention with Ilizarov technique can be easily,economically, and effectively solved, which provides a new way for clinical treatment.
引文
1杜刚强.皮肤伸展术治疗皮肤软组织缺损的的研究进展.滨州医学院学报,2013,36(2):139-141,135.
2中国医师协会皮肤科分会.皮肤及软组织感染诊断和治疗共识.临床皮肤科杂志,2009,38(12):810-812.
3Parrett BM,Matros E,Pribaz JJ,et al.Lower extremity trauma:trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.Plast Reconstr Surg,2006,117(4):1315-1322.
4Walter G,Kemmerer M,Kappler C,et al.Treatment algorithms for chronic osteomyelitis.Dtsch Arztebl Int,2012,109(14):257-264.
5黄雷,魏武,李兵,等.骨段滑移术治疗胫骨缺损合并软组织缺损.中华骨科杂志,2009,29(5):393-397.
6丛海波,隋海明,王晨霖,等.骨搬运治疗四肢大段骨缺损的临床研究.中华骨科杂志,2008,28(7):567-570.
7陈伟,齐新文,张英明,等.Ilizarov技术骨搬移治疗胫骨骨不连并软组织缺损感染.西部医学,2014,26(8):993-998.
8沈立锋,郭峭峰,黄凯,等.带蒂组织瓣结合骨搬移技术治疗小腿感染性软组织缺损及大段骨缺损.中华移植杂志(电子版),2012,6(4):241-245.
9Gurtner GC,Werner S,Barrandon Y,et al.Wound repair and regeneration.Nature,2008,453(7193):314-321.
10Pietramaggiori G,Liu P,Scherer SS,et al.Tensile forces stimulate vascular remodeling and epidermal cell proliferation in living skin.Ann Surg,2007,246(5):896-902.
11Ismavel R,Samuel S,Boopalan PR,et al.A simple solution for wound coverage by skin stretching.J Orthop Trauma,2011,25(3):127-132.
12Turgut G,Ozcan A,Sümer O,et al.Reconstruction of complicated scalp defect via skin traction.J Craniofac Surg,2009,20(1):263-264.
13Ilizarov GA.The tension-stress effect on the genesis and growth of tissues.PartⅠ.The influence of the stability of fixation and soft-tissue presevation.Clin Orthop Relat Res,1989,(238):249-281.
14Ilizarov GA.The tension-stress effect on the genesis and growth of tissues.PartⅡ.The influence of the rate and frequency of distraction.Clin Orthop Relat Res,1989,(239):263-285.
15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.中国骨伤,2013,26(4):287-290.
16殷渠东,顾三军,孙振中,等.胫骨骨和软组织缺损三种治疗方法的效果比较.中华创伤杂志,2015,31(3):245-248.
17倪国骅,吴学建,张德洪,等.皮肤弹性牵张法治疗小腿皮肤缺损骨外露.中华创伤骨科杂志,2015,17(7):629-631.
18倪国骅,吴学建,张德洪,等.皮肤弹性牵张法治疗足跟后皮肤缺损.中华整形外科杂志,2015,31(5):375-376.
19王新卫,张磊,万明才,等.腓动脉蒂复合组织瓣逆行转位治疗跟骨骨髓炎骨与软组织缺损.中华创伤骨科杂志,2017,19(3):256-260.
20Topaz M,Carmel NN,Silberman A,et al.The TopClosure?3S System,for skin stretching and a secure wound closure.Eur J Plast Surg,2012,35(7):533-543.
21Barrer S,Pavlides CA,Matsumoto T.Ideal laparotomy closure:comparison of retention sutures with new retention bridging devices.Am Surg,1976,42(8):582-584.
22杜海龙,何纯青,柳现飞,等.外固定支架结合负压封闭引流技术治疗GustiloⅢ型胫腓骨开放性骨折.中华创伤骨科杂志,2011,13(5):433-436.
23彭爱民.应用Ilizarov技术Ⅰ期修复伴有皮肤缺损的胫骨创伤性骨髓炎骨缺损.中国骨伤,2015,28(12):1125-1128.
24El-Alfy B,El-Mowafi H,El-Moghazy N.Distraction osteogenesis in management of composite bone and soft tissue defects.Int Orthop,2010,34(1):115-118.
25Kocialkowski A,Marsh DR,Shackley DC.Closure of the skin defect overlying infected non-union by skin traction.Br J Plast Surg,1998,51(4):307-310.
26张明利,王大为,郝岚,等.皮肤外扩张器的研制与临床应用.中华整形烧伤外科杂志,1995,11(3):161-164.
2中国医师协会皮肤科分会.皮肤及软组织感染诊断和治疗共识.临床皮肤科杂志,2009,38(12):810-812.
3Parrett BM,Matros E,Pribaz JJ,et al.Lower extremity trauma:trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.Plast Reconstr Surg,2006,117(4):1315-1322.
4Walter G,Kemmerer M,Kappler C,et al.Treatment algorithms for chronic osteomyelitis.Dtsch Arztebl Int,2012,109(14):257-264.
5黄雷,魏武,李兵,等.骨段滑移术治疗胫骨缺损合并软组织缺损.中华骨科杂志,2009,29(5):393-397.
6丛海波,隋海明,王晨霖,等.骨搬运治疗四肢大段骨缺损的临床研究.中华骨科杂志,2008,28(7):567-570.
7陈伟,齐新文,张英明,等.Ilizarov技术骨搬移治疗胫骨骨不连并软组织缺损感染.西部医学,2014,26(8):993-998.
8沈立锋,郭峭峰,黄凯,等.带蒂组织瓣结合骨搬移技术治疗小腿感染性软组织缺损及大段骨缺损.中华移植杂志(电子版),2012,6(4):241-245.
9Gurtner GC,Werner S,Barrandon Y,et al.Wound repair and regeneration.Nature,2008,453(7193):314-321.
10Pietramaggiori G,Liu P,Scherer SS,et al.Tensile forces stimulate vascular remodeling and epidermal cell proliferation in living skin.Ann Surg,2007,246(5):896-902.
11Ismavel R,Samuel S,Boopalan PR,et al.A simple solution for wound coverage by skin stretching.J Orthop Trauma,2011,25(3):127-132.
12Turgut G,Ozcan A,Sümer O,et al.Reconstruction of complicated scalp defect via skin traction.J Craniofac Surg,2009,20(1):263-264.
13Ilizarov GA.The tension-stress effect on the genesis and growth of tissues.PartⅠ.The influence of the stability of fixation and soft-tissue presevation.Clin Orthop Relat Res,1989,(238):249-281.
14Ilizarov GA.The tension-stress effect on the genesis and growth of tissues.PartⅡ.The influence of the rate and frequency of distraction.Clin Orthop Relat Res,1989,(239):263-285.
15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.中国骨伤,2013,26(4):287-290.
16殷渠东,顾三军,孙振中,等.胫骨骨和软组织缺损三种治疗方法的效果比较.中华创伤杂志,2015,31(3):245-248.
17倪国骅,吴学建,张德洪,等.皮肤弹性牵张法治疗小腿皮肤缺损骨外露.中华创伤骨科杂志,2015,17(7):629-631.
18倪国骅,吴学建,张德洪,等.皮肤弹性牵张法治疗足跟后皮肤缺损.中华整形外科杂志,2015,31(5):375-376.
19王新卫,张磊,万明才,等.腓动脉蒂复合组织瓣逆行转位治疗跟骨骨髓炎骨与软组织缺损.中华创伤骨科杂志,2017,19(3):256-260.
20Topaz M,Carmel NN,Silberman A,et al.The TopClosure?3S System,for skin stretching and a secure wound closure.Eur J Plast Surg,2012,35(7):533-543.
21Barrer S,Pavlides CA,Matsumoto T.Ideal laparotomy closure:comparison of retention sutures with new retention bridging devices.Am Surg,1976,42(8):582-584.
22杜海龙,何纯青,柳现飞,等.外固定支架结合负压封闭引流技术治疗GustiloⅢ型胫腓骨开放性骨折.中华创伤骨科杂志,2011,13(5):433-436.
23彭爱民.应用Ilizarov技术Ⅰ期修复伴有皮肤缺损的胫骨创伤性骨髓炎骨缺损.中国骨伤,2015,28(12):1125-1128.
24El-Alfy B,El-Mowafi H,El-Moghazy N.Distraction osteogenesis in management of composite bone and soft tissue defects.Int Orthop,2010,34(1):115-118.
25Kocialkowski A,Marsh DR,Shackley DC.Closure of the skin defect overlying infected non-union by skin traction.Br J Plast Surg,1998,51(4):307-310.
26张明利,王大为,郝岚,等.皮肤外扩张器的研制与临床应用.中华整形烧伤外科杂志,1995,11(3):161-164.