抗生素骨水泥联合负压封闭引流治疗糖尿病并发坏死性筋膜炎的临床效果

郭晓峰; 金柱成; 邓鑫鑫; 黄治虎; 薛明宇; 卜凡玉

doi:10.3760/cma.j.cn501225-20231030-00151

抗生素骨水泥联合负压封闭引流治疗糖尿病并发坏死性筋膜炎的临床效果

doi: 10.3760/cma.j.cn501225-20231030-00151

无锡市第九人民医院创面修复科，无锡　　214000

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通讯作者:
卜凡玉，Email：bufanyu@163.com

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- 收稿日期: 2023-10-30

Clinical efficacy of antibiotic bone cement combined with vacuum sealing drainage in treating diabetes mellitus complicated with necrotizing fasciitis

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Corresponding author: Bu Fanyu, Email: bufanyu@163.com

摘要

摘要: 目的探讨采用抗生素骨水泥联合负压封闭引流（VSD）治疗糖尿病并发坏死性筋膜炎的临床效果。方法采用回顾性观察性研究方法。2020年1月—2022年3月，无锡市第九人民医院收治12例符合入选标准的2型糖尿病并发坏死性筋膜炎患者，其中男7例、女5例，年龄27~76岁，初诊病变部位均在下肢。入院后及时行床边切开引流，留取创面分泌物标本行微生物培养，同时行综合性支持治疗。Ⅰ期行清创，清创后皮肤软组织缺损面积为40 cm×15 cm~80 cm×25 cm，用含庆大霉素、万古霉素的骨水泥填塞无效腔并行VSD治疗。待创面无明显感染后，行Ⅱ期抗生素骨水泥取出及创面修复术。观察并统计患者清创次数及截肢情况、感染控制情况、Ⅱ期创面处理方式及创面愈合情况、总住院天数、Ⅱ期术后随访坏死性筋膜炎复发情况。末次随访时，根据美国矫形足踝协会（AOFAS）评分标准评定患者行走功能情况。结果 11例患者均仅行1次清创手术即令创面感染得到控制，未进行截肢手术；1例患者足部有明显坏疽，经1次清创及截除坏疽肢体后感染得到控制。术后7 d内血常规以及感染指标逐步恢复正常。Ⅱ期直接缝合4例患者创面，采用腹股沟全厚皮修复6例患者创面，采用创缘带蒂或舌形皮瓣修复2例患者创面；术后创面愈合良好，无破溃。患者总住院天数为20~45 d。Ⅱ期术后随访3~24个月，所有患者均未出现坏死性筋膜炎复发。末次随访时，患者行走功能按AOFAS评分标准评定为优者10例、良者2例。结论采用抗生素骨水泥联合VSD治疗2型糖尿病并发坏死性筋膜炎能有效控制感染、减少清创次数，术后创面愈合好、行走功能佳。
- 糖尿病 /
- 筋膜炎，坏死性 /
- 骨水泥成形术 /
- 负压伤口疗法 /
- 抗菌药 /
- 创面修复
Abstract: Objective To explore the clinical efficacy of antibiotic bone cement combined with vacuum sealing drainage (VSD) in treating diabetes mellitus complicated with necrotizing fasciitis. Methods The retrospective observational study approach was used. From January 2020 to March 2022, 12 patients with type 2 diabetes complicated with necrotizing fasciitis who met the inclusion criteria were admitted to Wuxi Ninth People's Hospital, including 7 males and 5 females, aged 27 to 76 years. The initial diagnosis of lesions was in the lower limbs. After admission, bedside incision and drainage were performed timely, and a sample of wound exudate was collected for microbial cultivation. At the same time, the comprehensive supportive treatment was performed. At stage Ⅰ, debridement was performed, and the skin and soft tissue defect area was 40 cm×15 cm to 80 cm×25 cm after debridement. The dead space was filled with bone cement containing gentamicin and vancomycin and VSD was performed. After there was no obvious infection on the wound, the antibiotic bone cement was removed and wound repair surgery was performed at stage Ⅱ. The times of debridement, amputation, infection control, wound treatment method and wound healing at stage Ⅱ, total hospitalization day, and recurrence of necrotizing fasciitis during follow-up after the stage Ⅱ surgery. At the last follow-up, the walking function of patients was evaluated according to the scoring standards of American Orthopedic Foot and Ankle Association (AOFAS). Results Eleven patients had wound infection control with one debridement surgery and did not undergo amputation surgery; one patient had significant foot gangrene, and the infection was controlled after one debridement and amputation of the gangrenous limb. Blood routine and infection indicators gradually returned to normal within 7 days after surgery. At stage Ⅱ, the wounds in 4 patients were sutured directly, the wounds in 6 patients were repaired with full-thickness inguinal skin graft, while the wounds in 2 patients were repaired with pedicled or tongue-shaped flaps at the wound edge. The wounds healed well after surgery, with no ulceration. The total hospitalization day of patients was 20 to 45 days. Follow-up for 3 to 24 months after stage Ⅱ surgery showed no recurrence of necrotizing fasciitis in any patient. At the last follow-up, the walking function was evaluated as excellent in 10 cases and good in 2 cases according to the AOFAS scoring standard. Conclusions Antibiotic bone cement combined with VSD used in treating type 2 diabetes complicated with necrotizing fasciitis can effectively control infection and reduce the times of debridement, with good wound healing and walking function after surgery.
- Diabetes mellitus /
- Fasciitis, necrotizing /
- Cementoplasty /
- Negative-pressure wound therapy /
- Anti-bacterial agents /
- Wound repair
郭晓峰：实施手术、采集资料、分析数据、撰写论文；金柱成、邓鑫鑫、黄治虎、薛明宇：实施手术、采集资料；卜凡玉：酝酿和设计研究、实施手术、修改论文

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参考文献(23)

[1]	LeibleinM, MarziI, SanderAL, et al. Necrotizing fasciitis: treatment concepts and clinical results[J].Eur J Trauma Emerg Surg, 2018,44(2):279-290. DOI: 10.1007/s00068-017-0792-8.
[2]	DiabJ, BannanA, PollittT. Necrotising fasciitis[J]. Br Med J, 2020,27(369):m1428. DOI: 10.1136/bmj.m1428.
[3]	KarnutaJ, FeatherallJ, LawrenzJ, et al. What demographic and clinical factors are associated with in-hospital mortality in patients with necrotizing fasciitis?[J]. Clin Orthop Relat Res, 2020,478(8):1770-1779. DOI: 10.1097/CORR.0000000000001187.
[4]	HietbrinkF,BodeLG,RiddezL,et al.Triple diagnostics for early detection of ambivalent necrotizing fasciitis[J].World J Emerg Surg,2016,11:51.DOI: 10.1186/s13017-016-0108-z.
[5]	GohT,GohLG,AngCH,et al.Early diagnosis of necrotizing fasciitis[J].Br J Surg,2014,101(1):e119-125.DOI: 10.1002/bjs.9371.
[6]	SahuKK,MishraAK,LopezCA.Necrotizing fasciitis: challenges in diagnosis and management[J].QJM,2020,113(3):220-221.DOI: 10.1093/qjmed/hcz163.
[7]	YildizH,YombiJC.Necrotizing soft-tissue infections[J].N Engl J Med,2018,378(10):970.DOI: 10.1056/NEJMc1800049.
[8]	McHenryCR,PiotrowskiJJ,PetrinicD,et al.Determinants of mortality for necrotizing soft-tissue infections[J].Ann Surg,1995,221(5):558-563; discussion 563-565.DOI: 10.1097/00000658-199505000-00013.
[9]	MadubaCC,NnadozieUU.Breast necrotizing fasciitis following stillbirth managed with nipple areola conservation in a resource-poor setting: a case report[J].J Surg Case Rep,2020,2020(2):rjz397.DOI: 10.1093/jscr/rjz397.
[10]	IacopiE,CoppelliA,GorettiC,et al.Necrotizing fasciitis and the diabetic foot[J].Int J Low Extrem Wounds,2015,14(4):316-327.DOI: 10.1177/1534734615606534.
[11]	曹涛,计鹏,张智,等.抗生素骨水泥治疗糖尿病足溃疡的前瞻性随机对照研究[J].中华烧伤与创面修复杂志,2023,39(4):311-318.DOI: 10.3760/cma.j.cn501225-20221111-00485.
[12]	陈伟, 常树森, 周健, 等. 抗生素骨水泥联合游离股前外侧组织瓣序贯治疗糖尿病足溃疡的临床疗效 [J]. 中华烧伤与创面修复杂志, 2023, 39(4): 319-324. DOI: 10.3760/cma.j.cn501225-20220628-00267.
[13]	AhnJ,RaspovicKM,LiuGT,et al.Lower extremity necrotizing fasciitis in diabetic and nondiabetic patients: mortality and amputation[J].Int J Low Extrem Wounds,2019,18(2):114-121.DOI: 10.1177/1534734619836464.
[14]	ZhangZ,LiuP,YangB,et al.Necrotizing fasciitis caused by diabetic foot[J].Int J Infect Dis,2021,103:3-5.DOI: 10.1016/j.ijid.2020.11.132.
[15]	杨少玲,韩瑞,胡丽叶.糖尿病足坏死性筋膜炎病理生理机制及诊治[J/CD].中华损伤与修复杂志(电子版),2020,15(5):392-396.DOI: 10.3877/cma.j.issn.1673-9450.2020.05.012.
[16]	MarkakisK,BowlingFL,BoultonAJ.The diabetic foot in 2015: an overview[J].Diabetes Metab Res Rev,2016,32 Suppl 1:S169-178.DOI: 10.1002/dmrr.2740.
[17]	ArosiI,HinerG,RajbhandariS.Pathogenesis and treatment of callus in the diabetic foot[J].Curr Diabetes Rev,2016,12(3):179-183.DOI: 10.2174/1573399811666150609160219.
[18]	邱旭升,陈一心,戚晓阳,等.诱导膜技术治疗感染性骨缺损的疗效分析[J].中国修复重建外科杂志,2017,31(9):1064-1068.DOI: 10.7507/1002-1892.201704002.
[19]	WangX,WangZ,FuJ,et al.Induced membrane technique for the treatment of chronic hematogenous tibia osteomyelitis[J].BMC Musculoskelet Disord,2017,18(1):33.DOI: 10.1186/s12891-017-1395-6.
[20]	BistolfiA,FerraciniR,AlbaneseC,et al.PMMA-based bone cements and the problem of joint arthroplasty infections: status and new perspectives[J].Materials (Basel),2019,12(23):4002.DOI: 10.3390/ma12234002.
[21]	SavvidouOD,KaspirisA,TrikoupisI,et al.Efficacy of antimicrobial coated orthopaedic implants on the prevention of periprosthetic infections: a systematic review and meta-analysis[J].J Bone Jt Infect,2020,5(4):212-222.DOI: 10.7150/jbji.44839.
[22]	MorelliI,DragoL,GeorgeDA,et al.Masquelet technique: myth or reality? A systematic review and meta-analysis[J].Injury,2016,47 Suppl 6:S68-76.DOI: 10.1016/S0020-1383(16)30842-7.
[23]	SeligsonD,BerlingS.Antibiotic-laden PMMA bead chains for the prevention of infection in compound fractures: current state of the art[J].Eur J Orthop Surg Traumatol,2015,25(6):969-974.DOI: 10.1007/s00590-015-1652-z.

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1 抗生素骨水泥联合负压封闭引流（VSD）治疗2型糖尿病并发右下肢坏死性筋膜炎患者的效果。1A.Ⅰ期清创术前足背可见原溃疡创面和小腿床边切开引流创面；1B.术中扩大切开见小腿筋膜广泛坏死伴脓液；1C.术中清创见深部肌间隙脓液积聚；1D.术中彻底清除脓液和坏死筋膜，保留部分炎症较轻组织；1E.用抗生素骨水泥覆盖无效腔并用VSD敷料覆盖创面后；1F.Ⅰ期术后3周行Ⅱ期手术取出抗生素骨水泥见创面感染得到控制，肉芽组织新鲜；1G.取同侧腹股沟全厚皮覆盖创面后；1H.Ⅱ期术后6个月随访见创面愈合良好

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