Clinical effects of tibial periosteal distraction combined with antibiotic bone cement in treating diabetic foot ulcer
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摘要:
目的 探讨胫骨骨膜牵张术联合抗生素骨水泥治疗糖尿病足溃疡的临床效果。 方法 该研究为回顾性观察性研究。2021年3月—2024年3月, 甘肃省人民医院收治52例符合入选标准的糖尿病足溃疡患者, 其中男25例、女27例, 年龄34~77岁。根据患者采用的治疗方法, 将其分为仅行抗生素骨水泥治疗的对照组（22例）和行胫骨骨膜牵张术联合抗生素骨水泥治疗的联合组（30例）。统计患者截趾率、截肢率、住院时长、溃疡愈合耗时。首次治疗前及末次治疗后3周, 常规测量患足踝部皮肤温度及踝肱指数, 采用视觉模拟评分法（VAS）评估患足疼痛情况, 对患足行10 g尼龙丝检查评估其周围神经功能情况（以10 g尼龙丝测试值表示）。末次治疗后3周, 评估患者临床疗效并计算临床疗效总有效率。 结果 2组患者截趾率、截肢率比较, 差异均无统计学意义（P > 0.05）。联合组患者住院时长、溃疡愈合耗时分别为（23±5）、（41±6）d, 显著短于对照组的（27±5）、（46±6）d（t值分别为3.08、3.18, P值均 < 0.05）。联合组患者末次治疗后3周患足踝部皮肤温度为（34.1±1.5）℃, 踝肱指数为0.72±0.08, 均显著高于组内首次治疗前的（32.1±1.6）℃与0.58±0.09（t值分别为5.10、6.37, P < 0.05）及对照组末次治疗后3周的（31.8±1.1）℃和0.59±0.09（t值分别为6.88、5.49, P < 0.05）。联合组患者末次治疗后3周患足疼痛VAS评分显著低于组内首次治疗前及对照组末次治疗后3周（t值分别为8.16、6.83, P值均 < 0.05）, 10 g尼龙线测试值显著高于组内首次治疗前及对照组末次治疗后3周（t值分别为6.15、4.23, P值均 < 0.05）。末次治疗后3周, 联合组患者临床疗效总有效率为96.7%（29/30）, 显著高于对照组的63.6%（14/22）, χ2=7.51, P < 0.05。 结论 胫骨骨膜牵张术联合抗生素骨水泥治疗糖尿病足溃疡具有较好的临床效果, 能够缩短患者住院时长, 促进溃疡愈合, 减轻患足疼痛, 改善患足血供和周围神经功能。 Abstract:Objective To explore the clinical effects of tibial periosteal distraction combined with antibiotic bone cement in treating diabetic foot ulcer. Methods The study was a retrospective observational study. From March 2021 to March 2024, 52 patients with diabetic foot ulcers who met the inclusion criteria were admitted to Gansu Provincial People's Hospital, including 25 males and 27 females, aged 34-77 years. According to the treatment methods used by the patients, they were divided into control group (22 cases) treated with antibiotic bone cement alone and combined group (30 cases) treated with tibial periosteal distraction combined with antibiotic bone cement. Toe amputation rate, limb amputation rate, length of hospitalization, and ulcer healing time-consuming of patients were recorded. Before the first treatment and 3 weeks after the last treatment, the ankle skin temperature and ankle-brachial index of the affected foot were measured routinely, the pain of the affected foot was evaluated by using visual analog scale (VAS), and the peripheral nerve function of the affected foot was evaluated by 10 g nylon thread examination (denoted as 10 g nylon thread test value). Three weeks after the last treatment, the clinical efficacy of patients was evaluated and the overall rate of clinical efficacy was calculated. Results There were no statistically significant differences in the comparison of toe amputation rate and limb amputation rate of patients in the 2 groups (P > 0.05). The length of hospitalization and ulcer healing time-consuming of patients in combined group were (23±5) and (41±6) d, respectively, which were significantly shorter than (27±5) and (46±6) d in control group (with t values of 3.08 and 3.18, respectively, both P values < 0.05). The ankle skin temperature of the affected foot of patients in combined group was (34.1±1.5) ℃, and the ankle-brachial index was 0.72±0.08 three weeks after the last treatment, which were significantly higher than (32.1±1.6) ℃ and 0.58±0.09 before the first treatment within the group (with t values of 5.10 and 6.37, respectively, P < 0.05) and (31.8±1.1) ℃ and 0.59±0.09 three weeks after the last treatment in control group (with t values of 6.88 and 5.49, respectively, P < 0.05). The pain VAS score of the affected foot of patients in combined group 3 weeks after the last treatment was significantly lower than that before the first treatment within the group and 3 weeks after the last treatment in control group (with t values of 8.16 and 6.83, respectively, both P values < 0.05), and the 10 g nylon thread test value was significantly higher than that before the first treatment within the group and 3 weeks after the last treatment in control group (with t values of 6.15 and 4.23, respectively, both P values < 0.05). Three weeks after the last treatment, the overall rate of clinical efficacy of patients in combined group was 96.7% (29/30), which was significantly higher than 63.6% (14/22) in control group, χ2=7.51, P < 0.05. Conclusions Tibial periosteal distraction combined with antibiotic bone cement has good clinical effects in the treatment of diabetic foot ulcers. It can shorten the length of patients' hospitalization, promote the healing of the ulcers, reduce the pain in the affected foot, and improve the blood supply and peripheral nerve function in the affected foot. 本文亮点(1) 在抗生素骨水泥基础上使用胫骨骨膜牵张术治疗糖尿病足溃疡, 可以有效改善下肢血供, 促进溃疡愈合, 减轻患者疼痛, 缩短住院时间。(2) 该术式造成的损伤小、操作简单, 可作为糖尿病足溃疡治疗的新选择。 -
参考文献
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图 1 胫骨骨膜牵张术联合抗生素骨水泥治疗例1患者糖尿病足溃疡的效果。1A.首次治疗前左足底破溃流脓, 皮肤缺损, 肌腱外露；1B.首次治疗前第4趾干性坏疽；1C.首次治疗前下肢CT血管成像提示左下肢动脉串珠样改变, 局部管腔狭窄（箭头所指部位）；1D.Ⅰ期术中放置胫骨骨膜牵张装置情况；1E.Ⅰ期术中彻底清除坏死组织及坏死趾头情况；1F.Ⅰ期彻底清创后抗生素骨水泥填充创面情况；1G.Ⅰ期术后3周骨膜牵张X线侧位片, 可见骨膜被装置顶起；1H.Ⅱ期术中取出抗生素骨水泥, 见创面形成新鲜诱导膜；1I.Ⅱ期术中移植大张中厚皮封闭创面情况；1J.末次治疗后3周, 创面修复良好；1K.末次治疗后3周, 下肢CT血管成像提示左下肢串珠样改变明显改善, 局部新生血管网（箭头所指部位）；1L.末次治疗后3周, 下肢CT血管成像见血管显影明显, 血流通畅（箭头所指部位）
Figure 1. Effects of tibial periosteal distraction combined with antibiotic bone cement in the treatment of diabetic foot ulcer in case 1
图 2 采用抗生素骨水泥治疗例2患者糖尿病足溃疡的效果。2A.首次治疗前左足背与足趾红肿及足背溃疡形成；2B.首次治疗前下肢CT血管成像提示双下肢动脉粥样硬化改变、管腔不规则, 双侧胫前动脉、胫后动脉及腓动脉间断显影, 考虑管腔局部闭塞；2C.Ⅰ期彻底清创、去除坏死趾骨后创面情况；2D.Ⅰ期彻底清创后抗生素骨水泥填充创面情况；2E.Ⅱ期术中取出抗生素骨水泥, 见创面形成新鲜诱导膜；2F.Ⅱ期术中移植大张中厚皮修复创面情况；2G.末次治疗后3周, 创面完全愈合；2H.末次治疗后3周, 再次行下肢CT血管成像检查, 结果与图2B相近, 无明显改善
Figure 2. Effects of using antibiotic bone cement in the treatment of diabetic foot ulcer in case 2
表 1 2组糖尿病足溃疡患者一般资料比较
Table 1. Comparison of general data of patients with diabetic foot ulcers in 2 groups
组别 例数 年龄（岁, x±s） 性别（例） 糖尿病足溃疡病程[d, M（Q1, Q3）] 溃疡面积（cm2, x±s） Wagner分级（例） 男 女 Ⅲ级 Ⅳ级 联合组 30 57±10 16 14 18.00（11.75, 33.25） 22±11 18 12 对照组 22 55±8 9 13 18.00（14.25, 26.50） 27±14 10 12 统计量值 t=0.72 χ2=0.79 Z=-0.09 t=1.32 χ2=-1.03 P值 0.478 30.413 0.926 0.192 0.303 注：联合组患者行胫骨骨膜牵张术联合抗生素骨水泥治疗, 对照组患者仅行抗生素骨水泥治疗 
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表 2 2组糖尿病足溃疡患者治疗前后患足踝部皮肤温度及踝肱指数比较（x±s）
Table 2. Comparison of ankle skin temperature and ankle-brachial index of the affected foot in 2 groups of patients with diabetic foot ulcers before and after treatment
组别 例数 踝部皮肤温度（℃） 踝肱指数 t1值 P1值 t2值 P2值 首次治疗前 末次治疗后3周 首次治疗前 末次治疗后3周 联合组 30 32.1±1.6 34.1±1.5 0.58±0.09 0.72±0.08 5.10 < 0.001 6.37 < 0.001 对照组 22 31.9±1.4 31.8±1.1 0.60±0.09 0.59±0.09 0.30 0.765 0.40 0.694 t值 0.42 6.88 0.79 5.49 P值 0.674 < 0.001 0.432 < 0.001 注：联合组患者行胫骨骨膜牵张术联合抗生素骨水泥治疗, 对照组患者仅行抗生素骨水泥治疗；t值与P值为组间各指标各时间点比较所得；t1值与P1值、t2值与P2值分别为组内治疗前后踝部皮肤温度、踝肱指数比较所得
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表 3 2组糖尿病足溃疡患者治疗前后患足疼痛VAS评分及周围神经功能的10 g尼龙线测试值比较（x±s）
Table 3. Comparison of pain VAS scores and 10 g nylon thread test values of peripheral nerve function of the affected foot in 2 groups of patients with diabetic foot ulcers before and after treatment
组别 例数 疼痛VAS评分（分） 10 g尼龙线测试值（点） t1值 P1值 t2值 P2值 首次治疗前 末次治疗后3周 首次治疗前 末次治疗后3周 联合组 30 5.2±1.0 2.1±1.9 5.3±1.0 6.8±1.0 8.16 < 0.001 6.15 < 0.001 对照组 22 5.6±1.0 5.1±1.1 5.5±0.9 5.6±1.2 1.42 0.162 0.44 0.662 t值 1.45 6.83 0.79 4.23 P值 0.154 < 0.001 0.432 < 0.001 注：联合组患者行胫骨骨膜牵张术联合抗生素骨水泥治疗, 对照组患者仅行抗生素骨水泥治疗；t值与P值为组间各指标各时间点比较所得；t1值与P1值、t2值与P2值分别为组内治疗前后疼痛视觉模拟评分法（VAS）评分、10 g尼龙线测试值比较所得
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表 4 2类临床疗效糖尿病足溃疡患者一般资料及评估指标的单因素分析
Table 4. Univariate analysis of general data and assessment indicators in patients with diabetic foot ulcers with 2 types of clinical efficacy
临床疗效 例数 年龄（岁, x±s） 性别（例） Wagner分级（例） 糖尿病足溃疡病程（d, x±s） 溃疡面积（cm2, x±s） 手术方式（例） 住院时长（d, x±s） 溃疡愈合耗时（d, x±s） 男 女 Ⅲ级 Ⅳ级 联合组术式 对照组术式 起效 43 56±9 21 22 27 16 21.98±15.48 20±9 29 14 24±5 43±6 无效 9 59±9 5 4 1 8 32.89±17.91 27±9 1 8 26±6 46±7 统计量值 t=0.84 χ2 < 0.01 χ2=6.05 t=1.87 t=2.18 χ2=9.68 t=0.85 t=1.64 P值 0.400 > 0.999 0.014 0.067 0.034 0.002 0.397 0.108 临床疗效 例数 踝部皮肤温度（℃, x±s） 踝肱指数（x±s） 疼痛VAS评分（分, x±s） 10 g尼龙线测试值（点, x±s） 首次治疗前 末次治疗后3周 首次治疗前 末次治疗后3周 首次治疗前 末次治疗后3周 首次治疗前 末次治疗后3周 起效 43 32.1±1.5 33.3±1.8 0.60±0.09 0.69±0.10 5.4±1.0 3.1±1.9 5.2±0.9 6.4±1.2 无效 9 31.5±1.2 32.0±0.9 0.57±0.07 0.61±0.10 5.2±0.7 4.4±1.4 5.9±1.2 6.0±1.6 统计量值 t=-1.10 t=-2.23 t=-0.90 t=-2.19 t=-0.49 t=1.95 t=-1.98 t=-0.82 P值 0.277 0.030 0.374 0.034 0.631 0.057 0.054 0.414 注：起效包括显效与有效；联合组患者行胫骨骨膜牵张术联合抗生素骨水泥治疗, 对照组患者仅行抗生素骨水泥治疗；VAS为视觉模拟评分法, 10 g尼龙线测试值反映周围神经功能
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