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。治疗前及治疗后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）。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,均显著高于组内治疗前的（32.1±1.6）℃与0.58±0.09（t值分别为0.51、6.37,P<0.05）及对照组治疗后3周的（31.8±1.1）℃和0.59±0.09（t值分别为6.88、5.49,P<0.05）。联合组患者治疗后3周患足疼痛VAS评分显著低于组内治疗前及对照组治疗后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治疗前及对照组治疗后3周（t值分别为6.15、4.23,P值均<0.05）。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 and 3 weeks after 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 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 treatment, the clinical efficacy of patients was evaluated and the overall clinical efficacy rate was calculated. Results There was no statistically significant difference 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 of 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 at 3 weeks after treatment, which were significantly higher than (32.1±1.6) ℃ and 0.58±0.09 before treatment within the group (with t values of 0.51 and 6.37, respectively, P<0.05) and (31.8±1.1) ℃ and 0.59±0.09 at 3 weeks after 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 was significantly lower than that before treatment within the group and 3 weeks after 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 treatment within the group and 3 weeks after treatment in control group (with t values of 6.15 and 4.23, respectively, both P values <0.05). At 3 weeks after treatment, the overall clinical efficacy rate 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 in the treatment of diabetic foot ulcers has a good clinical effect, which can shorten the length of hospitalization of patients, promote the healing of the ulcers, reduce the pain of the affected foot, and improve the blood supply and peripheral nerve function of the affected foot. -
参考文献
(41) [1] 中华医学会内分泌学分会,中国内分泌代谢病专科联盟.糖尿病足溃疡创面治疗专家共识(2024)[J].中华内分泌代谢杂志,2024,40(7):565-569.DOI: 10.3760/cma.j.cn311282-20240625-00281. [2] 张晓,贺学军.糖尿病足保肢手术治疗的研究进展[J].中国医师杂志,2024,26(4):627-632.DOI: 10.3760/cma.j.cn431274-20231019-00414. [3] 简扬,魏在荣,陈伟,等.游离皮瓣在糖尿病足溃疡修复中的应用研究进展[J].中华烧伤与创面修复杂志,2023,39(4):376-380.DOI: 10.3760/cma.j.cn501225-20221216-00539. [4] AlfordAI,NicolaouD,HakeM,et al.Masquelet's induced membrane technique: review of current concepts and future directions[J].J Orthop Res,2021,39(4):707-718.DOI: 10.1002/jor.24978. [5] 邓鑫鑫,薛明宇,郭晓峰,等.骨水泥体外成形诱导膜技术在化脓性腱鞘炎中的应用[J].中华手外科杂志,2023,39(5):439-442.DOI: 10.3760/cma.j.cn311653-20221124-00307. [6] 姜新强,张防,时广力,等.应用骨膜牵张术治疗足趾坏疽一例[J].骨科临床与研究杂志,2021,6(6):365-366.DOI: 10.19548/j.2096-269x.2021.06.011. [7] 张防,姜新强,杨建军,等.对骨膜牵张术治疗糖尿病足的疗效观察[J].骨科临床与研究杂志,2022,7(6):367-371.DOI: 10.19548/j.2096-269x.2022.06.009. [8] 曾纳新,曹政,游艺,等.骨膜牵张技术治疗糖尿病足1例并文献复习[J].中南医学科学杂志,2019,47(5):558-560.DOI: 10.15972/j.cnki.43-1509/r.2019.05.029. [9] 中华医学会糖尿病学分会,中华医学会感染病学分会,中华医学会组织修复与再生分会.中国糖尿病足防治指南(2019版)(Ⅰ)[J].中华糖尿病杂志,2019,11(2):92-108.DOI: 10.3760/cma.j.issn.1674-5809.2019.02.004. [10] 吴冬冬,万能,杨卫玺.混合抗生素骨水泥填充技术对糖尿病足患者创面愈合情况、足背动脉血流动力学及下肢功能的影响[J].内蒙古医科大学学报,2021,43(6):652-655. [11] LeRoithD,BiesselsGJ,BraithwaiteSS,et al.Treatment of diabetes in older adults: an Endocrine Society* clinical practice guideline[J].J Clin Endocrinol Metab,2019,104(5):1520-1574.DOI: 10.1210/jc.2019-00198. [12] ArmstrongDG,BoultonA,BusSA.Diabetic foot ulcers and their recurrence[J].N Engl J Med,2017,376(24):2367-2375.DOI: 10.1056/NEJMra1615439. [13] EverettE,MathioudakisN.Update on management of diabetic foot ulcers[J].Ann N Y Acad Sci,2018,1411(1):153-165.DOI: 10.1111/nyas.13569. [14] WalshJW,HoffstadOJ,SullivanMO,et al.Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom[J].Diabet Med,2016,33(11):1493-1498.DOI: 10.1111/dme.13054. [15] 《多学科合作下糖尿病足防治专家共识(2020版)》编写组.多学科合作下糖尿病足防治专家共识(2020版)全版[J].中华烧伤杂志,2020,36(8):E01-E52.DOI: 10.3760/cma.j.cn501120-20200217-01000. [16] 冯卫忠,丁远峰,孙新娟,等.关于中国糖尿病足病分级诊疗模式的思考和策略[J].中华糖尿病杂志,2024,16(1):34-38.DOI: 10.3760/cma.j.cn115791-20230918-00167. [17] 刘欣,黄广涛,吴军.游离皮瓣在糖尿病足溃疡患者保肢治疗中的应用研究进展[J].中华烧伤与创面修复杂志,2024,40(10):985-990.DOI: 10.3760/cma.j.cn501225-20240130-00041. [18] IlizarovGA.The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation[J].Clin Orthop Relat Res,1989(238):249-281. [19] 中国医师协会骨科医师分会中国骨搬移糖尿病足学组.胫骨横向骨搬移技术治疗糖尿病足的专家共识(2020)[J].中国修复重建外科杂志,2020,34(8):945-950.DOI: 10.7507/1002-1892.202003046. [20] 谭浩.胫骨骨膜牵张术对糖尿病足患者患肢血运、静息疼痛及术后并发症的影响[J].糖尿病新世界,2024,27(10):183-186.DOI: 10.16658/j.cnki.1672-4062.2024.10.183. [21] 曾纳新,曹政,游艺,等.胫骨骨膜侧向牵张术治疗下肢慢性缺血性疾病[J].中华骨科杂志,2021,41(22):1607-1613.DOI: 10.3760/cma.j.cn121113-20200715-00450. [22] YuanY,DingX,LuH,et al.A novel and alternative treatment method for moderate diabetic foot ulcer: tibial periosteal distraction[J].J Orthop Surg Res,2024,19(1):889.DOI: 10.1186/s13018-024-05375-7. [23] ChenY,KuangX,ZhouJ,et al.Proximal tibial cortex transverse distraction facilitating healing and limb salvage in severe and recalcitrant diabetic foot ulcers[J].Clin Orthop Relat Res,2020,478(4):836-851.DOI: 10.1097/CORR.0000000000001075. [24] WangJ,HuangX,WangP,et al.Periosteal distraction for foot preservation contributes to favorable clinical effects and prognosis in a foot ulcer patient with critical limb ischemia after multiple operations[J].Am J Transl Res,2023,15(5):3766-3772. [25] 陈健,刘康,张锡平,等.胫骨骨膜牵张术治疗糖尿病足的短期疗效分析[J].实用骨科杂志,2022,28(8):757-761. [26] 刘杰,花奇凯,李山郎,等.骨膜牵张技术用于糖尿病足治疗的理论基础及临床结果验证[J].中国组织工程研究,2022,26(32):5236-5241. [27] 王春雷,张波,朱俊晖,等.骨膜牵张术联合生长因子治疗糖尿病足溃疡[J].遵义医科大学学报,2024,47(6):610-614. [28] PelissierP,MasqueletAC,BareilleR,et al.Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration[J].J Orthop Res,2004,22(1):73-79.DOI: 10.1016/S0736-0266(03)00165-7. [29] DaiJ,ZhouY,MeiS,et al.Application of antibiotic bone cement in the treatment of infected diabetic foot ulcers in type 2 diabetes[J].BMC Musculoskelet Disord,2023,24(1):135.DOI: 10.1186/s12891-023-06244-w. [30] 牛瑞芳,赵晨兵,袁慧娟,等.载抗生素骨水泥治疗2型糖尿病足溃疡效果及机制分析[J].中华医学杂志,2025,105(23):1931-1938.DOI: 10.3760/cma.j.cn112137-20250212-00319. [31] LiuC,YouJX,ChenYX,et al.Effect of induced membrane formation followed by polymethylmethacrylate implantation on diabetic foot ulcer healing when revascularization is not feasible[J].J Diabetes Res,2019,2019:2429136.DOI: 10.1155/2019/2429136. [32] 吕和,祝海炳,马一平,等.载万古霉素骨水泥治疗WagnerⅡ-Ⅳ级糖尿病足病例对照研究[J].中国骨伤,2021,34(10):947-952. [33] 赵晨兵,张会峰.载抗生素骨水泥治疗糖尿病足感染创面的研究进展[J].中华糖尿病杂志,2022,14(7):724-729.DOI: 10.3760/cma.j.cn115791-20211213-00660. [34] DongT,HuangQ,SunZ.Antibiotic-laden bone cement for diabetic foot infected wounds: a systematic review and meta-analysis[J].Front Endocrinol (Lausanne),2023,14:1134318.DOI: 10.3389/fendo.2023.1134318. [35] 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. [36] TangQ,JinH,TongM,et al.Inhibition of Dll4/Notch1 pathway promotes angiogenesis of Masquelet's induced membrane in rats[J].Exp Mol Med,2018,50(4):1-15.DOI: 10.1038/s12276-018-0062-9. [37] 李明辉,韩涛,吕利军,等.诱导膜及其作用机制[J].临床与病理杂志,2023,43(10):1872-1879.DOI: 10.11817/j.issn.2095-6959.2023.230152. [38] 肖顺娥,李海,张天华,等.抗生素骨水泥植入联合游离嵌合组织瓣移植序贯治疗严重痛风性创面的临床效果[J].中华烧伤与创面修复杂志,2025,41(1):53-60.DOI: 10.3760/cma.j.cn501225-20240919-00340. [39] GoswamiAG,BasuS,HudaF,et al.An appraisal of vascular endothelial growth factor (VEGF): the dynamic molecule of wound healing and its current clinical applications[J].Growth Factors,2022,40(3/4):73-88.DOI: 10.1080/08977194.2022.2074843. [40] PandyaUM,ManzanaresMA,TellecheaA,et al.Calreticulin exploits TGF-β for extracellular matrix induction engineering a tissue regenerative process[J].FASEB J,2020,34(12):15849-15874.DOI: 10.1096/fj.202001161R. [41] 李静,周羿辰,衡德忠.创面负压治疗联合骨膜牵张术治疗糖尿病足的临床研究[J].临床外科杂志,2024,32(7):763-766.DOI: 10.3969/j.issn.1005-6483.2024.07.025. -
图 1 采用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.术前左足底破溃流脓、皮肤缺损,肌腱外露；1B.术前第4趾干性坏疽；1C.术前下肢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,骨膜被装置顶起情况；1H.Ⅱ期术中打开骨水泥,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.治疗后3周,创面修复良好；1K.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.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）
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.术前左足背与足趾红肿及足背溃疡形成；2B.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期术中打开骨水泥,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.治疗后3周,创面完全愈合；2H.治疗后3周,复行下肢CTA检查,结果与图2B相近,无明显改善
Table 1. 2组糖尿病足溃疡患者一般资料比较
组别 例数 年龄（岁, 性别（例） 糖尿病足溃疡病程[d,M（Q1,Q3）] 溃疡面积（cm2, Wagner分级（例） Ⅲ级 Ⅳ级 男 女 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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Table 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（
组别 例数 踝部皮肤温度（℃） 踝肱指数 t1值 P1值 t2值 P2值 治疗前 治疗后3周 治疗前 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 0.06±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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Table 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（
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 治疗前 治疗后3周 治疗前 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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Table 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
临床疗效 例数 年龄（岁, 性别（例） Wagner分级（例） 糖尿病足溃疡病程（d, 溃疡面积（cm2, 手术方式（例） 住院时长（d, 溃疡愈合耗时（d, 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 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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