抗生素骨水泥与VSD联合游离股前外侧穿支嵌合肌皮瓣序贯治疗糖尿病性跟骨骨髓炎创面的效果

钟宇惠; 崔旭; 周思拓; 郭乐; 黄覛韬; 何志友; 杨浩林; 曾纪章; 梁鹏飞; 张丕红; 周捷

doi:10.3760/cma.j.cn501225-20251129-00493

抗生素骨水泥与VSD联合游离股前外侧穿支嵌合肌皮瓣序贯治疗糖尿病性跟骨骨髓炎创面的效果

doi: 10.3760/cma.j.cn501225-20251129-00493

1.
中南大学湘雅医院烧伤整形外科,长沙　410008
2.
湖南省交通医院外三科,长沙　410011

基金项目:

湖南省自然科学基金面上项目 2025JJ50512

详细信息

通讯作者:
周捷,Email：zhoujie7812@sina.com

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出版历程
- 收稿日期: 2025-11-29
- 网络出版日期: 2026-03-03

Effects of sequential treatment of diabetic calcaneal osteomyelitis wounds with antibiotic bone cement and VSD combined with free chimeric anterolateral thigh perforator myocutaneous flaps

1.
Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
2.
The Third Department of Surgery, Hunan Provincial Communications Hospital, Changsha 410011, China

Funds:

General Program of Hunan Provincial Natural Science Foundation 2025JJ50512

More Information

Corresponding author: Zhou Jie, Email: zhoujie7812@sina.com

摘要

摘要: 目的探讨应用抗生素骨水泥与负压封闭引流（VSD）联合游离股前外侧穿支嵌合肌皮瓣序贯治疗糖尿病性跟骨骨髓炎创面的效果。方法该研究为回顾性病例系列研究。2019年6月—2024年6月,中南大学湘雅医院烧伤整形外科收治12例符合入选标准的糖尿病性跟骨骨髓炎创面患者,其中男7例、女5例,年龄40~65岁,创面为Wagner Ⅲ级者8例、Wagner Ⅳ级者4例。Ⅰ期行清创+抗生素骨水泥临时填充覆盖+VSD治疗,其中清创后创面面积为6 cm×5 cm~18 cm×8 cm,骨缺损体积为1.0 cm×0.8 cm×0.5 cm~1.8 cm×1.5 cm×0.8 cm；Ⅱ期采用游离股前外侧穿支嵌合肌皮瓣修复创面,其中穿支皮瓣面积为10.0 cm×5.0 cm~20.0 cm×10.0 cm,肌瓣面积为3.0 cm×2.5 cm~7.0 cm×6.0 cm。将皮瓣供区创面直接缝合或移植大腿中厚皮修复。记录患者入院时及Ⅰ期治疗后7 d白细胞计数、中性粒细胞、超敏C反应蛋白水平以及创面分泌物标本微生物培养情况,Ⅰ期治疗后7 d创基肉芽组织生长情况。Ⅱ期术后观察皮瓣存活情况及供受区创面愈合情况。随访观察受区皮瓣血运、外观及质地,溃疡及骨髓炎有无复发,供区恢复情况及患肢功能。结果 Ⅰ期治疗后7 d,患者白细胞计数、中性粒细胞、超敏C反应蛋白水平分别为7.15（6.73,8.70）×10⁹/L、0.65（0.63,0.72）、15.50（12.48,25.50）mg/L,显著低于入院时的12.30（11.28,13.48）×10⁹/L、0.80（0.78,0.83）、73.20（57.25,93.75）mg/L（Z值分别为-2.905、-2.825、-3.059,P值均<0.05）。入院时,患者创面分泌物标本微生物培养结果均为阳性,创周红肿明显；Ⅰ期治疗后7 d,患者创面分泌物标本微生物培养结果均为阴性,创周无明显红肿,创基肉芽组织生长良好。Ⅱ期术后,仅2例患者皮瓣远端小面积表皮缺血坏死,经换药后创面延期愈合,其余患者皮瓣存活良好且受区创面均顺利愈合；所有患者供区创面愈合良好。随访6~18个月显示,皮瓣血运及外观良好,质地柔软；未见溃疡复发,X线检查未见明显骨髓炎复发征象；供区恢复良好且无明显瘢痕增生,患肢均能负重活动。结论采用抗生素骨水泥与VSD联合游离股前外侧穿支嵌合肌皮瓣序贯修复糖尿病性跟骨骨髓炎创面,在彻底清除感染病灶的基础上,实现了跟骨深部死腔的有效封闭与软组织覆盖,近期随访效果良好,值得临床推广。
- 糖尿病足 /
- 骨髓炎 /
- 负压伤口疗法 /
- 显微外科手术 /
- 股前外侧穿支皮瓣 /
- 抗生素骨水泥 /
- 嵌合皮瓣 /
- 创面修复
Abstract: Objective To explore the effect of sequential treatment of diabetic calcaneal osteomyelitis wounds with antibiotic bone cement and vacuum sealing drainage (VSD) combined with free chimeric anterolateral thigh perforator myocutaneous flaps. Methods This study was a retrospective case series study. From June 2019 to June 2024, 12 patients with diabetic calcaneal osteomyelitis wounds meeting the inclusion criteria were admitted to the Department of Burns and Plastic Surgery of Xiangya Hospital of Central South University, including 7 males and 5 females, aged 40 to 65 years. There were 8 cases of Wagner grade Ⅲ wounds and 4 cases of Wagner grade Ⅳ wounds. In stage Ⅰ, debridement+temporary antibiotic bone cement filling and coverage+VSD treatment was performed, in which the wound area after debridement was 6 cm×5 cm to 18 cm×8 cm, and the bone defect volume was 1.0 cm×0.8 cm×0.5 cm to 1.8 cm×1.5 cm×0.8 cm. In stage Ⅱ, free chimeric anterolateral thigh perforator myocutaneous flaps were used to repair the wounds, in which the area of the perforator flap was 10.0 cm×5.0 cm to 20.0 cm×10.0 cm, and the area of the muscle flap was 3.0 cm×2.5 cm to 7.0 cm×6.0 cm. The wound at the flap donor site was directly sutured or repaired by split-thickness skin graft from the thigh. The white blood cell count, neutrophil, high-sensitivity C-reactive protein level, and microbial culture of wound secretion specimens at admission and 7 days after stage Ⅰ treatment, and the growth of wound bed granulation tissue 7 days after stage Ⅰ treatment were recorded. After stage Ⅱ surgery, the flap survival and the wound healing in the donor and recipient areas were observed. During follow-up, the blood supply, appearance, and texture of the recipient area flaps, whether ulcers and osteomyelitis recurred, the recovery of the donor areas, and the function of the affected limbs were observed. Results Seven days after stage Ⅰ treatment, the white blood cell count, neutrophil, and high-sensitivity C-reactive protein level of the patients were 7.15 (6.73, 8.70)×10⁹/L, 0.65 (0.63, 0.72), and 15.50 (12.48, 25.50) mg/L, respectively, which were significantly lower than 12.30 (11.28, 13.48)×10⁹/L, 0.80 (0.78, 0.83), and 73.20 (57.25, 93.75) mg/L at admission (with Z values of -2.905, -2.825, and -3.059, respectively, P values all <0.05). At admission, the microbial culture results of the wound secretion specimens were all positive, and the redness and swelling around the wound were obvious; 7 days after stage Ⅰ treatment, the microbial culture results of the wound secretion specimens were all negative, there was no obvious redness or swelling around the wound, and the wound bed granulation tissue grew well. After stage II surgery, only two patients had a small area of ischemic epidermal necrosis at the distal end of the flap, and the wounds achieved delayed healing after dressing changes; the flaps of the other patients all survived well and the wounds in the recipient areas all healed smoothly; the donor area wounds of all patients healed well. Follow-up for 6 to 18 months showed that the blood supply and appearance of the flaps were good, and the texture was soft; no recurrence of ulcers was observed, and no obvious signs of recurrence of osteomyelitis were shown by X-ray examination; the donor areas recovered well without obvious scar hyperplasia, and the affected limbs were all able to perform weight-bearing activities. Conclusions Sequential repair of diabetic calcaneal osteomyelitis wounds with antibiotic bone cement and VSD combined with free chimeric anterolateral thigh perforator myocutaneous flaps, on the basis of thorough removal of infected lesions, achieves effective closure of deep calcaneal dead space and soft tissue coverage. The short-term follow-up effect is good, and it is worthy of clinical promotion.
- Diabetic foot /
- Osteomyelitis /
- Negative-pressure wound therapy /
- Microsurgery /
- Anterolateral thigh perforator flap /
- Antibiotic bone cement /
- Chimeric flap /
- Wound repair
钟宇惠：管理患者,收集与分析数据,撰写文章；崔旭、周捷：设计试验,实施研究,实施手术,修改文章,研究经费支持,对文章的知识性内容作批评性审阅；周思拓、杨浩林：实施研究,实施手术,采集数据；郭乐、黄覛韬、何志友：实施研究,采集和分析数据,指导研究；曾纪章、梁鹏飞、张丕红：实施研究,指导研究,对文章的知识性内容作批评性审阅

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图 1 载万古霉素骨水泥与负压封闭引流联合游离股前外侧穿支嵌合肌皮瓣序贯治疗例1患者右足糖尿病性跟骨骨髓炎创面的效果。1A.入院时CT示右足跟骨骨髓炎；1B.右足跟骨骨髓炎创面行Ⅰ期清创后载万古霉素骨水泥填充后即刻；1C.Ⅰ期清创+载万古霉素骨水泥临时填充覆盖+负压封闭引流治疗后3周右足跟部溃疡创面床建立；1D.Ⅱ期术中设计游离股前外侧穿支皮瓣；1E.Ⅱ期术中切取股前外侧穿支嵌合肌皮瓣后即刻；1F.Ⅱ期术中供瓣区拉拢缝合后即刻；1G.Ⅱ期术后即刻,皮瓣血运良好；1H.Ⅱ期术后6个月随访时,皮瓣外形良好

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图 2 载庆大霉素骨水泥与负压封闭引流联合游离股前外侧穿支嵌合肌皮瓣序贯治疗例2患者右足糖尿病性跟骨骨髓炎创面的效果。2A.入院时CT检查显示右足跟骨骨髓炎；2B.Ⅰ期清创+载庆大霉素骨水泥临时填充覆盖+负压封闭引流治疗后7 d,X线检查显示右足跟骨骨髓炎创面抗生素骨水泥填充情况；2C.Ⅰ期清创+载庆大霉素骨水泥临时填充覆盖+负压封闭引流治疗后3周右足跟部溃疡创面床建立；2D.Ⅱ期术中设计游离股前外侧穿支皮瓣；2E.Ⅱ期术中切取股前外侧穿支嵌合肌皮瓣后即刻；2F.Ⅱ期术中供瓣区拉拢缝合后即刻；2G.Ⅱ期术后即刻,皮瓣血运良好；2H.Ⅱ期术后6个月随访时,皮瓣血运良好,颜色较周围正常皮肤略偏红

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Table 1. 12例糖尿病性跟骨骨髓炎患者治疗前后各炎症指标水平比较[M（Q₁,Q₃）]

时间点	白细胞计数（×10⁹/L）	中性粒细胞	超敏C反应蛋白水平（mg/L）
入院时	12.30（11.28,13.48）	0.80（0.78,0.83）	73.20（57.25,93.75）
Ⅰ期治疗后7 d	7.15（6.73,8.70）	0.65（0.63,0.72）	15.50（12.48,25.50）
Z值	-2.905	-2.825	-3.059
P值	0.004	0.005	0.002
注：Ⅰ期治疗包括清创、抗生素骨水泥临时填充覆盖、负压封闭引流