本文選題：骨髓炎　切入點(diǎn)：骨缺損　出處：《第三軍醫(yī)大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景長(zhǎng)骨慢性骨髓炎的治療一直是骨科領(lǐng)域的重大難題,徹底清創(chuàng)是實(shí)現(xiàn)感染控制的基本前提,也是慢性骨髓炎的治療要點(diǎn),但這可能會(huì)導(dǎo)致難以治療的大段感染性骨缺損。目前,最常用于大段感染性骨缺損修復(fù)的技術(shù)主要包括:骨延長(zhǎng)技術(shù)及自體帶血管骨移植技術(shù),傳統(tǒng)的骨延長(zhǎng)技術(shù)存在釘?shù)栏腥�、斷釘、肌肉攣縮、鄰近關(guān)節(jié)僵硬等并發(fā)癥。自體帶血管骨移植技術(shù)需要顯微外科操作,而且存在取骨處并發(fā)癥,術(shù)后還可能發(fā)生應(yīng)力性骨折及骨不連。近年來,膜誘導(dǎo)技術(shù)被廣泛用于長(zhǎng)骨骨缺損的修復(fù)。該技術(shù)是一種重建骨缺損的兩期手術(shù)治療方法。Ⅰ期手術(shù)包括徹底清創(chuàng)后穩(wěn)定骨端,并使用聚甲基丙烯酸甲酯(PMMA)骨水泥植入骨缺損部位,誘導(dǎo)假膜形成;Ⅱ期手術(shù)包括取出骨水泥并在假膜內(nèi)植骨。外固定架是傳統(tǒng)膜誘導(dǎo)技術(shù)Ⅰ期清創(chuàng)術(shù)中最常用的固定方式。但外固定架有其固有的局限性,存在穩(wěn)定性差、釘?shù)栏腥�、佩戴困難等缺點(diǎn),而使用傳統(tǒng)內(nèi)固定裝置往往會(huì)導(dǎo)致感染難以控制。近年來抗生素骨水泥被覆的內(nèi)固定裝置在骨感染的治療中取得了良好的療效,因此我中心對(duì)傳統(tǒng)的膜誘導(dǎo)技術(shù)進(jìn)行了改進(jìn),使用抗生素骨水泥被覆的鎖定鋼板作為膜誘導(dǎo)技術(shù)Ⅰ期清創(chuàng)術(shù)中的固定方式。研究目的1.評(píng)估抗生素骨水泥被覆的鎖定鋼板作為膜誘導(dǎo)技術(shù)Ⅰ期清創(chuàng)術(shù)中固定方式對(duì)治療過程及臨床療效的影響,并與其它固定方式相比較。2.探討在膜誘導(dǎo)技術(shù)中使用抗生素骨水泥被覆鎖定鋼板的前提條件、最佳適應(yīng)癥以及缺點(diǎn)。研究方法采用回顧性分析2015年3月—2016年3月采用膜誘導(dǎo)技術(shù)治療的下肢慢性骨髓炎患者85例。其中男72例,女13例,年齡10~66歲,平均36.4歲。其中股骨57例,脛骨28例。骨感染持續(xù)時(shí)間平均在2.2年(0.25~30年)。其中創(chuàng)傷后骨髓炎共73例,血源性骨髓炎共12例。有8例患者入院時(shí)患肢存在紅腫熱痛癥狀�；颊咴诮邮苣ふT導(dǎo)技術(shù)治療之前,患肢平均接受2.65次手術(shù)治療(0~8次)。入院時(shí)患肢使用的固定方式包括內(nèi)固定鋼板19例,髓內(nèi)釘13例,外固定架21例。56例患者入院時(shí)患肢存在竇道,其中24例患者竇道分泌物細(xì)菌培養(yǎng)結(jié)果為陽(yáng)性。所有患者在Ⅰ期清創(chuàng)術(shù)中均使用抗生素骨水泥被覆的鎖定鋼板作為骨缺損斷端的穩(wěn)定方式。術(shù)后動(dòng)態(tài)觀察患者白細(xì)胞計(jì)數(shù)(WBC)、C-反應(yīng)蛋白(CRP)、紅細(xì)胞沉降率(ESR)、患肢臨床表現(xiàn)(竇道形成及紅腫熱痛)及X線片。研究結(jié)果Ⅰ期術(shù)中組織細(xì)菌培養(yǎng)陽(yáng)性的患者共有56例。Ⅰ期清創(chuàng)手術(shù)造成的骨缺損平均在7.3cm,(4~18cm)。有45例患者使用直型鎖定鋼板,有16例患者使用解剖型鎖定鋼板,有24例患者使用重建鎖定鋼板。Ⅰ期術(shù)后有68例患者傷口達(dá)到甲級(jí)愈合,17例患者傷口達(dá)到乙級(jí)愈合。Ⅰ期術(shù)中有4例脛骨骨髓炎患者通過實(shí)施局部皮瓣轉(zhuǎn)位技術(shù)閉合傷口。Ⅰ期術(shù)后共有5例患者出現(xiàn)感染復(fù)發(fā),Ⅱ期術(shù)后共有2例患者出現(xiàn)感染復(fù)發(fā),總感染復(fù)發(fā)率在8.25%。這些患者在接受進(jìn)一步治療后感染得到控制,并在隨訪期間無(wú)感染復(fù)發(fā)表現(xiàn)。所有患者植骨在Ⅱ期術(shù)后平均5.7月(4.5~6.5月)取得影像學(xué)愈合,隨訪過程中均可見植骨逐漸融合及皮質(zhì)化。研究結(jié)論我們認(rèn)為在膜誘導(dǎo)技術(shù)治療下肢長(zhǎng)骨慢性骨髓炎時(shí),抗生素骨水泥被覆的鎖定鋼板作為內(nèi)固定方式可以用于Ⅰ期清創(chuàng)手術(shù)。相比外固定架,該裝置能為患者提供更多的舒適度,而且不會(huì)增加感染復(fù)發(fā)率,對(duì)移植骨的愈合也沒有明顯影響。相比抗生素骨水泥覆蓋的髓內(nèi)釘,該裝置適用范圍更廣,制作、放置與取出過程更簡(jiǎn)單,對(duì)髓腔結(jié)構(gòu)影響更小。相對(duì)普通鋼板,鎖定鋼板特殊的角穩(wěn)定性使其更適用于慢性骨髓炎的治療。
[Abstract]:Study on the treatment of chronic osteomyelitis of long bone background is a major problem in the field of Department of orthopedics, thorough debridement is a basic prerequisite for infection control, but also the key points of the treatment of chronic osteomyelitis, but it may lead to some difficult to treat infected bone defects. At present, the most commonly used in large segmental infected bone defect repair technology including: bone lengthening and bone autograft, traditional bone lengthening technique has broken nails, nail infection, muscle contracture, adjacent joint stiffness and other complications. Bone autograft technique requires microsurgical operation, and the existence of donor site complications, may also occur stress fracture and nonunion of bone surgery after the induction. In recent years, membrane technology is widely used in repairing bone defect. The technique is a kind of two surgical methods in the treatment of bone defect reconstruction. One-stage surgery included debridement stable bone end, And the use of polymethylmethacrylate (PMMA) bone cement implantation bone defect site, induced by the second stage surgery including pseudomembrane formation; remove bone cement and bone graft in the internal fixator is pseudomembrane. Traditional membrane induced stage debridement of the most commonly used fixed. But external fixation has its inherent limitations, existence and stability poor wear nail infection. Disadvantages of difficulty, but using traditional internal fixation device will often lead to infection is difficult to control. In recent years, antibiotic bone cement coated internal fixation device in the treatment of bone infection in achieved good effect, so I center on traditional film induction technology was improved and the use of antibiotics in bone locking plate cement coated membrane technology as induced by I-stage debridement and fixation operation. The locking plate objective 1. assessment of antibiotic bone cement coated membrane as induction stage debridement fixed operation Influence on the course of treatment and clinical curative effect, and compared with other fixed.2. on condition of induced used in the technique of antibiotic bone cement coated locking plate in the film, the best indications and disadvantages. Methods a retrospective analysis from March 2015 to March 2016 85 patients with chronic osteomyelitis of lower extremity treated cases induced by the film. Male 72 cases, female 13 cases, age 10~66 years old, average 36.4 years old. Among them 57 cases of femur and tibia bone infection in 28 cases. The average duration of 2.2 years (0.25~30 years). Among them there were 73 cases of post-traumatic osteomyelitis, bone marrow blood inflammation in 12 cases. There were 8 patients with limb swelling there heat pain symptoms. Patients before receiving treatment induced membrane technology, the average limb treated 2.65 surgery (0~8). At the time of admission with fixed limb use include internal fixation in 19 cases, 13 cases of intramedullary nail and external fixation in 21 cases of.56 patients On admission patients with sinus tract, including 24 cases of patients with sinus tract bacterial culture results were positive. All patients with stable and clear locking plate antibiotic bone cement coating was used during surgery as a bone defect ends in one stage. The dynamic observation of white blood cell count after surgery (WBC), C- reactive protein (CRP), erythrocyte sedimentation rate (ESR), limb clinical manifestations (sinus formation and swelling and heat pain) and X-ray. The results of intraoperative tissue bacterial culture positive patients. There were 56 cases of one-stage debridement of bone defects caused by an average of 7.3cm (4~, 18cm) in 45 cases. Patients with a straight locking plate, 16 cases of patients with anatomical locking plate, 24 cases of patients with one-stage reconstruction of locking plate. 68 cases of postoperative wound healing reached, 17 patients with wound healing. B to stage I in 4 cases of tibial osteomyelitis patients through the implementation of Council Department of flap closure wound. Stage I after a total of 5 patients had recurrence of infection, phase II after a total of 2 patients had recurrence of infection, the total infection recurrence rate in 8.25%. infection was controlled in these patients for further treatment, and no infection during the follow-up period. All patients are complex: bone graft in phase II after an average of 5.7 months (4.5~6.5 months) achieved radiographic union, during follow-up showed bone graft fusion and gradually. The conclusion of the study we believe that cortical induction treatment of lower extremity chronic osteomyelitis in film, antibiotic bone cement coated locking plate as internal fixation can be used for one-stage debridement surgery. Compared with external fixation, the device can provide patients with more comfort, and will not increase the recurrence rate of infection, healing of the bone graft has no significant effects. Compared with antibiotic bone cement covered intramedullary nail, the It has wider application scope, simpler manufacture and placement, and less influence on medullary cavity structure. Compared with ordinary steel plate, the special angle stability of locking plate makes it more suitable for the treatment of chronic osteomyelitis.

【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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本文編號(hào)：1642464