抗生素骨水泥联合负压闭合治疗胫腓骨Gustilo-Ⅲ型骨折△

Antibiotic-loaded bone cement combined with vacuum-assisted closure for Gustilo type Ⅲ tibiofibular fractures

摘要:

[目的] 评价抗生素骨水泥联合负压辅助创面闭合（vacuum-assisted closure, VAC） 治疗胫腓骨Gustilo-Ⅲ型骨折的临床效果。[方法] 回顾性分析2020 年3 月—2021 年9 月本院收治的胫腓骨Gustilo-Ⅲ型骨折60 例患者的临床资料。依据术前医患沟通结果，31 例采用抗生素骨水泥联合VAC 治疗（联合组），29 例采用单一VAC 治疗（VAC 组）。比较两组围手术期、检验结果与随访情况。[结果] 两组均顺利完成手术，术中无严重并发症。两组患者的一期手术时间和VAS 评分无明显差异（P＞0.05）。联合组的二期术前时间[(9.9±1.7) d vs (11.0±1.9) d, P=0.014]、渗出评级[0/I/II/III/IV, (6/17/5/3/0) vs (2/11/10/4/2), P=0.017]、肉芽评级[I/II/III/IV, (18/8/4/1) vs (9/12/6/2), P=0.048]、细菌培养转阴率[阳/阴, (1/23) vs (6/17), P=0.035]、创面闭合方式[缝合/植皮/皮瓣, (24/5/2) vs (13/11/5), P=0.034]、创面愈合时间[(25.8±5.1) d vs (29.6±5.5) d, P=0.007]、住院时间[(29.6±4.5) d vs(33.0±5.5) d, P=0.011] 和治疗费用[(6.3±0.5) 万元vs (6.7±0.6) 万元, P=0.003] 均显著优于VAC 组。实验室检查方面，随时间推移,两组患者的WBC、NEU、CRP 和ESR 均显著下降（P＜0.05）。二期术前联合组的上述指标均显著优于VAC 组（P＜0.05）。联合组的骨折愈合时间[(6.2±1.7) 个月vs (7.3±1.5) 个月, P=0.011] 和骨折愈合情况[良好/延迟/骨不连/骨髓炎, (25/4/1/1) vs (17/6/2/4),P=0.016] 显著优于VAC 组。随时间推移，两组患者的局部瘢痕情况和患肢功能均显著改善（P＜0.05）。术后3 个月联合组的局部瘢痕情况和患肢Johner-Wruh 功能评级显著优于VAC 组（P＜0.05），术后6、12 个月两组间局部瘢痕情况和患肢功能的差异均无统计学意义（P＞0.05）。联合组的患者满意度明显高于VAC 组（P＜0.05）。[结论] 与单一采用VAC 治疗相比，抗生素骨水泥联合负压辅助创面闭合具有缩短治疗周期，降低感染风险和促进骨折愈合等优点。

Abstract:

[Objective] To evaluate the clinical outcomes of antibiotic-loaded bone cement combined with vacuum-assisted closure(VAC) for Gustilo-Ⅲ tibiofibular fractures. [Methods] A retrospective study was conducted on 60 patients who received treatments forGustilo type Ⅲ tibiofibular fractures in our hospital from March 2020 to September 2021. According to preoperative doctor-patient commu-nication, 31 patients were treated with antibiotic-loaded bone cement combined with VAC (the combination group), while the remaining 29patients were treated with VAC only (the VAC group) after a thorough debridement and external fixation in the first stage. The documents re-garding perioperative period, laboratory tests and follow-up were compared between the two groups. [Results] All patients in both groupshad operations performed smoothly without serious complications. Although there were no significant differences in the first-stage operationtime and VAS scores between the two groups (P＞0.05), the combination group proved significantly superior to the VAC group in terms ofthe time elapsed prior to the second stage of preoperative time [(9.9±1.7) days vs (11.0±1.9) days, P=0.014], exudation scale [0/I/II/III/IV,(6/17/5/3/0) vs (2/11/10/4/2), P=0.017], granulation scale [I/II/III/IV, (18/8/4/1) vs (9/12/6/2), P=0.048], the bacterial culture before the sec-ond stage of surgery [positive/negative, (1/23) vs (6/17), P=0.035], wound closure mode [suture/skin graft/flap, (24/5/2) vs (13/11/5), P=0.034], wound healing time [(25.8±5.1) days vs (29.6±5.5) days, P=0.007], hospital stay [(29.6±4.5) days vs (33.0±5.5) days, P=0.011] andthe treatment costs [(6.3±0.5) ten thousand yuan vs (6.7 + 0.6) ten thousand yuan, P=0.003]. Regarding laboratory tests, the WBC, NEU,CRP and ESR were significantly decreased over time in both groups (P＜0.05), which in the combination group were significantly better thanthose in the VAC group just before the second stage of surgery (P＜0.05). In addition, the combination group was significantly better than theVAC group in terms of fracture healing time [(6.2±1.7) months vs (7.3±1.5) months, P=0.011] and fracture union state [good/delayed/non-union/osteomyelitis, (25/4/1/1) vs (17/6/2/4), P=0.016]. The local scar grade and limb function based on Johner-Wruh criteria significantlyimproved over time in both groups (P＜0.05), which in the combination group were significantly better than those in the VAC group at 3months after surgery (P＜0.05), but became not statistically significant between the two groups at 6 and 12 months after surgery (P＞0.05).Moreover, the combination group was also significantly superior to the VAC group in term of the patient satisfaction (P＜0.05). [Conclusion]The antibiotic-loaded bone cement combined with vacuum assisted closure has the advantages of shortening treatment period, reducing therisk of infection and promoting fracture healing over the VAC only.