胫骨横向骨搬移治疗重度感染糖尿病足△

Tibia transverse transport for severely infected diabetic foot

摘要:

[目的] 探讨胫骨横向骨搬移 （tibial transverse transport, TTT） 治疗合并脓毒症/脓毒症休克的重度糖尿病足的疗效。 [方法]回顾性分析 2015 年 4 月—2020 年 8 月本院治疗的合并脓毒症/脓毒症休克的重度糖尿病足 77 例患者的临床资料。首先所有患者均接受矫正休克，改善全身情况，应用敏感抗生素和局部清创等治疗；然后根据医患沟通结果，45 例行 TTT 治疗， 32 例行传统治疗。比较两组临床及辅助检查结果。[结果]TTT 组的住院时间 [(21.8±7.6) d vs (28.6±12.0) d, P=0.007]、清创次数 [(2.1±0.5) 次 vs (3.5±1.0) 次, P＜0.001]、换药次数 [(19.7±7.5) 次 vs (25.1±11.1) 次, P=0.013]、出院时创面面积 [(68.2±27.4) cm² vs (105.2±20.5) cm² , P=0.003]、住院期间截肢率 [8(17.8%) vs 15(46.9%), P=0.006] 和死亡率 [1(2.2%) vs 7(21.9%), P=0.005] 均显著低于传统组。随访时间 1~72 个月，平均 （20.4±15.8） 个月。末次随访时足保留者死亡例数 TTT 组为 8 （22.2%） 例，传统组为 6 （60.0%）例，差异有统计学意义（P=0.022）。保肢成功例数 TTT 组为 26（72.2%）例，传统组为 0（0%）例，差异有统计学意义 （P＜0.001）。 截止末次随访时存活者 TTT 组的 PCS 评分 [(43.5±3.4) vs (40.6±2.1), P=0.043] 和 MCS 评分 [(46.4±3.6) vs (36.5±2.4), P＜ 0.001] 均显著优于传统组。随着时间的推移，两组的 PCS 评分和 MCS 评分均显著优于治疗前（P＜0.05）。辅助检查方面，随着时间推移，两组的 WBC、PCT、CRP、ESR、IL-6 均显著降低（P＜0.05）。出院时，TTT 组保肢者的 WBC、PCT、CRP、ESR、IL-6 均显著低于传统组（P＜0.05）。TTT 组出院时的 CTA 血管显像显著优于传统组（P＜0.05），末次随访时 TTT 组的 CTA 血管显像显著优于出院时（P＜0.05）。[结论]与传统治疗方法相比，TTT 治疗合并脓毒症或脓毒症休克的重度糖尿病足可明显提高创面愈合率，降低截肢率和死亡率，缓解疼痛，改善患肢功能，提高生活质量。

关键词:糖尿病足;脓毒症;Ilizarov 技术;张力-应力法则;胫骨横向骨搬移

Abstract:

[Objective] To explore the clinical outcomes of tibia transverse transport (TTT) for diabetic foot accompanied with sepsis or septic shock. [Methods] A retrospective study was conducted on 77 patients who received treatments for severe diabetic foot complicated with sepsis or septic shock in our hospital from April 2015 to August 2020. First of all, all the patients received treatments of anti-shock, im- provement of general condition with sensitive antibiotics, and local debridement. Subsequently, 45 patients were treated with TTT, while the remaining 32 patients were with traditional treatment according to the doctor-patient communication. The documents regarding clinical con- dition and auxiliary examination were compared between the two groups. [Results] The TTT group proved significantly superior to the tradi- tional group in terms of hospital stay [(21.8±7.6) days vs (28.6±12.0) days, P=0.007], debridement times [(2.1±0.5) times vs (3.5±1.0) times, P＜0.001], dressing change times [(19.7±7.5) times vs (25.1±11.1) times, P=0.013], wound area at discharge [(68.2±27.4) cm² vs (105.2±20.5) cm² , P=0.003], amputation rate during hospitalization [8(17.8%) vs 15(46.9%), P=0.006] and mortality in hospital [1(2.2%) vs 7 (21.9%), P= 0.005]. The follow-up period was 1~72 months with an average of (20.4±15.8) months. At the final follow-up, 8 (22.2%) patients in the TTT group and 6 (60%) patients in the traditional group died; the difference was statistically significant (P=0.022). And 26 (72.2%) patients in the TTT group while no patients (0%) in the traditional group were salvageable; the difference was statistically significant (P＜0.001). At the final follow-up, PCS score [(43.5±3.4) vs (40.6±2.1), P=0.043] and MCS score [(46.4±3.6) vs (36.5±2.4), P＜0.001] in the TTT group were sig- nificantly higher than those in the traditional group. As time went by, PCS score and MCS score in both groups were significantly higher than before treatment (P＜0.05). As for auxiliary examination, WBC, PCT, CRP, ESR, and IL-6 in both groups were significantly decreased over time (P＜0.05). At discharge, WBC, PCT, CRP, ESR, and IL-6 of limb salvage patients in TTT group were significantly lower than those in traditional group (P＜0.05). The CTA angiography in the TTT group at discharge was significantly better than that in the traditional group (P＜ 0.05), and the CTA angiography in the TTT group at the last follow-up was significantly better than that at discharge (P＜0.05). [Conclusion] Compared with traditional therapy, TTT treatment for severe diabetic foot complicated with sepsis or septic shock can significantly improve the wound healing rate, reduce the amputation rate and mortality, relieve pain, improve the function of affected limb, and improve the quality of life.

Key words:diabetic foot; sepsis; Ilizarov technique; law of tension-stress; tibia transverse transport