胫骨横向骨搬移治疗下肢难愈性创面的研究进展  

Research progress in the treatment of refractory lower limb ulcers by tibia transverse transport

作　　者：李山郎 花奇凯[1] 刘光炜 刘杰 余杰 聂新宇 何烈勋 邝晓聪[3] 陈炎 Li Shanlang;Hua Qikai;Liu Guangwei;Liu Jie;Yu Jie;Nie Xinyu;He Liexun;Kuang Xiaocong;Chen Yan(Department of Bone and Joint Surgery,the First Affiliated Hospital of Guangxi Medical University,Nanning 530021,China;Guangxi Collaborative Innovation Center for Biomedicine(Guangxi-ASEAN Collaborative Innovation Center for Major Disease Prevention and Treatment),Nanning 530021,China;Guangxi Key Laboratory of Regenerative Medicine,Guangxi Medical University,Nanning 530021,China)

机构地区：[1]广西医科大学第一附属医院骨科,南宁530021 [2]广西生物医药协同创新中心(广西-东盟重大疾病防治协同创新中心),南宁530021 [3]广西医科大学再生医学研究中心,南宁530021

出　　处：《中华骨科杂志》2021年第11期705-713,共9页Chinese Journal of Orthopaedics

基　　金：国家自然科学基金(82060406,81601930);中国博士后科学基金(2019M650235);广西自然科学基金(2017GXNSFAA198318,2016GXNSFBA380007,2017GXNSFAA198293);广西壮族自治区适宜技术推广项目(S2017032)。

摘　　要：下肢慢性难愈性创面的治疗周期长且预后差,绝大部分患者最终会因疗效不佳而截肢。基于张力-应力法则的Ilizarov技术的应用为下肢难愈性创面的治疗带来了希望。Ilizarov技术或牵张成骨技术除诱导骨生成外,还可刺激微血管增生和改善微循环,分为纵向骨搬移和胫骨横向骨搬移技术(胫骨近端皮质部分截骨后横向牵张)。这两类技术在临床中的应用各有其优缺点及适应证。纵向骨搬移主要用于促进成骨,适用于大段骨缺损、骨坏死或骨感染(伴或不伴软组织缺损)。而胫骨横向骨搬移技术为部分截骨搬移治疗,创伤小,对肢体稳定性的影响小,手术操作简单,并发症少,主要应用于下肢难愈性创面的治疗,如糖尿病足、血栓闭塞性脉管炎(Buerger病)、动脉粥样硬化闭塞症、静脉性溃疡、创伤引起的难愈创面等。胫骨横向骨搬移治疗重度糖尿病足取得了高愈合率、高保肢率及低复发率的良好疗效,是该技术治疗难愈性创面最成功的应用。胫骨横向骨搬移治疗血栓闭塞性脉管炎也可提高愈合率和保肢率,但总体疗效逊色于治疗重度糖尿病足。对下肢动脉硬化闭塞症,胫骨横向骨搬移通过刺激微血管网再生从而促进创面愈合,疗效优于传统方法,但应强调与血管重建术联合应用,以期达到最好的长期效果。有研究初步表明其作用机制与促进血管生长相关因子生成、平衡局部炎症微环境等相关。胫骨横向骨搬移治疗下肢难愈性创面的效果仍需大样本的随机对照研究证实。The treatment of lower extremity chronic refractory ulcers requires a long time but with poor prognosis.Thus,many patients end up with amputations.The treatment of lower extremity chronic and recalcitrant ulcers and limb salvage has been a challenge worldwide.The Ilizarov technique based on the law of"tension-stress"brings a new hope in treating lower limb chronic and recalcitrant ulcers.The Ilizarov technique and distraction osteogenesis not only induce bone formation but also lead to angiogenesis and improved microcirculation.The Ilizarov technique consists of longitudinal distraction of long bone and tibia trans-verse transport(TTT)(proximal tibial corticotomy followed by transverse distraction).These two techniques have their own advantages and disadvantages with different indications in clinical application.Longitudinal distraction of long bone is mainly used for bone formation,such as large bone defects,osteonecrosis or bone infection(with or without soft tissue loss or ulcers).Because of only a partial osteotomy in TTT,the trauma is minor and their effects on limb instability are limited.Moreover,the procedure is simple with only a few minor complications.Thus,it is ideal in treating lower limb ischemic ulcers,such as diabetic foot ulcers,thromboangiitis obliterans(Buerger's disease),ulcers caused by atherosclerotic occlusion,arterial or venous ulcers,and trauma wounds.Several studies reported that TTT achieved high healing and limb salvage rates in treating severe diabetic foot ulcer.However,TTT could achieve lower recurrent rate.Thus,it is the most successful application in treatment of chronic ulcers.TTT also improves healing and limb salvage in treatment of thromboangiitis obliterans.However,the overall effects are limited than those in treating diabetic foot ulcer.For lower limb atherosclerosis occlusion,TTT induces regeneration of microvessles and consequently leads to ulcer healing.The effects are better than other conventional treatments.A combination therapy with vascularization is emphasized to a

关 键 词：血栓闭塞性脉管炎 ILIZAROV技术 难愈性创面 骨搬移 长期效果 血管重建术 微血管网 骨坏死 

分 类 号：R658.3[医药卫生—外科学]