| BackgroundThe clinical etiology of hematogenous osteomyelitis is often divided into the following types:1.After injury;2.Acute infection;3.Proximity to the proliferation of soft tissue inflammation.Among them,chronic hematogenous osteomyelitis produces more virulence,more destructive,and more difficult to be cured.At present,the vast majority of chronic hematogenous osteomyelitis is usually attributed to the fact that the treatment of acute hematogenous osteomyelitis was not to be cured timely or the treatment method is improper.At present,due to the variety of clinical characteristics of hematogenous osteomyelitis,pathogenic bacteria continue to update and evolve,and clinical treatment plans lack uniform standard,so the effective treatment of the disease has became more difficult.The presentation of the Cierny-Mader(C-M)classification provides a basis for our clinical diagnosis.Among them,the most special type of bone infection and the most complex treatment are type IV chronic osteomyelitis,which usually has extensive bone loss and extensive involvement of soft tissues in adjacent parts of the lesion.A reference of the literature shows that the use of extended debridement beyond the normal soft tissue boundary can effectively increase the eliminate rate of necrosis and reduce the recurrence rate of infection.This treatment program called En-block resection was originally used for bone tumor treatment.To prevent the spread and metastasis of cancer cells,the current reform plan has been improved to confirm that there is also a high cure rate in the treatment of bone infections.But it was found that during the treatment of type IV osteomyelitis,multiple stages of debridement can cause severe defects in soft tissue and bone,so a single En-block resection has a new problem in bone infection treatment.The treatment of long-term bone defects currently known with clinically and documented in the report,usually includes debridement and bone grafting technology in first-stage,bone transplantation with pedicled blood vessels,bone extension of Ilizarov technology,and the selection of antibiotic bone cement prosthesis permanent filling replacement techno logy.However,these treatment techniques generally have long healing time in bone defects,Poor patient tolerance and compliance multiple complications in the treatment process and follow-up,and high technical shortcomings in the treatment of surgery.Therefore,it has become the focus of attention to find a new surgical approach that can operate easily,guide strongly,and have a low recurrence rate after surgery.Studies have reported that polymethyl methacrylate(PMMA)spacer was placed in the first step of the operation to fill the area of bone defect.After the infection is completely controlled,the induced membrane technique(Masquelet technique)for the repair of huge bone defects using autograft or allograft pine in the second phase is excellent.Studies have shown that the PMMA implanted in this technology can induce surrounding soft tissue to wrap around the membrane,which is highly vascularized and can simultaneously secrete and release vascular endothelial growth factor(VEGF)and bone morphogenetic protein(BMP)as well as a variety of other bone growth factors.In addition,it was found that the isolate of membrane induced had the function of proliferating and differentiating bone marrow stem cells.Due to the biological properties of the i nduced membrane,the rapid bone repair,proliferation,and plasticity in the second phase bone defect area after loose bone grafting can be realized.To sum up,the simple,effective and easy to learn,membrane induced technique can be used to repair the long bone defect after osteomyelitis removed.It is found that the technique has few clinical applications and few literature records,so further research and popularization of the technology has become a top priority.Bone cement containing antibiotics not only has the characteristics of producing biofilms(the biological characteristics of the membrane are to provide a variety of factors for rapid bone repair and a stable environment for soft tissue repair),but also has the slow release of antibiotics in the local to kill the pathogens of bone and soft tissue.On the other hand,due to the different local infections of severity degree and the uneven soft tissue cover conditions in different patients,these factors all restrict the success and the failure of the operation.Therefore,the use of induced membrane technology to treat osteomyelitis requires more consideration of the patient's age and constitution,the scope of expansion,the selection of fixation,the source of bone graft and the optimal period of bone graft should be studied further.In general,the expansion of trauma removal can effectively remove the lesions of hematogenous osteomyelitis,improve the removal rate of bone and soft tissue infections,and combined membrane induction technology to perfectly solve the limb reconstruction problem of huge bone defects.Objectives1.To explore a new clinical treatment pathway for the treatment of hematogenous osteomyelitis of the lower extremities by membrane inducted,and to evaluate its clinical treatment effect and feasibility and promotion of surgery.2.Comparison,analysis and safety evaluation of bone grafting pathway and osteogenesis effect were made by summarizing the source of bone grafting3.Summarize and analyze the clinical features,therapeutic effect and various influencing factors of the long-stage bone defect caused by the induced membrane technique in the treatment of hematogenous osteomyelitis in the lower extremities.Methods1.From May 2013 to June 2016,there were a total of 34 patients with osteomyelitis from hematogenous osteomyelitis in the lower extremities.All of these patients were included in the study using induced membrane technique after effective debridement.Among them,28 were males and 6 were females;The average age is 34.9 years(13 to 59years);Acute osteomyelitis 2 cases,chronic osteomyelitis 32 cases.There were 17 cases of osteomyelitis of femur and 17 cases of osteomyelitis of tibia.The average duration of bone infection was 145.1 months(0.2 to 360 months).The average follow-up was 24 months(23to 25 months).The contents of the follow-up were evaluated for the effective rate of infection clearance,the time of bone defect healing,the presence of complications,the score of limb function and the patient's quality of life,etc.,in order to obtain clinical efficacy and analogy.2.After the complete clinical follow-up data were obtained,the clinical data and imaging treatment results of the patients were reviewed and analyzed.The results of C-reactive protein,the time of bone defect healing,and the patient's limb function score were statistically analyzed by using independent sample T test.Results1.The average volume of bone defect in 34 patients after primary degenerative surgery was 116.8cm~3(31.4?251.2cm~3).Because of poor soft tissue condition,the wound could not be effectively closed in 5 patients with myelitis.The drainage tube is placed for 7-14days,an average of 11.9 days,the whole body application antibiotic time is 1.5-3 weeks,the average time is 2.3 weeks,and the antibiotic bone cement interplanting time is an average of 11.6 weeks.In 10 patients,bone transplantation was performed only with autologous loose bone,16 with autologous+allograft and 8 with tissue engineering bone.2.The average follow-up time of 34 patients was 24 months(23 to 25 months)and there were no missing cases.None of the patients had serious complications(such as metastasis of infection lesion and amputation of limb function).The imaging examination showed that the average time for bone healing was 6.5 months(5 to 9 months),and that patients could carry normal weight during an average of 6 months(4 to 9 months).Among them,three patients had repeated degenerative surgery due to the recurrence of infection after one stage of surgery.All patients did not experience a relapse of infection during the follow-up period of about two years.29(85%)patients with lower extremity function recovered well and were able to participate in physical labor normally.In 5 patients,the adjacent joint function was reduced to stiffness and was able to perform normal daily life.3.There was no significant difference in the duration of healing after bone transplantation,length of bone defect repair,selection of fixations,source of bone graft,and length of PMMA in vivo placement(p>0.05).There was a statistical difference between the duration of healing after bone transplantation and the age,constitution,duration of onset,and the site of infection(whether adjacent joints)(p<0.05).Time of weight-bearing,tobacco and alcohol addiction were also correlated in the clinical follow-up survey,which could slow down the rate of bone healing.The reduction of joint function and stiffness were mainly related to the patient's inability to tolerate functional exercise and the use of external fixator for adjacent joints or cross-joints.Conclusions1.Induced membrane technique is an effective and reliable method for the treatment of hematogenous osteomyelitis in the lower extremities.The first stage of thorough debridement and wound healing is a necessary condition.Complete control of infection,induction of membrane formation and adequate bone grafting in the second stage can effectively promote bone healing and cure osteomyelitis.Finally,the curative effect of the disease is guaranteed and the quality of life of patients is improved.2.Patients with poor soft tissue coverage,complications,and general physical conditions are all factors that hinder the recovery.Appellate factors can lead to the failure of the operation at different stages.Preoperative definition of infection range of bone and soft tissue,effective covering of soft tissue during surgery and choice of internal fixation are all prerequisites for improving the infection clearance rate and preserving the maximum function of the affected limb.The cure rate of hematogenous osteomyelitis can be achieved by the clean dressing change after operation,adequate drainage,the application of systemic sensitive antibiotics and the accurate grasp of the time of the presence of local antibiotic bone cement... |
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