1、创伤修复骨搬运治疗胫骨骨缺损中轴向偏移的危险因素分析冯东伟1,张雅欣1,武伟泽1,格格热1,丁佳楠1,王旭东1,李 东1,罗永洁1,赵 勇3,刘 鑫1,宋亚茹1,卞 睿1,张 旭1,贾和平1,马 创2 1.河北北方学院附属第一医院,河北 张家口 075000;2.新疆医科大学附属第一医院,乌鲁木齐 830054;3.康保县人民医院,河北 康保 076650【基金项目】国家自然科学基金(81760397);优秀青年科技人才培养项目(2019Q041)【共同第一作者】张雅欣【通信作者】贾和平,E-mail:13833308817 马创,E-mail:1516175919 【摘要】目的 探讨单臂外固
2、定架(Orthofix)胫骨近端截骨骨搬运治疗胫骨骨缺损中轴向偏移的危险因素。方法 回顾性分析 2016 年 3 月2019 年 7 月河北北方学院附属第一医院采用 Orthofix 治疗的 41 例胫骨骨缺损中骨搬运段发生偏移患者资料,男性 34 例,女性 7 例;年龄 1858 岁,平均 35.9 岁;道路交通伤28 例,摔伤 9 例,其他 4 例。41 例均为创伤后骨髓炎。根据 Paley 轴向偏移的分类标准,分成无轴向偏移组(22 例)和轴向偏移组(19 例),无轴向偏移组偏移角度5,轴向偏移组偏移角度5。比较两组患者一般资料及不同时期的影像学资料,采用多因素分析不同参数与轴向偏移的关
3、系。结果 患者均随访 1240 个月,平均22.5 个月。外固定装置拆除之前骨搬运段偏移40 例,外固定架拆除之后1 例。其中冠状面成角34例,成角 2.217.5,平均 6.33;矢状面成角 21 例,成角 1.511.8,平均 4.53。轴向偏移 19 例,通过更换 Schanz 钉调整力线以及对接端植骨后力线得到纠正 18 例。拆除外固定装置后患肢过度负重出现偏移 1例,行自体植骨钢板内固定治疗后力线得到恢复。单因素分析的结果提示,截骨平面、既往手术次数、骨缺损长度以及 Schanz 钉弯曲角度是轴向偏移的危险因素,而在置钉模式、Schanz 钉置入角度、外固定时间、对接时间及外固定指数
4、等方面比较差异无统统计学意义。多因素分析结果提示,截骨平面(OR=1.481,95%CI=1.1501.908)以及骨缺损距离(OR=1.728,95%CI=1.0272.906)是发生轴向偏移的独立危险因素。结论 采用 Orthofix 胫骨近端截骨行骨搬运的治疗中,骨搬运段会出现不同程度的轴向偏移,其中骨缺损距离越大越容易发生轴向偏移,截骨平面越靠近干骺端越不容易发生轴向偏移。【关键词】胫骨骨缺损;骨搬运;外固定架;轴向偏移;危险因素【中图分类号】R 683.42 【文献标识码】A 【DOI】10.3969/j.issn.1009-4237.2023.06.009Risk factors
5、of axial deviation during bone transport technique for tibial bone defects Feng Dongwei1,Zhang Yaxin1,Wu Weize1,Ge Gere1,Ding Jianan1,Wang Xudong1,Li Dong 1,Luo Yonghao1,Zhao Yong3,Liu Xin1,Song Yaru1,Bian Rui1,Zhang Xu1,Jia Heping1,Ma Chuang21.The First Affiliated Hospital of Hebei North College,Zh
6、angjiakou,Hebei 075000,China;2.Department of Microrepair and Recon-struction,the First Affiliated Hospital of Xinjiang Medical University,Urumqi 830054,China;3.Kangbao Country Peoples Hospital,Kangbao,Hebei 076650,China【Abstract】Objective To investigate the risk factors of axial deviation in the tre
7、atment of tibial bone de-fects by using bone transport technique with the monolateral rail system(Orthofix).Methods From Mar.2016 to Jul.2019 in our hospital,41 patients with deviation during their bone transport by Orthofix for tibial bone defects were retrospectively analyzed.There were 34 males a
8、nd 7 females aged 18-58 years,mean 35.9 years.The injury mechanisms were road traffic injuries in 28 patients,falls in 9 and others in 4.All the 41 cases had chronic osteomy-elitis.Based on the Paley axial deviation complication criteria,patients were divided into no axial deviation group with a dev
9、iation angle 5(n=22)and axial deviation group with a deviation angle 5(n=19).The demo-graphic data and imaging data at all time-points were analyzed by univariate and multivariate analysis.Results Pa-tients were followed up for 12-40 months,mean 22.5 months.Deviation of the transported bony segment
10、was ob-served in 40 patients before the removal of external fixators and in the rest one patient after the removal procedure.Among them,there were 34 cases of coronal plane angulation(2.2-17.5,mean 6.33)and 21 cases of sagittal plane angulation(1.5-11.8,mean 4.53).Axial deviation occurred in 19 case
11、s.The force line of 18 cases was 344创伤外科杂志 2023 年第 25 卷第 6 期 J Trauma Surg,2023,Vol.25,No.6well adjusted by replacing Schanz nail to reach a satisfactory level.For the rest case which experienced excessive weight bearing of the affected limb,resulting in valus deformity in the docking end,the force
12、line was corrected after internal fixation with autograft bone plate,and the bone healed in the end.The results of univariate analysis sugges-ted that the osteotomy plane size,times of previous surgeries,length of bone defects,and degrees of Schanz screw bending were the risk factors for axial devia
13、tion(big data for a higher risk),but the results for Schanz placement mode,Schanz placement angle,external fixation duration,docking time and external fixation index were negative.Further analysis by multivariate analysis showed that the osteotomy plane(OR=1.481,95%CI=1.150-1.908)and the length of b
14、one defect(OR=1.728,95%CI=1.027-2.906)were independent risk factors for axial deviation.Conclusion During the treatment of tibial bone defects by bone transport technique with a unilateral external fix-ator(Orthofix),axial deviation may occur in the transported bony segment.The larger the defect siz
15、e,the easier axi-al deviation occurs;the closer the osteotomy line to the metaphysis,the harder axial deviation occurs.【Key words】Tibial bone defects;Bone transport;External fixators;Axial deviation;Risk factors Ilizarov 技术主要用于治疗创伤、感染和肿瘤造成的四肢长骨骨缺损1。该技术遵循张力-应力法则,在外固定装置的辅助作用下,最终骨缺损得到修复2-3。20 世纪 70 年代
16、Bastiani 依据 Ilizarov 原理研发出单臂外固定架(Orthofix)。与环形外固定架比较,单臂外固定架具有佩戴简便、容易安放等独特优势4,且根据文献记载 Orthofix 与环形外固定架在治疗长骨骨缺损中的疗效相似5,但并发症的种类上还存在一定差异,尤其是轴向偏移6。报道使用 Orthofix 行骨搬运时发生轴向偏移的概率较环形外固定更大,这可能是由于单臂外固定装置相对不稳定所导致7。当搬运过程中发生轴向偏移时,不仅会对患侧的整体力线产生影响,而且对接端延迟愈合和再骨折的概率也随之增大8。本研究回顾性分析 2016 年 3 月2019 年 7 月河北北方学院附属第一医院应用 Orthofix 行胫骨骨搬运治疗的 41例胫骨骨缺损并发生偏移的患者,对患者不同时期的影像学资料进行分析,分析轴向偏移的相关危险因素。临床资料1 一般资料纳入标准:(1)诊断胫骨创伤后慢性骨髓炎,并接受 Orthofix 治疗的胫骨中段骨缺损;(2)年龄 1865 岁;(3)骨缺损长度3cm;(4)骨搬运出现偏移。排除标准:(1)病理性骨折导致的骨缺损;(2)合并神经血管损伤以及影响骨愈合的全身代
