【作者】 唐保永；

【导师】 张远鹰；

【作者基本信息】 吉林大学 ， 临床医学， 2010， 硕士

【摘要】 感染性骨缺损常是由高能量创伤导致的开放性粉碎性骨折所致。临床一旦发生,常迁延不愈,给医生和患者都带来很大的麻烦。感染性骨缺损的治疗,临床上常用的有两种方法,即传统的清创、灌洗、引流疗法及目前最流行的抗生素骨水泥植入术疗法。传统疗法由于对感染的控制率低的原因已经逐渐淘汰,而抗生素骨水泥植入术在感染性骨缺损的治疗上取得了良好的疗效。但随着抗生素的滥用和细菌耐药性的产生,导致目前常用的单一庆大霉素型抗生素骨水泥植入术疗法往往达不到控制感染的预期目的。近年来发展的万古霉素复合型抗生素骨水泥植入术疗法由于能对导致骨科感染的各种常见菌均起到有效的杀伤作用,故能有效的治愈感染性骨缺损。本文选取我院2007年2月至2009年9月共32例感染性骨缺损患者进行回顾性研究分析,其中治疗组24例,采用VCM复合型抗生素骨水泥植入术(有14例患者曾既往经受传统疗法),对照组8例(有3例患者既往曾接受传统疗法)。结果显示:17例既往经受传统治疗方法(清创、灌洗、引流术)者,1例感染得到控制,感染控制率为5.9%;经我院抗生素骨水泥植入术治疗后,15例感染得到控制,感染控制率为88.2%。治疗组共24例,21例感染得到控制,其治愈率为87.5%;对照组:共8例,有3例感染获得控制,其治愈率为37.5%。统计学处理:两种治疗方法的感染控制率差异有统计学意义(P<0.05);两组治愈率的差异有统计学意义(P<0.05)。由此,我们得出的结论是:1、彻底的清创术联合抗生素骨水泥植入术治疗感染性骨缺损,其临床疗效是肯定的,而准确的细菌培养结果在治疗中起着至关重要的作用。2、抗生素骨水泥在感染性骨缺损的治疗上较传统疗法(清创、灌洗、引流等)疗效更为肯定,具有局部提供有效杀菌浓度抗生素而全身较少毒副作用,能有效的控制感染和填充骨质缺损作用,为二期植骨打下了良好基础。3、万古霉素复合型抗生素骨水泥对感染性骨缺损的临床疗效要优于单一庆大霉素型抗生素骨水泥。4、抗生素骨水泥植入术也有其并发症,要注意添加的抗生素的量。其比值为抗生素量:骨水泥=1:20。5、真空调和方式较人工调和方式对骨水泥的力学特性和生物学特性影响较小。更多还原

【Abstract】 The fractures caused by all kinds of High-Energy injuries become more and more as the development of society, transport and construction, especially are some open fractures. It’s difficult to control the rate of infection in the treatment of the fractures. It’s difficult and it will cost a long time to heal infected bone defect because of the existence of both infection and bone defect. The disease always results in muscular atrophy and segmental scars which bring great inconvenience to the patient’s daily live and sometimes will need a amputation if the infection is out of control. At present there are two therapies to treat the disease which are traditional therapy and implantation of ALAC.We always take the therapy of implantation of ALAC to cure infected bone defect which can supply a high local concentrations of antibiotics with minimal systemic levels. Traditional therapy is less effective than the implantation of ALAC so we abandon traditional therapy instead of the implantation of ALAC.However,the irregular use of antibiotics and bacterial resistance to antibiotics reduce the rate of infection of the single-type gentamicin-loaded bone cement. Clinical research of other types of ALAC and complex types ALAC develop now base on above situation. But the research of complex types of ALAC is not enough. We take the method of VCM-Simplex ALAC to cure infected bone defect in China-Japan Union Hospital Of JiLin University and we also have a good clinical effect on controlling of infection. The article mainly observes the differences of the two methods and different antibiotic-loaded bone cements to find out a more effective treatment.Materials and Methods The retrospective study focuses on 32 patients with infected bone defect who agree to take the treatment of implantation of ALAC from February 2007 to Sep 2009. 45 cases of treatment group with implantation of VCM-Simplex ALAC, 17 males and 7 females; aged 15-68 years, the average age is 48.5 years, which includes 1 patient with humeral fracture, 6 patients with hip fracture, 6 patients with femur fracture,8 patients with tibia fracture, 1 patient with the disease of ankle,1 patient with both tibia fracture and fibula fracture. There are 8 old patients aged beyond 60 years, 3 patients with diabetes, heart disease and hypertension in the group, 1 patient after the surgery of femoral thrombosis and compartment syndrome.Besides, 14 patients have already treated by one or more times by the traditional method. The other treatment include 8 case patients who agree with the method of implantation of single-type gentamicin-loaded bone cement,6 males and 2 females, aged 19-69 years, the average age is 49.4 years. The group includes 1 patient with the disease of ilium, 4 patients with the disease of hip,1 patient with the disease of knee ,2 patients with the disease of tibia. There are 3 old patients aged beyond 60 years, 1 patient with the disease of renal inadequacy and other parts of infection. Besides, there are 3 patients have already take one or more operations of traditional treatment. Treatment We make preoperative routine exam and bacterial culture as well as sensitivity test. Application of prophylactic antibiotics is carried out three days or 5 five days before the operation. There are 32 patients in total in this search who agree to take the treatment of implantation of PMMA antibiotic-loaded bone cement. There are 24 patients in treatment group who agree to the treatment of implantation of VCM-Simplex ALAC. The other group has 8 patients who agree to take the treatment of implantation of Single-Type gentamicin-loaded bone cement. We also make some postoperative examinations for patients such as x-rays of bone , complete blood picture,ESR and CRP. We also take care of the cut and giving intravenous antibiotics for the patients.Result The treatment group are followed-up 4-43 months with a mean of 15.6 months and the Single-Type gentamicin-loaded bone cement group are followed-up 6-39 months with a mean of 25.3 months. There are 17 patients take the treatment of implantation of ALAC who have ever taken the treatment of traditional therapy. They are followed-up 5-39 months with a mean of 17.8 months. One patient of the 17 patients who were treatment by traditional therapy is cured and the curative rate of the traditional therapy is 5.9%.One patient got infected by other reason. The 17 patients were treated with the method of implantation of ALAC in our hospital and 15 patients are cured .The curative rate of the group is 88.2%. 21 patients of the 24 patients are cured in the treatment group and the curative rate is 87.5% .There are 3 patients cured in the group of 8 patients who agree with the method of implantation of Single-Type gentamicin-loaded bone cement. And the curative rate of the group is 37.5%. Statistics processing show that there is difference in the rate of infection controlling between the two therapies. There is difference in curative rate for infection between the two groups.Conclusion 1.Thorough débridement combine implantation of ALAC can led to a good clinical effect in the treatment of infected bone defect, what’s more, an accurate result of the bacterial culture and sensitivity test will play an important role in the treatment of the disease.2.The implantation of ALAC have a batter clinical effect than traditional therapy which can supply a high local concentrations of antibiotics with minimal systemic levels. It provides a good foundation for two-stage bone graft because it can control infection and fill the part of bone defect with ALAC.3.VCM-Simplex ALAC is a better choice than Single-Type gentamicin-loaded bone cement in the treatment of infected bone defect.4. Postoperative complications of the implantation of ALAC could happen and it will cause the fracture of bone cement so we should control the dose of antibiotics within ALAC.And the appropriate rate of antibiotics/bone cement is 1/20. 5.The model of mixing ALAC in the vacuum have a less influence than manual operation in the Mechanical Characteristics and Biological Characteristics.更多还原