Treating Chronic Osteomyelitis of the Lower Extremities - Are Muscle Flaps Better than Fasciocutaneous Flaps? - A Retrospective Review of 20-Years of NTUH Experience and a Systematic Review of the Literature

下肢慢性骨髓炎的治療方式－肌肉皮瓣真的優於筋膜皮膚皮瓣嗎？臺大醫院二十年治療經驗及系統性文獻回顧

劉昌杰(Tom J. Liu) ； 戴浩志(Hao-Chih Tai) ； 簡雄飛(Hsiung-Fei Chien)

《臺灣整形外科醫學會雜誌》 25卷3期 (2016/09) Pp. 204-216

摘要

背景：慢性骨髓炎是一個棘手的疾病，必須合併抗生素及外科治療才能達到治癒的目的。外科的治療方法包含確實的清創以及使用富含血流的組織覆蓋。然而，目前對於該使用肌肉皮瓣還是筋膜皮膚皮瓣仍有所爭論。目的及目標：進行一個含有對照組的回溯性研究及系統性文獻回顧，比較肌肉皮瓣和筋膜皮膚皮瓣治療下肢慢性骨髓炎的效果。材料及方法：一、回溯性研究：檢閱自西元1991年至2013年所有在台大醫院被診斷為下肢慢性骨髓炎並經過皮瓣重建的病歷。最後總共有26位住院案例符合篩選條件，其中18位經由肌肉皮瓣、8位經由筋膜皮膚皮瓣重建。我們又按照自由或是根蒂皮瓣再分成四個子群組，蒐集並比較多項參數，期能找到最適合治療病人的方式。二、系統性文獻回顧：我們至多個醫學資料庫查找近三十年所有相關的文獻並剔除案例數少於十例者，最後有13篇文獻被我們引用。結果：在回溯性研究中，所有個案的治療成功率是65.3%。有三個皮瓣壞死發生在自由肌肉皮瓣的子群組。有六個復發感染的案例分別發生在根蒂與自由肌肉皮瓣以及根蒂筋膜皮膚皮瓣的子群組中。在子群組的比較中，自由筋膜皮膚皮瓣有顯著較高的治療成功率。在系統性文獻回顧中，我們發現自由筋膜皮膚皮瓣雖然有較高的治療成功率(92%)但與其他三者之間沒有統計上的顯著。結論：這篇回溯性的研究以及系統性回顧發現筋膜皮膚皮瓣用於治療下肢慢性骨髓炎有不亞於肌肉皮瓣的效果。然而，將來仍需要蒐集更多的案例以及進行更嚴謹的研究來得到更可信的結果。

並列摘要

Background: Surgical treatment of chronic osteomyelitis requires radical debridement, obliteration of dead space, and wound coverage by vascularized tissue transfer. Controversy remains about the relative effectiveness of muscle flaps and fasciocutaneous flaps in eradicating chronic osteomyelitis. Aim and Objectives: To compare by retrospective chart review and by systematic review the effectiveness of treatment of chronic osteomyelitis in the lower extremities using either muscle flaps or fasciocutaneous flaps. Material and Methods: This retrospective study included 26 admissions (22 patients) diagnosed with chronic osteomyelitis of the lower extremities and treated with flap reconstruction at National Taiwan University Hospital from 1991 to 2013. Of these admissions, 18 admissions underwent muscle flap reconstruction (M group), of which 11 received pedicled muscle flaps (PM subgroup) and 7 free muscle flaps (FM subgroup); and 8 admissions underwent fasciocutaneous flap reconstruction (FC group), of which 2 pedicled fasciocutaneous flaps (PFC subgroup) and 6 free fasciocutaneous flaps (FFC subgroup). The two groups and four subgroups were compared with respect to patient characteristics, surgical complications and treatment outcomes. A systematic review was conducted by searching medical databases in the past 30 years for flap reconstructions of chronic osteomyelitis in the lower extremities. Only studies in which there were more than 10 cases were included; a total of 13 publications were included. We combined the total cases and success cases and sorted them into 4 subgroups like our retrospective study. Results: In the retrospective study, the two main groups had no significant differences except regarding complication rate. The four subgroups had no significant differences except regarding treatment success rate. Total treatment success rate was 65.3%. Three flap losses occurred in the M group, all of which were in the FM subgroup. 5 recurrent infections were noted in the M group, of which 2 were in the FM subgroup and 3 in the PM subgroup. One recurrent infection was encountered in the PFC subgroup. Two minor complications, a hematoma and an external skeletal fixation (ESF) infection, occurred in the PM subgroup. The complication rates of these two groups were significantly different (55.6% in the M group and 12.5% in the FC group, p= 0.04) and the treatment success rates of these four subgroups were significantly different (73%, 29%, 50% and 100% in the PM, FM, PFC, and FFC subgroup, respectively; p=0.049). Systematic review found that the success rate was higher in the FFC subgroup but the difference was not significant (84%, 83%, 78% and 92% in the PM, FM, PFC, and FFC subgroup, respectively; p=0.096). Conclusions: Our retrospective study and systematic review found that muscle flaps and fasciocutaneous flaps for reconstruction of chronic osteomyelitis defects of the lower extremities had an equal treatment success rate. We chose a given flap-type based on the lesion site and size, the decision of the patient after careful explanation of the relative advantages and disadvantages of the flap-types, and the surgeon’s preference, confidence, and familiarity with the flap-types. Further study involving more patients should be conducted to achieve more convincing outcomes.

並列關鍵字

chronic osteomyelitis ； lower extremities ； muscle flap ； fasciocutaneous flap ； recurrence