糖尿病足趾坏疽经趾骨截趾联合皮缘缝合的疗效及其影响因素

目的探讨Wagner 3~4级糖尿病足趾坏疽患者经趾骨截趾联合皮缘缝合的疗效,并对其影响因素进行分析。方法回顾性分析2016年1月至2020年6月空军特色医学中心内分泌科收治的,发生于足趾部的糖尿病坏疽且Wagner分级3~4级的患者资料,均行经趾骨截趾联合皮缘缝合术。根据创面愈合情况将患者分为甲级愈合组和非甲级愈合组,观察两组患者的临床资料,并采用t检验、非参数检验和χ²检验进行比较;根据术后是否应用抗生素及抗生素应用疗程分为未用抗生素组、抗生素应用7 d组和抗生素应用14 d组,比较各组患者的创面甲级愈合率;根据术后缝合情况,将患者分为一期缝合组和延期缝合组,比较各组患者的创面甲级愈合率。采用Kaplan-Meier生存曲线分析一期缝合与延期缝合组间创面随时间变化的愈合率。结果 45例患者纳入研究,44例(97.8%)患者创面愈合,缝合至创面愈合时间为14(14,20)d。甲级愈合33例(73.3%),乙级及丙级愈合11例(24.4%),1例(2.2%)行更高平面截肢。甲级愈合组趾肱指数(TBI)≥0.7为60.6%(20/33),高于非甲级愈合组16.7%(2/12),差异有统计学意义(χ²=5.155,P=0.023)。术后抗生素甲级愈合组84.8%(28/33)高于非甲级愈合组的25.0%(3/12),差异有统计学意义(χ²=12.047,P=0.001)。术后未用抗生素组14例,甲级愈合5例;抗生素应用7 d组17例,甲级愈合16例;抗生素应用14 d组14例,甲级愈合12例。术后抗生素应用7 d组与应用14 d组创面甲级愈合率差异无统计学意义(P=0.859)。一期缝合组37例,甲级愈合率78.4%(29/37);延期缝合组8例,甲级愈合4例。一期缝合组截趾术至创面愈合时间14.00(14.00,14.00)d,延期缝合组19.50(18.25,28.75)d,差异有统计学意义(Z=-3.591,P=0.001)。结论对于糖尿病足趾坏疽的患者,在软组织感染得到有效控制下,TBI≥0.7时截趾联合一期缝合并辅以短期抗感染治疗是糖尿病足趾坏疽患者的有效治疗方案。

Therapeutic effect and influencing factors of toe amputation combined with skin edge suture in diabetic toe gangrene

Objective To investigate the therapeutic effect and analyze the influencing factors of toe amputation combined with skin edge suture in patients with diabetic toe gangrene at Wagner stage 3 to 4.Methods The clinical data of 45 patients with diabetic toe gangrene underwent toe amputation combined with skin edge suture in Department of Endocrinology of Air Force Medical Center from January 2016 to June 2019 were retrospectively analyzed.The patients were divided into grade A healing group and non-grade A healing group according to the postoperative wound healing.The clinical data of the two groups were compared by t test,nonparametric test and chi square test.According to whether antibiotics were applied after surgery and the course of antibiotic application,they were divided into the group without antibiotics,the group with 7 days of antibiotics and the group with 14 days of antibiotics,then wound grade A healing rates between groups were compared.According to the postoperative suture,the patients were divided into a primary suture group and a delayed suture group,and the wound grade A healing rates of both groups were compared.Kaplan-Meier survival curve analysis was used for the wound healing rate over time between primary and delayed suture groups.Results Forty-five patients were included in the study.The time from suture to wound healing was 14(14,20)days.Among them,there were 33(73.3%)patients of grade A healing,11(24.4%)patients of grade B or C healing,and 1 patient(2.2%)underwent higher level amputation.The proportion of toe branchial index(TBI)≥0.7 in grade A healing group was higher than that in non-grade A healing group60.6%(20/33)vs.16.7%(2/12),χ2=5.155,P=0.023].The proportion of postoperative antibiotics use in grade A healing group was higher than that in non-grade A healing group84.8%(28/33)vs.25%(3/12),χ2=12.047,P=0.001].There were 14 cases in the group without antibiotics,5 cases with grade A healing;17 cases in the group with antibiotics for 1 week,16 cases with grade A healing;14 cases in the group with antibiotics for 2 weeks,12 cases with grade A healing.There was no significant difference in wound healing rate between the patients who used postoperative antibiotics for 7 days and 14 days(P=0.859).There were 37 cases in primary suture group,with grade A healing rate of 78.4%(29/37),and 8 cases in delayed suture group,4 cases with grade A healing rate.The postoperative wound healing time of primary suture group was shorter than that of delayed suture group14.00(14.00,14.00)days vs.19.50(18.25,28.75)days,Z=-3.591,P=0.001].Conclusion Under the effective control of soft tissue infection,toe amputation combined with primary suture and short-term anti-infective therapy is an effective treatment for patients with diabetic toe gangrene when TBI≥0.7.