Krause Fabian G, deVries Gwyneth, Meakin Colin, Kalla Timothy P, Younger Alastair S E
Foot Ankle Int. 2009 Jun;30(6):486-93. doi: 10.3113/FAI.2009.0486.
Diabetic patients with transmetatarsal amputation (TMA) for chronic forefoot ulceration or necrosis are at high risk for postoperative skin breakdown and subsequent amputation. Locally applied antibiotics may reduce the revision rate and improve the outcome.
In a retrospective comparative study, 60 diabetic patients (65 feet) with forefoot ulceration or necrosis were treated with TMA by three surgeons in three hospitals. In the "beads group'' (46 patients, 49 feet) TMA was combined with local application of bioabsorbable, tobramycin impregnated calcium sulphate beads (OsteoSet-T beads, Wright Medical, Memphis, TN) as a single-stage procedure. The remaining 16 patients had transmetatarsal amputation without beads at the surgeon's discretion and acted as a control group. For all patients, time to healing, length of hospital stay, number of revisions for wound breakdown and conversions to a higher-level amputation were retrospectively reviewed. Of the 60 patients 17 had died and three were lost to followup, leaving 40 patients available for latest followup at 29 months. The Foot & Ankle Outcome Score, Foot Function index, SF-36, and Comorbidity score were recorded.
The revision rate for wound breakdown after TMA was 8.2% (4/49) in the beads group, and 25% (4/16) in the control group (p<0.05). At latest followup, 27% (13/49) in the beads group, and 25% (4/16) in the control group had to be converted to transtibial amputation. Patients in the beads group scored worse for activities of daily living in the FAOS and SF-36 (p < 0.05), and demonstrated more health problems in the Comorbidity scores (not significant), indicating sicker individuals in the beads group.
Bioabsorbable calcium sulphate antibiotic beads may be a useful addition for TMA for patients with non-healing diabetic ulcerations of the forefoot. The single-stage procedure could have a significant impact on the management of diabetic forefoot ulcerations by preventing additional hospital stays, improving the patient's quality of life and minimizing cost.
因慢性前足溃疡或坏死而接受经跖骨截肢术（TMA）的糖尿病患者术后皮肤破溃及后续截肢风险很高。局部应用抗生素可能会降低翻修率并改善治疗效果。
在一项回顾性对照研究中，三家医院的三位外科医生对60例患有前足溃疡或坏死的糖尿病患者（65只脚）实施了TMA。在“珠子组”（46例患者，49只脚）中，TMA与局部应用生物可吸收的、含妥布霉素的硫酸钙珠子（OsteoSet-T珠子，Wright Medical，孟菲斯，田纳西州）作为一期手术联合进行。其余16例患者由外科医生自行决定进行了无珠子的经跖骨截肢术，作为对照组。对所有患者的愈合时间、住院时间、伤口破溃的翻修次数以及转为更高平面截肢的情况进行了回顾性分析。60例患者中，17例死亡，3例失访，40例患者在29个月时可进行最新随访。记录了足踝结局评分、足部功能指数、SF-36和合并症评分。
珠子组TMA术后伤口破溃的翻修率为8.2%（4/49），对照组为25%（4/16）（p<0.05）。在最新随访时，珠子组27%（13/49），对照组25%（4/16）不得不转为胫骨截肢。珠子组患者在FAOS和SF-36的日常生活活动评分中较差（p<0.05），在合并症评分中显示出更多健康问题（无显著性差异），表明珠子组患者病情更重。
对于前足糖尿病溃疡不愈合的患者，生物可吸收硫酸钙抗生素珠子可能是TMA的一种有用辅助手段。一期手术通过避免额外住院、改善患者生活质量和最小化成本，可能会对糖尿病前足溃疡的治疗产生重大影响。
