骨搬运技术联合局部载庆大霉素硫酸钙治疗胫骨感染性骨不连1例

2019-10-06 赵行琪 姜楠 林庆荣 生物骨科材料与临床研究

患者,女,18岁。车祸致左侧胫腓骨闭合性骨折,当地医院行切开复位钢板内固定。患者既往体健,无吸烟史。术后因切口愈合差以及反复流脓行多次清创手术,效果不佳。术后7个月,患者行钢板内固定取出手术,切口问题无明显改善,仍间断性流脓。患者于伤后11个月就诊于本院,生命体征平稳。专科查体可见右侧小腿前内侧有一约20CM长纵行切口瘢痕,局部有压痛,手术瘢痕中段可见0.5CM×0.5CM窦道,有脓性分泌物流出(

近年来,骨折内固定术后感染患者的数量不断增加,发生率为0.4%~16.1%。在处理此类疾病所需面临的两个关键问题是:如何判断感染所波及的范围;如何在彻底清除感染病灶后进行有效的骨缺损重建。既往传统的骨搬运技术仅为骨的延长技术,并不进行局部抗生素载体使用,这样在治疗过程就容易出现两种情况:搬运骨端可能会出现骨硬化及骨吸收,造成搬运端无法融合,需进行翻修手术或是植骨治疗;由于局部缺乏高浓度的抗生素,使得感染复发的风险大大提高。


故而,局部使用抗生素载体进行骨缺损填充是很有必要的。聚甲基丙烯酸甲酯(PMMA)是目前最常用的抗生素载体,但由于其不可生物降解且生物相容性较差的特性,使得其在骨搬运过程中能够发挥的作用有限。与之相比,硫酸钙是一种生物可降解材料,生物相容性佳且可载抗生素,使得其在感染性骨不连的治疗中越发受到青睐。本文笔者即报道1例胫骨感染性骨不连在骨搬运技术治疗中,联合采用硫酸钙载庆大霉素进行骨缺损填充,并对其随访结果进行汇报。


病例资料


患者,女,18岁。车祸致左侧胫腓骨闭合性骨折,当地医院行切开复位钢板内固定。患者既往体健,无吸烟史。术后因切口愈合差以及反复流脓行多次清创手术,效果不佳。术后7个月,患者行钢板内固定取出手术,切口问题无明显改善,仍间断性流脓。患者于伤后11个月就诊于本院,生命体征平稳。专科查体可见右侧小腿前内侧有一约20CM长纵行切口瘢痕,局部有压痛,手术瘢痕中段可见0.5CM×0.5CM窦道,有脓性分泌物流出(见图1A)。实验室血清炎症因子检查显示患者白细胞计数(WBC=5.93×109/L)[正常范围,(4~10)×109/L]、血沉(ESR=16.0mm/1h)[正常范围(0~20)mm/1h]以及C反应蛋白(CRP=1.6mg/L)[正常范围(0~5)mg/L]皆在正常范围之内。X线检查结果示左侧胫骨内侧骨皮质及后侧骨皮质不连续(见图1B、图1C)。基于X线检查,该患者可明确诊断为骨不连。窦道的存在提示该患者可能存在感染,进一步的核磁共振检查提示该患者有一个胫骨中段有一5.8CM×1.1CM的信号改变病灶,所以该患者的最终诊断为感染性骨不连(见图1D)。考虑彻底清创,去除这一感染病灶会造成较大的骨缺损,术前计划对该患者采用骨搬运技术联合局部载庆大霉素硫酸钙进行骨缺损的修复重建。


1.png


患者体位:患者麻醉满意后,取仰卧位,碘酒、酒精消毒后铺无菌单。左下肢功能位状态下,于胫骨中内侧安装外固定架。手术切口:以窦道中心做一约6CM的纵行切口,可见组织炎症反应明显,大量脓液流出。彻底清创:分离软组织至胫骨,可见胫骨陈旧性骨折端未愈合,疤痕增生。对病灶骨组织及软组织进行彻底清创,直至骨折两断端出现“红辣椒征”(Paprikasign):用骨刀沿骨折端向上切除约4CM胫骨,向下切除约3CM胫骨。截骨搬运:使膝关节屈曲100°,在胫骨平台前方斜坡处纵行切开髌韧带,暴露胫骨平台,用开口器开窗,然后依次用7号、8号扩髓钻顺行穿过截骨断端至胫骨远端扩髓,骨刀切断胫骨平台下10CM截骨。骨粉填充:用脉冲枪冲洗各手术切口及断端骨髓腔,随后将10cc医用硫酸钙(U.K.)与16万单位的庆大霉素进行均匀混合,填充至胫骨髓腔及去除死骨后的骨缺损部位,最后锁紧外固定架。C臂透视确认胫骨上端骨搬运处骨折对位对线良好,外固定架牢靠,以及载庆大霉素硫酸钙填充胫骨骨髓腔及骨缺损处。再次大量生理盐水冲洗各切口,逐层缝合各切口,无菌敷料及弹力绷带包扎。术中取多点组织进行培养,术后培养结果显示该患者为金黄色葡萄球菌感染。同时,组织病理学检查亦确定该患者为慢性化脓性骨髓炎改变(见图2)。所以,对该患者的最终诊断为胫骨感染性骨不连。术后1周患者开始进行骨搬运,搬运速度为1mm/d,分4次进行。术后1个月复查X线,可见搬运端新骨形成,同时硫酸钙部分吸收(见图3A)。术后2个月,新骨矿化且硫酸钙大部分吸收(见图3B)。术后半年,硫酸钙完全吸收,新骨进一步矿化,同时可见新骨皮质再通且接触端(dockingsite)处骨折开始愈合(见图3C)。术后1年,新骨基本完全矿化,髓腔再通,同时可见接触端处骨折已达影像学愈合(见图3D),随后进行外固定架拆除。在整个骨搬运过程中,患者未诉不良事件或是并发症的发生。末次随访时间为术后18个月,Paley功能评分为优秀,SF-36量表评分为98分(见图4)。


2.png


3.png


4.png


讨论


根据美国FDA在1986年的定义,骨不连为骨折术后半年未见骨折愈合且继续连续观察3个月仍未在X线上看到骨折愈合征象的一种骨折并发症。可以根据患者的病史以及X线表现进行骨不连的诊断,同时可根据一系列的并发体征进行感染性骨不连的诊断。而如何从感染范围来判断清创范围的大小,骨折相关感染/骨折内固定术后感染(FRI)的诊断确立应根据患者的病史、体征、影像学检查、血清和/或局部炎症因子水平以及病原微生物的培养结果,目前FRI的诊断“金标准”为组织病理学检查。根据X线检查结果的皮质连续性与否可以进行骨不连的诊断,但X线检查反映性新骨形成等征象也仅能告诉我们“可能”存在感染。相比之下,核磁共振检查可以清晰看到感染病灶并明确其范围,比X线检查更为敏感。核磁的这一特性能够帮助临床医师明确所需清创的范围,彻底清除感染。另外,一些研究也指出,核磁共振检查可在术后感染发生的1~2d即可发现感染。


回顾本文的这一病例,其感染征象并不典型,血清炎症因子结果也属正常。既往研究指出,通过综合WBC、ESR以及CRP三个指标的阳性数量可帮助判断骨不连患者是否存在感染。当三者全部为阳性时,骨不连患者可确诊为感染性骨不连;当三者全阴时,仍有19.6%的可能为感染性骨不连。也就是说,当在评价以上三个血清炎症因子时,不能因为三者都为阴性即排除感染,我们所提供的这例患者就属于这一情况。


骨缺损的重建技术可根据缺损长度选择,骨搬运技术通常用于缺损超过4~6CM的重建,与其他重建技术相比,其优点在于相对微创、使用方便且可延长部位多样。感染性骨不连治疗的关键在于如何在彻底清创形成大段骨缺损时对这一缺损进行重建。传统的骨搬运技术在治疗骨缺损时是不使用抗生素载体进行填充的,仅仅是利用外固定架在截骨后进行骨的搬运延长。在搬运的过程中,使用抗生素载体,局部维持抗生素的高浓度,可以有效预防感染的复发。所以,推荐感染性骨不连在使用骨搬运技术治疗时,联合应用抗生素载体填充骨缺损部位。


近年来,硫酸钙作为抗生素载体在临床上广泛使用,尤其在慢性骨髓炎的治疗方面取得令人非常满意的效果。也有许多研究对比硫酸钙和既往广泛使用的PMMA作为抗生素载体在感染性骨缺损治疗上的优劣。Howlin等的研究指出假体周围感染的治疗时,硫酸钙载抗生素应用可显著降低甚至清除假体周围组织及假体材料表面的生物膜形成,故而能够降低关节置换术后假体周围感染的发生率。McKee等的一项RCT研究分别比较了采用载抗生素的硫酸钙与载抗生素的PMMA治疗慢性骨髓炎的临床疗效,其研究结果显示硫酸钙在清除感染的效果方面与PMMA无显著差异。另外,因硫酸钙可被机体降解吸收,所以无需像PMMA进行二次手术取出。McConoughey等也进行了类似的研究,其在结论中指出,硫酸钙载抗生素抑制细菌生长的效果与PMMA载抗生素效果相似甚至更优。


本例患者的治疗选择硫酸钙替代PMMA作为骨缺损填充材料主要基于以下原因:PMMA作为骨缺损填充材料时,因不可被机体降解,通常需进行二次手术将其取出。而硫酸钙的一大特点是可被人体降解吸收,这就意味着其所载抗生素释放后并不会有异物残留,不为生物膜的形成提供表面(后期局部抗生素水平低,达不到最低抑菌浓度,异物的留存为生物膜的形成提供可能)。此外,生物相容性以及成骨诱导性的比较上,硫酸钙也是优于PMMA的。不同塑形后,PMMA与周围组织接触面积不定,继而导致抗生素释放速率不定,可能会影响抗菌效果。同时,PMMA在植入机体后具有产热效应,无疑会影响与之相结合的热敏感抗生素的抗菌效果。另外,载抗生素后的硫酸钙可在局部维持一个相当长时间的高浓度抗生素环境,其抗生素的释放伴随着自身的降解,因而能够降低感染的复发率。感染性骨缺损局部放置硫酸钙可起到占位效果,防止在搬运过程中的软组织卡压、阻挡骨搬运,这对于搬运段在接触端处与另一端相接髓腔再通是非常有利的。


综上所述,感染性骨不连的诊断需多方面综合考虑,血清炎症因子水平正常并不能排除感染,骨感染诊断的“金标准”为组织病理学检查。作为一种近年来新兴的抗生素载体,硫酸钙可弥补PMMA的诸多不足。本文所提供病例的诊治过程表明,长骨感染性骨不连,尤其是在彻底清创后存在较大骨缺损时,采用骨搬运技术联合局部载抗生素硫酸钙治疗时,可取得非常好的效果。


原始出处:


赵行琪,姜楠,林庆荣,胡岩君,余斌.骨搬运技术联合局部载庆大霉素硫酸钙治疗胫骨感染性骨不连1例[J].生物骨科材料与临床研究,2019,16(04):43-45.

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  2. [GetPortalCommentsPageByObjectIdResponse(id=2042990, encodeId=3f43204299009, content=<a href='/topic/show?id=72661016690b' target=_blank style='color:#2F92EE;'>#骨感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101669, encryptionId=72661016690b, topicName=骨感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7dc7399, createdName=apoenzyme, createdTime=Fri Dec 06 18:57:00 CST 2019, time=2019-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655470, encodeId=5a6416554e09c, content=<a href='/topic/show?id=7c2853311ac' target=_blank style='color:#2F92EE;'>#感染性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53311, encryptionId=7c2853311ac, topicName=感染性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=583d24724321, createdName=charl1234575, createdTime=Fri Jan 03 11:57:00 CST 2020, time=2020-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1404883, encodeId=c2d0140488332, content=<a href='/topic/show?id=7f234920369' target=_blank style='color:#2F92EE;'>#庆大霉素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49203, encryptionId=7f234920369, topicName=庆大霉素)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=74f82496953, createdName=shizhenshan, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1405934, encodeId=2f6a1405934a1, content=<a href='/topic/show?id=a5404e589d7' target=_blank style='color:#2F92EE;'>#局部#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47589, encryptionId=a5404e589d7, topicName=局部)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d14c2562456, createdName=chg122, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412177, encodeId=e55514121e74e, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601037, encodeId=f12e160103e0d, content=<a href='/topic/show?id=a1bc101698a3' target=_blank style='color:#2F92EE;'>#骨搬运#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101698, encryptionId=a1bc101698a3, topicName=骨搬运)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6dd418824680, createdName=yangpeizhi, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=2042990, encodeId=3f43204299009, content=<a href='/topic/show?id=72661016690b' target=_blank style='color:#2F92EE;'>#骨感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101669, encryptionId=72661016690b, topicName=骨感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7dc7399, createdName=apoenzyme, createdTime=Fri Dec 06 18:57:00 CST 2019, time=2019-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655470, encodeId=5a6416554e09c, content=<a href='/topic/show?id=7c2853311ac' target=_blank style='color:#2F92EE;'>#感染性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53311, encryptionId=7c2853311ac, topicName=感染性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=583d24724321, createdName=charl1234575, createdTime=Fri Jan 03 11:57:00 CST 2020, time=2020-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1404883, encodeId=c2d0140488332, content=<a href='/topic/show?id=7f234920369' target=_blank style='color:#2F92EE;'>#庆大霉素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49203, encryptionId=7f234920369, topicName=庆大霉素)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=74f82496953, createdName=shizhenshan, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1405934, encodeId=2f6a1405934a1, content=<a href='/topic/show?id=a5404e589d7' target=_blank style='color:#2F92EE;'>#局部#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47589, encryptionId=a5404e589d7, topicName=局部)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d14c2562456, createdName=chg122, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412177, encodeId=e55514121e74e, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601037, encodeId=f12e160103e0d, content=<a href='/topic/show?id=a1bc101698a3' target=_blank style='color:#2F92EE;'>#骨搬运#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101698, encryptionId=a1bc101698a3, topicName=骨搬运)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6dd418824680, createdName=yangpeizhi, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=2042990, encodeId=3f43204299009, content=<a href='/topic/show?id=72661016690b' target=_blank style='color:#2F92EE;'>#骨感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101669, encryptionId=72661016690b, topicName=骨感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7dc7399, createdName=apoenzyme, createdTime=Fri Dec 06 18:57:00 CST 2019, time=2019-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655470, encodeId=5a6416554e09c, content=<a href='/topic/show?id=7c2853311ac' target=_blank style='color:#2F92EE;'>#感染性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53311, encryptionId=7c2853311ac, topicName=感染性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=583d24724321, createdName=charl1234575, createdTime=Fri Jan 03 11:57:00 CST 2020, time=2020-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1404883, encodeId=c2d0140488332, content=<a href='/topic/show?id=7f234920369' target=_blank style='color:#2F92EE;'>#庆大霉素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49203, encryptionId=7f234920369, topicName=庆大霉素)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=74f82496953, createdName=shizhenshan, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1405934, encodeId=2f6a1405934a1, content=<a href='/topic/show?id=a5404e589d7' target=_blank style='color:#2F92EE;'>#局部#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47589, encryptionId=a5404e589d7, topicName=局部)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d14c2562456, createdName=chg122, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412177, encodeId=e55514121e74e, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601037, encodeId=f12e160103e0d, content=<a href='/topic/show?id=a1bc101698a3' target=_blank style='color:#2F92EE;'>#骨搬运#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101698, encryptionId=a1bc101698a3, topicName=骨搬运)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6dd418824680, createdName=yangpeizhi, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=)]
    2019-10-08 chg122
  5. [GetPortalCommentsPageByObjectIdResponse(id=2042990, encodeId=3f43204299009, content=<a href='/topic/show?id=72661016690b' target=_blank style='color:#2F92EE;'>#骨感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101669, encryptionId=72661016690b, topicName=骨感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7dc7399, createdName=apoenzyme, createdTime=Fri Dec 06 18:57:00 CST 2019, time=2019-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655470, encodeId=5a6416554e09c, content=<a href='/topic/show?id=7c2853311ac' target=_blank style='color:#2F92EE;'>#感染性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53311, encryptionId=7c2853311ac, topicName=感染性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=583d24724321, createdName=charl1234575, createdTime=Fri Jan 03 11:57:00 CST 2020, time=2020-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1404883, encodeId=c2d0140488332, content=<a href='/topic/show?id=7f234920369' target=_blank style='color:#2F92EE;'>#庆大霉素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49203, encryptionId=7f234920369, topicName=庆大霉素)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=74f82496953, createdName=shizhenshan, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1405934, encodeId=2f6a1405934a1, content=<a href='/topic/show?id=a5404e589d7' target=_blank style='color:#2F92EE;'>#局部#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47589, encryptionId=a5404e589d7, topicName=局部)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d14c2562456, createdName=chg122, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412177, encodeId=e55514121e74e, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601037, encodeId=f12e160103e0d, content=<a href='/topic/show?id=a1bc101698a3' target=_blank style='color:#2F92EE;'>#骨搬运#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101698, encryptionId=a1bc101698a3, topicName=骨搬运)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6dd418824680, createdName=yangpeizhi, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=)]
    2019-10-08 yb6561
  6. [GetPortalCommentsPageByObjectIdResponse(id=2042990, encodeId=3f43204299009, content=<a href='/topic/show?id=72661016690b' target=_blank style='color:#2F92EE;'>#骨感染#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101669, encryptionId=72661016690b, topicName=骨感染)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7dc7399, createdName=apoenzyme, createdTime=Fri Dec 06 18:57:00 CST 2019, time=2019-12-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1655470, encodeId=5a6416554e09c, content=<a href='/topic/show?id=7c2853311ac' target=_blank style='color:#2F92EE;'>#感染性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=53311, encryptionId=7c2853311ac, topicName=感染性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=583d24724321, createdName=charl1234575, createdTime=Fri Jan 03 11:57:00 CST 2020, time=2020-01-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1404883, encodeId=c2d0140488332, content=<a href='/topic/show?id=7f234920369' target=_blank style='color:#2F92EE;'>#庆大霉素#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49203, encryptionId=7f234920369, topicName=庆大霉素)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=74f82496953, createdName=shizhenshan, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1405934, encodeId=2f6a1405934a1, content=<a href='/topic/show?id=a5404e589d7' target=_blank style='color:#2F92EE;'>#局部#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=47589, encryptionId=a5404e589d7, topicName=局部)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d14c2562456, createdName=chg122, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412177, encodeId=e55514121e74e, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601037, encodeId=f12e160103e0d, content=<a href='/topic/show?id=a1bc101698a3' target=_blank style='color:#2F92EE;'>#骨搬运#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101698, encryptionId=a1bc101698a3, topicName=骨搬运)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6dd418824680, createdName=yangpeizhi, createdTime=Tue Oct 08 05:57:00 CST 2019, time=2019-10-08, status=1, ipAttribution=)]

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