小腿严重开放性骨折伴软组织缺损的治疗

目的 探讨小腿严重开放性骨折伴软组织缺损(Gustilo ⅢB型或ⅢC型)的治疗方法.方法 1990年1月至2008年12月,收治开放性胫腓骨骨折53例,其中Gustilo ⅢB型45例,ⅢC型8例.软组织缺损面积为6 cm×4 cm～18 cm×8 cm,8例伴骨缺损.急诊行骨折复位同定和血管修复,二期对软组织或骨缺损采用13种53块组织瓣移位或移植修复.骨折外固定支架固定35例,内固定16例,骨牵引及石膏固定2例.皮瓣或肌皮瓣47例,骨皮瓣6例.结果 51例获得随访,时间8个月～9年(平均18个月).骨折顺利愈合44例,愈合时间3.5～9.5个月,平均6.5个月.骨延迟愈合4例,骨不愈合3例,经手术植骨(5例)或骨外固定支架加压同定治疗(2例)均治愈.组织瓣移植53块,成活51块,坏死2块,成活率为96.2%.无截肢病例.结论 Gustilo ⅢB型或ⅢC型小腿严重开放性骨折,初期清创并采用以骨外支架为主的方法固定骨折,二期采用适当组织瓣移植修复软组织或骨缺损,是安全有效的治疗策略.

Treatment of severe open leg fractures complicated by bone or/and soft-tissue defects

Objective To investigate managements of severe open leg fractures complicated by bone or/and soft-tissue defects (Gustilo type Ⅲ B/C).Methods Between January 1990 and December 2008,53 patients (37 males and 16 females;aged 17 to 57 years) were treated for severe open leg fractures complicated by bone or/and soft-tissue defects (Gustilo type Ⅲ B:45;Gustilo type ⅢC:8) .The size of soft-tissue defects ranged from 6 cm×4cm to 18 cm ×8 cm.Bone loss occurred in 8 eases.Twenty-five cases were accompanied by head or thoracoabdominal injuries or traumatic shock.The management protocol consisted of primary debridement,bone stabilization (external fixation in 35 patients,simple internal fixation in 16 and bone traction or plaster cast in 2) and second-stage reconstruction of soft tissue defects and/or bone loss by transfer or transplantation of tissue flaps.Fifty-three tissue flaps of 13 types (47 myocutaneous flaps and 6 osteocutaneous flaps) were used to reconstruct the soft-tissue defects and/or bone loss.Results Of the 53 patients,51 were followed up for an average time of 18 months (range:8 months to 9 years).Primary bone union happened in 44 cases and the healing time of bone was 6.5 months (range:3.5 to 9.5 months).Delayed union of bone was found in 4 cases and non-anion in 3,5 of which were handled with bone grafting and 2 of which with bone compression with external fixator.Of the 53 tissue flaps,51 completely survived and the defects were reconstructed successfully.Two flaps necrosed because of vascular thrombosis and infection.The survival rate of flap was 96.2%.No leg amputation was needed in the series.Conclusion Adequate primary debridement,bone stabilization with external fixator or simple internal fixation and staged reconstruction of soft-tissue/bone defects by vascularized tissue flaps are reliable managements for severe open leg fractures complicated by bone or/and soft-tissue defects (Gustilo type Ⅲ B/C).