Masquelet技术结合小腿皮瓣治疗胫骨感染性骨缺损伴广泛软组织缺损的疗效分析

目的探讨Masquelet技术结合小腿皮瓣治疗胫骨感染性骨缺损伴广泛软组织缺损的疗效。方法回顾性分析2016年3月至2019年6月解放军联勤保障部队第九二〇医院骨科采用Masquelet技术结合小腿皮瓣治疗的23例胫骨感染性骨缺损伴有广泛胫前软组织缺损患者资料。其中男15例,女8例;年龄18~59岁(平均38.4岁);病程6~312个月(平均23.6个月);术前软组织缺损13例,窦道形成7例,贴骨瘢痕2例。所有患者均接受两阶段手术:①清创、锁定加压钢板固定、抗生素骨水泥诱导成膜以及小腿皮瓣修复软组织缺损;②感染控制后6~8周,去除骨水泥和固定物,清洗后再次固定断端,膜内植入松质骨颗粒。清创后创面软组织缺损面积4.0 cm×3.5 cm~18.0 cm×6.0 cm,骨缺损长度6~12 cm(平均8.4 cm)。应用局部带蒂筋膜皮瓣4例,腓肠神经营养皮瓣9例(顺行4例,逆行5例),隐神经营养血管皮瓣7例(顺行2例,逆行5例),逆行腓浅神经营养血管皮瓣1例,游离皮瓣2例。术后根据Paley骨折愈合评分标准评定疗效。结果所有患者术后获9~46个月(平均15.6个月)随访。其中18例皮瓣一期愈合;5例未愈合的患者经再次清创后,3例植皮后创面愈合,2例再次行皮瓣修复。骨感染控制21例,复发2例(分别发生于二期术后9个月和14个月)。患者骨缺损愈合时间为4~11个月(平均6.2个月)。根据Paley骨折愈合评分标准:优21例,良1例,差1例。结论应用Masquelet技术结合小腿多种皮瓣治疗胫骨感染性骨缺损合并广泛软组织缺损,在兼顾皮肤软组织修复的同时,有利于控制感染、形成完整的诱导膜和骨重建进程,疗效可靠。

Masquelet technique plus leg flap transfer to repair tibial infected defects complicated with extensive soft tissue defects

Objective To evaluate Masquelet technique plus flap transfer in repair of tibial infected defects complicated with extensive soft tissue defects in the lower leg.Methods A retrospective analysis was performed in the 23 patients who had been treated by Masquelet technique plus flap transfer at Institute of Orthopedics and Trauma,920 Hospital for tibial infected defects complicated with extensive soft tissue defects in the lower leg from March 2016 to June 2019.They were 15 males and 8 females,aged from 18 to 59 years(average,38.4 years).The duration of disease ranged from 6 to 312 months(average,23.6 months).All patients underwent surgery by 2 stages:1)debridement,locking compression plate fixation,formation of induced membrane by antibiotic-loaded bone cement,and repair of soft tissue defects with lower leg flaps;2)removal of bone cement and fixation 6 to 8 weeks after infection control,fixation of broken ends after rinse,followed by grafting of cancellous bone particles in the induced membrane.The area of wound soft tissue defects after debridement ranged from 4.0 cm×3.5 cm to 18.0 cm×6.0 cm,and the length of bone defects from 6 to 12 cm(average,8.4 cm).Locally grafted were pedicled fasciocutaneous flap in 4 cases,sural nerve nutrition skin flap in 9 cases(including 4 anterograde and 5 retrograde ones),saphenous nerve nutrition vascular flap in 7 cases(including 2 anterograde and 5 retrograde ones),retrograde superficial peroneal nerve nutrient vessel flap in one and free flap in 2 cases.The curative efficacy was evaluated according to the Paley fracture healing scores.Results All the 23 patients were followed up for 9 to 46 months(average,15.6 months).Flaps healed by the first stage in 18 cases and after skin grafting in 3 cases;skin flap transfer was conducted again in 2 cases.Infection was controlled in 21 cases but recurred in 2 cases at 9 and 14 months respectively after secondary surgery.The time for bone reunion ranged from 4 to 11 months(average,6.2 months).According to the Paley criteria for fracture healing,21 cases were excellent,one was good and one poor.Conclusion In the treatment of tibial infected defects complicated with extensive soft tissue defects,Masquelet technique plus transfer of a variety of lower leg flaps can result in reliable outcomes because it controls infection,promotes formation of complete induced membrane and accelerates the process of bone reconstruction along with repair of soft tissue defects.