Treatment of tibial defect and bone nonunion with limb shortening with external fixator and reconstituted bone xenograft

Objective: To explore the effect of external fixator and reconstituted bone xenograft (RBX) in the treatment of tibial bone defect, tibial bone nonunion and congenital pseudarthrosis of the tibia with limb shortening. Methods : Twenty patients ( 13 males and 7 females)with tibial bone defect, tibial bone nonunion or congenital pseudarthrosis of the tibia with limb shortening were treated with external fixation, Two kinds of external fixators were used: a half ring sulcated external fixator used in 13 patients and a combined external fixator in 7 patients.Foot-drop was corrected at the same time with external fixation in 4 patients. The shortened length of the tibia was in the range of 2-9 cm, with an average of 4.8 cm. For bone grafting, RBX was used in 12 patients, autogenous ilium was used in 3 patients and autogenous fibula was implanted as a bone plug into the medullary canal in 1 case,and no bone graft was used in 4 patients. Results: All the 20 patients were followed-up for 8 months to 7 years, averaging 51 months. Satisfactory function of the affected extremities was obtained. All the shortened extremities were lengthened to the expected length. For all the lengthening area and the fracture sites,bone union was obtained at the last. The average healing time of 12 patients treated with RBX was 4.8 months. Conclusions: Both the half ring sulcated external fixator and the combined external fixator have the advantages of small trauma, simple operation, elastic fixation without stress shielding and non-limitation from local soft tissue conditions, and there is satisfactory functional recovery of affected extremities in the treatment of tibial bone defects, tibial bone nonunion and congenital pseudarthrosis of the tibia combined with limb shortening.RBX has good biocompatibility and does not cause immunological rejections. It can also be safely used in treatment of bone nonunion and has reliable effect to promote bone healing.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

儿童胫骨结节骨骺骨折

Objective To discuss the characteristics, treatment method and prognosis of tibial tuberosity avulsion fracture in children. Methods From January 1995 to December 2007, there were 25 cases (23 boys and 2 girls). The age at injury ranged from 12 to 16 years(average 13.5 years). All cases were unilateral involved (10 of left, 15 of right). All of the injuries resulted from participation in athletic activities, 10 in basketball, 7 while jumping, and 8 in football game. According to the classification of Ogden, there were 1 type 1A, 4 type 1B, 5 type 2A, 7 type 2B, 4 type 3A, and 4 type 3B fractures. One type 1A fracture was treated nonoperatively with east immobilization, and other 24 fractures with open reduction and internal fixation. Results All of 25 cases were followed from 14 months to 7 years (average 43 months). The range of motion of knee joint was 0°-140° 3 months after operation, and all of them recovered to pre-injury levels of activity by 6 months after operation. According to Mosier clinical assessment system, the final outcome was evaluated as excellent in all. Wound healed primary, no compartment syndrome was found. The time of bony union ranged from 2 to 5 months, with the mean time of 3 months. No complications of infection, ex-tremities deformity and inner fixation failure were found. Conclusion The tuberosity avulsion fracture in children is an uncommon and special type of epiphyseal injury. These fractures occur in the narrow range of 13 to 16 years of age. The majority of patients are males, and most of them are unilateral involved. This in-jury has an excellent outcome without deformity or functional loss, once adequate reduction and fixation of fracture fragments have been achieved.     

经皮微创接骨板技术治疗胫骨远端骨折的疗效分析

目的 探讨经皮微创接骨板(MIPO)技术治疗胫骨远端骨折的的手术方法及疗效.方法 2006年3月至2010年2月采用MIPO技术治疗22例胫骨远端骨折患者,男8例,女14例;年龄24～75岁,平均45.3岁.术后定期复查X线片,观察骨折愈合情况,应用Johne-Wruhs方法评估患肢功能和骨折愈合情况.结果 所有患者术后获6～33个月(平均14个月)随访.全部患者骨折均获愈合,愈合时间为15～24周,平均18.6周,1例出现软组织损伤.按照Johner-Wruhs评分评定疗效:优12例,良9例,可1例,优良率为95.5%.结论应用MIPO技术治疗胫骨远端骨折,可有效提高骨折愈合率,获得良好功能,并能减少并发症的发生.

Abstract：

Objective To report the efficacy of treatment of distal tibial fractures with minimally invasive plate osteosynthesis (MIPO). Methods From March 2006 to January 2010, 22 cases of distal tibial fractures were treated with close reduction and the MIPO technique. They were 8 men and 14 women,with an average age of 45. 3 years (range, 24 to 75 years). The fracture healing was observed through regular follow-up radiography. Functional recovery of affected lower extremity was evaluated according to Johner-Wruhs scoring system. Results All the patients were followed up for an average of 14 months (range,6 to 33 months). All the fractures were healed after an average time of 18. 6 weeks (range, 15 to 24 weeks). Soft tissue problem occurred in only one case. According to Johner-Wruhs scoring, 12 cases were excellent, 9 good and one fair. The total excellent to good rate was 95. 5%. Conclusion In treatment of distal tibial fractures, MIPO technique can improve fracture healing and functional recovery through decreasing postoperative complications.     

Repair and reconstruction of severe leg injuries： retrospective review of eighty-five patients

Objective:To explore a good way of the reconstruction of severe tibial shaft fractures by using different flaps and external fixators. Methods: Eighty-five patients of TypeⅢC tibial shaft fractures with average age of 42.5 years were treated in our hospital from 1990 to 2005. Injuries were caused by motorcycle accidents in 66 patients, by machine accidents in 16 patients, and by stone bruise in 3 patients. The management procedures consisted of administration of antibiotics, serial debridment, bone grafting if needed, application of different flaps, such as free thoracoumbilical flaps, fasciocutaneous flaps, saphenous neurocutaneous vascular flaps, sural neurocutaneous vascular flaps and gastrocnemius muscular flaps, and different external fixations, for instance, half-ring fixators, unilateral axial dynamic fixators, AO fixators, Weifang fixators, and Hybrid fixators. The average follow up was 6.3 years. Results: All flaps survived. Eighty-three cases had bone healed. The average bone healing time of different external fixations was 5.5 months in 47 cases with half-ring fixators, 9.2 months in 4 cases treated with unilateral axial dynamic fixators, 8.5 months in 6 cases with AO fixators, 10.7 months in 16 cases with Weifang fixators, and 7.8 months in 10 cases with assembly fixators. Except half-ring fixation, other fixations all needed necessary bone graft. Two cases treated with unilateral axial dynamic fixators had nonunion of bone and developed osteomyelitis. The wounds healed after the removal of the fixators and immobilization by plaster. The last follow up examination showed ankle and knee motion was normal and no pain was noted. Conclusions: The combination of half-ring external fixators with various flaps provides good results for TypeⅢC tibial shaft fractures.     

Biplane osteotomy and bone transport combined external locking plating for sequential treatment of massive tibial bone defects北大核心CSCD

Objective To evaluate biplane osteotomy and bone transport combined external locking plating for sequential treatment of massive tibial bone defects. Methods Twenty-eight patients with massive tibial bone defects were reviewed who had been treated at Department of Repair and Reconstruction, Wuhan Puai Hospital from October 2013 to October 2019. They were divided into a bone transport group and a combined bone transport group (bone transport combined external locking plating) according to their surgical methods. In the bone transport group of 14 cases, there were 10 males and 4 females with an age of (38. 6 ±3. 2) years and a bone defect of (8. 0 ± 0. 5) cm; in the combined bone transport group of 14 cases, there were 9 males and 5 females with an age of (39. 1 ± 3. 9) years and a bone defect of (8. 3 ± 0. 3) cm. The time for wearing external fixator, fracture healing time, dock-in-site healing time, postoperative function assessment and complications were observed and compared between the 2 groups. Results There was no significant difference between the 2 groups in their preoperative general data, showing they were comparable (P > 0. 05). The bone transport group were followed up for 12 to 28 months (average, 18. 4 months) and the combined bone transport group for 12 to 26 months (average, 16. 8 months) . The time for wearing external fixator in the combined bone transport group [(8.4±0.7) months] was significantly shorter than that [(13.3±1.4) months ] in the bone transport group (P< 0. 05). No significant difference was observed between the 2 groups in either the fracture healing time [ (8. 4 土1.3) months versus (7. 4 ± 1. 2) months] or the dock-in-site healing time [(210. 2 ±9.1) months versus (206. 2 ± 9. 8) months ] (P > 0. 05). By the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring, the bone healing was excellent in 6, good in 5 and fair in 3 cases in the bone transport group while excellent in 8, good in 4 and fair in 2 cases in the combined bone transport group, showing no significant difference between the 2 groups in the excellent to good rate (P > 0. 05). By the postoperative functional assessment of the lower extremity, there were 7 excellent, 3 good, 3 fair and one poor cases in the bone transport group while 8 excellent, 5 good and one poor cases in the combined bone transport group, showing no significant difference between the 2 groups in the excellent to good rate (P > 0. 05). In the bone transport group, there were 3 cases of pin track infection, one case of dock-in-site nonunion, 2 cases of poor alignment of lower extremities, 2 cases of skin depression, one case of nail loosening, 5 cases of joint stiffness and 3 cases of delayed union of the distracted bone; in the combined bone transport group, there were one case of pin track infection, 2 cases of poor alignment of lower extremities, 3 cases of skin depression, 3 cases of joint stiffness, 2 cases of delayed union of the distracted bone and one case of refracture. Conclusion In the sequential treatment of massive tibial bone defects, biplane osteotomy and bone transport combined external locking plating can reduce the time for wearing external fixator and increase the satisfaction of patients. © The Author(s) 2022.     

游离肌皮瓣移植治疗难治性小腿和足部创伤后骨髓炎

Objective To evaluate the efficiency of free myocutaneous flap transfer for the treatment of refractory post-traumatic osteomyelitis of the lower leg and foot. Methods Eleven patients with refractory post-traumatic osteomyelitis of the lower legs and feet were treated between February 2004 and December 2007. There were 9 males and 2 females. The average age was 3.5 years. All patients had at least four to five unsuccessful surgical procedures and prolonged antibiotic treatment prior to presentation. The mean duration of osteomyelitis was 26 months (12-47 months). According to the Ciemy-Mader classification, there were 3 cases for ⅢA, 2 for ⅢBL, 4 for ⅥA and 2 for ⅥBL. After radical debridement, free myocutaneous flaps were immediately performed. Nine latissimus dorsi and 2 rectus abdominis myocutaneous flaps were used.External fixation was applied in 6 patients with skeletal instability due to tibial defects. Results An average follow-up was 3.5 years. Two cases suffered partial necrosis and were managed successfully with split-thickness skin grafts later. In 4 patients of presenting segmental bone defect, autogenous bone grafting was applied in one patient and achieved consolidation after 5 months; bone transplantation in 2 patients and achieved consolidation after 8 and 10 months; and vascularized fibula graft in one patient in whom the gap of the tibia was about 10 cm and achieved consolidation after 4 months. The other 7 patients of this group achieved bone consolidation without bone graft. Conclusion The cornerstone of the treatment of chronic osteomyelitis was to be the radical debridement of all involved necrotic and infected soft tissue and bone.The free myocutaneous flaps transfer which has the advantage of obliteration of dead space and stable coverage of the defect was a safe and viable treatment option in chronic osteomyelitis of the lower leg and foot.     

游离肌皮瓣移植治疗难治性小腿和足部创伤后骨髓炎

Objective To evaluate the efficiency of free myocutaneous flap transfer for the treatment of refractory post-traumatic osteomyelitis of the lower leg and foot. Methods Eleven patients with refractory post-traumatic osteomyelitis of the lower legs and feet were treated between February 2004 and December 2007. There were 9 males and 2 females. The average age was 3.5 years. All patients had at least four to five unsuccessful surgical procedures and prolonged antibiotic treatment prior to presentation. The mean duration of osteomyelitis was 26 months (12-47 months). According to the Ciemy-Mader classification, there were 3 cases for ⅢA, 2 for ⅢBL, 4 for ⅥA and 2 for ⅥBL. After radical debridement, free myocutaneous flaps were immediately performed. Nine latissimus dorsi and 2 rectus abdominis myocutaneous flaps were used.External fixation was applied in 6 patients with skeletal instability due to tibial defects. Results An average follow-up was 3.5 years. Two cases suffered partial necrosis and were managed successfully with split-thickness skin grafts later. In 4 patients of presenting segmental bone defect, autogenous bone grafting was applied in one patient and achieved consolidation after 5 months; bone transplantation in 2 patients and achieved consolidation after 8 and 10 months; and vascularized fibula graft in one patient in whom the gap of the tibia was about 10 cm and achieved consolidation after 4 months. The other 7 patients of this group achieved bone consolidation without bone graft. Conclusion The cornerstone of the treatment of chronic osteomyelitis was to be the radical debridement of all involved necrotic and infected soft tissue and bone.The free myocutaneous flaps transfer which has the advantage of obliteration of dead space and stable coverage of the defect was a safe and viable treatment option in chronic osteomyelitis of the lower leg and foot.     

一期短缩二期延长治疗下肢Gustilo ⅢC型开放性骨折的疗效分析

目的:探讨一期短缩二期延长治疗下肢Gustilo ⅢC型开放性骨折的疗效。方法:回顾性分析武汉市第四医院骨科2010年1月至2018年1月急诊收治的12例下肢Gustilo ⅢC型开放性骨折的患者资料,男8例,女4例;年龄22~67岁,平均41.2岁。所有患者均伴有骨与皮肤软组织缺损,合并下肢神经、血管损伤。软组织缺损...     

人工皮覆盖技术加外固定器在小腿重度开放骨折中的应用

目的:研究治疗小腿严重开放性骨折的有效治疗方法。方法:自2009年1月至2011年2月治疗56例严重小腿开放骨折患者,其中男42例,女14例;年龄18～68岁,平均43.6岁。清创后骨折用外固定支架固定加人工皮覆盖,接负压封闭吸引,5～7d后Ⅱ期缝合、植皮或皮瓣转移。观察创面修复情况、创面细菌培养情况、骨折愈合时间及患肢功能恢复情况并分析治疗疗效。结果:56例创面均愈合,平均愈合时间5.8个月。骨折愈合53例,延迟愈合3例。浅表感染1例,针道感染3例,无其他并发症。参照Ovadia等关节功能评定标准,优45例,良9例,可2例。结论:人工皮覆盖技术联合外固定支架治疗小腿GustiloⅢ型开放骨折,能促进创面修复及骨折愈合,缩短病程,值得推广。     

带监测皮岛游离腓骨复合组织瓣移植修复胫骨中上段Gustilo Ⅲ B和Ⅲ C型骨折

目的探讨小腿高能量损伤后应用移植带监测皮岛游离腓骨复合组织瓣早期修复胫骨中上段GustiloⅢB型和ⅢC型骨折的临床疗效。方法总结温州手足外科医院2004年12月至2010年6月采用带监测皮岛游离腓骨复合组织瓣联合外固定支架早期治疗胫骨中上段GustiloⅢB型和ⅢC开放性骨折10例,胫骨缺损长度4.1～6.5cm,软组织缺损面积3.2cm×5.2cm～5.1cm×8.3cm,单纯胫前血管损伤伴缺损4例,胫前与胫后血管同时损伤2例。损伤后行游离腓骨复合组织瓣移植中位时间8(7～11)d,复合组织瓣与受区血管直接吻合4例,腓动静脉桥接胫前动静脉6例。结果 10例中位随访时间15(12～24)个月,创面Ⅰ期愈合7例,Ⅱ期愈合2例;伤口不愈合并有死骨形成,经死骨摘除清创后愈合1例。中位住院时间29(25～42)d,X线摄片示术后18(12～24)周移植腓骨与胫骨骨愈合,患肢开始部分负重时间为术后12～24周,完全负重时间为48～72周。Enneking系统肢体功能评定结果:优4例、良3例、可2例、差1例。结论小腿高能量损伤后应用带监测皮岛的游离腓骨复合组织瓣早期修复胫骨中上段GustiloⅢB与ⅢC型骨折骨缺损可Ⅰ期完成带血运的骨移植及修复皮肤和软组织缺损,减少手术次数,早期封闭创面,促进骨折愈合,减少胫骨骨髓炎发生,有助于尽早恢复患者下肢功能。     

外固定支架结合负压封闭引流技术治疗Gustilo Ⅲ型胫腓骨开放性骨折

目的 探讨外固定支架结合负压封闭引流(VSD)技术治疗Gustilo Ⅲ型胫腓骨开放性骨折的疗效.方法 2006年10月至2009年11月采用外崮定支架结合VSD技术治疗19例Gustilo Ⅲ型胫腓骨开放性骨折患者,男14例,女5例;年龄17～62岁,平均30.1岁.开放性损伤按Gustilo分型:ⅢA型9例,ⅢB型8例,ⅢC型2例.所有患者均行急诊清创、骨折复位后外固定支架固定,采用VSD技术关闭创面,待创面洁净、肉芽生长后通过直接缝合(5例)、游离植皮(9例)或转移皮瓣(5例)等方法修复软组织创面.结果 19例患者术后获12～24个月(平均16.3个月)随访.所有患者经VSD治疗5～17 d(平均9.3 d)后关闭创面.2例因创面感染、组织坏死渗出,经多7欠清创并更换VSD敷料后,创面最终通过转移皮瓣得以修复.骨折愈合时间为4～10个月(平均5.6个月).结论外固定支架结合VSD技术治疗Gustilo Ⅲ型胫腓骨开放性骨折能在迅速有效地稳定骨折的同时,早期闭合创面,促进骨折愈合,减少并发症的发生.

Abstract：

Objective To report clinical efficacy of vacuum sealing drainage(VSD)and external fixation in the treatment of tibiofibular fractures of Gustilo type Ⅲ. Methods From October 2006 to November 2009,19 cases of Gustilo type Ⅲ tibiofibular fracture were treated in our department.They were 14men and 5 women,with an average age of 30.1 years(from 17 to 62 years).There were 9 cases of type ⅢA,8 cases of Type ⅢB 2 cases of typeⅢC.After emergency debridement,all the fractures were fixed with an extemal fixator following indirect reduction.The wounds were sealed with VSD.When the wounds were clean and granulation appeared,they were repaired by direct suture(5 cases),split-thickness skin graft(9 cases)and flap transposition(5 cases). Results The 19 cases were followed up for 12 to 24 months,with an average of 16.3 months.A11 the wounds were closed'after VSD for 5 to 17 days.Wound infection occurred in 2 cases and was finally repaired by flap transposition following repeated debridement and VSD.The fractures healed after 4 to 10 months(average,5.6 months). Conclusion External fixation combined with VSD is a simple and effective treatment for tibiofibular fractures of Gustilo type Ⅲ.because it can provide not only rapid fixation but also early wound sealing to facilitate fracture healing and reduce incidence of complications.     

真空负压封闭技术加外固定器治疗肢体开放性骨折

目的 探讨真空负压封闭技术(VS)加外固定器治疗四肢严重开放性骨折的效果。方法 近4年来收治63例四肢严重开放性骨折患者，采用VS加外固定器治疗，清创后骨折用Orthofix单边外固定器固定，创面或创腔内用Vacuseal材料覆盖，接负压封闭吸引，6～10d后二期缝合、植皮或皮瓣转移。结果 63例患者创面均愈合，浅表感染3例(4．8％)和针道感染13例19针(7．5％)；骨折愈合53例(84．1％)，延迟愈合或不愈合10例(15．9％)。平均愈合时间6．5个月。结论 VS技术结合外固定架固定治疗四肢严重开放性骨折，在迅速有效地稳定骨折的同时，能安全有效地封闭创面，缩短二期创面修复时间，促进骨折愈合，减少并发症；其方法简单有效，值得临床推广应用。     

Extreme bone lengthening using distraction osteogenesis after trauma: a case report

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.     

Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: a report of six cases

BACKGROUND: The treatment of type IIIB open tibial fractures remains a challenge for orthopedic surgeons, particularly with respect to the soft-tissue and subsequent bony reconstruction. The primary shortening and limb lengthening (PSLL) simplifies wound closure for severe open injuries without requiring microsurgical procedures as a main advantage. This method is thought to be also useful for type IIIB patients with polytrauma and other life-threatening injuries because it helps to control both wound sepsis and their general state. In the present study, we attempted to assess the problems, long-term functional outcome, and quality of life (QOL) of patients who were treated by PSLL for Gustilo type IIIB open tibial fractures in our facility. METHODS: Six patients with type IIIB open tibial fractures treated with PSLL were retrospectively reviewed. The mean shortening length was 7.4 cm (range, 4.5-10.3 cm). The mean percent shortening of the entire bone was 18.7% (range, 12.3-29.7%). Limb lengthening started at a mean interval of 10.3 months (range, 3-18 months) after the original injury. The mean healing index was 56.5 days/cm (range, 31.3-86.7 days/cm). The complications, functional outcome, and quality of life were evaluated for all cases. RESULTS: One superficial infection at the initial corticotomy, one deep infection around the shortening site, one refracture at the healed docking site, several wire breaks in external frames in two cases, and two severe equinovarus deformities occurred as complications of these procedures. Regarding functional outcome, three patients showed good outcome, two showed fair outcome, and one showed poor outcome. The percent shortening of the entire bone in the two fair cases were more than 25%. The median scale of physical health summary, mental health summary, and total general health summary in Short Form-36 (QOL) were lower than the standard scale in age-matched individuals. CONCLUSION: This PSLL treatment was thought to be a useful option for severe open fracture of the tibia, which had bony defect in more than 4.5 cm in length after serial debridement, although several complications occurred in this regimen. However, it is difficult to achieve an excellent function and QOL using these techniques. In addition, it is difficult for patients who underwent limb lengthening after shortening more than 25% of the total length of bone to gain good function.     

Coupled external fixator and skin flap transposition for treatment of exposed and nonunion bone

Objective: To discuss the effect of coupled external fixator and skin flap transposition on exposed and nonunion bones.Methods: The data of 12 cases of infected nonunion and exposed bone following open fracture treated in our hospital during the period of March 1998 to June 2008 were analysed. There were 10 male patients, 2 female patients,whose age were between 19-52 years and averaged 28 years.There were 10 tibial fractures and 2 femoral fractures. The course of diseases lasted for 12-39 months with the mean period of 19 months. All the cases were treated by the coupled external fixator and skin flap transposition.Results: Primary healing were achieved in 10 cases and delayed healing in 2 cases in whom the tibia was exposed due to soft tissue defect and hence local flap transposition was performed. All the 12 cases had bony union within 6-12 months afer operation with the average time of 8 months. They were followed up for 1-3 years and all fractures healed up with good function and no infection recurrence.Conclusion: The coupled external fixator and skin flap transposition therapy have shown optimal effects on treating infected, exposed and nonunion bones.     

Acute unreamed intramedullary nailing and soft tissue reconstruction with muscle flaps for the treatment of severe open tibial shaft fractures

BACKGROUND: The treatment of open tibial shaft fractures remains controversial. Important considerations in surgical management include surgical timing, fixation technique and soft tissue coverage. This study was performed to evaluate the results of acute surgical debridement, unreamed nailing and soft tissue reconstruction in the treatment of severe open tibial shaft fractures. PATIENTS AND METHODS: During a 10-year period between January 1993 and July 2002, 927 tibial shaft fractures were treated with interlocking intramedullary nails. Among them, there were 19 consecutive patients with Gustilo type IIIB to IIIC open tibial shaft fractures with extensive soft tissue injury needing a muscle flap coverage and being suitable for intramedullary nailing. All 19 patients were called for a late follow-up which was conducted with a physical examination and a radiographic and functional outcome assessment. The radiographs were reviewed to determine the fracture healing time and the final alignment. RESULTS: All 19 open fractures with severe soft tissue injury healed without any infection complications. The fractures united in a mean of 8 months. Nine patients had delayed fracture healing (union time over 24 weeks). One of these patients needed exchange nailing, one patient autogenous bone grafting and dynamisation on the nail and seven patients needed dynamisation of the nail before the final fracture healing. In all patients, the alignment was well maintained. However, seven patients had shortening of the tibia by 1-2 cm and two of them also external rotation of 10 degrees . The functional outcome was good in 18/19 patients. INTERPRETATION: Acute surgical debridement, unreamed interlocking intramedullary nailing and soft tissue reconstruction with a muscle flap appear to be a safe and effective method of treatment for Gustilo type IIIB open tibial shaft fractures.     

VSD结合外固定支架在西藏高原地区胫腓骨开放性骨折分期治疗中应用

目的：探讨负压吸引敷料结合外固定支架技术在西藏高原地区胫腓骨开放性骨折分期治疗中的应用及临床疗效。方法2014年8月-2015年8月收治16胫腓骨开放性骨折患者,其中男性12例,女性4例,年龄19~66岁,平均年龄39.4岁(19~66岁);胫腓骨中上段骨折4例,下段骨折12例。待患者病情稳定后患者生命体征稳定后,无继发性损伤,予行清创、外固定支架固定骨折端,并采用负压吸引敷料覆盖创面或创腔。7 d后更换VSD或予行二期缝合或软组织覆盖。 X线检查明确骨折愈合时间并记录相关并发症。结果本组16例创面均二期愈合,未见感染、皮肤或皮瓣坏死等软组织并发症。本组共随访患者12例(电话通知来院复诊),4例失访,平均随访18个月(12~24个月)。影像学检查明确平均骨折愈合时间为5.5个月(3~7个月),其中骨折一期临床愈合9例(75%),延迟愈合3例(25%)。随访期间除2例出现钉道感染,经保守治疗后治愈,余患者未见深部感染、植皮或皮瓣坏死、畸形愈合、骨不连或骨髓炎发生。结论负压吸引敷料结合外固定支架治疗西藏高原地区胫腓骨开放性骨折,在迅速有效地稳定骨折的同时,能安全有效地封闭创面,缩短二期创面修复时间,促进骨折愈合,减少并发症。