应用游离腓骨复合组织瓣修复骨与皮肤软组织缺损

目的探讨应用游离腓骨复合组织瓣修复下肢外伤性骨与皮肤软组织缺损的临床疗效。方法应用腓骨复合组织瓣游离移植修复14例腓骨下段外踝或胫骨伴皮肤软组织缺损。结果术后2周游离腓骨复合组织瓣均一期成活,1例软组织少部分坏死,经换药后痊愈。14例患者均获得2年随访。10例术后12个月随访时受区外形良好,腓骨胫骨化良好,再造踝关节稳定性强,匹配度高。末次随访时,根据Enneking系统肢体功能评定标准评价疗效:优9例,良2例,可2例,差1例。结论应用腓骨复合组织瓣游离移植修复骨与皮肤软组织缺损疗效可靠。     

肱骨远端难治性骨不连的修复

目的 探索肱骨远端难治性骨缺损与骨不连的显微外科修复方法。方法 肱骨远端骨缺损与骨不连12例，均有外科手术史及植骨史，病程8个月～3年10个月，平均12．5个月。肢体短缩4～11cm，其中8例假关节形成，4例缺损3～5cm。采用解剖钢板固定为支架，取吻合血管的腓骨移植修复，移植腓骨长5～15cm，平均8．5cm。结果 术后12例均获随访3～18个月，平均8．5个月。移植腓骨3～8个月全部愈合，随愈合时间延长，移植腓骨增粗，髓腔再通。退行变的肘关节面骨质恢复正常，肘关节伸屈、前臂旋转功能获得恢复，肢体短缩获得纠正，持重及精细操作均达到满意效果。结论 钢板内固定加吻合血管腓骨移植用于邻近关节疑难骨缺损、骨不连的修复，可重建关节功能，免除关节假体置换。     

吻合血管复合腓骨穿支皮瓣的应用解剖及临床应用

目的 报道吻合血管的复合腓骨穿支皮瓣的应用解剖及修复复合组织缺损的临床效果.方法 24侧下肢标本采用有色乳胶从腘动脉灌注,解剖观测腓动脉及其穿支血管的分布、蒂长、管径等.临床设计切取小腿外侧区的腓动脉穿支皮瓣与游离腓骨形成复合腓骨穿支皮瓣移植修复肢体复合组织缺损共16例,皮瓣面积为6 cm×4cm～16cm×8 cm,骨缺损长度6～16 cm,移植腓骨长度8～20 cm.结果 腓动脉沿途平均发出5.3支穿支,其中40.6%为肌皮穿支、59.4%为隔皮穿支,分布在腓骨后缘3.1 cm范围内.平均直径1.1 mm,穿支间距4～8 cm,外踝后上方15～25 cm、4～7 cm范围内均可发现穿支血管.移植的16例复合腓骨穿支皮瓣全部成活,随访10～36个月,平均22.3个月,移植的腓骨在术后3～5个月愈合,随时间延长及患者负重移植骨逐渐增粗.受区外形与肢体功能恢复满意.结论 腓动脉穿支数目及位置相对恒定,根据腓动脉皮穿支的发出位置,可设计复合腓骨穿支皮瓣,临床应用证明是修复肢体长段骨缺损合并皮肤软组织缺损的良好选择.     

带血管腓骨移植的远期疗效报告

目的分析带血管腓骨移植修复四肢长骨缺损的远期效果。方法对 19例应用带血管腓骨移植修复不同部位骨缺损患者进行 5～ 20年 (平均 10.79年 )远期随访,参照 Enneking系统对患肢功能进行评价,采用等级记分法,以达到正常肢体功能的百分数表示。对移植腓骨的转归,参照国际挽救肢体专题讨论会制定的“同种及带血管移植的放射学评价方法”进行结果评定。结果应用带血管腓骨移植修复骨缺损的远期效果因缺损类型的不同而存在较大差异。 9例先天性胫骨假关节患者,术后肢体功能恢复 65％,其中移植腓骨骨不连 1例、骨折 3例 (7次 )、成角畸形 5例; 3例先天性桡骨缺如患者,术后肢体功能恢复 62％, 3例术后均出现移植腓骨骨骺线早闭,畸形复发; 5例骨髓炎、骨外露、骨缺损并软组织缺损患者,术后肢体功能恢复 94％,仅 1例发生移植腓骨骨折; 1例前臂软组织缺损并尺骨缺损,尺神经、正中神经损伤者,术后肢体功能恢复 67％,骨愈合顺利; 1例桡骨海绵状血管瘤者,术后肢体功能恢复 100％,骨愈合顺利。结论带血管腓骨移植是修复长骨缺损的好方法,与其他组织瓣联合应用,可一次完成骨支架重建与软组织覆盖,有利于肢体功能的尽早恢复。但对先天性胫骨假关节和桡骨缺如患者 ,远期效果不甚理想。     

吻合血管腓骨游离移植治疗创伤性胫骨大段骨缺损

目的 观察吻合血管腓骨游离移植创伤性胫骨大段缺损的疗效.方法 采用吻合血管腓骨游离移植创伤性胫骨大段缺损患者6例,男5例,女1例,骨缺损长度平均5.5 cm,切取腓骨长度平均10.8 cm.结果 所有患者切口均Ⅰ期愈合,移植骨全部愈合且管径逐渐增粗.平均随访3年1个月,在患肢活动、负重后无移植骨骨折,供区踝关节无畸形.结论 吻合血管腓骨游离移植是治疗创伤性胫骨大段缺损的有效方法之一.     

吻合血管腓骨游离移植治疗创伤性胫骨大段骨缺损

目的 观察吻合血管腓骨游离移植创伤性胫骨大段缺损的疗效.方法 采用吻合血管腓骨游离移植创伤性胫骨大段缺损患者6例,男5例,女1例,骨缺损长度平均5.5 cm,切取腓骨长度平均10.8 cm.结果 所有患者切口均Ⅰ期愈合,移植骨全部愈合且管径逐渐增粗.平均随访3年1个月,在患肢活动、负重后无移植骨骨折,供区踝关节无畸形.结论 吻合血管腓骨游离移植是治疗创伤性胫骨大段缺损的有效方法之一.     

吻合血管腓骨游离移植治疗创伤性胫骨大段骨缺损

目的 观察吻合血管腓骨游离移植创伤性胫骨大段缺损的疗效.方法 采用吻合血管腓骨游离移植创伤性胫骨大段缺损患者6例,男5例,女1例,骨缺损长度平均5.5 cm,切取腓骨长度平均10.8 cm.结果 所有患者切口均Ⅰ期愈合,移植骨全部愈合且管径逐渐增粗.平均随访3年1个月,在患肢活动、负重后无移植骨骨折,供区踝关节无畸形.结论 吻合血管腓骨游离移植是治疗创伤性胫骨大段缺损的有效方法之一.     

游离腓骨移植修复胫骨慢性骨髓炎并长段骨缺损

目的探讨游离腓骨移植一期修复胫骨慢性骨髓炎合并长段骨缺损的方法和疗效。方法1996年3月～2003年12月，采用彻底清除病灶，切除长段死骨，取对侧带血管腓骨游离移植一期修复胫骨缺损的方法，治疗胫骨慢性骨髓炎合并长段骨缺损患者67例。年龄8～42岁。病程6个月～8年，平均2．8年。其中血源性骨髓炎14例，创伤性骨髓炎53例。18例合并同侧腓骨骨折；21例合并皮肤缺损及骨外露，缺损范围2cm×4cm～4cm×10cm；53例合并病理性骨折及骨不连；46例合并1～3个窦道。胫骨死骨长度8～22cm，平均12cm。细菌培养试验均显示阳性。46例单纯切取带血管腓骨瓣，21例携带皮瓣，腓骨切取长度10～28cm，平均15cm；皮瓣切取范围4cm×7cm～6cm×12cm。结果术后67例获随访12～45个月。2周内肢体炎性反应均消退，窦道愈合率达93．5％，窦道不愈合者经二次窦道清除后愈合。移植腓骨瓣骨折2例，经石膏固定2个月后愈合。21例携带皮瓣全部成活。X线片示移植腓骨均愈合，愈合时间4～6个月，平均4．2个月。按Enneking评价系统，肢体术后功能恢复平均为正常功能的79％。18岁以下患者腓骨增粗较快，可完全胫骨化；18岁以上患者腓骨增粗缓慢。结论对胫骨慢性骨髓炎合并长段骨缺损患者可行吻合血管的游离腓骨移植一期修复骨缺损，该术式能有效控制感染、缩短疗程及减少手术次数。     

异体脱钙骨移植修复儿童期骨不连接

目的　总结同种异体脱钙骨移植修复小儿骨不连接的效果。方法　 1990年 4月～ 1997年 9月 ,用无菌操作法取同种异体的新鲜尸骨制成的脱水脱钙骨块移植修复小儿先天性骨不连接 3例 ,后天性骨不连接 14例。结果　术后随访 2～ 9年。一次手术成功 9例 ,经二次手术成功 7例 ,1例先天性胫骨假关节经二次手术 ,术后 6个月有新生骨生长 ,1年后再复发。成功的 2例先天性胫骨假关节以及 5例慢性骨髓炎骨不连接 ,随访发现肢体有1.5～ 3.0 cm的短缩 ,但关节功能正常。结论　同种异体脱钙骨修复小儿骨不连接具有骨诱导能力强 ,抗原性低 ,骨愈合快和来源丰富、使用简便等特点。     

吻合血管腓骨复合组织皮瓣移植修复与重建胫骨重度开放性粉碎性骨折

目的 探讨吻合血管的腓骨复合组织皮瓣移植一期固定与重建胫骨重度开放性粉碎性骨折的效果.方法 2001年2月至2007年10月收治胫骨重度开放性粉碎性骨折伴软组织缺损患者23例,男16例,女7例;年龄16～52岁,平均26.8岁.按Gustilo分型均为Ⅲ型,其中胫骨骨折累及长度11～17 cm,平均15.6 cm;小腿皮肤软组织缺损范围6 cm×3 cm～20 cm×9 cm.均采用吻合血管的腓骨复合组织皮瓣一期同时修复与重建胫骨重度开放性粉碎性骨折及胫前软组织缺损.结果 术后移植组织全部成活,皮瓣弹性、色泽良好,所有患者获得5个月～7年(平均3.5年)随访.移植腓骨与胫骨平均在1.8个月时有骨愈合征象,术后3.5～4.5个月形成良好的骨性愈合并恢复行走功能.无骨不连及骨折不愈合病例.结论 采用吻合血管的腓骨复合组织皮瓣移植可有效地对胫骨重度开放性粉碎性骨折进行修复与重建,实现一期骨折固定与胫前皮肤软组织缺损的修复.     

Fifteen years�� follow-up on the use of vascularized fibular graft for the treatment of congenital pseudoarthrosis of the tibia: experience in Virgen del Rocio��s Hospital and review of the literature

Treatment of congenital pseudarthrosis of the tibia remains a challenge, and many methods have been attempted with varying results. Two girls and three boys with congenital pseudarthrosis of the tibia were treated by vascularized fibular grafting (VFG). The average age at VFG was 7.8 years (range, 4–14 years) with an average follow-up term of 14.7 years (range, 8–21 years). Four of the children had undergone multiple operations before VFG, while the other one had no such history. Bone consolidation was obtained in all cases after an average term of 6.2 months (range, 4–8 months). Complication of stress fracture and ankle pain occurred in zero and two cases, respectively, only in cases undergoing multiple operations. Leg length discrepancy was more prominent in the patients with multiple previous operations (mean, 6.5 cm) than in the case with no prior surgery whose discrepancy did not have clinical signification. The long-term results of vascularized fibular grafting for congenital pseudarthrosis of the tibia were excellent, especially in the case with no prior surgery. Vascularized fibular grafting should be considered as a primary treatment option for congenital pseudarthrosis of the tibia.     

先天性胫骨假关节的手术治疗

目的探讨先天性胫骨假关节的手术方式及疗效。方法对自1994年1月-2008年1月收治的先天性胫骨假关节7例。彻底切除假关节部位异常骨组织和增生的纤维结缔组织,钻通骨髓腔．创建新鲜的骨折断端。植骨方法分别为带血管蒂的腓骨移植或自体髂骨移植。固定方法采用髓内钉或Ilizarov外固定架固定,结合石膏及支具外固定。结果随访2-11年,5例骨折最终愈合,此5例中一次手术骨愈合3例,再骨折2例3次。失败2例,其中l例报告植骨Ilizamv外固定失败后,拒绝再治疗。另1例双侧胫腓假关节患儿,随访11年,共行5次髓内针内固定,3次Ilizarov外固定,均失败,患儿已14岁,轮椅生活,拒绝截肢。结论目前先天性胫骨假关节的治疗效果仍是不够理想．彻底切除病变组织带血管蒂的腓骨移植结合Ilizarov外固定或可提高治愈率。     

Congenital pseudarthrosis of both forearm bones: long-term results of two cases managed by free vascularized fibular graft.

We analyzed the clinical and radiographic outcome of 2 cases of congenital pseudarthrosis of both forearm bones managed by free vascularized fibular grafts. The follow-up periods were 17 and 13 years, respectively. The first patient, a 4-year-old girl, had reconstruction of both the radius and ulna by a vascularized fibular graft, restoring pronation/supination to 110 degrees. The second patient, a 17-year-old boy, underwent a 1-bone forearm procedure using a vascularized fibular graft. After surgery, he had a stable forearm that was shortened by approximately 15 cm. In these 2 cases of congenital pseudarthrosis of both forearm bones, bone union was obtained by means of vascularized fibular graft.     

Vascularised fibular graft for congenital pseudarthrosis of the tibia. Long-term results

Five children with congenital pseudarthrosis of the tibia treated by free vascularised fibular grafts were followed up until skeletal maturity. The ipsilateral fibula was used in four cases, the contralateral fibula in one. All our cases achieved bone union, but leg length discrepancy, atrophy of the foot and ankle stiffness were frequent complications, due perhaps to the many previous operations. Vascularised fibular grafting might achieve better results if it were done as the primary procedure.     

Free vascularised fibular grafts for congenital pseudarthrosis of the tibia

We describe 11 patients with congenital pseudarthrosis of the tibia treated by a free vascularised fibular graft (FVFG) and followed up from 10 to 64 months (mean 38). Bony union was achieved in nine of the 11 cases: two failures required amputation. The mean time for union in the successful cases was five months. Nine of the 11 patients had had an average of four surgical procedures before the FVFG, so the graft was a salvage procedure for which the only alternative was amputation. FVFG is recommended as a primary procedure for the treatment of congenital pseudarthrosis of the tibia if there is a large tibial defect (over 3 cm) or shortening of more than 5 cm. The primary use of this operation is not advised for cases in which standard orthopaedic procedures are expected to succeed. For a small defect with a favourable prognosis (Boyd and Sage 1958), we recommend conventional bone grafting, intramedullary nailing and electrical stimulation.     

Free vascularised fibular graft in the treatment of congenital pseudarthrosis of the tibia

Five cases of congenital pseudarthrosis of the tibia successfully treated by a free vascularised fibular graft are described. Follow-up ranged from 5 to 34 months with a mean of 17.5 months. The technique, which includes radical excision of abnormal bone and soft tissue around the pseudarthrosis, also permits primary bone lengthening, and correction of deformity. The early results indicate that satisfactory bony union is achieved in a relatively short period of time.     

Vascularized bone grafts in children. Specifics and indications

The authors report on the vascularized bone grafts used in children. Some of them are the same as those used in adults, like the fibula free flap. Others are growth plate transfers as the proximal fibular epiphysis, the iliac crest or the lateral scapular crest. Finally, other transfers are periosteal vascularized grafts. The indications and results are discussed concerning the congenital pseudarthrosis of the tibia (43 cases treated by the first author), the congenital pseudarthrosis of the forearm, the tumors of the limb and the post-traumatic defects. The specific indications in children are the microsurgical growth plate transfers, especially the epiphyseal growth fibula for the upper limb and the iliac crest for the lower limb.     

Free vascularized fibular grafts

Postoperative results in 21 patients with bone defects that had been treated with a free vascularized fibular graft (FVFG) were evaluated. Pathogeneses in 21 patients were bone defect or pseudarthrosis after trauma in eight, massive bone defect after resection of bone and soft tissue tumor in six, congenital pseudarthrosis of the tibia in six, and congenital arteriovenous fistula in the forearm in one patient. The follow-up ranged from 15 months to 12 years, with an average of four years and six months. At final review, 12 patients went on to primary bony union, and six additional patients obtained union following an additional conventional bone graft. Three FVFGs resulted in a non-vascularized fibular graft. However, two patients obtained union with additional bone graft. Only one patient failed to obtain bony union and eventually required an above-knee amputation. Bony union rates in congenital pseudarthrosis of the tibia treated with the FVFG were lower than those in other diseases. Variables related to the surgical procedures and other factors affecting results and complications were also evaluated.     

Residual nonunion following vascularised fibular graft treatment for congenital pseudarthrosis of the tibia: a report of two cases

Resection and reconstruction using a vascularised fibular graft is a viable alternative treatment for congenital pseudarthrosis of the tibia, although distal junctional nonunion and residual deformity are known complications that are difficult to treat. We illustrate 2 cases in which bony union was achieved following a technique using fibular grafting and intramedullary nailing, without additional bone grafting. This technique was feasible because of hypertrophy of the fibular graft.     

Use of a reversed-flow vascularized pedicle fibular graft for treatment of nonunion of the tibia

Ten patients with nonunion of the lower tibia were treated with a vascularized ipsilateral fibular graft, that was transferred distally and based on retrograde peroneal vessel flow. Eight patients were treated for congenital pseudarthrosis of the tibia; one had a nonunion subsequent to infection, and another patient had bone and skin loss due to infection. A posterior approach was used to expose the tibia and to harvest the fibula. Bone union and full weight-bearing were achieved in all cases by 9 months. The patients were followed-up for a mean of 1.8 years (range: 1.5 to 3 years).