加压外固定在胫腓骨开放骨折感染中的应用

１９９２年￣１９９８年，应用半环槽式外固定器治疗３１例胫腓骨开放性骨折，其中１９例早期行半环槽式外固定，１２例因早期内固定失败造成骨感染及感染性骨不连，二期行半环槽式外固定器固定，使创面及骨感染得到控制。骨愈合时间２￣８个月。且对半环槽式外固定器在早晚期感染的预防及控制中的作用进行回顾性研究，结果显示：半环槽式外固定器能给骨折端提供牢稳固定，且钢针远离骨折端及感染病灶，对骨折端血运干扰小，有利于创     

创伤后感染性胫骨骨不连的骨外固定治疗

１９８２－１９９５年，应用半环槽式外固定器成功的了２１例外伤后感染性胫骨骨不连，并对６例肢体短缩才重建了肢体长度。２１例均采用骨外固定器行骨断端加压固定，所有病便均行腓骨截骨术。合并肢体短缩者６例于同期或二期行胫呈下干骺端截骨延长术，以达到肢体长度的均衡。虽有再骨折、针道感染、钢针松动等并发症，但所有骨不连最终均达到愈合，创面感染快速得到控制。骨愈合时间３－１１个月，平均５个半月。肢体短缩者６均例     

外固定支架治疗严重胫腓骨开放性骨折

目的探讨半环槽式外固定器治疗严重胫腓骨开放性骨折的临床疗效。方法回顾性分析自1996年1月-2006年10月收治的76例GustiloIII型严重胫腓骨开放性骨折患者，其中ⅢA型4l例，ⅢB型22例，ⅢC型13例。其中57例伤口行彻底清创后采用直接缝合、游离植皮或局部皮瓣、肌皮瓣转位，一期闭合创面；19例经抗感染、局部换药后二期闭合创面，骨折均采用半环槽式外固定器进行固定。结果随访8—56个月，平均26个月。其中创面感染15例，经抗感染、换药、皮瓣转位后治愈；针道感染9例，经换药后治愈；未并发骨髓炎。骨折愈合时间3—15个月，平均6．3个月，其中4例延迟愈合；4例骨不连和2例骨缺损患者经再次手术加压固定或结合肢体延长术后骨愈合。结论半环槽式外固定器采用多向穿针三维立体固定，治疗GustiloⅢ型严重胫腓骨开放性骨折具有操作简单、固定稳固、微创、有利于控制感染及促进骨折愈合的优点，但仍需防治针道感染、骨不连、骨缺损等并发症。     

半环槽式外固定器结合有限内固定治疗复杂胫腓骨骨折

目的 探讨应用半环槽式外固定器结合有限内固定治疗复杂胫腓骨骨折的疗效。方法 应用拉力螺钉及钢丝对骨折区域内骨折块进行有限内固定，恢复骨折块正常解剖关系，经有限内固定后胫腓骨骨折区域用半环槽式外固定器固定，外固定范围不超出膝，踝关节，术后第2天行主动膝，踝关节活动锻炼，术后2－3周行走负重。结果 随访12－18个月，骨折骨性愈合时间20－24周（平均22周），无骨感染，骨外感，内固定物外感，肢体肿胀，关节僵硬。结论 半环槽式外固定器结合有限内固定术式是治疗复杂胫骨骨折的有效方法。     

半环槽式外固定器结合有限内固定治疗复杂胫腓骨骨折

目的：探讨应用半环槽式外固定器结合有限内固定治疗复杂胫腓骨骨折的疗效。方法：拉力螺钉及钢丝对骨折区域内骨折块进行有限内固定，恢复骨折块正常解剖几何关系，半环槽式外固定器固定经有限内固定后胫腓骨骨折区域，外固定范围不超出膝、踝关节。结果：早期功能锻炼，术后第2d行主动膝，踝关节活动锻炼，术后2－3周行走负重，随访12－18个月，骨折骨性愈合时间20－24周，平均22周，无骨感染，骨外露，内固定物外露，肢体肿胀，关节僵硬。结论：半环槽式外固定器结合有限内固定术是一种治疗复杂胫腓骨骨折的有效方法。     

骨外固定加压治疗胫骨干骨不连

目的 :通过观察半环槽式外固定器治疗胫骨骨不连的治疗效果 ,评价加压外固定对骨损伤修复的作用。方法 :采用半环槽式外固定器骨外加压固定治疗胫骨干骨不连 49例 (男 37例 ,女 12例 ) ,骨不连时间为 7～ 132个月。其中 7例感染性骨不连偏侧性骨缺损者 ,行病灶清除开放性植骨 ;5例感染性骨不连行病灶清除、内固定物取出、小腿皮瓣转位 ;10例骨不连、骨缺损伴伤肢短缩者 ,行胫骨干骺端截骨或骨骺牵伸延长。结果 :植骨全部成活 ,创面植皮获Ⅰ期愈合 ,肢体延长幅度 4.5～ 13 .5cm ,平均 7.5cm ,达到预期目标 ,49例患者均于术后 2 .5～ 10个月 ,获得骨愈合 ,平均 5 .4个月。结论 :骨外固定加压治疗胫骨干骨不连不仅具有确实的效果 ,而且有以下优点 :(1)方法简便、创伤小、局部血运干扰少 ;(2 )在局部感染的条件下仍可使用 ;(3)骨端始终保持有均匀的压应力和肢体功能锻炼时产生的生理应力刺激 ,有利于促进骨愈合 ;(4)可配合肢体延长联合使用 ,既治愈了骨不连 ,又均衡了双下肢长度 ,有利于肢体功能恢复。     

骨外固定技术治疗先天性胫骨假关节

先天性胫骨假关节（ＣＰＴ）仍是一个了解最少与治疗最困难的问题。传统方法治疗的成功率仅约５０％。作者报告用半环槽式外固定器治疗１１例ＣＰＴ。病人年龄２～１７岁，平均９岁。下肢短缩４～９ｃｍ。９例接受过１７次手术，包括３次带血管腓骨移植。手术治疗包括切除假关节端加压外固定同时行近干骺端截骨延长。结果９例假关节５～８个月愈合，１例２次手术１４个月愈合，１例未愈合。１１例骨延长５～９．５ｃｍ，平均７ｃｍ，愈合指数３３ｄ／ｃｍ。１０例随诊１～９年，平均３年１０个月。９例骨愈合与肢体功能良好，１例术后３年１１个月因明显外伤再骨折。作者认为骨外固定治疗ＣＰＴ创伤小，方法简便，同时可充分矫正患肢短缩畸形。半环槽式外固定器用克氏针做三维式外固定，固定稳固与负重活动产生的动力性轴向应力刺激是促进ＣＰＴ愈合的关键因素。     

骨外固定另压治疗胫骨干骨不连

目的：通过观察半环槽式外固定器治疗胫骨骨不连的治疗效果,评价加压外固定对骨损伤修复的作用。方法：采用半环槽式外固定器骨外加压固定治疗胫骨干不连４９例（男３７例,女１２例）,骨不连时间为７～１３２个月。其中７例感染性骨不连偏侧性骨缺损者,行病灶清除开放性植骨;５例感染性骨不连行病灶清除、内固定物取向、小腿皮瓣转位;１０有不连、骨缺损们伤肢短缩者,行胫骨干骺端截骨或骨骺牵伸延长。结果：植骨全部成活,创     

半环槽式骨外固定器治疗胫腓骨开放性骨折

目的：探讨半环槽式骨外固定器治疗胫腓骨开放性骨折的临床疗效。方法：2005年3月至2011年3月,经闭合手法复位或辅助克氏针撬拨复位半环槽式外固定器治疗94例胫腓骨开放性骨折患者,男63例,女31例;年龄17～65岁,平均39岁。横形骨折5例,斜形与螺旋形骨折19例,粉碎性骨折70例。骨折按Gustilo分类：ⅢA型49例,ⅢB型45例。术后观察伤口感染发生率、骨折愈合时间,并采用Johner-Wruhs评定标准对其功能进行评价。结果：所有患者获随访,时间14～63个月,平均29个月。骨折愈合时间16～39周,平均21.4周,无骨折不愈合、骨髓炎及小腿骨筋膜室综合征等并发症发生。94例中伤口I期愈合者81例,深部伤口感染者2例。功能评价采用Johner-Wruhs评定标准,优52例,良37例,中5例。结论：闭合复位或辅助克氏针撬拨复位及外固定器固定可降低胫腓骨开放性骨折感染率。对于胫腓骨开放性粉碎骨折半环槽式骨外固定器固定3～6周时根据骨折端愈合情况去除中间固定骨折块的克氏针,使支架动力化,可促进骨折愈合。     

组合半环式三维外固定器治疗复杂胫腓骨骨折

目的 探讨组合半环式三维外固定器治疗复杂的胫腓骨骨折的疗效。方法 应用组合半环式三维外固定器治疗Ⅱ、Ⅲ型开放性骨折、多段骨折、近关节部位骨折及陈旧性骨折不愈合等复杂的胫腓骨骨折共9例。结果 9例全部愈合。骨愈合时间：临床愈合平均8周，骨性愈合平均20周。1例针道感染，2例部分关节功能障碍。结论 组合半环式三维外固定器适用于治疗复杂的胫腓骨骨折，疗效可靠，创伤小，符合BO生物学观点，值得临床推广应用。     

胫骨骨折手术治疗后不愈合的原因及预防

目的 探讨胫骨骨折因手术治疗所致不愈合的原因分析及预防方法。方法 对589例胫骨骨折（包括胫腓骨骨折）手术治疗，加压钢板内固定320例，其它固定方法269例，包括外固定架100例；其中121例行骨膜旋转移植，87例行带蒂或带血管复合组织皮瓣移植，112例行腓骨截骨术，97例行植骨术。结果 589例胫骨骨折仅13例发生骨不愈合，6例为坚硬的加压钢板取出后原骨折处再次发生骨折。其余均达骨性愈合，随访平均24个月。结论 正确选择内外固定装置及安放位置，保护好邻近骨膜并作骨膜放旋转移植，必要时作腓骨截骨术，胫骨中下段骨折常规植骨，胫骨骨不愈合和再骨折发生率是可以预防的。     

腓骨内固定在治疗胫腓骨骨折中的作用

目的 探讨腓骨内固定在治疗胫腓骨骨折中的作用。方法 50例胫腓骨骨折，采用腓骨内固定、胫骨闭合手法复位加外固定方法治疗。其中闭合性骨折28例，开放性骨折12例，Pilon骨折10例；粉碎性骨折28例，斜形骨折12例、螺旋形骨折10例。结果 50例均达临床愈合。平均临床愈合时间为5个月，骨折位置良好，关节功能恢复正常，无皮肤坏死及感染发生。结论 腓骨固定适合于胫前皮肤条件不好的闭合性或开放性胫腓骨骨折和胫骨下1/3粉碎性骨折合并腓骨骨折的治疗。     

Reconstruction of a tibial defect with microvascular transfer of a previously fractured fibula

A 43-year-old man sustained severe injuries to his lower limbs with extensive soft-tissue damage and bilateral tibial-fibular fractures. Acutely, the patient underwent external fixation and a free latissimus dorsi flap for soft-tissue coverage of the left leg. However, the tibia had a nonviable butterfly fragment that left a 7-cm defect after debridement. Subsequently, the contralateral fractured fibula was used as a bridging vascularized graft for this tibial defect. The transfer of a fibula containing the zone of injury from a previous high-energy fracture has not been reported. This case demonstrates the successful microvascular transfer of a previously fractured fibula for the repair of a contralateral tibial bony defect.     

外固定器结合有限内固定治疗Ⅲ度开放性胫腓骨骨折

目的探讨外固定器结合有限内固定治疗严重胫腓骨开放性骨折的临床疗效。方法28例GustiloⅢ型胫腓骨开放性骨折,减张缝合11例,局部皮瓣转移7例,腓肠肌皮瓣6例,腓肠神经营养血管皮瓣4例。均一期闭合创面,骨折采用外固定器结合有限内固定进行固定。结果随访12～40个月。其中3例有针道感染,无骨髓炎发生,28例骨折均愈合,愈合时间6～18（9±3）个月。结论外固定器结合有限内固定治疗GustiloⅢ型骨折具有操作简单,固定可靠,微创,可同时处理骨缺损,但需防治针道感染。     

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.     

A Pilon Fracture With Fibular Head Dislocation Treated With the Use of 3D Preoperative Planning: A Case Report and Literature Review

Pilon fractures with intact fibula have been associated with low-energy trauma. However, the compression force onto the ankle joint can damage the tibiofibular linkage as in a Maisonneuve fracture. Herein, we describe a case of a patient who had a pilon fracture (AO type 43 C3.2) without a fibular fracture. Three-dimensional preoperative simulation by reduction with the surface registration technique was performed as the fibular length was intact and there was no reference for the tibial length. The preoperative simulation revealed superior fibular head dislocation and shortening of the distal tibia. After emergency external fixation on the day of arrival, a 2-staged surgery was performed. During the first operation, the fibular head was reduced and the tibial posterolateral fragment was fixed to restore the tibia length. During the second operation, medial and anterolateral fragments were fixed in order to reduce joint surface of the distal tibia. In general, proximal fibular head fractures are easily overlooked. In the case of pilon fractures with severe length shortening of the tibia without a fibular fracture, a proximal tibiofibular injury should be suspected.     

应用胫骨Ⅰ期短缩加Ⅱ期延长治疗严重胫骨开放性骨折

目的 评价应用胫骨Ⅰ期短缩加Ⅱ期延长的方法治疗严重胫骨开放性骨折的临床效果.方法 自2006年5月至2009年8月应用胫骨Ⅰ期短缩加Ⅱ期延长治疗5例严重胫骨开放骨折患者,均为男性;年龄23～41岁,平均35岁.清创和胫骨短缩后用单边外固定支架临时固定,血管损伤者行动脉吻合.1例伤口Ⅰ期闭合,2例经植皮后愈合,2例分别通过腓肠神经营养支筋膜瓣和交腿皮瓣闭合伤口.伤口愈合后从胫骨近端做截骨,应用Ilizarov架行胫骨延长,恢复小腿的长度.胫骨短缩3～5 cm,平均4.2 cm.结果 所有患者术后获18～24个月(平均20个月)随访.患者骨折短缩处伤口均获愈合,无一例发生感染.全部患者骨折均获愈合,愈合时间为6～12.5个月,平均9.6个月,平均愈合指数1.7个月/cm,患肢长度均恢复,与健侧无差别.按Paley功能评价标准:优3例,良1例,可1例.结论 应用胫骨Ⅰ期短缩加Ⅱ期延长治疗严重胫骨开放性骨折,具有安全可靠、简化治疗过程及减少皮瓣应用等优点,是一种较好的方法.

Abstract：

Objective To evaluate clinical results of primary shortening plus secondary lengthening of the tibia for sever tibial fractures. Methods From May 2006 to August 2009, 5 men with severe open tibial fracture were treated with primary shortening plus secondary lengthening of the tibia in our center. They were aged from 23 to 41 years (average, 35 years) . Four cases were Gustilo type MB and one was Gustilo type M C. The primary procedure included debridement, shortening of the tibia and temporary fixation with a unilateral external fixator, and arterial anastomosis in cases of vessel injury. The wounds healed primarily in one case, after skin graft in 2 cases, and after flap transplantation in 2 cases. After wound healing, secondary lengthening of the tibia was performed following osteotomy of the proximal tibia with an Ilizarov fixator to restore the length of the injured leg. The average shortening was 4. 2 cm (range, 3 to 5 cm). Results The average follow-up period was 20 months (range, 18 to 24 months). All the wounds were healed without signs of osteomyelitis. All the fractures united. The mean bone healing time was 9. 6 months (range, 6 to 12. 5 months) . The average healing index was 1. 7 months/cm. A normal length was restored in all the affected lower limbs. By Paley functional assessment system, 3 cases were excellent, one was good and one was fair. Conclusion Primary shortening plus secondary lengthening of the tibia is a reliable and successful method for sever tibial fractures, because it can simplify management and minimize the need for flap coverage.     

Fibula fracture stabilization with a guide wire as supplementary fixation in tibia fractures

The tibia is the most commonly fractured long bone. Although the goals of fracture management are straightforward, methods for achieving anatomical alignment and stable fixation are limited. Type of management depends on fracture pattern, local soft-tissue involvement, and systemic patient factors. Tibial shaft fractures with concomitant fibula fractures, particularly those at the same level, may be difficult to manage because of their inherent instability. Typically, management of lower extremity fractures is focused on the tibia fixation, and the associated fibula fracture is managed without fixation. In this article, we describe a novel technique for intramedullary fixation of the fibula, using a humeral guide wire as an adjunct to tibia fixation in the setting of tibial shaft fracture. This technique aids in determining length, alignment, and rotation of the tibia fracture and may help support the lower extremity as whole by stabilizing the lateral column. In addition, this technique can be used to help maintain reduction of the fibula when there is concern about the soft tissues of the lower extremity secondary to swelling or injury. Our clinical case series demonstrates the safety, effectiveness, and cost-sensitivity of this technique in managing select concurrent fractures of the tibia and fibula.     

Repair of a large soft tissue defect in the leg with cross-leg bridge free transfer of a latissimus dorsi myocutaneous flap: a case report

A 48-year-old man sustained a traffic accident injury to his left leg. It was an open fracture of the left tibia and fibula accompanied by a large soft tissue defect (27 cm×7 cm). Doppler examination revealed the posterior tibial artery was occluded due to thrombosis. Three weeks after injury, the latissimus dors myocutaneous flap was elevated with a T-shaped vascular pedicle and was interposed between the two vascular ends of the posterior tibial vessel of the contralateral leg. Two end to end anastomoses were performed between the two vascular ends of the posterior tibial vessel of the contralateral leg and the latissimus dors myocutaneous flap’s T-shaped vascular pedicle. The latissimus dorsi myocutaneous flap was used for repair of a large soft tissue defect of the left leg. The vascular pedicle was cut off after 28 days and the flap survived completely. After 3-years’ follow-up postoperatively, a good contour was confirmed at the recipient area. The right tibia and fibula fractures were confirmed healing radiologically. The posterior tibial artery of contralateral leg was demonstrated patent by clinical and Doppler examinations.     

外固定架一期固定后二期锁定钢板内固定治疗胫腓骨开放性骨折

目的评价应用外固定架固定后二期锁定钢板内固定治疗胫腓骨开放性骨折的疗效。方法对118例胫腓骨开放骨折患者行外固定架固定后二期锁定钢板内固定治疗。结果 118例均获随访,时间12～24个月。除1例因钢板移位影响骨折愈合外,其余患者骨折均愈合,时间3.1～5.2个月,骨折愈合率为99.2%;并发症发生率4.2%。按照Enneking评分系统评估疗效:优96例,良11例,可7例,优良率为90.7%。膝关节活动度:伸0°,屈135°,踝关节活动度:背伸30°,跖屈40°。结论外固定架固定后二期锁定钢板内固定治疗胫腓骨开放骨折操作简便,固定牢靠,骨折愈合快,并发症少,临床疗效满意。