分期保肢策略在严重小腿毁损伤救治中的应用

[目的]探讨分期保肢策略在严重小腿毁损伤救治临床应用的效果。[方法] 2015年9月～2019年1月,本科收治9例严重胫腓骨GustiloⅢB/C型开放性骨折伴严重皮肤软组织缺损患者,其中GustiloⅢB型6例,GustiloⅢC型3例,其中合并骨缺损者2例。采用分期保肢策略治疗:初期予彻底清创、外固定支架固定、血管神经吻合;待创面感染控制后,二期行植皮或皮瓣转移覆盖创面;三期待植皮或皮瓣转移术后创面愈合良好后,更换外固定支架为内固定稳定骨折,必要时行植骨治疗。[结果]所有患者均保肢成功,其中3例经植皮覆盖创面后愈合,6例经皮瓣转移覆盖创面后愈合。患者创面均未见明显感染,在创面愈合2～3周后拆除外固定,更换为内固定,其中2例骨缺损者经过同侧腓骨瓣转移,均达到骨性愈合。[结论]对于严重胫腓骨GustiloⅢB/C型开放性骨折伴严重皮肤软组织缺损患者,通过分期治疗,疗效确切,能有效保存患肢生理功能,避免截肢。     

应用封闭式负压引流及游离皮瓣治疗小儿肢体大面积软组织缺损

目的 探讨应用封闭式负压引流(VSD)及游离皮瓣治疗小儿肢体严重创伤性大面积软组织缺损的手术技巧及临床应用价值.方法 应用VSD及游离皮瓣治疗22例患儿,年龄3～10岁,均为四肢严重创伤后大面积软组织缺损,骨、肌腱等深部组织裸露或部分缺损,创面大小12 cm×8cm ～ 34 cm×25 cm,新鲜创面9例,感染坏死性创面13例.创面经彻底清创后,先行VSD覆盖创面.对合并不稳定骨折者,急诊行外固定支架固定骨折或克氏针内固定.5～9 d后去除VSD负压膜,根据软组织缺损及其深部组织损伤情况,再次清创后单纯行游离皮瓣移植修复8例,游离皮瓣加植皮修复14例.术后对皮瓣的存活情况和愈合质量进行随访.结果 合并深部组织裸露的肢体大面积软组织缺损的22例患儿,经负压封闭引流后,局部创面无明显感染,肌腱及骨外露区周围肉芽组织生长良好.再次清创后施行的游离皮瓣移植全部一期成活,未出现血管危象,感染控制良好,没有形成窦道.术后随访6～24个月,皮瓣质地柔软,外形良好,患肢功能恢复满意.结论 对于小儿严重创伤后深部组织裸露的肢体大面积软组织缺损,经彻底清创后,应用封闭式负压引流及游离皮瓣修复,可明显缩短治疗周期,提高手术成功率,最大限度恢复小儿患肢的功能.     

下肢Gustilo ⅢB型和ⅢC型骨折的保肢治疗及疗效评价

目的 探讨下肢Gustilo ⅢB型、ⅢC型开放性损伤的保肢治疗方法及其疗效. 方法 2008年10月至2012年1月共收治82例下肢Gustilo ⅢB型、ⅢC型骨折患者,男64例,女18例;年龄21 ～64岁,平均45.3岁.骨折Gustilo分型:ⅢB型63例,ⅢC型19例.骨折部位:胫腓骨37例,胫骨6例,股骨9例,双侧胫腓骨5例,胫腓骨合并股骨11例,胫腓骨合并跖趾骨14例.肢体创伤严重程度评分:＞7分29例,6～7分32例,＜6分21例.均采用负压封闭引流(VSD)技术和延期组织瓣修复的保肢策略治疗.创面最终覆盖方式:直接缝合4例,植皮13例,肌瓣移植16例,局部或交腿筋膜瓣移植41例,游离皮瓣移植4例. 结果 82例患者术后获4 ～53个月(平均17个月)随访.78例患者保肢成功,4例(Gustilo ⅢB型、ⅢC型各2例)患者行二期膝下截肢术.保肢成功的78例患者平均负压吸引1.6次,平均手术3.7次.骨折一期愈合66例,愈合时间平均为6.4个月;延迟愈合7例;骨不连5例.9例患者出现创面感染现象,3例发生慢性骨髓炎. 结论 对于下肢GustiloⅢB型、ⅢC型骨折患者,通过彻底清创及合理骨折固定,配合VSD技术及延期组织瓣修复,可有效恢复肢体功能.     

单边可延长外固定支架治疗GustiloⅢB/C型胫骨开放性骨折伴骨缺损

【摘要】〓目的〓探讨应用单边可延长外固定支架治疗GustiloⅢB、C型开放性胫骨骨折并骨缺损的临床疗效。方法 2011年6月至2014年6月,应用单边可延长外固定支架治疗GustiloⅢB/C型开放性胫骨骨折并骨缺损21例。主要方法:一期清创清除游离碎骨及严重污染的骨组织,修整骨折端整齐后短缩患肢对合、修复血管神经肌腱,安装单边可延长外固定支架,并在胫骨近端截骨;术后2周开始骨搬运延长,逐渐延长恢复短缩部分胫骨,恢复肢体长度,骨折愈合后拆除外固定支架。结果〓本组21例随访时间10个月~3年,平均18个月。17例均通过一期短缩肢体修复创面,3例通过局部旋转皮瓣修复创面,1例局部皮瓣部分坏死后通过植皮修复创面。所有骨折端及截骨端最终全部愈合,骨折愈合时间为5~13个月,平均时间8个月。结论〓应用单边可延长外固定支架治疗GustiloⅢB/C型开放性胫骨骨折伴骨缺损,通过急诊短缩患肢消灭创面,同时胫骨干骺端截骨延长的治疗方案,最终肢体长度恢复、骨折愈合。     

基层医院胫腓骨开放性骨折治疗体会

目的:观察分析胫腓骨开放性骨折早期处理及治疗效果.方法:131例(164肢)患者入院创面反复冲洗清创,早期修复软组织为主,提供软组织修复的初期稳定,选择合适的固定方式,外支架固定107肢,不扩髓绞锁髓内钉固定34肢,钢板内固定11肢,石膏外固定7肢等.结果:123例(154肢)均获7～21.5个月随访,平均11.5个月.骨折愈合时间4.5～21个月,平均7.7个月,其中延迟愈合6肢,占3.9%;2肢不愈合,占1.3%,二次手术治愈.Johner-Wruh评分标准:129肢优、19肢良,2肢中,4肢差,优良率96.1%.结论:胫腓骨开放性骨折,早期提供较理想的软组织修复,用外固定支架稳定骨折,尤其适用Ⅲ度开放骨折,可获良好治疗效果.     

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。     

伤害控制策略在严重多发伤并多发骨折治疗中的应用

目的总结严重多发伤合并多发性骨折病人的救治和应用伤害控制策略的治疗效果。方法回顾性分析2003年1月至2007年1月创伤严重度评分（injury severity score,ISS）大于25分的23例严重多发伤合并多发性骨折的病人应用伤害控制策略进行救治,并观察围手术期并发症、死亡率及骨折愈合情况,尤其是肢体和关节功能恢复情况。结果除1例右下肢严重毁损伤急诊清创骨牵引保肢术后3个月因骨缺损感染骨髓炎而作大腿截肢外,全部病例骨折愈合,未出现严重并发症,无围手术期死亡病例,肢体功能恢复满意。结论对严重多发伤合并多发性骨折的病人应用伤害控制策略治疗,效果满意。     

多功能外固定支架治疗重度开放性、粉碎性胫腓骨骨折78例

目的探讨多功能外固定支架治疗重度开放性、粉碎性胫腓骨骨折及对软组织损伤的处理。方法利用清创、外固定支架固定胫腓骨骨折并处理合并的软组织损伤。结果78例患者随访5-40个月,平均随访时间19个月。73例达骨性愈合,5例延迟愈合,7例发生创面感染,本组无肢体坏死及骨不连发生。结论应用多功能外固定支架治疗重度开放性、粉碎性胫腓骨骨折,可以克服此类骨折因骨质缺损或骨块多而碎不能有效固定的缺点,一期稳定骨折端,同时具有创伤小,早期可行功能锻炼以防止关节僵硬,有利于断端骨愈合及护理等优点。     

重度开放性Pilon骨折的治疗

目的 探讨重度开放性Pilon骨折的手术时机、手术方法选择及其对治疗效果的影响.方法 2003年4月至2008年7月收治开放性Pilon骨折患者21例,骨折按AO/OTA分类,均为C型,C2型17例,C3型4例;软组织损伤程度按照Gustilo标准,Ⅱ度18例,Ⅲ A度2例,Ⅲ B度1例.根据骨折类型、软组织损伤程度及受伤时间的不同采用两种不同的治疗方法,GustiloⅡ度C2型16例,GustiloⅡ度C3型2例,Gustilo ⅢA度C2型l例,采用创面清创胫骨有限内固定结合支架外固定术;GustiloⅢA度C3型1例,Gustilo ⅢB度C3型1例,采用创面清创跟骨牵引、延期手术.结果 所有患者术后获得6～48个月的随访,平均24个月.骨折复位情况影像学评估结果(Burwell-Charnley标准):解剖复位6例,复位一般14例,复位差1例.骨折全部愈合,愈合时间2.5～11个月,平均4.7个月,其中骨折延迟愈合2例,延迟愈合率9.5%.创面皮肤浅表坏死2例,浅表感染2例,深部感染1例,感染率14.3%.早期出现踝关节创伤性关节炎8例,发生率38.1%.按美国骨科协会足踝外科分会(American Orthopedic Foot Ankle Society,AOFAS)评分标准:评分为66～94分,平均85.2分.主要并发症包括皮肤、软组织坏死、感染,骨折延迟愈合,创伤性关节炎等.结论 治疗开放性Pilon骨折要根据骨折类型、软组织损伤程度及受伤时间的不同选择适当的手术时机和手术方式,正确评估软组织损伤情况、骨与软组织血运的保护是治疗关键.严格的清创、合理应用抗生素、酌情植骨、适时的功能锻炼可以减少并发症的发生.     

分期不同类型外固定架在治疗下肢Gustilo-Ⅲ C型骨折并腘动脉断裂中的应用

目的探讨分期不同类型外固定架在治疗下肢Gustilo-ⅢC型骨折腘动脉断裂中的应用效果。方法笔者自2009-01—2013-01诊治下肢Gustilo-ⅢC型骨折腘动脉断裂15例,所有患者创面进行彻底清创、修复腘动脉,一期给予跨膝关节单边外固定架固定,创面二期给予皮瓣、植皮处理,待局部软组织好转后,更换半环形外固定架给予固定骨折断端,解放膝关节,进行膝关节功能锻炼。结果 15例均获得随访平均3(2~6)年。本组中2例因后期感染难以控制,给予二期截肢,13例保肢成功,10例术后功能评价良好。术后26个月疗效按Johner-Wruhs评分标准评定:优7例,良4例,可2例。结论分期不同类型外固定架可以早期很好保护修复的腘动脉,二期稳定固定骨折断端,减少感染、软组织损伤等并发症的发生,是治疗Gustilo-ⅢC型骨折理想的固定方法。     

Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma

BACKGROUND: Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system. METHODS: Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation. RESULTS: Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity. CONCLUSION: Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.     

Mangling upper limb injuries in industry

The salvage of upper limbs mangled by industrial machinery became possible with the development of predictable techniques of vascular and microvascular anastamosis. Unfortunately, many of these salvaged limbs are associated with fair and poor functional outcomes. The quality of the skeletal fixation can have a substantial effect on the functional outcome and should be a major focus of the limb repair process. Internal plate fixation facilitates wound care and limb mobilization without tethering muscle-tendon units and is safe in the majority of severe upper limb injuries provided that all devitalized tissue is debrided and, if necessary, reconstructed using microvascular tissue transfers. Injury patterns, especially those which involve associated injury of the elbow or forearm ligaments, must be identified and treated appropriately. Internal fixation should restore anatomical alignment and provide sufficient stability to allow immediate active mobilization of the limb without contributing to devascularization of the soft tissues or skeleton.     

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.     

Infrapopliteal arterial injury: prompt revascularization affords optimal limb salvage.

Sixty-nine limbs with infrapopliteal arterial injuries were evaluated in 68 patients. Thirty-five (50%) cases were complicated by acute limb-threatening ischemia. Management consisted of revascularization (26 limbs), ligation (15 limbs), fasciotomy only (2 limbs), observation (18 limbs), and primary amputation (8 limbs). Penetrating injuries (n = 35) had a 33% incidence of ischemia and a reduced frequency of associated injury. One delayed amputation (3%) was required. In contrast, blunt injuries (n = 34) had a 68% incidence of ischemia and a greater frequency of associated injury. There were 20 amputations in the blunt group, including eight primary amputations performed in limbs with profound ischemia, complex open fractures, severe soft-tissue damage, and neural injury. Observation or ligation of single arterial injuries resulted in no early amputations. Associated local injuries in both groups included fracture or ligamentous disruption (64%), severe soft-tissue damage (32%), and nerve dysfunction (36%). In both groups, 15 of 35 ischemic limbs were salvaged by prompt revascularization (11 penetrating and four blunt injuries). Aggressive revascularization with autogenous repair or bypass is recommended for management of penetrating trauma. Though a good outcome will be achieved in some patients with combined blunt trauma and infrapopliteal arterial injury, the probability of delayed amputation and prolonged disability must be consciously integrated into the decision to pursue limb salvage. The prognosis for blunt injury complicated by arterial ischemia is poor; thus the severity of associated local and remote injuries will affect the results of revascularization program.     

截肢与保肢术治疗严重胫骨开放性骨折的病例对照研究

目的：比较Ⅰ期截肢和保肢手术治疗胫骨GustiloⅢB,ⅢC型开放性骨折患者的中期临床疗效.方法：自2007年7月至2010年6月,对分别采用截肢与保肢治疗的68例单侧胫骨GustiloⅢB,ⅢC型开放性骨折患者的临床资料进行回顾性分析.截肢组38例,男26例,女12例;平均年龄（44.9±16.3）岁;GustiloⅢB型21例,ⅢC型17例,根据小腿皮肤软组织损伤程度、骨折类型、位置和手术探查所见选择截肢平面.保肢组30例,男21例,女9例;平均年龄（43.5±14.7）岁;GustiloⅢB型23例,ⅢC型7例,根据患者具体情况选择骨折固定方式及创面修复方法.比较两组患者的手术时间、失血量、住院时间及术后感染率;比较两组患者术后平均负重时间及重返原工作率;采用痛觉模拟评分（VAS）评估患者的疼痛情况;并采用SF-36健康量表评估患者术后的生活质量.结果：共60例患者（截肢组33例,保肢组27例）获得随访,平均随访时间49.1个月.截肢组、保肢组的手术时间、失血量、住院时间及术后感染率分别为：（109.0±25.7）min,（245.0±58.6）min;（168.0±49.0）ml,（311.0±137.0）ml;（13.8±2.7） d,（28.8±13.1） d;7.9％,36.7％.至末次随访时,两组患者的VAS评分及重返原工作率比较差异无统计学意义,但截肢组术后平均负重时间更短.截肢组患者的生理机能评分优于保肢组,而保肢组患者的躯体疼痛评分优于截肢组,两组患者的心理健康比较差异无统计学意义.结论：Ⅰ期截肢与保肢手术均为治疗严重小腿开放性骨折的重要手段,两者中期临床疗效相当.     

Early Microvascular Reconstruction of Gustilo Type III-C Lower Extremity Wound: Case Report

Current algorithms for lower limb injuries recommend amputation for most Gustilo type III-C injuries with a limb salvage index score of 6–8 or more. Recent improvements in the timing and technique of microvascular flaps with the reduction in bone healing time as a result of better fixation devices and early bone grafting make the option of limb salvage after such severe injuries a valid and acceptable therapeutic approach. We present a case of severe shot gun injury to the leg with a limb salvage index score of 9 that was successfully salvaged by vascular reconstruction followed three days later with a microvascular osteocutaneous scapular flap anastomosed to the divided limbs of a preliminary arterio-venous fistule that had been constructed at the time of the initial vascular repair. The patient was able to walk unaided one year after the injury.     

下肢毁损伤保肢的综合治疗体会

目的通过对下肢严重毁损伤的诊疗的回顾性总结,探讨救治并进一步保全肢体和功能的方法。方法总结近5年来17例严重下肢毁损伤病人,均在伤后6～8 h内给予急症手术,根据情况行内固定或外固定,吻合损伤的血管和神经,一期或二期皮瓣转移或移植,术后给予综合治疗。结果本组中1例因单侧腹股沟以下血管多段挫裂并致缺血坏死,导致肾功能衰竭而截肢。其余16例病人肢体得以保全(其中有1例因家庭原因后来进行了截肢),15例术后功能评价良好。结论合理的手术处理和术后的综合治疗,可以有效挽救严重创伤濒临截肢的肢体,降低致残率,减轻患者家庭及社会负担。     

下肢严重开放性损伤的显微外科修复

目的探讨下肢严重开放性损伤的显微外科修复及临床疗效。方法对下肢损伤根据Gustil和Andserson分类ⅢB16例、ⅢC29例，采用显微外科技术修复结合稳定的固定方法和损伤肢体部位筋膜间室广泛切开减压进行治疗结果38例43肢存活，7例二期截肢。全部病例随访5～60个月，骨折愈合，无骨关节感染发生．组织瓣全部成活，质地与色泽较好；存活肢体外形与功能满意16例，基本满意20例．不满意2例。结论下肢严重开放性损伤危及肢体的存活与功能，对伤肢主干血管重建、神经损伤及软组织缺损的修复是关键。应用显微外科技术修复与重建，可提高临床疗效。     

Vascular injuries of the limbs: a fifteen-year Georgian experience.

OBJECTIVES: to analyse the causes of injury, surgical approaches, outcome and complication of vascular trauma of the upper and lower limbs in patients with vascular injuries operated on over a period between 1981 and 1995. PATIENTS: in 157 patients, the injuries were penetrating in 136 cases and blunt in 21. Isolated vascular trauma was present in 92 (58.6%) patients, 65 cases (41.4%) were aggrevated by concomitant bone fractures, severe nerve and soft tissue damage. The most frequently injured vessels were the superficial femoral (20. 6%) and brachial (19.1%) arteries. RESULTS: saphenous vein interposition grafting was applied with good results in 34 patients, polytetrafluoroethylene grafts were used in three cases, end-to-end anastomoses in 42 cases, venous bypasses in five cases, and venous patches in seven cases. Seventeen patients underwent arterial repair and nine, venous repair. Fasciotomy was used in 18 cases, and vessels were ligated in 14 cases. Blood flow was restored in 91 patients (58.0%), and collaterals compensated in 31 cases (19.7%). Fourteen primary and nine secondary amputations were performed. Twelve patients died. The limb salvage rate was 77.7% (84.1% among surviving patients). CONCLUSIONS: most vascular injuries associated with limb trauma can be managed successfully unless associated by severe concomitant damage to bones, nerves and soft tissues.     

The pathomechanism of posttraumatic edema of the lower limbs: II--Changes in the lymphatic system

BACKGROUND: The peripheral lymphatic system reacts to penetrating microorganisms and self-antigens released from tissues and cells damaged by trauma or intracellular pathogens. The response of regional lymph nodes to tissue trauma has not been thoroughly studied. We investigated the changes in lower limb lymphatics and nodes after fractures and soft tissue injuries. This type of injury is frequently complicated by limb edema. Posttraumatic edema of lower limbs is characterized by long-lasting swelling of the limb, erythema, and increased skin temperature at the site of injury. This suggests that a local inflammatory process is proceeding, even though the process of bone or soft tissue healing is considered to be completed. METHODS: Twenty-one patients with closed lower limb bone fractures and soft tissues injuries were studied by means of isotope lymphography. RESULTS: Dilated lymphatics of the entire limb were found in all patients, and 62% of them showed enlarged inguinal lymph nodes. Venous thrombosis was found in 24% of cases. There was no correlation between the degree of lymphatic dilatation, lymph node enlargement, and bone fracture or soft tissue injury or venous thrombosis. Surgical intervention was not an independent factor for lymph node enlargement. CONCLUSION: This study has shown that although the fracture or injured tissues are clinically healed, local inflammatory reaction at the site of injury persists and cytokine signals are sent to the regional lymph nodes.