高压脉冲灌洗装置在治疗胫腓骨开放性骨折中的应用

目的探讨高压脉冲灌洗装置在胫腓骨开放性骨折中的临床应用效果。方法应用高压脉冲灌洗装置急诊清创的方法治疗23例胫腓骨开放性骨折,均行外固定支架固定,一期缝合或二期行皮瓣转移或创面植皮。结果19例病人一期愈合,4例病人行二期植皮或皮瓣转移术后愈合。所有创口或切口均无感染。结论急诊清创、高压脉冲灌洗装置灌洗治疗是预防开放性骨折术后感染的有效方法。     

胫腓骨严重开放骨折伴软组织缺损的治疗(附11例报告)

胫腓骨严重开放骨折,局部皮肤软组织坏死缺损,骨折端外露,是治疗骨折中的一大难题,也是发生骨不连的主要原因之一,治疗不当往往造成肢体严重残废。1988年以来,我们采用腓肠肌内侧头肌皮瓣旋转移位修复软组织缺损,同时用李氏半环槽型或双杆型外固定器加压固定骨折断端,治疗胫腓骨开放骨折伴软组织缺损11例,达到既快速修复了软组织缺损,又固定了骨折断端,促进骨折愈合,与既往传统治疗方法相比,缩短了治疗时间,获得满意效果,报告如下:     

外固定支架联合股前外侧肌皮瓣治疗GustiloⅢB/C型开放性胫腓骨骨折

目的探讨外固定支架联合股前外侧肌皮瓣治疗GustiloⅢB/C型开放性胫腓骨折的疗效。方法采用回顾性病例系列研究分析2016年3月至2019年6月苏州大学附属瑞华医院收治的15例GustiloⅢB/C型开放性胫腓骨骨折患者临床资料,其中男11例,女4例;年龄22~67岁[(48.5±12.6)岁]。患者入院后均急诊Ⅰ期行清创,对主要血管、神经和肌腱进行探查修复,并用外固定支架对骨折断端进行固定。术后均遗留不同程度的创面坏死、感染以及骨缺损。Ⅱ期清创后组织缺损面积为10.0 cm×5.0 cm~30.0 cm×8.0 cm,均采用股前外侧肌皮瓣修复,肌皮瓣切取面积为10.5 cm×5.5 cm~30.5 cm×8.5 cm。术后2周内观察供区愈合、皮瓣成活情况。末次随访时,观察皮瓣外形、感觉恢复情况、骨折愈合情况及相关并发症,并采用下肢功能评分(LEFS)评估患肢功能。结果患者均获随访12~32个月[(22.0±5.8)个月]。肌皮瓣供区均Ⅰ期愈合,仅遗留线性瘢痕。12例肌皮瓣完全成活。2例面积较大的肌皮瓣远端出现部分坏死,经过清创植皮后创面愈合;1例肌皮瓣术后出现血管危象,采用对侧大隐静脉桥接修复栓塞静脉后皮瓣成活。末次随访皮瓣外形恢复良好,感觉部分恢复,皮瓣两点辨别觉为18~26 mm。骨折均愈合好,无骨髓炎等严重感染相关并发症。患肢LEFS为47~69分[(59.0±9.5)分]。结论采用外固定支架联合股前外侧肌皮瓣治疗GustiloⅢB/C型开放性胫腓骨骨折,可较好恢复小腿软组织缺损处的外形,并且能有效减少严重感染相关并发症的发生。     

开放性胫腓骨骨折伴皮肤软组织缺损33例治疗体会

总结开放性胫腓骨骨折伴皮肤软组织缺损33例治疗体会,认为早期手术、彻底清创、骨折内固定,掌握好软组织修复时机与方法,可提高疗效,预防严重并发症发生。     

游离股前外侧穿支皮瓣联合外固定支架在小腿Gustilo Ⅲ型骨折中的临床应用

目的探讨游离股前外侧穿支皮瓣联合外固定支架在小腿Gustilo Ⅲ型骨折中的临床应用效果。方法回顾性分析2015年1月—2018年1月四川宜宾中康骨科医院骨科应用游离ALTP联合外固定支架治疗小腿Gustilo Ⅲ C型骨折患者25例,男性19例,女性6例;年龄18～59岁,平均42. 5岁。致伤原因:道路交通伤10例,机械伤15例。均有明确的骨折和血管、神经、肌肉以及皮肤软组织损伤,均属于Gustilo Ⅲ C型。小腿创面缺损范围7. 5cm×8. 5cm～25. 0cm×13. 0cm。Ⅰ期急诊下行清创探查术,修复重要的血管、神经、肌腱,骨折予以外支架固定。待创面清洁时,Ⅱ期行游离ALTP修复创面。术后均予以抗感染、抗血栓、抗血管痉挛等治疗,皮瓣成活后根据下肢力线及骨愈合情况更改内固定术。结果 22例游离皮瓣顺利成活,3例因皮瓣切取面积较大,远端少许坏死,经换药、植皮等处理后创面愈合。皮瓣成活后17例患者拆除外固定支架更改内固定,8例患者外固定支架成为终极的固定方式。25例均获随访,随访时间10～18个月,平均12.4个月。骨折端对位良好,力线恢复,骨愈合正常。结论游离皮瓣联合外固定支架治疗小腿Gustilo Ⅲ型骨折可有效修复创面,促进骨愈合,临床效果好。     

小腿Gustilo ⅢB型骨折的手术治疗

28例小腿GustiloⅢB型骨折行急诊清创有限内固定+外固定支架固定术,Ⅱ期对软组织缺损及骨外露行皮(肌)瓣修复,随访18～32个月,25例骨折愈合。该术式治疗GustiloⅢB型骨折安全有效。     

外固定结合有限内固定治疗合并软组织损伤的胫腓骨骨折

对34例合并软组织损伤的胫腓骨骨折采用Ⅰ期或择期清创、外固定结合有限内固定治疗,选用皮瓣修复皮肤缺损.按照Edwards评定,治疗优良率为90%.     

封闭负压引流治疗腕部开放性骨折合并软组织缺损

目的评价应用封闭负压引流(vacuum sealing drainage,VSD)治疗腕部开放性骨折合并软组织缺损的临床效果。方法16例腕部开放性骨折合并软组织缺损,经清创、骨折复位固定,肌腱、神经、血管修复后,用VSD治疗创面1~2次,再Ⅱ期皮片移植或皮瓣转移修复。结果所有病例无骨筋膜室综合征发生,合并的缺损创面肉芽组织生长良好,细菌培养阴性,皮片移植和皮瓣修复后创面均愈合,骨折全部愈合,腕关节功能优良率87%。结论用VSD治疗腕部开放性骨折合并软组织缺损,能预防骨筋膜室综合征的发生,降低创面感染的风险,促进创面修复,获得较好的腕关节功能,值得临床应用推广。     

分期治疗胫腓骨远端开放骨折的疗效分析

对收治的胫腓骨远端开放骨折患者35例急诊行胫骨外固定架固定＋伤口清创缝合/伤口清创负压封闭引流（ VSD）覆盖创面,恢复胫骨长度及下肢基本力线,术后使用抗生素预防感染,伤口情况稳定后Ⅱ期拆除外固定,行胫腓骨骨折内固定治疗,术后踝关节功能锻炼。随访15～27个月（平均20个月）,伤口均无感染,6例伤口局部皮肤坏死,经清创VSD治疗均获得愈合。     

有限内固定结合单侧多功能外固定架治疗胫腓骨严重开放粉碎性骨折

目的观察有限内固定结合单侧多功能外固定支架治疗胫腓骨严重开放粉碎性骨折的疗效。方法使用有限内固定(钢丝、螺丝钉、克氏针)结合单侧多功能外固定架固定胫骨,同时钢板、克氏针、钢丝固定腓骨治疗胫腓骨严重开放粉碎性骨折。结果本组42例随访6~24个月,平均12个月。伤口愈合情况:25例I期甲级愈合;15例皮肤发黑、坏死,经换药,皮瓣转移愈合;2例感染,经换药引流、分泌物培养、选用敏感抗生素、皮瓣转移及植皮后愈合,无一例骨髓炎。骨折愈合情况:40例于骨折术后13~32周愈合,平均18周;2例骨缺损致骨不连在伤口愈合后3个月行植骨+钢板内固定,术后3个月骨折愈合。另螺钉松动1例,松动伴钉道感染1例,经用酒精点滴钉孔痊愈,无血管、神经损伤。除1例踝关节僵直外,其余41例膝、踝关节功能正常。结论该手术操作简单,创伤小,复位好,固定可靠,是治疗胫腓骨严重开放粉碎性骨折的良好方法。     

复杂性胫腓骨骨折137例

目的 探讨复杂性胫腓骨骨折治疗中骨折与软组织损伤处理的方法。方法 对１３７例复杂性胫腓骨骨折的治疗进行分析。其中胫腓骨多段骨折８９例,伴有软组织缺损的胫腓骨开放粉碎骨折２７例,合并血管神经损伤的胫腓骨骨折２１例,有１１８例获得１０个月￣５年２个月的随访,平均随访２年３个月。     

Ilizarov骨搬移技术治疗胫骨大段骨缺损合并软组织缺损

目的 探讨Ilizarov技术Ⅰ期治疗胫骨大段骨缺损合并软组织缺损的可行性.方法 2003年9月-2010年9月收治胫骨大段骨缺损合并软组织缺损患者24例,均为胫骨开放性骨折(Gustilo Ⅲ B型20例,Gustilo Ⅲ C型4例).在患肢上安放Ilizarov外固定架.清创术后小腿胫前内侧软组织缺损10 cm×6 cm,胫骨骨缺损(8±4)cm.对15例胫骨骨缺损＜5 cm的患者使用Ⅰ期清创、腓骨截骨、胫骨缺损端加压.对9例胫骨缺损＞5 cm的患者采用Ⅰ期清创、骨运输-骨延长.对15例患者采用Ⅰ期清创,封闭创面或缩小创面、骨搬移,Ⅱ期清理皮肤嵌顿及清理骨折端.结果 所有患者随访10～24个月,平均14个月.骨缺损均得以重建,患肢肢体长度与健侧之差＜2 cm,骨折愈合,创面均闭合.1例术后出现腓总神经麻痹,术后3个月恢复.19例未通过额外手术进行修复.3例通过游离皮片植皮成活,2例通过局部旋转皮瓣修复覆盖创面.结论 Ⅰ期使用Ilizarov外固定架进行骨搬移肢体是治疗胫骨骨缺损合并软组织缺损的有效方法.     

负压吸引结合微创分期策略治疗胫腓骨开放性骨折

目的观察负压吸引结合微创分期策略治疗胫腓骨开放性骨折的疗效。方法回顾性分析2010年3月~2014年5月收治的60例Gustilo-ⅢA和ⅢB型开放性胫腓骨骨折病例的临床资料,其中男性32例,女性28例;年龄18~65岁,平均30.6岁。采用负压创面治疗技术结合微创分期策略治疗,Ⅰ期手术彻底清创,使用克氏针、螺钉、钢丝或可吸收线进行有限固定。然后按照创面的大小安装合适的负压吸引装置。术后应用抗生素预防感染治疗,1周后打开负压封闭吸引装置,观察肉芽组织生成情况,视伤口情况再次进行负压封闭引流(VSD)覆盖或行植皮、皮瓣转移覆盖。Ⅱ期手术应用锁定加压钢板或微创内固定系统(LISS)钢板进行闭合复位经皮微创插入钢板内固定术。观察疗效和并发症,探讨该术式适应证和并发症的防治,并进行1年以上的随访,观察其远期疗效。结果负压吸引结合微创分期策略治疗胫腓骨开放性骨折住院时间短,治疗费用少,术后并发症少,骨折愈合快,平均愈合时间7.2个月。结论负压创面治疗技术结合微创分期策略治疗高能量胫腓骨开放性骨折安全微创、简单、切实可行,且并发症相对较少,值得推广。     

VSD技术序贯背阔肌皮瓣游离移植治疗胫腓骨严重开放性骨折骨外露

目的探讨应用负压封闭引流(VSD)技术序贯背阔肌皮瓣游离移植治疗胫腓骨严重开放性骨折骨外露的临床效果。方法 2002年2月~2012年6月,应用VSD技术序贯背阔肌皮瓣游离移植修复19例GustiloⅢB和ⅢC型胫腓骨骨折骨外露患者,男性13例,女性6例;年龄17~68岁,平均37.3岁。其中GustiloⅢB型11例,GustiloⅢC型8例,骨外露创面面积16cm×13cm~25cm×17cm。所有患者入院后先行清创,VSD覆盖创面,抗感染治疗,待创面清洁无感染后行背阔肌皮瓣游离移植修复骨外露。结果术后随访12~36个月,平均22个月。本组19例移植肌皮瓣均成活,2例出现皮瓣尖端坏死,1周后行坏死组织清除并植皮修复,其余小腿创面均Ⅰ期愈合,术后无感染及血管危象发生。19例中13例骨折于术后8~21个月达到骨性愈合;4例胫骨缺损者于术后3个月行取自体髂骨植骨并更换为钢板内固定,9~14个月骨折愈合;2例胫骨骨折术后3~6个月X线摄片示骨折局部骨质吸收,骨折端萎缩,无骨痂生长,于术后6个月时行取髂骨植骨并钢板内固定,分别于10、13个月达骨性愈合。5例因皮瓣臃肿,影响日常生活,后期给予皮瓣修整术后明显改善;5例吻合神经的皮瓣感觉功能有不同程度恢复。膝关节功能活动基本正常,6例踝关节功能部分受限,主要表现为背曲受限,与胫前肌群损伤有关。结论应用VSD技术序贯背阔肌肌皮瓣游离移植治疗GustiloⅢB和ⅢC型胫骨骨折骨外露,能获得良好的临床效果。     

外固定复位器在复杂胫骨平台骨折中的应用

目的观察外固定复位器在治疗复杂胫骨平台骨折的作用。方法采用外固定器复位有限微创双切口内固定治疗复杂胫骨平台骨折30例。结果30例均获随访,随访时间为14~30个月,平均20个月,切口均一期愈合,未发生骨折不愈合,按照Lysholm评分标准,优良率为93.33%。结论外固定器复位有限切开内固定治疗复杂胫骨平台骨折复位容易,手术时间短,对膝关节软组织创伤小,固定牢靠能早期进行功能锻炼,是复杂胫骨平台骨折较为理想的治疗方法。     

External fixation combined with limited internal fixation in the treatment of pilon tibia fractures

BACKGROUND/AIM: Intraarticular fractures of the tibial plafond (pilon fractures) belong to the group of most severe fractures. They are usually caused by high-energy trauma and frequently associated with a marked soft-tissue damage. Surgical treatment has replaced the traditional nonoperative treatment. The aim of this study was to present the results of the treatment of distal tibial intraarticular fracture by the use of internal fixation, as well as the combination of minimal internal fixation and external fixation. METHODS: The study included 47 patients with pilon tibia fractures who went through at the Clinic for Orthopedics and Traumatology, School of Medicine, Nis (1995-2004). Within the analayzed group there were 33 (70.2%) males and 14 (29.8%) females. The patients mean age was 45.8 years. In the first group, which consisted of 22 patients, open reduction and internal fixation of both the tibia and the fibula was performed in the two separate incisions. The second group consisted of 25 patients managed with external fixation by external fixator "Mitkovi?" with limited internal fixation. Besides external fixation, a minimal internal fixation was performed by the use of Kirschner wires and screws. The patients were followed-up inside a 24-months-period. Results. The obtained was a substantially high number of complications after open reduction and internal fixation in the group of patients. There was no difference in a long-term clinical outcome. Postoperative osteitis, as the most severe complication in the management of closed pilon tibia fractures, was not registered in the second group. CONCLUSION: Considering the results obtained in this study, it can be concluded that external fixation by the "Mitkovi?" external fixator with the minimal internal fixation is a satisfactory method for the tratment of fractures of the tibial plafond causing less complications than internal fixation.     

External fixation and infection of soft tissues close to fracture localization

We evaluated the method of external fixation for stabilization of unstable closed and open first-degree diaphyseal fractures of long bones of lower extremities in 19 patients with infections of soft tissues close to the fracture location. The results are compared with those of another group (n = 392) of patients, with similar fractures without infections close to the fracture site, treated with inner stabilization methods. In the first group of patients, we noticed postoperative osteitis of the tibia in two cases (10%), but no pseudarthrosis or lesions of important blood vessels. In the second group of patients, the incidence of postoperative osteitis was 8.6% (n = 34) and the incidence of pseudarthrosis was 2% (n = 8). Among these patients, three lesions of important blood vessels were diagnosed. Our conclusion is that when the method of external fixation is used in combination with skillful operative techniques, the infection of soft tissues near the fracture location has no principal influence on the frequency of osteitis.     

Ipsilateral fibular transfer for a large tibial defect caused by a gunshot injury: case report

Segmental bony defects in open fractures of the tibia are bridged with bone grafting, free vascularized fibular grafts, or an external ring fixator. A 33-year-old man sustained a gunshot injury to his left leg, resulting in Gustillo type IIIB open fractures of the tibia and fibula. The tibia had a segmental massive defect of 19 cm in the midshaft. Debridement and immediate application of an Ilizarov external fixator were performed. The midportion of the ipsilateral fractured fibula served as a bridging vascularized graft for the tibial defect. Good bony union and fibular hypertrophy were obtained. Use of a fractured fibula from a zone previously injured by a gunshot has not been reported. This case demonstrates the successful transfer of a fractured fibula for the bridging of an ipsilateral tibial defect caused by a gunshot injury.     

Tibia and fibula fractures in soccer players

We performed a retrospective review of 31 athletes who sustained a fracture of the lower leg from a direct blow while playing soccer. Fifteen fractures involved both the tibia and fibula, 11 only the tibia, and 5 only the fibula. Information was collected using a standardized questionnaire. The mean follow-up from the time of injury was 30 months. Injuries typically occurred in young, competitive athletes during game situations. The mechanisms were broadly classified into several categories: contact during a slide tackle (13, 42%), a collision with the goalkeeper (8, 26%), two opposing players colliding while swinging for a loose ball (7, 23%), or a player being kicked by a standing opponent (3, 10%). The majority of fractures (26, 90%) occurred while the athletes were wearing shin guards. The point of impact was with the shin guard prior to the fracture in 16 cases (62%). Return to competitive soccer averaged 40 weeks for combined tibia and fibula fractures, 35 weeks for isolated tibia fractures, and 18 weeks for isolated fibula fractures. Injuries were associated with a high incidence of major complications (12 out of 31, 39%), especially in concurrent tibia and fibula fractures (8 out of 15, 50%). These findings suggest that lower leg fractures in soccer players are serious injuries, often necessitating a prolonged recovery time. In addition, this study questions the ability of shin guards to protect against fractures. Received: 1 March 1998 Accepted: 10 August 1998