下肢创伤性截肢后残端问题的影响因素及其手术治疗

目的 探讨下肢创伤性截肢后残端问题的影响因素及其手术治疗.方法 1992年11月至2008年8月共收治72例(80侧)下肢踝关节以上创伤性截肢后因残端问题而进行手术治疗的患者,其中男47例,女25例;年龄9～60岁,平均(28.8±12.4)岁.小腿截肢48侧,大腿截肢32侧.从受伤截肢到因残端问题接受手术治疗的时间平均为32.7个月.对患者残端问题进行评价,将性别、单双侧截肢、截肢部位(大腿与小腿)、致伤原因作为因素,截肢到首次残端修整术时间、软组织多余臃肿、皮肤明显瘢痕、皮肤溃疡、神经瘤、骨刺作为水平,统计分析每一因素与各水平间的关系.通过ADL评分评价手术后的效果.结果 14侧行胫腓骨融合术,12侧残端修整术≥2次,双侧截肢者13例21侧(8例双侧残端同时修整),再截肢5侧.80侧残端问题中有53侧(66.3%)原始截肢时未行残端肌肉固定成形术,瘢痕多者42侧(52.5%),神经瘤38侧(47.5%),软组织过多臃肿皱褶24侧(30.0%),皮肤溃疡14侧(17.5%).原始截肢到首次残端修整术的时间小腿截肢比大腿截肢长,差异存统计学意义(P=0.030);大腿截肢软组织臃肿多于小腿截肢,差异有统计学意义(P=0.007);单侧截肢患者骨刺发生率高于舣侧截肢患者,差异有统计学意义(P=0.018).41例患者入院时ADL评分平均为(85.31±7.24)分,出院时为(95.40±3.92)分,差异有统计学意义(t=-11.536,P=0.000).结论 单双侧截肢、截肢部位是影响下肢创伤性截肢后残端问题的重要因素.选择适当的患者进行残端修整术及胫腓骨融合术可获得良好疗效.

Surgical strategies for stump problems following trauma-related amputation of lower extremity

Objective To investigate the surgical management strategies for stump problems fol-lowing trauma-related amputation of lower limb. Methods From November 1992 to August 2008, 72 consecutive patients, who had been troubled by stump problems after above-the-ankle amputation due to trauma, underwent revision surgery of the stump. They were 47 men and 25 women, aged from 9 to 60 (average, 28.8±12.4) years old. The stump problems in all these cases were analyzed retrospectively. Gender, unilateral or bilateral amputation, amputation level, trauma cause were hypothesized as group factors; duration between the original amputation and the first revision surgery, soft tissue redundancy, scar, ulcer, neuroma, and exostosis were taken as levels in each group. The correlations between factors and levels were analyzed statistically. Activities of daily living (ADL) scores were also obtained to estimate effectiveness of the management strategies. Results Eighty problem stumps were treated surgically, including 48 above-knee amputations and 32 below-knee amputations. The duration from the original amputation to the first revision surgery in the below-knee amputation cases was longer than that in the above-knee amputation ones( P = 0.030); the soft tissue redundancy in the above-knee amputation cases was higher than in the below-knee amputation ones (P=0.007); the exostosis in the unilateral amputation was higher than in the bilateral one (P=0.018). The differences in the A DL scores in 41 cases between initial hospitalization and discharge were significant (t=-11.536, P=0.000) . Conclusion Since stump problems following trauma-related amputation of lower limb can have crucial influence on living and work of the amputees, appropriate surgical management should be recommended due to its reliable therapeutic effects.