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。

Sequential therapy of VSD and free latissimus dorsi flap for treatment of severe open tibiofibular fractures with bone exposure

Objective To evaluate the surgical technique and clinical significance of the sequential therapy of vacuum sealing drainage ( VSD) and free latissimus dorsi flap in the treatment of severe open fractures of tibia and fibula with bone exposure .Methods From Feb.2002 to Jun.2012,19 cases of Gustilo ⅢB andⅢC open fracture in tibia and fibula , which included large soft-tissue defects and bone exposure ,were treated with the sequential ther-apy of VSD and free latissimus dorsi flap transplantation ,including 13 males and 6 females with an average age of 37.3(17-68) years.Among the patients,11 cases were Gustilo IIIB and 8 cases were Gustilo ⅢC.The bone expo-sure area varied from 16cm ×13cm to 25cm ×17cm.All patients were radically debrided first ,treated with the se-quential therapy of VSD and anti-infective therapy .After the wound was clean without infection ,free latissimus dorsi flap transplantation was conducted for open fractures of tibia and fibula with bone exposure .Results All 19 pa-tents were followed up for 12 to 36 months (average,22 months).The flaps survived in all 19 patients and no infec-tion and vascular crisis happened ,except 2 cases got distal flap tip necrosis ,and healed after debridement and skin graft.Among the patients,13 patients achieved bone healing after 8-21 months;4 patients with tibiar bone defect were treated by autogenous iliac crest bone graft and replaced with plate fixation at 3 months after surgery , and a-chieved bone healing after 9-14 months; at 3 to 6 months after operation ,2 patients with tibial fractures were con-firmed bone loss,bone atrophy and without callus formation by X-ray,and they were treated by autogenous iliac crest bone graft and plate fixation at 6 months after surgery ,and achieved bone healing after 10-13 months.Five patients received a second flap repair and significanlly improved with good appearances .Five patients with flap implantation combined with nerve anastomosis had different degrees of nerve function recovery after surgery . All patients a-chieved normal knee function , 6 patients with tibialis anterior muscle injury had limited ankle dorsi flexion after sur-gery.Conclusion Sequential therapy of VSD and free latissimus dorsi flap transplantation can get good clinical re -sults for the treatment of Gustilo ⅢB and ⅢC open tibiofibular fractures with bone exposure .