骨搬移联合开放植骨和负压封闭引流技术治疗胫骨感染性骨缺损

Bone transport combined with open bone grafting and vacuum sealing drainage for treatment of infectious tibial bone defect

目的探讨应用Ilizarov骨搬移联合开放植骨和负压封闭引流（VSD）技术治疗胫骨感染性骨缺损的临床疗效。方法采用回顾性病例系列研究分析2010年3月-2015年5月收治的8例创伤后胫骨感染性骨缺损患者的临床资料，其中男7例，女1例；年龄22—51岁，平均39．4岁。所有患者首先彻底清创，去除感染及坏死的骨与软组织，清创后胫骨骨缺损长度为3．5-13．5cm，平均8cm。软组织缺损面积为2．3cm×1．1cm-8．5cm×6．0cm，平均4．8cm×2．5cm。安装Ilizarov环形外固定架后，6例行单平面或双平面截骨骨搬移，待断端临近对接时，行开放植骨。另外2例清创后直接行断端短缩和开放植骨，同时行干骺端截骨延长。所有患者开放植骨后创面用VSD覆盖，行负压引流。记录骨搬移或延长时间、植骨后创面愈合时间、对接点愈合时间、再生区固化时间、外固定架佩戴时间和外固定指数。采用Ilizarov方法研究与应用学会（ASAMI）评分标准进行骨愈合和功能评价。结果外固定架拆除后，所有患者均随访10.2—36．4个月，平均12．2个月。创面均顺利愈合，无一例感染复发或遗留感染。骨搬移或延长时间为30—69d，平均50d。7例创面自行愈合，愈合时间为1．2—6个月，平均3．4个月。1例创面经植皮后愈合。所有对接点和再生区均愈合和固化良好。对接点愈合时间为5．3-10个月，平均6．8个月。再生区固化时间为4．8—8．5个月，平均6．2个月。外固定架佩戴时间为6．5-11．5个月，平均8．6个月。外固定指数为0．7-1．9个月／cm，平均1．2个月／cm。按ASAMI评分标准：骨愈合优7例，差1例；功能结果优4例，良4例。结论Ilizarov骨搬移联合开放植骨和VSD技术能促进对接点创面愈合和骨性愈合，缩短外固定架的佩戴时间，是治疗胫骨感染性骨缺损伴皮肤缺损的有效方法。

Objective To assess the efficacy of using the Ilizarov bone transport combined with open bone grafting and vacuum sealing drainage （VSD） to treat infected tibial bone defect. Methods A retrospective case series study was made on 8 patients sustaining posttraumatic infectious tibial bone defect treated between March 2010 and May 2015. There were 7 male and 1 female patients between 22 and 51 years （mean, 39.4 years）. All patients underwent radical resection of the infected/necrotic bone and debridement of the soft tissue. Length of bone defects after debridement averaged 8 cm （ range, 3.5-13.5 cm） and wound size averaged 4.8 cm×2.5 cm （range, 2.3 cm×1.1 cm-8.5 cm×6.0 cm）. Stabilization was finished with Ilizarov circular external frame in all patients. Six patients were candidates for single- or double-level bone transport, and the cancellous bone autograft was placed openly within the butterfly defect after docking. Other 2 patients were treated with one-stage shortening of the fracture ends and open cancellous bone grafting, and the bone lengthening was performed. Then the grafted wounds were covered by VSD. Data were recorded including the bone transport or lengthening time, wound healing time, union time of docking sites, consolidation time of regenerate zones, external fixation time and external fixation index. Bone results and functional results were evaluated according to the criteria given by association for the study and application of the method of Ilizarov （ASAMI）. Results Duration of follow-up was 10.2-36.4 months （mean, 12.2 months）. All the wounds achieved successful healing and eradication of infection. Mean bone transport time was 50 days （range, 30-69 days）. Seven patients showed self- healing wounds, and mean healing time was 3.4 months （range, 1.2-6 months）. One patient experienced wound closure by skin grafting. Union and consolidation were achieved in all docking sites and regenerate zones. Mean union time of docking sites after bone grafting was 6.8 months （range, 5.3-10 months）. Mean consolidation time of regenerate zones was 6.2 months （ range, 4.8-8.5 months）. Mean external fixation time was 8. 6 months （range, 6. 5-11.5 months ） with a mean external fixation index of 1.2 months/cm（range, 0.7-1.9 months/cm）. According to the criterion of ASAMI, bony results were excellent in 7 patients and poor in 1 patient, and functional results were excellent in 4 patients and good in 4 patients. Conclusion Ilizarov bone transport technique combined with open bone grafting and VSD for infectious tibial bone defect can accelerate bone union and wound healing at docking sites and reduce external fixation time.