带锁髓内钉治疗严重开放性胫骨骨折

Interlocking Intramedullary Nail in Severe Open Fracture of Tibia

目的总结带锁髓内钉在治疗严重开放性胫骨骨折的临床结果并分析影响骨折愈合的相关因素。方法对1999年1月～2002年5月收治的17例严重开放性胫骨骨折的患者,按Gustilo分型GustiloⅡ型3例,GustiloⅢa型12例,GustiloⅢb型2例。均采用带锁髓内钉在彻底清创后进行静力型固定,同时对合并伤进行相应的处理。17例中,Ⅰ期闭合创面15例,其中3例直接缝合,12例局部转移皮瓣或肌皮瓣+游离植皮;延迟闭合创面2例,其中1例为交腿皮瓣,1例为腓肠肌带蒂皮瓣+游离植皮。结果术后随访1年,骨折全部愈合,愈合时间5.5～18个月,平均愈合时间8.6个月。1例胫骨中下段前成角10°,1例主钉断裂,创面感染1例,转移皮瓣部分坏死1例,有膝前疼痛者6例,膝关节、踝关节功能均正常。结论严重开放性胫骨骨折常合并较重的软组织损伤或污染,在早期彻底清创的基础上应用带锁髓内钉治疗胫骨骨折具有手术损伤少、骨折内固定稳定性好、利于创面闭合、可以早期活动关节等优点,是治疗胫骨开放性骨折的一种较好的方法。

Objective To study the clinical effect of interlocking intramedullary nail in the treatment of severe open fracture of tibia and analyze the related factors influenced the fracture healing. Methods Seventeen patients with severe open fracture of tibia admitted during January 1999 to May 2002 were enrolled in the study. According to Gustilo classification,the 17 cases were in 3 groups:GustiloⅡ 3 cases,Gustilo Ⅲ a 12 cases and Gustilo Ⅲ b 2 cases. All of them were fixed with interlocking intramedullary nail after a thorough debridement . The complicated wound were treated with appropriate management. Of the 17 cases,the wound surface were closed in first attention in 15 cases and 2 cases in delayed healing. In the 15 cases of first attention,3 cases were sutured directly,12 cases were partially transplanted with cutaneous flap or musculocutaneous flap and free skin graft. In the 2 delayed healing patients were transplantation of leg to leg flap 1 case, pedicle gastrocnemius muscle flap and free skin graft 1 case. Results All of the seventeen cases were followed up over 1 year and all had bony union,the healing time was 5.5～18 months(average 8.6 months).Among them one case had 10°angle anterior malformation in the middle-low segment of tibia shaft,but the functions of knee and ankle joints were normal;one case infected on the wound surface;the main nail broke in one case and knees pain in anterior sites were in six cases. Conclusion The severe open fracture of tibia is often complicated by severe trauma or contamination of the soft tissue. After a thorough debridement,interlocking intramedullary nail is an ideal treatment for severe open fracture of tibia with the advantages of less trauma,reliable fixation,convenient dressing exchange and permitting of joint exercise early.