儿童内踝外伤性缺损的修复重建

REPAIR AND RECONSTRUCTION OF TRAUMATIC DEFECT OF MEDIAL MALLEOLUS IN CHILDREN

目的探讨以带血管蒂腓骨头骨骺复合组织瓣修复重建儿童内踝外伤性缺损的手术方法及临床效果。方法2003年7月-2007年12月,收治8例车轮绞伤导致内踝PetersonⅥ型骨骺损伤患儿。男5例,女3例;年龄2～10岁。左侧5例,右侧3例。内踝完全缺如,均伴内踝周围皮肤缺损,范围4.0cm×2.0cm～9.5cm×5.5cm。受伤至入院时间为6～8h2例,24～168h6例。术中设计腓骨头骨骺复合组织瓣一期修复内踝及其周围软组织缺损。切取皮瓣4.5cm×2.5cm～10.0cm×6.0cm,截取腓骨头骨骺长度2.5～3.0cm。供区直接缝合。结果术后伤口均Ⅰ期愈合,复合组织瓣全部成活,无血运障碍;供区愈合良好。患儿均获随访,随访时间1～5年。内踝骨骺6～9周愈合。皮瓣色泽及弹性较好,无瘢痕挛缩。无踝关节内翻畸形发生,负重及行走满意。6例踝关节屈伸正常;2例轻度受限,背屈18～20°,跖屈35°。距骨无内移,踝关节无过度外翻。按美国矫形足髁协会足踝功能评判标准,优7例,良1例。内踝骨骺无早闭发生,骨化中心逐渐明显或增大,发育与对侧基本保持同步。供区膝关节屈伸活动度正常,无内翻不稳定。结论腓骨头骨骺复合组织瓣可一期修复儿童内踝骨骺及周围软组织缺损,重建的内踝可随儿童的生长同步发育,是重建儿童内踝外伤性缺损的理想方法之一。

Object ive To inves t igate the operat ive method and cl inical ef fect of repai r ing and reconstructing the traumatic defect of medial malleolus in children with complex tissue flap of vascularized fibular head epiphysis. Methods From July 2003 to December 2007, 8 children with defect of medial malleolus due to wheel injury were treated, including 5 boys and 3 girls aged 2-10 years old. The medial malleolus were completely defected （5 cases at left foot and 3 cases at right foot） and combined with the skin defect around the medial malleolus （4.0 cm × 2.0 cm - 9.5 cm × 5.5 cm）. The time from injury to hospital admission was 6-8 hours in 2 cases, and 24-168 hours in 6 cases. The complex of vascularized fibular head epiphysis and tissue flap was adopted to repair the defect. The flap 4.5 cm × 2.5 cm - 10.0 cm × 6.0 cm in size and the fibular head epiphysis 2.5-3.0 cm in length were harvested. The donor site was sutured directly. Results All wounds healed by first intention, all the composite tissue flap survived with good blood circulation, all the epiphysis of medial malleolus healed within 6-9 weeks, and all the donor sites healed well. All the child patients were followed up for 1-5 year. The color and elasticity of the flaps were good, without cicatricial contracture. The patients had no inversion of ankle joint, with satisfying loading and walking function. Six cases had normal flexion and extension of the ankle and 2 cases were l imited sl ightly （dorsiflexion 10-20°, plantarflexion 35°）. Talus has no inner move and ankle joint had no eversion. Seven cases were graded as excellent and 1 as good according to the standard of American Orthopaedic Foot ＆ Ankle Society. For the medial malleolus, no premature closure of epiphysis occurred, and the center of ossification grew gradually and well developed l ike the contralateral side. The donor knee joint had normal flexion and extension function, without inversion and instabil ity. Conclusion The complex of vascularized fibular head epiphysis and tissue flap can repair the epiphysis and soft tissue defect of medial malleolus in children at one stage, and the reconstructed medial malleolus can develop with the growth of children. It is a satisfactory method of reconstructing the traumatic defect of medial malleolus in children.