190例小腿严重损伤的修复重建

Reconstruction of severe leg injuries in 190 patients

目的总结结合不同的皮瓣和外固定架治疗严重胫骨干骨折的经验。方法1990-2007年，共治疗GustiloⅢB和GustiloⅢC型胫骨干骨折190例，其中GustiloⅢB型160例，GustiloⅢC型30例。男169例，女21例；平均年龄42．5岁。交通伤132例，机器压砸伤32例，石块砸伤26例。治疗措施包括抗生素、清创、植皮、各种组织瓣（游离胸脐皮瓣20例，腓肠神经营养血管皮瓣108例，隐神经营养血管皮瓣12例，腓浅神经营养血管皮瓣2例，筋膜皮瓣26例，腓肠肌内、外头肌皮瓣22例）、各种外固定架（半环架84例，单边轴动力外固定架12例，AO外固定架12例，潍坊三维外固定架42例，组合式外固定架40例）。平均随访7．3年。结果所有皮瓣成活。186例骨折愈合，平均骨愈合时间：84例半环架为7．5个月，8例单边轴动力外固定架11．2个月，12例AO外固定架8．5个月，42例潍坊三维外固定架8．1个月，40例组合式外固定架7．8个月。除半环架外，其他外固定架都需植骨。4例骨折未愈合，为单边轴动力外固定架固定后发生骨髓炎，经再次手术后愈合。最近随访发现所有患者的膝、踝关节功能正常，无患肢疼痛。结论皮瓣与外固定架结合足治疗GustiloⅢB和GustiloⅢC型胫骨干骨折的较好方法。

Objective To discuss experiences in reconstruction of severe tibial shaft fractures by using different flaps and external fixations. Methods The study involved 190 patients with type GustiloⅢb Ⅲ c （ 160 patients） and GustiloⅢC （30 patients） tibia[ shaft fractures treated from 1990 to 2007. There were 169 males and 21 females, at average age of 42.5 years. The injury causes included traffic accidents in 132 patients, machine accidents in 32 and stone smashing in 26. The management procedure consisted of administration of antibiotics, serial debridement and different flap grafting （including free thoracoumbilical flaps in 20 patients, sural neurocutaneous vascular flaps in 108, saphenous neurocutaneous vascular flaps in 12, superficial peroneal neurocutancous flap in two, fasciocutaneous flaps in 26 and gastrocnemius muscular flaps in 22 ） and different external fixators （ half-ring fixators in 84 patients, unilateral axial dynamic fixators in 12, AO fixators in 10, Wcifang fixators in 42 and hybrid fixators in 40）. The average follow-up was 7.3 years. Results All flaps survived. Of all, 186 patients obtained fracture healing, with mean fracture healing time varying in different patients treated with different external fixators ： 7.5 months for 84 patients treated with haff-ring fixators, 11.2 months for eight with unilateral axial dynamic fixators, 8.5 months for 12 with AO fixators, 8.1 months for 42 with Weifang fixators and 7.8 months for 40 with assembly fixators. Except for half-ring fixation, the other fixators needed necessary bone graft. Four patients treated with unilateral axial dynamic fixators resulted in nonunion due to osteomyelitis. The latest follow up showed that the function of the ankle and knee was normal, with no pain. Conclusion Combination of half-ring external fixators with various flaps provides good method for treatment of GustiloⅢ B and Ⅲ c tibial shaft fractures.