下肢骨折内固定术后隐性感染致骨不连

Subclinical infection complicating nonunion in the lower limbs after internal fixation for fractures

目的探讨下肢骨折内固定术后隐性感染致骨不连的治疗方法。方法2000年-2005年,共收治下肢骨折内固定术后隐性感染致骨不连患者8例,男5例,女3例;年龄24岁～72岁,平均年龄47.3岁;均为闭合性骨折。予以内固定取出,同时行病灶清刮、伤口灌洗术,其中2例胫骨骨折患者取出原内固定物后即行植骨加单边外固定支架重新固定,2例股骨骨折患者取出内固定后即予植骨加桥接钢板内固定,3例胫骨骨折、1例股骨骨折患者取出内固定后予下肢管形石膏托固定,Ⅱ期再行植骨内固定。8例患者根据伤口分泌物细菌培养结果行静脉抗炎治疗。结果术后1例伤口窦道形成,其余7例患者切口正常愈合。4例予Ⅰ期自体髂骨植骨加固定,术后3例骨折愈合,1例6个月未见骨痂生长,再予植骨、交锁髓内钉固定。另4例未Ⅰ期固定者3个月后均未见骨痂生长,再予行切开植骨内固定术,术中未见肉芽样组织及渗出。所有8例患者在植骨固定术后平均22.4个月骨折愈合。结论隐性感染是造成骨折不愈合的重要原因之一,及时病灶清刮、伤口灌洗,根据时机植骨固定是促进骨折愈合的正确方法。

Objective To discuss the treatment of subclinical infection complicating nonunion in the lower limbs after internal fixation for fractures. Methods From 2000 to 2005, 8 patients with subclinical infection complicating nonunion in the lower limbs after internal fixation for fractures were treated in our hospital. The age ranged from 24 to 72 years（median,47.3years）. 5 patients were male,and 3 patients were female.All the cases were closed fractures .The implantation was removed and the lesion was debrided and lavaged at the same time. 2 patients who had a fracture of tibia underwent refixation with unilateral external skeletal fixation plus bone grafting after the removal of initial intemal fixation. 2 patients with femoral fracture underwent internal fixation with bridge plate and bone grafting after the removal of initial implant.4 patients （3 tibial fracture,1 femoral fracture respectively） were immobilized with long leg plaster cast after removing the implant and twe-stage bone grafting with internal fixation was performed later. Antibiotics were applied to all the patients according to the result of bacterial culture of the secretion obtained from the nonunion site. Results 7 of 8 patients＇ wounds healed well except for 1 with fistula.The union of fractures developed in 3 of 4 patients who had a internal fixation with one-stage autogenous iliac cancellous bone grafting except 1 without observable growth of callus 6 months later after the secondary surgical procedure who underwent bone grafting and interlocking intramedullary nailing subsequently. There were no obvious growth of callus in another 4 patients who hadn＇t internal fixation 3 months after the removal of the initial implant. As the two-stage treatment, that 4 patients underwent open bone grafting and internal fixation and there were no granulation tissue and transudation in the operation field. The average bone healing time of the 8 cases was 22.4 months after the bone grafting with internal fixation. Conclusion Subclinical infection is one of the most important factors causing persistent fracture nonunion. Proper debridement and lavage, followed by timely bone grafting when permited, may be. the preferred treatment for promoting bone union.