延迟清创的胫腓骨开放性骨折围手术期感染防治

Prevention of Infection for Severe Open Tibiofibula Fracture with Delayed déBridement During the Perioprative Period

目的探讨清创时间延迟的胫腓骨开放性骨折围手术期的感染防治及疗效。方法我科自2008年1月至2009年4月共收治胫腓骨开放性骨折，并行延迟清创缝合者85例（87肢）。其中男68例，女17例；年龄17～78岁，平均40．5岁。Gustilo分度，Ⅰ度3例，Ⅱ度16例，Ⅲ度66例（其中ⅢA24例，ⅢB12例（14个肢体），ⅢC30例）。受伤8～38h，平均14．20h；其中8～12h37例，12～24h38例，24～36h7例，大于36h3例。合并创伤性休克13例，贫血者38例，营养不良者22例；创面分泌物涂片或培养阳性者19例。患者入院后均予以及时清创，并按骨折Gustilo分度和伤情选择恰当的固定及处理方式。术后常规使用抗生素1～3d，并注重支持对症治疗，及时纠正贫血和低蛋白血症。结果肢体缺血坏死再截肢2例，二期改行内固定20例。创面甲级愈合50例（58．8％），乙级愈合21例（24．7％），丙级14例（16．5％）。术后合并贫血70例，营养不良67例，均于3d内纠正到满意效果。结论对伤情严重且受伤时间长的胫腓骨开放性骨折，只要清创彻底，固定方式恰当，合理使用抗生素，注重支持对症治疗，仍然可以获得较低的感染率。

Objective To investigate the prevention of infection for open tibiofibula fracture with delayed debridement during the perioprative period. Methods Since January 2008 to April 2009,85 cases （87 legs） with open tibia and fibula fractures,age from 17 to 78 years old,were treated in our department,among whom there were 68 man,17 women and 3 type Ⅰ, 16 type Ⅱ , 66 type Ⅲ according to Gustilo classification;the average time to debridement was 14.2 hours,18 cases appeared positive by smear or cultivation of secretions before surgery. The 85 patients were all given debridement and suitable fixation or other managements in accordance with Gustilo classification and early use of antibiotics;anemia or bypoproteinemia were also corrected in time. Results 2 cases received amputation as a result of avascular necrosis. 20 cases received internal fixation during the second stage;in the end there were good wound healing with 50 cases of class A（58.8%）,21 cases of class B （24. 7%）,and 14cases of C（16. 5%）. After surgery, there were 70 cases complicated by anemia, 67 cases by hypoproteinemia corrected in 3 days with the active support treatment. Conclusion Even if serious injuries and delayed open fracture of tibiafibula,as long as we can provide thorough debridement,appropriate fixation,early use of antibiotics and pay attention to the support treatment,the in feetion rate will still be low.