下肢创伤后大段感染性骨缺损的分型及修复

Classification and repair of massive posttraumatic infection-induced bone defects in lower extremities

目的 探讨下肢创伤后大段感染性骨缺损的分型以及修复方法. 方法 2002年3月至2008年12月共收治42例下肢创伤后大段感染性骨缺损患者,男29例,女13例;平均年龄34.2岁.感染性骨缺损部位：股骨3例,胫骨39例.根据其缺损特点分为3型：单纯大段感染性骨缺损（Ⅰ型）、大段感染性骨缺损并大面积皮肤软组织缺损（Ⅱ型）、大段感染性骨缺损并肢体短缩畸形（Ⅲ型）,本组Ⅰ型6例,Ⅱ型35例,Ⅲ型1例.所有患者在彻底清创基础上分别应用单纯腓骨瓣移植或移位（6例）、腓骨皮瓣移植（31例）、腓骨瓣＋股前外侧皮瓣移植（4例）、骨牵引延长＋腓骨瓣移植（1例）同期进行修复. 结果 42例患者术后获6～41个月（平均26.3个月）随访.除2例因移植腓骨坏死而截肢、2例感染未能控制外,其余38例患者骨缺损均得到成功修复,下肢外形及功能恢复均满意.参照Johner-Wruhs疗效评定标准：优17例,良18例,可3例,差4例,优良率为83.3%.结论 下肢创伤后大段感染性骨缺损根据其缺损特点可分为3型;针对性应用不同形式的腓骨瓣,能同期修复下肢各种类型创伤后大段感染性骨缺损.

Objective To investigate the classification and its application in one-stage repair of massive posttraumatic bone defects which are infection-induced and refractory in lower extremities. Methods From March 2002 to December 2008, we treated 42 patients with massive posttraumatic refractory infection-induced bone defects in lower extremities. We classified the defects into 3 types： simple massive infection-induced bone defects （type Ⅰ）, massive infection-induced bone and soft-tissue defects （type Ⅱ） and massive infection-induced bone defects plus limb shortening （type Ⅲ）. After thorough debridement, various types of vascularized fibular grafts were used to repair the 3 kinds of defects accordingly. Simple fibular grafts were used in 6 cases, transplantation with fibular and skin flaps was used in 31 cases, fibular grafts combined with anterior lateral thigh flap in 4 cases, and one-stage limb lengthening and fibular graft in one. Results The follow-ups of 6 to 41 （average, 26. 3） months revealed that the refractory bone defects were repaired successfully in 38 cases, amputation due to necrosis of fibular grafts in 2 cases and uncontrolled infection in 2 cases. In the 38 cases, infections were controlled effectively, circulation of the traumatic limbs was good,contour and function were restored satisfactorily, and no obvious complication was found in donor limbs. By Johner-Wruhs evaluation, 17 cases were excellent, 18 cases good, 3 cases fair and 4 cases poor, with a total excellent and good rate of 83.33%. Conclusions Refractory and massive posttraumatic infection-induced bone defects in lower extremities can be classified into 3 types. They can be repaired using various types of vascularized fibular grafts according to the defect types at one-stage.