外固定支架结合有限内固定或负压引流治疗小腿Gustilo Ⅲ型骨折的临床疗效观察

Treatment of Gustilo Grade Ⅲ Leg Fractures by Combining External Fixation with Limited Internal Fixation or Vacuum-sealing Drainage

目的探讨外固定支架结合有限内固定或负压引流(vacuum-sealing drainage,VSD)治疗小腿GustiloⅢ型骨折的临床疗效.方法 2006年7月至2008年12月期间,共收治40例严重开放性小腿中下段骨折患者.骨折根据AO分型:41C型7例,42C型14例,43C型11例,42C+43B型3例,33B+41C型3例,左侧43C+右侧42B型2例;软组织损伤程度根据Gustilo-Anderson分型:ⅢA型17例,ⅢB型13例,ⅢC型10例.全部患者均在8 h内实施清创、骨折复位和外固定支架固定以恢复小腿的力线.其中,17例ⅢA型和10例ⅢB型骨折,Ⅰ期结合钢板、螺钉进行有限内固定.对于合并严重软组织损伤和部分骨缺损的另3例ⅢB型和全部ⅢC型骨折,I期清创和外固定架固定后采用VSD持续负压吸引,常规使用广谱抗生素1周,局部条件改善后Ⅱ期采用游离皮瓣或邻近肌皮瓣闭合创面.外固定架视骨折愈合情况于术后3～8月拆除,钢板和螺钉于1a后取出.结果Ⅰ期手术时间90～210 min(平均170 min),术中输血量400～1500 mL.1例严重损伤合并大面积软组织和骨缺损患者术后2周出现感染最终截肢,另2例患者1a后骨折部仍愈合不牢固,经植骨后愈合;其余37例均获骨性愈合,愈合时间8～18个月,平均11.6个月.术后1a根据小腿功能综合评定标准评定:优28例,良9例,差3例.结论利用外固定支架结合有限内固定和负压引流治疗小腿GustiloⅢ型骨折可以获得良好的临床效果.

Objective To explore the clinical effects of external fixation associated with limited internal fixation or vacuum-sealing drainage on Gustilo grade Ⅲ leg fractures. Methods From July 2006 to December 2008, 40 cases with leg severe open fractures were emergently treated in our department. According to the AO classification, fractures were classified as 41C in 7 cases, 42C in 14 cases, 43C in 11 cases, 42C＋43B in 3 cases, 33B＋43C in 3cases, and 43C on the left side＋42B on the right side in 2 cases. Soft tissue injuries were grouped according to the Gustilo-Anderson classification as ⅢA in 17 cases, ⅢB in 13 cases, and ⅢC in 10 cases. All the patients were debrided within 8 hours, and then fracture reposition was performed to reestablish theleg alignment. Limited internal fixation with plates and screws were performed on all 17 Gustilo ⅢA cases and 10 Gustilo ⅢB cases at the first operation. But all the Gustilo ⅢC cases and 3 Gustilo ⅢB cases who had severe soft tissue injuries and bone loss only received Vacuum-sealing drainage （VSD）. Broad-spectrum antibiotics were regularly used and VSD must be especially maintained easy and smooth for one week or more after operation. Limited internal fixation and transplanted free skin flaps or adjacent musculocutaneoues flaps were not used to close wounds until the condition of the wounds had been improved. The external fixation frames were removed 3-8 months after operation counting on the condition of fracture healing. These limited internal fixations were taken out after 1 year or more. Results The first operations were completed within 90-210 minutes （170 minutes on average）. The blood transfusions in the process were from 400 mL to 1500 mL. 1 cases with severe soft tissue injuries and bone loss had suffered from the injured leg amputation after 2 weeks resulted from infection. Poor fracture healing was found in 2 case by 1 year after operation but the 2 cases were healing through bone graft. The rest 37 cases had obtained bone union and the healing time was from 8 to 18 months （11.6 months on average）. The lower limb function was evaluated according to comprehensive evaluation standards one year after operation and the results of 28 cases were excellent, 9 were good and 3 were poor. Conclusion External fixation associated with limited internal fixation or vacuum-sealing drainage to treat Gustilo grade Ⅲ leg fractures can get satisfactory therapeutic effects.