骨段滑移术治疗胫骨缺损合并软组织缺损

Management of Bone Defect of Tibia and Soft Tissue Loss with Bone Transpoxt

目的总结骨段滑移术治疗胫骨长节段骨缺损合并小腿软组织缺损的疗效、适应证及术后康复在促进功能恢复中的作用。方法在2005年1月到2011年1月6年间治疗胫骨长节段性骨缺损合并小腿软组织缺损共13例,男性10例,女性3例;年龄16～35岁,平均24岁。胫骨缺损部位在胫骨中下段11例,在胫骨中上段2例。缺损长度7～15cm,平均9cm。软组织缺损位于小腿的前内侧,范围3cm×2cm～18cm×10cm。采用Orthofix重建外固定架,一期截骨,7d后开始延长,每日1mm,到胫骨远近缺损骨端紧密对合,维持固定直至骨愈合。小腿软组织缺损感染重、渗出多者使用负压封闭引流技术。术后进行康复治疗。结果从开始治疗到去除外固定架,治疗用时11～23个月,平均18个月。13例胫骨骨缺损获得重建,患肢肢体长度与健侧相差小于2cm,截骨延长新生骨部分愈合良好。11例骨缺损接触端自行愈合,有2例骨折断端软组织内陷阻止骨端接触,1例采用软组织松解,1例行软组织松解加自体植骨术。创面均得到覆盖。闭合的创面部分凹陷为贴骨瘢痕,遇阴雨天不适。骨段滑移过程中在牵开3cm左右时患者感到小腿疼痛,对症治疗后大多可继续进行延长,有4例停止延长3～5d后继续延长直至完成。外固定架未出现固定钉明显松动现象,中间2枚固定钉在滑移的中后期有不同程度的对皮肤切割现象,将皮肤钉孔拉成椭圆形,此钉孔在骨段滑移停止后3周左右恢复正常。所有患者膝关节活动正常,踝关节背伸活动可达15°～30°。结论骨段滑移术是治疗胫骨长节段骨缺损合并软组织缺损的一种较好的方法,最适合的病例是胫骨中上段或中下段长节段骨缺损合并软组织缺损,胫骨近端和远端有置入固定钉的足够长度,腓骨完整性较好的患者。结合康复治疗可使伤残肢体功能最大限度地恢复。

Objective Summary the efficacy,indications,and the roles in promoting postoperative rehabilitation functional recovery of bone section slipping technique in the treatment of long bone defect in tibial bone with a small segment of soft tissue defects.Methodes From January 2005 to January 2011,there are 13 cases long segmental tibial bone defects with small soft tissue defects.Male 10 cases,3 females;Age：16 to 35 years,mean 24 years of age,tibial bone defects were in the tibia of the lower segment in 11 cases,in the upper in 2 cases.The defect length was 7~15 cm with an average of 9 cm.Soft tissue defects were in anteromedial part of the legs with the area of 3 cm×2 cm^18 cm×10 cm.A daily prolongation of 1 mm was performed 7 days after the osteotomy.The distal and proximal part were fixed when they closely contacted,and the fipation was maintained nutil the union.Those whose legs soft tissue had seriously infection and exudation vaccum sealing drainage technology were used.Postoperative rehabilitation was proceeded.Results From the start of treatment to exception fixation,treatment with 11 to 23 months at an average of 18 months.13 cases of tibial bone defects access to reconstruction.The length difference between limb and contralateral limb is less than 2 cm,some new bone extension osteotomy healed well.11 cases of exposure to end of bone defects were self-healing.2 cases of fracture fragments and soft tissue retraction prevented contact with the bone side,one case of soft tissue released,and one case of soft tissue released and autogenous bone graft.Wounds were covered.Part of the closure of the wound were depressed as post bone scar.They were discomfort in rainy days.Patients feeled pain when bone segment was pulled apart about 3 cm in the process of Slip.Prolongation can be continued after the symptomatic treatment.4 patients continued to extend when they stopped extension of 3 to 5 days until completion.Fixed external fixator pin did not loose,but the two retaining screws in the middle to late stage slipped on the skin.Nail holes were pulled into an oval shape and the nail holes in the bone segment were back to normal after the cessation of slip about 3 weeks.All patients were with normal knee,and ankle dorsiflexion activity up to 15°~30°.Conclusion Bone segment slip is a good way in the treatment of tibial long segmental bone defect with soft tissue defects.The most suitable cases are the tibial long segment bone defect in the upper or the lower of the proximal tibia with soft tissue defects and there are an enough length for nails to fix.The fibulas are with good integrity.Rehabilitation therapy can help to maximize the recovery of limb function.