Gustilo Ⅲ型胫骨开放骨折创面覆盖时机的探讨

Gustilo type Ⅲ open tibial fractures and timing to closure

[目的]探讨GustiloⅢ型胫骨开放骨折创面覆盖的最佳时机和方法。[方法]对2005年1月～2011年1月收治的GustiloⅢ型胫骨开放骨折患者进行随访,观察其创面覆盖的时机、方法及愈合情况、并发症及下肢功能恢复情况。[结果]31例患者获得随访,平均随访时间14.5个月(12～34个月)。平均33.5岁(15～52岁)。伤后就诊时间平均为3.5 h(1～12 h)。骨折部位:近端1/3 6例,中段15例,远端1/3 10例。Gustilo分型:ⅢA型8例,ⅢB型13例,ⅢC型10例。AO分类:A1型3例,B2型6例,B3型5例,C1型6例,C2型7例,C3型4例。创面一期闭合11例,VSD治疗后再次清创延期闭合20例。局部旋转皮瓣6例,腓肠肌皮瓣7例,腓肠神经营养皮瓣2例,游离皮瓣4例,游离植皮12例。外固定架固定5例,钢板螺钉内固定21例,不扩髓髓内针内固定5例。一期植骨4例,骨不连、骨缺损植骨2例。并发症方面:局部浅层感染2例(一期闭合组、延期闭合组各1例),经VSD治疗后感染控制,创面及骨折愈合,慢性骨髓炎1例(延期闭合组),经冲洗引流并清除局部死骨后窦道闭合,二期行局部植骨,骨折愈合。[结论]对于GustiloⅢ型胫骨开放骨折,一期闭合创面不会增加创面的感染率,还缩短了住院时间,减少了手术次数,减轻了患者的痛苦和经济压力,但适用于有相当临床经验及有显微外科技术基础的单位开展。延期闭合创面可以减少游离皮瓣等技术的应用,降低了手术难度,相对也减少了皮瓣切取所带来的副损伤。术后早期积极的康复功能锻炼能够帮助取得满意的疗效。

[Objective]To investigate the timing of closure for Gustilo type Ⅲ open tibial fractures.[Method]The clinical data of 31 cases were reviewed.The follow-up was 12 to 34 months（averaging 14.5 months）.[Result]Eleven injuries were closed primarily,one（9.09%） resulted in superficial infection.The other twenty cases were left open for an average of four to six days before closure of the wound,resulting in two（10%） infections.There was no statistically significant difference in infection rates between patients who were treated with primary closure at initial debridement and patients treated with delayed closure.[Conclusion] Primary closures provide a lower number of operations,and decrease health care costs and hospital stays with no increase in infection.Primary closure in open fractures is appropriate in properly selected patients.Delayed closures with the negative pressure wound therapy over fractures have less complex plastic surgery procedures such as free flaps,and an increase in simpler procedures such as split skin grafts.Primary closure is acceptable based on the surgeon＇s discretion regarding the adequacy of debridement and low contamination of the wound.