组织移植结合骨滑移治疗小腿皮肤软组织伴大段胫骨缺损

TISSUE TRANSPLANTATION WITH BONE TRANSMISSION FOR TREATING LARGE DEFECTS OF TIBIALBONE AND SOFT TISSUE

目的探讨组织移植结合骨滑移治疗小腿皮肤软组织伴大段胫骨缺损的疗效。方法 2006年2月-2011年2月,收治外伤性小腿皮肤软组织伴大段胫骨缺损15例。男12例,女3例;年龄16～54岁,平均32岁。GustiloⅢ型开放骨折术后皮肤坏死、骨外露、感染11例,闭合骨折切开复位内固定术后皮肤坏死、感染2例,小腿断肢再植术后骨外露2例。小腿皮肤软组织缺损范围为5 cm×5 cm～22 cm×17 cm。8例伴肢体短缩、成角畸形,肢体短缩长度2～5 cm,平均3.5 cm。骨缺损长度4～18 cm,平均8 cm。创面采用皮瓣(9例)及皮片(6例)移植修复,待创面愈合后3个月行骨滑移和肢体延长矫形术,其中2例采用双截骨滑移术,14例骨断端对合后行自体骨移植和对位调整。结果创面修复术后皮瓣及皮片均成活,创面愈合时间3周～18个月,平均3.5个月。骨延长长度6～22 cm,平均8 cm。骨愈合去除外固定时间9.5～39.0个月,平均15个月。愈合指数40～65 d/cm,平均55 d/cm。患者均获随访,随访时间1～5年,平均4年。小腿创面均愈合良好,无感染、破溃发生;下肢恢复完全负重行走功能,步态正常6例、遗留跛行9例。去除外固定后6个月膝关节活动范围:伸膝均达0°;屈膝达120～160°,平均150°;踝关节功能根据美国矫形足踝协会(AOFAS)评分标准评定,获优7例,良4例,可4例,优良率73.3%。结论组织移植结合骨滑移能有效修复小腿皮肤软组织和大段胫骨缺损,骨连接强度高,供区损伤小。

Objective To investigate the effectiveness of tissue transplantation combined with bone transmission in treatment of large defects oftibial bone and soft tissue. Methods Between February 2006 and February 2011, 15 cases of traumatic tibia bone and soft tissue defects were treated. There were 12 males and 3 females, aged from 16 to 54 years （mean, 32 years）. After internal and external fixations of fracture, 11 patients with open fracture （Gustilo type III） had skin necrosis, bone exposure, and infection; after open reduction and internal fixation, 2 patients with closed fracture had skin necrosis and infection; and after limb replantation, 2 patients had skin necrosis and bone exposure. The area of soft tissue defect ranged from 5 cm x 5 cm to 22 cm x 17 cm. Eight cases had limb shortening with an average of 3.5 cm （range, 2-5 cm） and angular deformity. The lenghth of bone defect ranged from 4 to 18 cm （mean, 8 cm）. The flap transplantation and skin graft were used in 9 and 6 cases, respectively; bone transmission and limb lengthening orthomorphia were performed in all cases at 3 months after wound healing; of them, 2 cases received double osteotomy bone transmission, and 14 cases received autologous bone graft and reset after apposition of fracture ends. Results All flaps and skin grafts survived; the wound healed at 3.5 months on average （range, 3 weeks-18 months）. The length of bone lengthening was 6-22 cm （mean, 8 cm）. The time of bone healing and removal of external fixation was 9.5-39.0 months （mean, 15 months）. The healing index was 40-65 days/cm （mean, 55 days/cm）. All patients were followed up 1-5 years （mean, 4 years）. The wounds of all the cases healed well without infection or ulceration. The functions of weight-bearing and walking were recovered; 6 cases had normal gait and 9 cases had claudication. The knee range of motion was 0 in extention, 120-160 in flexion （mean, 150 ）. According to the American Orthopaedic Foot and Ankle Society （AOFAS） scoring system for ankle function, the results were excellent in 7 cases, good in 4 cases, and fair in 4 cases, with an excellent and good rate of 73.3%. Conclusion Tissue transplantation combined with bone transmission is an effective method to treat large defects of soft tissue and tibial bone, which can increase strength of bone connection and reduce damage to the donor site.