分期治疗伴皮肤软组织缺损的开放Pilon骨折疗效观察

EFFECTIVENESS OBSERVATION OF STAGED TREATMENT OF OPEN Pilon FRACTURE COMBINED WITH SOFT TISSUE DEFECT

目的探讨分期治疗伴皮肤软组织缺损的开放Pilon骨折疗效。方法 2007年6月-2012年12月,收治18例伴皮肤软组织缺损的开放Pilon骨折患者。男14例,女4例;年龄19~55岁,平均35岁。致伤原因:高处坠落伤12例,交通事故伤4例,机器挤压伤2例。骨折按AO分型:B2型1例,B3型3例,C1型5例,C2型5例,C3型4例。16例伴腓骨骨折,其中14例为简单骨折,2例为粉碎骨折。软组织损伤按Gustilo分型均为ⅢB型。一期清创,封闭式负压引流结合外固定支架固定,对简单腓骨骨折行内固定;二期对Pilon骨折及粉碎腓骨骨折行复位内固定,同时切取大小为6 cm×5 cm^18 cm×14 cm的皮瓣修复软组织缺损,供区植皮修复。结果二期术后2例皮瓣发生部分坏死,余皮瓣均顺利成活。供区切口均Ⅰ期愈合,植皮均成活。18例均获随访,随访时间6~24个月,平均12个月。X线片示骨折均愈合,愈合时间5~8个月,平均6个月。随访期间无内固定失效。末次随访时,踝关节活动度为26~57°,平均37°;按美国矫形足踝协会(AOFAS)评分标准评分为72~86分,平均80.2分。术后2例(11%)出现踝关节创伤性关节炎。结论分期治疗伴皮肤软组织缺损的开放Pilon骨折有利于正确评估软组织损伤情况、缩短病程并促进关节面复位,减少感染发生,是一种有效治疗方法。

ObjectiveTo explore the effectiveness of staged treatment of open Pilon fracture combined with soft tissue defect. MethodsBetween June 2007 and December 2012, 18 cases of open Pilon fracture combined with soft tissue defect were treated. There were 14 males and 4 females with an average age of 35 years （range, 19-55 years）. The causes of injury included falling from height in 12 cases, traffic accident in 4 cases, and crushing by machine in 2 cases. According to AO classification, 1 case was classified as type B2 fracture, 3 cases as type B3 fracture, 5 cases as type C1 fracture, 5 cases as type C2 fracture, and 4 cases as type C3 fracture. Sixteen cases accompanied by fibular fracture （14 cases of simple fibular fracture and 2 cases of communicated fibular fracture）. According to Gustilo classification, the soft tissue injuries were all type IIIB. In first stage, debridement and vaccum sealing drainage combined with external fixation were performed; open reduction and internal fixation of simple fibular fracture were used. In second stage, open reduction and internal fixation of Pilon fracture and communicated fibular fracture were performed, and the flaps of 6 cm × 5 cm to 18 cm × 14 cm were applied to repair soft tissue defect at the same time. The donor site was repaired by skin graft. ResultsPartial necrosis occurred in 2 flaps, the other 16 flaps survived completely. The incisions of donor sites healed by first intention, the skin graft survived completely. The average follow-up interval was 12 months （range, 6-24 months）. The X-ray films showed that the bone healing time ranged from 5 to 8 months （mean, 6 months）. No internal fixation failure was found. At last follow-up, the average range of motion of the ankle joint was 37° （range, 26-57°）. According to the American Orthopedic Foot and Ankle Society （AOFAS） scale, the average score was 80.2 （range, 72-86）. Traumatic arthritis occurred in 2 cases （11%）. ConclusionThe staged treatment has the advantages of accurate evaluation of soft tissue injury, shortened cure time, good reduction of the articular surface, and reduced incidence of infection, so it is an optimal method to treat open Pilon fracture combined with soft tissue defect.