应用混合式外固定支架骨搬运技术治疗胫骨干骺端骨缺损

Management of bone defects at tibial metaphysis by bone transport technique with linear-circular hy- brid external fixators

目的探讨应用混合式外固定支架骨搬运技术治疗胫骨干骺端骨缺损的疗效。方法回顾性分析2009年12月至2013年2月收治并获完整随访的9例男性胫骨干骺端骨缺损患者资料，年龄25～66岁，平均45．0岁；骨缺损部位：胫骨近端4例，远端5例；感染性骨缺损5例，非感染性骨缺损4例。双侧胫骨长度差异平均为13．0mm（-2-30mm），胫骨缺损长度平均为8．3cm（4-13cm）。对于非感染性骨缺损患者，一期行外固定支架固定、缺损端修整术，一期或二期于胫骨正常干骺端行截骨延长术。对感染性骨缺损患者先行扩创、混合式外固定支架固定、抗生素骨水泥或抗生素人工骨植入术，二期于正常干骺端行截骨延长术。结果9例患者术后获平均22．4个月（16-35个月）随访。所有患者的延长端和对合端均达骨性愈合，延长长度平均为8．9cm（5-13cm）。除1例合并短缩、马蹄足畸形的患者拒绝矫正外，其余8例患者术后胫骨短缩平均为4mm（1-14mm）。外固定指数平均为1．8个月／cm（1．2-2．6个月/cm），无感染复发。末次随访时，根据Paley等提出的评分标准评定疗效：骨性结果：优7例，良2例；功能结果：优4例，良5例。并发症发生情况为1．4种／例。结论应用混合式外固定支架骨搬运技术可成功治疗胫骨干骺端骨缺损，保留邻近关节的功能，可靠地固定胫骨两端的小段松质骨。但需谨慎应用对合端加压的方法促进愈合，建议积极进行自体骨植骨。

Objective To report our successful clinical experience of managing tibial metaphyseal bone defects with linear-circular hybrid external fixators to restore limb functions. Methods We managed and fully followed 9 male patients with fibial metaphyseal bone defects from December of 2009 to February of 2013. They were aged from 25 to 66 years （average, 45.0 years）, Four had a proximal end and 5 a distal end affected; 5 cases were infected and 4 non-infected. The average length of tibial shortening was 13.0 mm （from - 2 to 30 ram） before operation; the mean length of bone defects was 8.3 cm （from 4 to 13 cm）. The non-infected patients were managed with debridement and trimming at the defect end, and primary fixation with linear-circular hybrid external fixators, followed by immediate or delayed osteotomy and bone lengthening after one or two months at the normal meta- physeal end. The infected patients were managed with debridement and fixation before the defects were filled with antibiotics-impregnated bone cement or artificial bone. The osteotomy and bone lengthening was performed see- ondarily. The fixators were not removed until consolidation was noticed in both the distracted area and the docking site and the patients were able to ambulate without aids. Results On average the 9 were followed up for 22.4 months （from 16 to 35 months）. They achieved bony healing in both the distracted area and the docking site. Their average distraction length was 8.9 cm （from 5 to 13 cm）. The leg length discrepancy was 4 mm （froml to 14 mm） shorter on average after operation except in one patient with shortening and equinus deformity who refused cor- rectiorL The average external fixation index （EFI） was 1.8 month/cm （from 1.2 to 2. 6 month/cm）. No infection relapsed. According to Paley＇s criteria, the bony results were excellent in 7 and good in 2 cases, and the functional results were excellent in 4 and good in 5 cases, The total complication rate was 1.4 per patient. Conclusions Bone transport technique with linear-circular hybrid external fixators is effective in management of tibial non-union with metaphyseal bone defects because it can preserve functions of the adjacent joints and stabilize securely the small peri-articular segments of cancellous bone. However, surgeons should be prudent in stimulating bone union at the docking site by gradual compression through linear-circular hybrid external fixators. Autograft is strongly recommended at the docking site.