有限内固定结合外固定架治疗感染性胫骨骨折疗效分析

Clinical efficacy of limited internal fixation combined with external fixator in treatment of infective tibial fractures

目的应用有限内固定结合外固定架治疗感染性胫骨骨折,评估其临床疗效。方法 2005年8月-2011年6月共收治43例胫骨骨折且合并感染患者,男31例,女12例;年龄16～58岁,平均36.3岁;其中胫骨上段9例,中段10例,中、下段24例;窦道形成16例,骨外露12例,所有患者采用克氏针螺钉、螺钉、可吸收螺钉和钢丝等有限内固定结合单臂外固定支架固定的方法治疗,随访收集其临床资料,包括影像学结果、骨折愈合时间、胫骨骨折评估结果及相关并发症,评估其临床疗效。结果 781例胫骨骨折患者中共出现43例感染性胫骨骨折,感染率为7.8%;分离出病原菌43株,其中金黄色葡萄球菌20株,铜绿假单胞菌11株,大肠埃希菌6株,其他菌6株,革兰阳性菌对万古霉素、多黏菌素、美罗培南耐药率<25.0%;革兰阴性菌对亚胺培南、庆大霉素耐药率<7.0%;术后随访时间6～24个月,平均骨折愈合时间6.5个月,术后12月Johner-Wruhs评估:优9例、良27例、中4例、差2例,总体优良率83.7%;共24例患者接受二期转位肌皮瓣移植术,2例患者出现感染复发,1例行扩大截骨外固定治愈,另1例治疗失败,接受截肢处理。结论有限内固定结合外固定架及系统的围手术期抗感染治疗对感染性胫骨骨折可取得较为满意的临床效果。

OBJECTIVE To evaluate the clinical efficacy of limited internal fixation combined with external fixator in treatment of infective tibial fractures.METHODS A total of 43cases of tibial fracture complicated with infections, who were treated in the hospital from Aug 2005 to Jun 2011,were enrolled in the study,including 31cases of males and 12cases of females,aged between 16 and 58 years old（median age：36.3years）.The subjects included 9cases of proximal tibial fracture,10cases of middle tibial fracture,and 24cases of proximal and middle tibial fractures,16cases of sinus formation,and 12cases of bone exposure;all the subjects were treated with the limited internal fixation combined with external fixator consisting of Kirschner screw,screw,absorbable screws,and steel wires,the follow-up was conducted,the clinical data were collected,including the imaging result,fracture healing time,result of evaluation of tibial fractures,and incidence of complications,and the clinical efficacy was evaluated.RESULTS Of totally 781cases of tibial fractures,the infective tibial fractures occurred in 43cases with the infection rate of 7.8%.Totally 43strains of pathogens have been isolated,among which there were 20strains of Staphylococcus aureus,11strains of Pseudomonas aeruginosa,6strains of Escherichia coli,and 6strains of other species.The drug resistance rates of the gram-positive bacteria to vancomycin,polymycin,and meropenem were less than 25.0%;the drug resistance rates of the gram-negative bacteria to imipenem and gentamycin were less than 7.0%.After a 6-24months follow-up,the average fracture healing time was 6.5months,and the evaluation of Johner-Wruhs 12months after surgery concluded that there were 9cases of excellent healing,27cases of good healing,4cases of moderate healing,and 2cases of poor healing;totally 24cases have accepted the phaseⅡ transposition flap grafting,among whom the recurrent infections occurred in 2cases,1case was cured after expanding osteotomy combined with external fixation,and 1case was failed and had to receive the amputation. CONCLUSIONThe limited internal fixation combined with external fixator and systemic perioperative treatment of infections can achieve satisfactory therapeutic effect on the infective tibial fractures.