合并内侧软组织缺损的复杂胫骨近端开放性骨折的分阶段治疗策略

Stages treatment strategies for open and complex proximal tibia fractures complicated with medial soft tissue defects

目的：总结分析合并内侧软组织缺损的复杂胫骨近端开放性骨折分阶段治疗的策略及疗效。方法2007年5月-2011年7月我院共收治 GustiloⅡ-ⅢB 型合并内侧软组织缺损的复杂胫骨近端开放性骨折25例，对所有患者行急诊一期清创、患肢跟骨牵引，通过内侧伤口对胫骨内侧柱骨折进行复位，尽可能恢复胫骨内侧柱的长度、轴线及内侧胫骨平台关节面的平整，必要时行克氏针临时固定，对清创后不稳定的软组织缺损伤口行负压封闭引流敷料覆盖引流，术后使用抗生素和视伤口情况反复清创，待内侧伤口稳定后，二期行单纯外侧经皮锁定钢板内固定、自体髂骨植骨、内侧皮瓣转移修复创面。末次随访时膝关节功能按美国特种外科医院（HSS）膝关节功能评分法进行评定。结果25例患者术后均获随访，随访10-30个月。所有患者外侧手术切口无感染、坏死发生；内侧转移皮瓣除2例皮瓣周缘表皮坏死，经换药完全愈合，其他23例皮瓣均完全成活；均无骨髓炎发生。术后复查 X 线示内固定装置在位，无松动、断裂。骨折均骨性愈合，无延迟愈合，骨折愈合时间12-23个月。末次随访时膝关节功能按 HSS 膝关节功能评分法进行评定：优8膝，良13膝，可4膝，差1例，优良率为84.00%。结论合并内侧软组织缺损的复杂胫骨近端开放性骨折是一种特殊类型的开放性骨折，临床治疗较为困难，通过分阶段的连续治疗，伤口稳定后二期采用单纯外侧经皮锁定钢板内固定、自体髂骨植骨、内侧皮瓣转移治疗，达到了同时修复创面和复位固定骨折的目的，具有并发症少、能够明显提高手术疗效等优点。

Objective To analytically summarize the stages treatment strategies for open and complex proximal tibia fractures complicated with medial soft tissue defects and its efficacy. Methods From May 2007 to July 201 1,25 patients with Gustilo Ⅱ - ⅢB open and complex proximal tibia fractures complicated with medial soft tissue defects were treated;patients underwent emergency debridement,traction of calcaneus in fracture limb,medial column reset by the medial wounds,as far as possible restored medial column tibial length,axis and the medial tibial plateau articular surface,if necessary,temporary Kirschner wire fixation was performed,wound dressings for vacuum sealing drainage was used in post-debridement unstable soft tissue defects,use of postoperative antibiotics and treated the wounds with repeated debridement.After the inside wounds got stable recovery,stage II pure lateral percutaneous locking plate fixation was performed,autologous iliac bone transplantation,medial skin flap transfer repair the wounds.At last follow- up,the functions of knee joint were evaluated according to American Hospital for Special Surgery （HSS）knee function scores. Results A 10-30 month follow-up for all the 25 patients was done.No infection and necrosis occurred in lat-eral operative incisions.Two cases had peripheral epidermal necrosis of medial graft flap and they completely healed after we changed the dressing.The other 23 cases survived;no osteomyelitis occurred.Post-operative X-ray presented internal fixation device located in the correct position without loosening and rupture.Bone fractures got bony healing withouut delayed union,bone healing time was 12-23 months.By HSS knee func-tion scores the knee joint functional outcomes at last follow-up were excellent in 8 knees,good in 13 knees, fair in 4 knees,poor in 1 cases,the excellent and good response rate was 84.00%. Conclusion Open and complex proximal tibia fractures complicated medial soft tissue defects is a special type of open fractures,clini-cal treatment is difficult.By continuous stages treatment,after incision got stable recovery,at stage two treat-ment,a simple lateral percutaneous locking plate fixation,autologous iliac bone graft,the medial skin flap transfer repair can reach to the goal of wounds repair and restoration fixation for fractures,with advantages of less complications and of significantly improving the operation efficacy.