小腿创伤术后软组织缺损的因素分析与治疗对策

Factor analysis and treatment strategies of post-operative soft-tissue defect in leg trauma

目的 分析小腿创伤术后易引起软组织缺损的高危因素,探讨防止软组织缺损的措施及出现软组织缺损后的处理方法. 方法 回顾分析1999年1月至2012年12月在我院收治的217例因小腿严重创伤术后出现软组织缺损同时伴骨外露、内固定外露的病例.201例行了各种皮瓣手术,包括皮神经营养血管皮瓣89例,任意皮瓣21例,游离皮瓣75例,交腿皮瓣16例.16例行植皮手术.对伴软组织缺损骨折的处理,已行钢板内固定117例中,96例行钢板取出,21例未取出钢板;已行髓内钉内固定13例中,取出髓内钉4例,未取出9例;对骨折已行外固定的56例者,39例未调整外固定,17例重新调整外固定. 结果 217例小腿外伤术后出现软组织缺损的病例中,201例行了各种皮瓣手术,皮瓣完全坏死l例,皮瓣远端部分坏死14例,其中6例经换药后愈合,5例行清创植皮术后愈合,3例再次行皮瓣转移术.177例骨折1年内一期愈合.23例骨折延迟愈合.8例骨折不愈合,行二期植骨及骨折重新固定手术后愈合.9例因骨髓炎长期不能控制,6例行感染骨段切除、骨搬运手术后愈合,3例行截肢术. 结论 小腿创伤术后出现软组织缺损是一严重并发症,多与初期处理时手术时机把握不当及手术方式不当有关.出现软组织并发症后,需要尽早灵活选用各种皮瓣解决软组织覆盖问题.早期行内固定者,若软组织缺损不多、内固定外露少、感染轻,可以不取出内固定而行皮瓣覆盖手术：若软组织缺损重,内固定外露多且感染重,则在皮瓣手术的同时需取出内固定改用外固定.

Objective To analyze risk factors for soft-tissue defects after surgery on leg trauma,to discuss methods for prevention of soft-tissue defects and its treatment.Methods A retrospective analysis was conducted on 217 cases of soft-tissue defects with bone exposure and / or internal fixation exposure after surgery on leg trauma from January,1999 to December,2012.Soft-tissue defects with various flaps were used in 201 cases,including neurocutaneous flap（89 cases）,random flap（21 cases）,free flap（75 cases）,cross-leg flap（16 cases）,and by skin grafting in 16 cases.For the 117 internal plate-fixated fractures,96 removed the plate and 21 cases did not remove the plate.For the 13 intramedullary nail fixations,4 cases of intramedullary nails were removed,9 cases were not removed.For the 56 cases of external fixation of the fractures,39 patients had unadjusted external fixation,17 cases re-adjusted external fixations.Results Of the 217 cases of soft-tissue defect after surgery on legs,201 cases were conducted flap surgery.The flap was completely necrosis in one case,and partial distal necrosis were in 14 cases,of which 6 cases healed after changing the dressing,5 underwent debridement and skin grafting,3 cases underwent flap surgery again.In cases of fracture patients,177 cases healed within 1 year,delayed union 23 cases,nonunion eight cases.Nonunion healing after bone grafting and re-fixation surgery.In 9 cases of uncontrollable osteomyelitis,6 patients underwent bone removal and bone transport surgery,3 patients underwent amputation.Conclusion Soft-tissue defects after surgery on leg trauma is a serious complication whose prevalence is associated,in a certain degree,with incorrect surgical time and methods.It is crucial for early repair of soft-tissue defects by using various kinds of proper flaps whenever soft-tissue complication occurs.In patients with early stage internal fixation,flap surgery without internal fixation removing is feasible if little soft-tissue defect,little exposed internal fixation and mild infection,otherwise it is necessary to remove internal fixation and re-fix by external fixation before flap surgery.