静脉移植桥接血管蒂的游离腓骨瓣移植治疗长骨感染性骨缺损

Free vascularized fibular graft bridged vascular pedicle by vein transplantation for infective long bone defect reconstruction

目的探讨静脉移植桥接血管蒂的游离腓骨瓣移植治疗长骨感染性骨缺损及软组织缺损的手术方法及临床疗效。方法回顾性分析自2008年6月至2014年1月收治的17例长骨感染性骨缺损患者病例资料，男11例，女6例；年龄1．5-55岁，平均31．3岁；股骨8例，胫骨5例，肱骨3例，桡骨1例；骨缺损长度为4～19cm，平均9．4cm；其中8例合并软组织缺损（5．0cm×3．0cm-17．0cm×5．5cm）。感染性骨缺损端彻底清创后，负压封闭灌洗引流2-3周，待肉芽生长新鲜，设计并切取腓骨瓣或腓骨皮瓣移植进行重建，移植自体静脉并端端吻合桥接受区血管与腓骨瓣的血管蒂。静脉移植桥接腓骨瓣的动、静脉血管蒂长度5-18cm，平均9．6cm；移植腓骨皮瓣面积6．5cm×4．0cm-18．0cm×6．0cm。结果17例腓骨瓣手术及术后恢复顺利，均无血管危象。伤口一期愈合11例，延期1-2周愈合6例。术后6-8周X线片示移植腓骨端骨痂形成。15例获得随访，随访9个月-6年，平均30个月，2例失访。13例骨缺损一期愈合，2例腓骨一端与受区未愈合，再次手术后愈合。1例移植腓骨术后7个月发生应力骨折，经外固定架治疗4个月后愈合。感染性骨缺损愈合时间4．2～9．8个月，平均5．9个月，末次随访时采用Enneking系统评分，优11例，良3例，可1例，优良率93．3％。手术后肢体功能恢复满意。结论静脉移植桥接游离腓骨（皮）瓣血管蒂，不仅能有效地修复长骨感染性骨缺损和局部软组织缺损，而且可以改善骨缺损局部血运，控制感染，明显缩短疗程，是治疗肢体长骨感染性骨缺损及合并软组织缺损的有效手段。

Objective To explore the surgical method and curative effect of free vaseularized fibular graft bridged vascu- lar pediele by vein transplantation for infective long bone defect with or without soft tissue defect reconstruction. Methods From June 2008 to January 2014, 17 patients with infective long bone defect were treated, 11 male and 6 female, 1.5 to 55 years old and averaged 31.3 years. 8 cases in femur, 5 cases in tibia, 3 cases in humerus and 1 case in radius. Bone defect were 4 to 19 cm in length with an average of 9.4 cm. 8 cases with soft tissue defect, from 5.0 cm×3.0 cm to 17.0 cm×5.5cm. Required adequate surgical debfidement, and vacuum sealing drainage （VSD） was used. Free vaseularized fibular （skin） flap was designed and harvested . Artery and veins close to the health site were dissected, and bridged vascular pedicle of free vascularized fibular flap by autologous vein transplantation with end to end anastomosis. The length free vascularized fibular graft was from 5 to 18 era, with an average of 9.6 era. The free fibula flap ranged from 6.5 cm×4.0 cm to 18.0 cm×6.0 cm. Results All the 17 cases of fibular flap survived, no vascular crisis happened. Post-operative wound primary healed in 11 cases, delayed 1 to 2 weeks to heal in 6 cases. Callus was seen in the 6 to 8 weeks later. 15 cases were followed from 9 months to 6 years （averaged 30 months） while 2 cases were lost to follow-up. Bone defect primary healed in 13 cases, and the fibula graft unhealed in 2 cases, but healed again after a second operation. Fibula stress fracture occurred in one case at 7 months after grafting procedures and bone union was achieved 4 months after reapplying an external fixator. Infected bone defect healing time ranged from 4.2 to 9.8 months, averaged 5.9 months. According to the Enneking score, 11 cases were excellent, good in 3 cases, one in fair. Excellent and Good rate was 93.3%. Conclusion Free vascularized fibular （skin） graft with vein bridged vascular pedicle can not only effectively repair infected bone and soft tissue defect, but also improve local blood supply and control infection, shorten the course of treatment, which is an effective treatment of infective long bone defects with or without soft tissue defects.