胫后血管肌间隙支胫骨骨膜瓣联合自体植骨修复胫骨骨缺损

TIBIAL PERIOSTEAL FLAP PEDICLED WITH INTERMUSCULAR BRANCH OF POSTERIOR TIBIAL VESSELS COMBINED WITH AUTOLOGOUS BONE GRAFT FOR TIBIAL BONE DEFECT

目的探讨胫后血管肌间隙支胫骨骨膜瓣联合自体植骨修复胫骨骨缺损的临床疗效。方法 2007年1月-2013年12月,收治创伤性小腿胫骨骨缺损合并皮肤软组织缺损19例。其中男14例,女5例;年龄18~49岁,平均28岁。胫骨骨折部位:中段6例,下段13例。Gustilo分型:ⅢA型4例,ⅢB型14例,ⅢC型1例(胫前动脉损伤)。骨缺损长4.3~8.5 cm,平均6.3 cm;软组织缺损范围8 cm×5 cm^17 cm×9 cm。受伤至手术时间3~8 h,平均4 h。一期行清创外固定架固定、封闭式负压引流治疗,待创面肉芽组织新鲜后应用腓肠神经营养皮瓣或胫后动脉穿支皮瓣修复,皮瓣切取范围10 cm×6 cm^19 cm×11 cm;二期行胫后血管肌间隙支胫骨骨膜瓣联合自体髂骨植骨修复骨缺损,骨膜瓣切取范围6.5 cm×4.0 cm^9.0 cm×5.0 cm,植骨长4.5~9.0 cm,拆除外固定架改用锁定钢板螺钉内固定。结果术后皮瓣全部成活,质地柔软,创面Ⅰ期愈合。患者均获随访,随访时间18~40个月,平均22.5个月。自体移植骨均愈合,愈合时间3~9个月,平均6.5个月;无内植物松动、断裂等并发症发生。患肢局部无疼痛及异常活动,恢复负重和行走功能。患肢长度恢复,与健侧相差0.5~1.5 cm;膝、踝关节活动良好,未出现感染、畸形愈合、马蹄足畸形等。末次随访时,参照Johner等标准评定临床疗效,获优15例,良3例,可1例,优良率为94.7%。结论胫后血管肌间隙支胫骨骨膜瓣联合自体植骨是修复胫骨骨缺损的有效方法之一。

Objective To investigate the effectiveness of tibial periosteal flap pedicled with intermuscular branch of posterior tibial vessels combined with autologous bone graft in the treatment of tibial bone defects. Methods Between January 2007 and December 2013, 19 cases of traumatic tibia bone and soft tissue defects were treated. There were 14 males and 5 females, aged from 18 to 49 years （mean, 28 years）. The tibial fracture site located at the middle tibia in 6 cases and at the distal tibia in 13 cases. According to Gustilo type, 4 cases were rated as type III A, 14 cases as type III B, and 1 case as type III C （injury of anterior tibial artery）. The length of bone defect ranged from 4.3 to 8.5 cm （mean, 6.3 cm）. The soft tissue defects ranged from 8 cm×5 cm to 17 cm×9 cm. The time from injury to operation was 3 to 8 hours （mean, 4 hours）. One-stage operation included debridement, external fixation, and vacuum sealing drainage. After formation of granulation tissue, the fresh wound was repaired with sural neurovascular flap or posterior tibial artery perforator flap. The flap size ranged from 10 cm×6 cm to 19 cm×11 cm. In two-stage operation, tibial periosteal flap pedicled with intermuscular branch of posterior tibial vessels combined with autologous bone graft was used to repair tibial defect. The periosteal flap ranged from 6.5 cm×4.0 cm to 9.0 cm×5.0 cm; bone graft ranged from 4.5 to 9.0 cm in length. External fixation was changed to internal fixation. Results All flaps survived with soft texture, and no ulcer and infection occurred. All incisions healed by the first intention. All patients were followed up 18-40 months （mean, 22.5 months）. All graft bone healed, with the healing time from 3 to 9 months （mean, 6.5 months）. No complication of implant loosening or fracture was observed. No pain and abnormal activity in the affected leg occurred. All patients resumed weight-bearing and walking function. The length of the limb was recovered and difference value was 0.5-1.5 cm between normal and affected sides. The function of the knee and ankle joint was good without infection, malunion, and equinus. According to the Johner standard at last follow-up, the results were excellent in 15 cases, good in 3 cases, and fair in 1 case, with an excellent and good rate of 94.7%. Conclusion Tibial periosteal flap pedicled with intermuscular branch of posterior tibial vessels combined with autologous bone graft is an effective method to treat bone defect of the tibia.