外固定支架固定后二期髓内固定治疗胫骨干开放性骨折

Secondary intramedullary nailing following external fixation for open tibial shaft fractures

目的探讨经外固定支架一期固定髓内钉二期固定治疗胫骨干开放性骨折的疗效。方法回顾性分析2011年3月至2014年6月收治的28例胫骨干开放性骨折患者资料，男17例，女11例；年龄21～62岁，平均38．2岁。彻底清创后，外固定支架临时固定骨折，一期关闭或二期通过植皮或组织瓣修复创面，软组织条件允许后拆除外固定支架并改为非扩髓髓内钉固定。观察骨折愈合时间及并发症发生情况，末次随访时根据Johner—Wruhs评价标准评估临床疗效。结果28例患者术后获12～18个月（平均13．5个月）随访，所有骨折均获骨性愈合，骨折愈合时间为4～15个月（平均4．9个月）。4例患者骨折延迟愈合，经改为动态固定后获得愈合。所有患者均无深部感染、断钉、畸形愈合及肢体短缩等并发症，有5例患者术后有轻度膝关节疼痛。末次随访时根据Johner—Wruhs评价标准评估临床疗效：优18例，良7例，中3例，优良率为89．3％。结论采用非扩髓的髓内钉固定经外固定支架一期固定的胫骨干开放性骨折，骨折愈合良好，并有利于肢体的早期功能锻炼，临床效果满意。

Objective To explore the clinical efficacy of secondary unreamed intramedullary nailing following primary external fixation for open tibial shaft fractures. Methods From March 2011 to June 2014, we treated 28 open tibial shaft fractures. They were 17 men and 11 women, aged from 21 to 62 years （average, 38.2 years）. After thorough debridement, the tibia was stabilized temporarily with external fixation. The wounds were handled with primary closure or secondary repair with skin grafts or tissue flaps. After the wounds healed, the external fixation was replaced by unreamed intramedullary nailing. Fracture union and complications were documented. The clinical efficacy was evaluated at the final follow-ups according to the Johner-Wruhs scoring system. Results All the 28 patients were followed up for 12 to 18 months （average, 13.5 months）. Bony union was achieved in all after 4 to 15 months （average, 4.9 months）. Delayed union was observed in 4 cases which were healed after dynamic fixation. There was no deep infection, nail breakage, malunion or limb short- ening in any one. Mild knee pain was reported by 5 cases after surgery. According to the Johner-Wruhs criteria, 18 cases were excellent, 7 good, and 3 moderate, giving an excellent to good rate of 89.3%. Conclusion Primary external fixation and secondary unreamed intramedullary nailing can result in good fracture union with satisfactory biomechanical stability and favorable early rehabilitation in the treatment of open tibial shaft frac- tures.