应用骨搬运术同期治疗合并难治性软组织缺损的胫骨大段骨缺损

SIMULTANEOUS REPAIR OF TIBIA BONE DEFECT AND REFRACTORY SOFT TISSUE DEFECT BY BONE TRANSPORT TECHNIQUE

目的探讨应用骨搬运术同期治疗胫骨大段骨缺损及合并的难治性皮肤软组织缺损疗效。方法2010年1月-2014年12月,收治胫骨大段骨缺损合并难治性皮肤软组织缺损患者35例。其中男21例,女14例;年龄18~47岁,平均29岁。均为交通事故伤导致GustiloⅢ型开放性胫骨骨折。骨折位于胫骨上1/3段1例,中1/3段19例,下1/3段15例。均于伤后4~10 h行单边外固定支架治疗,5~10 d后出现胫骨皮肤软组织坏死、感染并伴有脓性分泌物渗出。伤后至该次手术时间为21 d^5个月,平均2个月。皮肤软组织缺损范围6 cm×5 cm^10 cm×8 cm;清除坏死骨后骨缺损长度为6~11 cm,平均8 cm。安置Orthofix外固定支架持续骨延长,创面规律换药。结果 35例患者均获随访,随访时间12~22个月,平均16个月。患者骨缺损全部修复,骨愈合时间为9~20个月,平均15个月;均未见明显下肢力线偏移。截骨段延长6~11 cm,平均8 cm;停止延长治疗后外固定支架继续保留2~10个月,平均5个月。所有患者治疗期间均未出现血管、神经损伤,术后无骨髓炎、再骨折等并发症发生。患者皮肤软组织缺损均愈合,愈合时间1~3个月,平均1.3个月。其中5例外固定支架针道有不同程度感染,经换药后好转。拆除外固定支架后采用Johner-Wruhs标准评价疗效,获优26例、良5例、可4例,优良率为88.6%。结论对于合并难治性皮肤软组织缺损的胫骨大段骨缺损患者,如皮瓣修复困难,可选择骨搬运术,通过持续牵拉同期修复软组织及骨缺损。

Objective To explore the feasibility and effectiveness of bone transport technique for simultaneous repair of tibia defect and refractory soft tissue defect. Methods Thirty-five patients with tibia bone defect combined with refractory soft tissue defect were treated between January 2010 and December 2014, and the clinical data were retrospectively analyzed. There were 21 males and 14 females with an average age of 29 years（range, 18- 47 years）. All patients had Gustilo type III open tibial fractures, which were caused by traffic accident. Fracture located at the upper 1 / 3 of the tibia in 1 case, at the middle 1 / 3 of the tibia in 19 cases, and at the lower 1 / 3 of the tibia in 15 cases. All patients underwent external fixation after 4- 10 hours of trauma, and tibial skin necrosis, infection, and purulent exudation were observed after 5- 10 days of operation. The time from injury to admission was 21 days to 5 months（mean, 2 months）. After debridement, the average length of tibia defect was 8 cm（range, 6- 11 cm）; the area of soft tissue defect was 6 cm× 5 cm to 10 cm× 8 cm. Orthofix external fixation was applied to tract the bone and soft. Results All 35 patients were followed up 12- 22 months（mean, 16 months）. The average time of bony healing was 15 months（range, 9- 20 months）, and no obvious force line offset was found. Osteotomy segment was extended from 6 to 11 cm（mean, 8 cm）; after treatment, the external fixation support was retained for 2 to 10 months（mean, 5 months）. No blood vessel and nerve injuries were found during treatment, and no osteomyelitis and refracture happened after operation. The skin and soft tissue defects healed, and the healing time was 1 to 3 months（mean, 1. 3 months）. Different degrees of infection occurred in 5 cases, and was cured after dressing change. According to Johner-Wruhs＇ evaluation criteria after external fixator was removed, the results were excellent in 26 cases, good in 5 cases, and moderate in 4 cases, with an excellent and good rate of 88. 6 %. Conclusion Bone transport technique can simultaneously repair tibia bone defect and soft tissue defect by continuous bone and soft tissue traction.