腓骨截骨结合自体髂骨植骨治疗胫骨术后骨不连

Fibular osteotomy with autogenous iliac bone graft in treatment of postoperative nonunion of tibia

目的探讨采用腓骨截骨结合自体髂骨植骨治疗胫骨术后骨不连的临床疗效。方法对2008年7月至2013年6月第二军医大学长海医院收治的45例胫骨术后骨不连患者进行腓骨截骨结合自体髂骨植骨治疗。根据骨不连分型:肥大型29例,萎缩型14例,假关节2例。首次固定器械:钢板固定32例,髓内钉固定11例,外固定支架固定2例,对其中8例钢板内固定稳定患者行单纯腓骨截骨自体髂骨植骨术,对35例内固定和2例外固定失效患者行固定取出更换锁定加压钢板+腓骨截骨结合自体髂骨植骨术,通过定期正侧位X线观察骨折愈合情况和相关并发症,并根据Olerud-Molander评分标准对踝关节功能进行评分。结果患者手术时间为1.3~2.5(1.7±0.5)h,术中出血量为200~500(250.0±59.6)mL,腓骨截骨长度为2~3(2.4±0.5)cm,髂骨植骨量为3~23(7.8±1.3)cm3。随访时间为12~48(16.5±3.3)个月,45例患者的骨折愈合时间为3~11(5.6±2.4)个月。26例(58%)患者在3~5个月愈合,13例(29%)患者6~8个月愈合,其余6例(13%)患者9~11个月愈合。肢体无短缩27例,短缩<1cm者9例,短缩1~2cm 6例,短缩>2cm 3例。末次随访时评定下肢关节功能:优23例,良14例,可5例,差3例。结论腓骨截骨结合自体髂骨植骨可以对骨折断端进行加压,增加断端接触面积,促进骨折愈合,减少并发症。

Objective To assess the clinical efficacy of fibular osteotomy with autogenous iliac bone graft for treatment of nonunion of the tibia. Methods A cohort of 45 patients with postoperative nonunion of tibia between Jul. 2008 and Jun. 2013 were treated by fibular osteotomy combined with autogenous iliac bone graft in Changhai Hospital of Second Military Medical University. According to anatomical classification, there were 29 cases of hypertrophic nonunion, 17 cases of atrophic nonunion and two cases of pseudoarthrosis. For primary fixation, 32 cases had plates internal fixation, 11 had intramedullary nail and two had external fixation. Eight patients with stable plate internal fixation were treated by fibular osteotomy with autogenous iliac bone graft, 35 patients with failed internal fixation and two patients with failed external fixation were treated by removing implant and exchanging compression plate with fibular osteotomy using autogenous iliac bone graft. The status of fracture healing and relative complications were assessed by lateral and frontal X-ray. Functional recovery of the ankle was evaluated by Olerud-Molander Ankle Score （OMAS）. Results The operation time was 1.3-2. 5 （1.7±0. 5） h, the intra-operation blood loss volume was 200-500 （250. 0± 59. 6） mL, the fibular osteotomy length was 2-3 （2.4±0. 5） cm, and the volume of iliac grafting was 3-23 （7. 8±1.3） cm3. The follow-up time was 12-48 （16. 5±3.3） months and the fraction healing time was 3-11 （5. 6±2.4） months. The healing of 26 （ 58 % ） patients took 3-5 months, 13 （ 2 9 % ） patients took 6-8 months and 6 （ 13 % ） patients took 9-11 months. Twenty-seven patients had no limb shortening, nine patients had limb shortening of 〈1 cm, six patients had limb shortening of 1-2 cm and three patients had limb shortening of 〉2 cm. The function of lower limb joints was excellent in 23 cases, good in 14 cases, common in 5 cases and bad in 3 cases at last follow-up. Conclusion The fibular osteotomy with autogenous iliac bone graft can create pressure on the broken bone end and increase the broken bone end contact area, promoting fracture healing and reducing complications.