短缩再植结合肢体延长术治疗小腿中下段严重离断伤

Application of shortened replantation combined with limb lengthening in treatment of severe amputation of middle and distal lower leg

目的探讨短缩再植结合肢体延长技术治疗小腿中下段严重离断伤的临床疗效和技术要点。方法 2009年4月—2016年5月,采用一期短缩再植二期延长技术治疗小腿中下段离断伤12例。其中男9例,女3例;年龄16~32岁,平均28岁。致伤原因:交通事故伤4例,重物砸伤6例,机器挤压伤2例。受伤至就诊时间为30 min^6 h,平均3 h 12 min。其中右小腿中下段完全离断6例,左小腿中下段不全离断4例,左踝关节平面完全离断2例。肢体短缩4.0~12.5 cm,平均7.3 cm;再植术后1.5~8.0个月行肢体延长术,延长时间1.7~5.3个月,平均3.1个月。结果 12例短缩再植后再延长均达到双下肢等长,术后延长段骨矿化良好,骨断端和延长骨段均达骨性愈合,愈合时间7~16个月,平均11.3个月。所有患者均获随访,随访时间6个月~5年,平均2年5个月。膝关节活动范围:过伸0~5°,平均3°;屈曲110~140°,平均120°。除2例踝关节融合外,其余患者跖屈15~45°,平均26°;背屈10~25°,平均15°。足底感觉恢复至S_3+4例,S_3 6例,S_2 2例。末次随访时根据Kofoed功能评定标准评价,获优7例,良3例,可2例。结论通过短缩再植结合肢体延长技术治疗小腿中下段严重离断伤,扩大了下肢离断再植适应证,降低了再植难度,治疗更简便有效。

Objective To investigate the effectiveness and technical points of shortened replantation combined with limb lengthening in the treatment of severe amputation of middle and distal lower leg. Methods Twelve cases of severe amputation of middle and distal lower leg were treated with shortened replantation at the 1st stage and limb lengthening at the 2nd stage between April 2009 and May 2016. There were 9 males and 3 females with an average age of 28 years （range, 16-32 years）. The injury causes included traffic accident injury in 4 cases, heavy pound injury in 6 cases, and machine crush injury in 2 cases. The interval from injuries to treatment ranged from 30 minuts to 6 hours （mean, 3 hours and 12 minutes）. All of 12 cases, 6 cases were completely amputated in the right middle and distal lower leg, 4 were not completely amputated in the left middle and distal lower leg, and 2 were ankle amputations. The limbs were 4.0-12.5 cm shorter than the contralateral sides, with an average of 7.3 cm. Limb lengthening was performed at 1.5- 8.0 months after replantation and the time of extension was 1.7-5.3 months （mean, 3.1 months）. Results All 12 patients recovered the same lengths of both lower extremities after shortened replantation and limb lengthening. The lengthened segments gained good bone mineralization, bony union was achieved at lengthened segments and broken end of fracture at 7-16 months （mean, 11.3 months）. All patients were followed up 6 months to 5 years （mean, 2 years and 5 months）. The range of motion of the knee joint were 0-5° （mean, 3°） in hyperextension and 110-140° （mean, 120°） in flexion. Except for 2 cases of ankle arthrodesis, plantar flexion angles were 15-45° （mean, 26°） and dorsiflexion angles were 10-25° （mean, 15°） in the other cases. The plantar sensation was restored to the S3 level in 4 cases, S3 level in 6 cases, and S2 level in 2 cases. At last follow-up, the affected limb function were excellent in 7 cases, good in 3 cases, fair in 2 cases according to Kofoed functional evaluation criteria. Conclusion It expanded indications for replantation of lower limb amputation, reduced the operation difficulty and trauma with shortened replantation combined with limb lengthening in the treatment of severe amputation of middle and distal lower leg.