钢板内固定一期确定性治疗Gustilo Ⅲ型长管状骨开放性骨折

Plate osteosynthesis for one-stage definite treatment of Gustilo type Ⅲ open fractures of long bone

目的 探讨钢板内固定一期确定性治疗Gustilo Ⅲ型长管状骨开放性骨折的疗效.方法 回顾性分析2006年1月至2016年6月解放军第五十九医院创伤显微外科应用钢板一期确定性内固定治疗的69例Gustilo Ⅲ型长管状骨开放性骨折患者资料,男47例,女22例;年龄2～ 62岁,平均34.2岁.骨折部位及Gustilo分型：胫、腓骨干27例（ⅢA型13例,ⅢB型12例,ⅢC型2例）,胫骨远端4例（ⅢA型2例,ⅢB型2例）;尺、桡骨干14例（ⅢA型9例,ⅢB型3例,ⅢC型2例）;肱骨干12例（ⅢA型7例,ⅢB型3例,ⅢC型2例）,肱骨远端3例（均为ⅢA型）;股骨干6例（ⅢA型5例,ⅢC型1例）,股骨远端3例（ⅢA型2例,ⅢC型1例）.受伤至手术时间4～17h,平均9.6h.彻底清创后应用锁定钢板（CLP）、限制接触型加压板（LC-DCP）或重建锁定钢板、1/3管型钢板确定性固定骨折,ⅢA型减张或直接无张力闭合伤口,合并软组织缺损者应用穿支皮瓣、皮神经营养血管皮瓣、传统轴型皮瓣及肌皮瓣、局部皮瓣一期修复深部组织外露创面,同时完成其他必要的肢体结构及功能重建（包括神经修复、血管修复12例,肌腱、韧带修复5例,动力肌重建3例）.遗留浅表创面一期或二期断层植皮.结果 所有患者平均住院时间为19 d（5 ～37 d）,1例腓肠神经营养血管皮瓣局灶坏死,2例表浅多重耐药感染.69例患者均获随访,时间为12 ～ 27个月（平均19.2个月）.均未发生深部骨感染.4例患者内固定物断裂,1例松动,予更换髓内钉或钢板翻修（各2例）及自体植骨.骨性愈合时间为5～15个月（平均7.7个月）,肢体功能、外形恢复满意.结论 在能做到彻底清创及满意软组织覆盖前提下的Gustilo Ⅲ型长管状骨开放性骨折患者,采用钢板一期确定性固定可获得满意效果,是髓内钉及外固定支架之外的另一选择,尤其适用于干骺端、关节内、上肢和儿童骨折.

Objective To report our efficacy of one-stage definite treatment of Gustilo type Ⅲ open fractures of long bone by plate osteosynthesis.Methods A retrospective case series study was conducted of the 69 cases who had undergone plate osteosynthesis for one-stage definite treatment of Gustilo type Ⅲ open fractures of long bone from January 2006 to June 2016 at Microsurgery and War Trauma Center of Chengdu Military Command,59 Hospital of Chinese PLA.They were 47 males and 22 females with an average age of 34.2 years （from 2 to 62 years）.There were 27 shaft fractures of tibia or fibula （13 cases of type ⅢA,12 cases of type Ⅲ B and 2 cases of type Ⅲ C）,4 fractures of distal tibia （2 cases of type Ⅲ A and 2 cases of type ⅢB）,14 shaft fractures of ulna or radius （9 cases of type ⅢA,3 cases of type ⅢB and 2 cases of type Ⅲ C）,12 factures of humeral shaft （7 cases of type Ⅲ A,3 cases of type Ⅲ B and 3 cases of type Ⅲ C）,3 fractures of distal humerus （all type ⅢC）,6 fractures of femoral shaft （5 cases of type ⅢA and one type Ⅲ C）,and 3 fractures of distal femur （2 cases of type ⅢA and one type ⅢC）.The intervals between injury and operation ranged from 4 to 17 hours,averaging 9.6 hours.After thorough debridement,osteosynthesis was performed with locking compression plate,limited contact dynamic compression plate or/and reconstruction locking plate,or 1/3 tubular plate.Direct closure with decreased tension or without tension was used for type Ⅲ A injury;deep open defects were repaired with perforator flaps,neurovascular axis flaps,traditional axis flaps and muscular flaps,or local flaps;limb reconstructions included neurovascular repair in 12 cases,tendon and ligament repair in 5 cases,and muscle reconstruction in 3 cases.Superficial defects were covered by skin grafts simultaneously or secondarily.Results The duration of hospitalization averaged 19 days （from 5 to 37 days）.Partial necrosis occurred in one case of sural neurovascular axis flap.Superficial infection with multiple antibiotic-resistant bacteria occurred in 2 cases.Follow-up for the 69 patients ranged from 12 to 27 months （average,19.2 months）.No deep bone infection occurred.Implant breaking occurred in 4 cases and implant loosening in one.The implant failures were corrected by change into intramedullary nails or plate refixation （respectively in 2 cases） in addition to bone graft.Bone union was achieved after 5 to 15 months （average,7.7 month）with satisfactory aesthetic and functional outcomes.Conclusion For patients with Gustilo type Ⅲ open fracture of long bone,especially those with metaphyseal,intraarticular or upper limb fracture and pediatric ones,plate osteosynthesis can be a satisfactory one-stage definite treatment besides intramedullar nailing and external fixation,providing that through debridement and satisfactory soft-tissue coverage can be achieved.