胫骨平台骨折术后不同期感染的治疗

Treatment of postoperative infection of tibial plateau fracture at different stages

目的探讨胫骨平台骨折术后早期和迟发性感染的治疗方法选择。方法采用回顾性病例系列研究分析2013年2月—2017年2月浙江大学医学院附属第二医院收治的21例胫骨平台骨折术后感染患者临床资料,其中男16例,女5例;年龄28~68岁,平均51.9岁。所有患者根据情况积极清创,感染区予局部抗生素硫酸钙或骨水泥控制感染,闭合创面时若存在软组织缺损则行腓肠肌肌瓣转移术予以覆盖。早期感染12例均保留内置物,予以彻底清创、抗生素使用控制感染。迟发性感染患者9例,其中1例予以局部换药至骨折愈合,后拆除内置物并予以清创闭合伤口;2例关节面已破坏严重,无法重建,其中1例Ⅰ期直接行股骨下段截肢术,另外1例Ⅰ期拆除钢板改用外固定支架固定,反复清创后Ⅱ期行关节融合术;其余6例均采取拆除内置物改外固定支架固定,予以彻底清创及抗生素使用,其中3例骨缺损患者Ⅱ期行植骨术。定期复查所有患者感染情况、膝关节功能美国特种外科医院(HSS)评分及骨折愈合情况。结果患者均获随访18~60个月,平均37.4个月。患者均局部予抗生素硫酸钙或骨水泥控制感染,其中10例感染患者行腓肠肌肌瓣转移术,伤口均愈合良好,无再发骨折或感染复发。12例早期感染患者均成功保留内置物,骨折均愈合。根据HSS评分标准:优7例,良3例,中2例,优良率为83%(10/12)。9例迟发性感染患者除外截肢及关节融合2例,其余7例迟发性感染患者骨折或骨缺损均愈合。根据HSS评分标准:优1例,良3例,中2例,差1例,优良率为57%(4/7)。结论对于胫骨平台术后早期感染患者,可首先尝试保留内置物,早期清创并联合抗生素使用积极控制感染;对于迟发性感染患者,除骨折稳定且尚在愈合的患者可尝试保留内置物外,采用拆除内置物并彻底清创、局部联合全身抗生素使用可有效控制感染。同时,腓肠肌肌瓣转移、抗生素硫酸钙及骨水泥局部使用等均有利于感染控制,可以取得良好的临床治疗效果。

Objective To investigate the treatment options for early and delayed postoperative infection of tibial plateau fracture.Methods A retrospective case series study was conducted to analyze 21 patients with postoperative infection of tibial plateau fracture admitted to the Second Affiliated Hospital of Medical College of Zhejiang University from February 2013 to February 2017.There were 16 males and five females,aged 28-68 years,with an average age of 51.9 years.Infection control was achieved in all patients through debridement and local application of antibiotic calcium sulfate or bone cement in all patients and gastrocnemius muscle flap transfer was conducted if necessary.The implants were retained in the 12 patients with early infection through thorough debridement and antibiotic therapy.Of all the nine patients with delayed infection,the implant of one patient was removed after local wound dressing until fracture union and the following debridement closure was performed;two patients with severe damage of knee joint had no chance of reconstruction,with one patient treated with lower femoral amputation and another with replacement of plate by external fixator at stage I and arthrodesis at stage II.The implants were replaced by external fixator followed by debridement and antibiotic therapy in the remaining six patients with delayed infection,among which stage II bone grafting was performed in three patients with bone defect.Infection,bone healing and knee function score of Hospital for Special Surgery(HSS)were evaluated in all patients at regular intervals.Results All patients were followed up for 18-60 months,with an average of 37.4 months.All patients were treated with antibiotic calcium sulfate or bone cement to control infection.Ten patients with infection underwent gastrocnemius muscle flap transfer,and the wounds were healed well with no recurrence of fracture and infection.The implants of 12 patients with early infection were successfully retained,and the fractures were healed.According to HSS scoring criteria,the knee joint function results were excellent in seven patients,good in three,and moderate in two,with an overall excellent and good rate of 83%(10/12).Infection was controlled in nine patients with delayed infection,and fractures or bone defects were healed in seven patients with delayed infection except patients receiving amputation and joint fusion.According to HSS scoring criteria,knee joint function results were excellent in one patient,good in three,moderate in two and poor in one,with an excellent and good rate of 57%(4/7).Conclusions Patients with early postoperative infection of tibial plateau fracture may attempt to retain the implants through early debridement and antibiotic therapy.For patients with delayed infection,although implants may also be retained in stable cases with ongoing fracture healing,removal of implants instead by external fixator is recommended and infection can mostly be controlled by debridement and antibiotic therapy.Meanwhile,gastrocnemius muscle flap transfer and antibiotic calcium sulfate or bone cement contributing to the control of infection can achieve good clinical results.