负压封闭引流技术在多发伤合并GustiloⅢC型开放性骨折患者保肢治疗中的应用

Application of vacuum sealing drainage in limb salvage of multiple trauma patients with Gustilo typeⅢC open fracture

目的探讨负压封闭引流(vsd)技术在多发伤合并GustiloⅢC型开放性骨折患者保肢救治中的安全性和有效性。方法采用回顾性病例对照研究分析2005年10月一2015年10月华中科技大学同济医学院附属同济医院收治的102例多发伤合并GustiloⅢC型开放性骨折患者的临床资料,其中男66例,女36例;年龄17~65岁[(34.2士10.1)岁]。损伤严重度评分(ISS)18~26分[(19.8±3.2)分]。骨折部位:股骨骨折34例,胫/腓骨骨折66例,股骨+胫/腓骨骨折35例。58例急诊术后使用VSD技术治疗(VSD组),44例急诊术后使用常规换药法治疗(常规组)。比较两组创面活动性出血,再次血管探查、骨筋膜间隔综合征、创面感染坏死、气性坏疽、延迟截肢、全身炎症反应综合征(SIRS)、脓毒症、深静脉血栓(DVT)发生率、人均清创次数、住院时间、植皮/皮瓣率、骨折内固定率、难愈创面发生率、骨不连发生率、神经完全损害发生率、英国医学研究委员会(BMRC)评分优良率及截肢率/保肢率。结果患者均获随访6-14个月[(8.4士2.1)个月]。两组术后保肢率的比较差异无统计学意义(P>0.05)。术后保肢治疗的指标比较中,两组创面活动性出血、气性坏疽、再次血管探查和延迟截肢比较差异无统计学意义(P>0.05);常规组和VSD组的创面感染坏死率分别为32%和15%(P<0.05),骨筋膜间隔综合征发生率分别为22%和7%(P<0.05)o住院期间,DVT发生率和骨折内固定率比较差异无统计学意义(P>0.05);常规组和VSD组SIRS发生率分别为92%和73%(P<0.05),脓毒症发生率分别为28%和10%(P<0.05),人均清创次数分别为4.2次和3.2次(P<0.05)住院时间分别为42.1d和30.2d和(P<0.05),植皮/皮瓣率分别为69%和46%(P<0.05);随访结果中,两组伤后截肢率和保肢率比较差异无统计学意义(P>0.05);常规组和VSD组难愈创面发生率分别为28%和10%(P<0.05),骨不连发生率分别为22%和6%(P<0.05),神经完全损害发生率分别为36%和12%(P<0.05),BMRC评分优良率分别为83%和96%(P<0.05).结论VSD技术可促进术后创面愈合,预防并发症,继而减少清创手术次数并缩短住院时间,明显提高患者预后效果和肢体功能,是一种相对安全有效的治疗多发伤合并GustiloⅢC型骨折的方法。

Objective To investigate the safety and effectiveness of vacuum sealing drainage treatment on limb salvage in multiple trauma patients combined with Gustilo type IIIC fracture.Methods A retrospective case control study was conducted to analyze the clinical data of 102 patients diagnosed with multiple trauma combined with Gustilo type III C fracture admitted to Tongji Hospital from October 2005 to October 2015.There were 66 males and 36 females,aged 17-65 years[(34.2±10.1)years].The injury severity score(ISS)ranged from 18 to 26 points[(19.8±3.2)points].There were 34 patients with femur fracture,66 with tibia/fibula fracture,35 with femur and tibia/fibula fracture.Among the patients,58 were treated with VSD(VSD group)and 44 were treated with routine dressing change after emergency operation(routine group).The two groups were compared for active bleeding,re-vascular exploration,osteofascial compartment syndrome,wound infection and necrosis,gas gangrene,delayed amputation,systemic inflammatory response syndrome(SIRS),sepsis,deep venous thrombosis(DVT)incidence,per capita debridement times,length of stay,skin graft/skin flap rate,fracture fixation rate,incidence of refractory wounds,incidence of nonunion,incidence of complete nerve damage,British medical research council(BMRC)score,and amputation rate/salvage rate.Results All patients were followed up for 6-14 months[(8.4±2.1)months].There was no significant difference in limb salvage rate between the two groups after operation(P>0.05).Among the indexes of limb salvage treatment after operation,no significant differences were found between the routine group and VSD group in active bleeding,gas gangrene,re-vascular exploration and delayed amputation(P>0.05);the wound infection and necrosis rates were 32%and 15%(P<0.05);the incidence rates of osteofascial compartment syndrome were 22%and 7%(P<0.05).During the hospital stay,there were no significant differences in DVT incidence and fracture internal fixation rate between the two groups;SIRS incidence rates of routine group and VSD group were 92%and 73%(P<0.05);the incidence rates of sepsis were 28%and 10%(P<0.05);the per capita debridement times in routine group and VSD group were 4.2 times and 3.2 times,respectively(P<0.05);hospitalization durations were 42.1 days and 30.2 days(P<0.05);skin graft/skin flap rates were 69%and 46%(P<0.05).In the follow-up results,there was no significant difference in the amputation rate/salvage rate between the two groups(P<0.05).The incidence of refractory wounds was 28%in routine group and 10%in VSD group(P<0.05);the incidence of nonunion was 22%and 6%(P<0.05);the incidence of complete neurological damage was 36%and 12%(P<0.05);the excellent and good rate of BMRC score was 83%and 96%(P<0.05).Conclusions VSD technology can promote wound healing after operation,prevent complications,reduce the number o￡debridement operations and shorten hospital stay,significantly improving the prognosis and limb function of patients.It is a relatively safe and effective method for the treatment of multiple trauma combined with Gustilo typeⅢC fracture.