单臂外固定支架联合游离皮瓣在治疗前臂Gustilo Ⅲ型骨折中的应用

Single-arm external stent combined with free flap used in forearm fractures of Gustilo typeⅢ

目的探讨单臂外固定支架联合游离皮瓣治疗前臂GustiloⅢ型骨折的疗效。方法回顾性分析2015年9月至2018年1月西南医科大学附属中医医院修复重建外科中心应用单臂外固定支架联合游离皮瓣治疗16例前臂开放性骨折伴软组织缺损患者资料,男11例,女5例;年龄18~64岁,平均41.6岁。骨折根据Gustilo分型:ⅢB型9例,ⅢC型7例。前臂及手部软组织缺损范围为7.5 cm×5.5 cm^16.5 cm×11.0 cm。一期急诊下行清创探查术,修复重要的血管、神经、肌腱,骨折复位后予以单臂外固定支架固定。待创面清洁后,二期行游离皮瓣修复创面。游离股前外侧穿支皮瓣修复创面9例,游离髂腹股沟皮瓣修复创面7例。5例患者外固定支架成为终极的固定方式,11例患者皮瓣成活后采用钢板内固定。术后记录并发症情况,末次随访时按中华医学会手外科学会上肢部分功能评定试用标准评价上肢功能。结果14例游离皮瓣顺利成活,2例股前外侧皮瓣因术后24 h出现静脉危像,经探查后,危像解除,皮瓣成活。术后16例患者获9~18个月(平均13.5个月)随访。骨折端对位良好,力线恢复,骨愈合良好。术后采用Anderson前臂骨折评价标准评定:优10例,良4例,可2例。末次随访时按中华医学会手外科学会上肢部分功能评定试用标准评价上肢功能:优11例,良5例。所有患者均未出现钉道感染及骨不连的现象。结论单臂外固定支架联合游离皮瓣治疗前臂GustiloⅢ型骨折可以有效恢复上肢力线,促进骨愈合,可提供合理的时机选择修复创面,减少了术后感染、骨髓炎等并发症的发生,帮助患肢恢复良好的功能。

Objective To evaluate the clinical application of single-arm external stent combined with free flap in the treatment of forearm fractures of Gustilo typeⅢ.Methods A retrospective study was conducted of the 16 patients who had been treated at Repair and Reconstruction Center,Traditional Chinese Medicine Hospital Affiliated to Southwest Medical University from September 2015 to January 2018 for open forearm fractures combined with soft tissue defects with single-arm external stent combined with free flap.They were 11 men and 5 women,aged from 18 to 64 years(average,41.6 years).By the Gustilo classification,9 cases were typeⅢB and 7 typeⅢC.The area of soft tissue defects at the upper arm and hand ranged from 7.5 cm×5.5 cm to 16.5 cm×11.0 cm.Emergency debridement was performed at the primary stage.After repair of major blood vessels,nerves and tendons,the reduced fractures were fixated with a single-arm external stent.The soft tissue defects were repaired with free flaps at the secondary stage.Nine cases were repaired with a free anterolateral perforating branch flap and 7 with a free ilioinguinal flap.The single-arm external stent became the ultimate fixation mode in 5 cases but was changed into plate fixation after survival of the flaps in the other 11 cases.Complications were recorded postoperatively.At the last follow-up,the upper limb function was evaluated according to the tentative criteria for evaluation of the upper limb function proposed by the Hand Surgery Society of Chinese Medical Association.Results Of all the free flaps,14 survived smoothly but 2 anterolateral ones survived only after the venous crisis appearing at 24 h after operation was relieved by exploration.The 16 patients were followed up for 9 to 18 months(average,13.5 months).The fractures united well with fine alignment of the fracture ends and recovered force line.According to the Anderson criteria for forearm fractures,10 cases were excellent,4 good and 2 fair after operation.According to the tentative criteria for evaluation of the upper limb function proposed by the Hand Surgery Society of Chinese Medical Association,11 cases were excellent and 5 good.No nail infection or nonunion occurred.Conclusion In the treatment of forearm fractures of Gustilo typeⅢ,single-arm external stent plus free flap can effectively restore the force line of upper extremity,promote bone healing,allow reasonable timing for wound repair,reduce postoperative complications like infection and osteomyelitis and facilitate functional recovery of the affected extremity.