腓肠肌内侧头肌瓣转移联合膜诱导技术治疗合并骨缺损的胫骨中上段前内侧Gustilo-AndersonⅢB损伤

Transfer of medial gastrocnemius head muscle flap combined with induced membrane technique in treatment of anterior medial Gustilo-Anderson typeⅢB injury of the middle and upper tibia accompanied by bone defect

目的探讨应用腓肠肌内侧头肌瓣转移联合膜诱导技术治疗合并骨缺损的胫骨中上段前内侧Gustilo-Anderson ⅢB损伤的效果。方法采用回顾性病例系列研究分析2017年4月至2019年1月空军军医大学西京医院收治的21例合并骨缺损胫骨中上段前内侧Gustilo-Anderson ⅢB损伤患者的临床资料,其中男15例,女6例;年龄18~66岁[(38.6 ± 7.6)岁]。软组织缺损范围8.0 cm × 6.0 cm~16.0 cm × 12.0 cm、胫骨缺损长度为3.5~11.0 cm[(5.5 ± 1.8)cm]。患者入院后均急诊Ⅰ期使用膜诱导技术行骨缺损修复固定及软组织缺损修复,术中切取转移大小约为12.0 cm × 8.0 cm~22.0 cm × 13.0 cm的腓肠肌内侧头肌瓣,术后1周内观察转移肌瓣成活情况;创面稳定1周,Ⅱ期行肌瓣表面植皮,观察肌瓣植皮成活情况及创面愈合时间;Ⅲ期采用膜诱导技术行骨缺损重建,观察骨断端愈合时间;比较骨缺损修复前与末次随访时感染指标(白细胞计数、超敏C-反应蛋白、红细胞沉降率、降钙素素原、白细胞介素-6)、患肢下肢功能评分(LEFS)和Mazur 踝关节功能评分。末次随访时观察骨折愈合情况及相关并发症,并使用下肢Johner-Wruhs 评分系统评价下肢功能。结果患者均获随访11~26个月[(18.4 ± 5.1)个月]。急诊Ⅰ期21例患者转移肌瓣均成活。Ⅱ期所有肌瓣表面植皮均成活,创面愈合时间1~4周[(3.1 ± 0.5)周]。Ⅲ期术后骨断端愈合时间6~10个月[(8.2 ± 0.7)个月]。末次随访时,感染指标较骨缺损修复前显著降低(P < 0.01)。患肢LEFS和Mazur 踝关节功能评分[(52.2 ± 8.9)分、(75.2 ± 13.1)分]较骨缺损修复前[(36.0 ± 5.6)分、(53.7 ± 14.6)分]显著提高(P <0.01)。末次随访时软组织缺损区创面修复满意,骨缺损断端均愈合,其中3例发生骨延迟愈合,均无感染、骨髓炎、足下垂等并发症的发生。末次随访时下肢Johner-Wruhs 评分:优18例,良2例,中1例,差0例,优良率为95%。结论腓肠肌内侧头转移肌瓣联合膜诱导技术治疗合并骨缺损的胫骨中上段前内侧Gustilo-Anderson ⅢB损伤,可有效修复损伤肢体、减少感染并恢复下肢部分功能,临床效果满意。

Objective To analyze the therapeutic effect of medial gastrocnemius muscle flap transfer combined with induced membrane technique in repairing anterior medial Gustilo-Anderson type ⅢB injury of the middle and upper tibia accompanied by bone defect.Methods A retrospective case series study was conducted to analyze 21 patients with anterior medial Gustilo-Anderson type ⅢB injury of middle and upper tibia accompanied by bone defectanterior medial tibial fractures admitted to Xijing Hospital,Air Force Military Medical University from April 2017 to January 2019.There were 15 males and 6 females,with the age of(38.6±7.6)years(range,18-66 years).After admission,all patients had bone defect repair and fixation and soft tissue defect repair using membrane induction technique in the first stage.The area of soft tissue defect ranged from8.0 cm×6.0 cm to 16.0 cm ×12.0 cm.The length of tibial defect was(5.5±1.8)cm(ranged,3.5-11.0 cm).The size of metastasis of medial gastrocnemius flap ranged fyom 12.0 cm ×8.0 cm to 22.0 cm×13.0 cm.The survival rate of muscle flap was observed.One week after the wound was stabilized,skin grafting on the surface of muscle flap was performed at second stage.The graft survival was observed.The induced membrane technique was used to reconstruct bone defects at third stage.The infection index,lower extremity functional scale(LEFS)and Mazur ankle function score were compared before and at the last follow-up.The fracture healing and related complications were observed,and the lower limb function was evaluated by Johner-Wruhs scoring system at the last follow-up.Results All patients were followed up for 11-26 months[(18.4±5.1)months].The muscle flap transferred survived in all patients at first stage.The skin graft survived at second stage,and the wound healing time was 1-4 weeks[(3.1±0.5)weeks].After the surgery at third stage,the healing time of bone fracture was(8.2+0.7)months(range,6-10 months).A significantly lowered level of infection was observed at the last follow-up compared to that before operation(P<0.01).The LEFS and Mazur ankle function scores of the affected limb were(52.2±8.9)points and(75.2±13.1)points at the last follow-up,significantly higher than those before operation[(36.0±5.6)points,(53.7±14.6)points](P<0.01).The soft tissue defect was repaired satisfactorily,and the broken ends of bone defects were healed at the last follow-up.Delayed bone union occurred in 3 patients,but no infection,osteomyelitis,foot drop or other complications occurred.According to Johner-Wruhs score,18 patients were rated as excellent,2 patients as good,1 patient as fair and 0 patient as poor,with the excellent and good rate of 95%.Conclusion For patients with anterior medial Gustilo-Anderson type ⅢB injury of the middle and upper tibia accompanied by bone defect,transfer of medial gastrocnemius head muscle flap combined with induced membrane technique can effectively repair the injured limb,reduce infection and restore partial function of the lower limb,indicating that the procedure is an effective treatment strategy with satisfactory clinical results.