Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia
Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia
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DOI：
10.1302/0301-620x.82b7.10482
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发表时间：
2000-09-01
影响因子：
--
通讯作者：
Smith, RM
中科院分区：
文献类型：
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作者：
Gopal, S;Majumder, S;Smith, RM
我们对1990年至1998年期间发生严重（Gustilo IIIb或IIIc）胫骨开放性骨折的84例连续患者的病例记录进行了回顾性分析。所有患者均接受了根治性治疗，包括早期用肌肉瓣覆盖软组织，由矫形外科和整形外科联合服务。我们理想的治疗方法是彻底清创损伤区以外的伤口，骨骼稳定和早期的软组织覆盖带血管的肌肉瓣。所有患者均随访至骨折愈合或1年，排除4例死亡和3例失访后，我们回顾了80例84处骨折。有67名男性和13名女性，平均年龄为37岁（3 - 89岁），5例损伤为IIIc级，79例为IIIb级; 12例为部位41，43例为部位42，29例为部位43，均立即进行清创和骨折稳定。在33例病例中，软组织重建也在一个阶段完成，而在另外30例中，它是在72小时内实现的。其余21人的延误超过72小时，往往是由于与肢体受伤无关的关键原因。所有IIIc级损伤均立即进行血管重建，并立即用两个皮瓣覆盖。所有患者均得到了挽救，有4例截肢，1例早期截肢，1例中期截肢，2例晚期截肢，最终保肢率为95%。总的来说，使用了9个带蒂肌瓣和75个游离肌瓣;皮瓣失败率为3.5%，使用19个外固定器械和65个内固定器械（钉或钢板）实现了骨折稳定。3例患者有明显的节段性缺损，需要骨转移手术来实现骨愈合。在其余患者中，51例骨折（66%）进展为一期骨愈合，而26例（34%）需要骨刺激手术来实现这一结果。总体而言，外固定支架组的植皮浅表感染率为6%，骨折部位深部感染率为9.5%，严重针道感染率为37%。最后复查时，所有患者骨折愈合后均能自由行走，无感染迹象。采用积极的矫形外科和整形外科联合方法治疗这些非常严重的损伤，效果良好;立即内固定和用肌瓣覆盖健康的软组织是安全的。事实上，延迟覆盖（>72小时）与大多数问题有关。对于整形外科医生来说，外固定会带来实际困难，一些慢性钉道感染和我们仅有的畸形愈合病例。我们倾向于使用内固定。我们建议在可能的情况下将患者转诊至专科中心。如果局部因素阻止了这一点，我们建议在与相关中心讨论后，最初的清创和桥接外固定，然后转移，是最安全的程序。
We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998, All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year.After exclusion of four patients tone unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89), Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43, Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged, There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%, Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3,5%, Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome, Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9,5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection.The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.