CAJ | 학술논문

目的探讨Gustilo Ⅲ型胫腓骨开放性骨折急诊清创后伤口闭合的时机与方法选择.方法回顾性分析2011年2月至2014年1月收治的36例GustioⅢ型胫腓骨开放性骨折患者资料,男30例,女6例;年龄为6 ～ 82岁,平均37.5岁.2例GustiloⅢA型骨折患者予外固定支架固定,皮肤原位植皮,一期闭合伤口;34例GustiloⅢB、ⅢC型骨折患者一期应用外固定支架固定骨折、负压封闭引流覆盖创面,二期(清创后5 ～15d)采用不同组织瓣覆盖创面:吻合血管股前外侧肌皮瓣10例,腓肠肌内侧头肌皮瓣6例,腓肠肌外侧头肌皮瓣3例,远端蒂腓肠神经营养血管皮瓣3例,远端蒂腓血管穿支皮瓣7例,远端蒂胫后血管穿支皮瓣5例.结果 34例二期闭合伤口患者组织瓣均成活,伤口一期愈合.36例患者术后获6 ～ 20个月(平均10个月)随访.33例患者骨折愈合时间为6～12个月,平均8.5个月;另3例患者发生骨折不愈合,分别于术后6、7、8个月予以植骨后骨折获愈合.无伤口迟发感染等并发症发生.末次随访时美国特种外科医院膝关节功能评分平均为88.5分(86 ～ 91分),Baird-Jackson踝关节功能评分平均为92.5分(90～ 96分).结论对于GustiloⅢ型胫腓骨开放性骨折,其伤口的闭合应遵循损伤控制理论,分期应用不同类型组织瓣闭合伤口.对于软组织或肌肉床良好、可急诊原位植皮者,可一期闭合伤口;对于小腿严重软组织缺损患者,应先予负压封闭引流敷料覆盖创面,择期应用邻近皮瓣、肌皮瓣或游离皮瓣修复,二期闭合伤口.
목적 탐토Gustilo Ⅲ형경비골개방성골절급진청창후상구폐합적시궤여방법선택.방법 회고성분석2011년2월지2014년1월수치적36례GustioⅢ형경비골개방성골절환자자료,남30례,녀6례;년령위6 ～ 82세,평균37.5세.2례GustiloⅢA형골절환자여외고정지가고정,피부원위식피,일기폐합상구;34례GustiloⅢB、ⅢC형골절환자일기응용외고정지가고정골절、부압봉폐인류복개창면,이기(청창후5 ～15d)채용불동조직판복개창면:문합혈관고전외측기피판10례,비장기내측두기피판6례,비장기외측두기피판3례,원단체비장신경영양혈관피판3례,원단체비혈관천지피판7례,원단체경후혈관천지피판5례.결과 34례이기폐합상구환자조직판균성활,상구일기유합.36례환자술후획6 ～ 20개월(평균10개월)수방.33례환자골절유합시간위6～12개월,평균8.5개월;령3례환자발생골절불유합,분별우술후6、7、8개월여이식골후골절획유합.무상구지발감염등병발증발생.말차수방시미국특충외과의원슬관절공능평분평균위88.5분(86 ～ 91분),Baird-Jackson과관절공능평분평균위92.5분(90～ 96분).결론 대우GustiloⅢ형경비골개방성골절,기상구적폐합응준순손상공제이론,분기응용불동류형조직판폐합상구.대우연조직혹기육상량호、가급진원위식피자,가일기폐합상구;대우소퇴엄중연조직결손환자,응선여부압봉폐인류부료복개창면,택기응용린근피판、기피판혹유리피판수복,이기폐합상구.
Objective To explore timing and methods for open tibiofibular fractures of Gustilo type Ⅲ.Methods From February 2011 to January 2014,36 cases of Gustilo Ⅲ open tibiofibular fracture were treated in our department.They were 30 males and 6 females,6 to 82 years of age (average,37.5 years).Two cases of Gustilo type Ⅲ A were treated with external fixation,skin grafting in situ,and primary wound closure.The other 34 cases of Gustilo Ⅲ B and Ⅲ C were treated with external fixation and vacuum sealing drainage (VSD) for the wounds at the primary stage,and wound coverage with different tissue flaps at the secondary stage (5 to 15 days after debridement).Anterolateral thigh musculocutaneous flap with vascular anastomosis was used in 10 cases,the medial head of the gastrocnemius musculocutaneous flap in 6,the lateral head of the gastrocnemius musculocutaneous flap in 3,distal sural neurovascular fasciocutaneous flap in 3,distal sural vascular perforator flap in 7,and distal posterior tibial vascular perforator flap in 5.Results The tissue flaps survived and wounds healed at one intention in all the 34 cases with secondary wound closure.All the 36 cases obtained follow-up from 6 to 20 months (average,10 months).Thirty-three fractures were cured from 6 to 12 months (average,8.5 months) after operation.Nonunion occurred in 3 cases which were healed by bone grafting at respectively 6,7 and 8 months after operation.No delayed wound infection was observed.At the last follow-up,the average score of Hospital for Special Surgery was 88.5 (from 86 to 91) and the average score of Baird-Jackson evaluation system was 92.5 (from 90 to 96).Conclusions In line with the trauma control concept,the wound closure for open tibiofibular fracture of Gustilo Ⅲ should be performed with different types of tissue flap at 2 stages.Primary closure can be done for those whose soft tissue conditions are good enough for skin graft in situ at emergency.For those with massive soft tissue defect,VSD should be used to cover the wound at first stage before secondary wound coverage with adjacent or free skin flaps.