应用人工骨一期植骨治疗开放性掌骨缺损的疗效分析

目的 探讨应用Osteoset人工骨一期植骨治疗开放性掌骨缺损的临床效果.方法 符合入选标准的开放性掌骨缺损13例,急诊手术行彻底清创、AO微型钛板或克氏针内固定联合Osteoset人工骨一期植骨进行治疗,伴有皮肤软组织缺损的患者同时行皮瓣移植修复.结果 所有患者创面均一期愈合,皮瓣移植均完全存活,术后随访6～16个月,平均11.6个月.所有骨缺损术后均愈合,愈合时间2～3个月,平均2.4个月.按中华医学会手外科学会手部功能评定标准,优良率达92％.结论 应用Osteoset人工骨一期植骨加内固定治疗开放性掌骨缺损,能有效缩短病程,减少并发症,有利于术后功能尽早恢复,早期彻底清创和良好的创面覆盖是手术成功的关键.     

一期植骨闭合创面治疗感染性胫骨骨缺损

目的探讨一期清创、植骨、皮瓣、肌皮瓣转移或移植治疗感染性胫骨骨缺损的可行性。方法自2000年12月至2005年1月，对8例感染性胫骨骨缺损骨折患者彻底清创，应用皮瓣、肌皮瓣转移或移植覆盖创面，对胫骨骨缺损同时行松质骨植骨及灌注冲洗。结果8例患者转移或移植的皮瓣、肌皮瓣均成活，伤口均一期愈合，植骨在术后7～9个月获得骨性愈合，经术后7个月至4年9个月随访，感染无复发，肢体行走功能及外观满意。结论对感染性胫骨骨缺损行彻底清创、松质骨植骨、皮瓣、肌皮瓣转移或移植、灌注冲洗是一种实用、有效的方法。     

感染性胫骨缺损的显微外科治疗

目的探讨通过一次性清创、植骨、皮瓣肌皮瓣转移或移植修复感染性胫骨缺损。方法自1995年2月～2003年4月,选择性地对5例感染性胫骨缺损病例彻底清创,应用皮瓣肌皮瓣转移或移植,Ⅰ期修复小腿软组织缺损伴感染创面的同时,对胫骨缺损同期行大块植骨。结果5例经转移或移植的皮瓣肌皮瓣均成活。其伤口均获Ⅰ期愈合,但1例于术后9个月时钢板处出现感染形成小窦道,经切除窦道,取出钢板后获得愈合。5例骨缺损经大块植骨者均在术后7～9个月(平均8个月)获得骨愈合。经术后随访1～5年,感染无复发,肢体负重功能及外形满意。结论经严格选择手术适应证,在对感染性软组织及骨创面行彻底清创、消灭死腔、充分引流的基础上,对Ⅰ期应用皮瓣肌皮瓣覆盖创面并同期植骨可持积极态度。     

开放性颗粒植骨治疗合并软组织缺损的感染性骨缺损

治疗合并软组织缺损的感染性骨缺损的传统方法包括扩创、固定、软组织覆盖创面和植骨。这些方法手术次数多，骨愈合时间长。近年来有学者采用火柴棒状的的髂骨条行一期植骨的方法，骨愈合时间较传统手段为短。自2000年7月～2003年2月，我科应用开放性颗粒植骨治疗14例合并软组织缺损感染性骨缺损的患者，骨愈合的时间较传统手段更短。现分析、讨论如下。     

一期锁定钢板外置固定联合二期皮瓣修复治疗合并软组织缺损的胫骨近端骨折

目的探讨一期锁定钢板外置固定联合二期皮瓣修复治疗合并皮肤软组织缺损的开放性胫骨近端骨折的安全性及有效性。方法回顾性分析自2014-01—2018-12诊治的23例合并皮肤软组织缺损的开放性胫骨近端骨折,所有患者一期急诊彻底清创、骨折复位、锁定钢板外置固定并负压封闭引流覆盖创面,待创面清洁后二期行皮瓣修复创面(游离股前外侧皮瓣13例,内侧腓肠肌肌皮瓣10例)。结果 23例术后均获得随访,随访时间平均14.6(12～18)个月。创面愈合时间为(15.0±2.5)d。22例骨折二期愈合,骨折愈合时间为(10.7±1.8)周。1例骨折不愈合,予以自体骨植骨并更换为钢板内固定。术后12个月采用Johner-Wruhs评分标准评定疗效:优12例,良8例,可3例;患肢膝关节活动度为(121.7±14.9)°,下肢功能LEFS评分为(67.1±6.4)分,膝关节功能HSS评分为(87.3±6.1)分。结论对于合并皮肤软组织缺损的开放性胫骨近端骨折,一期锁定钢板外置固定在降低骨折复位难度的同时有利于骨折愈合,二期联合游离或带蒂皮瓣修复缺损创面可以有效控制感染并给予骨折处营养支持与软组织保护。     

植骨术在感染性开放性骨不连中的应用

感染性骨不连临床多见，处理原则是彻底去除导致创口不愈合的各项因素，采用多种方法使创面愈合，二期处理骨不连要待创口愈合３～６个月后进行［１］。但治疗时间的延长造成患者经济与精神的很大痛苦，又影响肢体功能的康复。我科自１９９０年２月～１９９５年８月间共收治该类患者２１例，经彻底扩创、一期植骨外固定架固定，结合闭式灌注冲洗治疗，效果满意，现总结如下。临床资料骨不连中股骨干骨折２例，胫腓骨骨折１９例；原始均为开放性损伤，其中２例为枪伤，１９例为车祸伤；首次行钢板固定者１２例，行外固定架者３例，石膏外固定…     

一期植骨结合VSD治疗严重开放性Pilon骨折的疗效分析

目的 探讨一期植骨结合负压封闭引流术在治疗开放性复杂Pilon骨折中的临床疗效.方法 回顾性研究湖北医药学院附属东风总医院2010年1月-2012年1月收治的开放性复杂Pilon骨折56例,全部采用一期植骨结合负压封闭引流术,有限内固定结合外固定支架治疗,搜集术后皮瓣和软组织愈合情况、骨折愈合率、踝关节功能评分等临床资料.结果 骨折全部愈合,无创面软组织感染缺血等并发症发生.Helfer评分,优22例,良21例,可8例,差5例,优良率达到了76.8％.结论 一期植骨结合负压封闭引流术治疗严重开放性Pilon骨折可同时处理骨折复位固定、骨缺损及软组织覆盖等问题,具有操作简单、预防感染明显、骨折愈合率高和关节功能恢复良好等作用.     

肱骨骨不连的原因分析及治疗

目的探讨肱骨骨不连的原因和不同固定、植骨方法治疗肱骨骨不连的临床疗效。方法对51例肱骨骨不连进行回顾性分析。固定方式：钢板内固定30例，交锁髓内钉内固定12例，单臂或组合式外固定架8例，异体骨板加螺钉内固定1例。植骨来源：自体髂骨植骨16例，重组合异种骨植骨(RBX)12例，自体髂骨联合RBX植骨17例，异体骨植骨2例，异体骨联合RBX植骨2例。结果51例患者中，2例失访。49例随访8个月～9年，平均4年7个月。总愈合率89．8％，钢板治疗组愈合率83．3％，外固定架治疗组愈合率100％，交锁髓内针治疗组愈合率100％。12例单独应用RBX植骨治疗肱骨骨不连全部愈合；自体髂骨联合RBX植骨15例愈合，愈合率88．2％；自体髂骨植骨14例愈合，愈合率87．5％。结论髓内针内固定或外固定架固定治疗肱骨骨不连较钢板优越，创伤小，固定确实，功能恢复满意；RBX植骨治疗骨不连，安全、无免疫排斥反应、生物相容性好，对促进骨愈合疗效可靠。     

应用一期植骨治疗开放性掌指骨骨质缺损

目的 探讨应用一期植骨治疗急性开放性掌、指骨骨质缺损的临床效果.方法 2003年至2010年治疗合并骨质缺损开放性掌、指骨骨折15例24指,急诊手术予彻底清创、自体骨(髂骨或桡骨)移植,微型钢板或克氏针内固定,其中6例8指因皮肤缺损行皮瓣修复术,对合并血管损伤予同时修复.结果 13例伤口Ⅰ期愈合;2例2指伤口边缘表浅坏死,经换药后愈合.术后随访时间为3个月至2年,平均8个月,14例23指骨折顺利愈合,1例1指因骨不愈合于3个月后再次行植骨术.骨折愈合时间为1.5～4.5个月,平均2.6个月.手功能按手指关节总活动度(TAM)系统标准评定,优良率为79.2％.结论 一期植骨治疗急诊开放性掌、指骨骨质缺损能有效保持手指外形和功能,缩短病程;彻底清创和良好的软组织覆盖是手术成功的必要条件.     

手术治疗累及距下关节跟骨骨折11例体会

目的 分析跟骨关节内骨折手术复位及人工骨植骨的方法及疗效，提高临床治愈率。方法 随访2001年8月-2004年2月采用切开复位加Y形钢板内固定伴必要时人工骨植骨治疗的SandersⅡ～Ⅳ型跟骨骨折11例11足，其中Ⅱ型1足，Ⅲ型9足，Ⅳ型1足。术中直视下复位Bohler角及跟骨后关节面。骨缺损处以人工骨颗粒填塞，Y型钢板固定跟骨，伤口负压引流，围手术期抗生素应用。术后随访8-36个月，平均14个月。结果采用张铁良跟骨骨折评分方法，评价效果优7足，良2足，可2足，优良率为81．8％；早期伤口皮缘坏死4足，发生率占36．4％；远期并发症为行走疼痛。结论 Y型钢板加人工骨植骨治疗累及距下关节面的跟骨骨折疗效确切，但须注意切口皮瓣保护以及引流通畅彻底。     

Immediate autografting of bone in open fractures with bone loss of the hand: a preliminary report. Case reports.

Three patients with open fractures of the hand associated with bone loss were treated within four to six hours of injury by corticocancellous bone grafting and soft tissue coverage after meticulous debridement, copious irrigation of the wounds, and broad-spectrum antibiotics given intravenously. Long term follow-up was uneventful and showed that the graft had taken and healed well with early and full restoration of function and a good cosmetic result. Immediate corticocancellous bone grafting of an injured hand could be used in selected cases with well-debrided, surgically clean wounds as long as there is a rich blood supply. Adequate bone fixation, soft tissue coverage, and broad-spectrum antibiotics given intravenously will remove the risk of infection. Hand architecture is corrected while wound contracture and secondary deformity are avoided. Both patients' discomfort and hospital costs are considerably reduced.     

Early prophylactic autogenous bone grafting in type III open tibial fractures

The authors report the results achieved in patients with type III open tibial fractures who underwent primary autogenous bone grafting at the time of debridement and skeletal stabilisation. Twenty patients with a mean age of 35.8 years (range, 24-55) were treated between 1996 and 1999. Eight fractures were type IIIA, 11 were type IIIB, and 1 was type IIIC. At the index procedure, wound debridement, external fixation and autogenous bone grafting with bone coverage were achieved. The mean follow-up period was 46 months (range, 34-55). The mean time to fixator removal was 21 weeks (range, 14-35), and the mean time to union was 28 weeks (range, 19-45). Skin coverage was achieved by a myocutaneous flap in 2 patients, late primary closure in 4, and split skin grafting in 14. One (5%) of the patients experienced delayed union, and 1 (5%) developed infection. In tibial type III open fractures, skin coverage may be delayed, using the surrounding soft tissue to cover any exposed bone after thorough débridement and wound cleansing. Primary prophylactic bone grafting performed at the same time reduces the rate of delayed union, shortens the time to union, and does not increase the infection rate.     

Unilateral external fixation until healing with the dynamic axial fixator for severe open tibial fractures

One hundred one cases of open tibia fractures were treated until healing with a unilateral external fixation device that permits fracture site compression with weight bearing. There were 38 type II and 63 type III (24 IIIA, 33 IIIB, six IIIC) open fractures. A standard protocol was followed including irrigation and debridement and, when necessary, flap coverage (19 cases) and bone grafting (31 cases). Fixators were applied at the first debridement and removed when the fracture was healed. All patients were permitted early partial weight bearing and progressed to full weight bearing with fixator dynamization. Ninety-six cases healed in the fixator (12-50 weeks; average, 24.6). Three of the five failures were associated with screw complications. Five patients required screw changes and 29 required oral antibiotic therapy for screw complications. Ninety-five percent of healed cases had angulation of less than 10 degrees (in any plane). There were only six fracture site infections during the course of treatment. Dynamic axial fixation may be applied at the first debridement and be used until healing in severe open tibia fractures. Change of the fixator to another treatment method is not required.     

小腿严重开放性骨折伴软组织缺损的治疗

目的 探讨小腿严重开放性骨折伴软组织缺损(Gustilo ⅢB型或ⅢC型)的治疗方法.方法 1990年1月至2008年12月,收治开放性胫腓骨骨折53例,其中Gustilo ⅢB型45例,ⅢC型8例.软组织缺损面积为6 cm×4 cm～18 cm×8 cm,8例伴骨缺损.急诊行骨折复位同定和血管修复,二期对软组织或骨缺损采用13种53块组织瓣移位或移植修复.骨折外固定支架固定35例,内固定16例,骨牵引及石膏固定2例.皮瓣或肌皮瓣47例,骨皮瓣6例.结果 51例获得随访,时间8个月～9年(平均18个月).骨折顺利愈合44例,愈合时间3.5～9.5个月,平均6.5个月.骨延迟愈合4例,骨不愈合3例,经手术植骨(5例)或骨外固定支架加压同定治疗(2例)均治愈.组织瓣移植53块,成活51块,坏死2块,成活率为96.2%.无截肢病例.结论 Gustilo ⅢB型或ⅢC型小腿严重开放性骨折,初期清创并采用以骨外支架为主的方法固定骨折,二期采用适当组织瓣移植修复软组织或骨缺损,是安全有效的治疗策略.     

Early prophylactic bone grafting of high-energy tibial fractures

Fifty-three high-energy tibial fractures treated with early prophylactic posterolateral bone grafting were retrospectively reviewed. The bone-grafting procedures were performed at a mean of ten weeks following injury and at a mean of eight weeks following soft-tissue coverage. Ninety-six percent of the fractures had associated injuries with a mean injury severity score of 20.9. Seventy-nine percent of the fractures were classified as Grade III open fractures, and 40% had bone loss greater than 50% of the cortical circumference. Ninety-six percent of the fractures healed at a mean time of 43 weeks after injury. Segmental bone loss and soft-tissue injury requiring flap coverage were the best predictors of prolonged time to union. Comparison with a matched historical control group of tibial fractures not receiving early bone grafts revealed a mean reduction in time to union of 11.7 weeks (p = 0.03). The incidence of chronic osteomyelitis was 1.9%. These results are attributed to early and repeated aggressive debridement, immediate rigid external fixation, early soft-tissue coverage, and early posterolateral bone grafting. Recommendations include posterolateral cancellous bone grafting two weeks following wound closure by delayed primary closure, split-thickness skin graft, or local rotational myoplasty. A six-week delay following freely vascularized soft-tissue coverage prior to bone grafting is suggested.     

儿童足踝部开放性损伤的处理

 目的 探讨儿童足踝部开放性损伤的特点、治疗方法及临床疗效。方法 回顾性分析2004年2月至2010年6月收治的35例足踝部损伤的病历资料,男22例,女13例;年龄3~14岁,平均8.4岁。交通伤28例,利器切割及机器辗绞伤7例。左18例,右17例,均为单侧;前中足5例,后足及踝部30例。其中合并骨折30例。按照Gustilo分型,Ⅰ型5例、Ⅱ型8例、Ⅲ型22例。Ⅰ型、Ⅱ型及早期收治的10例Ⅲ型病例在急诊行清创缝合或(和)骨折复位内固定术+皮瓣移植术;后期收治的12例Ⅲ型病例一期行清创、闭式负压引流术+石膏外固定或克氏针临时固定,二期行骨折复位(伴或不伴植骨)内固定+皮瓣移植术。结果 30例患儿获得随访,随访时间6~89个月,平均38.7月。2例Ⅱ型患儿术后伤口皮肤局部坏死,行植皮术愈合;10例Ⅲ型患儿一期行急诊手术,手术次数2~6次,平均3.6次;创面愈合时间3~15周,平均8.3周。1例出现慢性骨髓炎,窦道残留,经多次病灶清除植骨后痊愈; 2例足踝及小腿外侧肌肉坏死行皮瓣移植,术后3年因瘢痕组织挛缩出现足踝部内翻畸形,行外固定架矫形后正常行走。12例行分期治疗的Ⅲ型患儿皮瓣均存活,色泽及弹性良好,愈合时间3~8周,平均6.8周。伴发足踝部骨折者骨折愈合良好。按Maryland标准评分[1],优17 足、良9足、中3例、差1例,优良率为86.7%。结论 儿童足踝部创伤以车祸伤为多见;按损伤程度分级分期治疗可取得较好临床疗效。     

Infected tibial nonunion: Good results after open cancellous bone grafting in 37 cases

We treated 37 infected tibial shaft nonunions by debridement followed by open autogenous cancellous bone grafting in a 2-stage procedure. Additional surgery was done in 21 fractures including second debridement before bone grafting and/or a second limited bone grafting and/or a split-thickness skin grafting. All fractures healed after an average of 11 (8-16) months. During 2 years follow-up there were no recurrences of the infection. Two cases of early refracture occurred, both healed following new bone grafting.     

Acute unreamed intramedullary nailing and soft tissue reconstruction with muscle flaps for the treatment of severe open tibial shaft fractures

BACKGROUND: The treatment of open tibial shaft fractures remains controversial. Important considerations in surgical management include surgical timing, fixation technique and soft tissue coverage. This study was performed to evaluate the results of acute surgical debridement, unreamed nailing and soft tissue reconstruction in the treatment of severe open tibial shaft fractures. PATIENTS AND METHODS: During a 10-year period between January 1993 and July 2002, 927 tibial shaft fractures were treated with interlocking intramedullary nails. Among them, there were 19 consecutive patients with Gustilo type IIIB to IIIC open tibial shaft fractures with extensive soft tissue injury needing a muscle flap coverage and being suitable for intramedullary nailing. All 19 patients were called for a late follow-up which was conducted with a physical examination and a radiographic and functional outcome assessment. The radiographs were reviewed to determine the fracture healing time and the final alignment. RESULTS: All 19 open fractures with severe soft tissue injury healed without any infection complications. The fractures united in a mean of 8 months. Nine patients had delayed fracture healing (union time over 24 weeks). One of these patients needed exchange nailing, one patient autogenous bone grafting and dynamisation on the nail and seven patients needed dynamisation of the nail before the final fracture healing. In all patients, the alignment was well maintained. However, seven patients had shortening of the tibia by 1-2 cm and two of them also external rotation of 10 degrees . The functional outcome was good in 18/19 patients. INTERPRETATION: Acute surgical debridement, unreamed interlocking intramedullary nailing and soft tissue reconstruction with a muscle flap appear to be a safe and effective method of treatment for Gustilo type IIIB open tibial shaft fractures.     

前臂及手部毁损性骨折治疗体会

【】目的:探讨前臂及手部毁损性骨折的早期修复及功能重建的手术方法及疗效。方法:对2010-2014年收治36例前臂及手部毁损性骨折进行急性修复及功能重建,根据毁损性骨折的分型₁,其中a2型12例,b2型10例,c2 型14例,所有创面采用脉冲冲洗器冲洗,骨折采用外固定支架、克氏针固定,一期修复神经、肌腱、血管,创面以VSD封闭。结果:术后随访10个月-24月,患肢功能都有不同程度的恢复,明显优于假肢,其中5例去除负压后创面直接缝合,伴骨骼、肌腱、神经外露者以皮瓣覆盖后治愈,浅表感染20例,经清创、换药、植皮后治愈,骨髓炎7例,经过去除死骨,换药及多次负压引流后治愈,骨折一期愈合18例,延迟愈合6例,骨缺损不愈合12例,经植骨内固定后愈合。结论：外固定支架、克氏针、脉冲冲洗器、VSD联合治疗开放性前臂及手部毁损性骨折,具有创伤小、清创彻底、减轻创伤后肿胀、降低感染率等优点,为功能恢复、骨折愈合及二期处理提供有利条件。     

Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft-tissue transfer

Forty-two consecutive patients with chronic osteomyelitis complicating persistent tibial nonunion and chronic osteomyelitis complicating tibial fracture with segmental bone loss were treated from January 1979 through December 1986 using a protocol including either open cancellous bone grafting (Friedlaender-Papineau technique), posterolateral bone grafting (Harmon technique), or local or microvascular soft-tissue transfer before cancellous bone grafting. Each patient had undergone surgical debridement and intravenous antibiotic therapy before inclusion in this study. Patients were classified using a staging system which included consideration of anatomic location of the infection within the bone; extent of bone involvement; quality of soft-tissue envelope and vascular integrity; and generalized host status. The overall success rate for arresting the osteomyelitis and healing the nonunion was 62% (26/42). If the six patients who refused additional bone graft surgery, the one patient who represented poor patient selection, and the patient who refused ankle arthrodesis are eliminated, the success rate for healing of the nonunion and resolving the osteomyelitis in this difficult patient population is: open bone cell graft, 66% (12/18); soft-tissue transfer 87.5%, (7/8); and posterolateral bone grafting, 87.5% (7/8). Use of a standardized classification system allows comparison of treatment results. Adequate debridement is crucial in treating osteomyelitis complicating established long bone fractures and nonunions. Determining the extent of debridement has proven to be the single most difficult aspect technically. Patient selection and pretreatment education are crucial. Caring for these patients is not only labor intensive and demanding of personnel and hospital resources, but demanding of the patients as well.