PDF《时效性与分阶段概念》

中国组织工程研究 第19 卷第4期2015C01C22 出版 Chinese Journal of Tissue Engineering Research January 22,

2015 Vol.

19, No.4 P.O. Box 10002, Shenyang

110180 www.CRTER.org

554 www.CRTER.org 程永涛,男,1982 年生, 陕西省铜川市人,汉族, 新疆医科大学在读硕士, 主要从事创伤骨科临床与 基础研究. 通讯作者:赵岩,博士, 主任医师,硕士生导师, 新疆医科大学第一附属医 院显微修复外科,新疆维 吾尔自治区乌鲁木齐市

830054 doi:10.3969/j.issn.2095-4344. 2015.04.011 [http://www.crter.org] 中图分类号:R318 文献标识码:B 文章编号:2095-4344 (2015)04-00554-08 稿件接受:2014-11-24 Cheng Yong-tao, Studying for master'

s degree, Department of Microsurgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, Xinjiang Uygur Autonomous Region, China Corresponding author: Zhao Yan, M.D., Chief physician, Master'

s supervisor, Department of Microsurgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, Xinjiang Uygur Autonomous Region, China Accepted: 2014-11-24 外固定支架与有限内固定及负压封闭引流修复GustiloⅡ、Ⅲ型关节骨折: 时效性与分阶段概念 程永涛1 ,王维2 ,赵岩1 ,张海洋1 ,张述才1 (1 新疆医科大学第一附属医院显微修复外科,新疆维吾尔自治区乌鲁木齐市 830054;

2 西安交通大学第二附属医院急诊科,陕西省西安市 710014) 文章亮点:

1 开放性关节骨折的诊治,目前临床上诊治方法和观点各不相同,尤其是 GustiloⅡ、Ⅲ型开放性关节骨折的 修复,对于清创的时限,软组织的保护与修复,骨折的内、外固定治疗,目前都未有共识.

2 文章在秉承开放性骨折修复原则的基础上,提出了时效性概念,同时通过临床观察和验证指出对于软组织 的损伤采取分阶段治疗,一期清创负压封闭引流技术封闭延期闭合,二期修复;

关节部骨折应用克氏针有限 内固定联合铰链式、组合式外固定架固定治疗具有微创、安全性高的优点,采用时效性分阶段手术方案明显 减少并发症、降低截肢率,预后满意,值得临床借鉴和推广. 关键词: 植入物;

骨植入物;

开放性;

关节骨折;

负压封闭引流;

内固定;

外固定;

时效性;

分阶段 主题词: 骨折,开放性;

关节;

内固定器;

外固定器 摘要 背景: 开放性关节骨折由于其损伤和部位的特殊性, 尤其 Gustilo 分型较高, 损伤严重的患者, 手术治疗复杂, 同时关节部的骨折手术复位要求高,感染、术后并发症高发以及潜在的截肢率高,一次手术修复骨折及周围 组织结构显得尤为困难. 目的:探讨应用外固定支架结合有限内固定联合负压封闭引流时效性分阶段修复 GustiloⅡ、Ⅲ型开放性关节 骨折的有效性. 方法:2012年1月至2013年12月采用外固定架结合有限内固定联合负压封闭引流时效性分阶段修复Gustilo Ⅱ、Ⅲ型骨折患者

13 例,男11 例,女2例,GustiloⅡ型3例,GustiloⅢ型10 例.所有患者均按照时效性 原则,第一时间或有效时间内行急诊清创术,骨折采用外固定架结合有限内固定治疗,应用负压封闭引流方 法封闭创面,分阶段修复软组织损伤和骨折. 结果与结论:13 例患者术后随访 6-18 个月,12 例在二期术后经植皮或组织瓣转移修复愈合.创面愈合时间 12-18 d,平均

14 d;

1 例一期清创后发生感染,经二期清创负压封闭引流覆盖创面感染控制后植皮愈合.

4 例发生钉道局部感染, 换药后针道结痴、 感染控制.

5 例患者于术后

4 个月随访期间外固定远端部分 Schanz 钉松动.13 例患者均达到骨折临床愈合标准,愈合时间为 4-12 个月.提示 GustiloⅡ、Ⅲ型开放性关节骨折 患者采用时效性分阶段治疗,有利于正确评估关节骨折和软组织损伤情况,分阶段应用外固定架固定骨折以 及负压封闭引流技术保护软组织,二期修复创面,明显控制感染和并发症,降低截肢率,缩短治疗周期,是 一种有效的修复方案. 程永涛,王维,赵岩,张海洋,张述才. 外固定支架与有限内固定及负压封闭引流修复 GustiloⅡ、Ⅲ型关节 骨折:时效性与分阶段概念[J].中国组织工程研究,2015,19(4):554-561. External fixation associated with limited internal fixation and vacuum sealing drainage repair Gustilo II and III fracture: time effectiveness and staging Cheng Yong-tao1 , Wang Wei2 , Zhao Yan1 , Zhang Hai-yang1 , Zhang Shu-cai1 (1 Department of Microsurgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, Xinjiang Uygur Autonomous Region, China;

2 Emergency Department, the Second Affiliated Hospital of Xi'

an Jiaotong University, Xi'

an 710014, Shaanxi Province, China) Abstract BACKGROUND: Due to specificity of injury and site, surgical treatment for open fractures is complex and difficult, especially for those patients with high Gustilo grading and severe damage. At the same time, joint fracture requires high reduction technique and may induce high infection rate or complications, even high amputation rate. The fracture and surrounding tissue cannot be restored through one surgery. OBJECTIVE: To explore the clinical effects of external fixation associated with limited internal fixation and vacuum-sealing drainage on Gustilo II and III open fractures. METHODS: From January

2012 to December 2013,

13 cases of Gustilo II and III fractures were treated by external fixation combined with limited internal fixation and vacuum-sealing drainage. There were

11 male and 程永涛,等. 外固定支架与有限内固定及负压封闭引流修复 GustiloⅡ、Ⅲ型关节骨折:时效性与分阶段概念 ISSN 2095-4344 CN 21-1581/R CODEN: ZLKHAH

555 www.CRTER.org

2 female. Three cases were Gustilo II fracture and

10 cases were Gustilo III fractures. According to the principle of timeliness, patients received the first or effective emergency debridement. All the fractures were fixed by external fixator combined with limited internal fixation. The wounds were sealed with vacuum-sealing drainage. Phased restoration of soft tissue injury and fracture treatment were performed. RESULTS AND CONCLUSION: The involved

13 patients were followed up for 6-18 months, and

12 cases were healed by split-thickness skin graft or flap transposition at the second phase. The wound healing time was 12-18 days, with an average of

14 days. Wound infection occurred in

1 case and was finally repaired by split-thickness skin graft following debridement and vacuum-sealing drainage. Pin tract infection occurred in

4 cases and was controlled by dressing. Schanz screw loose occurred in

5 cases at

4 months postoperatively. All the

13 cases had obtained bone union and the healing time was 4-12 months. Gustilo II and III open fractures can be treated by timeliness and staging method, which is conductive to properly assess articular fractures and soft tissue injury. External fixator combined with limited internal fixation and vacuum-sealing drainage by phased application can not only protect soft tissue and accelerate tissue repair, but also reduce infection and complications, lower the amputation rate, and shorten treatment time. So it is an effective treatment for Gustilo II and III fractures. Subject headings: Fracture, Open;

Joints;

Internal Fixators;

External Fixators Cheng YT, Wang W, Zhao Y, Zhang HY, Zhang SC. External fixation associated with limited internal fixation and vacuum sealing drainage repair Gustilo II and III fracture: time effectiveness and staging. Zhongguo Zuzhi Gongcheng Yanjiu. 2015;

19(4):554-561.

0 引言 Introduction 开放性关节骨折由于关节结构和形态复杂,神经血管 经行及周围软组织菲薄,损伤多为高能量致伤,治疗方法 上存在很大争议,尚无统一标准可循,尤其是GustiloⅡ、 Ⅲ型损伤已然成为创伤骨科医师面临的治疗难题.其致伤 因素、暴力大小及作用方式、关节损伤及污染程度各异, 伤情迥异,临床治疗方法也有所不同,其临床预后不仅与 损伤程度相关,更与治疗策略和方法密切相关,正确、恰 当的治疗可以有效减少并发症的发生,提高损伤愈合率, 缩短治疗时间,降低致残率,如处置不当,后期致残率及 截肢率极高. 时效性指的是首次清创尽量争取在清创的最佳时间 或第一时间段内,有效的控制手术时间,减少感染暴露 概率,减低组织损伤.对于开放性关节部骨折,充分清 创,有效引流是一切治疗的前提和关键,不得存在侥幸 心理,必须从严要求.对于清创时限问题,所谓的黄金 期

6 h原则 并不是绝对的,大部分开放性关节损伤入 院已超过此时限. 开放性关节骨折由于其损伤和部位的特殊性,尤其 Gustilo分型较高,损伤严重的患者,手术治疗复杂,同时 关节部的骨折手术复位要求高,感染、术后并发症高发以 及潜在的截肢率高,一次手术修复骨折及周围组织结构显 得尤为困难,因此需要开展分期修复手术. 新疆医科大学第一附属医院骨科中心自2012年1月至 2013年12月共收治复杂开放性关节骨折GustiloⅡ、 Ⅲ型患 者13例,其中肘关节3例,腕关节3例,膝关节2例,踝关 节5例, 所有患者均按照时效性原则, 第一时间或有效时间 内行急诊清创术, 骨折采用外固定架结合有限内固定治疗, 应用负压封闭引流方法封闭创面,分阶段修复软组织损伤 和骨折.全部获得随访,对其临床资料进行回顾性分析, 评价疗效及并发症,以期为复杂开放性关节骨折修复方案 的制定提供参考.

1 对象和方法 Subjects and methods 设计:回顾性病例分析. 时间及地点:于2012年1月至2013年12月在新疆医科 大学第一附属医院骨科中心完成. 对象: 诊断标准:①符合开放性骨........