External fixation associated with limited internal fixation and vacuum sealing drainage repair Gustilo II and III fracture: time effectiveness and staging

doi:10.3969/j.issn.2095-4344.2015.04.011

Abstract

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 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.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: Fracture, Open, Joints, Internal Fixators, External Fixators

CLC Number:

R318

Cheng Yong-tao, Wang Wei, Zhao Yan, Zhang Hai-yang, Zhang Shu-cai. External fixation associated with limited internal fixation and vacuum sealing drainage repair Gustilo II and III fracture: time effectiveness and staging[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(4): 554-561.

Figures/Tables 2

2.1 参与者数量分析按意向性分析，纳入13例开放性关节骨折患者，采用外固定支架结合有限内固定联合负压封闭引流技术时效性分阶段治疗，全部进入结果分析，无脱落。 2.2 治疗结果 13例患者中1例皮肤软组织损伤一期愈合，12例患者经分阶段一期清创负压封闭引流覆盖创面后，二期给予植皮和组织瓣转移术、局部推进皮瓣修复术后创面及软组织缺损修复愈合。创面愈合时间12-18 d，平均 14 d；平均住院时间14 d。13例均获随访，随访时间6-18个月。术中透视和术后7 d X射线片检查示骨折对位对线良好。本组13例患者骨折愈合情况，均达到骨折一期愈合标准，愈合时间为4-12个月；肘关节部骨折3例，2例于术后4个月X射线片检查证实达到骨性愈合标准，1例因部分骨质缺损于术后6个月X射线片检查可见部分骨性连接，于 12个月复查证实达到骨性愈合标准；腕部2例患者于术后 4个月X射线片检查提示骨折达到临床愈合标准，1例尺骨远端部分骨质缺损于术后8个月X射线片检查证实骨折达到临床愈合标准；2例膝部骨折分别于术后4，7个月达到骨折愈合标准；踝部骨折5例患者中1例腓骨远端骨质缺如者于术后6个月X射线片检查证实骨折达到临床愈合标准，余4例患者均于术后4个月达到骨折愈合标准。外固定架使用时间平均为7.5个月。 2.3 关节功能评分结果关节功能分别应用肘关节Mayo评分系统、腕关节Gartland and Werley评分系统、膝关节HSS评分系统、踝关节AOFAS评分系统进行功能的评定。 3例肘关节骨折患者优1例，良1例，差1例，因致伤因素导致肘关节骨质严重缺损，具体评价见表2。 3例腕关节骨折患者优1例，良2例，其中1例因尺骨远端因创伤致骨质缺如伴三角纤维复合体损伤导致旋前功能丢失，1例因骨间膜损伤导致旋后功能丢失，具体评价见表3。 2例膝关节骨折患者优1例，良1例；具体评价见表4。 5例踝关节骨折患者平均AOFAS评分83分，优1例，良2例，可1例，1例因踝关节骨折伴发距骨完全脱位合并韧带严重损伤，后期出现距骨体坏死，导致评分为差，具体评价见表5。 2.4 典型病例典型病例1：男，18岁，入院后可见左侧肘后不规则形皮肤裂伤伴撕脱，骨折端外露，肘关节脱位，术前X射线示肘关节粉碎性骨折，骨折分型：肱骨远端C3.3骨折，尺桡骨近端C3.2型骨折，合并尺神经损伤、软组织缺损，开放性骨折分型：GustiloⅢ型，入院后急诊行清创，血管神经探查，一期骨折复位克氏针有限内固定结合铰链式外固定架固定，软组织行负压封闭引流技术封闭后二期行中厚皮片植皮愈合(图1)。典型病例2：男，46岁，电锯切割伴绞伤致右侧前臂及腕部、出现伴活动障碍。入院后可见前臂背侧及腕部皮肤软组织撕脱伴挫伤，腕关节脱位，桡骨远端外露。术前X射线示右侧腕关节开放性骨折，骨折分型：盖氏Ⅱ型，合并桡动脉、桡神经损伤，软组织缺损，开放性骨折分型：GustiloⅢ型，完善术前准备，急诊行清创、血管神经肌腱探查修复吻合术，骨折行一期复位后组合式外固定架固定，软组织行边缘牵张负压封闭引流技术封闭，二期行局部推进皮瓣修复缺损后愈合(图2)。典型病例3：男，40岁，车祸致左侧膝部疼痛、出血伴活动障碍。入院后行X射线示开放性膝关节骨折，股骨远端髁间骨折，骨折分型：C1.3型，开放性骨折分型：GustiloⅢ型，急诊行清创，骨折复位组合式外固定架固定，软组织行一期修复闭合后局部负压封闭引流装置覆盖后一期愈合(图3)。典型病例4：男，17岁，机械绞伤致右侧踝关节疼痛、出血伴活动障碍入院。入院后行X射线示右侧距骨脱位，腓骨远端骨折，骨折分型：43-C1.1合并距骨SneppenⅣ型，合并局部软组织缺损，开放性骨折分型：GustiloⅢ型，入院后急诊行清创、血管神经探查修复、骨折复位克氏针有限内固定结合组合式外固定架固定，软组织行清创后负压封闭引流装置封闭，二期植皮后愈合(图4)。 2.5 不良反应 13例患者中1例一期清创后发生感染，经二期清创负压封闭引流装置覆盖创面感染控制后植皮愈合；2例出现创口感染，经加强换药后控制；4例发生钉道局部感染，经换药后乙醇敷料包裹针道后结痴、感染控制。随访4个月时5例患者、随访10个月8例患者外固定远端部分Schanz钉出现松动，因骨折均达到初期愈合和临床愈合标准不影响固定和骨折愈合，未做特殊处理。"

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