小腿严重创伤并发坏死感染的保肢策略  

Limb salvage strategies for severe lower leg trauma complicated with necrotic infection

作　　者：刘昆 刘琳琳 马丙涛 李唐波 乔林 张树明 徐建强 LIU Kum;LIU Lin-lin;MA Bing-ao;LI Tang bo;QIAO Lin;ZHANG Shu-ming;XU Jian-qiang(Department of Orthopedis,PLA Rocket Force Characteristic Medical Center,Beijing,100088,China)

机构地区：[1]中国人民解放军火箭军特色医学中心骨科,北京100088

出　　处：《中国骨与关节杂志》2025年第3期207-213,共7页Chinese Journal of Bone and Joint

摘　　要：目的总结小腿严重创伤发生坏死感染濒临截肢病例的保肢策略及治疗效果。方法回顾分析2009年7月至2020年12月我院收治的32例发生坏死感染濒临截肢的小腿Gustilo Ⅲb、Ⅲc型严重损伤患者,采取分期手术的策略进行保肢治疗,一期通过感染病灶清除术、负压敷料技术以及敏感抗生素治疗控制感染,二期利用显微外科技术通过游离皮瓣、带蒂皮瓣及植皮术封闭创面,三期通过外固定架骨搬移骨延长技术修复骨缺损,四期根据需要采取跟腱延长、肌腱转位、神经修复、踝关节融合等方法进行功能重建。观察指标:保肢成功率,保肢肢体功能恢复情况,感染控制时间,皮瓣成活情况,骨折愈合时间,平均治疗周期,主要并发症。结果32例中28例保肢成活,2例由于肢体缺血时间长、远端肢体渐进坏死而截肢,1例由于感染不能控制危及生命而截肢,1例因急性肺栓塞死亡,保肢成功率为87.5%。保肢成功的28例患者中,8例日常行走中无明显跛行步态,快步行走时可看出跛行;16例行走中有轻微跛行步态,不需拐杖辅助;4例跛行较为明显,需扶手杖行走。按照Johner-Wruhs胫骨干骨折治疗效果的评定标准,优8例,良16例,可4例,差0例,优良率85.7%。目前尚无保肢成活后再截肢者。平均Iowa膝关节功能评分为90.8分;平均Iowa踝关节功能评分为81.4分。感染控制平均需要15.5天,需2.4次病灶清除手术。皮瓣成活情况:28例皮瓣均成活,其中一次手术完全成活18例,另有10例因边缘坏死,经换药或清创植皮手术后二期愈合。自受伤开始到骨折愈合外固定架拆除平均20.2个月,从受伤开始到功能恢复稳定平均31.2个月。主要并发症:28例中外固定钉道均发生过不同程度的钉道感染,经换药及抗生素治疗后好转。28例中22例进行了骨搬移治疗,22例骨搬移断端对合后均有软组织嵌顿,进行了断端清理及植骨术。28例中11例有不同�Objective To summarize the limb salvage strategies and treatment effects for severe lower leg trauma patients.The patients that were on the verge of amputation were combined with necrotic infection.Methods A retrospective study of 32 cases with severe Gustilo Ⅲb and Ⅲc injuries in lower legs was conducted.All were on the brink of amputation due to necrotic infection,and were treated by staged surgical strategy.In the first stage,infection was controlled through infection lesion clearance surgery,vacuum sealing drainage(VSD),and sensitive antibiotic treatment.In the second stage,microsurgical techniques were used to seal the wound through free skin flaps,pedicled skin flaps,and skin grafts.In the third stage,bone defects were repaired through external fixation and distraction osteogenesis.In the fourth stage,functional reconstruction was performed as needed,including Achilles tendon extension,tendon transposition,nerve repair,and ankle joint fusion.Observation indicators:success rate of limb salvage,function of limb,infection control time,flap survival,fracture healing time,treatment cycle,and major complications.Results Among the 32 cases,28 survived limb salvage,2 were amputated because of progressive necrosis of the distal limbs due to prolonged ischemia,1 was amputated due to uncontrollable life-threatening infection,and 1 died due to acute pulmonary embolism.The success rate of limb salvage was 87.5%.Among the28 patients(successful limb salvage),8 had no obvious limping gait during daily walking,but could be seen limping during brisk walking;16 cases showed slight limping gait during walking,without the need for crutches;four cases showed significant limping and required walking with crutches.According to the Johner-Wruhs evaluation criteria for the treatment effect of tibial shaft fracture,there were 8 cases of excellent,16 cases of good,4 cases of fair,and0 case of poor,with an excellent and good rate of 85.7%.There were no amputees who had survived limb salvage.The average Iowa knee joint function scor

关 键 词：创伤和损伤 小腿 感染 保肢 

分 类 号：R681.2[医药卫生—骨科学]