Naique S B, Pearse M, Nanchahal J
Department of Musculoskeletal Surgery, Imperial College School of Medicine, Charing Cross Hospital Campus, London W6 8RF, UK.
J Bone Joint Surg Br. 2006 Mar;88(3):351-7. doi: 10.1302/0301-620X.88B3.17120.
Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.
尽管普遍认为ⅢB型开放性胫骨骨折需要骨科和整形外科联合进行专业治疗，但英国的大多数患者最初是在当地医院就诊，这些医院没有专门的创伤治疗设施。本研究的目的是比较直接就诊于专科中心的患者（原发组）与最初在当地中心接受治疗的患者（三级组）的治疗结果。我们回顾了73例连续的ⅢB型开放性胫骨干骨折患者，平均随访14个月（8至48个月）。原发组有26例骨折，三级组有47例骨折。三级组中有22例（47%）患者的初始骨骼固定需要进行翻修。尽管皮瓣手术时机与皮瓣失败之间没有统计学上的显著关系，但所有失败病例（63例中的6例；9.5%）均发生在三级组。骨折愈合的总体平均时间为28周，不受骨骼固定类型的影响。8.5%的患者发生深部感染，但没有骨折持续感染的情况。受伤后超过6小时进行清创的患者感染率并未增加。保肢率为93%。患侧肢体功能评分平均为正常肢体的74%。复查时，67%的患者已恢复工作，另有10%的患者考虑康复后重返工作岗位。原发组和三级组在骨折愈合时间、感染率和Enneking肢体重建评分方面没有统计学差异。三级组出现的并发症增加和翻修手术提示，严重开放性胫骨骨折应直接转诊至专科中心，由骨科和整形外科医生同时进行联合治疗。
