Nazerani Shahram, Kalantar Motamedi Mohammad Hosein, Ebadi Mohamad Reza, Ebrahimpoor Adel, Nazerani Tara, Bidarmaghz Bardia
Department of Surgery, Tehran University of Medical Sciences, Tehran, IR Iran.
Trauma Research Center, Baqiyatallah University of Medical Sciences, and Attending Faculty , Azad University of Medical Sciences, Tehran, IR Iran.
Trauma Mon. 2012 Jan;16(4):164-9. doi: 10.5812/kowsar.22517464.3553. Epub 2012 Jan 15.
Upper tibia defects ,type3b Gustilo, due to huge size and volume are very difficult to reconstruct; usually several operations are needed for bone and soft tissue defects and the definite one stage reconstruction is yet to be found.
In this article we reintroduce the rib- latissimus flap as an acceptable method to reconstruct tibia defects in selected cases.
The latissimus muscle with one or two ribs revascualrized by reverse flow from perforators is harvested; the ribs are bisected after harvest yielding four to six struts of vascularized bone to fill the huge upper tibia defect. Internal fixation is very important and we favor LCP plates for long bone fixation and the rib struts are fixed in place by small titanium screws to maintain the "picket fence" design. The muscle is then wrapped around the ribs and the defect is completely reconstructed.
During the past 9 years we have used the rib-latissimus dorsi (RLD) muscle flap, without serratus muscle, in 7 patients with combined bone and soft tissue defects of the upper tibia. All the flaps healed without any major complications and only one stress fracture was seen and treated. The ribs healed and in a median of 14 months hypertrophied to the size of the upper tibia. Nonunion was not observed and patients with lower extremity defects were able to bear full weight within an average of seven months.
The fractures of tibia type 3a and 3b Gustilo are devastating injuries requiring several operations. Several combinations of RLD-Serratus have already been reported but a rib-LD muscle with "picket fence" design has not been reported .The RLD transfer with two ribs divided into four struts for bone coverage and muscle to cover all the upper tibia soft tissue defect can be a useful tool in the armamentarium of the surgeon treating combined defects in a single stage.
3B型Gustilo胫骨上段缺损由于尺寸和体积巨大，重建非常困难；通常需要多次手术来修复骨和软组织缺损，目前尚未找到确定的一期重建方法。
在本文中，我们重新介绍肋骨-背阔肌皮瓣作为一种在特定病例中重建胫骨缺损的可接受方法。
切取由穿支逆行供血的带有一根或两根肋骨的背阔肌；肋骨切取后一分为二，得到四至六根带血管蒂的骨支柱，用于填充巨大的胫骨上段缺损。内固定非常重要，我们倾向于使用锁定加压钢板（LCP）固定长骨，并用小钛螺钉将肋骨支柱固定到位，以维持“栅栏”设计。然后将肌肉包裹在肋骨周围，完成缺损的完全重建。
在过去9年中，我们对7例胫骨上段合并骨与软组织缺损的患者使用了不带锯肌的肋骨-背阔肌（RLD）肌皮瓣。所有皮瓣均愈合，无任何严重并发症，仅出现1例应力性骨折并得到治疗。肋骨愈合，平均14个月后增厚至胫骨上段大小。未观察到骨不连，下肢缺损患者平均7个月内能够完全负重。
3A型和3B型Gustilo胫骨骨折是严重损伤，需要多次手术。已有多篇报道介绍了RLD-锯肌的几种组合方式，但尚未见采用“栅栏”设计的肋骨-LD肌皮瓣的报道。将两根肋骨分成四个支柱用于骨覆盖、肌肉用于覆盖胫骨上段所有软组织缺损的RLD转移术，可成为外科医生一期治疗合并缺损的有用手段。
