Hwang Kyu Tae, Kim Sang Wha, Sung Il Hoon, Kim Jeong Tae, Kim Youn Hwan
Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Korea.
Department of Plastic and Reconstructive Surgery, Seoul National University, College of Medicine, Seoul National University Hospital, Seoul, Korea.
Microsurgery. 2016 Sep;36(6):453-9. doi: 10.1002/micr.22428. Epub 2015 May 15.
Early reconstruction of severe open fractures, performed within 7 days of the injury, has a better outcome than closure after 7 days. However, the uncertain demarcation of damaged tissue often results in delayed reconstruction. In this article, we report our surgical outcomes of delayed reconstruction using latissimus dorsi free flap with internal fixation. Twenty-three patients with Gustilo type IIIB open tibial fractures Between March 2009 and May 2012 were included in this study. There were 16 cases of distal 1/3 fracture of the tibia, 4 of midshaft fracture, 1 of proximal 1/3 fracture, and 2 of segmental fracture. Serial debridement with application of negative pressure wound therapy (NPWT) was performed before the final operation. All patients underwent internal fixation of the bone and reconstruction of soft tissue defect using latissimus dorsi free flap. The number of serial debridements, excluding those performed during emergency and finial operation, ranged from 1 to 5 (mean 2.69) times. Mean time from injury to final operation was 10.65 (range, 7-22) days. All flaps survived without complications. Three cases (13%) were infected, and three cases required further bone graft surgery to facilitate bone union (13%). Bone union was achieved after a mean 6.3 (range, 3-12) months. Mean follow-up period was 16.34 (range, 12-26) months. During follow-up, all patients were able to ambulate without use of an aid. In cases of severe open fracture, treatment should emphasize soft tissue coverage rather than rushing to achieve definitive fixation in the setting of poor surrounding tissues. When delayed reconstruction is inevitable, radical debridement is performed first, then NPWT is used as bridging therapy, and free flap could be considered for definite soft tissues coverage. © 2015 Wiley Periodicals, Inc. Microsurgery 36:453-459, 2016.
在损伤后7天内对严重开放性骨折进行早期重建，其效果优于7天后进行的创口闭合。然而，受损组织界限难以确定常导致重建延迟。在本文中，我们报告了使用背阔肌游离皮瓣联合内固定进行延迟重建的手术结果。本研究纳入了2009年3月至2012年5月期间23例Gustilo IIIB型开放性胫骨骨折患者。其中胫骨远端1/3骨折16例，中段骨折4例，近端1/3骨折1例，节段性骨折2例。在最终手术前进行了多次清创并应用负压伤口治疗（NPWT）。所有患者均接受了骨内固定及使用背阔肌游离皮瓣修复软组织缺损。除急诊手术和最终手术期间进行的清创外，连续清创次数为1至5次（平均2.69次）。从受伤到最终手术的平均时间为10.65天（范围7 - 22天）。所有皮瓣均存活且无并发症。3例（13%）发生感染，3例需要进一步进行骨移植手术以促进骨愈合（13%）。平均6.3个月（范围3 - 12个月）后实现骨愈合。平均随访期为16.34个月（范围12 - 26个月）。随访期间，所有患者无需辅助即可行走。对于严重开放性骨折，治疗应强调软组织覆盖，而非在周围组织条件较差时急于进行确定性固定。当不可避免地需要延迟重建时，应首先进行彻底清创，然后使用NPWT作为过渡治疗，可考虑采用游离皮瓣进行确定性软组织覆盖。© 2015威利期刊公司。显微外科学36:453 - 459，2016。
