Li Tao, Yang Ze Z, Peng Ming Z, Zhou Xiao J, Liu Zhi Y, Rui Bi Y, Li Qi, Guo Shang C, Xiao Ming, Wang Jin W
Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital Affiliate to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Shanghai Sixth People's Hospital Affiliate to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Injury. 2017 Nov;48(11):2426-2432. doi: 10.1016/j.injury.2017.09.024. Epub 2017 Sep 25.
The treatment of open femur fractures with reimplantation of large extruded segments remains one of the most difficult clinical management scenarios. The situation is even complicated when the extruded segments contains a large osteoarticular segment and no consensus exist about the efficient sterilization. We successfully managed five cases of open femur fracture by reimplantation of a large osteoarticular segment. While the outcomes were favourable, we performed an in vitro investigation in a rat model to determine whether the bone segment preparation strategy was optimal.
After meticulous debridement and sterilization with povidone-iodine scrub/orthopaedic antibiotic solution, osteoarticular segments of the femur were reimplanted successfully in five patients with Gustilo-Anderson IIIa-IIIb fractures. Furthermore, in vitro study performed to assess the relative efficacy of various methods of sterilization employed osteoarticular segments of rat femurs. After contamination, osteoarticular segments were treated via one of the following protocols: (1) saline rinse; (2) povidone-iodine scrub and saline rinse; (3) povidone-iodine scrub and autoclaving; (4) povidone-iodine scrub and immersion in antibiotic solution; (5) povidone-iodine scrub and immersion in povidone-iodine solution; or (6) povidone-iodine scrub and gamma-irradiation. The osteoarticular segments were then cultured and finally evaluated for infection and morphological changes.
At the mean 40 month follow-up, there were no infection in the patients and the fractures achieved completed union. For the basic research, only approaches involving povidone-iodine scrub with autoclaving or antibiotic solution immersion were 100% effective in eliminating bacterial growth. Furthermore, povidone-iodine scrub with antibiotic solution immersion preserved the articular surface morphology.
Our study suggests that reimplantation of extruded osteoarticular segments of long bone may represent a feasible alternative to amputation. This is the first description of such a technique and its long-term outcomes in the clinical setting, which were corroborated with the outcomes of in vitro investigation in a rat model, concluding that contaminated extruded osteoarticular segments can be adequately sterilized for reimplantation by cleaning with povidone-iodine scrub followed by brief soaking in antibiotic solution. However, it remains unclear whether the antibacterial efficacy of different sterilizations noted in vitro is reflected in vivo, warranting further research.
对大段挤压出的骨段进行再植入治疗开放性股骨骨折，仍然是临床治疗中最棘手的情况之一。当挤压出的骨段包含大的骨关节段且对于有效的灭菌方法尚无共识时，情况就更加复杂。我们成功地通过再植入大的骨关节段治疗了5例开放性股骨骨折。虽然结果良好，但我们在大鼠模型中进行了一项体外研究，以确定骨段制备策略是否最佳。
在使用聚维酮碘擦洗/骨科抗生素溶液进行细致的清创和灭菌后，股骨的骨关节段成功再植入5例Gustilo-Anderson IIIa-IIIb型骨折患者体内。此外，进行体外研究以评估使用大鼠股骨骨关节段的各种灭菌方法的相对效果。污染后，骨关节段通过以下方案之一进行处理：（1）生理盐水冲洗；（2）聚维酮碘擦洗和生理盐水冲洗；（3）聚维酮碘擦洗和高压灭菌；（4）聚维酮碘擦洗并浸泡在抗生素溶液中；（5）聚维酮碘擦洗并浸泡在聚维酮碘溶液中；或（6）聚维酮碘擦洗和伽马射线照射。然后对骨关节段进行培养，最后评估感染情况和形态变化。
在平均40个月的随访中，患者均未发生感染，骨折实现完全愈合。对于基础研究，只有涉及聚维酮碘擦洗并高压灭菌或浸泡在抗生素溶液中的方法在消除细菌生长方面100%有效。此外，聚维酮碘擦洗并浸泡在抗生素溶液中可保留关节表面形态。
我们的研究表明，长骨挤压出的骨关节段再植入可能是截肢的一种可行替代方法。这是对这种技术及其在临床环境中的长期结果的首次描述，这与大鼠模型中的体外研究结果相佐证，得出结论：通过聚维酮碘擦洗清洁，然后在抗生素溶液中短暂浸泡，受污染的挤压出的骨关节段可以充分灭菌以进行再植入。然而，体外观察到的不同灭菌方法的抗菌效果在体内是否得到体现仍不清楚，需要进一步研究。
