Ali Mazen, Reda Fekhaoui Mohammed, Abbassi Hatem, Issaoui Hichem, Gargouri Mahdi, Razanabola Fredson
Department of Orthopedic Surgery and Trauma, Regional Hospital of Orleans, Orleans, France.
Department of Trauma and Orthopaedic Surgery, Ibn Sina University Hospital, Faculty of Medicine, Mohammed V University of Rabat, Rabat, Morocco.
Wounds. 2020 Dec;32(12):E110-E113.
Severe lower extremity trauma cases are challenging for most orthopedic surgeons if a degloving injury with open fracture is associated, especially in the elderly population. The management of the soft tissue is essential for bone union and reduction of infection.
The authors present the case of an 87-year-old female admitted to their department after a road accident in which she sustained an open fracture of the distal tibia classified as Gustilo-Anderson Type II, a closed fracture of the lateral malleoli, and a degloving of the posterior and lateral aspect of the left leg. After antibiotic delivery, she underwent surgical debridement and wound irrigation, 5 hours after the accident. The avulsed skin flap was conserved, the fracture of the lateral malleoli was fixed using the minimally invasive plate osteosynthesis technique, and an external fixation was applied for the distal tibia fracture. After 1 week, the necrotic skin flap and muscle were excised, and negative pressure wound therapy with instillation and dwell time (NPWTi-d) was applied for 9 days. Once granulation tissue with healthy wound edges was obtained, a split-thickness skin graft was used to provide total coverage. After 8 weeks, external fixation was replaced by a plaster cast. Eight weeks later, all wounds and fractures were healed, and the patient was able to return to their daily activities.
The authors' main goal was achieved: preserving the architecture of the leg, achieving bone union, and avoiding infection. A large part of this good result comes back to NPWTi-d, a promising treatment that grants clinical benefit for the patient and surgeon. Additional research and larger prospective studies are required before giving a strict recommendation.
对于大多数骨科医生来说，严重的下肢创伤病例具有挑战性，尤其是伴有开放性骨折的脱套伤，在老年人群中更是如此。软组织的处理对于骨愈合和减少感染至关重要。
作者介绍了一名87岁女性的病例，她在道路交通事故后被收治入院，事故中她遭受了胫骨远端开放性骨折（Gustilo-Anderson II型）、外踝闭合性骨折以及左腿后外侧脱套伤。事故发生5小时后，在给予抗生素治疗后，她接受了手术清创和伤口冲洗。撕脱的皮瓣得以保留，外踝骨折采用微创钢板接骨术固定，胫骨远端骨折应用了外固定架。1周后，切除坏死的皮瓣和肌肉，并应用带灌洗和驻留时间的负压伤口治疗（NPWTi-d）9天。一旦获得具有健康伤口边缘的肉芽组织，就使用中厚皮片移植以实现完全覆盖。8周后，外固定架被石膏固定取代。8周后，所有伤口和骨折均愈合，患者能够恢复日常活动。
作者的主要目标得以实现：保留腿部结构、实现骨愈合并避免感染。这一良好结果很大程度上归功于NPWTi-d，这是一种有前景的治疗方法，为患者和外科医生带来了临床益处。在给出严格推荐之前，还需要进行更多研究和更大规模的前瞻性研究。
