Bishop A T, Wood M B, Sheetz K K
Department of Orthopedics, Mayo Clinic, Rochester, Minnesota 55905, USA.
J Bone Joint Surg Am. 1995 Dec;77(12):1867-75. doi: 10.2106/00004623-199512000-00011.
Reconstruction after massive loss of bone about the ankle is difficult because of the limited amount of surrounding soft tissue and because of technical factors pertaining to adequate internal or external fixation. Conventional techniques are often unsuccessful because of the frequency of associated deep infection and of previous operative procedures. In this report, we describe eleven patients with a large defect of the distal aspect of the tibia who were managed at our institution with arthrodesis of the ankle with free vascularized bone graft. The defect was related to a tumor resection; an acute open fracture with bone and soft-tissue loss caused by a shotgun injury; or osteomyelitis, either alone or in combination with septic arthritis, with chronic non-union following a fracture of the ankle. A free fibular graft was used in osseous defects that were larger than four centimeters, and a free iliac-crest graft was used in smaller defects. Osteocutaneous or osteomuscular flaps were constructed to cover accompanying soft-tissue defects when necessary. A successful fusion was obtained in nine of the eleven patients. The results in the remaining two were regarded as clinical failures, and a below-the-knee amputation was performed. One amputation was done because of recurrent infection and the other, because of failure of the fracture to unite after four years.
踝关节周围骨质大量缺损后的重建手术颇具难度，这是由于周围软组织量有限，以及与合适的内固定或外固定相关的技术因素所致。传统技术常常难以成功，原因在于深部感染的频发以及既往手术操作。在本报告中，我们描述了11例胫骨远端存在大的骨缺损的患者，他们在我们机构接受了带血管游离骨移植的踝关节融合术治疗。该缺损与肿瘤切除、猎枪伤导致的伴有骨和软组织缺损的急性开放性骨折，或单独的骨髓炎，或骨髓炎合并化脓性关节炎以及踝关节骨折后慢性不愈合有关。对于大于4厘米的骨缺损使用游离腓骨移植，较小的缺损则使用游离髂嵴移植。必要时构建骨皮瓣或骨肌瓣以覆盖伴随的软组织缺损。11例患者中有9例成功实现融合。其余2例的结果被视为临床失败，并进行了膝下截肢。其中1例截肢是因为反复感染，另1例是因为骨折四年后仍未愈合。
