2020年8月,太原长城骨伤手外科医院创伤骨科收治1例右臂环形软组织节段性缺损无骨折不完全性"断臂"患者,采用短缩肱骨外固定支架固定,血管、神经和肌肉一期直接修复,前臂筋膜室预防性减张术。术后1周减张口直接缝合,成功保肢。术后18个月随访,肱骨骨折愈合外固定支架拆除,右肘关节、前臂旋转、腕关节功能正常,手功能大部分恢复,可完成日常生活及部分精细操作。

Objective:To evaluate the treatment of infected nonunion after internal fixation of subtrochanteric fracture with a reconstruction stent of external fixation.Methods:A retrospective study was conducted to analyze the data of 5 male patients with infected nonunion after internal fixation of subtrochanteric fracture who had been treated and completely followed up at The Great Wall Orthopaedics and Hand Surgery Hospital from January 2017 to October 2022. The patients were (30.0±13.5) years old. Seinsheimer fracture types: ⅢA (1 case), ⅢB (1 case), Ⅳ (2 cases), and Ⅴ (1 case); original internal fixation: intramedullary system (4 cases) and plate fixation (1 case); the Cierny-Mader anatomical classification: type Ⅳ (diffuse type) for all. After complete debridement at stage one, 2 or 3 hydroxyapatite (HA) coated screws were placed at both fracture ends from the lateral side of the femur for unilateral reconstruction external fixation. Next, a hybrid external fixation scaffold was added with a 1/3 ring at the sagittal position and 1 or 2 HA screws in 4 cases while unilateral reconstruction external fixation was constructed at both sides by inserting 2 HA screws into both fracture ends from the anterior femur at the sagittal position in 1 case. Antibiotic bone cement was used to fill bone defects of (3.8±1.8) cm. At 6 to 8 weeks after debridement when infection did not recur, antibiotic bone cement was removed before autogenous iliac bone grafting was performed in 3 patients and osteotomy bone transport in 2 patients. Infection control, bone union time, time for removal of external fixation stent, complications, Sanders hip function score and Paley bone outcome score were recorded.Results:The 5 patients were followed up for (23.4±8.1) months after surgery. Infection at the fracture ends was controlled after 1 time of debridement in 3 patients and after 2 times of debridement in 2 patients. The loosening HA screws were replaced twice due to infection at the proximal nail tract, and autologous bone grafting was performed at the opposite fracture ends in 1 case; no complications occurred in the other 4 cases. Bony union was achieved at the extended segment and fracture ends in all patients. The time for imaging union after bone reconstruction was (10.2±3.4) months. The time for wearing a stent of external fixation was (18.0±4.5) months. There was no recurrent infection or lingering infection. According to the Sanders hip function score at the last follow-up, 4 cases were excellent and 1 case was good; according to the Paley bone outcome score, the curative effect was excellent in all.Conclusion:Application of a reconstruction stent of external fixation combined with antibiotic bone cement can control infection at the first stage and conduct bone reconstruction at the second stage to successfully treat the infected nonunion and preserve the hip function after internal fixation of subtrochanteric fracture.

2021年6月和8月,太原长城骨伤手外科医院分别收治拇指复合组织块完全离断的患者各1例,经清创、骨折固定及神经、血管、肌腱修复,拇指复合组织块再植成活,康复锻炼2个月。术后6个月随访,拇指功能、感觉、外观恢复良好,可完成日常生活及部分精细操作。

Objective:To summarise the advantages and disadvantages of applying the method of retrograde replantation with an operative position of foot stepping and knee bending for replantation of rotational avulsed and fractured great toes.Methods:From January 2016 to June 2021, 11 rotational avulsed and fractured great toes were replanted with the method of retrograde replantation in an operative position of foot stepping and knee bending. Of the 11 patients, 10 were males and 1 was female, aged 18 to 50 years old with an average of 32 years old. Causes of injury: 5 of driving belt, 4 of machinery crush and 2 of car accident. Injury sites: 4 on left great toes and 7 on right great toes. All of the injuries were with fracture and exposure of proximal tendons of flexor and extensor. Seven patients had the follow-up reviews by outpatient clinic visiting, 2 over mobile phone and 2 via WeChat.Results:After surgery, 9 great toes completely survived and 2 great toes had necrosis. The survival rate of toe replantation was 81.8%(9/11). The operation time was 2 to 3 hours, with an average of 2.5 hours. Postoperative X-ray film showed that 8 to 12 weeks after the operation, the fracture and joint fusion were healed at first stage in the survived toes. All patients were entered in follow-up for 3 to 18 months with 10.5 months in average. The survived great toes were plump and the toenail grown well. At the final follow-up, the static TPD at the toes was 8-12 mm, with an average of 10 mm. There was no effect shown on either walking or running.Conclusion:The retrograde replantation method with an operative position of foot stepping and knee bending for great toe replantation has the characteristics of a good field of view and convenient in operation under microscope, a short operation time, and a high survival rate of replantation.

Objective:To report our experience in successful limb salvage in 2 cases of femoral fracture of Gustilo type ⅢC after warm ischemia beyond 10 hours.Methods:From February 2016 to April 2017, 2 patients with femoral fracture of Gustilo type ⅢC were treated at The Great Wall Orthopaedic and Hand Surgery Hospital after warm ischemia beyond 10 hours.Both of them were male, 42 and 27 years of age.After debridement, bone shortening for 8.0 cm and 10.0 cm respectively was followed by replantation. The fractures were fixated end to end with a compression plate, the femoral artery was anastomosed directly and the muscles were sutured end to end.Secondary osteotomy was conducted 4 months after successful replanta-tion, followed by unilateral external fixation for reconstruction.Limb lengthening began one week after sec-ondary osteotomy.The efficacy was assessed by the Paley criteria.Results:Scattered irregular necrosis occurred in the leg muscles but was cured by dermatoplasty through a decompressive incision 40 days after debridement for 4 times.The affected limbs in the 2 cases were successfully saved and lengthened to the same length as the opposite one.The limbs were lengthened for 8.0 and 10.0 cm and for 3.0 and 3.5 months, respectively.The unilateral external fixator was worn for 29 and 24 months, respectively.The plantar sensation recovered to S4 one year after operation.Follow-up at 6 months after removal of external fixation showed excellent bony outcomes and good functional outcomes in both cases According to the Paley criteria.Conclusion:For femoral fracture of Gustilo type ⅢC after warm ischemia beyond 10 hours, thorough debridement, plate fixation, bone shortening and replantation at one stage, followed by secondary limb lengthening using unilateral external fixation, may be practical and effective procedures, as long as in-dications for limb salvage should be comprehensively followed.

目的 探讨应用短缩-延长技术在小腿严重创伤保肢中的疗效.方法 回顾性分析2007年7月至2017年2月期间太原长城骨伤手外科医院采用一期急性短缩,二期骨延长技术治疗的小腿严重创伤患者8例,均为高能量损伤男性患者,平均年龄37.2(20～51)岁.受伤部位:右小腿上段1例,中下段4例(右侧3例,左侧1例),小腿远端3例(右侧2例,左侧1例).受伤至就诊时间平均6.1(3～10)h,热缺血时间平均8.5(5～13)h.彻底清创后,骨缺损部软组织缺损、骨外露,软组织缺损面积在8 cm×4 cm～20 cm×12 cm之间.胫腓骨均同时短缩,短缩再植后患肢较健侧肢体平均短缩9.8(7～10)cm.选择4.0骨圆针固定胫腓骨(4例)、4.0骨圆针加钢丝固定胫腓骨(1例)、腓骨钢板固定加单边外固定架固定胫骨(1例)、单边外固定架加4.0骨圆针固定胫骨(2例).骨折固定后修复血管、肌腱和神经.再植术后平均2.6(1.5～8.0)个月行Orthofix重建外固定支架固定胫骨行截骨延长术,术后1周肢体开始延长.结果 本组8例患者清创后一期短缩肢体至远、近折端相接触;其中有7例术前伤口为横断创面,经彻底清创短缩肢体后,神经、肌腱、血管均无张力直接吻合,创面一期闭合;1例术前软组织损伤范围大,清创后软组织缺损面积约20 cm×12 cm,且伤口长度与肢体纵轴相一致,短缩后伤口无法一期闭合,给予创面封闭负压引流.术后1周行邮票植皮,再植术后2周闭合创面,无伤口感染等并发症发生.8例患者肢体延长术后均获平均2.8(1.5～9.0)年随访.1例患者延长过程中近端3枚钉道口出现短期红肿、浆液性分泌物,经换药、口服抗生素治疗后愈合,伤口无感染.肢体延长后均与健侧等长,延长段骨矿化好.平均延长时间2.7(2.3～3.5)个月,肢体离断处骨折均愈合;愈合时间平均11.6(10～15)个月.重建外固定支架佩戴时间平均16.6(12～30)个月.外固定架指数2.3个月/cm.8例骨断端和延长骨段均达到骨性愈合.足底感觉于再植术后平均3.5(2.0～9.5)年.恢复至S42例(小腿远端离断),S34例(小腿远端离断1例,中下段3例),S22例(小腿上段离断1例,中下段1例).再植术后平均3.5(2.0～9.5)年按肢体再植后功能评价陈氏标准3级.Paley骨与功能分级评定肢体功能恢复结果为优2例,良6例.结论 急性短缩再植,二期肢体延长技术在小腿严重创伤保肢治疗中是一种实用、有效的方法,可以提高肢体再植的成功率,缩短和降低再植的难度,不需游离血管、神经和皮瓣的修复,一期闭合伤口,提高了再植端骨折的愈合率,治疗更简便有效.