基于骨整形理念治疗Gustilo <b>Ⅲ</b>B型踝关节开放性骨折的临床效果

林芳; 康永强; 芮永军; 刘军; 王亚朋; 吴永伟; 马运宏; 王鹏; 单笑天

doi:10.3760/cma.j.cn501225-20260108-00016

基于骨整形理念治疗Gustilo ⅢB型踝关节开放性骨折的临床效果

doi: 10.3760/cma.j.cn501225-20260108-00016

无锡市第九人民医院创伤骨科,无锡　214000

基金项目:

无锡市“太湖人才计划”顶尖医学团队 WXTTP-2020-06

无锡市卫生健康委重大项目 Z202401

无锡市“双百”中青年卫生拔尖人才 HB2023126

详细信息

通讯作者:
芮永军,Email：ruiyongjun@suda.edu.cn

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出版历程
- 收稿日期: 2026-01-08

Clinical efficacy of applying orthoplastic principle in treating Gustilo type ⅢB open ankle joint fractures

Department of Trauma Orthopedics, Wuxi Ninth People's Hospital, Wuxi 214000, China

Funds:

Wuxi Top Medical Expert Team of "Taihu Talent Program" WXTTP-2020-06

Wuxi Municipal Health Commission Major Project Z202401

Wuxi "Double Hundred" Award for Outstanding Young and Middle‐aged Medical Talents HB2023126

More Information

Corresponding author: Rui Yongjun, Email: ruiyongjun@suda.edu.cn

摘要

摘要: 目的探讨基于骨整形理念治疗Gustilo ⅢB型踝关节开放性骨折的临床效果。方法该研究为回顾性病例系列研究。2018年1月—2024年8月,无锡市第九人民医院收治33例符合入选标准的Gustilo ⅢB型踝关节开放性骨折患者,其中男25例、女8例,年龄25~65（44±12）岁,皮肤软组织缺损面积为6 cm×3 cm~27 cm×14 cm,骨缺损长度为3.0~9.2 cm（平均3.7 cm）。对所有患者均基于骨整形理念进行治疗。Ⅰ期第1阶段：急诊彻底清创后,于胫骨缺损区置入抗生素骨水泥,采用外固定支架或被覆抗生素骨水泥的钢板进行临时固定,并修复神经、肌腱,残留创面以负压封闭引流敷料覆盖；Ⅰ期第2阶段：伤后第3~7天再次清创并更换抗生素骨水泥,根据骨折情况调整或保留内固定,设计并切取股前外侧皮瓣（面积为7 cm×3 cm~30 cm×15 cm）修复创面。根据缺损大小及局部张力,对供区创面采用阶梯式处理：张力小者直接拉拢缝合；张力大者,术中先适度拉拢创缘,待术后水肿消退后,再行直接缝合或取对侧大腿刃厚皮片修复。Ⅱ期第3阶段（唯一阶段）：伤后7~30周（平均15.8周）取出抗生素骨水泥,计算骨缺损体积并精确切取髂骨后与万古霉素混合填塞骨缺损,缝合诱导膜及皮肤软组织。记录术后皮瓣成活情况及不同阶段感染相关并发症发生情况。随访时记录皮瓣外观、质地,皮瓣供受区瘢痕情况,骨愈合情况。末次随访时,采用足踝功能评估量表评估患足功能并计算其日常生活能力恢复百分比,通过36项健康调查简表（SF-36）评估患者健康结局,计算患者的生理健康总评和心理健康总评得分。结果术后皮瓣完全成活者30例；皮瓣部分坏死者3例,其中1例经清创后直接缝合,2例经清创植皮后愈合。发生感染相关并发症者4例,其中浅表感染者3例（Ⅰ期第2阶段后1例,Ⅱ期第3阶段后2例）,经清创后感染得到控制,创面愈合；骨感染者1例（Ⅰ期第2阶段后）,经再次彻底清创、抗生素骨水泥填塞后感染得到控制,植骨愈合。随访12~57个月（平均26.7个月）,所有皮瓣颜色、质地良好；皮瓣供区发生瘢痕增生者3例,皮瓣受区仅遗留线性瘢痕。末次随访时,患足足踝功能评估量表评分为（71±4）分,日常生活能力恢复至（85±5）%；SF-36中的生理健康总评得分为（78±4）分,心理健康总评得分为（70±11）分。结论基于骨整形理念治疗Gustilo ⅢB型踝关节开放性骨折,术后感染率及其他并发症发生率低,且踝关节功能恢复良好。
- 骨折,开放性 /
- 踝关节 /
- 胫骨 /
- 外科皮瓣 /
- 骨折固定术 /
- 骨整形理念 /
- 创面修复
Abstract: Objective To investigate the clinical efficacy of applying orthoplastic principle in treating Gustilo type ⅢB open ankle joint fractures. Methods This study was a retrospective case series study. From January 2018 to August 2024, 33 patients with Gustilo type ⅢB open ankle joint fractures who met the inclusion criteria were admitted to Wuxi Ninth People's Hospital, including 25 males and 8 females, aged 25-65 (44±12) years. The area of skin and soft tissue defects ranged from 6 cm×3 cm to 27 cm×14 cm. The length of bone defect ranged from 3.0 to 9.2 cm (with mean of 3.7 cm). All patients were treated based on the orthoplastic principle. Phase Ⅰ-Stage 1: after thorough debridement was performed in emergency department, antibiotic bone cement was inserted in the tibial defect, an external fixator or an antibiotic bone cement-coated steel plate was applied for temporary stabilization. Nerves and tendons were repaired, and the remaining wound was covered with vacuum sealing drainage dressing. Phase Ⅰ-Stage 2: on days 3 to 7 after injury, the wound was debrided again, and the antibiotic bone cement was replaced. The internal fixation was adjusted or retained according to the fracture status, and an anterolateral thigh flap (with size ranging from 7 cm×3 cm to 30 cm×15 cm) was designed and harvested to repair the wound. A stepwise strategy was employed for treating the donor site wounds based on the defect size and local tension. For wounds with low tension, primary closure was performed. For wounds with high tension, the wound edges were appropriately pulled together during operation, and either direct closure or split-thickness skin grafting from the opposite thigh was carried out after the postoperative edema subsided. Phase Ⅱ-Stage 3 (the only stage): 7 to 30 weeks after injury (with mean of 15.8 weeks), the antibiotic bone cement was removed, the volume of bone defect was measured, and the iliac crest bone was harvested precisely, mixed with vancomycin, and used to fill the bone defect; the induced membrane and skin soft tissue were then sutured. Postoperative flap survival and infection-related complications at different stages were recorded. During follow-up, flap appearance and texture, scar condition at the donor and recipient sites, and bone healing were documented. At the last follow-up, the affected foot function was assessed using the foot and ankle ability measure (FAAM) scale, and the percentage of recovery in daily living ability was calculated. Patient health outcomes were assessed using the 36-item short form health survey (SF-36), and the scores of the physical component summary (PCS) and mental component summary (MCS) were calculated. Results Complete flap survival was achieved in 30 patients after operation. Partial flap necrosis occurred in 3 patients, among whom 1 case healed by direct suture after debridement, and 2 cases healed by skin grafting after debridement. Infection-related complications occurred in 4 patients, including superficial infection in 3 cases (1 case after Stage 2 in Phase Ⅰ, 2 cases after Stage 3 in Phase Ⅱ), all of which were controlled after debridement with wound healing. Bone infection occurred in 1 case (after Stage 2 in Phase Ⅰ), which was controlled after repeated thorough debridement and antibiotic bone cement packing, and bone grafting healed. The follow-up period ranged from 12 to 57 months (with mean of 26.7 months). All flaps showed good color and texture. Scar hyperplasia at the flap donor site occurred in 3 cases, while only linear scars remained at the recipient site. At final follow-up, the FAAM scale score of the affected foot was 71±4, and the recovery of daily living ability reached (85±5)%. The PCS score on the SF-36 was 78±4, and the MCS score was 70±11. Conclusions Applying the orthoplastic principle for treating Gustilo type ⅢB open ankle joint fractures results in low infection and other complication rates, along with satisfactory functional recovery of the ankle joint.
- Fractures, open /
- Ankle joint /
- Tibia /
- Surgical flaps /
- Fracture fixation /
- Orthoplastic principle /
- Wound repair
林芳：病例管理、收集与分析数据、起草论文、修改并完善论文；康永强、芮永军：研究设计与实施、完成手术操作,协助修改文章、提供研究经费支持、对文章的知识性内容进行批判性审阅；刘军、王亚朋、吴永伟、马运宏：研究实施、手术操作、数据采集；王鹏、单笑天：病例随访、数据整理与分析

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图 1 Gustilo ⅢB型踝关节开放性骨折“两期三阶段”救治流程图

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图 2 基于骨整形理念治疗1例患者重物砸伤致Gustilo ⅢB型左踝关节开放性骨折伴骨与软组织复合缺损的效果。2A、2B.分别为受伤时X线片示左踝关节骨折及左腓骨中段骨折的正位、侧位观；2C.急诊消毒后,可见皮肤软组织缺损、粉碎性骨折；2D.急诊术中去除游离骨块；2E.急诊钢板内固定术后X线片示胫腓骨骨折力线及复位良好,骨缺损区用骨水泥填塞；2F.急诊手术完成骨水泥钢板固定时外观；2G.伤后3 d再次清创,游离移植右侧股前外侧皮瓣修复创面；2H、2I.分别为伤后20周,取出骨水泥、植骨并附加钢板；2J.伤后20周,植骨后X线片；2K.伤后22个月随访时,患者能站立；2L.伤后22个月随访时,X线片示骨愈合良好并取出部分内固定

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