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

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
- 网络出版日期: 2026-04-30

Clinical efficacy of orthoplastic management for Gustilo type ⅢB open ankle 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。所有患者均基于骨整形理念进行治疗。Ⅰ期第一阶段：急诊彻底清创后,于胫骨缺损处置入抗生素骨水泥,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期第二阶段：伤后第3~7天再次清创并更换骨水泥,根据骨折情况更换或保留终末内固定,设计并切取股前外侧皮瓣修复创面。Ⅱ期第三阶段：伤后7~30周（平均15.8周）取出骨水泥,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,缝合诱导膜及软组织。记录术后皮瓣成活情况及不同阶段感染相关性并发症发生情况。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得分并计算其日常生活能力恢复情况,通过36项健康调查简表（SF-36）评估患者的生理健康总评和心理健康总评得分,以反应其健康结局。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例皮瓣部分坏死者经清创后直接缝合,2例经清创后植皮愈合。发生感染相关性并发症者4例,其中浅表感染者3例（Ⅰ期第二阶段后1例,Ⅱ期第三阶段后2例）,经清创后感染得到控制,创面愈合；骨感染者1例（Ⅰ期第二阶段后）,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。
- 开放性骨折 /
- 踝关节 /
- 胫骨 /
- 外科皮瓣 /
- 骨折固定术 /
- 骨整形 /
- 创面修复
Abstract: Objective To investigate the clinical efficacy of orthoplastic management for Gustilo type ⅢB open ankle fractures. Methods This study was a retrospective case series study. From January 2018 to August 2024, 33 patients with Gustilo type IIIB open ankle 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 (mean 3.7 cm). All patients were treated with a standardized orthoplastic management. Phase 1 (Stage 1): emergency radical debridement was performed, antibiotic-loaded bone cement was placed in the tibial defect, temporary stabilization was achieved with an external fixator or an antibiotic cement-coated plate, nerves and tendons were repaired, and the remaining wound was covered with vacuum-assisted closure. Phase 1 (Stage 2): within 3 to 7 days, repeat debridement and bone cement exchange were performed, definitive internal fixation was either applied or retained, and soft tissue reconstruction was completed with a free anterolateral thigh (ALT) flap. Phase 2 (Stage 3): at 7 to 30 weeks post-injury (mean 15.8 weeks), the bone cement spacer was removed, the defect volume was measured, and precise iliac crest bone graft mixed with vancomycin was implanted; the induced membrane and soft tissues 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 score of the affected foot was evaluated using the foot and ankle function assessment scale, and the recovery of activities of daily living was calculated. The Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were assessed using the 36-Item Short Form Health Survey (SF-36) to reflect patient health outcomes. Results Complete flap survival was achieved in 30 patients. 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 after stage I second phase, 2 after stage II third phase), all of which were controlled after debridement with wound healing. Bone infection occurred in 1 case (after stage I second phase), which was controlled after repeated thorough debridement and antibiotic-loaded bone cement packing, and bone grafting healed. The follow-up period ranged from 12 to 57 months (mean 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 score score of the affected foot was (71±4) points, and the recovery of activities of daily living reached (85±5)%. The PCS score on the SF-36 was (78±4) points, and the MCS score was (70±11) points. Conclusions The orthoplastic management for Gustilo type ⅢB open ankle fractures resulted in low infection and complication rates, along with satisfactory functional recovery of the ankle joint.
- Fractures, open /
- Ankle joint /
- Tibia /
- Surgical flaps /
- Fracture fixation /
- Orthoplastic management /
- 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,并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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参考文献(40)

[1]	WangZ, TangX, LiS, et al. Treatment and outcome prognosis of patients with high-energy transsyndesmotic ankle fracture dislocation-the "Logsplitter" injury[J]. J Orthop Surg Res, 2017,12(1):3. DOI: 10.1186/s13018-016-0502-y.
[2]	李海, 邓呈亮, 肖顺娥, 等. 旋股外侧动脉嵌合穿支皮瓣修复足踝部复合组织缺损的效果[J].中华烧伤与创面修复杂志,2025,41(4):370-377. DOI: 10.3760/cma.j.cn501225-20240202-00045.
[3]	XuY, FanX, HeX, et al. Reconstruction of massive tibial bone and soft tissue defects by trifocal bone transport combined with soft tissue distraction: experience from 31 cases[J]. BMC Musculoskelet Disord, 2021,22(1):34. DOI: 10.1186/s12891-020-03894-y.
[4]	MococainP, Bejarano-PinedaL, GlissonR, et al. Biomechanical effect on joint stability of including deltoid ligament repair in an ankle fracture soft tissue injury model with deltoid and syndesmotic disruption[J]. Foot Ankle Int, 2020, 41(9): 1158-1164. DOI: 10.1177/1071100720929007.
[5]	计鹏, 曹涛, 张智, 等. 股前外侧嵌合穿支皮瓣修复足踝部复杂创面的效果[J].中华烧伤与创面修复杂志,2023,39(10):926-932. DOI: 10.3760/cma.j.cn501225-20230627-00232.
[6]	芮永军, 吴永伟, 刘军, 等. 游离皮瓣修复Gustilo ⅢB、ⅢC型胫腓骨骨折伴软组织缺损的临床疗效[J].中华创伤杂志,2018,34(10):881-885. DOI: 10.3760/cma.j.issn.1001-8050.2018.10.005.
[7]	WordsworthM, LawtonG, NathwaniD, et al. Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of major trauma networks and national guidelines[J]. Bone Jt J, 2016, 98-B(3): 420-424. DOI: 10.1302/0301-620X.98B3.35818.
[8]	唐举玉, 卿黎明, 吴攀峰, 等. 改良腓动脉穿支螺旋桨皮瓣修复足踝部皮肤软组织缺损[J].中华显微外科杂志,2015,38(04):338-341. DOI: 10.3760/cma.j.issn.1001-2036.2015.04.008.
[9]	仲海燕, 陈勇, 杜轩宇, 等. 足踝部高压电烧伤创面修复的带蒂轴型皮瓣选择策略[J].中华烧伤与创面修复杂志,2023,39(10):939-946. DOI: 10.3760/cma.j.cn501225-20230613-00212.
[10]	MundiR, ChaudhryH, NiroopanG, et al. Open tibial fractures: updated guidelines for management[J]. JBJS Rev, 2015, 3(2): e1. DOI: 10.2106/JBJS.RVW.N.00051.
[11]	唐崧杰, 崔红旺, 王挺锐. 外固定支架联合负载抗生素硫酸钙对胫腓骨开放性骨折患者术后感染及骨愈合的影响[J]. 解放军医学杂志, 2023, 48(9): 1034-1039. DOI: 10.11855/j.issn.0577-7402.1404.2023.0213.
[12]	KrijghDD, TeunisT, ListEB, et al. Mental health is strongly associated with capability after lower extremity injury treated with free flap limb salvage or amputation[J]. Eur J Trauma Emerg Surg, 2024,50(3):755-762. DOI: 10.1007/s00068-024-02459-1.
[13]	刘文剑, 张红艳, 刘德伍. 不同类型的组织瓣修复胫骨近端骨折术后钢板外露伴感染创面的临床效果[J].中华烧伤与创面修复杂志,2023,39(12):1140-1148. DOI: 10.3760/cma.j.cn501225-20231101-00171.
[14]	杨亮, 周荣, 巨积辉, 等. 游离双侧股前外侧内增压型串联皮瓣修复足踝部大面积创面的临床疗效[J].中华烧伤与创面修复杂志,2025,41(1):61-69. DOI: 10.3760/cma.j.cn501225-20240508-00164.
[15]	胡大海, 张月. 毁损性创面修复重建技术及策略探索[J].中华烧伤与创面修复杂志,2024,40(9):812-817. DOI: 10.3760/cma.j.cn501225-20240807-00296.
[16]	胡大海, 李梦洋, 王鹏. 复杂创面修复前沿进展:从微环境调控到精准医疗实践[J].中华烧伤与创面修复杂志,2025,41(5):417-425. DOI: 10.3760/cma.j.cn501225-20250407-00171.
[17]	王绍钱, 王徽, 贾其余. 膜诱导技术联合游离超薄股前外侧穿支皮瓣修复足踝部创面的临床疗效分析[J]. 解放军医学杂志, 2025, 50(11): 1407-1413. DOI: 10.11855/j.issn.0577-7402.1121.2025.0716.
[18]	ChummunS, WrightTC, ChapmanTWL, et al. Outcome of the management of open ankle fractures in an ortho-plastic specialist centre[J]. Injury, 2015,46(6):1112-1115. DOI: 10.1016/j.injury.2014.12.017.
[19]	CortezA, UrvaM, HaongaB, et al. Outcomes of intramedullary nailing and external fixation of open tibial fractures: three to five-year follow-up of a randomized clinical trial[J]. J Bone Joint Surg Am, 2022,104(21):1877-1885. DOI: 10.2106/JBJS.22.00016.
[20]	陈桂全, 陈伟明, 梁嘉均, 等. 皮瓣移植联合VSD技术修复下肢骨折内固定术后钢板外露创面[J].中华显微外科杂志,2021,44(2):175-177. DOI: 10.3760/cma.j.cn441206-20201225-00421.
[21]	MyattA, SaleebH, RobertsonGAJ, et al. Management of Gustilo-Anderson IIIB open tibial fractures in adults-a systematic review[J]. Br Med Bull, 2021,139(1):48-58. DOI: 10.1093/bmb/ldab013.
[22]	WangY, ZhouM, WangP, et al. Orthoplastic management of Gustilo-Anderson type IIIB/C open tibial fractures: a consecutive 10-year series from China Level I trauma center[J]. Int J Surg, 2025,111(9):6135-6150. DOI: 10.1097/JS9.0000000000002809.
[23]	亚历山德鲁·瓦伦汀·杰奥尔杰斯库. 小腿和足部重建的骨整形方法[J].中华显微外科杂志,2022,45(3):241-249. DOI: 10.3760/cma.j.cn441206-20220313-00049.
[24]	赵广跃, 祝勇刚, 杨照. 严重下肢开放性骨折治疗存在的问题和骨整形新策略[J].中华创伤杂志,2020,36(12):1057-1060. DOI: 10.3760/cma.j.cn501098-20200118-00059.
[25]	CullenS, FlahertyD, FitzpatrickN, et al. Outcomes following surgical fixation of Gustilo-Anderson IIIb open tibial fractures[J]. Acta Orthop Belg, 2024,90(1):83-89. DOI: 10.52628/90.1.12387.
[26]	Al-HouraniK, StoddartM, KhanU, et al. Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments: the Bristol experience 2014 to 2018[J]. Bone Joint J, 2019,101-B(8):1002-1008. DOI: 10.1302/0301-620X.101B8.BJJ-2018-1526.R2.
[27]	OstermannPA, SeligsonD, HenrySL. Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases[J]. J Bone Joint Surg Br, 1995,77(1):93-97.
[28]	MartinI, SaraD, MarcoDN, et al. Availability and quality assessment of Clinical Practice Guidelines on orthoplastic surgery treatment of open fractures of the lower limb using AGREE II tool: a systematic review[J]. J Plast Reconstr Aesthet Surg, 2025,100:341-361. DOI: 10.1016/j.bjps.2024.11.061.
[29]	FranklinJL, JohnsonKD, HansenST. Immediate internal fixation of open ankle fractures: report of thirty-eight cases treated with a standard protocol[J]. J Orthop Trauma, 2020,34Suppl 1:S1-S8. DOI: 10.1097/BOT.0000000000001736.
[30]	GopalS, MajumderS, BatchelorAG, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia[J]. J Bone Joint Surg Br, 2000, 82(7):959-866. DOI: 10.1302/0301-620x.82b7.10482.
[31]	康永强, 吴永伟, 芮永军, 等. 表面覆盖抗生素骨水泥的钢板内固定技术一期治疗GustiloⅢB型胫腓骨开放性骨折疗效分析[J]. 中国修复重建外科杂志, 2024, 38(4): 426-431. DOI: 10.7507/1002-1892.202401099.
[32]	赵海磊, 孙志刚, 赵晓慧, 等. 股前外侧穿支皮瓣游离移植联合骨搬运序贯治疗小腿大面积皮肤软组织损伤伴大段胫骨缺损的临床效果[J].中华烧伤与创面修复杂志,2025,41(3):242-250. DOI: 10.3760/cma.j.cn501225-20240926-00350.
[33]	康永强, 芮永军, 吴永伟, 等. 3D打印量化植骨辅助Masquelet技术二阶段治疗Gustilo ⅢB、ⅢC型胫腓骨骨折长段骨缺损的疗效[J].中华创伤杂志,2023,39(3):252-258. DOI: 10.3760/cma.j.cn501098-20221226-00813.
[34]	ZelenskiNA, ArchualA, TangtiphaiboontanaJ, et al. The effect of free versus local flaps on time to union in open tibia fractures[J]. Plast Reconstr Surg, 2023,151(3):655-663. DOI: 10.1097/PRS.0000000000009934.
[35]	YangY, CaoZ, SunN, et al. Clinical effects of different types of flaps selected according to local conditions in the treatment of diabetic foot defects[J]. J Orthop Surg Res, 2024,19(1):634. DOI: 10.1186/s13018-024-05122-y.
[36]	张演基, 李海, 吴祥奎, 等. 游离股前外侧嵌合皮瓣的临床应用与遵义分型[J].中华烧伤与创面修复杂志,2025,41(5):447-453. DOI: 10.3760/cma.j.cn501225-20241108-00438.
[37]	芮永军, 徐永清, 朱庆棠, 等. 严重开放性胫腓骨骨折诊断及早期固定循证指南(2025版)[J].中华创伤杂志,2025,41(11):1021-1034. DOI: 10.3760/cma.j.cn501098-20250812-00440.
[38]	D'CunhaEM, Penn-BarwellJG, McMasterJ, et al. Orthoplastic treatment of open lower-limb fractures improves outcomes: a 12-year review[J]. Plast Reconstr Surg, 2023, 151(2): 308e-314e. DOI: 10.1097/PRS.0000000000009861.
[39]	D'AlleyrandJG, MansonTT, DancyL, et al. Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications?[J]. J Orthop Trauma, 2014,28(5):288-293. DOI: 10.1097/BOT.0000000000000001.
[40]	芮永军, 戚剑, 唐举玉, 等. 严重肢体创伤创面早期修复专家共识[J].中华显微外科杂志,2023,46(4):368-382. DOI: 10.3760/cma.j.cn441206-20230407-00062.

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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例患者重物压伤致Gustilo ⅢB型左踝关节开放性骨折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,示皮肤软组织缺损、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.伤后第3天再次清创,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,X线片示骨愈合良好并取出部分内固定

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