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EFFECTIVENESS OBSERVATION OF STAGED TREATMENT OF OPEN Pilon FRACTURE COMBINED WITH SOFT TISSUE DEFECT

Objective To explore the effectiveness of staged treatment of open Pilon fracture combined with soft tissue defect. Methods Between June 2007 and December 2012, 18 cases of open Pilon fracture combined with soft tissue defect were treated. There were 14 males and 4 females with an average age of 35 years (range, 19-55 years). The causes of injury included falling from height in 12 cases, traffic accident in 4 cases, and crushing by machine in 2 cases. According to AO classification, 1 case was classified as type B2 fracture, 3 cases as type B3 fracture, 5 cases as type C1 fracture, 5 cases as type C2 fracture, and 4 cases as type C3 fracture. Sixteen cases accompanied by fibular fracture (14 cases of simple fibular fracture and 2 cases of communicated fibular fracture). According to Gustilo classification, the soft tissue injuries were all type IIIB. In first stage, debridement and vaccum sealing drainage combined with external fixation were performed; open reduction and internal fixation of simple fibular fracture were used. In second stage, open reduction and internal fixation of Pilon fracture and communicated fibular fracture were performed, and the flaps of 6 cm × 5 cm to 18 cm × 14 cm were applied to repair soft tissue defect at the same time. The donor site was repaired by skin graft. Results Partial necrosis occurred in 2 flaps, the other 16 flaps survived completely. The incisions of donor sites healed by first intention, the skin graft survived completely. The average follow-up interval was 12 months (range, 6-24 months). The X-ray films showed that the bone healing time ranged from 5 to 8 months (mean, 6 months). No internal fixation failure was found. At last follow-up, the average range of motion of the ankle joint was 37° (range, 26-57°). According to the American Orthopedic Foot and Ankle Society (AOFAS) scale, the average score was 80.2 (range, 72-86). Traumatic arthritis occurred in 2 cases (11%). Conclusion The staged treatment has the advantages of accurate evaluation of soft tissue injury, shortened cure time, good reduction of the articular surface, and reduced incidence of infection, so it is an optimal method to treat open Pilon fracture combined with soft tissue defect.

游离腓骨皮瓣修复前足复合组织缺损

目的 总结游离腓骨皮瓣修复前足复合组织缺损的疗效。 方法2000年6月－2011年11月，应用游离腓骨皮瓣修复前足复合组织缺损12例。致伤原因：交通事故伤8例，压砸伤4例。伤后至入院时间6 h～21 d。创面范围8 cm × 6 cm～30 cm × 18 cm。均伴跖骨缺损，缺损长度5～14 cm。切取腓骨皮瓣范围10 cm × 8 cm～16 cm × 12 cm，腓骨长度6～16 cm。 结果术后1例发生静脉危象，其余皮瓣全部成活。12例均获随访，随访时间1～3年，平均2年5个月。移植骨愈合时间4～6个月。末次随访时采用美国足踝外科协会（AOFAS）评分，为70～92分，平均81分。 结论游离腓骨皮瓣可一期修复前足复合组织缺损，是较理想的治疗方法。

急诊拇指再造20例

STAGED TREATMENT OF INFECTIOUS LONG BONE DEFECT IN LOWER EXTREMITY

ObjectiveTo explore the clinical application and effectiveness of antibiotic-loaded cement spacer combined with free fibular graft in the staged treatment of infectious long bone defect in the lower extremity. MethodsA retrospective analysis was made on the clinical data from 12 patients with infectious long bone defect in the lower extremity between June 2010 and June 2012. Of the 12 cases, there were 9 males and 3 females with an average age of 33 years (range, 19-46 years), including 3 cases of femoral shaft bone defect, 7 cases of tibial shaft bone defect, and 2 cases of metatarsal bone defect. The causes were traffic accident injury in 7 cases, crashing injury in 3 cases, and machine extrusion injury in 2 cases. The length of bone defect ranged from 6 to 14 cm (mean, 8 cm). The soft tissue defect area ranged from 5.0 cm×3.0 cm to 8.0 cm×4.0 cm companied with tibial shaft and metatarsal bone defect in 9 cases. The sinus formed in 3 femoral shaft bone defects. The time between injury and operation was 1-4 months (mean, 2 months). At first stage, antibiotic-loaded cement spacer was placed in the bone defect after debridement and the flaps were used to repair soft tissue defect in 9 cases; at second stage (6 weeks after the first stage), defect was repaired with free fibular graft (7-22 cm in length, 14 cm on average) after antibiotic-loaded cement spacer removal. The area of the cutaneous fibular flap ranged from 6.0 cm×4.0 cm to 10.0 cm×5.0 cm in 10 cases. ResultsAll wounds healed by first intention, and the healing time was 12-18 days, 14 days on average. Twelve cases were followed up 12-36 months (mean, 17 months). Bone healing time ranged from 4 to 6 months (5.5 months on average). The cutaneous fibular flap had good appearance. The function at donor site was satisfactory; no dysfunction of the ankle joint or tibial stress fracture occurred after operation. The mean Enneking score was 25 (range, 20-28) at last follow-up. ConclusionInfection can be well controlled with the antibiotic-loaded cement spacer during first stage operation, and free fibular graft can increase the bone defect healing rate at second stage. Staged treatment is an optimal choice to treat infectious long bone defect in the lower extremity.

近指间关节复合组织缺损的显微外科修复

目的总结近指间关节复合组织缺损显微外科修复的疗效。 方法2005年3月－2011年3月，对12例示、中指近指间关节复合组织缺损患者采用游离带关节的第2足趾复合组织移植修复。男9例，女3例；年龄17～38岁，平均24.6岁。致伤原因：电锯伤3例，交通事故伤4例，机器绞伤5例。软组织缺损范围3.0 cm × 1.0 cm～5.5 cm × 2.5 cm。伤后至手术时间3 h～4 d，平均32 h。 结果12例均获随访，随访时间5个月～4年，平均2.5年。术后48 h 1例发生皮瓣静脉危象，行静脉皮瓣移植修复成活；余11例移植复合组织均顺利成活。移植骨均愈合良好，愈合时间5～12个月，平均8个月。随访期间无关节退行性变。11例术后14个月按照中华医学会手外科学会上肢部分功能评定试用标准评价，获优3例，良4例，可4例。 结论对于近指间关节复合组织缺损，通过显微外科方法修复可以最大程度恢复手指外观、感觉及功能。

桥式吻合血管组合皮瓣修复小腿大面积皮肤缺损

目的 探讨桥式吻合血管组合皮瓣修复小腿大面积皮肤缺损的临床效果。 方法 1997年2月~2003年10月，采用桥式吻合血管的组合皮瓣修复小腿大面积皮肤缺损8例，男7例，女1例；年龄10~49岁。均为车祸伤。新鲜外伤3例，陈旧外伤5例。均为胫腓骨骨折合并大面积皮肤缺损、骨外露，皮肤缺损范围25 cm×18 cm~70 cm×12 cm，伴胫前或胫后血管长段挫灭缺损3~7 cm。 结果 术后1例发生皮瓣静脉危象，经重新吻合静脉后，危象缓解；1例皮瓣尖端3 cm×1 cm坏死，经换药后创面愈合；1例伤口感染，经换药后创面愈合，其余皮瓣均成活。术后4~6周皮瓣断蒂，双小腿分开；5~10个月骨折愈合。均获随访2~7年，皮瓣颜色正常，弹性好，毛发生长，恢复保护性感觉，可以正常工作生活。 结论 桥式吻合血管组合皮瓣为皮瓣提供了可靠的供应血管，是治疗濒临截肢肢体的一种较好方法。

双Endobutton双环套锁内固定术治疗Tossy Ⅲ型肩锁关节脱位及Neer ⅡB型锁骨远端骨折

目的总结双Endobutton双环套锁内固定术治疗TossyⅢ型肩锁关节脱位和NeerⅡB型锁骨远端骨折的疗效。 方法2010年4月－2013年4月采用双Endobutton双环套锁内固定术治疗17例Tossy Ⅲ型肩锁关节脱位和7例Neer ⅡB型锁骨远端骨折患者。男16例，女8例；年龄18～47岁，平均34岁。受伤至手术时间1～7 d，平均3.5 d。 结果术后患者切口均Ⅰ期愈合，无感染、臂丛神经及血管损伤等并发症发生。21例获随访，其中14例脱位患者随访时间12～20个月，7例骨折患者为12～24个月。锁骨远端骨折均获骨性愈合，愈合时间4～8个月，平均6个月。随访期间肩锁关节脱位无复发。术后12个月，Constant-Murley评分：脱位患者为（89.3±3.2）分，骨折患者为（87.2±2.6）分；按Karlsson标准评定：脱位患者获A级14例，B级3例；骨折患者获A级5例，B级2例。 结论双Endobutton双环套锁内固定术治疗Tossy Ⅲ型肩锁关节脱位和Neer ⅡB型锁骨远端骨折创伤小，手术操作简便，近期疗效满意。

携带隐神经终末支的游离足内侧皮瓣在手部高压注射伤中的应用

目的总结携带隐神经终末支的游离足内侧皮瓣治疗手部高压注射伤的疗效。方法 2014 年 3 月—2018 年 6 月，收治 16 例 16 指高压注射伤患者。其中男 12 例，女 4 例；年龄 21～58 岁，平均 42 岁。拇指 3 例，示指 6 例，中指 5 例，环指 2 例。高压乳胶漆注射伤 10 例，高压油枪注射伤 6 例。受伤至入院时间为 1 h～2 d，平均 6.5 h。急诊行显微外科清创；亚急诊行携带隐神经终末支的游离足内侧皮瓣修复创面，皮瓣范围 4.5 cm×3.0 cm～8.0 cm×5.0 cm。结果术后皮瓣全部成活，未发生指端坏死或部分坏死。患者均获随访，随访时间 8～24 个月，平均 15 个月。末次随访时患指外观满意，皮瓣弹性、血运良好，指端指体饱满，远、近指间关节处横纹初显，无指体冷耐受差发生。皮瓣两点辨别觉为 5～10 mm，平均 7.5 mm。手功能采用手指关节总活动度（TAM）法评定，获优 10 指，良 4 指，可 2 指。供区无并发症发生。结论携带隐神经终末支的游离足内侧皮瓣是治疗手部高压注射伤的一种有效方法，术后手指外形、感觉及功能恢复良好。

Effectiveness of dorsal perforator flap of cross-finger proper digital artery in treatment of high-pressure injection injuries of the finger

Objective To investigate the effectiveness of dorsal perforator flap of cross-finger proper digital artery in the treatment of finger soft tissue defect caused by high-pressure injection injury. MethodsBetween July 2011 and June 2020, 14 cases of finger soft tissue defect caused by high-pressure injection injury were repaired with dorsal perforator flap of cross-finger proper digital artery. All patients were male, with a mean age of 36 years (range, 22-56 years). The defects were located on the index finger in 8 cases, middle finger in 4 cases, and ring finger in 2 cases. The causes of injury include 8 cases of emulsion paint injection, 4 cases of oil paint injection, and 2 cases of cement injection. The time from injury to debridement was 2-8 hours, with a mean time of 4.5 hours. The soft tissue defects sized from 4.0 cm×1.2 cm to 6.0 cm×2.0 cm. The flaps sized from 4.5 cm×1.5 cm to 6.5 cm×2.5 cm. The donor site of the flap was repaired with skin graft. The pedicle was cut off at 3 weeks after operation, and followed by functional exercise. ResultsAll flaps and skin grafts at donor sites survived, and the wounds healed by first intention. Twelve patients were followed-up 16-38 months (mean, 22.6 months). The texture and appearance of all flaps were satisfactory. The color and texture of the flaps were similar to those of the surrounding tissues. The two-point discrimination of the flap was 10-12 mm, with a mean of 11.5 mm. There were different degrees of cold intolerance at the end of the affected fingers. At last follow-up, the finger function was evaluated according to the Upper Extremity Functional Evaluation Standard set up by Hand Surgery Branch of Chinese Medical Association, 3 cases were excellent, 8 cases were good, and 1 case was poor. Conclusion The dorsal perforator flap of cross-finger proper digital artery can effectively repair finger soft tissue defect caused by high-pressure injection injury. The operation was simple, and the appearance and function of the finger recover well.

游离髂腹股沟皮瓣修复踇甲皮瓣供区

目的探讨游离髂腹股沟皮瓣修复踇甲皮瓣供区的疗效。方法2017 年 1 月—2018 年 12 月，收治 12 例手指软组织缺损患者。男 10 例，女 2 例；年龄 27～50 岁，平均 36.8 岁。损伤指别：拇指 8 例，示指 3 例，中指 1 例。手指软组织缺损范围为 2.5 cm×1.6 cm～5.0 cm×3.5 cm。4 例合并骨缺损。受伤至入院时间为 2～9 h，平均 4.9 h。术中切取大小为 3.0 cm×2.0 cm～6.0 cm×4.5 cm 的踇甲皮瓣修复手指缺损后，以旋髂浅动脉为血管蒂的游离髂腹股沟皮瓣接力修复供区创面，皮瓣切取范围为 4.0 cm×3.0 cm～7.0 cm×5.0 cm。游离髂腹股沟皮瓣供区直接拉拢缝合。结果手术时间 300～500 min，平均 353.3 min。除 1 例游离髂腹股沟皮瓣术后出现血管危象，经对症处理后成活外，其余皮瓣均顺利成活。供区切口均Ⅰ期愈合。患者均获随访，随访时间 3～18 个月，平均 9 个月。游离髂腹股沟皮瓣质地、颜色与周围皮肤相似，随访期间无破溃发生。患者对足部外观及功能均满意。结论游离髂腹股沟皮瓣供区隐蔽、损伤小，是修复踇甲皮瓣供区的可选方案之一。