摘要
目的探讨分区应用、分层应用负压封闭引流(Vacuum-assisted closure,VAC)在Gustilo IIIB和IIIC型开放性骨折感染治疗中的应用效果。方法2006年12月～2008年1月应用VAC治疗GustiloIIIB和IIIC型开放性骨折感染患者35例,年龄5～66岁,平均37.3岁。交通伤24例,机器损伤4例,火器伤3例,烧伤4例,IIIB型28例(胫腓骨22例,骨盆2例,尺桡骨3例,股骨1例),IIIC型7例(胫腓骨5例,跖趾骨2例)。骨折均已行骨折固定及血管修复,遗留创面或皮肤坏死范围为(3～50)cm×(2～35)cm。入院时骨折感染距伤后时间3～34d,平均12d。所有病例均先行清创,更换骨折固定类型或调整外固定架固定位置,在感染的肌肉间隙、关节间隙、骨折间隙等分区应用、分层应用VAC,并根据置管部位和引流情况决定拔管次序和时间,5～7d根据引流情况进行更换引流装置,应用次数为1～4次/例,平均2.2次/例。创面有新鲜肉芽组织后,12例行皮瓣移植和肌瓣移植,23例25处伤口皮片植皮或缝合修复创面。感染性腔隙或骨髓腔可延长应用单纯负压管吸引7～14d。创面愈合后3～6个月视骨折愈合进度和骨折固定稳定情况保留原有固定或更换永久性骨折固定物。结果本组35例创面经清创后应用封闭负压吸引后,创面感染均得到控制,创面清洁时间为7～17d,平均10.5d。创面水肿减轻,出现新鲜肉芽组织,范围减小10%～15%,细菌培养阴性。游离植皮及组织瓣移植一次全部成活33例,2例游离植皮者由于面积大,术后患者搓动遗留有小创面,经再次植皮后完全消灭创面。所有患者体温血象正常,局部无窦道、无疼痛,感染均得到有效控制。结论分区应用、分层应用VAC,并根据置管部位和引流情况决定拔管次序和时间,可以有效地控制Gustilo IIIB和IIIC型开放性骨折的继发感染。
Objective To explore the effects of region-and layer-wise application of Vacuum-assisted closure （VAC） in infection of Gustilo ⅢB and ⅢC open fracture. Methods We treated 35 patients of Gustilo ⅢB and ⅢC open fracture infection with VAC from Dec 2006 to Jan 2008. The age ranges from 5-66 years, averaging out at 37.3 years. Among the patients, 24 cases were caused by traffic accidents, 4 cases were machine injuries, 3 cases were firearm injuries, and 4 cases were burns. Twenty-eight cases were type ⅢB, including tibia and fibula （22 cases）, pelvis （2 cases）, ulna and radius （3 cases）, femur （1 case）; while 7 cases were type ⅢC, including tibia and fibula （5 cases）, metatarsus and toe （2 cases）. All fractures have previously undergone fixation and vessel repair, with remaining trauma surface or skin necrosis area ranging （3-50）cm×（2-35）cm. The duration from injury to fracture infection was 3-34 days, averaging 12 days. All cases were given debridement, and changed the pattern of fracture fixation or adjusting the position of outer fixation device. Then the VAC was applied in a region-and layer-wise manner in the intermuscular space, interjoint space and the interfracture space, The sequential and time of tube withdrawal was decided by tube position and drainage pattern, with drainage changes every 5-7 days according to the drainage state. The drainage were applied 1-4 times per case, averaging out at 2.2 times. When fresh granulation tissue emerged in the trauma surface, 12 cases undergone flap transplantation undergone skin graft or suture to cover the trauma and muscle transplantation, and 23 cases （25 lesions） surface. Infectious cavity or bone marrow cavity can be subjected to simple vacuum drainage for a prolonged 7-14 days. Retention of former fixation or change to a permanent fracture fixation were determined by the healing process and the stability of the fixation 3-6 months after the trauma surface healing. Results The 35 cases investigated all showed well control of the trauma surface infection after debridement and subsequent vacuum drainage. The duration of clean trauma surface was 7-17 days, averaging out at 10.5 days. The swelling of the trauma surface was alleviated, fresh granulation tissue emerged, and the area of trauma surface were reduced by 10%-15%, with a negative result of bacterial culture. Thirty-three cases of skin graft and tissue flap transplantation showed one-time full recovery, and 2 cases of skin graft still had small trauma surfaces after first transplantation, fully recovered by re-transplantation. All patients were normal in body temperature and blood routine test, without local fistula or pain. Infection were effectively controlled. Conclusions Region-and layer-wise application of VAC with tube withdrawal decided by tube position and drainage pattern, can effectively control secondary infection after Gustilo ⅢB and ⅢC type open fracture.
出处
《中国骨肿瘤骨病》
2008年第4期193-197,共5页
Chinse Journal Of Bone Tumor And Bone Disease
基金
全军"十一五"卫生科研基金资助项目(06MA269)
关键词
开放性骨折
感染
负压封闭引流
Open fracture
Infection
Vacuum-assited closure
作者简介
通讯作者：杨润功
