Advances in early repair and reconstruction of severe limb injuries_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 XU Yongqing

Institute of Orthopedic Trauma, 920th Hospital of Joint Logistic Support Force of Chinese PLA, Kunming Yunnan, 650032, P. R. China;

Corresponding?author：

XU Yongqing, Email: xuyongqingkm@163.net

Keywords：

Severe limb injury; repair and reconstruction; skin flap; infection

DOI：

10.7507/1002-1892.202512047

Video：

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Severe limb injuries are multi-tissue damage caused by high-energy trauma, directly threatening the survival of the limb and the patient’s life. Their treatment is a major challenge in the field of trauma orthopedics. The core of treatment lies in the comprehensive assessment by a multidisciplinary team, followed by making a scientific decision on limb preservation. In terms of repair and reconstruction strategies, the timing of soft tissue coverage is crucial. Delayed primary flap repair (3-7 days after injury) has become the mainstream choice. It is performed after multiple debridements to ensure the cleanliness of the wound, significantly improving the success rate of flaps and reducing the risk of infection. The fixation method for fractures needs to be dynamically decided: external fixation frames are key for damage control and temporary fixation, creating conditions for soft tissue recovery; when the conditions are mature, they can be replaced with intramedullary nails or plates, etc., to achieve strong and stable fixation. For complex cases with severe contamination or infection, treatment needs to be carried out in stages: after thorough debridement in the initial stage, local sustained-release antibacterial therapy with antibiotics such as vancomycin bone cement can be applied, combined with closed negative pressure drainage technology for wound management. The final treatment can be external; for large bone defects, induced membrane technology or bone transportation technology can be used for repair. In addition, emerging infection prevention methods such as recombinant Staphylococcus aureus vaccines, and bone defect repair technologies such as three-dimensional printing personalized prostheses, show promising application prospects.

1.	McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS). J Orthop Trauma, 1994, 8(2): 81-87.
2.	Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type Ⅲ (severe) open fractures: a new classification of type Ⅲ open fractures. J Trauma, 1984, 24(8): 742-746.
3.	顧立強, 朱慶棠, 戚劍. 開放性骨折改良Gustilo分型與保肢策略. 中華顯微外科雜志, 2017, 40(1): 13-15.
4.	范新宇, 徐永清, 王騰, 等. 膜誘導技術聯合顯微外科技術治療Gustilo ⅢB、ⅢC型小腿開放性骨折. 中華創傷骨科雜志, 2019, 21(10): 843-847.
5.	Mundy LR, Truong T, Shammas RL, et al. Acute treatment patterns for lower extremity trauma in the United States: Flaps versus amputation. J Reconstr Microsurg, 2017, 33(8): 563-570.
6.	Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg, 1986, 78(3): 285-292.
7.	陳雪松. Gustilo-AndersonⅢB、ⅢC型脛骨開放骨折的一期修復重建策略. 創傷外科雜志, 2017, 19(1): 5-8.
8.	陳雪松, 徐永清, 陳建明, 等. GustiloⅢB、ⅢC型小腿及足踝部開放性骨折的一期修復與重建. 中華創傷骨科雜志, 2014, 16(11): 939-945.
9.	British Orthopaedic Association. British Orthopaedic Association Audit Standards for Trauma(BOAST): The Management of Distal Radius Fractures[S]. 2017.
10.	芮永軍, 戚劍, 唐舉玉, 等. 嚴重肢體創傷創面早期修復專家共識. 中華顯微外科雜志, 2023, 46(4): 368-382.
11.	芮永軍, 徐永清, 朱慶棠, 等. 嚴重開放性脛腓骨骨折診斷及早期固定循證指南 (2025 版). 中華創傷雜志, 2025, 41(11): 1021-1034.
12.	芮永軍, 吳永偉, 劉軍, 等. 早期內固定聯合穿支血管蒂皮瓣治療前臂Gustilo ⅡB、Ⅲ C型開放性骨折伴軟組織缺損. 中華創傷骨科雜志, 2018, 20(8): 648-653.
13.	Bi?en ?, Akdemir M, Ekin A. Management of orthopaedic injuries in Libyan civil war: experiences of a distant hospital. Int Orthop, 2020, 44(9): 1639-1646.
14.	Albright PD, Ali SH, Jackson H, et al. Delays to surgery and coronal malalignment are associated with reoperation after open tibia fractures in tanzania. Clin Orthop Relat Res, 2020, 478(8): 1825-1835.
15.	Haonga BT, Liu M, Albright P, et al. Intramedullary nailing versus external fixation in the treatment of open tibial fractures in Tanzania: Results of a randomized clinical trial. J Bone Joint Surg (Am), 2020, 102(10): 896-905.
16.	Goldman AH, Tetsworth K. AAOS clinical practice guideline summary: Prevention of surgical site infection after major extremity trauma. J Am Acad Orthop Surg, 2023, 31(1): e1-e8.
17.	Giannoudis PV, Papakostidis C, Kouvidis G, et al. The role of plating in the operative treatment of severe open tibial fractures: a systematic review. Int Orthop, 2009, 33(1): 19-26.
18.	郭孝菊, 李軍, 萬值穎, 等. 旋耕機造成下肢毀損傷的特點及感染控制體會. 昆明醫科大學學報, 2020, 41(10): 129-133.
19.	劉剛, 王軍, 王陶, 等. 農業旋耕機的致傷特點及治療策略. 中華創傷骨科雜志, 2015, 17(7): 570-574.
20.	Morgenstern M, Vallejo A, McNally MA, et al. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. Bone Joint Res, 2018, 7(7): 447-456.
21.	方炫程, 許錦, 黃建榮. 磷酸鈣骨水泥藥物緩釋體系的研究進展. 廣州醫科大學學報, 2023, 51(6): 62-68.
22.	Gao X, Xu Z, Li S, et al. Chitosan-vancomycin hydrogel incorporated bone repair scaffold based on staggered orthogonal structure: a viable dually controlled drug delivery system. RSC Adv, 2023, 13(6): 3759-3765.
23.	Kang Y, Wu Y, Ma Y, et al. A novel primary antibiotic cement-coated locking plate as a temporary fixation for the treatment of open tibial fracture. Sci Rep, 2023, 13(1): 21890. doi: 10.1038/s41598-023-49460-z.
24.	徐永清, 朱躍良, 范新宇, 等. 二處截骨骨搬移治療脛骨大段骨缺損合并軟組織缺損. 中華創傷骨科雜志, 2012, 14(10): 831-834.
25.	徐永清, 朱躍良, 范新宇, 等. 二處截骨骨搬移治療脛骨大段骨缺損合并軟組織缺損的再認. 中華創傷骨科雜, 2015, 17(10): 850-853.
26.	徐永清, 朱躍良, 林瑋, 等. 雙處截骨縱向搬移治療長段小腿感染性復合缺損. 生物骨科材料與臨床研究, 2018, 15(5): 14-17.
27.	楊銀, 徐永清, 李剛, 等. 3D打印微孔鈦(鉭)假體重建下肢骨髓炎致大段骨缺損的療效分析. 中華創傷骨科雜志, 2024, 26(3): 247-254.
28.	吳昊, 郭征. 3D打印多孔鈦與鈦合金及多孔鉭骨科植入物的性能比較及應用展望. 中華創傷骨科雜志, 2020, 22(10): 916-920.
29.	Wu Y, Shi X, Wang J, et al. A surface metal ion-modified 3D-printed Ti-6Al-4V implant with direct and immunoregulatory antibacterial and osteogenic activity. Front Bioeng Biotechnol, 2023, 11: 1142264. doi: 10.3389/fbioe.2023.1142264.
30.	張曉艷, 徐永清, 王毅, 等. 3D打印微孔鈦假體重建創傷后骨感染致股骨中下段大段骨缺損的療效. 中華創傷雜志, 2025, 41(3): 282-288.
31.	Wu Y, Shi X, Zi S, et al. The clinical application of customized 3D-printed porous tantalum scaffolds combined with Masquelet's induced membrane technique to reconstruct infective segmental femoral defect. J Orthop Surg Res, 2022, 17(1): 479. doi: 10.1186/s13018-022-03371-3.
32.	張曉艷, 徐永清, 王毅, 等. 3D打印微孔鈦(鉭)假體重建長骨大段骨缺損的研究現狀與展望. 中華創傷骨科雜志, 2025, 27(5): 438-443.
33.	徐永清, 范新宇, 王騰, 等. 皮瓣加3D打印微孔鈦 (鉭) 假體治療下肢軟組織缺損伴大段骨缺損. 中華顯微外科雜志, 2022, 45(1): 21‐27.
34.	徐永清, 范新宇, 王騰, 等. 3D打印定制化微孔鈦假體治療脛骨大段感染性骨缺損的近期療效觀察. 中華創傷骨科雜志, 2025, 27(6): 529-535.
35.	徐永清, 范新宇, 王騰, 等. 3D 打印微孔鈦假體與皮瓣聯合植入治療四肢大段感染性骨缺損臨床療效. 中國修復重建外科雜志, 2025, 39(5): 521-528.
36.	Zeng H, Yang F, Feng Q, et al. Rapid and broad immune efficacy of a recombinant five-antigen vaccine against staphylococcus aureus infection in animal models. Vaccines (Basel), 2020, 8(1): 134. doi: 10.3390/vaccines8010134.
37.	Jiang XY, Gong MQ, Zhang HJ, et al. The safety and immunogenicity of a recombinant five-antigen Staphylococcus aureus vaccine among patients undergoing elective surgery for closed fractures: A randomized, double-blind, placebo-controlled, multicenter phase 2 clinical trial. Vaccine, 2023, 41(38): 5562-5571.

1. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS). J Orthop Trauma, 1994, 8(2): 81-87.
2. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type Ⅲ (severe) open fractures: a new classification of type Ⅲ open fractures. J Trauma, 1984, 24(8): 742-746.
3. 顧立強, 朱慶棠, 戚劍. 開放性骨折改良Gustilo分型與保肢策略. 中華顯微外科雜志, 2017, 40(1): 13-15.
4. 范新宇, 徐永清, 王騰, 等. 膜誘導技術聯合顯微外科技術治療Gustilo ⅢB、ⅢC型小腿開放性骨折. 中華創傷骨科雜志, 2019, 21(10): 843-847.
5. Mundy LR, Truong T, Shammas RL, et al. Acute treatment patterns for lower extremity trauma in the United States: Flaps versus amputation. J Reconstr Microsurg, 2017, 33(8): 563-570.
6. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg, 1986, 78(3): 285-292.
7. 陳雪松. Gustilo-AndersonⅢB、ⅢC型脛骨開放骨折的一期修復重建策略. 創傷外科雜志, 2017, 19(1): 5-8.
8. 陳雪松, 徐永清, 陳建明, 等. GustiloⅢB、ⅢC型小腿及足踝部開放性骨折的一期修復與重建. 中華創傷骨科雜志, 2014, 16(11): 939-945.
9. British Orthopaedic Association. British Orthopaedic Association Audit Standards for Trauma(BOAST): The Management of Distal Radius Fractures[S]. 2017.
10. 芮永軍, 戚劍, 唐舉玉, 等. 嚴重肢體創傷創面早期修復專家共識. 中華顯微外科雜志, 2023, 46(4): 368-382.
11. 芮永軍, 徐永清, 朱慶棠, 等. 嚴重開放性脛腓骨骨折診斷及早期固定循證指南 (2025 版). 中華創傷雜志, 2025, 41(11): 1021-1034.
12. 芮永軍, 吳永偉, 劉軍, 等. 早期內固定聯合穿支血管蒂皮瓣治療前臂Gustilo ⅡB、Ⅲ C型開放性骨折伴軟組織缺損. 中華創傷骨科雜志, 2018, 20(8): 648-653.
13. Bi?en ?, Akdemir M, Ekin A. Management of orthopaedic injuries in Libyan civil war: experiences of a distant hospital. Int Orthop, 2020, 44(9): 1639-1646.
14. Albright PD, Ali SH, Jackson H, et al. Delays to surgery and coronal malalignment are associated with reoperation after open tibia fractures in tanzania. Clin Orthop Relat Res, 2020, 478(8): 1825-1835.
15. Haonga BT, Liu M, Albright P, et al. Intramedullary nailing versus external fixation in the treatment of open tibial fractures in Tanzania: Results of a randomized clinical trial. J Bone Joint Surg (Am), 2020, 102(10): 896-905.
16. Goldman AH, Tetsworth K. AAOS clinical practice guideline summary: Prevention of surgical site infection after major extremity trauma. J Am Acad Orthop Surg, 2023, 31(1): e1-e8.
17. Giannoudis PV, Papakostidis C, Kouvidis G, et al. The role of plating in the operative treatment of severe open tibial fractures: a systematic review. Int Orthop, 2009, 33(1): 19-26.
18. 郭孝菊, 李軍, 萬值穎, 等. 旋耕機造成下肢毀損傷的特點及感染控制體會. 昆明醫科大學學報, 2020, 41(10): 129-133.
19. 劉剛, 王軍, 王陶, 等. 農業旋耕機的致傷特點及治療策略. 中華創傷骨科雜志, 2015, 17(7): 570-574.
20. Morgenstern M, Vallejo A, McNally MA, et al. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. Bone Joint Res, 2018, 7(7): 447-456.
21. 方炫程, 許錦, 黃建榮. 磷酸鈣骨水泥藥物緩釋體系的研究進展. 廣州醫科大學學報, 2023, 51(6): 62-68.
22. Gao X, Xu Z, Li S, et al. Chitosan-vancomycin hydrogel incorporated bone repair scaffold based on staggered orthogonal structure: a viable dually controlled drug delivery system. RSC Adv, 2023, 13(6): 3759-3765.
23. Kang Y, Wu Y, Ma Y, et al. A novel primary antibiotic cement-coated locking plate as a temporary fixation for the treatment of open tibial fracture. Sci Rep, 2023, 13(1): 21890. doi: 10.1038/s41598-023-49460-z.
24. 徐永清, 朱躍良, 范新宇, 等. 二處截骨骨搬移治療脛骨大段骨缺損合并軟組織缺損. 中華創傷骨科雜志, 2012, 14(10): 831-834.
25. 徐永清, 朱躍良, 范新宇, 等. 二處截骨骨搬移治療脛骨大段骨缺損合并軟組織缺損的再認. 中華創傷骨科雜, 2015, 17(10): 850-853.
26. 徐永清, 朱躍良, 林瑋, 等. 雙處截骨縱向搬移治療長段小腿感染性復合缺損. 生物骨科材料與臨床研究, 2018, 15(5): 14-17.
27. 楊銀, 徐永清, 李剛, 等. 3D打印微孔鈦(鉭)假體重建下肢骨髓炎致大段骨缺損的療效分析. 中華創傷骨科雜志, 2024, 26(3): 247-254.
28. 吳昊, 郭征. 3D打印多孔鈦與鈦合金及多孔鉭骨科植入物的性能比較及應用展望. 中華創傷骨科雜志, 2020, 22(10): 916-920.
29. Wu Y, Shi X, Wang J, et al. A surface metal ion-modified 3D-printed Ti-6Al-4V implant with direct and immunoregulatory antibacterial and osteogenic activity. Front Bioeng Biotechnol, 2023, 11: 1142264. doi: 10.3389/fbioe.2023.1142264.
30. 張曉艷, 徐永清, 王毅, 等. 3D打印微孔鈦假體重建創傷后骨感染致股骨中下段大段骨缺損的療效. 中華創傷雜志, 2025, 41(3): 282-288.
31. Wu Y, Shi X, Zi S, et al. The clinical application of customized 3D-printed porous tantalum scaffolds combined with Masquelet's induced membrane technique to reconstruct infective segmental femoral defect. J Orthop Surg Res, 2022, 17(1): 479. doi: 10.1186/s13018-022-03371-3.
32. 張曉艷, 徐永清, 王毅, 等. 3D打印微孔鈦(鉭)假體重建長骨大段骨缺損的研究現狀與展望. 中華創傷骨科雜志, 2025, 27(5): 438-443.
33. 徐永清, 范新宇, 王騰, 等. 皮瓣加3D打印微孔鈦 (鉭) 假體治療下肢軟組織缺損伴大段骨缺損. 中華顯微外科雜志, 2022, 45(1): 21‐27.
34. 徐永清, 范新宇, 王騰, 等. 3D打印定制化微孔鈦假體治療脛骨大段感染性骨缺損的近期療效觀察. 中華創傷骨科雜志, 2025, 27(6): 529-535.
35. 徐永清, 范新宇, 王騰, 等. 3D 打印微孔鈦假體與皮瓣聯合植入治療四肢大段感染性骨缺損臨床療效. 中國修復重建外科雜志, 2025, 39(5): 521-528.
36. Zeng H, Yang F, Feng Q, et al. Rapid and broad immune efficacy of a recombinant five-antigen vaccine against staphylococcus aureus infection in animal models. Vaccines (Basel), 2020, 8(1): 134. doi: 10.3390/vaccines8010134.
37. Jiang XY, Gong MQ, Zhang HJ, et al. The safety and immunogenicity of a recombinant five-antigen Staphylococcus aureus vaccine among patients undergoing elective surgery for closed fractures: A randomized, double-blind, placebo-controlled, multicenter phase 2 clinical trial. Vaccine, 2023, 41(38): 5562-5571.

Chinese Journal of Reparative and Reconstructive Surgery

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