真皮下血管网层反取皮回植联合负压封闭引流在下肢大面积皮肤撕脱伤中的应用
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摘要
目的:总结下肢大面积皮肤撕脱伤后急诊给予真皮下血管网层反取皮回植联合负压封闭引流后的临床疗效。方法:收集2010年7月至2018年3月收治的30例下肢大面积皮肤撕脱伤患者的临床资料。男20例,女10例;年龄16～67(48±13)岁。车祸伤19例,碾轧伤11例。受伤至手术时间3～10(5±1) h。所有病例给予I期彻底清创,真皮下血管网层反取皮植皮后多切口引流结合负压封闭引流技术覆盖7～10 d。拆除VSD观察创面成活情况:如果坏死面积大,需清创切痂待创面肉芽生长满意后择期再次取皮植皮术;小面积坏死皮肤加强换药直至愈合。结果:30例均获随访,时间7～48(20±11)个月。无一例出现感染,30例经Ⅰ期成活面积均达到85%以上;5例皮肤坏死范围在12%左右,Ⅱ期经再次清创游离植皮后愈合,其余患者经过加强换药后均获愈合。真皮下血管网层回植的皮肤颜色、弹性、感觉、耐磨耐压性良好,各关节活动良好,未见明显皮肤粘连引起肢体活动受限。结论:真皮下血管网层回植联合负压封闭引流治疗下肢大面积皮肤撕脱伤,可大大降低了创面感染率,促进了皮片与创面的贴敷,利于引流,提高了反取皮的成活率,改善了下肢关节功能。
Objective:To summarize the clinical effect of emergency subcutaneous vascular network reverse skin replantation combined with vacuum sealing after drainage of large area skin avulsion injury. Methods:Clinical data of 30 patients with extensive skin avulsion of the lower limb treated between July 2010 and March 2018 were collected. There were 20 males and 10 females,ranging in age from 16 to 67 years old,with an average of(48±13) years old. Cause of injury:19 cases of car accident injury,11 cases of crush injury. The surgery time was 3 to 10 h,with an average of(5±1) h. All cases were completely debrided in stage I. The subdermal vascular network was reversed and skin grafted with multiple incision drainage combined with negative pressure closed drainage technique for 7 to 10 days. The wounds were removed by VSD observation :if the necrotic area is large,debridement is required. After the granulation growth of the wound is satisfactory,the skin grafting is performed again after electrification;the small area of necrotic skin strengthens the dressing and heals. Results:30 patients were followed up for 7 to 48 months,with an average of(20±11) months.No infection in 1 case appeared,30 patients,living area more than 85% of the wound after treatment survival in the stageⅠ;The skin necrosis ranged from about 12% in 5 patients in the stageⅡ.The second stage was healed after redebriding free skin grafts. The other patients were healed after the dressing,capillary meshwork layer of skin color,good elasticity,feeling,wearable pressure,each joint activities is good,no obvious skin adhesion cause physical activity is limited. Conclusion:Reverse skin grafting combined with VSD for the treatment of large skin avulsion of lower limb can greatly reduce wound infection rate,promote the application of skin and wound,conducive to drainage,improve the survival rate of reverse skin grafting and improve the function of lower limb joints.
Objective:To summarize the clinical effect of emergency subcutaneous vascular network reverse skin replantation combined with vacuum sealing after drainage of large area skin avulsion injury. Methods:Clinical data of 30 patients with extensive skin avulsion of the lower limb treated between July 2010 and March 2018 were collected. There were 20 males and 10 females,ranging in age from 16 to 67 years old,with an average of(48±13) years old. Cause of injury:19 cases of car accident injury,11 cases of crush injury. The surgery time was 3 to 10 h,with an average of(5±1) h. All cases were completely debrided in stage I. The subdermal vascular network was reversed and skin grafted with multiple incision drainage combined with negative pressure closed drainage technique for 7 to 10 days. The wounds were removed by VSD observation :if the necrotic area is large,debridement is required. After the granulation growth of the wound is satisfactory,the skin grafting is performed again after electrification;the small area of necrotic skin strengthens the dressing and heals. Results:30 patients were followed up for 7 to 48 months,with an average of(20±11) months.No infection in 1 case appeared,30 patients,living area more than 85% of the wound after treatment survival in the stageⅠ;The skin necrosis ranged from about 12% in 5 patients in the stageⅡ.The second stage was healed after redebriding free skin grafts. The other patients were healed after the dressing,capillary meshwork layer of skin color,good elasticity,feeling,wearable pressure,each joint activities is good,no obvious skin adhesion cause physical activity is limited. Conclusion:Reverse skin grafting combined with VSD for the treatment of large skin avulsion of lower limb can greatly reduce wound infection rate,promote the application of skin and wound,conducive to drainage,improve the survival rate of reverse skin grafting and improve the function of lower limb joints.
引文
[1]宋永焕,李士,林大木,等.负压封闭引流技术联合人工真皮治疗足踝部皮肤软组织缺损[J].中国骨伤,2016,29(8):761-763.SONG YH,LI S,LIN DM,et al.Negative pressure closed drainage combined with artificial dermis for the treatment of skin and soft tissue defects of the foot and ankle[J].Zhongguo Gu Shang/China JOrthop Trauma,2016,29(8):761-763.Chinese with abstract in English.
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[2]龚滨,童伟林,何梦.交通事故致下肢皮肤撕脱伤48例治疗的体会[J].创伤外科杂志,2016,18(8):498-500.GONG B,TONG WL,HE M.Experience in treatment of 48 cases of lower limb skin avulsion injury caused by traffic accident[J].Chuang Shang Wai Ke Za Zhi,2016,18(8):498-500.Chinese.
[3]曾开,王裕辉,刘文豪,等.筛孔状中厚皮片反植联合闭式负压引流术对四肢严重皮肤撕脱伤疗效[J].深圳中西医结合杂志,2017,27(19):166-167.ZENG K,WANG YH,LIU WH,et al.Effect of mesh shaped medium thickness skin graft combined with closed negative pressure drainage on severe skin avulsion of extremities[J].Shen Zhen Zhong Xi Yi Jie He Za Zhi,2017,27(19):166-167.Chinese.
[4]叶舟,占蓓蕾,占允中,等.封闭式负压引流术在四肢皮肤撕脱伤中的应用[J].中国骨伤,2011,24(9):742-744.YE Z,ZHAN BL,ZHAN YZ,et al.Application of closed negative pressure drainage in skin avulsion of extremities[J].Zhongguo Gu Shang/China J Orthop Trauma,2011,24(9):742-744.Chinese with abstract in English.
[5]Leland HA,Rounds AD,Burtt KE,et al.Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma[J].Microsurgery,2018,38(3):259-263.
[6]司徒朴,陈杰,陈金火,等.暴露真皮下血管网的带蒂皮瓣[J].第一军医大学学报,1986,6(1):60-61.SI TP,CHEN J,CHEN JH,et al.A pedicled flap that exposes the subdermal vascular network[J].Di Yi Jun Yi Da Xue Xue Bao,1986,6(1):60-61.Chinese.
[7]陈友慈,廖坚文,李灿彬.全厚皮片联合封闭负压引流装置修复皮肤撕脱伤的应用效果分析[J].广东医学,2018,39(9):1376-1379.CHEN YC,LIAO JW,LI CS,et al.Analysis of application effect of full thickness skin combined with closed negative pressure drainage device in repairing skin avulsion[J].Guang Dong Yi Xue,2018,39(9):1376-1379.Chinese.
[8]刘金林,田晓瑜,马金赛,等.Ⅰ期清创皮瓣移植联合VSD在皮肤软组织缺损修复中的应用[J].中国骨与关节损伤杂志,2018,33(1):100-101.LIU JL,TIAN XY,MA JS,et al.Application of one stage debridement flap transplantation combined with VSD in the repair of skin and soft tissue defects[J].Zhongguo Gu Yu Guan Jie Sun Shang Za Zhi,2018,33(1):100-101.Chinese.
[9]张衡,官建中,周建生.阶梯状修剪原位回植结合持续负压封闭引流技术[J].中华全科医学,2017,15(4):602-604.ZHANG H,GUAN JZ,ZHOU JS.Stepped trimming in situ replantation combined with continuous negative pressure closed drainage[J].Zhonghua Quan Ke Yi Xue,2017,15(4):602-604.Chinese.
[10]Bai LC,Jia F,Sun RF.Clinical application of vacuum sealing drainage in treatment of soft tissue defect in lower limbs trauma[J].J Henan Univ Sci Tech,2014,32(4):259-260,263.
[11]Han N,Xu CG,Wang TB,et al.Electrical stimulation does not enhance nerve regeneration if delayed after sciatic nerve injury:the role of fibrosis[J].Neural Regen Res,2015,10(1):90-94.
[12]李强,宋世锋,张伟,等.负压封闭引流联合负载万古霉素硫酸钙与自体骨治疗慢性骨髓炎的临床研究[J].中国骨伤,2017,30(11):1059-1061.LI Q,SONG SF,ZHANG W,et al.Clinical study of negative pressure closed drainage combined with vancomgcin sulfate and autogenous bone in the treatment of chronic osteomyelitis[J].Zhongguo Gu Shang/China J Orthop Trauma,2017,30(11):1059-1061.Chinese with abstract in English.
[13]Kehlet H,Wilmore DW.Multimodal strategies to improve surgical outcome[J].Am J Surg,2002,183(6):630-641.
[14]Kehlet H,Wilmore DW.Evidence based surgical care and the evolution of fast track surgery[J].Ann Surg,2008,24(2):189-198.
[15]戴斌,皋沛,董启榕,等.加速康复外科理念在脊髓型颈椎病手术中应用的临床研究[J].中国骨伤,2018,31(8):740-745.DAI B,GAO P,DONG QR,et al.Clinical study on the application of accelerated rehabilitation surgery in the treatment of cervical spondylotic myelopathy[J].Zhongguo Gu Shang/China J Orthop Trauma,2018,31(8):740-745.Chinese with abstract in English.
[16]Harsten A,Kehlet H,Ljung P,et al.Total intravenous generalanaesthesia vs.spinal anaesthesia for total hip arthroplasty:a randomised,controlled trial[J].Acta Anaesthesiol Scand,2015,59(3):298-309.
[17]张宜杰,吴英夏,申梓玄,等.多发伤急诊救治的一体化模式探讨[J].中华灾害救援医学,2017,5(12):712-715.ZHANG YJ,WU YX,SHEN ZX,et al.Discussion on the integrated mode of emergency treatment for multiple injuries[J].Zhonghua Zai Hai Jiu Yuan Yi Xue,2017,5(12):712-715.Chinese.
[18]Nelson G,Altman AD,Nick A,et al.Guidelines for pre and intra operative care in gynecologic/oncology surgery:Enhanced Recovery After Surgery(ERAS)Society recommendations Par[J].Gynecol Oncol,2016,140(2):313-322.