A prospective randomized controlled study of the effectiveness of artificial dermis combined with split-thickness skin for repairing wounds with bone and tendon exposure in hands and feet
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摘要:
目的 探讨人工真皮联合刃厚皮修复手足骨骼与肌腱外露创面的临床疗效。 方法 采用前瞻性随机对照研究方法。选择郑州市第一人民医院烧伤科2018年10月—2020年2月收治的符合入选标准的82例手足骨骼与肌腱外露创面患者，采用随机数字表法将其分为皮瓣组（41例，其中男27例、女14例）和人工真皮+刃厚皮组（41例，其中男29例、女12例），其年龄均为（37±7）岁。2组患者创面彻底清创后，皮瓣组患者创面移植游离股前外侧皮瓣；人工真皮+刃厚皮组患者创面移植人工真皮并给予持续负压吸引，待创面人工真皮完全血管化后，移植自体大腿外侧刃厚皮。自体皮片/皮瓣移植术后1周，观察创面移植物成活情况并计算移植物成活率；记录创面完全愈合时间、手术次数、住院时间、住院费用、自体皮片/皮瓣移植术后住院期间手术相关并发症发生情况并计算并发症发生率；自体皮片/皮瓣移植术后6个月，采用温哥华瘢痕量表（VSS）评价受区瘢痕增生情况，分别采用总主动活动度（TAM）系统评定方法与美国矫形外科足踝协会踝与后足功能量表（AOFAS-AHS）评价手、足功能恢复情况。对数据行χ2检验、Fisher确切概率法检验、独立样本t检验。 结果 自体皮片/皮瓣移植术后1周，2组患者创面移植物成活率相近（P>0.05）。人工真皮+刃厚皮组患者创面完全愈合时间与住院时间分别为（29±5）、（35±5）d，较皮瓣组的（22±4）、（28±5）d明显延长（t=6.96、6.22，P<0.01）；与皮瓣组比较，人工真皮+刃厚皮组患者手术次数明显减少（t=7.39，P<0.01），自体皮片/皮瓣移植术后住院期间手术相关并发症发生率明显降低（P<0.01），住院费用无明显变化（P>0.05）。自体皮片/皮瓣移植术后6个月，2组患者受区VSS评分相近（t=0.32，P>0.05）；人工真皮+刃厚皮组患者手功能的TAM评分和足功能的AOFAS-AHS评分分别为（40±6）、（62±12）分，明显高于皮瓣组的（34±6）、（53±11）分（t=4.66、3.41，P<0.01）。 结论 采用人工真皮联合刃厚皮修复手足骨骼与肌腱外露创面手术次数相对皮瓣修复术少，可降低手术相关并发症发生率，改善患者术后手足关节功能，无明显瘢痕增生，但创面愈合时间和住院时间也可能会相应延长。 Abstract:Objective To explore the clinical effects of artificial dermis combined with split-thickness skin for repairing wounds with bone and tendon exposure in hands and feet. Methods A prospective randomized controlled study was conducted. From October 2018 to February 2020, 82 patients with bone and tendon exposed wounds in hands and feet admitted to the Department of Burns of Zhengzhou First People′s Hospital who met the inclusion criteria were selected. All the patients were divided into flap group (41 cases, including 27 males and 14 females) and artificial dermis+split-thickness skin group (41 cases, including 29 males and 12 females) according to the random number table, with age of (37±7) years. After complete debridement of wounds of patients in the two groups, the wounds of patients in flap group were transplanted with anterolateral femoral free flaps; the wounds of patients in artificial dermis+split-thickness skin group were grafted with artificial dermis with continuous negative pressure suction applied, and then grafted with split-thickness skin from autologous lateral thigh once the vascularization of artificial dermis was completed. One week after autologous skin graft/flap grafting, the survival of wound graft was observed and the graft survival rate was calculated. The complete wound healing time, number of operation, length of hospital stay, hospitalization cost, and the occurrence of surgery-related complications during hospitalization after autologous skin graft/flap grafting were recorded, and the incidence of complications was calculated. Six months after autologous skin graft/flap grafting, the scar hyperplasia of recipient area was evaluated by Vancouver Scar Scale (VSS), while the recovery of hand and foot function was evaluated by Total Action Mobility (TAM) System Rating method and American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Function Scale (AOFAS-AHS), respectively. Data were statistically analyzed with chi-square test, Fisher's exact probability test, and independent sample t test. Results One week after autologous skin graft/flap grafting, the survival rates of wound grafts were similar in the two groups (P>0.05). The complete wound healing time and length of hospital stay were (29±5) and (35±5) d for patients in artificial dermis+split-thickness skin group, respectively, which were significantly longer than (22±4) and (28±5) d in flap group (t=6.96, 6.22, P<0.01). Compared with those in flap group, the number of operations was fewer (t=7.39, P<0.01), the incidence of surgery-related complications during hospitalization after autologous skin graft/flap grafting was lower (P<0.01), but there was no significant change in hospitalization cost of patients in artificial dermis+split-thickness skin group (P>0.05). Six months after autologous skin graft/flap grafting, the VSS scores of recipient area of patients in the two groups were similar (t=0.32, P>0.05); the TAM score of hand function and AOFAS-AHS score of foot function of patients in artificial dermis+split-thickness skin group were 40±6 and 62±12, respectively, which were significantly higher than 34±6 and 53±11 of flap group (t=4.66, 3.41, P<0.01). Conclusions The combined application of artificial dermis and split-thickness skin results in fewer number of operation compared with using flaps in the repair of wounds with bone and tendon exposure in hands and feet, reducing the incidence of surgery-related complications and improving the postoperative hand and foot joint function of patients, without significant scar hyperplasia, although it may also prolong the wound healing time and length of hospital stay accordingly. -
Key words:
- Skin, artificial /
- Skin transplantation /
- Hand /
- Foot /
- Split-thickness skin /
- Wounds with bone and tendon exposure
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所有作者均声明不存在利益冲突上海交通大学医学院附属第九人民医院章一新教授团队在《Burns & Trauma》杂志发文《The modified bilobed flap for reconstructing sacral decubitus ulcers》，回顾性分析2015年1月—2019年12月使用改良双叶皮瓣治疗7例骶尾部压疮面积为 6.2 cm×4.5 cm~11 cm×10 cm的患者的效果。结果显示，术后改良双叶皮瓣均成活，随访12个月未见皮瓣坏死或复发等明显并发症。作者认为臀上动脉浅支或第4腰动脉后支可为双叶皮瓣提供可靠的血供，且皮瓣中可携带臀上神经。该方法操作简单、疗效可靠，可用于骶尾部深度压疮的修复。孙佳辰，编译自《Burns Trauma》，2020，8:tkaa012；申传安，审校
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1 人工真皮+刃厚皮修复热压伤患者清创后手骨骼与肌腱外露创面。1A.清创术前可见左手第2~5指基底苍白、表皮撕脱、痛觉迟钝，掌侧创面基底红白相间、质韧；1B.彻底清创后可见骨骼与肌腱外膜；1C.人工真皮移植术后即刻；1D.人工真皮移植后负压封闭引流第5天；1E.负压封闭引流2周后可见左手第2~5指背侧肉芽组织生长良好，肌腱外露创面呈线状；1F.术中扩创后创面外观；1G.自体刃厚皮移植术后即刻；1H.刃厚皮移植2周后创面基本愈合；1I、1J.分别为术后6个月随访创面外观、屈曲功能，均良好
表1 2组手足骨骼与肌腱外露创面患者临床资料比较
组别 例数 性别（例） 年龄（岁， 创面形成原因（例） 部位（例） 创面总面积（cm2， 骨骼与肌腱外露面积（cm2， 骨骼和肌腱外露面积与非骨骼和肌腱外露面积比值 男 女 交通事故伤 热压伤 烧伤后创面感染坏死 手 足 皮瓣组 41 27 14 37±7 22 13 6 24 17 10±6 7±3 2.1±0.5 人工真皮+刃厚皮组 41 29 12 37±7 21 13 7 22 19 11±5 7±3 2.2±0.5 统计量值 — t=0.15 χ2=0.72 χ2=1.26 t=0.15 t=0.07 t=0.27 P值 0.08 0.88 0.79 0.24 0.88 0.94 0.79 注：皮瓣组患者创面采用股前外侧皮瓣修复；“—”表示无此统计量值 
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表2 2组手足骨骼与肌腱外露创面患者治疗相关情况比较(
组别 例数 创面完全愈合时间（d） 手术次数（次） 住院时间（d） 住院费用（万元） 皮瓣组 41 22±4 3.3±0.6 28±5 4.7±0.5 人工真皮+刃 厚皮组 41 29±5 2.5±0.4 35±5 4.6±0.6 t值 6.96 7.39 6.22 1.51 P值 <0.01 <0.01 <0.01 0.14 注：皮瓣组患者创面采用股前外侧皮瓣修复
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期刊类型引用(21)
1. 隋磊，谢强，孔宇，王晓雪，郝宇，李小东. 双层人工真皮联合负压封闭引流和自体刃厚皮片移植治疗慢性难愈合创面的疗效. 局解手术学杂志. 2025(02): 125-129 . 
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本站查看14. 冯颜杰，欧阳欢庆，涂智鑫，袁剑，吴伟强. 双层人工真皮在手部或足部骨质肌腱外露创面治疗中的应用效果分析. 世界复合医学. 2023(10): 54-56+60 . 百度学术15. 吴磊，周济宏，杨婷，蒋琪霞. 人工真皮替代物应用于伤口护理的研究进展. 护理学报. 2022(05): 42-46 . 百度学术16. 戚建武，陈邵，孙斌鸿，柴益铜，黄剑，李一，杨科跃，孙赫阳，陈宏. 游离背阔肌肌皮瓣联合人工真皮及刃厚皮治疗下肢脱套伤的临床效果. 中华烧伤与创面修复杂志. 2022(04): 347-353 . 本站查看17. 刘江涛，黄书润，欧阳容兰，王一勇. 小腿穿支皮瓣修复足踝部皮肤软组织缺损. 中国现代手术学杂志. 2022(02): 114-119 . 百度学术18. 曾皓，张烁，徐泽华，罗文跃，龙丽芸. 双层人工真皮在骨质肌腱外露创面中的应用. 临床医药实践. 2022(08): 583-585+618 . 百度学术19. 王春书，张鹏飞，王亮，薛士辉，杜康，汪剑龄，孙中洋. 人工真皮与游离植皮修复指腹皮肤软组织缺损的比较研究. 实用骨科杂志. 2022(09): 778-781+851 . 百度学术20. 刘江涛，欧阳容兰，李丽香，黄书润，李小毅. 膝降动脉穿支皮瓣应用于膝周软组织缺损创面修复的效果分析. 东南国防医药. 2022(05): 486-489 . 百度学术21. 由夫超，田文平，曹立鹤，高晗，马昌志，何雪峰. 人工真皮联合全厚皮移植在手指局部软组织缺损中的应用. 手术电子杂志. 2022(06): 26-31 . 百度学术其他类型引用(6)
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