人工真皮联合刃厚皮修复手足骨骼与肌腱外露创面效果的前瞻性随机对照研究

狄海萍; 母心灵; 史继静; 薛继东; 刘磊; 郭海娜; 邢培朋; 夏成德

doi:10.3760/cma.j.cn501120-20210325-00103

人工真皮联合刃厚皮修复手足骨骼与肌腱外露创面效果的前瞻性随机对照研究

doi: 10.3760/cma.j.cn501120-20210325-00103

1.
郑州市第一人民医院烧伤科　　450004
2.
郑州市第一人民医院骨科　　450004
3.
郑州市第一人民医院干细胞中心　　450004

基金项目:

河南省医学科技攻关计划联合共建项目 LHGJ20191000

河南省科技发展计划 202102310133

详细信息

通讯作者:
母心灵，Email：muxinlinggege@163.com

计量
- 文章访问数: 370
- HTML全文浏览量: 61
- PDF下载量: 87
- 被引次数: 0
出版历程
- 收稿日期: 2021-03-25

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

1.
Department of Burns, Zhengzhou First People′s Hospital, Zhengzhou 450004, China
2.
Department of Orthopedic Surgery, Zhengzhou First People′s Hospital, Zhengzhou 450004, China
3.
Stem Cell Center, Zhengzhou First People′s Hospital, Zhengzhou 450004, China

Funds:

The Joint Project of Henan Medical Science and Technology Research Program of China LHGJ20191000

Science and Technology Development Plan of Henan Province of China 202102310133

More Information

Corresponding author: Mu Xinling, Email: muxinlinggege@163.com

摘要

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。
- 皮肤，人工 /
- 皮肤移植 /
- 手 /
- 足 /
- 刃厚皮 /
- 骨骼与肌腱外露创面
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.
- Skin, artificial /
- Skin transplantation /
- Hand /
- Foot /
- Split-thickness skin /
- Wounds with bone and tendon exposure
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

HTML全文

参考文献(34)

[1]	王永胜,邱健钊,李军,等.人工真皮覆盖修复手足小面积创面的效果[J].临床骨科杂志,2017,20(1):64-66.DOI: 10.3969/j.issn.1008-0287.2017.01.028.
[2]	刘少华,李有斌,范嘉文,等.旋股外侧动脉降支游离穿支皮瓣修复伴骨外露的踝部皮肤软组织缺损[J].中华整形外科杂志,2021,37(7):790-794.DOI: 10.3760/cma.j.cn114453-20190624-00202.
[3]	蒋亮,朱红菊,唐佳玉,等.藻酸盐敷料联合rhGM-CSF用水胶体封闭治疗肌腱、骨外露的疗效研究[J/CD].中华损伤与修复杂志:电子版,2020,15(5):376-382.DOI: 10.3877/cma.j.issn.1673-9450.2020.05.009.
[4]	WangHJ,WeiLG,WangCH,et al.A new form of artificial skin to promote permanent wound coverage: a preliminary report[J].Ann Plast Surg,2017,78(3 Suppl 2):S148-152.DOI: 10.1097/SAP.0000000000001021.
[5]	ZhuC,LiuJ,HeB,et al.The role of human immortal skin keratinocytes-acellular dermal matrix scaffold in skin repair and regeneration[J].J Cell Biochem,2019,120(8):12182-12191.DOI: 10.1002/jcb.28588.
[6]	邢培朋,郭海娜,狄海萍,等.游离股前外侧皮瓣联合动脉血管重建修复腕部高压电烧伤创面的临床效果[J].中华烧伤杂志,2020,36(6):419-425.DOI: 10.3760/cma.j.cn501120-20200219-00067.
[7]	沈余明,陈旭,张琮,等.旋股外侧动脉降支血流桥接皮瓣修复患者腕部高压电烧伤创面的效果[J].中华烧伤杂志,2017,33(7):422-425.DOI: 10.3760/cma.j.issn.1009-2587.2017.07.006.
[8]	WangW,LiP,LiW,et al.Osteopontin activates mesenchymal stem cells to repair skin wound[J].PLoS One,2017,12(9):e0185346.DOI: 10.1371/journal.pone.0185346.
[9]	王君,井刚,董道全,等.人工真皮联合自体刃厚皮片移植修复老年患者下肢感染创面[J].组织工程与重建外科杂志,2020,16(5):374-377.DOI: 10.3969/j.issn.1673-0364.2020.05.006.
[10]	朱鑫,赵志坚,陈坤峰.皮瓣移植修复胫腓骨骨折固定术后小腿皮肤坏死28例[J].中华显微外科杂志,2018,41(1):74-77.DOI: 10.3760/cma.j.issn.1001-2036.2018.01.019.
[11]	董其强,谢书强,王礼军,等.负压封闭引流联合Lando®人工真皮并结合自体皮移植应用于手足部骨肌腱外露伴骨折创面的临床研究[J/CD]. 中华损伤与修复杂志:电子版,2020,15(1):51-55.DOI: 10.3877/cma.j.issn.1673-9450.2020.01.008.
[12]	姜凯,丁永虎,丁小珩.应用双层人工真皮修复指端及甲床缺损[J].中华手外科杂志,2020,36(3):203-205.DOI: 10.3760/cma.j.cn311653-20200223-00062.
[13]	LiuT,QiuC,BenC,et al.One-step approach for full-thickness skin defect reconstruction in rats using minced split-thickness skin grafts with Pelnac overlay[J/OL].Burns Trauma,2019,7:19[2021-03-25].https://pubmed.ncbi.nlm.nih.gov/31413962/.DOI: 10.1186/s41038-019-0157-0.
[14]	于子云,张晓丽,刘晓辉,等.Lando双层人工真皮在手部皮肤缺损中的应用[J].实用手外科杂志,2021,35(1):13-15.DOI: 10.3969/j.issn.1671-2722.2021.01.004.
[15]	王飞,周萍,段淑芳,等.人工真皮支架联合灌洗式负压封闭引流在肌腱或骨外露创面修复中的应用[J/CD]. 中华损伤与修复杂志:电子版,2020,15(6):470-474.DOI: 10.3877/cma.j.issn.1673-9450.2020.06.008.
[16]	陈欣,杜伟力,温春泉,等.单层型+双层型人工真皮复合移植修复下肢大面积骨外露创面的疗效[J].中华创伤杂志,2021,37(6):519-525.DOI: 10.3760/cma.j.cn501098-20210104-00007.
[17]	王成,陈欣,沈余明,等.人工真皮联合自体皮片修复创伤后骨和/或肌腱外露创面的临床研究[J].中国医刊,2020,55(12):1334-1337.DOI: 10.3969/j.issn.1008-1070.2020.12.018.
[18]	LagusH,KankuriE,NuutilaK,et al.Induced granulation tissue but not artificial dermis enhances early host-graft interactions in full-thickness burn wounds[J].World J Surg,2018,42(4):981-991.DOI: 10.1007/s00268-017-4270-6.
[19]	WangJ,ChenY,ZhouG,et al.Polydopamine-coated Antheraea pernyi (A. pernyi) silk fibroin films promote cell adhesion and wound healing in skin tissue repair[J].ACS Appl Mater Interfaces,2019,11(38):34736-34743.DOI: 10.1021/acsami.9b12643.
[20]	ZajicekR,KubokR,PetrovaN,et al.Complex approach to skin repair in an extensively burned child: a case study[J].J Wound Care,2020,29(8):458-463.DOI: 10.12968/jowc.2020.29.8.458.
[21]	李佳玲,王宇翀,薛春雨,等.人工真皮联合KCI负压吸引装置修复头皮恶性肿瘤术后颅骨外露[J].中华医学美学美容杂志,2021,27(3):199-202.DOI: 10.3760/cma.j.issn.1671-0290.2021.03.011.
[22]	邵阳,林伟,刘建疆,等.分叶背阔肌皮瓣游离移植修复小腿不规则软组织缺损创面[J].中华显微外科杂志,2019,42(5):450-454.DOI: 10.3760/cma.j.issn.1001-2036.2019.05.008.
[23]	刘安铭,周鑫,欧昌良,等.以足部为供区的微型皮瓣移植修复手指软组织缺损[J].中华手外科杂志,2019,35(5):391-392.DOI: 10.3760/cma.j.issn.1005-054X.2019.05.027.
[24]	李敏雄,马军,郑紫君,等.双层人工真皮复合自体皮移植修复骨质和/或肌腱外露创面的临床疗效[J].中华烧伤杂志,2020,36(3):179-186.DOI: 10.3760/cma.j.cn501120-20191119-00437.
[25]	弓辰,唐洪泰,王光毅,等.国产人工真皮移植结合自体皮移植修复骨质肌腱外露创面的疗效评价[J/CD]. 中华损伤与修复杂志:电子版,2016,11(1):34-39.DOI: 10.3877/cma.j.issn.1673-9450.2016.01.008.
[26]	宋德恒,刘继松,郝擎宇,等.人工真皮在整形外科中的应用[J].中国美容医学,2018,27(1):137-140.
[27]	SobtiN,JiE,BrownRL,et al.Evaluation of acellular dermal matrix efficacy in prosthesis-based breast reconstruction[J].Plast Reconstr Surg,2018,141(3):541-549.DOI: 10.1097/PRS.0000000000004109.
[28]	刘洋,张宜澜,黄亚兰,等.人工真皮联合碱性成纤维细胞生长因子在瘢痕和皮肤深度创面整复中的临床应用[J] . 中华烧伤杂志,2016,32(4):198-203. DOI: 10.3760/cma.j.issn.1009-2587.2016.04.003.
[29]	张卫峰,冯亚高,陶忠生,等.人工真皮修复手足部肌腱和骨外露创面[J].临床骨科杂志,2016,19(4):448-450.DOI: 10.3969/j.issn.1008-0287.2016.04.025.
[30]	HeimbachDM,WardenGD,LutermanA,et al.Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment[J].J Burn Care Rehabil,2003,24(1):42-48.DOI: 10.1097/00004630-200301000-00009.
[31]	YeongEK,ChenSH,TangYB.The treatment of bone exposure in burns by using artificial dermis[J].Ann Plast Surg,2012,69(6):607-610.DOI: 10.1097/SAP.0b013e318273f845.
[32]	刘魁,孙一种,赵延宾,等.人工真皮与皮瓣修复术在下肢开放性损伤治疗中的疗效比较[J].中国骨与关节损伤杂志,2019,34(6):657-658.DOI: 10.7531/j.issn.1672-9935.2019.06.035.
[33]	李廷,王晨,程大胜,等.人工真皮支架早期修复特重烧伤手足深度创面[J].第二军医大学学报,2016,37(1):1-4.DOI: 10.16781/j.0258-879x.2016.01.0001.
[34]	苑莎莎,范炜,王香坤,等.lando双层人工真皮修复材料与自体刃厚皮片移植对创面细胞因子的影响[J].河北医药,2020,42(7):1003-1006,1011.DOI: 10.3969/j.issn.1002-7386.2020.07.009.

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

下载: 全尺寸图片幻灯片

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，x¯±s）	创面形成原因（例）			部位（例）		创面总面积（cm²，x¯±s）	骨骼与肌腱外露面积（cm²，x¯±s）	骨骼和肌腱外露面积与非骨骼和肌腱外露面积比值
组别	例数	男	女	年龄（岁，x¯±s）	交通事故伤	热压伤	烧伤后创面感染坏死	手	足	创面总面积（cm²，x¯±s）	骨骼与肌腱外露面积（cm²，x¯±s）	骨骼和肌腱外露面积与非骨骼和肌腱外露面积比值
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

下载: 导出CSV

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(x¯±s)

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