岛状股后复合组织瓣修复坐骨结节及大转子区窦腔型压疮的临床效果

周孝亮; 涂家金; 叶华; 汪显林; 孙俊锋; 龙丽芸; 丁玉梅

doi:10.3760/cma.j.cn501225-20220420-00148

岛状股后复合组织瓣修复坐骨结节及大转子区窦腔型压疮的临床效果

doi: 10.3760/cma.j.cn501225-20220420-00148

赣州市人民医院烧伤整形科，赣州　　341000

基金项目:

赣州市指导性科技计划 GZ2020ZSF167

详细信息

通讯作者:
涂家金，Email：m18007079751@163.com

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出版历程
- 收稿日期: 2022-04-20

Clinical effects of island posterior femoral composite tissue flaps in the repair of sinus cavity pressure ulcers in the areas of ischial tuberosity and greater trochanter

Department of Burns and Plastic Surgery, Ganzhou People's Hospital, Ganzhou 341000, China

Funds:

Ganzhou Guiding Science and Technology Plan GZ2020ZSF167

More Information

Corresponding author: Tu Jiajin, Email: m18007079751@163.com

摘要

摘要: 目的探讨应用岛状股后复合组织瓣修复坐骨结节及大转子区窦腔型压疮的临床效果。方法采用回顾性观察性研究方法。2018年12月—2021年12月，赣州市人民医院收治23例符合入选标准的坐骨结节及大转子区窦腔型压疮患者，其中男16例、女7例，年龄45~86岁。清创前坐骨结节压疮大小为1.5 cm×1.0 cm~8.0 cm×5.0 cm，大转子区压疮大小为4.0 cm×3.0 cm~20.0 cm×10.0 cm。治疗基础疾病后，行清创+负压封闭引流5~14 d。所有创面均采用岛状股后复合组织瓣转移修复，面积为4.5 cm×3.0 cm~24.0 cm×12.0 cm，蒂宽3~5 cm，蒂长5~8 cm，旋转半径30~40 cm。将大部分供区创面直接缝合，仅对4个供区创面采用对侧大腿外侧中厚皮片修复。术后观察复合组织瓣成活情况、供受区创面愈合情况及并发症发生情况，随访压疮复发情况以及皮瓣的外观和质地。结果 23例患者共32个创面采用岛状股后复合组织瓣（筋膜皮下瓣3个、筋膜皮瓣+筋膜皮下瓣24个、筋膜皮瓣+筋膜真皮瓣2个、筋膜皮瓣+筋膜皮下瓣+股二头肌肌瓣2个、筋膜皮瓣+筋膜皮下瓣+股薄肌肌瓣1个）修复。术后31个复合组织瓣存活良好，1个筋膜皮瓣+筋膜皮下瓣远端少部分坏死，成活率为96.9%（31/32）。术后29个受区创面愈合；2个创面因患者翻身不当致皮瓣蒂部撕裂，床旁清创后1周愈合；1个创面因皮瓣淤紫致少部分坏死，再次清创后10 d愈合。31个供区（含4个植皮区）创面愈合，1个供区创面因出院时搬运不当而撕裂，再次清创缝合后15 d愈合。并发症发生率为12.5%（4/32），以皮瓣蒂部及供区切口裂开为主（3个），皮瓣远端淤血次之（1个）。随访3~24个月，患者压疮均未复发，皮瓣外观好、质地柔软。结论岛状股后复合组织瓣血运好、旋转半径大、组织量足，修复坐骨结节及大转子区窦腔型压疮术后成活率高、创面愈合好、供区创面植皮率低、术后并发症少、远期疗效佳。
- 压力性溃疡 /
- 坐骨 /
- 外科皮瓣 /
- 创面修复 /
- 复合组织瓣 /
- 大转子
Abstract: Objective To explore the clinical effects of island posterior femoral composite tissue flaps in the repair of sinus cavity pressure ulcers in the areas of ischial tuberosity and greater trochanter. Methods The retrospective observational study was conducted. From December 2018 to December 2021, 23 patients with sinus cavity pressure ulcers in the areas of ischial tuberosity and greater trochanter who met the inclusion criteria were admitted to Ganzhou People's Hospital, including 16 males and 7 females, aged 45 to 86 years. The size of pressure ulcers in ischial tuberosity ranged from 1.5 cm×1.0 cm to 8.0 cm×5.0 cm, and the size of pressure ulcers in greater trochanter ranged from 4.0 cm×3.0 cm to 20.0 cm×10.0 cm before debridement. After treatment of underlying diseases, debridement and vacuum sealing drainage for 5 to 14 days were performed. All the wounds were repaired by island posterior femoral composite tissue flaps, with area of 4.5 cm×3.0 cm-24.0 cm×12.0 cm, pedicle width of 3-5 cm, pedicle length of 5-8 cm, and rotation radius of 30-40 cm. Most of the donor site wounds were sutured directly, and only 4 donor site wounds were repaired by intermediate thickness skin graft from the contralateral thigh. The survival of composite tissue flaps, wound healing of the donor and recipient sites and the complications were observed. The recurrence of pressure ulcers, and the appearance and texture of flaps were observed during follow-up. Results A total of 32 wounds in 23 patients were repaired by island posterior femoral composite tissue flaps (including 3 fascio subcutaneous flaps, 24 fascial flaps+fascio subcutaneous flaps, 2 fascial flaps+fascial dermal flaps, 2 fascial flaps+fascio subcutaneous flaps+femoral biceps flaps, and one fascial flap+fascio subcutaneous flap+gracilis muscle flap). Among them, 31 composite tissue flaps survived well, and a small portion of necrosis occurred in one fascial flap+fascio subcutaneous flap post surgery. The survival rate of composite tissue flap post surgery was 96.9% (31/32). Twenty-nine wounds in the recipient sites were healed, and 2 wounds were torn at the flap pedicle due to improper postural changes, and healed one week after bedside debridement. One wound was partially necrotic due to the flap bruising, and healed 10 days after re-debridement. Thirty-one wounds in the donor sites (including 4 skin graft areas) were healed, and one wound in the donor site was torn due to improper handling at discharge, and healed 15 days after re-debridement and suture. The complication rate was 12.5% (4/32), mainly the incision dehiscence of the flap pedicle and the donor sites (3 wounds), followed by venous congestion at the distal end of flap (one wound). During the follow-up of 3 to 24 months, the pressure ulcers did not recur and the flaps had good appearance and soft texture. Conclusions The island posterior femoral composite tissue flaps has good blood circulation, large rotation radius, and sufficient tissue volume. It has a high survival rate, good wound healing, low skin grafting rate in the donor site, few postoperative complications, and good long-term effect in the repair of sinus cavity pressure ulcers in the areas of ischial tuberosity and greater trochanter.
- Pressure ulcer /
- Ischium /
- Surgical flaps /
- Wound repair /
- Composite tissue flaps /
- Greater trochanter
周孝亮：酝酿和设计研究、实施手术、采集资料、分析数据及撰写论文；涂家金：对文章的专业知识进行审阅、修改文章及指导；叶华、汪显林、孙俊锋、龙丽芸、丁玉梅：实施手术、采集资料、分析数据

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参考文献(35)

[1]	KottnerJ, CuddiganJ, CarvilleK, et al. Prevention and treatment of pressure ulcers/injuries: the protocol for the second update of the international Clinical Practice Guideline 2019[J]. J Tissue Viability, 2019, 28(2): 51-58. DOI: 10.1016/j.jtv.2019.01.001.
[2]	KanjLF, WilkingSV, PhillipsTJ. Pressure ulcers[J]. J Am Acad Dermatol, 1998, 38(4):517-536; quiz 537-538. DOI: 10.1016/s0190-9622(98)70113-6.
[3]	MunozN, PosthauerME. Nutrition strategies for pressure injury management: implementing the 2019 international Clinical Practice Guideline[J].Nutr Clin Pract,2022,37(3):567-582.DOI: 10.1002/ncp.10762.
[4]	刘毅,张绪生,张诚,等.褥疮的临床分型及手术治疗原则[J].中国修复重建外科杂志,2007,21(9):932-936.
[5]	刘毅,张鲜英,肖斌,等.17例窦道型压疮的临床特点及处理体会[J].中国修复重建外科杂志,2014,28(8):981-984. DOI: 10.7507/1002-1892.20140216.
[6]	徐永清,何晓清,范新宇,等.臀部不同部位压疮治疗方法的选择[J].中华显微外科杂志,2021,44(3):255-260. DOI: 10.3760/cma.j.cn441206-20201028-00368.
[7]	ArikrishnanD, BalakrishnanTM, JanardhanamJ. Pedicled chimeric perforator flap based on inferior gluteal vessel axis for the reconstruction of stage-four primary ischial pressure sores-a new design[J]. Indian J Plast Surg, 2021,54(2): 177-185. DOI: 10.1055/s-0041-1729505.
[8]	刘本全,董德升,史明艳,等.En bloc切除清创联合臀大肌肌瓣治疗坐骨结节压疮合并慢性骨髓炎的临床效果[J].中华烧伤与创面修复杂志,2022,38(4):363-368.DOI: 10.3760/cma.j.cn501120-20210122-00032.
[9]	张修航,高欣欣,陈欣欣,等.基于组织病理类型的坐骨结节压力性损伤临床修复策略[J].中华烧伤杂志,2019,35(4):261-265. DOI: 10.3760/cma.j.issn.1009-2587.2019.04.005.
[10]	KimJH,KwonHJ,MoonSH,et al.Trochanteric area reconstruction with free flap using perforators as recipients: an alternative and effective option[J].Microsurgery,2020,40(1):32-37.DOI: 10.1002/micr.30424.
[11]	徐承新,刘毅,陈黎明,等.臀部筋膜脂肪瓣修复坐骨结节和大转子复发性窦道型压疮[J].中国修复重建外科杂志,2020,34(10):1354-1355.DOI: 10.7507/1002-1892.202003071.
[12]	冯光,郝岱峰,张新健,等.坐骨结节压力性损伤的分型及修复策略[J/CD].中华损伤与修复杂志:电子版,2019,14(5): 339-343.DOI: 10.3877/cma.j.issn.1673-9450.2019.05.004.
[13]	侯春林,顾玉东.皮瓣外科学[M].2版.上海:上海科学技术出版社,2013:587-590.
[14]	王剑利,王根,赵刚,等.游离股后侧穿支动脉皮瓣的解剖学研究及临床应用[J].中华显微外科杂志,2013,36(1):7-10.DOI: 10.3760/cma.j.issn.1001-2036.2013.01.003.
[15]	LiXC,CuiJL,MaharjanS,et al.Clinical application and the free posterior thigh perforator flap[J].Ann Plast Surg,2017,78(5):526-532.DOI: 10.1097/SAP.0000000000000920.
[16]	AlganS, TanO. Profunda femoris artery perforator flaps: a detailed anatomical study[J]. J Plast Surg Hand Surg,2020,54(6): 377-381. DOI: 10.1080/2000656X.2020.1801456.
[17]	周晔,祝庆海,侯辰兴,等.股深动脉穿支皮瓣的解剖学特点及其在口腔颌面部缺损修复中的应用[J].中华口腔医学杂志,2022,57(6):604-610. DOI: 10.3760/cma.j.cn112144-20220321-00122.
[18]	BoyceMK,MettTR,IpaktchiR,et al.Flap coverage using the posterior gluteal thigh flap[J].Oper Orthop Traumatol,2018,30(4):245-252.DOI: 10.1007/s00064-018-0546-8.
[19]	XieY,ZhuangYH,XueL,et al.A composite gluteofemoral flap for reconstruction of large pressure sores over the sacrococcygeal region[J].J Plast Reconstr Aesthet Surg,2015,68(12):1733-1742.DOI: 10.1016/j.bjps.2015.08.016.
[20]	侯春林,李晓华,刘岩,等.以臀下动脉股后皮支为蒂的股后筋膜皮瓣治疗臀骶部褥疮[J].中华显微外科杂志,1995,18(2):114-115. DOI: 10.3760/cma.j.issn.1001-2036.1995.02.121.
[21]	王君,潘云川,徐家钦,等.双侧臀部旋转皮瓣修复骶尾部巨大压疮52例[J].中华烧伤杂志,2017,33(12):775-777. DOI: 10.3760/cma.j.issn.1009-2587.2017.12.011.
[22]	孙佳琳, 郭鹏飞, 崔正军, 等. 臀上动脉穿支接力皮瓣修复骶尾部压疮的临床效果[J]. 中华烧伤杂志,2020,36(8): 726-729. DOI: 10.3760/cma.j.cn501120-20190607-00265.
[23]	曹世坤,余道江,安璐,等.自由式穿支皮瓣在臀部压疮修复中的应用[J].中华解剖与临床杂志,2020,25(4):365-370. DOI: 10.3760/cma.j.cn101202-20200130-00023.
[24]	宋子卫,林舟丹,何少康. 阔筋膜张肌肌皮瓣移植治疗大转子部压疮的疗效[J].临床骨科杂志, 2017, 20(1): 69-70. DOI: 10.3969/j.issn.1008-0287.2017.01.031.
[25]	陈黎明,刘毅,张诚,等. 改良的阔筋膜张肌肌皮瓣修复大转子创面[J].中国美容医学, 2019, 28(4): 17-19.
[26]	孙晓晨,刘毅,陈黎明. 臀大肌为蒂的“风筝”肌皮瓣修复坐骨结节压疮[J].中国美容整形外科杂志,2020,31(7): 400-401,414. DOI: 10.3969/j.issn.1673-7040.2020.07.005.
[27]	ChouCY, SunYS, ShihYJ, et al. A descriptive, retrospective study of using an oblique downward-design gluteus maximus myocutaneous flap for reconstruction of ischial pressure ulcers[J]. Ostomy Wound Manage,2018,64(3): 40-44.
[28]	MohanAT, ZhuL, SurYJ, et al. Application of posterior thigh three-dimensional profunda artery perforator perforasomes in refining next-generation flap designs: transverse, vertical, and s-shaped profunda artery perforator flaps[J]. Plast Reconstr Surg,2017,139(4): 834e-845e. DOI: 10.1097/PRS.0000000000003224.
[29]	BoissiereF, GandolfiS, RiotS, et al. Flap venous congestion and salvage techniques: a systematic literature review[J]. Plast Reconstr Surg Glob Open,2021,9(1): e3327. DOI: 10.1097/GOX.0000000000003327.
[30]	AndrianasoloJ, FerryT, BoucherF, et al. Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy[J]. BMC Infect Dis,2018,18(1): 166. DOI: 10.1186/s12879-018-3076-y.
[31]	沈运彪, 夏懋, 柯海文, 等. 清创联合皮瓣转移“两步法”治疗4期压疮39例[J]. 中华烧伤杂志,2020,36(9): 870-872. DOI: 10.3760/cma.j.cn501120-20190729-00318.
[32]	朱雄翔,胡大海,郑朝,等. 多发性压力性溃疡的外科治疗[J].中华烧伤杂志,2008,24(1): 6-8. DOI: 10.3760/cma.j.issn.1009-2587.2008.01.003.
[33]	黄兆伦,黄晓栋,万里,等. 持续双负压微压力引流联合重组人表皮生长因子在压疮皮瓣修复术后的应用效果[J].中国现代手术学杂志,2021,25(4): 284-288. DOI: 10.16260/j.cnki.1009-2188.2021.04.010.
[34]	刘衍松,伊力扎提·伊力哈木,曹天勇,等. 术后封闭负压引流在臀部压疮修复中的应用[J].吉林医学, 2019, 40(11): 2615-2616. DOI: 10.3969/j.issn.1004-0412.2019.11.084.
[35]	储国平,吕国忠,朱宇刚,等. 部分去表皮的股后侧双叶皮瓣修复坐骨结节压疮15例[J].中华烧伤杂志,2018,34(8): 559-561. DOI: 10.3760/cma.j.issn.1009-2587.2018.08.015.

1 岛状股后复合组织瓣修复患者右侧大转子区及左侧坐骨结节伴骶尾部窦腔型压疮的效果。1A.清创前右侧大转子区压疮情况，创基有潜行腔隙；1B.清创后右侧髋关节囊暴露，于右侧股后区设计筋膜皮瓣+筋膜皮下瓣的岛状股后复合组织瓣；1C.复合组织瓣修复右侧大转子区，供区移植中厚皮术后即刻；1D.术后8个月随访，右侧大转子区压疮无复发，皮瓣外观良好；1E.清创前左侧坐骨结节和骶尾部压疮情况；1F.经负压封闭引流14 d后，创基清洁，于股后区设计筋膜皮瓣+筋膜皮下瓣的岛状股后复合组织瓣；1G.复合组织瓣修复左侧坐骨结节和骶尾部术后即刻；1H.术后8个月随访，左侧坐骨结节和骶尾部压疮无复发，皮瓣外观良好

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