Clinical efficacy of local injection of platelet-rich plasma combined with double-layer artificial dermis in treating wounds with exposed tendon on extremity
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摘要:
目的 探讨富血小板血浆（PRP）局部注射联合双层人工真皮治疗四肢肌腱外露创面的临床疗效。 方法 采用回顾性观察性研究方法。2017年12月—2022年10月贵州中医药大学第二附属医院创伤骨科收治16例、贵阳钢厂职工医院烧伤整形科收治32例符合入选标准的各种原因导致的四肢肌腱外露创面患者，其中男39例、女9例，年龄26~58岁。按照治疗方法将患者分为单纯PRP组、单纯人工真皮组和PRP+人工真皮组，每组16例。分别采用自体PRP、双层人工真皮或两者联合进行创面治疗，并于肉芽组织生长良好后行自体刃厚头皮移植术。Ⅱ期术后7 d，观察患者自体皮成活情况，并计算成活率。记录患者创面愈合时间及住院时间。创面愈合后3、6个月，采用温哥华瘢痕量表（VSS）对瘢痕的色泽、厚度、充血情况、柔软度等进行评分，并计算总分。记录整个治疗过程中，不良反应发生情况。对数据行 χ 2检验、Fisher确切概率法检验、单因素方差分析、LSD检验、Kruskal-Wallis H检验、Nemenyi法检验、Bonferroni校正。 结果 Ⅱ期术后7 d，单纯PRP组、单纯人工真皮组和PRP+人工真皮组患者自体皮成活率总体比较，差异无统计学意义（ P>0.05）。PRP+人工真皮组患者创面愈合时间、住院时间分别为（20.1±3.0）、（24±4）d，均较单纯PRP组的（24.4±5.5）、（30±8）d明显缩短（ P<0.05），也均较单纯人工真皮组的（24.8±4.9）、（32±8）d明显缩短（ P<0.05）。创面愈合后3、6个月，PRP+人工真皮组患者瘢痕柔软度得分均明显低于单纯PRP组（ Z值分别为12.91、15.69， P<0.05）和单纯人工真皮组（ Z值分别为12.50、12.91， P<0.05）。3组患者瘢痕色泽、充血情况、厚度得分和总分比较，差异均无统计学意义（ P>0.05）。单纯人工真皮组有1例患者覆盖双层人工真皮后10 d，因局部表皮葡萄球菌感染导致双层人工真皮部分液化脱落，予创面换药，同前再次行人工真皮移植及后续治疗；其余患者治疗过程中均未发生不良反应。 结论 PRP局部注射联合双层人工真皮治疗四肢肌腱外露创面的疗效确切，不仅可显著缩短创面愈合时间和住院时间，还可在一定程度上改善创面愈合后远期瘢痕柔软度，是一种值得推广应用的临床治疗技术。 Abstract:Objective To investigate the clinical efficacy of local injection of platelet-rich plasma (PRP) combined with double-layer artificial dermis in treating wounds with exposed tendon on extremity. Methods A retrospective observational study was conducted. From December 2017 to October 2022, 16 patients were admitted to Department of Orthopaedic Trauma of the Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, and 32 patients were admitted to Department of Burns and Plastic Surgery of Guiyang Steel Factory Staff Hospital. All the patients had wounds with exposed tendon on extremity caused by various reasons and met the inclusion criteria. There were 39 males and 9 females, aged 26 to 58 years. The patients were divided into PRP alone group, artificial dermis alone group, and PRP+artificial dermis group, with 16 patients in each group. The wounds were treated with autologous PRP, double-layer artificial dermis, or thei combination of autologous PRP and double-layer artificial dermis, followed by autologous split-thickness scalp grafting after good growth of granulation tissue. On the 7 th day after the secondary surgery, the autograft survival was observed, and the survival rate was calculated. The wound healing time and length of hospital stay of patients were recorded. At 3 and 6 months after wound healing, the Vancouver scar scale (VSS) was used to score the pigmentation, height, vascularity, and pliability of scars, and the total score was calculated. Adverse reactions during the entire treatment process were recorded. Data were statistically analyzed with chi-square test, Fisher's exact probability test, one-way analysis of variance, least significant difference test, Kruskal-Wallis H test, Nemenyi test, and Bonferroni correction. Results On the 7 th day after the secondary surgery, there was no statistically significant difference in the autograft survival rate of patients among PRP alone group, artificial dermis alone group, and PRP+artificial dermis group ( P>0.05). The wound healing time and length of hospital stay of patients in PRP+artificial dermis group were (20.1±3.0) and (24±4) d, respectively, which were significantly shorter than (24.4±5.5) and (30±8) d in PRP alone group ( P<0.05) and (24.8±4.9) and (32±8) d in artificial dermis alone group ( P<0.05). At 3 and 6 months after wound healing, the pliability scores of patients in PRP+artificial dermis group were significantly lower than those in PRP alone group (with Zvalues of 12.91 and 15.69, respectively, P<0.05) and artificial dermis alone group (with Zvalues of 12.50 and 12.91, respectively, P<0.05). There were no statistically significant differences in pigmentation, vascularity, height scores, and total score of scar of patients among the three groups ( P>0.05). In artificial dermis alone group, one patient experienced partial liquefaction and detachment of the double-layer artificial dermis due to local infection of Staphylococcus epidermidis, which received wound dressing change, second artificial dermis transplantation, and subsequent treatment as before. No adverse reactions occurred in the remaining patients during the whole treatment process. Conclusions Local injection of PRP combined with double-layer artificial dermis is effective in treating wounds with exposed tendon on extremity, which can not only significantly shorten wound healing time and length of hospital stay, but also improve scar pliability after wound healing to some extent in the long term. It is a clinically valuable treatment technique that is worth promoting and applying. -
参考文献
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1 局部注射富血小板血浆（PRP）+自体刃厚头皮移植治疗例1患者左足肌腱外露创面。1A.伤后18 d左足创面情况，创面较周围皮肤凹陷，表面覆盖黑色痂壳，创缘略红肿；1B.清创术中见创基晦暗，浅筋膜层脂肪变性坏死；1C.清创后即刻；1D.创面注射PRP过程中；1E.刃厚头皮移植术后7 d，皮片存活良好；1F.刃厚头皮移植术后10 d，创面基本愈合
2 双层人工真皮+自体刃厚头皮移植治疗例2患者右足肌腱外露创面。2A.术前创面覆盖黑色痂壳，第2、3、4跖趾关节处有黄白色液化坏死组织附着；2B.清创术中，去除黑色痂壳后创面情况；2C.清创后、移植双层人工真皮前；2D.移植人工真皮后7 d，𧿹长伸肌腱外露处见部分肉芽组织覆盖；2E.移植人工真皮后14 d，支架血管化充分；2F.头皮移植术后6 d存活良好
3 局部注射富血小板血浆（PRP）+双层人工真皮+自体刃厚头皮移植治疗例3患者右足肌腱外露创面。3A.清创术中，见创面软组织变性、液化；3B.清创后即刻，局部趾伸肌腱外露；3C.局部注射自体PRP过程中；3D.移植双层人工真皮术后即刻；3E.移植双层人工真皮术后7 d，部分肌腱外露创面被肉芽组织覆盖；3F.移植双层人工真皮后14 d，支架完全血管化，肉芽组织完全覆盖外露肌腱；3G.移植自体刃厚头皮后即刻；3H.头皮移植术后10 d存活良好；3I.创面愈合后6个月，瘢痕色泽接近肤色，充血情况不明显
表1 3组四肢肌腱外露创面患者一般资料比较
表1. Comparison of general information of patients with exposed tendon wounds on extremity among three groups
组别 例数 性别（例） 年龄（岁， 清创后肌腱外露创面面积（cm 2， 致伤原因（例） 男 女 热力烧伤 化学烧伤 慢性创面 单纯PRP组 16 14 2 36±9 7.4±3.3 11 3 2 单纯人工真皮组 16 12 4 37±10 6.8±3.0 12 1 3 PRP+人工真皮组 16 13 3 37±10 7.6±2.6 11 3 2 统计量值 χ 2=0.88 F=0.09 F=0.30 — P值 0.895 0.913 0.744 0.866 注：PRP为富血小板血浆；“—”表示无此项 
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表2 3组四肢肌腱外露创面患者Ⅱ期术后7 d自体头皮成活情况分级（例）
表2. Classification of autologous scalp survival in pa‑tients with tendon exposure wounds on extremity in three groups on the 7th day after the second stage surgery
组别 例数 优 良 一般 单纯PRP组 16 12 3 1 单纯人工真皮组 16 11 2 3 PRP+人工真皮组 16 12 3 1 注：PRP为富血小板血浆；自体皮成活率91%~100%为优，81%~90%为良，≤80%为一般
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表3 3组四肢肌腱外露创面患者创面愈合时间和住院时间比较（d，
表3. Comparison of wound healing time and hospitali‑zation time of patients with tendon exposure wounds on extremity among three groups
组别 例数 创面愈合时间 住院时间 单纯PRP组 16 24.4±5.5 30±8 单纯人工真皮组 16 24.8±4.9 32±8 PRP+人工真皮组 16 20.1±3.0 ab 24±4 ab F值 10.69 10.35 P值 0.005 0.006 注：PRP为富血小板血浆；创面愈合时间为创面从首次注射PRP（单纯PRP组、PRP+人工真皮组）或行人工真皮移植（单纯人工真皮组）至创面完全愈合时间；与单纯PRP组比较， a P<0.05；与单纯人工真皮组组比较， b P<0.05
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表4 3组四肢肌腱外露创面患者创面愈合后各时间点瘢痕的VSS评分比较[分， M（ Q 1， Q 3）]
表4. Comparison of VSS scores of scar in patients with tendon exposure wounds on extremity among three groups in each time point after wound healing
组别 例数 3个月 6个月 色泽 充血情况 厚度 柔软度 总分 色泽 充血情况 厚度 柔软度 总分 单纯PRP组 16 1.00（1.00，2.00） 1.00（1.00，2.00） 1.00（1.00，2.00） 1.00（1.00，2.75） 5.50（4.00，8.75） 1.00（0.25，2.00） 1.00（1.00，2.00） 1.00（0，2.00） 1.00（1.00，2.00） 4.00（2.00，7.00） 单纯人工真皮组 16 1.50（1.00，2.00） 1.00（1.00，2.00） 1.00（0，2.00） 1.50（1.00，2.00） 5.50（3.00，7.00） 1.00（1.00，1.00） 1.00（1.00，2.00） 1.00（0，1.00） 1.00（1.00，1.75） 4.00（3.00，5.00） PRP+人工真皮组 16 1.00（1.00，2.00） 1.00（1.00，2.00） 1.00（0.25，2.00） 1.00（0，1.00） ab 4.50（3.25，6.75） 1.00（1.00，1.00） 1.00（1.00，1.75） 0.50（0，1.00） 0.50（0，1.00） ab 3.00（2.00，4.00） H值 0.16 0.22 0.27 10.67 1.39 0.13 0.03 1.12 14.93 1.73 P值 0.925 0.896 0.876 0.005 0.500 0.938 0.984 0.571 0.001 0.420 注：VSS为温哥华瘢痕量表，PRP为富血小板血浆；与单纯PRP组比较， a P<0.05；与单纯人工真皮组比较， b P<0.05
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