Clinical efficacy of membrane induction technique combined with local myocutaneous flap in repairing sinus cavity pressure injury in the greater trochanteric region
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摘要:
目的 探讨膜诱导技术联合局部肌皮瓣修复大转子区窦腔型压力性损伤的临床疗效。 方法 该研究为回顾性病例系列研究。2020年1月—2023年1月，空军军医大学第一附属医院烧伤与皮肤外科收治12例符合入选标准的大转子区窦腔型压力性损伤且伴有不同程度感染的患者，其中男8例、女4例，年龄42~76岁，单侧大转子区压力性损伤者9例、双侧大转子区压力性损伤者3例，3例患者并发脓毒症。清创前压力性损伤创面外口面积为1.5 cm×1.0 cm~3.0 cm×3.0 cm，术中清创时测量的内腔面积为10.0 cm×8.5 cm~20.0 cm×10.0 cm。改善全身一般状况后，Ⅰ期行清创后抗生素骨水泥覆盖/填塞，Ⅱ期移植面积为10.0 cm×9.0 cm~22.5 cm×11.5 cm局部肌皮瓣修复创面，将供瓣区创面直接缝合。对比所有患者Ⅰ期术前与Ⅰ期术后7 d的白细胞计数、C反应蛋白、降钙素原、红细胞沉降率等炎症指标水平及创面分泌物标本微生物培养阳性比，记录并发脓毒症患者Ⅰ期术前与Ⅰ期术后3 d精神状况、体温、心率、呼吸频率，观察所有患者Ⅱ期术后局部肌皮瓣成活及创面愈合情况，随访所有患者压力性损伤复发情况及肌皮瓣外观和质地。 结果 12例患者Ⅰ期术后7 d的白细胞计数、C反应蛋白水平、降钙素原水平、红细胞沉降率均较Ⅰ期术前明显下降（t值分别为6.67、7.71、2.72、3.52，P<0.05）；Ⅰ期术后7 d创面分泌物标本微生物培养阳性比为2/12，较Ⅰ期术前的11/12明显降低（P<0.05）。3例并发脓毒症患者Ⅰ期术后3 d精神状况较Ⅰ期术前明显好转，体温恢复正常，心率<90次/min，呼吸频率<20次/min。共15个创面经局部肌皮瓣移植修复，Ⅱ期术后14个局部肌皮瓣存活良好，创面愈合；1个局部肌皮瓣远端少部分坏死，经床旁清创缝合后14 d愈合。Ⅱ期术后随访3~24个月，所有患者压力性损伤均未复发，肌皮瓣不臃肿，肌皮瓣颜色与周围皮肤组织近似且质地柔软。 结论 采用膜诱导技术联合局部肌皮瓣治疗大转子区窦腔型压力性损伤，可以通过抗生素骨水泥的覆盖/填塞降低患者全身炎症指标水平，减轻创面处的细菌负荷，形成诱导膜，为后期创面修复提供良好基础；局部肌皮瓣展现出了成活率高、并发症少、外观佳的良好临床效果，术后压力性损伤复发率低。 Abstract:Objective To investigate the clinical efficacy of membrane induction technique combined with local myocutaneous flap in repairing sinus cavity pressure injury in the greater trochanteric region. Methods The study was a retrospective case series study. From January 2020 to January 2023, 12 patients with sinus cavity pressure injury in the greater trochanteric region combined with varying degrees of infection who met the inclusion criteria were admitted to the Department of Burns and Cutaneous Surgery of the First Affiliated Hospital of Air Force Medical University, including 8 males and 4 females, aged 42-76 years. There were 9 patients with unilateral greater trochanteric pressure injury and 3 patients with bilateral greater trochanteric pressure injury. Three patients were complicated with sepsis. The external wound opening area of pressure injury before debridement was 1.5 cm×1.0 cm-3.0 cm×3.0 cm, and the internal cavity area measured during intraoperative debridement was 10.0 cm×8.5 cm-20.0 cm×10.0 cm. After the general condition of the whole body was improved, the covering/filling with antibiotic bone cement after debridement was performed in stage Ⅰ, the wound was repaired with local myocutaneous flap with the area of 10.0 cm×9.0 cm-22.5 cm×11.5 cm in stage Ⅱ, and the wound in the donor area was sutured directly. The levels of inflammatory indexes including white blood cell count, C-reactive protein, procalcitonin, and erythrocyte sedimentation rate, as well as the positive proportions of bacterial culture in wound exudation samples of all patients before and at 7 days after stage Ⅰ surgery were compared. The mental status, body temperature, heart rate, and respiratory rate of patients complicated with sepsis before and at 3 days after stage Ⅰ surgery were recorded. The survival of local myocutaneous flap and wound healing were observed in all patients after stage Ⅱ surgery. The recurrence of pressure injury and the appearance and texture of the myocutaneous flap were followed up in all patients. Results Compared with those before stage Ⅰ surgery, the white blood cell count, C-reactive protein level, procalcitonin level, and erythrocyte sedimentation rate of 12 patients at 7 days after stage Ⅰ surgery were significantly decreased (with t values of 6.67, 7.71, 2.72, and 3.52, respectively, P<0.05). The proportion of positive bacterial culture in wound exudation samples at 7 days after stage Ⅰ surgery was 2/12, which was significantly lower than 11/12 before stage Ⅰ surgery (P<0.05). The mental state of 3 patients complicated with sepsis improved significantly at 3 days after stage Ⅰ surgery, which was improved as compared with that before stage Ⅰ surgery, their body temperature returned to normal, heart rate was <90 times/min, and respiratory rate was <20 times/min. A total of 15 wounds were repaired by local myocutaneous flaps, 14 local myocutaneous flaps survived well after stage Ⅱ surgery and the wounds were healed, while a partial necrosis occurred at the distal end of one local myocutaneous flap, which was healed at 14 days after bedside debridement and suturing. Follow-up for 3 to 24 months after stage Ⅱ surgery showed that the pressure injury was not recurrent in any patient, the flap was not bloated, the color of the myocutaneous flap was similar to the surrounding skin tissue, and the myocutaneous flap was soft in texture. Conclusions Membrane induction technique combined with local myocutaneous flap in the treatment of sinus cavity pressure injury in the greater trochanteric region can decrease the systematic levels of inflammatory indexes of patients and reduce the bacterial load of the wound by covering or filling with antibiotic bone cement, and form the induction membrane to provide a good basis for later wound repair. The local myocutaneous flap shows good clinical effects including a high survival rate, few complications, good appearance, and low recurrence rate of postoperative pressure injury. -
参考文献
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1 膜诱导技术联合臀部肌皮瓣修复患者大转子区窦腔型压力性损伤的效果。1A.入院后，CT检查可见左侧股骨头缺如（箭头所指），周围结构紊乱；1B.清创前左侧大转子区压力性损伤创面伴有明显的潜行窦腔；1C.Ⅰ期清创（去除坏死骨质）+抗生素（万古霉素）骨水泥填塞后即刻；1D.Ⅰ期术后7 d于臀部健康皮肤设计臀部肌皮瓣；1E.Ⅱ期转移臀部肌皮瓣修复大转子区压力性损伤术后即刻；1F.Ⅱ期术后12个月随访，患者压力性损伤未复发，肌皮瓣外观好、无臃肿
表1 12例大转子区窦腔型压力性损伤患者Ⅰ期术前和Ⅰ期术后7 d炎症指标水平比较（
表1. Comparison of inflammation index levels in 12 patients with sinus cavity pressure injury in the greater trochanteric region before and at 7 days after stage Ⅰ surgery
时间点 白细胞计数（×109/L） C反应蛋白（mg/L） 降钙素原（ng/L） 红细胞沉降率（mm/h） Ⅰ期术前 12.7±2.4 87±15 0.39±0.17 33±10 Ⅰ期术后7 d 9.6±1.5 44±14 0.24±0.08 21±9 t值 6.67 7.71 2.72 3.52 P值 0.001 0.001 0.005 0.020 
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