多学科团队协作模式下游离股前外侧穿支皮瓣修复糖尿病足溃疡的临床效果

赵建军; 谢振军; 赵国红; 张建华; 孙华伟; 白辉凯; 张会峰; 张东宾; 肖二辉; 朱国松

doi:10.3760/cma.j.cn501225-20231107-00184

多学科团队协作模式下游离股前外侧穿支皮瓣修复糖尿病足溃疡的临床效果

doi: 10.3760/cma.j.cn501225-20231107-00184

1.
河南省人民医院（郑州大学人民医院）手足显微与创面修复外科,郑州　　450003
2.
河南省人民医院（郑州大学人民医院）内分泌科,郑州　　450003
3.
河南省人民医院（郑州大学人民医院）血管外科,郑州　　450003
4.
河南省人民医院（郑州大学人民医院）感染性疾病科,郑州　　450003
5.
河南省人民医院（郑州大学人民医院）麻醉手术部,郑州　　450003

基金项目:

河南省科技攻关项目 242102311085

详细信息

通讯作者:
谢振军,Email：xzj65@126.com

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出版历程
- 收稿日期: 2023-11-07

Clinical effects of free anterolateral thigh perforator flaps in repairing diabetic foot ulcers under a multi-disciplinary team cooperation model

1.
Department of Hand and Foot Microscopy and Wound Repair Surgery, Henan Provincial People's Hospital (People's Hospital of Zhengzhou University), Zhengzhou 450003, China
2.
Department of Endocrinology, Henan Provincial People's Hospital (People's Hospital of Zhengzhou University), Zhengzhou 450003, China
3.
Department of Vascular Surgery, Henan Provincial People's Hospital (People's Hospital of Zhengzhou University), Zhengzhou 450003, China
4.
Department of Infectious Diseases, Henan Provincial People's Hospital (People's Hospital of Zhengzhou University), Zhengzhou 450003, China
5.
Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital (People's Hospital of Zhengzhou University), Zhengzhou 450003, China

Funds:

Science and Technology Research Project of Henan Province of China 242102311085

More Information

Corresponding author: Xie Zhenjun, Email: xzj65@126.com

摘要

摘要: 目的探讨多学科团队（MDT）协作模式下游离股前外侧穿支皮瓣修复糖尿病足溃疡（DFU）的临床效果。方法该研究为回顾性观察性研究。2018年6月—2022年12月,河南省人民医院（郑州大学人民医院）手足显微与创面修复外科收治49例符合入选标准的DFU患者,其中男28例、女21例,年龄47~68岁,2型糖尿病病程6个月~21年。在MDT协作模式下,内分泌科医师全面评估患者、稳定患者全身情况、控制并发症,血管外科医师评估和改善患者下肢血供,感染性疾病科医师提供抗感染治疗方案,麻醉手术部医师评估患者围手术期风险、保障患者围手术期安全,心内科、神经内科、营养科、康复科等科室医师根据患者情况主动适时参与治疗。手足显微与创面修复外科医师行创基准备,采用游离股前外侧穿支皮瓣修复创面。Ⅰ期行1次或多次清创后,创面面积为5.0 cm×4.5 cm~17.0 cm×10.0 cm。行1次或2次负压封闭引流治疗后,Ⅱ期采用游离股前外侧穿支皮瓣（面积为6 cm×5 cm~18 cm×11 cm）修复创面,将皮瓣的旋股外侧动脉降支及其伴行静脉分别与受区动、静脉吻合,皮瓣供区创面直接拉拢缝合。术后观察患者是否平稳度过围手术期、皮瓣成活情况、皮瓣供受区创面愈合情况；术后随访时,观察皮瓣质地、外形,有无新发溃疡及患者的行走能力。结果患者均平稳度过围手术期。46例患者皮瓣顺利成活；2例患者皮瓣完全坏死,其中1例患者行小腿带蒂皮瓣修复后溃疡愈合,另1例患者行小腿截肢；1例患者皮瓣部分坏死,经换药、移植皮片后愈合。患者皮瓣供受区创面均愈合良好。术后随访6~24个月,皮瓣质地良好、外形较佳,无新发溃疡,患者日常行走无明显障碍。结论 MDT协作模式能充分地保障DFU患者围手术期安全。采用游离股前外侧穿支皮瓣修复DFU创面,皮瓣成活率较高,可降低截肢率,临床效果较佳。
- 糖尿病足 /
- 溃疡 /
- 外科皮瓣 /
- 穿支皮瓣 /
- 显微外科手术 /
- 多学科团队 /
- 创面修复 /
- 保肢
Abstract: Objective To explore the clinical effects of free anterolateral thigh perforator flaps in repairing diabetic foot ulcers (DFUs) under a multi-disciplinary team (MDT) cooperation model. Methods The study was a retrospective observational study. From June 2018 to December 2022, 49 DFU patients who met the inclusion criteria were admitted to the Department of Hand and Foot Microscopy and Wound Repair Surgery of Henan Provincial People's Hospital (People's Hospital of Zhengzhou University), including 28 males and 21 females, aged from 47 to 68 years, with type 2 diabetes history period ranging from 6 months to 21 years. Under a MDT cooperation model, the physicians from department of endocrinology comprehensively assessed the patients, stabilized the patients' general condition, and controlled their complications, the surgeons from department of vascular surgery assessed and improved the patients' lower limb blood supply, the physicians from department of infectious diseases provided anti-infection treatment plans, the physicians from department of anesthesiology and perioperative medicine assessed the patients' perioperative risk and ensured their perioperative safety, and according to the patients' condition, the physicians from departments such as cardiology, neurology, nutrition, and rehabilitation actively and timely participated in the treatment. The surgeons from department of hand and foot microscopy and wound repair surgery prepared the wound base and used free anterolateral thigh perforator flaps to repair the wounds. After once or multiple debridement in the first stage, the wound area ranged from 5.0 cm×4.5 cm to 17.0 cm×10.0 cm. After once or twice vacuum sealing drainage treatment, the free anterolateral thigh perforator flaps were used to repair the wounds with incision area of 6 cm×5 cm to 18 cm×11 cm in the second stage. The descending branches of lateral circumflex femoral artery and the accompanying veins of flaps were anastomosed to the arteries and veins in the recipient sites, respectively. The wounds in the flap donor sites were sutured directly. After surgery, whether the patient's perioperative period was stable, the survival of flaps, the healing of wounds in the flap donor and recipient sites were observed. During the follow-up, the texture and appearance of flaps, whether there was a new ulcer, and the patient's walking ability were observed. Results All the patients had stable perioperative period. Among them, the flaps in 46 patients survived successfully; the flaps in 2 patients developed complete necrosis, including 1 case whose ulcer was healed after repair of pedicled flap from the lower leg, and 1 case who underwent amputation of the lower leg; the flap in 1 patient developed partial necrosis, which was healed after dressing change and skin grafting. The wounds in the flap donor and recipient sites healed well. During the postoperative follow-up of 6-24 months, the flaps had good texture and appearance with no new ulcers, and the patients had no obvious impairment in daily walk. Conclusions The MDT cooperation model can sufficiently ensure the perioperative safety of DFU patients. The free anterolateral thigh perforator flaps can repair the DFU wounds achieving good clinical effects with high flap survival rate and decreased amputation rate.
- Diabetic foot /
- Ulcer /
- Surgical flaps /
- Perforator flap /
- Microsurgery /
- Multi-disciplinary team /
- Wound repair /
- Limb salvage
赵建军：手术实施、论文撰写、数据整理；谢振军、赵国红：研究指导、论文修改；张建华、孙华伟、白辉凯：病例随访、数据采集；张会峰、张东宾、肖二辉、朱国松：围手术期管理、数据收集

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参考文献(35)

[1]	中华医学会糖尿病学分会,中华医学会感染病学分会,中华医学会组织修复与再生分会.中国糖尿病足防治指南(2019版)(Ⅴ)[J].中华糖尿病杂志,2019,11(6):387-397. DOI: 10.3760/cma.j.issn.1674-5809.2019.06.005.
[2]	WangAP,LvGZ,ChengXB,et al.Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)[J/OL].Burns Trauma,2020,8:tkaa017[2023-11-07].https://pubmed.ncbi.nlm.nih.gov/32685563/.DOI: 10.1093/burnst/tkaa017.
[3]	《多学科合作下糖尿病足防治专家共识(2020版)》编写组.多学科合作下糖尿病足防治专家共识(2020版)全版[J].中华烧伤杂志,2020,36(8):E01-E52.DOI: 10.3760/cma.j.cn501120-20200217-01000.
[4]	简扬,魏在荣,陈伟,等.游离皮瓣在糖尿病足溃疡修复中的应用研究进展[J].中华烧伤与创面修复杂志,2023,39(4):376-380.DOI: 10.3760/cma.j.cn501225-20221216-00539.
[5]	GazzarusoC,GallottiP,PujiaA,et al.Predictors of healing, ulcer recurrence and persistence, amputation and mortality in type 2 diabetic patients with diabetic foot: a 10-year retrospective cohort study[J].Endocrine,2021,71(1):59-68.DOI: 10.1007/s12020-020-02431-0.
[6]	WagnerFWJr.The dysvascular foot: a system for diagnosis and treatment[J].Foot Ankle,1981,2(2):64-122.DOI: 10.1177/107110078100200202.
[7]	郭晓峰,邓鑫鑫,黄治虎,等.带蒂皮瓣联合膜诱导技术修复糖尿病患者足踝部创面的效果[J].中华烧伤与创面修复杂志,2023,39(4):325-329.DOI: 10.3760/cma.j.cn501225-20221212-00534.
[8]	龙露瑶,陈燕微,邓如非,等.延迟腓肠神经营养血管皮瓣在糖尿病足溃疡中的应用与研究进展[J].中华烧伤与创面修复杂志,2024,40(3):296-300.DOI: 10.3760/cma.j.cn501225-20231102-00173.
[9]	贾伟平.中国糖尿病防治的战略思考及体系建设的创新实践[J].中华内科杂志,2019,58(1):1-4.DOI: 10.3760/cma.j.issn.0578-1426.2019.01.001.
[10]	魏在荣,简扬.糖尿病足创面外科治疗模式探讨[J].中华烧伤与创面修复杂志,2023,39(4): 305-310.DOI: 10.3760/cma.j.cn501225-20230213-00044.
[11]	唐通军,李丹,曾爱红,等.多学科协作诊疗模式在公立医院行政管理中的探索[J].中华医院管理杂志,2019,35(3):262-264.DOI: 10.3760/cma.j.issn.1000-6672.2019.03.022.
[12]	冉兴无.用指南规范医疗行为,进一步降低我国糖尿病足的截肢率[J].中华糖尿病杂志,2019,11(2):81-82.DOI: 10.3760/cma.j.issn.1674-5809.2019.02.001.
[13]	Mathoulin-PélissierS,ChevreauC,BelleraC,et al.Adherence to consensus-based diagnosis and treatment guidelines in adult soft-tissue sarcoma patients: a French prospective population-based study[J].Ann Oncol,2014,25(1):225-231.DOI: 10.1093/annonc/mdt407.
[14]	PowellHA,BaldwinDR.Multidisciplinary team management in thoracic oncology: more than just a concept?[J].Eur Respir J,2014,43(6):1776-1786. DOI: 10.1183/09031936.00150813.
[15]	JiSZ,LiuXB,HuangJ,et al.Consensus on the application of negative pressure wound therapy of diabetic foot wounds[J/OL].Burns Trauma,2021,9:tkab018[2023-11-07].https://pubmed.ncbi.nlm.nih.gov/34212064/.DOI: 10.1093/burnst/tkab018.
[16]	海峡两岸医药卫生交流协会烧创伤暨组织修复专委会.负压伤口疗法在糖尿病足创面治疗中的应用全国专家共识(2021版)[J].中华烧伤杂志,2021,37(6):508-518.DOI: 10.3760/cma.j.cn501120-20210107-00010.
[17]	黄红军,牛希华,杨冠龙,等.抗生素骨水泥在糖尿病足溃疡创面应用的临床效果[J].中华烧伤杂志,2019,35(6):464-466.DOI: 10.3760/cma.j.issn.1009-2587.2019.06.013.
[18]	赵晨兵,张会峰.载抗生素骨水泥治疗糖尿病足感染创面的研究进展[J].中华糖尿病杂志,2022,14(7):724-729.DOI: 10.3760/cma.j.cn115791-20211213-00660.
[19]	曹涛,计鹏,张智,等.抗生素骨水泥治疗糖尿病足溃疡的前瞻性随机对照研究[J].中华烧伤与创面修复杂志,2023,39(4):311-318.DOI: 10.3760/cma.j.cn501225-20221111-00485.
[20]	方栋,孙良业,谢肇.载万古霉素骨水泥间隔器治疗跟骨创伤后骨感染的疗效[J].中华创伤杂志,2019,35(2):109-114.DOI: 10.3760/cma.j.issn.1001-8050.2019.02.003.
[21]	高磊,石宇,李天博,等.带腓动脉穿支的腓肠神经营养皮瓣在糖尿病足创面修复中的应用[J].中国美容整形外科杂志,2022,33(3):139-142.DOI: 10.3969/j.issn.1673-7040.2022.03.004.
[22]	胡长青,连勇,白晓亮,等.游离胸背动脉穿支皮瓣修复小腿远端及足踝部创面九例[J].中华烧伤杂志,2018,34(4):240-242.DOI: 10.3760/cma.j.issn.1009-2587.2018.04.009.
[23]	中华医学会显微外科学分会.MBCMA股前外侧皮瓣临床应用指南(2016征求意见稿)[J].中华显微外科杂志,2016,39(4):313-317.DOI: 10.3760/cma.j.issn.1001-2036.2016.04.001.
[24]	计鹏,曹涛,张智,等.股前外侧嵌合穿支皮瓣修复足踝部复杂创面的效果[J].中华烧伤与创面修复杂志,2023,39(10):926-932.DOI: 10.3760/cma.j.cn501225-20230627-00232.
[25]	李雷,巨积辉,周正虎,等.开槽灌洗序贯Flow-through型股前外侧嵌合肌皮瓣治疗胫骨慢性骨髓炎[J].中华显微外科杂志,2019,42(3):223-227.DOI: 10.3760/cma.j.issn.1001-2036.2019.03.004.
[26]	杨力,蔡斌,薛君荣,等.个体化股前外侧皮瓣游离移植修复复杂难愈性创面的临床效果[J].中华烧伤杂志,2020,36(8):730-734.DOI: 10.3760/cma.j.cn501120-20190621-00281.
[27]	赵国红,魏鹏飞,孙华伟,等.多叶连体股前外侧穿支皮瓣一期修复手背合并多指指背软组织缺损[J].中华显微外科杂志,2020,43(6):553-557.DOI: 10.3760/cma.j.cn441206-20200428-00219.
[28]	钟怡鸣,孙焕伟,陈东,等.携带阔筋膜的股前外侧穿支皮瓣修复头皮及硬脑膜缺损八例[J].中华显微外科杂志,2022,45(5):552-556.DOI: 10.3760/cma.j.cn441206-20220319-00055.
[29]	蒋玲丽,李海,魏在荣,等.股前外侧嵌合穿支皮瓣修复糖尿病足溃疡创面[J].中华显微外科杂志,2021,44(2):141-145.DOI: 10.3760/cma.j.cn441206-20200813-00320.
[30]	杨力,李科霖,庞远翔,等.游离旋股外侧动脉降支组织瓣修复Wagner 3级或4级糖尿病足创面的临床效果[J].中华烧伤与创面修复杂志,2022,38(12):1148-1155.DOI: 10.3760/cma.j.cn501225-20220321-00076.
[31]	陈伟,常树森,周健,等.抗生素骨水泥联合游离股前外侧组织瓣序贯治疗糖尿病足溃疡的临床疗效[J].中华烧伤与创面修复杂志,2023,39(4):319-324.DOI: 10.3760/cma.j.cn501225-20220628-00267.
[32]	任高宏,胡稷杰,裴国献.倒“Y”形血管吻合游离皮瓣移植在肢体创面修复与功能重建中的应用[J].中华显微外科杂志,2012,35(1):27-31,插图1-5.DOI: 10.3760/cma.j.issn.1001-2036.2012.01.012.
[33]	刘飞,闫炜琪,马强,等.股前外侧血流桥接嵌合穿支皮瓣游离移植治疗伴主干动脉缺损的上肢复合组织缺损的临床效果[J].中华烧伤与创面修复杂志,2024,40(2):172-179.DOI: 10.3760/cma.j.cn501225-20231103-00176.
[34]	柳志锦,巨积辉,周荣,等.带阔筋膜血流桥接型股前外侧穿支皮瓣修复伴伸肌腱缺损的手、足背侧创面[J].中华创伤杂志,2021,37(10):894-899.DOI: 10.3760/cma.j.cn501098-20210326-00204.
[35]	刘学光,周建东,陈政,等.股前外侧Flow-through皮瓣联合Masquelet技术在胫骨远端Gustilo ⅢC型骨折急诊保肢中的应用[J].中华显微外科杂志,2024,47(3):261-266.DOI: 10.3760/cma.j.cn441206-20231107-00070.

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图 1 采用游离股前外侧穿支皮瓣修复患者左足跟糖尿病足溃疡创面的效果。1A.入院时,左足跟皮肤软组织感染坏死,跟骨破坏、外露；1B.清创2次、行2次负压封闭引流后,左足跟创面肉芽组织鲜红,跟骨外露；1C.Ⅱ期术前设计股前外侧穿支皮瓣；1D.Ⅱ期术中皮瓣血运良好,切取皮瓣备用；1E.采用皮瓣修复创面后即刻,血运良好；1F.术后1年随访,皮瓣外观良好,无新发溃疡

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