基于窦道情况及皮肤软组织缺损范围的坐骨结节压疮临床修复策略

邓如非; 龙露瑶; 陈燕微; 姜臻宇; 江澜; 邹立津; 张友来

doi:10.3760/cma.j.cn501225-20231114-00194

基于窦道情况及皮肤软组织缺损范围的坐骨结节压疮临床修复策略

doi: 10.3760/cma.j.cn501225-20231114-00194

南昌大学第一附属医院烧伤整形与创面修复医学中心，南昌　　330006

基金项目:

国家自然科学基金地区科学基金项目 81760343

江西省自然科学基金面上项目 20202BABL206072

详细信息

通讯作者:
张友来，Email：lancet_zylbs@163.com

计量
- 文章访问数: 375
- HTML全文浏览量: 118
- PDF下载量: 70
- 被引次数: 0
出版历程
- 收稿日期: 2023-11-14

Clinical repair strategy for ischial tuberosity pressure ulcers based on the sinus tract condition and range of skin and soft tissue defects

Medical Center of Burn Plastic and Wound Repair, the First Affiliated Hospital of Nanchang University, Nanchang 330006, China

Funds:

Regional Science Foundation Program of National Natural Science Foundation of China 81760343

General Program of Natural Science Foundation of Jiangxi Province of China 20202BABL206072

More Information

Corresponding author: Zhang Youlai, Email: lancet_zylbs@163.com

摘要

摘要: 目的探讨基于窦道情况及皮肤软组织缺损范围的坐骨结节压疮临床修复策略。方法该研究为回顾性观察性研究。2017年7月—2023年3月，南昌大学第一附属医院收治21例符合入选标准的坐骨结节Ⅲ、Ⅳ期压疮患者，其中男13例、女8例，年龄14~84岁。共有坐骨结节压疮31处，清创前压疮面积为1.5 cm×1.0 cm~8.0 cm×6.0 cm。行en bloc切除清创后，皮肤软组织缺损范围为6.0 cm×3.0 cm~15.0 cm×8.0 cm。根据清创后创面窦道深浅、大小及皮肤软组织缺损范围，按以下3种情况修复创面。（1）无窦道或窦道浅、皮肤软组织缺损范围为6.0 cm×3.0 cm~8.5 cm×6.5 cm者，行直接拉拢缝合、Z字改形术、臀部局部皮瓣转移或股后皮神经营养血管皮瓣V-Y推进修复。（2）窦道深且小、皮肤软组织缺损范围为8.5 cm×4.5 cm~11.0 cm×6.5 cm者，行股薄肌肌瓣转移填塞后直接拉拢缝合或Z字改形术或联合臀下动脉穿支皮瓣转移修复。（3）窦道深且大、皮肤软组织缺损范围为7.5 cm×5.5 cm~15.0 cm×8.0 cm者，行股薄肌肌瓣联合臀大肌肌瓣转移填塞后直接拉拢缝合或Z字改形术或联合臀部局部皮瓣转移修复，行股二头肌长头肌瓣转移填塞后联合股后皮神经营养血管皮瓣旋转修复，行臀下动脉穿支脂肪筋膜瓣转移填塞后联合股后皮神经营养血管皮瓣V-Y推进修复。共使用7个臀部局部皮瓣（切取面积为8.0 cm×6.0 cm~19.0 cm×16.0 cm）、21个股薄肌肌瓣（切取面积为18.0 cm×3.0 cm~24.0 cm×5.0 cm）、9个臀下动脉穿支皮瓣或臀下动脉穿支脂肪筋膜瓣（切取面积为8.5 cm×6.0 cm~13.0 cm×7.5 cm）、10个臀大肌肌瓣（切取面积为8.0 cm×5.0 cm~13.0 cm×7.0 cm）、2个股二头肌长头肌瓣（切取面积为17.0 cm×3.0 cm、20.0 cm×5.0 cm）、5个股后皮神经营养血管皮瓣（切取面积为12.0 cm×6.5 cm~21.0 cm×10.0 cm）。将供区创面直接拉拢缝合。术后观察肌瓣、脂肪筋膜瓣、皮瓣存活情况及供区创面愈合情况，随访患者压疮修复情况及有无复发。结果术后，所有臀部局部皮瓣、股薄肌肌瓣、臀大肌肌瓣、臀下动脉穿支脂肪筋膜瓣及股二头肌长头肌瓣均存活良好。1例患者1个股后皮神经营养血管皮瓣远端部分坏死，经换药后创面愈合；1例患者1个臀下动脉穿支皮瓣远端出现淤紫，经拆除部分缝线后有所缓解，但仍出现少部分坏死，经床旁清创缝合后创面愈合；其余股后皮神经营养血管皮瓣及臀下动脉穿支皮瓣存活良好。1例患者供区创面因术后出血导致切口开裂，经清创+Z字改形术+换药后愈合；其余患者供区创面愈合良好。随访3~15个月，所有患者压疮均得到修复且未复发。结论坐骨结节压疮清创后创面若无窦道形成或窦道表浅，可根据皮肤软组织缺损范围选择直接拉拢缝合、Z字改形术、臀部局部皮瓣转移或股后皮神经营养血管皮瓣V-Y推进修复；若窦道深，则可根据窦道大小及皮肤软组织缺损范围，选择合适的组织瓣转移填塞窦道，并联合个体化的皮瓣封闭创面，以获得良好的修复效果。
- 压力性溃疡 /
- 坐骨 /
- 外科皮瓣 /
- 清创术 /
- 显微外科手术 /
- 皮肤软组织缺损 /
- 创面修复
Abstract: Objective To investigate the clinical repair strategy for ischial tuberosity pressure ulcers based on the sinus tract condition and range of skin and soft tissue defects. Methods The study was a retrospective observational study. From July 2017 to March 2023, 21 patients with stage Ⅲ or Ⅳ ischial tuberosity pressure ulcers who met the inclusion criteria were admitted to the First Affiliated Hospital of Nanchang University, including 13 males and 8 females, aged 14-84 years. There were 31 ischial tuberosity pressure ulcers, with an area of 1.5 cm×1.0 cm-8.0 cm×6.0 cm. After en bloc resection and debridement, the range of skin and soft tissue defect was 6.0 cm×3.0 cm-15.0 cm×8.0 cm. According to the depth and size of sinus tract and range of skin and soft tissue defects on the wound after debridement, the wounds were repaired according to the following three conditions. (1) When there was no sinus tract or the sinus tract was superficial, with a skin and soft tissue defect range of 6.0 cm×3.0 cm-8.5 cm×6.5 cm, the wound was repaired by direct suture, Z-plasty, transfer of buttock local flap, or V-Y advancement of the posterior femoral cutaneous nerve nutrient vessel flap. (2) When the sinus tract was deep and small, with a skin and soft tissue defect range of 8.5 cm×4.5 cm-11.0 cm×6.5 cm, the wound was repaired by the transfer and filling of gracilis muscle flap followed by direct suture, or Z-plasty, or combined with transfer of inferior gluteal artery perforator flap. (3) When the sinus tract was deep and large, with a skin and soft tissue defect range of 7.5 cm×5.5 cm-15.0 cm×8.0 cm, the wound was repaired by the transfer and filling of gracilis muscle flap and gluteus maximus muscle flap transfer, followed by direct suture, Z-plasty, or combined with transfer of buttock local flap; and transfer and filling of biceps femoris long head muscle flap combined with rotary transfer of the posterior femoral cutaneous nerve nutrient vessel flap; and filling of the inferior gluteal artery perforator adipofascial flap transfer combined with V-Y advancement of the posterior femoral cutaneous nerve nutrient vessel flap. A total of 7 buttock local flaps with incision area of 8.0 cm×6.0 cm-19.0 cm×16.0 cm, 21 gracilis muscle flaps with incision area of 18.0 cm×3.0 cm-24.0 cm×5.0 cm, 9 inferior gluteal artery perforator flaps or inferior gluteal artery perforator adipofascial flaps with incision area of 8.5 cm×6.0 cm-13.0 cm×7.5 cm, 10 gluteal maximus muscle flaps with incision area of 8.0 cm×5.0 cm-13.0 cm×7.0 cm, 2 biceps femoris long head muscle flaps with incision area of 17.0 cm×3.0 cm and 20.0 cm×5.0 cm, and 5 posterior femoral cutaneous nerve nutrient vessel flaps with incision area of 12.0 cm×6.5 cm-21.0 cm×10.0 cm were used. The donor area wounds were directly sutured. The survival of muscle flap, adipofascial flap, and flap, and wound healing in the donor area were observed after operation. The recovery of pressure ulcer and recurrence of patients were followed up. Results After surgery, all the buttock local flaps, gracilis muscle flaps, gluteus maximus muscle flaps, inferior gluteal artery perforator adipofascial flaps, and biceps femoris long head muscle flaps survived well. In one case, the distal part of one posterior femoral cutaneous nerve nutrient vessel flap was partially necrotic, and the wound was healed after dressing changes. In another patient, bruises developed in the distal end of inferior gluteal artery perforator flap. It was somewhat relieved after removal of some sutures, but a small part of the necrosis was still present, and the wound was healed after bedside debridement and suture. The other posterior femoral cutaneous nerve nutrient vessel flaps and inferior gluteal artery perforator flaps survived well. In one patient, the wound at the donor site caused incision dehiscence due to postoperative bleeding in the donor area. The wound was healed after debridement+Z-plasty+dressing change. The wounds in the rest donor areas of patients were healed well. After 3 to 15 months of follow-up, all the pressure ulcers of patients were repaired well without recurrence. Conclusions After debridement of ischial tuberosity pressure ulcer, if there is no sinus tract formation or sinus surface is superficial, direct suture, Z-plasty, buttock local flap, or V-Y advancement repair of posterior femoral cutaneous nerve nutrient vessel flap can be selected according to the range of skin and soft tissue defects. If the sinus tract of the wound is deep, the proper tissue flap can be selected to fill the sinus tract according to the size of sinus tract and range of the skin and soft tissue defects, and then the wound can be closed with individualized flap to obtain good repair effect.
- Pressure ulcer /
- Ischium /
- Surgical flaps /
- Debridement /
- Microsurgery /
- Skin and soft tissue defects /
- Wound repair
邓如非、龙露瑶：实施手术、采集资料、撰写论文；陈燕微、姜臻宇、江澜：实施手术、采集资料、整理数据；邹立津、张友来：酝酿和设计研究、实施手术、修改论文、经费支持

所有作者均声明不存在利益冲突

HTML全文

参考文献(22)

[1]	李汉华,黄志锋,熊兵,等.坐骨结节扩大清创降低坐骨压疮术后创面复发风险的临床研究[J].医学研究生学报,2021,34(4):379-383.DOI: 10.16571/j.cnki.1008-8199.2021.04.009.
[2]	DjedovicG,MorandiEM,MetzlerJ,et al.The posterior thigh flap for defect coverage of ischial pressure sores - a critical single-centre analysis[J].Int Wound J,2017,14(6):1154-1159.DOI: 10.1111/iwj.12776.
[3]	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.
[4]	林炳远,郭峭峰,黄凯,等.股薄肌肌瓣治疗老年人Ⅲ、Ⅳ度坐骨结节褥疮的疗效分析[J].中华老年医学杂志,2016,35(9):982-985.DOI: 10.3760/cma.j.issn.0254-9026.2016.09.015.
[5]	苏卫国,李德平,邢培朋,等. 穿支皮瓣联合肌瓣修复老年患者坐骨结节Ⅳ期压疮的效果[J]. 中华烧伤杂志,2017,33(9):545-549. DOI: 10.3760/cma.j.issn.1009-2587.2017.09.004.
[6]	白晓龙,孙绍骞,杨玉辉.股二头肌长头肌皮瓣联合股后筋膜皮瓣修复坐骨结节压力性溃疡[J].中国老年学杂志,2013,33(23):6032-6033.DOI: 10.3969/j.issn.1005-9202.2013.23.126.
[7]	海恒林,申传安,柴家科,等.股二头肌长头肌瓣联合半V形股后筋膜皮瓣修复坐骨结节压疮[J].中华烧伤杂志,2012,28(1):57-59.DOI: 10.3760/cma.j.issn.1009-2587.2012.01.015.
[8]	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.
[9]	褚万立,郝岱峰.美国国家压疮咨询委员会2016年压力性损伤的定义和分期解读[J/CD].中华损伤与修复杂志(电子版),2018,13(1):64-68.DOI: 10.3877/cma.j.issn.1673-9450.2018.01.014.
[10]	TavakoliK,RutkowskiS,CopeC,et al.Recurrence rates of ischial sores in para- and tetraplegics treated with hamstring flaps: an 8-year study[J].Br J Plast Surg,1999,52(6):476-479.DOI: 10.1054/bjps.1999.3126.
[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]	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.
[13]	LarsonDL,HudakKA,WaringWP,et al.Protocol management of late-stage pressure ulcers: a 5-year retrospective study of 101 consecutive patients with 179 ulcers[J].Plast Reconstr Surg,2012,129(4):897-904.DOI: 10.1097/PRS.0b013e3182442197.
[14]	DeijkersRL, van ElzakkerEPM, PijlsBG. Debridement, antibiotics, and implant retention with the direct anterior approach for acute periprosthetic joint infection following primary THA[J]. JB JS Open Access, 2020, 5(2): e0062. DOI: 10.2106/JBJS.OA.19.00062.
[15]	CyphertEL, LearnGD, HurleySK, et al. An additive to PMMA bone cement enables postimplantation drug refilling, broadens range of compatible antibiotics, and prolongs antimicrobial therapy[J]. Adv Healthc Mater, 2018, 7(21): e1800812. DOI: 10.1002/adhm.201800812.
[16]	LaycockPA, CooperJJ, HowlinRP, et al. In vitro efficacy of antibiotics released from calcium sulfate bone void filler beads[J]. Materials (Basel),2018,11(11):2265.DOI: 10.3390/ma11112265.
[17]	陈华,高磊,程景波,等. 负压封闭引流下骨水泥联合股后带蒂肌皮瓣移植治疗坐骨结节Ⅳ期压疮的疗效分析[J]. 中国美容整形外科杂志,2022,33(6):350-352,362. DOI: 10.3969/j.issn.1673-7040.2022.06.010.
[18]	LegemateCM, van der KwaakM, GobetsD,et al. The pedicled internal pudendal artery perforator (PIPAP) flap for ischial pressure sore reconstruction: technique and long-term outcome of a cohort study[J]. J Plast Reconstr Aesthet Surg, 2018, 71(6):889-894. DOI: 10.1016/j.bjps.2018.01.032.
[19]	STARKWJ. The use of pedicled muscle flaps in the surgical treatment of chronic osteomyelitis resulting from compound fractures[J].J Bone Joint Surg Am, 1946, 28: 343-350.
[20]	WongC,Saint-CyrM.The pedicled descending branch muscle-sparing latissimus dorsi flap for trunk and upper extremity reconstruction[J].J Plast Reconstr Aesthet Surg,2010,63(4):623-632.DOI: 10.1016/j.bjps.2009.01.059.
[21]	周孝亮,涂家金,叶华,等.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[J].中华烧伤与创面修复杂志,2023,39(1):65-70.DOI: 10.3760/cma.j.cn501225-20220420-00148.
[22]	叶学浪,黄珊,周望高,等.缺损创面的测量与穿支皮瓣设计的临床观察[J].中华显微外科杂志,2022,45(1):46-49.DOI: 10.3760/cma.j.cn441206-20211013-00237.

下载: 全尺寸图片幻灯片

1 股薄肌肌瓣联合臀大肌肌瓣转移填塞后联合臀部局部皮瓣转移修复例1患者左侧坐骨结节Ⅳ期压疮的效果。1A.入院时，创面伴潜行窦道；1B.术中行en bloc切除清创后窦道深且大、皮肤软组织缺损范围较大；1C.术中切取股薄肌肌瓣；1D.术中切取臀大肌肌瓣及臀部局部皮瓣；1E.术中将臀部局部皮瓣转移修复创面后；1F.随访9个月，压疮得到修复且未复发

下载: 全尺寸图片幻灯片

2 股二头肌长头肌瓣转移填塞后联合股后皮神经营养血管皮瓣旋转修复例2患者左侧坐骨结节Ⅳ期压疮合并慢性骨髓炎的效果。2A.入院时，创面伴潜行窦道；2B.术中行en bloc切除清创后窦道深且大、皮肤软组织缺损范围较大；2C.术前股二头肌长头肌瓣及股后皮神经营养血管皮瓣设计；2D.术中切取肌瓣转移填塞窦道，旋转皮瓣修复创面；2E.肌瓣与皮瓣转移后间断缝合创面；2F.随访10个月，压疮未见局部破溃或复发

下载: 全尺寸图片幻灯片

3 臀下动脉穿支脂肪筋膜瓣转移填塞后联合股后皮神经营养血管皮瓣V-Y推进修复例3患者右侧坐骨结节Ⅳ期压疮合并慢性骨髓炎的效果。3A.入院时，创面窦道基底可触及坐骨结节骨质；3B.术中行en bloc切除清创后设计臀下动脉穿支脂肪筋膜瓣及股后皮神经营养血管皮瓣V-Y推进修复压疮；3C.术中切取臀下动脉穿支皮瓣及股后皮神经营养血管皮瓣后即刻；3D.术中剔除臀下动脉穿支皮瓣皮肤制成脂肪筋膜瓣，转移填塞窦道；3E.皮瓣V-Y推进并“Y”形缝合修复压疮；3F.术后14 d拆线，创面愈合

下载: 全尺寸图片幻灯片