脊柱内固定术后患者难愈性创面的修复方法及其效果

李莉莉; 于文昌; 李波; 吴德勇; 王进勇; 邹晓辉; 汪明柱; 徐向荣

doi:10.3760/cma.j.cn501225-20240218-00066

脊柱内固定术后患者难愈性创面的修复方法及其效果

doi: 10.3760/cma.j.cn501225-20240218-00066

中南大学湘雅医学院附属常德医院（常德市第一人民医院）烧伤整形科，常德　　415000

详细信息

通讯作者:
徐向荣，Email：13973661455@163.com

计量
- 文章访问数: 2297
- HTML全文浏览量: 31
- PDF下载量: 63
- 被引次数: 0
出版历程
- 收稿日期: 2024-02-18

Repair methods and effects of refractory wounds in patients after spinal internal fixation operation

Department of Burns and Plastic Surgery, Changde Hospital, Xiangya School of Medicine, Central South University (the First People's Hospital of Changde City), Changde 415000, China

More Information

Corresponding author: Xu Xiangrong, Email: 13973661455@163.com

摘要

摘要: 目的探讨脊柱内固定术后患者难愈性创面的修复方法及其效果。方法该研究为回顾性观察性研究。2020年11月—2023年10月，中南大学湘雅医学院附属常德医院烧伤整形科收治10例脊柱内固定术后难愈性创面患者，其中男3例、女7例，年龄35~68岁，其中胸腰椎结核者6例、胸腰椎骨折者3例、骶椎脊索瘤复发根治性切除术后皮肤软组织合并骨缺损者1例，清创后创面面积为6.0 cm×1.5 cm~27.0 cm×6.5 cm。根据创面情况，决定创面修复手术是Ⅰ期还是Ⅱ期进行。2例患者创面为Ⅰ型创面，行清创、直接缝合及术后置管持续冲洗引流；8例患者创面为Ⅱ型创面，采用局部皮瓣（包括末端为真皮脂肪瓣的旋转皮瓣）、肌瓣或肌瓣联合局部皮瓣修复，其中皮瓣大小为10.0 cm×5.0 cm~27.0 cm×14.0 cm，肌瓣大小为8.0 cm×5.0 cm×4.0 cm~17.0 cm×9.5 cm×2.0 cm。供瓣区创面均直接缝合，统计Ⅱ型创面患者采用的创面治疗方法。观察术后创面愈合情况。随访观察创面感染、复发情况，内固定材料保留情况及脊柱运动功能。结果 Ⅱ型创面患者中采用局部皮瓣者3例（其中采用末端为真皮脂肪瓣的旋转皮瓣者1例）、肌瓣者3例（其中采用背阔肌肌瓣者1例、竖脊肌肌瓣者2例）、肌瓣（采用背阔肌肌瓣及竖脊肌肌瓣者各1例）联合局部皮瓣者2例。仅1例骶椎脊索瘤根治术后继发缺损患者修复术后创面愈合欠佳，经换药愈合，其余9例患者创面均愈合良好。随访4~18个月，10例患者局部创面未出现感染、复发，内固定材料未发生松动，脊柱运动功能无明显受限。结论对于脊柱内固定术后难愈性创面，根据患者的创面类型，行Ⅰ期清创缝合及冲洗引流或于Ⅰ、Ⅱ期行局部皮瓣、肌瓣、肌瓣联合局部皮瓣移植等，既修复了创面，又保留了内固定材料，疗效可靠。
- 脊柱 /
- 骨折固定术，内 /
- 感染 /
- 难愈性创面 /
- 创面修复
Abstract: Objective To explore the repair methods and effects of refractory wounds in patients after spinal internal fixation operation . Methods The study was a retrospective observational study. From November 2020 to October 2023, 10 patients with refractory wounds after spinal internal fixation operation were admitted to the Department of Burns and Plastic Surgery of Changde Hospital of Xiangya School of Medicine of Central South University. They were 3 males and 7 females, aged 35 to 68 years. There were 6 cases of thoracolumbar tuberculosis, 3 cases of thoracolumbar fracture, and 1 case of recurrent sacrococcygeal chordoma with skin, soft tissue, and bone defects after radical resection. The wound areas after debridement were 6.0 cm×1.5 cm to 27.0 cm×6.5 cm. The wound repair operation was decided to perform in the primary stage or in the secondary stage according to the wound situation. Two patients with type Ⅰ wounds were treated with debridement, direct suture, and continuous irrigation and drainage with catheter after operation. Eight patients with type Ⅱ wounds were repaired with local flaps (including rotation flap with dermis-fat flap at the end), muscle flaps, or muscle flaps combined with local flaps. The flap sizes were 10.0 cm×5.0 cm to 27.0 cm×14.0 cm, and the sizes of muscle flap were 8.0 cm×5.0 cm×4.0 cm to 17.0 cm×9.5 cm×2.0 cm. The wounds in flap donor areas were sutured directly. The wound treatment methods of patients with type Ⅱ wounds were recorded. The wound healing was observed after operation. The infection and recurrence of wounds, the retention of internal fixation materials, and spinal motor function were observed during follow-up. Results Among patients with type Ⅱ wounds, there were 3 cases applied with local flaps (including 1 case with rotation flap with dermis-fat flap at the end), 3 cases with muscle flaps (including 1 case with latissimus dorsi muscle flap and 2 cases with erector spinal muscle flaps), and 2 cases with muscle flaps (1 case with latissimus dorsi muscle flap and 1 case with erector spinal muscle flap) combined with local flaps. Only 1 case with secondary defects after radical surgery of sacrococcygeal chordoma had poor wound healing which healed after dressing change, and the wounds of the remaining 9 cases all healed well. During the follow-up of 4 to 18 months, no infection or recurrence of local wounds developed in 10 patients, the internal fixation materials were not loosening, and there was no significant limitation in spinal motor function. Conclusions For refractory wounds after spinal internal fixation operation, according to the wound type of patients, debridement, suture, irrigation, and drainage in the primary stage, or transplantation of local flaps, muscle flaps, muscle flaps combined with local flaps are performed in the primary stage or in the secondary stage. These methods are proved to have reliable therapeutic effects, not only repairing the wounds, but also retaining the internal fixation materials.
- Spine /
- Fracture fixation, internal /
- Infection /
- Refractory wound /
- Wound repair
李莉莉：撰写文章、分析数据并实施手术；于文昌、李波、吴德勇、王进勇、邹晓辉、汪明柱：实施手术及收集资料；徐向荣：设计手术方案、实施手术、修改文章

所有作者均声明不存在利益冲突

HTML全文

参考文献(30)

[1]	刘少强,齐强,陈仲强.腰椎术后感染的危险因素及合理防治[J].中华外科杂志,2013,51(12):1128-1132.DOI: 10.3760/cma.j.issn.0529-5815.2013.12.016.
[2]	DolanRT,ButlerJS,VaccaroAR,et al.Current strategies for reconstruction of soft tissue defects of the spine[J].Clin Spine Surg,2020,33(1):9-19.DOI: 10.1097/BSD.0000000000000936.
[3]	张心灵,林志禹,陈玉杰,等.脊柱后路内固定术后切口愈合不良的整形外科治疗[J].北京大学学报(医学版),2023(5):910-914.DOI: 10.19723/j.issn.1671-167X.2023.05.020.
[4]	DumanianGA, OndraSL, LiuJ, et al. Muscle flap salvage of spine wounds with soft tissue defects or infection[J]. Spine (Phila Pa 1976),2003,28(11):1203-1211. DOI: 10.1097/01.BRS.0000067260.22943.48.
[5]	张忠荣,杨星华,孙红振,等.胸腰椎后路内固定术后感染的分析与治疗[J].中国临床医生,2012,40(2):36-37.DOI: 10.3969/j.issn.1008-1089.2012.02.012.
[6]	YuanW,LiuX,ZhouX,et al.Management of early deep wound infection after thoracolumbar instrumentation: continuous irrigation suction system versus vacuum-assisted closure system[J].Spine (Phila Pa 1976),2018,43(18):E1089-E1095.DOI: 10.1097/BRS.0000000000002615.
[7]	官浩,陈阳.重视胸骨切开术后胸骨深部伤口感染的预防和处理[J].中华烧伤与创面修复杂志,2024,40(2):125-130.DOI: 10.3760/cma.j.cn501225-20231212-00235.
[8]	曹学新,张永磊,赵树青,等.股后肌瓣联合股后皮神经营养血管皮瓣及闭式灌洗治疗Ⅳ期坐骨结节压疮的临床效果[J].中华烧伤与创面修复杂志,2024,40(2):159-164.DOI: 10.3760/cma.j.cn501225-20231017-00115.
[9]	闫廷飞,孙晨曦,杨勇,等. 腰椎内固定术后感染的临床研究[J]. 中华骨科杂志,2016,36(22):1463-1468. DOI: 10.3760/cma.j.issn.0253-2352.2016.22.009.
[10]	BürgerJ,PalmowskiY,PumbergerM.Comprehensive treatment algorithm of postoperative spinal implant infection[J].J Spine Surg,2020,6(4):793-799.DOI: 10.21037/jss-20-497.
[11]	KasliwalMK,TanLA,TraynelisVC.Infection with spinal instrumentation: review of pathogenesis, diagnosis, prevention, and management[J].Surg Neurol Int,2013,4(Suppl 5):S392-403.DOI: 10.4103/2152-7806.120783.
[12]	YudistiraA,AsmiraganiS,ImranAW,et al.Surgical site infection management following spinal instrumentation surgery: implant removal vs. implant retention: an updated systematical review[J].Acta Inform Med,2022,30(2):115-120.DOI: 10.5455/aim.2022.30.115-120.
[13]	PalmowskiY,BürgerJ,KienzleA,et al.Antibiotic treatment of postoperative spinal implant infections[J].J Spine Surg,2020,6(4):785-792.DOI: 10.21037/jss-20-456.
[14]	DowdellJ,BrochinR,KimJ,et al.Postoperative spine infection: diagnosis and management[J].Global Spine J,2018,8(4 Suppl):S37-43.DOI: 10.1177/2192568217745512.
[15]	张恒岩,翁惠玲,余可谊.负压封闭引流技术治疗脊柱后路内固定术后感染研究进展[J].中华骨与关节外科杂志,2019,12(3):226-230,235.DOI: 10.3969/j.issn.2095-9958.2019.03.14.
[16]	MouësCM, VosMC, van den BemdGJ, et al. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial[J]. Wound Repair Regen, 2004,12(1):11-17. DOI: 10.1111/j.1067-1927.2004.12105.x.
[17]	沈兴利,张子凡,孙柏峰,等. 脊柱结核手术治疗研究进展[J]. 脊柱外科杂志,2018,16(4):253-256,封3. DOI: 10.3969/j.issn.1672-2957.2018.04.014.
[18]	GaoQ,HanC,RomaniMD,et al.Posterior-only debridement, internal fixation, and interbody fusion using titanium mesh in the surgical treatment of thoracolumbar tuberculosis with spinal epidural abscess: a minimum 5-year follow-up[J].BMC Musculoskelet Disord,2021,22(1):917.DOI: 10.1186/s12891-021-04797-2.
[19]	高永建,欧云生,权正学,等.胸腰椎脊柱结核外科治疗的研究进展[J].中国修复重建外科杂志,2018,32(1):112-117.DOI: 10.7507/1002-1892.201705124.
[20]	甘良雨,谢昆,温冰.创面负压治疗联合背阔肌肌瓣逆行翻转技术在治疗脊柱内固定术后深部感染中的应用[J].中华创伤骨科杂志,2018,20(2):147-151.DOI: 10.3760/cma.j.issn.1671-7600.2018.02.010.
[21]	肖海军,侯春林,陈爱民,等.带蒂背阔肌肌瓣转移治疗胸椎术后慢性脑脊液漏一例[J].中华显微外科杂志,2005,28(4):304.DOI: 10.3760/cma.j.issn.1001-2036.2005.04.048.
[22]	计鹏,陶克,张智,等.负压封闭引流联合竖脊肌肌瓣修复脊柱内固定术后深部感染创面的临床应用[J].空军军医大学学报,2022,43(3):305-308.DOI: 10.13276/j.issn.2097-1656.2022.03.008.
[23]	VitazTW,OishiM,WelchWC,et al.Rotational and transpositional flaps for the treatment of spinal wound dehiscence and infections in patient populations with degenerative and oncological disease[J].J Neurosurg,2004,100(1 Suppl Spine):S46-51.DOI: 10.3171/spi.2004.100.1.0046.
[24]	孙杨,杨宝辉.抗生素骨水泥链珠治疗脊柱骨折内固定术后迟发性感染的疗效分析[J].颈腰痛杂志,2021,42(6):805-808.DOI: 10.3969/j.issn.1005-7234.2021.06.014.
[25]	ChenY,PuS,ChenZ,et al.Efficacy of antibiotic bone cement in the treatment of burkholderia cepacia infection after spinal internal fixation surgery: case report and literature review[J].World Neurosurg,2024,182:e155-e162.DOI: 10.1016/j.wneu.2023.11.063.
[26]	DaldalI,SenkoyluA.Strategies of management of deep spinal infection: from irrigation and debridement to vacuum-assisted closure treatment[J].Ann Transl Med,2020,8(2):33.DOI: 10.21037/atm.2019.11.60.
[27]	OgiharaS,MuraseS,OguchiF,et al.Deep surgical site infection after posterior instrumented fusion for rheumatoid upper cervical subluxation treated with antibiotic-loaded bone cement: three case reports[J].Medicine (Baltimore),2020,99(26):e20892.DOI: 10.1097/MD.0000000000020892.
[28]	唐崧杰,崔红旺,王挺锐.外固定支架联合负载抗生素硫酸钙对胫腓骨开放性骨折患者术后感染及骨愈合的影响[J].解放军医学杂志,2023,48(9):1034-1039.DOI: 10.11855/j.issn.0577-7402.1404.2023.0213.
[29]	侯春林,顾玉东.皮瓣外科学[M].3版.上海:上海科学技术出版社,2019.
[30]	程琳,杜伟力,张颖,等.骶尾部慢性放射性溃疡的分期修复策略[J].中华烧伤杂志,2021,37(3):225-231.DOI: 10.3760/cma.j.cn501120-20210104-00003.

下载: 全尺寸图片幻灯片

1 末端为真皮脂肪瓣的双侧臀部旋转皮瓣填塞无效腔并修复例1患者骶椎脊索瘤内固定术后皮肤软组织及骨缺损创面的效果。1A.清创后见骶椎脊索瘤术后皮肤软组织及骨缺损；1B.Ⅱ期术中设计末端为真皮脂肪瓣的双侧臀部旋转皮瓣；1C.Ⅱ期术中将双侧臀部旋转皮瓣切取后可见暴露的骶尾部骨水泥；1D.Ⅱ期术中削除双侧皮瓣远端各宽约3 cm的表皮形成真皮脂肪瓣后；1E.Ⅱ期皮瓣修复术后即刻；1F.Ⅱ期术后18个月随访，臀部创面愈合良好

下载: 全尺寸图片幻灯片

2 局部旋转皮瓣联合逆行竖脊肌肌瓣修复例2患者胸椎骨折内固定术后椎旁肌肉缺损创面的效果。2A.Ⅰ期清创术前，探及皮下窦道；2B.Ⅰ期清创术中见椎旁无效腔及失活组织；2C.Ⅱ期拟行竖脊肌肌瓣联合局部旋转皮瓣修复术，设计弧形皮瓣切口；2D.Ⅱ期术中切取竖脊肌肌瓣；2E.Ⅱ期术后即刻；2F.Ⅱ期术后9个月随访时，创面愈合良好

下载: 全尺寸图片幻灯片