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

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徐向荣，Email：13973661455@163.com

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- 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

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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

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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

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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

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