Curative effects of two kinds of pedicled flaps in repairing the full-thickness electric burn wounds deep to tendon or bone in the knee
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摘要:
目的 比较隐动脉皮瓣与逆行股前外侧穿支皮瓣移植修复膝部Ⅳ度电烧伤创面的临床疗效。 方法 该研究为回顾性队列研究。2018年7月—2022年2月,郑州市第一人民医院收治34例符合入选标准的膝部Ⅳ度电烧伤患者,其中男26例、女8例,年龄18~54岁。根据膝部电烧伤创面采用的修复方式,将患者分为采用隐动脉皮瓣修复的隐动脉皮瓣组（18例）、采用逆行股前外侧穿支皮瓣修复的股前外侧皮瓣组（16例）。隐动脉皮瓣组患者清创后骨和/或肌腱外露面积为5 cm×4 cm~12 cm×7 cm,伴关节开放者5例,皮瓣切取面积为9 cm×6 cm~25 cm×12 cm；股前外侧皮瓣组患者清创后骨和/或肌腱外露面积为7 cm×5 cm~15 cm×7 cm,伴关节开放者6例,皮瓣切取面积为15 cm×10 cm~39 cm×25 cm。根据切取皮瓣宽度选择直接缝合或采用躯干中厚皮移植修复供瓣区创面。术后观察皮瓣成活情况。末次随访时,观察皮瓣色泽、质地；检测皮瓣两点辨别觉距离；采用中华医学会手外科学会上肢部分功能评定试用标准评定皮瓣感觉恢复情况,并计算感觉恢复优秀比；采用国际膝关节委员会膝关节主观评分量表评定膝关节功能；采用皮瓣综合评价量表评定皮瓣修复效果,并计算优秀比。 结果 2组患者术后皮瓣大部分存活良好,仅股前外侧皮瓣组有2例患者皮瓣远端坏死3~5 cm2,行植皮或局部拉拢缝合后愈合。术后12~18个月进行末次随访时,2组患者皮瓣色泽、质地与膝部皮肤组织相近。隐动脉皮瓣组患者皮瓣感觉恢复优秀比为18/18,明显高于股前外侧皮瓣组的5/16（P<0.05）。隐动脉皮瓣组患者皮瓣两点辨别觉距离为（11.7±1.5）mm,明显短于股前外侧皮瓣组的（21.5±1.7）mm（t=-1.84,P<0.05）。2组患者膝关节功能评分及皮瓣修复效果优秀比均无明显差异（P>0.05）。 结论 膝部Ⅳ度电烧伤创面可以通过隐动脉皮瓣与逆行股前外侧穿支皮瓣修复。采用这2种皮瓣修复后,膝关节功能均恢复好,且采用隐动脉皮瓣修复后,感觉恢复更佳。 Abstract:Objective To compare the curative effects of saphenous artery flap and retrograde anterolateral femoral perforator flap in repairing the full-thickness electric burn wounds deep to tendon or bone in the knee. Methods This study was a retrospective observational study. From July 2018 to February 2022, 34 patients with full-thickness electric burn wounds deep to tendon or bone in the knee and conformed to the inclusion criteria were admitted to Zhengzhou First People's Hospital, including 26 males and 8 females, aged 18 to 54 years. According to the repair method of the electric burn wounds in the knee, the patients were divided into saphenous artery flap group (18 cases) repaired with saphenous artery flap and anterolateral femoral flap group (16 cases) repaired with retrograde anterolateral femoral perforator flap. The exposed area of bone or tendon after debridement was 5 cm×4 cm to 12 cm×7 cm, 5 patients were combined with open joint, and the resected area of the flap was 9 cm×6 cm to 25 cm×12 cm in saphenous artery flap group; the exposed area of bone or tendon after debridement was 7 cm×5 cm to 15 cm×7 cm, 6 patients were combined with open joint, and the resected area of the flap was 15 cm×10 cm to 39 cm×25 cm in anterolateral femoral flap group. According to the resected width of the flap, the wounds in the flap donor areas were repaired by direct suture or medium thickness skin graft. The survival of the flap was observed after surgery. At the last follow-up, the color and texture of the flap were recorded, and the two-point discrimination distance of the flap was detected. The sensory recovery of the flap was evaluated using the trial standards for evaluation of partial function of upper extremity by the Hand Surgery Society of Chinese Medical Association, and the excellent ratio of sensory recovery was calculated. The function of knee joint was assessed using the Knee Subjective Score Scale of International Knee Documentation Committee. The repairing effect of the flap was evaluated using comprehensive evaluation scale of flap, and the excellent ratio was calculated. Results Most of the flaps in patients in the 2 groups survived well after surgery, only 2 patients in the anterolateral femoral flap group had distal flap necrosis of 3 to 5 cm2, which healed after skin grafting or local suture. At the last follow-up of 12 to 18 months after surgery, the color and texture of the flap in patients in the two groups were similar to that of the skin tissue in the knee. The excellent ratio of sensory recovery of the flap was 18/18 in patients in saphenous artery flap group, which was significantly higher than 5/16 in anterolateral femoral flap group (χ2=5.71, P<0.05). The two-point discrimination distance of the flap was (11.7±1.5) mm in patients in saphenous artery flap group, which was significantly shorter than (21.5±1.7) mm in anterolateral femoral flap group (t=-1.84, P<0.05). The score of the knee joint function and the excellent ratio of the repairing effect of the flap had no statistically significant differences in patients in the two groups (P>0.05). Conclusions The full-thickness electric burn wounds deep to tendon or bone in the knee can be repaired by the saphenous artery flap and retrograde anterolateral femoral perforator flap. After repaired by the two flaps, the appearance and the function of the knee joint recover well, while the sensory recovery is better after repaired by the saphenous artery flap. -
Key words:
- Burns, electric /
- Knee joint /
- Surgical flaps /
- Sensation /
- Wound repair
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参考文献
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图 1 采用隐动脉皮瓣修复例1患者右膝部Ⅳ度电烧伤创面的效果。1A.术前膝关节外侧创面可见黑色腐肉样组织,部分溶痂；1B.清创后可见膝关节开放、髌骨外侧外露、部分皮质变性,设计同侧小腿隐动脉皮瓣,皮瓣面积为13 cm×13 cm；1C.腓肠筋膜覆盖封闭膝关节腔后即刻；1D.术中隐动脉皮瓣切取后即刻；1E.术中将皮瓣转移至创面,边缘缝合后即刻；1F.术后12个月随访时,皮瓣存活良好、外形略臃肿；1G、1H.分别为术后12个月随访时,膝关节屈曲近90°,行膝关节CT三维重建见膝关节功能良好
图 2 采用逆行股前外侧穿支皮瓣修复例2患者右膝部Ⅳ度电烧伤创面的效果。2A.入院时膝关节创面,呈焦炭状,部分崩裂,基底呈腐肉样；2B.清创后可见股直肌、股内侧肌等远端坏死,胫骨上段外露变黑,膝关节周围组织及腓肠肌近端变性；2C.术中设计同侧皮瓣,皮瓣面积为39 cm×25 cm；2D.术中解剖出3条皮穿支；2E.术中切取皮瓣后逆行转移覆盖膝部创面,皮瓣下放置引流管后；2F、2G、2H.分别为术后12个月随访时,皮瓣存活良好,供瓣区完全愈合,膝关节X线片提示膝关节软骨破坏
Table 1. 2组患者膝部Ⅳ度电烧伤创面采用皮瓣修复后末次随访时的效果比较
组别 例数 皮瓣感觉恢复（例） 皮瓣两点辨别觉距离（mm, 膝关节功能评分（分, 皮瓣修复效果评级（例） S4级 S3+级 S3级 优 良 中 差 隐动脉皮瓣组 18 13 5 0 11.7±1.5 91±7 15 3 0 0 股前外侧皮瓣组 16 0 5 11 21.5±1.7 89±7 11 4 0 1 统计量值 — t=-1.84 t=0.63 — P值 — <0.001 0.553 — 注：隐动脉皮瓣组和股前外侧皮瓣组患者分别采用隐动脉皮瓣和逆行股前外侧穿支皮瓣修复创面；“—”表示无此项 
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