Strategy for wound repair of skin and soft tissue defect and systematic rehabilitation treatment for functional reconstruction of patients with severe burn or trauma on knees
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摘要: 目的 探讨膝部严重烧创伤患者皮肤软组织缺损创面修复及功能重建系统康复治疗策略。 方法 2015年1月—2016年10月,笔者单位收治26例膝部严重烧创伤后皮肤软组织缺损患者,其中14例患者合并髌韧带缺损,16例患者合并膝关节囊缺损。入院后1~3 d行创面清创,清创后膝部皮肤软组织缺损面积10 cm×7 cm~42 cm×18 cm。清创后行VSD治疗,5~7 d后行皮瓣修复术。9例患者缺损采用局部旋转皮瓣修复;7例患者膝部皮肤软组织缺损合并5 cm×3 cm~9 cm×7 cm膝关节囊缺损,采用带阔筋膜的股前外侧游离皮瓣修复;10例患者膝部皮肤软组织缺损合并6 cm×3 cm~12 cm×4 cm髌韧带缺损,采用带髂胫束的股前外侧游离皮瓣修复。本组患者皮瓣切取面积为11 cm×9 cm~22 cm×15 cm。术后采用"一早、二持续、三序贯"的系统康复治疗策略行膝关节功能重建。术前及术后12个月,采用国际膝关节文献委员会(IKDC)膝关节评估表对患者膝关节疼痛程度及功能进行评分。术后2周、12个月采用关节量角器测定患者膝关节屈曲度及伸直度。术后6、12个月,采用彩色多普勒超声观察患者膝关节囊完整性及髌韧带连续性。 结果 本组所有患者术后皮瓣存活良好,创面愈合良好。2例采用股前外侧游离皮瓣修复患者,术后皮瓣远端出现坏死,行清创及自体大腿中厚皮移植修复后创面愈合。术后12个月患者IKDC膝关节评估表评分为(79±8)分,明显高于术前的(64±7)分(
t =7.20,P <0.05)。术后12个月患者膝关节屈曲度为(117±10)°,明显大于术后2周的(35±8)°(t =32.65,P <0.05)。术后12个月患者膝关节伸直度为(12±9)°,显著小于术后2周的(61±9)°(t =19.63,P <0.05)。术后6、12个月,9例采用局部旋转皮瓣修复患者膝关节囊完整性及髌韧带连续性良好,7例采用带阔筋膜的股前外侧游离皮瓣修复患者膝关节囊完整性良好,10例采用带髂胫束的股前外侧游离皮瓣修复患者髌韧带连续性良好。术后12个月随访,皮瓣存活良好,患者膝部外形良好,膝关节活动功能正常。 结论 膝部严重烧创伤后皮肤软组织缺损创面采用局部旋转皮瓣或带阔筋膜、髂胫束的股前外侧游离皮瓣修复,术后早期行膝关节系统康复治疗,患者膝部外形及功能恢复良好。Abstract: Objective Strategy for wound repair of skin and soft tissue defect and systematic rehabilitation treatment for functional reconstruction of patients with severe burn or trauma on knees. Methods From January 2015 to October 2016, 26 patients with skin and soft tissue defect on knees after severe burn or trauma were hospitalized in our unit. Among these patients, 14 patients had patellar ligament defect, and 16 patients had knee joint capsule defect. Wound debridement was operated on 1 to 3 days after admission. After debridement, the area of skin and soft tissue defect ranged from 10 cm×7 cm to 42 cm×18 cm. Vacuum sealing drainage (VSD) treatment was performed after debridement, and flap transplantation operation was performed after VSD treatment for 5 to 7 days. Defects of nine patients were treated with local rotation flaps. Seven patients with skin and soft tissue defects on knees and knee joint capsule defects of 5 cm×3 cm to 9 cm×7 cm were treated with free anterolateral femoral flaps combined with fascia lata. Ten patients with skin and soft tissue defects on knees and patellar ligament defects of 6 cm×3 cm to 12 cm×4 cm were treated with free anterolateral femoral flaps combined with iliotibial tract. The area of flaps ranged from 11 cm×9 cm to 22 cm×15 cm. After flap transplantation operation, functional reconstruction of knee joint was carried out according to early, continuous, and sequential systematic rehabilitation treatment strategy. The pain degree and function of knee joint of patients were scored by the International Knee Documentation Committee (IKDC) Knee Evaluation Form before operation and 12 months after operation. The knee joint flexion and extension degrees of patients were measured by joint protractor in 2 weeks and 12 months after operation. The color Doppler ultrasound was used to evaluate integrity of knee joint capsule and continuity of patellar ligament of patients in 6 and 12 months after operation. Results All flaps of 26 patients survived well, and wounds healed completely after the operation. Distal parts of flaps of 2 patients treated with free anterolateral femoral flaps had local necrosis after the operation, and their wounds healed after debridement and transplantation of autologous intermediate split-thickness skin graft of thigh. The IKDC Knee Evaluation Form score of patients was (79±8) points in 12 months after operation, which was significantly higher than (64±7) points before operation (t =7.20,P <0.05). The flexion degree of knee joint of patients was (117±10)° in 12 months after operation, which was significantly larger than (35±8)° in 2 weeks after operation (t =32.65,P <0.05). The extension degree of knee joint of patients was (12±9)° in 12 months after operation, which was significantly smaller than (61±9)° in 2 weeks after operation (t =19.63,P <0.05). In 6 and 12 months after operation, 9 patients treated with local rotation flaps had good integrity of knee joint capsule and continuity of patellar ligament; 7 patients treated with free anterolateral femoral flaps and fascia lata had good integrity of knee joint capsule; 10 patients treated with free anterolateral femoral flaps and iliotibial tract had good continuity of patellar ligament. During follow-up of 12 months, all flaps survived well; knees of all patients had good appearance; knee joints functioned normally. Conclusions Good appearance and function of knees can be achieved by repairing wound of skin and soft tissue defect on knees after severe burn or trauma with local rotation flaps or free anterolateral femoral flaps with fascia lata or iliotibial tract plus systematic rehabilitation treatment of knee joint in early stage after flap transplantation operation. -
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