Lyu SJ,Yan ZD,Fan RH,et al.Effects and mechanism of glycine on rat cardiomyocytes pretreated with serum from burned rats[J].Chin J Burns Wounds,2023,39(5):434-442.DOI: 10.3760/cma.j.cn501225-20230206-00035.
Citation: Wang H,Zhou T,Liu YJ,et al.Effects of four types of perforator flaps pedicled with cutaneous neurotrophic vessels in repairing wounds on the volar side of hands[J].Chin J Burns Wounds,2023,39(11):1038-1046.DOI: 10.3760/cma.j.cn501225-20230720-00009.

Effects of four types of perforator flaps pedicled with cutaneous neurotrophic vessels in repairing wounds on the volar side of hands

doi: 10.3760/cma.j.cn501225-20230720-00009
Funds:

Medical Science Research Plan Project of Hebei Province of China 20201453

Tracking Project of Medical Applicable Technology in Hebei Province of China GZ2021030

Science and Technology Plan Project of Tangshan City 22150219J

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  •   Objective   To investigate the effects of four types of perforator flaps pedicled with cutaneous neurotrophic vessels in repairing wounds on the volar side of hands.   Methods   A retrospective observational study was conducted. From May 2012 to July 2021, 122 patients with wounds on the volar side of hands who met the inclusion criteria were admitted to the Department of Hand Surgery of the Second Hospital of Tangshan, including 74 males and 48 females, aged 18-76 years. There were 15 cases of palm injury alone, 101 cases of finger injury alone, and 6 cases of simultaneous palm and finger injury. The wounds with area ranging from 1.5 cm×1.2 cm to 15.0 cm×6.0 cm were all repaired by transplantation of perforator flaps pedicled with cutaneous neurotrophic vessels, including 16 cases of the ulnar artery perforator flap carrying the medial antebrachial cutaneous nerve, 20 cases of the dorsal metacarpal artery perforator flap carrying the dorsal metacarpal cutaneous nerve, 21 cases of the digital artery dorsal perforator flap of thumb carrying the terminal branch of lateral antebrachial cutaneous nerve, and 65 cases of the digital artery dorsal perforator flap of the 2 nd to 5 th finger carrying the dorsal branch of digital nerve, with the sizes of flaps ranging from 1.8 cm×1.4 cm to 20.0 cm×6.0 cm. High-frequency color Doppler ultrasonography was performed to locate and measure the perforators and cutaneous nerves of the flaps preoperatively. The cutaneous nerves carried by the flaps were all anastomosed with the nerves at the recipient sites during the operation. The donor sites were closed directly or repaired with split- or full-thickness free skin graft from the ipsilateral thigh or proximal medial forearm. The survival of the flaps and skin grafts at the flap donor sites, and the healing of incisions at the flap donor sites were observed postoperatively. The patients were followed up, and at the last follow-up, the static two-point discrimination distances of the flaps were measured, the degree of satisfaction of patients with the appearances of the flaps and flap donor sites were evaluated based on the evaluation criteria of Michigan Hand Function Questionnaire, and the functions of the affected hands were evaluated according to the trial criteria for upper limb function evaluation of the Hand Surgery Society of the Chinese Medical Association.   Results   After surgery, the distal end of the ulnar artery perforator flap carrying the medial antebrachial cutaneous nerve transplanted in one patient and the digital artery dorsal perforator flap of the 2 nd to 5 th finger carrying the dorsal branch of digital nerve transplanted in two patients were partially necrotic but healed after dressing change; the flaps transplanted in the other 119 patients all survived. All skin grafts at the flap donor sites survived, and all incisions at the flap donor sites healed after surgery. The follow-up period was 10 to 36 months, with an average of 16 months. At the last follow-up, the static two-point discrimination distances of the ulnar artery perforator flaps carrying the medial antebrachial cutaneous nerve was 10 to 20 mm. Ten patients were strongly satisfied and 6 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps. Seven patients were strongly satisfied and 9 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites. Functional evaluation of the affected hand was excellent in 7 cases, good in 7 cases, and fair in 2 cases. For the dorsal metacarpal artery perforator flap carrying the dorsal metacarpal cutaneous nerve, the static two-point discrimination distances of the flaps was 8 to 18 mm; 13 patients were strongly satisfied and 7 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps; 10 patients were strongly satisfied and 10 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites; the functional evaluation of the affected hand was excellent in 11 cases, good in 7 cases, and fair in 2 cases. For the digital artery dorsal perforator flap of thumb carrying the terminal branch of lateral antebrachial cutaneous nerve, the static two-point discrimination distances of the flaps was 6 to 11 mm; 17 patients were strongly satisfied and 4 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps; 13 patients were strongly satisfied and 8 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites; the functional evaluation of the affected hand was excellent in 15 cases and good in 6 cases. For the digital artery dorsal perforator flap of the 2 nd to 5 th finger carrying the dorsal branch of digital nerve, the static two-point discrimination distances of the flaps was 5 to 12 mm; 43 patients were strongly satisfied and 22 patients were satisfied in the evaluation of satisfaction with the appearance of the flaps; 47 patients were strongly satisfied and 18 patients were satisfied in the evaluation of satisfaction with the appearance of the flap donor sites; the functional evaluation of the affected hands were excellent in 39 cases, good in 21 cases, and fair in 5 cases.   Conclusions   With the assistance of high-frequency color Doppler ultrasonography, four types of perforator flaps pedicled with cutaneous neurotropic vessels which are used to repair different types of wounds on the volar side of the hand can have reliable blood supply, are easy to cut, cause minimal secondary damage to the donor area, and have good recovery of the flap sensation after surgery.

     

  • 证明超声清创法可显著减轻烧伤残余创面的细菌负荷,减少术后血肿形成,促进移植皮片成活,从而缩短患者病程。

    烧伤,尤其是深度烧伤会遗留严重瘢痕,对患者身心造成损害1, 2, 3。深度烧伤创面难以愈合或一次封闭困难,均会导致残余创面形成。临床上修复残余创面常采用清创+植皮术,而传统清创手术易误伤创面周围健康组织4,违背现代精准医学的治疗理念。近年来,超声清创技术在糖尿病足、下肢静脉溃疡、压疮、骨外露等创面修复5, 6, 7, 8中取得了良好效果,但目前国内鲜见将超声清创技术应用于烧伤残余创面的相关报告。解放军联勤保障部队第980医院(以下简称本单位)近年来将超声清创技术应用于烧伤残余创面,取得了良好的临床效果。

    本回顾性队列研究符合《赫尔辛基宣言》的基本原则,根据本单位伦理委员会政策,临床资料可以在不泄露患者身份信息的前提下分析、使用。

    纳入标准:(1)原发深Ⅱ度或Ⅲ度烧伤经清创植皮后仍存在残余创面;(2)创面分布相对集中,创面总面积≥1%TBSA,且至少存在1处残余创面直径≥5 cm。(3)对残余创面行传统清创法或超声清创法+植皮治疗者。排除标准:资料不全者。

    2017年8月—2021年8月,本单位收治64例符合入选标准的患者,其中男41例、女23例,年龄为9个月~67岁,平均年龄31岁,烧伤总面积25%~90%TBSA,残余创面总面积1%~17%TBSA,致伤原因:火焰烧伤者36例,热液烫伤者23例,电烧伤者5例。根据创面清创方法,将患者分为超声清创组(34例)和传统清创组(30例)。2组患者性别、年龄、致伤原因、烧伤部位等一般情况比较,差异均无统计学意义(P>0.05);2组患者烧伤总面积、残余创面面积、伤后清创时间等创面情况均相似(P>0.05)。见表1。清创前,2组患者的所有创面中均有细菌感染:超声清创组创面中检出金黄色葡萄球菌者12例、铜绿假单胞菌者15例、鲍曼不动杆菌者5例、粪肠球菌者3例、阴沟肠杆菌者2例,其中复合感染者3例;传统清创组创面检出金黄色葡萄球菌者11例、铜绿假单胞菌者15例、鲍曼不动杆菌者3例、肺炎克雷伯菌者2例、阴沟肠杆菌者2例,其中复合感染者3例。

    表1  2组烧伤残余创面患者一般资料及其烧伤创面情况比较
    组别例数性别(例)年龄(岁,x¯±s致伤原因(例)烧伤部位(例)烧伤总面积(%TBSA,x¯±s残余创面面积(%TBSA,x¯±s伤后清创时间(d,x¯±s
    火焰烧伤热液烫伤电烧伤头面颈部前后躯干四肢
    超声清创组34221231±13191234201051±1410.9±4.032±6
    传统清创组30191132±1317112319850±1210.1±2.933±5
    统计量值χ2=0.01t=0.30χ2=0.10χ2=0.14t=0.29t=0.89t=0.71
    P0.9090.9720.9490.9320.7070.9070.169
    注:TBSA为体表总面积
    下载: 导出CSV 
    | 显示表格

    2组患者入院后均行常规补液、换药等治疗,术前纠正电解质紊乱、低蛋白血症、贫血、血糖和血压异常等情况,选择敏感抗生素防治感染,改善创面微循环。术中全身麻醉下对创面进行清创:(1)超声清创组创面,采用超声清创机根据创面大小使用500~2 000 mL生理盐水清除坏死组织或陈旧性肉芽至新鲜点状出血,清创后以1∶250 000肾上腺素盐水浸润的纱布覆盖创面以减少出血。超声机功率设置(50%~80%额定功率)及清创时长根据肉芽生长、坏死组织残存及感染情况确定。(2)传统清创组创面,采用传统锐性清创的方式,清创同时以1∶250 000肾上腺素盐水浸润的纱布湿敷,必要时行电凝止血。清创结束后,2组创面均使用过氧化氢、氯已定、生理盐水等冲洗3~5遍后植皮。功能部位或对容貌影响较大的暴露区创面首选大张皮片植皮;非功能部位创面,尤其是供皮困难者,选择移植邮票皮。植皮后四肢等部位采用无菌纱布适当加压包扎;面部等不易包扎的部位予缝线打包加压固定。术后行抗生素治疗,每2~3天换药1次。对于Ⅰ期手术后未愈合创面行二次清创+植皮术,2组创面的清创方式均分别同其Ⅰ期。

    1.4.1   创面分泌物细菌阳性率

    术后3 d,于创面分泌物较多处选取标本行微生物培养及药物敏感试验检测细菌情况并计算细菌阳性率。创面细菌阳性率=细菌阳性患者例数÷患者总例数×100%。

    1.4.2   皮片成活率及皮下血肿发生率

    术后7 d,对于采用邮票皮治疗者,若面积较大,则统计5处约5 cm×5 cm植皮区内成活皮片数量;若面积较小,则统计所有植皮区域内成活皮片数量4。对于采用大张皮植皮者,行大体观察直接评估皮片成活情况。皮片成活标准为贴附良好、颜色红润、按压后充血明显、无明显滑动。皮片成活率=成活皮片数÷移植皮片总数×100%。术后7 d,大体观察创面皮下血肿发生率,皮下血肿发生率=皮下血肿形成患者例数÷患者总例数×100%。

    1.4.3   创面愈合时间及二次清创率

    出院时,统计患者创面愈合时长(二次清创者以Ⅱ期创面愈合时间为准)及清创次数并计算二次清创率,二次清创率=二次清创患者例数÷患者总例数×100%。

    采用SPSS 17.0统计软件对数据进行分析。符合正态分布的计量资料数据以x¯±s表示,组间比较采用独立样本t检验;计数资料数据以例(百分率)表示,组间比较采用χ2检验。P<0.05为差异有统计学意义。

    术后3 d,超声清创组创面感染金黄色葡萄球菌者2例、铜绿假单胞菌者2例,传统清创组创面感染金黄色葡萄球菌者5例、铜绿假单胞菌者3例、鲍曼不动杆菌者1例、肺炎克雷伯菌者1例、阴沟肠杆菌者1例;超声清创组患者创面细菌阳性率为11.8%(4/34)明显低于传统清创组的36.7%(11/30),χ2=5.51,P=0.019。

    术后7 d,超声清创组创面的移植皮片成活率为(92±5)%,明显高于传统清创组的(84±10)%(χ2=6.78,P<0.001);超声清创组创面皮下血肿发生率为17.6%(6/34),明显低于传统清创组的40.0%(12/30),χ2=3.94,P=0.047。

    出院时,超声清创组创面愈合时长为(11.0±2.0)d,明显短于传统清创组的(13.0±3.1)d,(t=3.81,P<0.001);超声清创组创面二次清创率为2.9%(1/34),明显低于传统清创组的20.0%(6/30),χ2=4.76,P=0.030。

    患者男,38岁,致伤原因为电烧伤,全身多处均为Ⅲ度烧伤,总面积为26%TBSA,主要位于左下肢(14%TBSA)及头面部(3%TBSA)、左上肢(3%TBSA)、背部(4%TBSA)、左臀部(2%TBSA),伤后被送至当地医院治疗,其间行全身多处创面削痂+Meek植皮术。患者于伤后25 d转入本单位。入院时,患者部分创面已经基本封闭,已愈合区域与肉芽创面相互交错;残余创面主要位于背部,面积为2%TBSA,其表面可见肉芽组织增生及稀薄分泌物。入院后,从患者创面分泌物中检出金黄色葡萄球菌,后续采用静脉输注抗生素抗感染、纠正电解质紊乱等措施改善患者全身状况,创面每2~3天换药1次。入院后第7天,在全身麻醉下采用超声清创机对患者背部残余创面进行清创,清创机功率设置为75%额定功率,使用约500 mL生理盐水冲洗创面。然后选择右侧背部皮肤为供皮区,切取相应大小刃厚皮片行邮票皮移植术并采用无菌纱布适当加压包扎。术后行抗生素治疗,每2~3天换药1次。术后3 d,取创面中少量分泌物行微生物培养,未检出细菌。术后7 d,创面皮片成活率约为98%,皮片下无明显血肿。术后12 d创面完全愈合。见图1

    1  超声清创法+邮票皮移植治疗背部烧伤患者残余创面的疗效。1A.伤后25 d入院时,创面中较少肉芽组织增生;1B.伤后32 d背部创面清创术前,见肉芽组织增生明显,突出皮面;1C.清创术中;1D.术后12 d,邮票皮片存活良好

    浅Ⅱ度烧伤经适当处理后可愈合,但深Ⅱ度及Ⅲ度等深度烧伤创面愈合困难,勉强愈合后也会遗留瘢痕或反复破溃,严重影响机体外观和功能9, 10, 11。因此,对深度烧伤常在早期行外科手术修复,常形成残余创面需在Ⅱ期行清创植皮术。理想的清创方式应具备高效且尽量保留健康组织、减少出血、降低住院费用、减轻创面中细菌负荷及提高愈合率等特点12。烧伤残余创面存在已愈合区域与坏死组织或肉芽组织相互交叉、镶嵌分布、边缘不规则等特点,清创难度大,传统锐性清创法的应变效能差,会造成周围正常组织不必要的损伤,出血较多。这导致经验较少的年轻医师在治疗残余创面的过程中存在较多突出问题4

    超声清创法是近年来兴起的清创方式,为残余创面清创提供了新的选择13。高频超声以热效应为主,低频超声以机械效应为主,即分别具有空化效应与声流作用14, 15, 16。超声清创机采用低频、高能超声波加载喷射流技术,在冲洗创面过程中会产生空化效应,即通过超声波形成的空化泡崩塌产生的微射流及高压可清除坏死组织17, 18, 19。超声清创机操作灵活,可用于平面或腔隙等不同类型创面;还可根据坏死组织或肉芽组织情况选择不同的功率,达到最佳清创效果。同时,超声清创机可将液体以雾化的形式喷出,使液体全面接触创面以更精确地清除非活性组织,又避免了对周围正常组织的附带损伤51720

    创面细菌负荷的减轻程度是反映清创效果的一个重要指标。创面细菌负荷与细菌生物膜形成密切相关,生物膜可保护细菌免受抗生素、防腐剂和宿主免疫的影响,还可逐步释放浮游细菌导致创面持续感染,严重影响创面皮片成活率21, 22, 23, 24, 25, 26。有研究显示超声不仅对革兰阳性、革兰阴性、需氧和厌氧细菌具有明显抗菌作用27, 28,还可以有效清除细菌生物膜21,显著减少细菌负荷,改善创面条件29, 30, 31。本研究结果显示,超声清创组术后3 d创面细菌阳性率显著低于传统清创组,同时前者的二次清创率也显著低于后者,提示超声清创法在清除创面坏死组织,减轻细菌负荷等方面具有显著作用,其结果与前述既往国内外研究结果一致。

    此外,超声清创法可有效减轻术后炎症反应和疼痛,还可促进伤口组织中碱性FGF和EGF的高表达,改善创面微循环,促进血管生成和胶原沉积,提升组织再生和修复能力,这可能与超声产生的空化效应和声流作用等机械能刺激信号转导,继发广泛的细胞效应有关18, 1932, 33, 34。本研究中超声清创组的皮片成活率显著高于传统清创组,且创面愈合时间显著短于传统清创组。移植皮片的成活率与皮下积血、积液等密切相关。相关研究指出,超声清创机可通过热效应达到减少出血的效果535, 36,但由于术中出血与组织液、膨胀液或冲洗液等混合在一起,难以精确估计出血量。但是本研究显示,超声清创组皮下血肿发生率显著低于传统清创组,提示减少术中出血和皮下血肿形成可能是超声清创法提高皮片成活率,促进创面愈合的机制之一。

    综上,与传统清创法相比,超声清创法可在烧伤残余创面清创中彻底清除坏死组织和陈旧性肉芽组织、减轻细菌负荷、降低皮下血肿发生率,促进移植皮片成活,从而缩短创面愈合时间,为烧伤残余创面的修复提供了新的方法和选择。超声清创法对于提高烧伤残余创面的修复效果具有重要意义,值得临床推广。

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