抗生素骨水泥植入联合游离嵌合组织瓣移植序贯治疗严重痛风性创面的临床效果

肖顺娥; 李海; 张天华; 吴祥奎; 吴必华; 魏在荣; 邓呈亮

doi:10.3760/cma.j.cn501225-20240919-00340

抗生素骨水泥植入联合游离嵌合组织瓣移植序贯治疗严重痛风性创面的临床效果

doi: 10.3760/cma.j.cn501225-20240919-00340

遵义医科大学附属医院烧伤整形外科,遵义　　563000

基金项目:

贵州省高层次创新型人才“千”层次人才 xmrc120240201

省部共建协同创新中心项目 2020-39

详细信息

通讯作者:
邓呈亮,Email：cheliadeng@sina.com

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出版历程
- 收稿日期: 2024-09-19

Clinical effect of antibiotic-loaded bone cement implantation combined with free chimeric tissue flap transplantation in the sequential treatment of severe gouty wounds

Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China

Funds:

High-Level Innovative Talents "Thousand" Level Talents Of Guizhou Province of China xmrc120240201

Collaborative Innovation Center of Chinese Ministry of Education 2020-39

More Information

Corresponding author: Deng Chengliang, Email: cheliadeng@sina.com

摘要

摘要: 目的探讨抗生素骨水泥植入联合游离嵌合组织瓣移植序贯治疗严重痛风性创面的临床效果。方法该研究为回顾性观察性研究。2019年7月—2022年7月,遵义医科大学附属医院收治11例符合入选标准的严重痛风性创面患者,均为男性,年龄33~71岁。创面位于手部者2例、踝部者5例、足部者4例。清创后,创面面积为5.0 cm×4.0 cm~22.0 cm×6.0 cm,均采用抗生素骨水泥植入联合游离嵌合组织瓣移植序贯修复。采用游离旋髂浅动脉穿支嵌合骨皮瓣修复者2例,切取皮瓣面积分别为5.5 cm×4.0 cm、8.0 cm×6.0 cm,切取髂骨瓣体积分别为2.0 cm×2.0 cm×1.5 cm、3.5 cm×2.0 cm×2.0 cm；采用游离旋髂深动脉穿支嵌合骨皮瓣修复者2例,切取皮瓣面积分别为6.0 cm×4.0 cm、7.5 cm×5.0 cm,切取髂骨瓣体积分别为2.0 cm×1.5 cm×1.5 cm、2.5 cm×2.0 cm×1.5 cm；采用游离旋股外侧动脉降支穿支嵌合肌皮瓣修复者7例,切取皮瓣面积为9.5 cm×6.0 cm~25.0 cm×6.5 cm,肌瓣体积为4.0 cm×3.0 cm×2.0 cm~6.0 cm×5.0 cm×2.5 cm。直接缝合供区创面。将嵌合组织瓣游离移植至受区创面,其中的髂骨瓣用于填塞骨缺损,肌瓣用于填塞创腔,皮瓣用于覆盖创面；血管蒂中的动静脉与受区动静脉吻合。观察患者入院时及抗生素骨水泥植入术后3 d白细胞计数、中性粒细胞及超敏C反应蛋白水平变化情况以及创面分泌物标本细菌培养情况,创基肉芽组织生长情况。Ⅱ期术后,观察移植嵌合组织瓣成活情况、是否发生血管危象,供、受区创面愈合情况。随访时,观察受区移植组织瓣血运、外观及质地,观察患肢、患指功能及外观,观察供、受区并发症发生情况。结果抗生素骨水泥植入术后3 d,患者白细胞计数、超敏C反应蛋白水平及中性粒细胞均较入院时显著下降（Z值分别为-2.93、-2.93,t=8.63,P<0.05）。入院时,11例患者创面均存在细菌感染,创周红肿明显；抗生素骨水泥植入术后3 d,所有患者创面分泌物标本细菌培养结果均为阴性,创周无明显红肿,创基肉芽组织生长良好。Ⅱ期术后,11例患者嵌合组织瓣均顺利成活,未发生血管危象；1例患者足背受区创面愈合欠佳,经换药后延期愈合,其余患者受区创面均顺利愈合；所有患者供区切口均愈合良好。随访6~24个月,受区皮瓣血运、质地及外观良好；4例带髂骨瓣移植患者,骨愈合均良好,9例下肢创面患者均能负重活动,2例手部创面患者握捏、对掌、对指等功能明显改善；供、受区均未出现明显并发症。结论针对严重痛风性创面,采取Ⅰ期清创联合抗生素骨水泥植入、Ⅱ期游离嵌合骨皮瓣或肌皮瓣修复的序贯治疗方案,可使得术后创面感染得到良好控制,愈合较好,患指或患肢功能恢复佳,无明显并发症,值得推广。
- 痛风 /
- 显微外科手术 /
- 游离皮瓣 /
- 嵌合皮瓣 /
- 抗生素骨水泥 /
- 创面修复
Abstract: Objective To evaluate the clinical effect of antibiotic-loaded bone cement implantation combined with free chimeric tissue flap transplantation in the sequential treatment of severe gouty wounds. Methods This study was a retrospective observational study. From July 2019 to July 2022, 11 male patients with severe gouty wounds who were aged 33 to 71 years and met the inclusion criteria were admitted and treated at the Affiliated Hospital of Zunyi Medical University. The wounds were located on the hands in 2 cases, the ankles in 5 cases, and the feet in 4 cases. After debridement, the wound area ranged from 5.0 cm×4.0 cm to 22.0 cm×6.0 cm. All wounds were sequentially repaired with antibiotic-loaded bone cement implantation combined with free chimeric tissue flaps transplantation. Two cases were repaired by free perforating branch of superficial circumflex iliac artery with chimeric osseous flaps, with the areas of harvested skin flaps being 5.5 cm×4.0 cm and 8.0 cm×6.0 cm, respectively, and the volumes of iliac bone flaps being 2.0 cm×2.0 cm×1.5 cm and 3.5 cm×2.0 cm×2.0 cm, respectively. Two cases were repaired by free perforating branch of deep circumflex iliac artery with chimeric osseous flaps, with the areas of harvested skin flaps being 6.0 cm×4.0 cm and 7.5 cm×5.0 cm, respectively, and the volumes of iliac bone flaps being 2.0 cm×1.5 cm×1.5 cm and 2.5 cm×2.0 cm×1.5 cm, respectively. Seven cases were repaired by free chimeric myocutaneous flaps based on the descending branch of the lateral circumflex femoral artery. The areas of harvested skin flaps ranged from 9.5 cm×6.0 cm to 25.0 cm×6.5 cm, and the volumes of muscle flaps ranged from 4.0 cm×3.0 cm×2.0 cm to 6.0 cm×5.0 cm×2.5 cm. The donor site wounds were directly sutured. The chimeric tissue flap was freely transplanted to the recipient wound site, of which the iliac bone graft was used to fill the bone defect, the muscle flap was utilized to fill the wound cavity, and the skin flap was employed to cover the wound surface; the arteries and veins in the vascular pedicle were anastomosed with those in the recipient area. At admission and 3 days post antibiotic-loaded bone cement implantation, the changes in white blood cell count, neutrophil and hypersensitive C-reactive protein level, as well as the bacterial culture of wound secretions specimen, and the growth of granulation tissue were observed. After stage Ⅱ surgery, the survival of transplanted chimeric tissue flaps, the occurrence of vascular crisis, and the healing of wounds in donor and recipient sites were observed. During follow-up, the blood supply, appearance, and texture of the transplanted tissue flaps in the recipient sites, the function and appearance of the affected limbs and fingers, and the complications in the donor and recipient sites were observed. Results Three days post antibiotic-loaded bone cement implantation, white blood cell count, hypersensitive C-reactive protein level, and neutrophil significantly decreased compared with those at admission (with Z values of -2.93 and -2.93 respectively, t=8.63, P<0.05). At admission, all patients exhibited bacterial infections with redness and swelling around the wounds. Three days post antibiotic-loaded bone cement implantation, bacterial cultures of wound secretions specimen were negative, local redness resolved, and granulation tissue showed good growth. After stage Ⅱ surgery, all chimeric flaps survived without vascular crises. The wound healing in the recipient site of the dorsum of the foot in one patient was poor and delayed but healed after dressing changes; all the other recipient sites in remaining patients healed successfully. The donor incision healed well in all patients. During 6 to 24 months of follow-up, the flaps in the recipient area demonstrated good blood circulation, texture, and appearance. Bone healing was achieved in 4 patients with iliac grafts. Nine patients with lower limb wounds were able to bear weight, and the functions including gripping, palm alignment, and finger alignment were significantly improved in 2 patients with hand wounds. No significant complications were observed in donor or recipient sites. Conclusions In treating patients with severe gouty wounds, the sequential strategy of stage Ⅰ debridement with antibiotic-loaded bone cement implantation followed by stage Ⅱ free chimeric osseous flaps or myocutaneous flaps repair can achieve effectively control of postoperative wound infection, promote wound healing, and well restore the functions of affected finger or limb with no obvious complications, which is worthy of promotion for clinical application.
- Gout /
- Microsurgery /
- Free flap /
- Chimeric flap /
- Antibiotic-loaded bone cement /
- Wound repair
肖顺娥：实施研究、采集数据、统计分析以及撰写论文；李海、张天华：实施研究、起草及修改文章；吴祥奎、吴必华：实施研究、采集数据；魏在荣：酝酿及设计研究；邓呈亮：分析数据、修改文章、经费支持

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图 1 抗生素骨水泥植入联合旋髂浅动脉穿支嵌合骨皮瓣移植序贯修复患者左足痛风性创面。1A.左足创面术前外观,可见局部皮肤软组织缺损,第1跖趾关节处骨破坏并缺损,创面可见痛风石沉积；1B.入院时左足CT三维成像,提示第1跖趾关节处骨质破坏伴周围软组织肿胀、肿块；1C.左足创面清创后予抗生素骨水泥植入后；1D.Ⅱ期手术前创面外观；1E.旋髂浅动脉穿支嵌合骨皮瓣设计；1F、1G.分别为切取旋髂浅动脉穿支嵌合骨皮瓣术中及断蒂后；1H.游离移植旋髂浅动脉穿支嵌合骨皮瓣修复左足创面术后即刻外观；1I.术后12个月随访时左足情况,受区外观满意；1J.术后12个月随访,左足X线片可见骨皮瓣移植后骨愈合良好

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Table 1. 11例严重痛风性创面患者入院时及抗生素骨水泥植入术后3 d各炎症指标水平的比较

时间点	白细胞计数[×10⁹/L,M（Q₁,Q₃）]	中性粒细胞（x¯±s）	超敏C反应蛋白水平[mg/L,M（Q₁,Q₃）]
入院时	11.49（9.58,12.67）	0.82±0.09	48.43（18.16,101.30）
术后3 d	7.94（6.97,9.07）	0.64±0.09	11.13（7.76,34.47）
统计量值	Z=-2.93	t=8.63	Z=-2.93
P值	0.003	<0.001	0.003