A multicenter study on the classification and repair effects of stage 4 pressure injury in ischial tuberosity in elderly patients
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摘要:
目的 探讨老年坐骨结节4期压力性损伤的分型及其修复效果。 方法 该研究为回顾性观察性研究。将皖南医学院第一附属医院、蚌埠医科大学附属蚌埠市第三人民医院、安徽医科大学附属六安医院（下称3家医院）2021年1月—2022年12月收治的45例符合入选标准的4b、4c、4d型老年坐骨结节4期压力性损伤患者作为对照组,其中男28例、女17例,年龄 60~78岁。将3家医院2023年1月—2024年12月收治的50例符合入选标准的4b、4c、4d型老年坐骨结节4期压力性损伤患者作为观察组,其中男31例、女19例,年龄 60~80岁。对观察组患者在其入院时进行坐骨结节4期压力性损伤分型,针对性选择手术方式：对于4b型,优选筋膜皮瓣修复,包括带皮肤蒂筋膜皮瓣（12例）、风筝皮瓣（14例）；对于4c型,优选肌皮瓣修复（17例）；对于4d型,优选岛状肌皮瓣（4例）或肌瓣联合皮瓣（3例）修复。对于对照组患者,根据术者临床经验选择手术方式修复压力性损伤：对于4b型,采用带皮肤蒂筋膜皮瓣修复者18例、风筝皮瓣修复者6例；对于4c型,采用带皮肤蒂筋膜皮瓣修复者6例、风筝皮瓣修复者7例、肌皮瓣修复者3例；对于4d型,采用风筝皮瓣修复者2例、肌皮瓣修复者3例。2组患者创面床准备好后,创面大小为5.5 cm×4.5 cm~8.0 cm×7.0 cm,移植组织瓣大小为5.0 cm×4.5 cm~10.0 cm×8.0 cm。将供瓣区创面直接拉拢缝合或采用接力皮瓣修复。统计2组患者1次手术修复创面愈合率、创面愈合时间、住院时间、住院治疗费用、出院时压力性损伤愈合量表（PUSH）评分、随访时压力性损伤复发率。 结果 观察组患者1次手术修复创面愈合率为88.00%（44/50）,明显高于对照组的66.67%（30/45）,相对风险为1.32,95%置信区间为1.08~1.61,χ2=6.48,P<0.05。采用多因素logistic回归分析校正基线资料后,观察组患者1次手术修复创面愈合率仍明显高于对照组（相对风险为1.30,95%置信区间为1.05~1.59,χ2=6.14,P<0.05）。观察组患者创面愈合时间为（18±5）d,明显短于对照组的（27±6）d（均数差值为-9 d,95%置信区间为-12~-7 d,t=7.73,P<0.05）。采用多因素协方差分析校正基线资料后,观察组患者创面愈合时间仍明显短于对照组（均数差值为-9 d,95%置信区间为-11~-6 d,F=37.10,P<0.05）。观察组患者住院时间显著短于对照组（t=5.04,P<0.05）,住院治疗费用显著少于对照组（t=2.11,P<0.05）,出院时PUSH评分显著低于对照组（t=3.08,P<0.05）。出院后随访2~24个月,观察组患者压力性损伤复发率显著低于对照组（χ2=5.02,P<0.05）。 结论 将老年坐骨结节4期压力性损伤细分为多个亚型有助于指导临床选择合适的修复策略,提高1次手术修复创面愈合率,缩短创面愈合时间和住院时间,减少住院治疗费用,降低压力性损伤复发率,值得临床推广。 Abstract:Objective To explore the classification and repair effects of stage 4 pressure injury in ischial tuberosity in elderly patients. Methods This study was a retrospective observational study. From January 2021 to December 2022, 45 elderly patients with stage 4 pressure injury in ischial tuberosity of type 4b, 4c, and 4d, who met the inclusion criteria and were admitted to the First Affiliated Hospital of Wannan Medical College, Bengbu Third People's Hospital Affiliated to Bengbu Medical University, and Lu'an Hospital Affiliated to Anhui Medical University (hereinafter referred to as the three hospitals) were selected as the control group, including 28 males and 17 females, aged 60 to 78 years. Fifty elderly patients with stage 4 pressure injury in ischial tuberosity of type 4b, 4c, and 4d, who met the inclusion criteria and were admitted to the three hospitals from January 2023 to December 2024 were selected as the observation group, including 31 males and 19 females, aged 60 to 80 years. The stage 4 pressure injury in ischial tuberosity of patients in observation group were classified on admission, and the targeted surgical methods were selected. For type 4b, the fascial flap was preferred for repair, including fascial flap with skin pedicle (12 cases) and kite flap (14 cases); for type 4c, myocutaneous flap repair was preferred (17 cases); for type 4d, island myocutaneous flap (4 cases) or a combination of muscle flap and flaps (3 cases) was preferred for repair. The surgical methods for repairing the pressure injury of patients in control group were selected based on the surgeon's clinical experience. The type 4b was repaired with fascial flap with skin pedicle in 18 cases and kite flap in 6 cases; the type 4c was repaired with fascial flap with skin pedicle in 6 cases, kite flap in 7 cases, and myocutaneous flap in 3 cases; the type 4d was repaired with kite flap in 2 cases and myocutaneous flap in 3 cases. The sizes of wounds in the two groups of patients were 5.5 cm×4.5 cm to 8.0 cm×7.0 cm after the wound bed was prepared, and the sizes of grafted tissue flaps were 5.0 cm×4.5 cm to 10.0 cm×8.0 cm. The wounds in the flap donor sites were directly sutured or repaired with a relay flap. The following data were recorded, including the wound healing rate after one-time surgical repair, wound healing time, length of hospital stay, hospitalization treatment cost, pressure ulcer scale for healing (PUSH) score at discharge, and recurrence rate of pressure injury during follow-up in two groups of patients. Results The wound healing rate after one-time surgical repair of patients in observation group was 88.00% (44/50), which was significantly higher than 66.67% (30/45) in control group (with relative risk of 1.32, 95% confidence interval of 1.08 to 1.61, χ2=6.48, P<0.05). After adjusting the general information using multiple logistic regression analysis, the wound healing rate after one-time surgical repair of patients in observation group was still significantly higher than that in control group (with relative risk of 1.30, 95% confidence interval of 1.05 to 1.59, χ2=6.14, P<0.05). The wound healing time of patients in observation group was (18±5) d, which was significantly shorter than (27±6) d in control group (with mean difference of -9 d, 95% confidence interval of -12 to -7 d, t=7.73, P<0.05). After adjusting the general information using multivariate covariance analysis, the wound healing time of patients in observation group was still significantly shorter than that in control group (with mean difference of -9 d, 95% confidence interval of -11 to -6 d, F=37.10, P<0.05). The length of hospital stay of patients in observation group was significantly shorter than that in control group (t=5.04, P<0.05), the hospitalization treatment cost was significantly lower than that in control group (t=2.11, P<0.05), and the PUSH score at discharge was significantly lower than that in control group (t=3.08, P<0.05). After a follow-up period of 2 to 24 months after discharge, the recurrence rate of pressure injury of patients in observation group was significantly lower than that in control group (χ2=5.02, P<0.05). Conclusions Dividing stage 4 pressure injury in ischial tuberosity into multiple subtypes in elderly patients can help guide clinical selection of appropriate repair strategies, increase the wound healing rate after one-time surgical repair, shorten the wound healing time and length of hospital stay, reduce hospitalization treatment cost, and lower the recurrence rate of pressure injury. It is worthy of clinical promotion. -
Key words:
- Aged /
- Surgical flaps /
- Myocutaneous flap /
- Multicenter study /
- Ischial tuberosity /
- Pressure injury /
- Subtype /
- Wound repair
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参考文献
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图 1 股二头肌长头岛状肌皮瓣修复例1老年患者4d型坐骨结节压力性损伤的效果。1A.术前压力性损伤外口大小为4.0 cm×3.0 cm,设计岛状肌皮瓣；1B.术前探查窦道；1C.术中切取岛状肌皮瓣；1D.术中岛状肌皮瓣经隧道转移覆盖创面后；1E.术后5 d,岛状肌皮瓣完全成活；1F.出院后12个月随访时,供受区外形良好,无瘢痕增生,压力性损伤无复发
图 2 股二头肌长头肌瓣联合风筝皮瓣修复例2老年患者4d型坐骨结节压力性损伤的效果。2A.术前设计肌瓣和皮瓣；2B.术中切取肌瓣；2C.术中转移皮瓣；2D.肌瓣联合皮瓣封闭创面后即刻；2E.术后12 d,皮瓣完全成活；2F.出院后6个月随访时,供受区外形良好,无瘢痕增生,压力性损伤无复发
Table 1. 2组老年坐骨结节4期压力性损伤患者一般资料比较
组别 例数 年龄（岁, 性别（例） 病因（例） 基础疾病（例） 入院时PUSH评分（分, 男 女 脊髓损伤 脑血管意外 其他 贫血 高血压 其他 对照组 45 67±7 28 17 28 9 8 21 18 8 13.0±3.1 观察组 50 69±7 31 19 31 10 9 20 19 9 14.0±1.8 统计量值 t=-0.81 χ2<0.01 χ2<0.01 χ2=0.27 t=-1.88 P值 0.419 0.983 >0.999 0.874 0.062 注：对于对照组患者,根据术者临床经验选择手术方式；对观察组患者在其入院时进行坐骨结节4期压力性损伤分型,针对性地选择手术方式；其他病因包括术后卧床、骨折等,其他基础疾病包括糖尿病、冠心病、甲状腺功能亢进等；PUSH为压力性损伤愈合量表 
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组别 例数 校正前 校正后 对照组 45 30（66.67） 29（64.44） 观察组 50 44（88.00） 44（88.00） 相对风险（95%置信区间） 1.32（1.08~1.61） 1.30（1.05~1.59） χ2值 6.48 6.14 P值 0.011 0.013 注：对于对照组患者,根据术者临床经验选择手术方式；对观察组患者在其入院时进行坐骨结节4期压力性损伤分型,针对性地选择手术方式；采用多因素logistic回归分析校正年龄、性别、病因、基础疾病及入院时压力性损伤愈合量表评分等基线资料对指标的影响
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组别 例数 校正前 校正后 对照组 45 27±6 27±6 观察组 50 18±5 18±5 均数差值（95%置信区间） -9（-12~-7） -9（-11~-6） 统计量值 t=7.73 F=37.10 P值 <0.001 <0.001 注：对于对照组患者,根据术者临床经验选择手术方式；对观察组患者在其入院时进行坐骨结节4期压力性损伤分型,针对性地选择手术方式；采用多因素协方差分析校正年龄、性别、病因、基础疾病及入院时压力性损伤愈合量表评分等基线资料对指标的影响
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Table 4. 2组老年坐骨结节4期压力性损伤患者次要指标比较
组别 例数 住院时间（d, 住院治疗费用（元, 出院时PUSH评分（分, 随访时压力性损伤复发情况[例（%）] 对照组 45 34±6 41 983±17 635 2.1±0.8 8（17.78） 观察组 50 27±6 34 532±16 735 1.6±0.8 2（4.00） 统计量值 t=5.04 t=2.11 t=3.08 χ2=5.02 P值 <0.001 0.038 0.003 0.025 注：对于对照组患者,根据术者临床经验选择手术方式；对观察组患者在其入院时进行坐骨结节4期压力性损伤分型,针对性地选择手术方式；PUSH为压力性损伤愈合量表
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