中华烧伤与创面修复杂志

Clinical effect of multisegmental lymphatic-venous anastomosis in the treatment of post-traumatic lymphedema

Wang Junjie, Wang Xuebin, Wang Erping, Tang Yin, Guo Zonghui

, Available online , doi: 10.3760/cma.j.cn501225-20250219-00073

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Objective To investigate the clinical effect of multisegmental lymphatic-venous anastomosis (LVA) in the treatment of post-traumatic lymphedema (PTL). Methods This study was a retrospective case series study. From January to August 2024, 7 patients with PTL who met the inclusion criteria were admitted to the Department of Microprosthetic Hand Surgery of Ningbo NO.2 Hospital. There were 3 males and 4 females, aged 51-75 years. The lesions involved the upper limb in 3 patients and the lower limb in 4 patients. All patients underwent multisegmental LVA. Distal to the site of lymphatic injury in the limb, functional collecting lymphatic vessels in the superficial layer of the subdermal fat were anastomosed with adjacent superficial veins with good valvular function. At the site of lymphatic injury in the limb, functional collecting lymphatic vessels in the superficial layer of the deep fascia were anastomosed with adjacent superficial veins with good valvular function. After surgery, all patients received complete decongestive therapy (CDT). The completion of surgery, occurrence of complications, and recurrence of PTL were recorded for the 7 patients. The affected limb circumferences before surgery and at 3 days, 1 month, 3 months, and 6 months after surgery were compared among 3 patients with upper limb involvement and 3 patients with lower limb involvement. Body weight, muscle balance and bioelectrical impedance between the healthy and affected limbs measured by a body composition analyzer before surgery and at 14 days after surgery in 7 patients. Results All 7 patients completed the surgery successfully. One patient with upper limb involvement developed lymphangitis in the affected limb at 7 days after surgery. After anti-infective treatment followed by CDT, the limb circumference returned to the level at 3 days after surgery at 1 month after surgery. No adverse surgical complications occurred in the remaining patients. During postoperative follow-up, no recurrence of PTL was observed in the 7 patients. Before surgery and at 3 days, 1 month, 3 months, and 6 months after surgery, the hand and wrist circumferences at the affected side in the 3 patients with upper limb involvement were (20.4±3.6), (20.0±3.0), (19.8±3.2), (19.7±3.0), and (19.5±2.6) cm, respectively; the forearm circumferences were (29±6), (27±5), (26±6), (25±4), and (23±4) cm, respectively; the upper arm circumferences were (35±4), (34±4), (33±5), (32±4), and (31±4) cm, respectively; the foot and ankle circumferences at the affected side in the 3 patients with lower limb involvement were (27±4), (25±4), (25±5), (24±4), and (24±4) cm, respectively; the calf circumferences were (38±9), (35±8), (34±8), (33±8), and (33±8) cm, respectively; the thigh circumferences were (49±10), (47±10), (47±10), (46±10), and (46±10) cm, respectively. At the afftected side of patients, from 3 days to 6 months after surgery, the forearm, upper arm, foot and ankle, calf, and thigh circumferences were all significantly smaller than those before surgery (P<0.05), the forearm circumference at 1 to 6 months after surgery, the upper arm circumference at 3 and 6 months after surgery, the foot and ankle circumference at 3 months after surgery, the calf circumference at 1 to 6 months after surgery, and the thigh circumference at 3 and 6 months after surgery were all significantly smaller than those at 3 days after surgery (P<0.05), the forearm circumference at 3 and 6 months after surgery, the upper arm circumference at 3 and 6 months after surgery, the foot and ankle circumference at 3 months after surgery, and the thigh circumference at 3 and 6 months after surgery were all significantly smaller than those at 1 month after surgery (P<0.05), and the forearm and upper arm circumferences at 6 months after surgery were significantly smaller than those at 3 months after surgery (P<0.05). Compared with those before surgery, the body weight and muscle balance of the affected limb in the 7 patients at 14 days after surgery decreased significantly (with t values of 3.181 and 3.221, respectively, P<0.05), and the bioelectrical impedance of the affected limb increased significantly (t=-6.631, P<0.05). Conclusions In the surgical treatment of PTL, multisegmental LVA can reduce the affected limb circumference and effectively improve edema symptoms, and combined with CDT can continuously enhance the therapeutic effect.

A prospective clinical study on the application of SS-DSA combined with CDU in ALTF reconstruction of extremity soft tissue defects

Tian Yongsheng, Zhang Yuji, Wu Junbang, Liu Zeyu, Wang Guiyang, Wang Shi, Dong Shuai, Wu Chenglong, Zhou Rong, Ju Jihui

, Available online , doi: 10.3760/cma.j.cn501225-20260317-00110

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Objective To investigate the clinical efficacy of superselective digital subtraction angiography (SS-DSA) combined with color Doppler ultrasound (CDU) in assisting anterolateral thigh flap (ALTF) reconstruction of extremity soft tissue defects. Methods This was a prospective case series study. From October 2024 to August 2025, 50 patients (37 males and 13 females, aged 35-76 years) with extremity soft tissue defects who met the inclusion criteria were treated at Suzhou Ruihua Orthopedic Hospital, and all underwent ALTF reconstruction. Preoperatively, CDU and SS-DSA were used to determine the number and locations of perforators in the flap donor site, as well as the characteristics of their source arteries. The findings from SS-DSA and CDU were integrated (i.e., combined method) to identify the dominant perforator and target source artery and to develop an individualized flap design. Thorough debridement was performed, and the post-debridement defect size ranged from 8 cm×6 cm to 32 cm×20 cm. The flaps were harvested and transferred to the recipient site. Under an operating microscope, end-to-end or end-to-side anastomosis was performed between the flap vessels and the recipient vessels, and then the wound was closed. The flap was designed to extend approximately 1 cm beyond the margins of the recipient-site defect. A total of 51 flaps were harvested from the 50 patients. Donor site wounds of flap were repaired by direct suture or full-thickness skin grafting. Intraoperatively, the number and locations of the observed perforators and their source arteries were recorded. Flap thickness and vascular pedicle length were also documented. Using intraoperative exploration as the gold standard, the sensitivity and positive predictive value among CDU, SS-DSA, and the combined method for perforator localization were compared. The distances between the perforator localization points determined by the three methods and the actual intraoperative perforator entry points (i.e., perforator localization error distance) were compared. The accuracy of the combined method in predicting the source artery of perforators was calculated. In performing SS-DSA perforator localization, the total procedure time, dose-area product (DAP), fluoroscopy time (FT), and estimated glomerular filtration rate (eGFR) before and after angiography were caculated. The puncture site was observed after angiography. Postoperatively, flap survival and healing of donor site wounds were observed. Results A total of 89 ALTF perforators were identified intraoperatively, including 47 oblique, 32 descending, 5 anterior, 3 transverse, and 2 ascending branches; 69 perforators were actually used, including 43 oblique, 19 descending, 5 anterior, and 2 ascending branches. The mean flap thickness was (1.4±0.5) cm, and the mean pedicle length was (13±3) cm. The sensitivities of CDU, SS-DSA, and the combined method were 86.52%, 85.39%, and 95.51%, respectively, and the corresponding positive predictive values were 87.50%, 87.36%, and 96.59%, respectively. The perforator localization error distance of the combined method was 0.31 (0.25, 0.37) cm, which was significantly shorter than those of CDU (0.66 (0.58, 0.74) cm) and SS-DSA (0.67 (0.58, 0.75) cm), respectively, with Z values of -7.82 and -7.45, respectively, both P values <0.05. The combined method achieved 100%(89/89) accuracy in predicting the source artery of perforators. The total procedure time of SS-DSA ranged from 19-47 min, the DAP was 102.05 (76.90, 128.50) Gy·cm², and the FT was 6.08 (4.42, 7.20) min. There was no statistically significant difference in eGFR between post-angiography and pre-angiography (P>0.05). No obvious complications were observed at the puncture site after angiography. Postoperatively, all flaps survived, and all donor site wounds healed well. Conclusions SS-DSA combined with CDU provides accurate perforator localization for anterolateral thigh flaps, facilitates individualized flap design, and demonstrates good safety, with satisfactory outcomes in the reconstruction of extremity soft tissue defects.

Clinical effects of different types of chimeric perforator flap transplantation in the treatment of lower extremity wounds with bone exposure

Wang Jing, Huang Shuqing, Liu Jingyi, Lei Zeyuan, Yang Zhibin

, Available online , doi: 10.3760/cma.j.cn501225-20250527-00245

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Objective To investigate the clinical effects of different types of chimeric perforator flap transplantation in the treatment of lower extremity wounds with bone exposure. Methods This study was a retrospective case series study. From January 2019 to August 2024, 15 patients with lower extremity wounds with bone exposure who met the inclusion criteria were admitted to the Department of Plastic Surgery of the Second Affiliated Hospital of Army Medical University (the Third Military Medical University), among whom 12 patients were combined with osteomyelitis. Among the 15 patients, there were 8 males and 7 females, aged 27-66 years, and the wound area after the last debridement ranged from 3.0 cm×2.0 cm to 22.0 cm×4.5 cm. According to the wound area, depth, composition of defective tissue, anatomical site, and vascular conditions of the affected limb, chimeric perforator flaps containing muscle flaps, muscle flaps and iliac bone flaps, or muscle flaps and fascial flaps were used, including circumflex iliac artery chimeric perforator flaps, superficial circumflex iliac artery combined with superficial inferior epigastric artery chimeric perforator flaps, lateral circumflex femoral artery chimeric perforator flaps, and thoracodorsal artery chimeric perforator flaps, to repair lower extremity wounds with bone exposure. The area of the chimeric perforator flaps ranged from 4.0 cm×3.0 cm to 25.0 cm×5.0 cm. The donor site wounds of the chimeric perforator flaps were repaired by direct suture, free skin grafting, or local flap transfer. The survival of the transplanted chimeric perforator flaps in the early postoperative period was observed. Follow-up was conducted to observe the survival and appearance of the transplanted chimeric perforator flaps, wound healing and complications in both donor and recipient sites, scar formation in the donor site, and weight-bearing activity of all patients, and signs of osteomyelitis recurrence in patients combined with osteomyelitis. Results One patient who underwent transplantation of a chimeric perforator flap based on the descending branch of the lateral circumflex femoral artery containing a muscle flap and a fascial flap developed venous vascular crisis within 24 hours after surgery, with the flap becoming dark purple; the flap survived after emergency vascular exploration and secondary venous anastomosis and recanalization. One patient who underwent transplantation of a chimeric perforator flap based on the oblique branch of the lateral circumflex femoral artery containing a muscle flap developed partial necrosis of the distal end of the flap 10 days after surgery, and the flap survived after dressing changes and free skin grafting. The transplanted chimeric perforator flaps in the remaining 13 patients survived smoothly. Postoperative follow-up of 3-6 months showed that the transplanted chimeric perforator flaps in 15 patients all survived well, among whom 7 patients had bulky flaps; all the wounds in both donor and recipient sites healed well in 15 patients, with no complications such as infection, sinus tract formation, or persistent pain, and only linear scars remained in the donor sites, but 3 patients had abnormal skin sensation in the donor sites; all 15 patients were able to perform weight-bearing activities; no signs of osteomyelitis recurrence were observed in the 12 patients combined with osteomyelitis. Conclusions The use of different types of chimeric perforator flap to repair lower extremity wounds with bone exposure has the advantages of fewer complications, high flap survival rate, high cure rate of osteomyelitis, and good recovery of lower extremity function, and is a reliable clinical regimen for repairing wounds and reconstructing lower extremity function in lower extremity injuries with bone exposure.

Analysis of influencing factors for the occurrence of transient hypernatremia in patients with extensively severe burns

Zhang Yue, Zhao Deli, Zhang Wanfu, Han Fei, Guan Hao, Hu Dahai

, Available online , doi: 10.3760/cma.j.cn501225-20251219-00534

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Objective To investigate the influencing factors for the occurrence of transient hypernatremia (TH) in patients with extensively severe burns. Methods This study was a bidirectional cohort study. Clinical data of 126 patients with extensively severe burns (97 males and 29 females, aged 18 to 64 years) who met the inclusion criteria and were admitted to the First Affiliated Hospital of Air Force Medical University from August 2021 to December 2025 were retrospectively analyzed. The incidence of hypernatremia was recorded. Among 118 patients who underwent surgical treatment, patients who underwent first escharectomy at ≤5 days after injury were included in early escharectomy group (n=39), and patients who underwent first escharectomy at >5 days after injury were included in late escharectomy group (n=79). The incidence of hypernatremia was compared between the two groups of patients. According to whether received air-fluidized bed (AFB) therapy, patients were divided into AFB group (n=89) and non-AFB group (n=37). The incidence of hypernatremia was compared between the two groups of patients, and independent risk factors for the occurrence of hypernatremia in patients with extensively severe burns were screened. For patients who underwent pulse contour cardiac output (PiCCO) monitoring during the shock stage, extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) were compared between 20 patients with hypernatremia and 35 patients without hypernatremia. Fifty-five patients with extensively severe burns (35 males and 20 females, aged 20 to 63 years) who met the inclusion criteria and were admitted to this hospital from May to December 2025 were prospectively enrolled. At 3 days after injury, eschar tissue, wound skin tissue, and peripheral venous blood were collected. Using the random number table method, samples from 5 patients with hypernatremia (set as high Na⁺ group) and 5 patients without hypernatremia (set as non-high Na⁺ group) were selected. Sodium content in eschar was determined by inductively coupled plasma mass spectrometry. Serum levels of interleukin-1 (IL-1), IL-6, tumor necrosis factor-α (TNF-α), and hyaluronic acid were detected by enzyme-linked immunosorbent assay. Protein expression level of sodium voltage-gated channel alpha subunit 5 (SCN5A) in wound skin tissue was detected by Western blotting. Results In the retrospective cohort study of 126 patients, 50 patients (39.7%) developed hypernatremia 3 to 5 days after injury, among whom 41 patients had TH, and 9 patients died. In the 41 patients with TH, the serum sodium began to increase 2 to 3 days after injury, peaked 5 to 8 days after injury, and gradually recovered by 10 days after injury. The incidence of hypernatremia of patients in late escharectomy group was 32.9% (26/79), which was significantly higher than 7.7% (3/39) in early escharectomy group (χ²=8.96, P<0.05). The incidence of hypernatremia of patients in AFB group was significantly higher than that in non-AFB group (P<0.05). The results of multivariate logistic regression analysis showed that AFB therapy was not an independent risk factor for hypernatremia in patients with extensively severe burns (OR=1.80, with a 95% CI of 0.40 to 8.20, P>0.05), while both total burn area and full-thickness burn area were independent risk factors for hypernatremia in patients with extensively severe burns (with ORs of 3.50 and 2.10, respectively, 95% Cis of 1.90 to 6.70 and 1.20 to 3.80, respectively, P<0.05). Among patients who underwent PiCCO monitoring during the shock stage, EVLWI and PVPI in patients with hypernatremia were significantly higher than those in patients without hypernatremia (with t values of 3.45 and 4.28, respectively, P<0.05). In the prospective cohort study, sodium content in eschar at 3 days after injury in high Na⁺ group of patients was (128±9) mmol/kg, which was significantly higher than (102±6) mmol/kg in non-high Na⁺ group (t=5.38, P<0.05). Compared with those in non-high Na⁺ group, serum levels of IL-1, IL-6, TNF-α, and hyaluronic acid in high Na⁺ group of patients were significantly increased 3 days after injury (P<0.05), while the protein expression level of SCN5A in wound skin tissue was significantly decreased (P<0.05). Conclusions TH after extensively severe burns is not merely an elevation in serum sodium, but involves sodium accumulation in the eschar, inflammation-mediated sodium redistribution, and sodium release during the reabsorption phase. Early escharectomy can effectively reduce the risk of occurrence of TH in patients with extensively severe burns, and its mechanism may be associated with the removal of some sodium-containing eschar and a reduction in sodium release.

Analysis of risk factors for the occurrence of early dysfunction of blood coagulation in elderly patients with severe burns

Duan Deqing, Wu Zongyan, Chen Yong, Deng Hongao, Hu Shiqiang, Lin Huan, Mao Yuangui, Zhang Hongyan

, Available online , doi: 10.3760/cma.j.cn501225-20250507-00209

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Objective To investigate the risk factors for the occurrence of early dysfunction of blood coagulation in elderly patients with severe burns. Methods This study was a retrospective case-control study. From June 2015 to June 2025, 158 elderly patients with severe burns who met the inclusion criteria were admitted to the First Affiliated Hospital of Nanchang University, including 94 males and 64 females, aged 60 to 97 years. The patients were divided into early dysfunction of blood coagulation group (45 cases) and non-early dysfunction of blood coagulation group (113 cases) according to the presence or absence of early dysfunction of blood coagulation. Gender, age, total burn area, full-thickness burn area, admission time after injury, cause of burn, combination of inhalation injury, combination of underlying diseases, modified Baux score, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, body temperature, blood pH value, platelet count, and base excess, lactic acid, hemoglobin, serum sodium, serum potassium, serum calcium, plasma fibrinogen (FIB) levels on admission, length of hospital stay, and clinical prognosis between the two groups of patients were compared. The risk factors and independent risk factors affecting the occurrence of early dysfunction of blood coagulation in elderly patients with severe burns were screened, and the prediction model was constructed according to the independent risk factors. The receiver operating characteristic curve was used to evaluate the predictive value of the prediction model and each independent risk factor for the occurrence of early dysfunction of blood coagulation in aforementioned elderly patients with severe burns. Results There were statistically significant differences in the total burn area, full-thickness burn area, on admission modified Baux score, APACHEⅡ score, platelet count, serum calcium level, blood pH value, plasma FIB level, combination of inhalation injury, and clinical prognosis between the two groups of patients (with t values of 2.270, 7.615, 5.975, 2.319, -2.172, and -7.861, respectively, Z values of -2.168 and -2.568, respectively, χ² values of 20.090 and 10.286, respectively, P<0.05). There were no statistically significant differences in the other indicators between the two groups of patients (P>0.05). The results of univariate logistic regression analysis showed that the total burn area, full-thickness burn area, combination of inhalation injury, modified Baux score, APACHEⅡ score, platelet count, serum calcium level, and plasma FIB level on admission were all risk factors for early dysfunction of blood coagulation in elderly patients with severe burns (with ORs of 1.022, 1.074, 0.141, 1.045, 1.070, 0.996, <0.001, and 0.568, respectively, 95% CIs of 1.003-1.042, 1.047-1.102, 0.055-0.359, 1.027-1.064, 1.008-1.135, 0.992-0.999, <0.001-0.002, and 0.380-0.849, respectively, P<0.05). The results of multivariate logistic regression analysis showed that the full-thickness burn area, modified Baux score, platelet count, and serum calcium level on admission were independent risk factors for early dysfunction of blood coagulation in elderly patients with severe burns (with ORs of 1.181, 1.254, 0.991, <0.001, respectively, 95% CIs of 1.085-1.287, 1.106-1.423, 0.984-0.998, <0.001-0.009, P<0.05). In terms of predicting early dysfunction of blood coagulation in elderly patients with severe burns, the area under the receiver operating characteristic curve of the prediction model constructed based on the independent risk factors was 0.977 (with a 95% CI of 0.959-0.994), which was higher than 0.844 (with a 95% CI of 0.781-0.908), 0.782 (with a 95% CI of 0.711-0.853), 0.634 (with a 95% CI of 0.526-0.742), and 0.838 (with a 95% CI of 0.770-0.905) of the full-thickness burn area, modified Baux score, platelet count, and serum calcium level on admission, respectively. Conclusions Full-thickness burn area, modified Baux score, platelet count, and serum calcium level on admission are independent risk factors for early dysfunction of blood coagulation in elderly patients with severe burns. The prediction model based on these four indicators has a good predictive value for the occurrence of early dysfunction of blood coagulation in elderly patients with severe burns.

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