人工真皮与自体皮片复合移植联合负压封闭引流整复关节部位瘢痕的效果

人工真皮与自体皮片复合移植联合负压封闭引流整复关节部位瘢痕的效果

陈永新张元文姚志慧赵耀唐文明潘文东

本文来源：《中华整形外科杂志》2023年6月第39卷第6期

DOI:10. 3760 / cma.j.cn114453-20220626-00193

作者单位：解放军联勤保障部队第926医院烧伤整形科，开远661600

通信作者：张元文，Email：alexzyw983@163.com

引用本文

陈永新，张元文，姚志慧，等. 人工真皮与自体皮片复合移植联合负压封闭引流整复关节部位瘢痕的效果 [J] . 中华整形外科杂志, 2023, 39(6) : 590-595. DOI: 10.3760/cma.j.cn114453-20220626-00193.

【摘要】

目的探讨应用人工真皮与自体刃厚皮片复合移植联合负压封闭引流整复烧伤后关节部位瘢痕的临床效果。

方法回顾性分析解放军联勤保障部队第926医院烧伤整形科2019年1月至2020年12月收治的大面积烧伤后关节部位瘢痕挛缩畸形或瘢痕溃疡患者的临床资料。一期手术行挛缩瘢痕切除松解或瘢痕溃疡清创，Lando®人工真皮移植，联合负压封闭引流，待创面完全血管化后，揭除硅胶膜，二期手术移植自体刃厚皮片。术后随访观察植皮成活情况和远期植皮区外观、瘢痕形成情况及关节功能恢复情况。

结果共纳入32例患者，男24例，女8例，年龄18～45岁，平均33岁。瘢痕位于手背掌指关节4例、腕关节4例、肘关节10例、膝关节及腘窝14例，有 1例患者同时进行了双侧膝关节瘢痕溃疡修复手术，故共计33个手术部位，其中瘢痕挛缩畸形 23个部位，瘢痕溃疡5个部位，瘢痕挛缩畸形伴瘢痕溃疡5个部位。人工真皮覆盖2周后拆除负压装置，32例患者（33个手术部位）人工真皮血管化良好。自体皮片移植术后完全成活，成活率100%（33/33）。术后随访3～12个月，植皮区无破溃，皮肤色泽接近正常，无明显瘢痕挛缩及增生，关节功能满意。

结论人工真皮与自体刃厚皮片复合移植联合负压封闭引流整复烧伤后关节部位瘢痕挛缩或瘢痕溃疡，术后皮肤色泽、质地良好，关节功能恢复满意。

【关键词】瘢痕；关节；人工真皮；负压封闭引流

基金项目：国家自然科学基金（81860338）

Effect of composite transplantation of artificial dermis and autologous skin graft combined with vacuum sealing drainage in the reconstruction of joint scars

Chen Yongxin, Zhang Yuanwen, Yao Zhihui, Zhao Yao, Tang Wenming, Pan Wendong

Department of Burns and Plastic Surgery, No. 926 Hospital, Joint Logistics Support Force of PLA, Kaiyuan 661600, China

Corresponding author: Zhang Yuanwen, Email: alexzyw983@163.com

【Abstract】

Objective To investigate the clinical effect of composite transplantation of artificial dermis and autologous razor-thin graft combined with vacuum sealing drainage in the repair of joint scar after burn.

Methods The clinical data of patients with scar contracture deformity or scar ulcer after extensive burn admitted to the Department of Burns and Plastic Surgery of No. 926 Hospital of the Joint Logistics Force of PLA from January 2019 to December 2020 were retrospectively analyzed. Patients received one-stage contracture scar excision and release or scar ulcer debridement, Lando®artificial dermis transplantation combined with vacuum sealing drainage, removal of the silicone membrane after complete vascularization of the wound, and secondary transplantation of autologous razor-thin graft. The survival and long-term appearance of skin graft, formation of scar and function recovery of joint were observed.

Results A total of 32 patients were included, including 24 males and 8 females, aged from 18 to 45 years, with an average age of 33 years. Scars were found in 4 cases of the metacarpophalangeal joint, 4 cases of the wrist joint, 10 cases of the elbow joint, and 14 cases of the knee joint and popliteal fossa. One patient underwent surgery to repair bilateral knee joint scar ulcers simultaneously, resulting in a total of 33 surgical sites. Among them, there were 23 sites of scar contracture deformities, 5 sites of scar ulcers, and 5 sites of scar contracture deformities with scar ulcers. After 2 weeks of artificial dermis coverage, the negative pressure device was removed, and the artificial dermis stent vascularization was good in 32 patients (33 surgical sites). After autologous skin graft transplantation, the survival rate was 100% (33/33). Postoperative follow-up for 3 to 12 months showed that there was no ulceration in the skin graft area, the skin color was close to normal, and there were no obvious scar contractures or hyperplasia. The joint function was satisfactory.

Conclusion The composite transplantation of artificial dermis and autologous razor-thin graft combined with vacuum sealing drainage is good to repair scar contracture or scar ulcer of joint after burn, the skin color and texture after operation, and the recovery of joint function is satisfactory.

【Key words】Cicatrix; Joints; Artificial dermis; Vacuum sealing drainage

Fund program: National Nature Science Foundation of China(81860338)

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.

大面积烧伤患者创面愈合后遗留不同程度的瘢痕增生，尤其关节等功能部位的瘢痕，常常伴有挛缩畸形导致关节活动障碍，或在伤后功能锻炼过程中瘢痕反复破溃、难以愈合，严重影响患者工作和生活。如何在供区损伤最小条件下使大面积烧伤后关节部位瘢痕得到最大程度的修复一直是临床治疗的难题，人工真皮的问世一定程度上解决了这个难题［1］。我科应用Lando人工真皮与自体刃厚皮片复合移植联合负压封闭引流（vacuum sealing drainage，VSD）整复大面积烧伤后关节部位瘢痕，取得较满意的效果，现报道如下。

资料与方法

一、资料选择

回顾性分析解放军联勤保障部队第926医院烧伤整形科2019年1月至2020年12月收治的大面积烧伤后关节部位瘢痕挛缩畸形或瘢痕溃疡患者的临床资料。纳入标准：（1）烧伤后关节部位出现瘢痕挛缩畸形或瘢痕溃疡，需手术修复；（2）有足够面积的正常头皮或大腿部皮肤可作为供皮区；（3）患者和（或）家属愿意参加本研究，自愿签署知情同意书。排除标准：（1）瘢痕溃疡创面感染严重，如创面大量脓性分泌物、创周组织炎症反应重；（2）合并有心脑血管、肝、肾等严重疾病；（3）对胶原、硫酸软骨素过敏；（4）研究者认为有其他不适合条件。

治疗前均向患者和（或）家属交代手术风险及可能发生的并发症，同时告知手术可能的获益，患者和（或）家属经慎重考虑后签署知情同意书，并同意将资料用于本研究。本研究已参考赫尔辛基宣言。

二、方法

（一）手术方法

术中采用全身麻醉或硬膜外麻醉。先对影响关节功能的挛缩瘢痕充分切除、松解，对瘢痕溃疡创面进行局部清创，彻底清除坏死、老化无活力组织，尽量保留间生态组织，依次用双氧水、生理盐水反复冲洗。根据创面大小将Lando®人工真皮（深圳齐康医疗器械有限公司，国械注准20173461356）修剪至略大于创面，置于生理盐水中浸泡不少于3 min，取出后覆盖于创面，硅胶膜与创面边缘用2.0或3.0非可吸收丝线无张力间断缝合。用尖刀片在硅胶膜上切多个引流小口（约0.1 cm×0.5 cm），再覆盖相同大小负压引流材料（武汉维斯第医用科技股份有限公司，国械注准20143142322），用2.0或3.0不可吸收丝线将负压引流材料与切口边缘正常组织间断缝合固定后，用半透性粘贴薄膜（英国Skinth & Nephew公司，批号20152641041）采用叠瓦式粘贴覆盖并超出创面外正常皮肤约1.5 cm，保持材料完整、密闭，连接负压装置。检查材料密闭、完整、无漏气后，用无菌纱布绷带包扎固定，对部分关节挛缩畸形较明显的患者，加用石膏外固定联合制动。术后2周拆除负压装置及人工真皮外层硅胶膜，确认人工真皮完全血管化后，二期手术移植刃厚皮片，厚度为0.2～0.3 mm，供皮区位于头部或大腿，将大张皮片移植于创面，并再次以负压引流材料封闭固定。供皮区用含银抗菌敷料、纱垫、医用棉垫等适当加压包扎。

（二）术后管理

患者返回病房后给予持续负压引流治疗，调节负压至125～200 mmHg（1 mmHg=0.133 kPa），同时记录引流液颜色及引流量。若术后24 h内出血量较多，应立即暂停负压引流并查找原因，彻底止血后继续连接负压，若负压引流管出现堵塞时应及时用少量生理盐水对负压封闭引流管道进行冲洗，经冲洗无效则更换引流管或VSD材料。供皮区于术后 5 d 去除外层敷料，保留内层油性含银敷料，保持干燥待自然脱落愈合。

（三）随访及观察指标

自体皮片移植术后1周，观察皮片成活情况并计算成活率。皮片成活率=移植物成活数÷移植物总数×100%。植皮术后3～12个月对患者进行随访，评价植皮区外观和瘢痕形成情况、供皮区瘢痕形成情况以及关节功能恢复情况。

三、统计学处理

采用描述性方法进行统计分析。

结果

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人工真皮与自体皮片复合移植联合负压封闭引流整复关节部位瘢痕的效果