人工全膝关节置换术后切口缘皮肤坏死的修复

MANAGEMENT OF SKIN NECROSIS AROUND INCISION FOLLOWING TOTAL KNEE ARTHROPLASTY

目的探讨人工全膝关节置换术(total knee arthroplasty,TKA)术后切口缘皮肤坏死的原因及修复方法。方法 2007年6月-2013年6月,收治7例TKA术后切口缘皮肤坏死患者。其中男5例,女2例;年龄59~78岁,平均69岁。关节置换原因:骨性关节炎4例,创伤性关节炎2例,类风湿性关节炎1例。合并糖尿病2例,高血压2例,长期服用激素1例,吸烟史2例;2例膝关节周围有瘢痕。皮肤坏死范围10 cm×2 cm^13 cm×8 cm;TKA术后至切口缘皮肤坏死清创时间为7~15 d,平均12 d。彻底清创后,采用隐动脉皮瓣4例、腓肠肌内侧头肌皮瓣2例、腓肠肌外侧头肌皮瓣1例修复创面;其中2例同时行髌韧带重建。供区断层皮片游离移植修复。结果术后皮瓣、肌皮瓣均成活,创面Ⅰ期愈合;供区植皮均成活,切口均Ⅰ期愈合。无术后早期相关并发症发生。7例均获随访,随访时间6~12个月,平均7.8个月。皮瓣与肌皮瓣外形与质地良好;假体无松动、移位;无感染复发。术后6个月膝关节活动度为45~110°,平均85°;根据膝关节学会评分系统(KSS)评分,获优3例,良2例,一般1例,差1例。结论早期发现、彻底清创、及时行轴型皮瓣或肌皮瓣修复是治疗TKA术后切口缘皮肤坏死并挽救膝关节假体的关键。

Objective To investigate the risk factors of skin necrosis around incision after total knee arthroplasty （TKA）, and explore the measures of prevention and treatment. Methods Between June 2007 and June 2013, 7 patients with skin necrosis around incision after TKA were treated. There were 5 males and 2 females with an average age of 69 years （range, 59-78 years）, including osteoarthritis in 4 cases, traumatic arthritis in 2 cases, and rheumatoid arthritis in 1 case. Two cases complicated by diabetes, and 2 cases by hypertension; 1 case received long-term hormone therapy; and 2 cases had a history of smoking. Scar was seen near knee joint in 2 cases. The skin necrosis ranged from 10 cm × 2 cm to 13 cm × 8 cm. The time from TKA to debridement was 7-15 days （mean, 12 days）. After thorough debridement, the saphenous artery skin flap, medial head of gastrocnemius muscle flap, lateral head of gastrocnemius muscle flap were used in 4 cases, 2 cases, and 1 case respectively; reconstruction of patellar ligament was performed in 2 cases. Donor sites were repaired by split-thickness skin graft. Results All the flaps and myocutaneous flaps survived well, and all wounds healed by first intention. At donor site, the grafted skins survived and wounds healed by first intention. No early complication occurred. All cases were followed up 6-12 months （mean, 7.8 months）. The flaps and myocutaneous flaps had good texture and appearance; no prosthetic loosening and displacement happened, no secondary infection was observed after operation. The knee range of motion was 45-110° （mean, 85°） at 6 months after operation. According to the Knee Society Score （KSS）, the results were excellent in 3 cases, good in 2 cases, general in 1 case, and poor in 1 case at 6 months after operation. Conclusion Early discovery, thoroughly debridement, and timely repair with axial pattern flap or myocutaneous flap are the key factors to treat skin necrosis around incision after TKA and save the artificial prosthesis.