创面封闭式负压引流联合冷藏技术在手足皮肤回植中的应用

Application of vacuum sealing drainage and cryopreservation technology in hand and foot skin replantation

目的:总结联合使用封闭式负压引流技术(vacuum sealing drainage,VSD)、冷藏技术回植手足撕脱皮肤的临床效果与体会。方法:自2012年3月至2013年10月利用联合技术回植手足撕脱皮肤13例,男8例,女5例;年龄18~62岁,平均32岁。受伤至就诊时间1~4 h,平均2.4 h。受伤原因:机器伤7例,车轮碾压6例。受伤部位:手指2例,手背侧5例,足背侧6例。撕脱皮肤面积:5 cm×6 cm^12 cm×16 cm,4例患者合并肌腱、骨外露。均采用封闭式负压引流技术封闭创面,-4℃或-80℃保存撕脱皮肤。-4℃低温保存皮肤4 d后原位回植5例,修复皮瓣供区3例;-80℃冷冻皮肤伤后7~8 d回植4例,45 d回植1例。结果:13例回植皮肤中,1例小腿至足背部皮肤脱套伤患者足背皮肤回植完全坏死,1例4指皮肤脱套伤45 d回植后成活约30%,后多次植皮治愈。余回植皮肤成活面积大于85%,换药后治愈。按照贾金鹏等的皮肤成活面积评价标准,获得优11例,中1例,差1例。成活11例病例无植皮处破溃等并发症,术后随访4~22个月,植皮柔韧性良好。感觉恢复按BMRC标准:S3+3例,S35例,S23例。结论:应用创面封闭式负压引流技术联合冷藏技术回植手足撕脱皮肤,为Ⅱ期手术患者创面准备及治疗方案的选择提供了时间空间。尤其对于大面积皮肤撕脱患者,可有效利用撕脱皮肤,减少植皮供区,减轻患者经济负担及痛苦,减少植皮供区瘢痕、色素沉着等并发症,疗效满意。

Objective：To summarize the clinical effect of avulsed skin replantation of hand and foot via vacuum sealing drainage （VSD） combing low temperature technique.Methods：From March 2012 to October 2013,13 cases with avulsed skin replantation of hand foot using combined technique included 8 males and 5 females with an average age of 32 years old ranging from 18 to 62 years.The time from injury to hospital was 1 to 4 hours （2.4 hour in average）.The reasons of injury included machine injury in 7 cases and rolling over by cars in 6 cases.The parts of injuried involved finger in 2 cases,back of the hand in 5 cases and dorsum of foot in 6 cases.The area of avulsed skin was 5 cm×6 cm to 12 cm×16 cm,tendon and bone exposure was found in 4 cases.VSD was operated in all patients and the avulsed skin was refrigerated in the temperature of-4 ℃ or-80 ℃.After 4 days,the skin stored in the-4 ℃ was replanted to the wounded place in 5 cases and in 3 cases the skin was planted to the donor site of flap.The skin stored in the-80 ℃ was replanted in 4 cases after 7 or 8 days,1 case after 45 days.Results：Of the 13 cases,1 case of degloved injury from lower leg to dorsal foot,the replanted skin was necrosis completely; 1 case of degloving injury with fourth finger,the skin which replanted after 45 days survived approximately 30％,cured after skin-graft many times.In the other cases,the survival area of replanted skin was more than 85％,all cured after dressing.According to the standard of skin survival area evaluation by Jia et al,11 cases showed excellent,1 showed medium and 1 showed inferior.There were no complication about grafted skin rupture after the skin survived in 11 patients,after 4 to 22 months follow-up,the resiliency of grafted skin showed good.Sensation recovery was measured by BMRC standard：3 cases of S3＋,5 cases of S3,3 cases of S2.Conclusion：VSD combining lower temperature technique in skin replantation provides time and space for wound preparation and treatment plan for the patients who need second surgery,especially for the large area skin degloving,this method could utilize the degloved skin efficiently,decrease the donor site area,alleviate the pain and financial burden,reduce the scar formation of donor site and impediment.