皮瓣修复创伤性软组织缺损：骨骼肌关节囊及钢板的处理原则

Perioperative management in traumatic soft tissue defects with revascularized flaps

背景:四肢创伤常合并有肌腱、关节囊、骨质和内植物的外露,需要行皮瓣修复。研究表明,皮瓣是修复四肢创伤后软组织缺损的重要方法,但皮瓣围手术期软组织床的处理至今少有报道。目的:文章探讨皮瓣修复创伤性软组织缺损的的围手术期处理策略。方法:纳入二期皮瓣修复软组织缺损94例,术中止血带下清创,根据情况决定骨、肌腱、关节囊和内植物的取舍,大量生理盐水冲洗后,切取皮瓣覆盖创面,并恰当引流。结果与结论:修复的皮瓣全部成活,5例骨外露病例皮瓣渗出,28例肌腱及关节囊外露组均正常愈合。未发生与保留内植物相关的并发症,但有3例出现骨折延迟愈合,1例出现骨不连。结果提示,皮瓣治疗围手术期的处理要引起关注,仔细清创,合理选择皮瓣,充分引流,规范应用抗生素是治疗成功的关键。对于创面中骨、肌腱、关节囊和钢板等所谓异物的处理,既要权衡利弊,更要适当放宽保留的指征。

BACKGROUND：Traumatic soft tissue defects of the limbs are usual y accompanied with the exposure of tendon, joint capsule, bone or internal fixator, which can be reconstructed by skin flap. Previous research has shown that it is an important method to repair traumatic tissue defects with flaps. However, rarely research reports perioperative management about flap bed so far. OBJECTIVE：To explore the perioperative strategy for repairing traumatic soft tissue defects with revascularized flaps. METHODS：Total y 94 cases undergoing secondary skin flap repair were enrol ed. Intraoperative debridement using tourniquet was performed, and the wound was washed with mass of physiological saline. Whether the tissues, including bone, tendon, joint capsule and internal fixator, were reserved or not depended on their viability, and then the flaps were harvested to repair defects, and drainage was placed properly at last. RESULTS AND CONCLUSION：The flaps survived in al cases. Exudation occurred in 5 cases with the exposure of bone, and 28 cases with the exposure of tendon or joint capsule healed normal y. No complications were associated with the reservation of the internal fixators, but delayed-union occurred in three cases and nonunion in one case. These findings indicate that the perioperative treatment of the application of skin flap is worthy of attention. Careful debridement, advisable choice of the flap, efficient drainage and using antibiotic normatively are al keys. Treatment of the bone, tendon, joint capsule and internal fixator which are exposed should not only weigh the advantage and disadvantage, but also relax the indication of reserving them.