慢性创面外露内置物的保全和创面修复临床策略

Clinical strategies for preservation of the exposed implant in chronic wounds and wound repair

目的探讨慢性创面外露内置物的保全和创面修复临床策略。方法2016年1月-2019年1月,解放军总医院第四医学中心收治8例伴有内置物外露的术后创面不愈合患者,其中男4例、女4例,年龄10~73岁。患者中2例腹部外伤术后腹部补片外露,2例颅脑术后钛板外露,3例骨折手术后内固定物外露,1例颅脑术后脑脊液引流管外露。入院时取创面分泌物行细菌培养,在控制血糖、纠正贫血和低蛋白血症的基础上,尽快行创面彻底清创,清创后创面面积为2.0 cm×0.5 cm^6.0 cm×5.0 cm。4例患者创面清创后直接封闭,其中1例直接缝合;1例创面局部填充富血小板血浆凝胶后直接缝合;2例采用局部皮瓣修复,皮瓣面积分别为10.0 cm×8.0 cm、12.0 cm×8.0 cm,供瓣区直接缝合;术后均行持续负压封闭引流(VSD)治疗。4例患者创面清创后行持续VSD治疗,待创基情况改善后,1例患者创面逐渐愈合,1例患者创面直接缝合,2例患者创面取大腿或头部刃厚皮修复。观察并记录入院时创面分泌物细菌培养结果、术后创面愈合情况和随访情况。结果本组6例患者入院时创面分泌物细菌培养结果为阳性,共培养出细菌10株,以表皮葡萄球菌为主。所有患者术后皮片或皮瓣均成活,切口愈合,创面封闭,内置物全部保全。随访1~3年,所有患者修复创面均无复发。结论针对伴有外露内置物的术后慢性创面,在彻底清创后,可通过直接缝合或皮瓣移植Ⅰ期封闭清洁创面;组织缺损比较大、感染比较重的创面可先行持续VSD治疗,Ⅱ期直接缝合或移植皮片封闭创面,从而实现保全内置物和修复创面的治疗目标。

Objective To explore the clinical strategies for preservation of the exposed implant in chronic wounds and wound repair.Methods From January 2016 to January 2019,totally 8 patients(4 males and 4 females,aged 10 to 73 years)sustaining postoperative chronic wounds with exposed implants were admitted to the Fourth Medical Center of PLA General Hospital.There were 2 cases of abdominal patch exposure after abdominal trauma surgery,2 cases of titanium plate exposure post craniocerebral surgery,3 cases of internal fixator exposure post orthopedic surgery,and 1 case of cerebrospinal fluid drainage tube exposure after craniocerebral surgery.The wound exudate was collected for bacterial culture on admission.On the basis of glycemic control and correction of anemia and hypoproteinemia,thorough wound debridement was performed as soon as possible and the wound area after debridement ranged from 2.0 cm×0.5 cm to 6.0 cm×5.0 cm.The wounds of 4 patients were immediately closed after debridement,including 1 case by primary closure,1 case by primary closure after local filling of platelet rich plasma gel,and 2 cases by local flap transplantation,with flap size of 10.0 cm×8.0 cm and 12.0 cm×8.0 cm,respectively.The donor sites of flaps were sutured directly and all the incisions were treated with continuous vacuum sealing drainage(VSD)after surgery.The other 4 patients were treated with continuous VSD after debridement to improve the wound bed.The wound of 1 case healed gradually,1 case received direct wound suturing,and the wounds of 2 cases were repaired with thin split-thickness skin grafts from the thigh or the head.The results of bacterial culture of wound exudate on admission,wound healing post surgery,and follow-up were observed and recorded.Results The bacterial culture of wound exudate on admission was positive in 6 patients,and 10 strains of bacteria were isolated with Staphylococcus epidermidis as the main pathogen.All the skin grafts or flaps of patients survived post surgery,with the incisions and wounds healed and all the implants preserved.After 1 to 3 years of follow-up,no recurrence of wound was found in any patient.Conclusions The postoperative chronic wounds with exposed implants can be closed in primary stage by direct suturing or flap transplantation if it is clean enough on the basis of thorough debridement.The wounds with large defects or serious infection can be treated with continuous VSD firstly and then closed with direct suturing or skin grafting for delayed wound closure,thereby to reach the treatment goal of preserving the implants and repairing the wounds simultaneously.