人工真皮与皮瓣移植修复指骨间关节周围软组织缺损的疗效比较

Clinical efficacy of artificial dermis and flap transfer in treatment of soft tissue defect around interphalangeal joint:a comparative study

目的比较人工真皮再生基质(以下简称人工真皮)和皮瓣移植治疗指骨间关节周围软组织缺损的临床疗效。方法通过门诊随访,回顾性分析宁波市第六医院手外科于2018年1月-2022年1月收治的60例指骨间关节周围软组织缺损患者的临床资料,根据手术方式分成2组,每组30例,A组为皮瓣组,男19例,女11例,年龄(44.83±11.56)岁,包括单一软组织缺损5例,软组织缺损伴有骨折6例,软组织缺损伴有肌腱和(或)韧带损伤10例,软组织缺损伴有血管和(或)神经损伤3例,软组织缺损伴有其他2种以上复合伤6例;缺损面积为2.5 cm×1.2 cm~5.0 cm×1.6 cm;入院后急诊清创及骨、肌腱损伤处理后,行皮瓣(游离皮瓣、邻指皮瓣及岛状皮瓣)移植手术,术后1~6周开始功能锻炼。B组为双层人工真皮修复材料组,男17例,女13例,年龄(44.70±11.20)岁,包括单一软组织缺损6例,软组织缺损伴有骨折6例,软组织缺损伴有肌腱和(或)韧带损伤9例,软组织缺损伴有血管和(或)神经损伤5例,软组织缺损伴有其他2种以上复合伤4例;缺损面积为3.1 cm×1.3 cm~4.5 cm×1.8 cm。B组同A组清创及骨、肌腱损伤处理方式后覆盖人工真皮,待人工真皮完全血管化后,二期行刃厚皮片移植,并于皮片移植术后1~2周开始功能锻炼。观察对比两组患者在皮瓣移植或刃厚皮片移植间隔时间、皮瓣或刃厚皮片成活率、温哥华瘢痕量表(VSS)评分、TPD及总主活动度(TAM)等方面的疗效差异。数据比较采用t检验、χ^(2)检验、Mann-Whitney U检验,P<0.05为差异有统计学意义。结果A组皮瓣移植间隔时间(2.93±2.48)d,B组植皮间隔时间(19.87±3.35)d,两组比较差异有统计学意义(P<0.05)。A组皮瓣成活率(96.00±9.32)%,B组皮片成活率(98.17±3.07)%,两组比较差异无统计学意义(P>0.05)。术后所有患者门诊随访11~14(12.00±0.93)个月,A组部分患者术区外观臃肿,指体活动略微受限;B组患者指体活动正常,术区及供区无明显瘢痕增生。A、B组TPD分别为(8.67±2.01)mm、(9.50±1.81)mm;A、B组VSS评分分别为(3.40±1.07)分、(3.17±0.91)分;A、B组TAM评分分别为(18.30±1.97)分、(18.93±1.64)分,两组TPD测量、VSS评分及TAM评分组间比较差异均无统计学意义(P>0.05)。结论双层人工真皮修复材料在治疗指骨间关节周围软组织缺损中疗效确切,效果满意,具有与皮瓣手术相当的临床效果,值得临床推广使用。

Objective To compare the clinical effecacy of artificial dermal regeneration matrix(as"artificial dermis"hereafter)and flap transfer in the treatment of soft tissue defects around interphalangeal joint.Methods Through postoperative follow-up at outpatient clinic,a retrospective study was conducted on the clinical data of 60 patients who had soft tissue defects around the interphalangeal joints and received treatment in the Department of Hand Surgery,the Sixth Hospital of Ningbo from January 2018 to January 2022.According to applied surgical procedures,patients were divided into a flap transfer group(group A,n=30)and an artificial dermis group(group B,n=30).Group A included 19 males and 11 females aged 44.83 years±11.56 years including 5 patients with simple soft tissue defects,and 6 with soft tissue defects and fractures,10 with soft tissue defects with tendon and(or)ligament injuries,3 with soft tissue defects and vessel and(or)nerve injuries,and 6 with soft tissue defects and over 2 other types of compound injuries.The defect areas ranged from 2.5 cm×1.2 cm to 5.0 cm×1.6 cm.After emergency debridement and treatment for bone and tendon injuries,the patients in group A received transfers of free flap or transfers with adjacent digit flaps or island flaps.Postoperative functional exercise started from 1-6 weeks after surgery.Patients in group B included 17 males and 13 females,aged 44.70 years±11.20 years and there were 6 patients with simple soft tissue defects,6 with soft tissue defects and fractures,9 with soft tissue defects and tendon and(or)ligament injuries,5 with soft tissue defects and vessel and(or)nerve injuries,and 4 with soft tissue defects and over 2 other types of compound injuries.The defect area ranged from 3.1 cm×1.3 cm to 4.5 cm×1.8 cm.Debridement and treatment of the bone and tendon injury in group B were the same as what in group A,but the patients in group B received artificial dermis coverage other than transfer of flap.After an artificial dermis had completely vascularised,a split-thickness skin graft was performed over the neo-dermis in the second phase surgery.Postoperative functional exercise started from 1-2 weeks after artificial dermis grafting surgery.The interval time of flap transfer or split-thickness skin grafting,survival rate of flap transfer or split-thickness skin grafting,Vancouver Scar Scale(VSS),TPD and total active movement(TAM)were compared between the 2 groups.The count data were analysed by Chi-square test.All measured data were analysed by independent sample t test or Mann-Whitney U test.P<0.05 indicates a statistically significant difference.Results The interval time of flap transfer in group A and artificial dermis grafting in group B were 2.93 days±2.48 days and 19.87 days±3.35 days,respectively.There was a statistically significant difference between the 2 groups(P<0.05).All patients were entered in postoperative outpatient follow-up for 11-14 months(12.00 months±0.93 months).The appearance of flaps of some patients in group A was bloated with slightly limited digit movement.In group B,the digit movement was normal,without obvious scar hyperplasia in both of the recipient and donor sites.The survival rate of flap transfer or artificial dermis graft,TPD,VSS score and TAM score for group A and group B were 96.00%±9.32% and 98.17%±3.07%,respectively,8.67 mm±2.01 mm and 9.50 mm±1.81 mm,3.40±1.07 and 3.17±0.91 and 18.30±1.97 and 18.93±1.64,respectively.There were no significant differences between the 2 groups(P>0.05).Conclusion In comparison with the transfer of flap,an artificial dermis is also effective and satisfactory in the treatment of soft tissue defects around the interphalangeal joint.Further large scale and multi-centre investigations are required.