不同类型的组织瓣修复胫骨近端骨折术后钢板外露伴感染创面的临床效果

Clinical effects of different types of tissue flaps in repairing the wounds with steel plate exposure and infection after proximal tibial fracture surgery

目的探讨不同类型的组织瓣修复胫骨近端骨折术后钢板外露伴感染创面的临床效果。方法采用回顾性观察性研究方法。2015年1月—2021年12月,武警江西总队医院收治11例符合入选标准的胫骨近端骨折术后钢板外露伴感染创面患者,其中男9例、女2例,年龄26~61岁。创面位于小腿近端外侧者5例、内侧者2例,小腿近端内侧及膝下胫前者4例,清创后创面面积为14 cm×6 cm~22 cm×11 cm,采用不同类型的组织瓣修复创面,并根据钢板周围感染情况决定是否立即拆除钢板。应用以包含旋股外侧动脉降支终末细小分支的肌肉为蒂的逆行股前外侧肌皮瓣者3例;应用腓肠肌内侧头肌瓣联合比目鱼肌内侧半肌瓣者6例,应用腓肠肌外侧头肌瓣联合胫前肌肌瓣者2例,肌瓣血运稳定后移植健侧大腿薄中厚皮片封闭创面。肌皮瓣切取面积为15 cm×7 cm~18 cm×8 cm,肌瓣切取面积为6.0 cm×4.0 cm~18.0 cm×12.0 cm。3例应用逆行股前外侧肌皮瓣的患者中2例大腿供瓣区创面经直接缝合关闭,在1例患者大腿供瓣区创面缝合后未闭合处移植健侧大腿薄中厚皮片予以修复。将8例应用小腿肌瓣者供瓣区切口直接缝合。术后观察并记录组织瓣成活情况和肌瓣上移植皮片存活情况、组织瓣受区创面愈合情况及愈合时间、供瓣区缝合口愈合及移植皮片存活情况。记录术后及随访期间是否拆除钢板。随访时,观察组织瓣外形及质地,组织瓣受区有无红肿、破溃或窦道形成;记录骨折愈合时间。末次随访时,测量患者膝关节屈伸活动度并根据Hohl膝关节功能评定标准评价膝关节功能,测定8例应用小腿肌瓣修复创面的患者踝关节跖屈肌力;采用温哥华瘢痕量表(VSS)评估供瓣区瘢痕情况,观察瘢痕是否影响患肢活动。结果11例患者术后组织瓣均成活;1例患者逆行股前外侧肌皮瓣的远端皮肤坏死,行换药+健侧大腿薄中厚皮片移植后创面愈合;2例患者腓肠肌内侧头肌瓣远端肌肉坏死,经换药治疗后肉芽组织生长良好。肌瓣上移植的皮片均存活良好。组织瓣受区创面均愈合,愈合时间为组织瓣移植术后13~42 d;供瓣区缝合口愈合、移植皮片均存活良好。1例患者在应用腓肠肌内侧头肌瓣联合比目鱼肌内侧半肌瓣修复创面时即拆除了钢板;1例患者在应用以包含旋股外侧动脉降支终末细小分支的肌肉为蒂的逆行股前外侧肌皮瓣修复创面3周后仍有渗出,拆除钢板后创面愈合;其余患者钢板得以保全。随访6~25个月,除1个逆行股前外侧肌皮瓣蒂部较臃肿外,其余组织瓣外形、质地良好;1例患者出院后6周组织瓣受区出现红肿,经抗感染治疗后红肿消退无复发;1例患者出院后3个月组织瓣受区反复破溃渗液,形成窦道,拆除钢板后窦道愈合。患者骨折愈合时间为伤后6~15个月。末次随访时,患者膝关节功能评定为优者4例、良者6例、差者1例;8例应用小腿肌瓣修复创面的患者中7例踝关节跖屈肌力为Ⅵ级,1例踝关节跖屈肌力为Ⅴ级;供瓣区瘢痕VSS评分为2~7分,瘢痕未明显影响患肢活动。结论以包含旋股外侧动脉降支终末细小分支的肌肉为蒂的逆行股前外侧肌皮瓣、腓肠肌肌瓣联合比目鱼肌或胫前肌肌瓣是常用逆行股前外侧肌皮瓣、腓肠肌肌瓣的衍生类型,用其修复胫骨近端骨折术后钢板外露伴感染创面不仅可保障手术顺利进行,还可尽可能保全钢板和促进骨折愈合,同时不明显影响患肢功能。

Objective To investigate the clinical effects of different types of tissue flaps in repairing the wounds with steel plate exposure and infection after proximal tibial fracture surgery.Methods A retrospective observational study was conducted.From January 2015 to December 2021,11 patients with steel plate exposure and infected wounds after proximal tibial fracture surgery who met the inclusion criteria were admitted to Jiangxi Provincial General Hospital of Armed Police,including 9 males and 2 females,aged 26 to 61 years.The wounds were located on the lateral side of the proximal leg in 5 cases,on the medial side of the proximal leg in 2 cases,and on the medial side of the proximal leg and the anterior tibia below the knee in 4 cases.After debridement,the wound area was 14 cm×6 cm-22 cm×11 cm.The wounds were repaired with different types of tissue flaps,and the steel plates were removed immediately if necessary,according to the infection around the steel plates.The reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery was used in 3 cases;the medial gastrocnemius muscle flap combined with the medial half of soleus muscle flap was used in 6 cases,and the lateral gastrocnemius muscle flap combined with the anterior tibial muscle flap was used in 2 cases.After the muscle flaps had stable blood supply,the wounds were closed with thin intermediate thickness skin graft from the healthy thigh.The area of myocutaneous flap ranged from 15 cm×7 cm to 18 cm×8 cm,and the area of muscle flap ranged from 6.0 cm×4.0 cm to 18.0 cm×12.0 cm.Among the 3 patients who were treated with reverse anterolateral thigh myocutaneous flap,the wounds of flap donor site on thighs were closed by direct suturing in 2 cases,and the wound in the flap donor site of thigh in 1 case that was not closed after suture was repaired with thin intermediate thickness skin graft from healthy thigh.The incisions in the flap donor sites of 8 cases treated with calf muscle flaps were sutured directly.After surgery,the survivals of tissue flap and skin graft on the muscle flap,wound healing status and wound healing time in recipient sites of tissue flaps,suture site healing in flap donor site,and survival of skin graft were observed and recorded.Whether the steel plate was removed after operation and during follow-up was recorded.During follow-up,the shape and texture of tissue flap,whether the recipient site of tissue flap had redness,swelling,ulceration,or sinus formation were observed,the fracture healing time was recorded.At the last follow-up,the knee joint flexion and extension range of motion was measured and the knee joint function was evaluated according to Hohl's knee joint function evaluation criteria;the plantar flexor muscle strength of ankle joint was measured in 8 patients who were treated with calf muscle flaps for wound repair;the Vancouver scar scale(VSS)was used to evaluate the scar condition in the flap donor site,and whether the scar affected the movement of the affected limbs was observed.Results Tissue flaps of 11 patients all survived after surgery.The distal end of the reverse anterolateral thigh myocutaneous flaps was necrotic in 1 patient,and the wound was healed after dressing change and grafting with thin intermediate thickness skin from healthy thigh.The distal muscle necrosis of the medial gastrocnemius muscle flap was observed in 2 patients,and the granulation tissue grew well after dressing change.The skin graft on the muscle flap survived well.All the wounds in the recipient sites of tissue flaps were healed,and the healing time was 13 to 42 days after tissue flap transplantation.The suture site of flap donor site healed,and the skin graft survived well.In 1 patient,the steel plate was removed when the wound was repaired with the medial gastrocnemius muscle flap combined with the medial half of soleus muscle flap.One patient still had exudation after 3 weeks of wound repair with the reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery,and the wound was healed after removing the steel plate.The steel plates of the other patients were preserved.During the follow-up of 6-25 months,except for 1 reverse anterolateral thigh myocutaneous flap had bloated pedicle,the other tissue flaps had good appearance and texture.One patient had redness and swelling in the recipient site of the tissue flap at 6 weeks after discharge,and the redness and swelling subsided without recurrence after anti-infection treatment.In 1 patient,repeated rupture and exudation occurred in the recipient site of tissue flap in 3 months after discharge,resulting in sinus tract formation,which was healed after the removing of steel plate.The fracture healing time of patients ranged from 6 to 15 months after injury.At the last follow-up,the knee joint function was evaluated as excellent in 4 cases,good in 6 cases,and poor in 1 case.Among the 8 patients who were treated with calf muscle flaps for wound repair,7 patients had ankle joint plantar flexor muscle strength of gradeⅥ,and 1 patient had ankle plantar flexor muscle strength of gradeⅤ.The VSS scores of scars in the flap donor sites ranged from 2 to 7,and scars did not significantly affect the movement of the affected limbs.Conclusions The reverse anterolateral thigh myocutaneous flap pedicled with the muscle containing the terminal small branch of the descending branch of the lateral circumflex femoral artery and the gastrocnemius muscle flap combined with soleus muscle flap or anterior tibial muscle flap are the derived types of the commonly used reverse anterolateral thigh myocutaneous flap and gastrocnemius muscle flap.Using them to repair the wounds with steel plate exposure and infection after proximal tibial fracture surgery can not only ensure the smooth operation,but also preserve the steel plate and promote fracture healing as much as possible,without significantly affecting the function of the affected limb.