人工真皮结合刃厚皮片一期移植与中厚皮片移植修复皮瓣供区的比较分析

Retrospective comparation of repairing of skin flap donor site with one-stage transplantation of artificial dermis combined with split-thickness skin graft and full-thickness skin graft

目的探讨人工真皮结合刃厚皮片一期移植修复皮瓣供区皮肤缺损的临床疗效。方法回顾2018年1月至2021年12月收治且符合纳排标准的上海交通大学医学院附属第六人民医院骨科皮瓣手术患者资料,共221例。根据皮瓣供区修复方式分为两组,观察组115例,皮瓣供区皮肤缺损范围为11~240 cm^(2),应用人工真皮结合刃厚皮片一期移植修复;对照组106例,供区范围11~243 cm^(2),应用中厚皮片修复供区皮肤缺损。随访6~24个月,观察两组移植皮片存活率、供皮区愈合时间、患者满意度[视觉模拟自评量表(VAS)评分]、皮瓣供区瘢痕增生情况[温哥华瘢痕量表(VSS)评分]、供区周围上下肢关节功能[臂肩手功能障碍评分(DASH)和美国足踝外科医师协会(AOFAS)评分],并应用SPSS、GraphPad Prism 9软件统计分析,数据比较采用t检验、Wilcoxon检验、χ^(2)检验及Fisher精确检验。结果人工真皮联合刃厚皮移植组的皮片存活率稍高于中厚皮片移植组,但差异无统计学意义(95.7%和93.4%,P>0.05)、两组在创面愈合时间[观察组和对照组分别为18.00(16.00,20.00)d和17.50(16.00,20.00)d]及患者满意度[观察组和对照组得分分别为5.00(4.00,6.00)及5.00(4.00,7.00)]差异无统计学意义(P>0.05)。人工真皮联合刃厚皮移植组无论是受皮区还是供皮区的瘢痕程度均优于中厚皮片组[(受皮区VSS评分分别为4.00(3.00,5.00)和5.00(4.00,6.00),Z=-3.647,P<0.01;供皮区VSS评分分别为2.00(1.00,3.00)和4.00(3.00,4.25),Z=-8.859,P<0.01)]。人工真皮联合刃厚皮移植组的相邻关节功能明显优于中厚皮片组[上肢功能评分分别为41.50(40.00,47.00)和49.00(45.25,54.00),Z=-4.961,P<0.01;下肢功能评分分别为91.00(87.00,93.50)和82.00(78.00,86.25),Z=-7.857,P<0.01]。结论人工真皮结合刃厚皮片一期移植是修复皮瓣供区良好的方法,可以给供区,特别是腱膜上提供良好的组织覆盖,在避免瘢痕挛缩同时确保了肌腱组织的有效滑动,有利于相邻关节功能的恢复。

Objective To investigate the clinical efficacy of one-stage transplantation of artificial dermis combined with split-thickness skin grafts for repairing skin defects in the skin flap donor site.Methods A retrospective review of 221 patients who underwent skin flap surgery at the Department of Orthopedics,Shanghai Sixth People′s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2018 to December 2021 was conducted.According to the repair method of the skin flap donor site,the patients were divided into two groups.There were 115 patients in the observation group,and the skin defect range of the skin flap donor site was 11-240cm^(2).The patients were treated with one-stage transplantation of artificial dermis combined with split-thickness skin grafts.There were 106 patients in the control group,and the skin defect range of the skin flap donor site was 11-243cm^(2).The patients were treated with one-stage transplantation of full-thickness skin grafts.Follow up for 6 to 24 months was conducted to observe the survival rate of two groups of skin grafts,healing time of the donor site,patient satisfaction[Visual Analog Self Rating Scale(VAS)],scar hyperplasia in the flap donor site[Vancouver scar scale(VSS)],and joint function of the upper and lower limbs around the donor site[disabilities of the arm shoulder and hand(DASH)and American orthopaedic foot and ankle society(AOFAS)].SPSS and GraphPad Prism 9 software were used for statistical analysis,and t-test,Wilcoxon test,chi square test,and Fisher′s exact test were used for data comparison.Results The survival rate of the artificial dermis combined with blade thickness skin grafting group was slightly higher than that of the medium thickness skin grafting group,but the difference was not statistically significant(95.7%and 93.4%,P>0.05).There was no statistically significant difference between the two groups in wound healing time[observation group and control group were 18.00(16.00,20.00)days and 17.50(16.00,20.00)days respectively]and patient satisfaction[observation group and control group were 5.00(4.00,6.00)and 5.00(4.00,7.00)days respectively(P>0.05)].The degree of scar formation in both the recipient and donor areas of the artificial dermis combined with blade thickness skin grafting group was better than that in the medium thickness skin grafting group(the VSS scores in the recipient area were 4.00(3.00,5.00)and 5.00(4.00,6.00),Z=-3.647,P<0.01).The VSS scores of the donor site were 2.00(1.00,3.00)and 4.00(3.00,4.25),Z=-8.859,P<0.01),respectively.The adjacent joint function of the artificial dermis combined with blade thick skin grafting group was significantly better than that of the medium thick skin grafting group[upper limb function scores were 41.50(40.00,47.00)and 49.00(45.25,54.00),Z=-4.961,P<0.01].The lower limb function scores were 91.00(87.00,93.50)and 82.00(78.00,86.25)(Z=-7.857,P<0.01),respectively.Conclusion One-stage transplantation of artificial dermis combined with split-thickness skin grafts is a good method for repairing skin flap donor sites,which can provide good tissue coverage for the donor site,especially on the tendon sheath,while avoiding scar contracture and ensuring the effective sliding of tendon tissues,which is beneficial to the recovery of adjacent joint function.