下肢关节部位外伤行骨科内固定手术后切口感染创面临床治疗方法探讨  

Exploration on clinical treatment of incisional wound infection after orthopedic internal fixation for lower extremity joint injuries

作　　者：杜伟力[1] 沈余明[1] 胡骁骅[1] 程琳[1] Du Weili;Shen Yuming;Hu Xiaohua;Cheng Lin(Department of Burns,Beijing Jishuitan Hospital,Beijing 100035,China)

机构地区：[1]北京积水潭医院烧伤科,100035

出　　处：《中华烧伤杂志》2021年第3期216-224,共9页Chinese Journal of Burns

基　　金：首都卫生发展科研专项(首发2020-2-1123);北京市自然科学基金(7192082);北京积水潭医院青年人才培养“学科新星”计划(XKXX201822)。

摘　　要：目的探讨下肢关节部位外伤行骨科内固定手术后切口感染创面的临床治疗方法。方法采用回顾性队列研究方法。2014年2月—2019年12月,北京积水潭医院收治214例下肢闭合性外伤后患者,其中男143例、女71例,年龄16~65岁。患者均行骨科内固定手术,因术后切口感染形成髌骨骨折术后创面42例、胫骨平台骨折术后创面30例、跟腱断裂术后创面72例、跟骨骨折术后创面45例、Pilon骨折术后创面25例,其中浅表感染31例、深部感染183例。根据术后切口处创面评估情况,进行换药治疗和/或彻底清创(清创后创面面积4 cm×3 cm~11 cm×5 cm)、内固定物处理。针对彻底清创后的创面进行持续负压封闭引流(VSD),再根据切口及其周围皮肤组织情况、感染情况、缝合张力、内固定物或骨或跟腱组织外露情况,选择直接缝合+VSD治疗或者移植组织瓣修复。以创面部位及损伤情况为依据,组织瓣类型可选择逆行股前外侧穿支皮瓣、腓肠内侧动脉穿支皮瓣、腓肠肌肌皮瓣、腓肠神经营养血管皮瓣、腓骨短肌肌瓣、胫后动脉穿支皮瓣、游离股前外侧穿支皮瓣。供瓣区直接拉拢缝合或移植断层皮片修复。统计内固定物取出情况、创面修复方式、采用组织瓣类型及大小、组织瓣成活情况、创面愈合情况,随访观察感染是否复发、供受区外观及下肢关节功能恢复情况。结果髌骨骨折术后创面患者内固定物全部去除,其中36例创面采用逆行股前外侧穿支皮瓣修复,6例创面采用腓肠内侧动脉穿支皮瓣修复。胫骨平台骨折术后创面患者中,内固定物完全保留18例、部分取出6例、完全取出6例,创面直接缝合8例、移植腓肠肌肌皮瓣21例、移植腓肠内侧动脉穿支皮瓣1例。跟腱断裂术后创面患者中,内固定物完全保留10例、完全取出62例,创面直接缝合10例、移植腓肠神经营养血管皮瓣62例。跟骨骨折术后创面患Objective To explore the clinical treatment of incisional wound infection after orthopedic internal fixation for lower extremity joint injuries.Methods A retrospective cohort study was conducted.From February 2014 to December 2019,214 patients with lower limb closed injury were treated in Beijing Jishuitan Hospital,including 143 males and 71 females,aged from 16 to 65 years.All patients underwent orthopedic internal fixation,after which incisional wound infection developed in 42 cases of postoperative wounds of patellar fracture,30 cases of postoperative wounds of tibial plateau fracture,72 cases of postoperative wounds of Achilles tendon rupture,45 cases of postoperative wounds of calcaneal fracture,and 25 cases of postoperative wounds of Pilon fracture with 31 cases of superficial infection and 183 cases of deep infection.According to the postoperative evaluation of the incisional wounds,dressing change and/or thorough debridement(with wound area from 4 cm×3 cm to 11 cm×5 cm after debridement),and internal fixation treatment were performed.After thorough debridement,wounds were treated with continuous vacuum sealing drainage(VSD),and then direct suture+VSD or flap transplantation were performed according to the incision and its surrounding skin tissue,infection,suture tension,exposure of internal fixation or bone or Achilles tendon tissue.According to the wound site and injury,the flap types of retrograde anterolateral thigh perforator flap,medial sural artery perforator flap,gastrocnemius myocutaneous flap,sural neurovascular flap,peroneal brevis muscle flap,posterior tibial artery perforator flap,and free anterolateral thigh perforator flap could be selected.The donor site wound was closed by direct suture or grafted with split-thickness skin graft.The removal of internal fixation,wound repair method,type and size of flaps,survival of flaps,and wound healing were recorded.The recurrence of infection,appearance of donor and recipient areas,and recovery of lower limb joint function were followed up.Results Al

关 键 词：下肢 外科手术 伤口愈合 骨科 切口感染创面 治疗 

分 类 号：R619+.6[医药卫生—外科学] R378.1+1[医药卫生—临床医学]