摘要
目的探讨足部严重创伤采用显微外科技术修复与重建的方法和临床疗效。方法选择2008年11月至2019年10月上海交通大学医学院附属新华医院(崇明)和温州医科大学附属浙江省台州医院收治的足部严重创伤患者, 均采用显微外科吻合技术急诊原位回植修复+二期显微外科组织移植技术精准重建, 恢复足部功能和外形。根据足部损伤部位、范围、平面、程度等特点进行评估, 设计手术方案, 急诊在显微镜下进行患足有效清创和残余组织原位回植修复。根据患足一期组织回植成活情况, 二期采用显微外科组织移植技术精准修复缺损与功能重建。术后定期随访, 根据术后足部皮肤成活情况、色泽弹性、外观形态、供区瘢痕、皮肤感觉、感染控制、患者认可度指标进行疗效评价, 按照皮瓣肿胀4级判断标准进行足部肿胀程度评价;根据足部损伤术后疼痛程度、关节屈伸范围、畸形程度和行走能力进行足部活动功能评价。结果共选择足部严重创伤患者23例, 男15例, 女8例, 年龄17~69岁, 平均38.5岁;左足10例, 右足13例。23例中一期原位回植修复成活15例;足底内侧部分皮肤坏死给予二期植皮处理2例, 皮瓣移植修复足跟部分皮肤坏死1例, 前足底皮肤坏死伴感染2例, 皮瓣或骨皮瓣移植修复足背皮肤坏死感染合并骨缺损3例。术后23例获6~48个月随访, 平均18.5个月, 创面完全愈合, 皮肤色泽、弹性与周围正常皮肤接近, 足部无明显臃肿畸形, 足底感觉功能恢复均为S3~S4级, 瘢痕较小, 行走自由, 无明显跛行。术后疗效评价:满意16例, 一般7例;足部肿胀程度评价:早期为Ⅰ度3例, Ⅱ度10例, Ⅲ度8例, Ⅳ度2例;后期为Ⅰ度15例, Ⅱ度6例, Ⅲ度2例。活动功能评价:优3例、良13例、中7例, 优良率约为69.6%(16/23)。结论采用显微外科技术进行足部严重创伤的修复与重建, 恢复足部功能与外形, 疗效可靠, 患者满意, 是目前治疗足部严重创伤的有效方法之一。
Objective To investigate the clinical effect of the repair and reconstruction of severe foot trauma by microsurgical methods.Methods Patients with severe foot trauma were admitted to Xinhua Hospital(Chongming),Affiliated with Shanghai Jiao Tong University School of Medicine,and Taizhou Hospital,Affiliated with Wenzhou Medical University in Zhejiang Province from November 2008 to October 2019.All patients were treated with orthotopic replantation using microsurgical anastomosis in emergency and precise microsurgical reconstruction in the second stage.A retrospective analysis of the clinical effect of the reconstructed appearance and function was performed.The evaluation and surgical design were carried out according to the characteristics of the injury site,range,plane,degree,etc.,and adequate debridement and orthotopic replantation of residual tissue was performed under the microscope in emergency.Then regular follow-up was conducted to evaluate the postoperative efficacy,the degree of foot swelling,and the observation of foot activity and function.Results A total of 23 patients with severe foot trauma were enrolled,including 15 males and 8 females,aged from 17 to 69 years old,with an average of 38.5 years old.Among them were the left foot in 10 cases and the right foot in 13 cases.15 of the 23 patients survived orthotopic replantation.2 cases of medial plantar skin necrosis were treated by skin graft in the second stage,1 case of heel skin necrosis and 2 cases of anterior plantar skin necrosis with infection were repaired by flaps,and 3 cases of dorsal skin necrosis with infection combined with bone defect were repaired by flaps or osteocutaneous flap.After the operation,23 patients were followed up for 6 to 48 months,with an average of 18.5 months.The wounds were completely healed,the color and elasticity were close to the surrounding normal skin,and there was no apparent swelling deformity on foot.The sensory function of the foot was all restored to grades S3-S4,with a small scar,and they walked freely without noticeable limping.The efficacy was evaluated according to a survival situation,color elasticity,appearance and morphology,donor scar,skin sensation,infection control,and patient recognition.16 cases were satisfied with the outcomes,and 7 reported moderate.Skin swelling rating in the early stage was 1st degree in 3 cases,2nd degree in 10 cases,3rd degree in 8 cases,4th degree in 2 cases;in the later stage was 1st degree in 15 cases,2nd degree in 6 cases,3rd degree in 2 cases.Foot function is assessed by the degree of postoperative pain,function of flexion and extension,degree of deformity,and walking ability,which is excellent in 3 cases,good in 13 cases,general in 7 cases,with a reasonable rate of about 69.6%(16/23).Conclusions The microsurgical technique is one of the most effective methods to repair and reconstruct the function and appearance of the foot with severe trauma for now.
作者
林涧
吴立志
陶文全
张天浩
王之江
林加福
Lin Jian;Wu Lizhi;Tao Wenquan;Zhang Tianhao;Wang Zhijiang;Lin Jiafu(Department of Center for Orthopaedic Repair and Reconstruction,The Xinhua Hospital(Chongming)Affiliated to Medical College,Shanghai Jiao Tong University,Shanghai 202150,China;Department of Microsurgery,Taizhou Hospital,Wenzhou Medical University,Wenzhou 317000,China;Shanghai Chongming District Medical Emergency Center,Shanghai 202150,China;Department of Anatomy in FuJian Health College,Fuzhou 350101,China)
出处
《中华整形外科杂志》
CSCD
2022年第5期558-564,共7页
Chinese Journal of Plastic Surgery
基金
上海市科学技术委员会科研计划项目(14411973200)
上海市卫生和计划生育委员会面上项目(201840198)
上海市卫生健康委员会专项研究基金项目(2020YJZX0143)。
关键词
足
创伤
显微外科技术
修复与重建
临床疗效
Foot
Trauma
Microsurgical technique
Repair and reconstruction
Clinical efficacy
