探讨供氧条件下负压封闭引流(VSD)联合自体皮移植治疗难愈性糖尿病足溃疡的临床效果。

选择新疆维吾尔自治区人民医院2018年3月至2020年3月收治的难愈性糖尿病足溃疡患者100例为研究对象，按照随机数字表法分为观察组与对照组，每组各50例。观察组患者给予抗感染、换药、控制血糖及对症支持治疗，完善相关检查后择期给予清创手术。清创手术后，按照患者创面大小将Vacuseal材料进行裁剪后贴于创面，在距离创面3 cm正常皮肤处进行开口并将引流管从中引出，将贴附的材料与创面边缘间断缝合，再将生物半透膜紧贴于患者整个皮肤创面。贴附完成后将引流管与中心负压装置进行连接，保持持续性负压吸引，负压吸引压力值维持在40 kPa左右，每日负压吸引时间约为6 h。每天均按先纯氧再臭氧的顺序进行VSD供氧，纯氧氧流量为5 L/min，1 h/d；臭氧氧流量为10 mL/min，30 min/d。每天换药时对患者创面进行评估，当创面分泌物少，肉芽组织色泽鲜艳红润，质地坚实无水肿，无炎症现象，血糖控制达到标准，进行自体皮移植。术后要求患者绝对卧床休息，将患侧肢体抬高并制动。术后4 d进行首次换药，而后根据创面移植皮肤生长情况进行换药，间隔2~3 d。治疗期间使用胰岛素控制血糖。对照组患者不给予纯氧和臭氧治疗，其余治疗同观察组。比较2组患者治疗结束后1周临床疗效；治疗前和治疗结束后1周创面瘙痒、肉芽组织形态、视觉模拟评分法(VAS)评分；治疗结束后1个月截肢率、植皮存活率和植皮痊愈时间；治疗结束后1周基质金属蛋白酶(MMP)-2和MMP-9水平变化。数据比较采用t检验和χ²检验。

治疗结束后1周，观察组患者治疗的总有效率为98.00%(49/50)，显著高于对照组患者[82.00%(41/50)]，差异有统计学意义(χ²＝7.111，P<0.05)。观察组患者治疗前创面瘙痒、肉芽组织形态和VAS评分分别为(2.18±0.34)、(2.10±0.29)、(5.49±0.87)分，治疗结束后1周分别为(1.03±0.26)、(1.07±0.18)、(2.43±0.41)分；对照组患者治疗前创面瘙痒、肉芽组织形态和VAS评分分别为(2.21±0.39)、(2.13±0.32)、(5.53±0.98)分，治疗结束后1周分别为(1.64±0.31)、(1.58±0.23)、(3.39±0.53)分，2组治疗前与治疗结束后1周各项指标评分比较差异均有统计学意义(P<0.05)，且观察组患者治疗结束后1周创面瘙痒、肉芽组织形态和VAS评分均显著低于对照组，差异均有统计学意义(t＝10.661、12.348、10.131，P<0.05)。2组患者截肢率比较，差异无统计学意义(P>0.05)；观察组患者植皮存活率为98.00%(49/50)，显著高于对照组[84.00%(42/50)]，差异有统计学意义(χ²＝4.396，P＝0.039)；观察组患者植皮痊愈时间(14.73±1.42) d，少于对照组患者[(18.32±1.81) d]，差异有统计学意义(t＝11.034，P<0.05)。观察组患者治疗前MMP-2和MMP-9表达水平分别为285.34±28.19、363.29±20.81，治疗结束后1周分别为167.49±21.08、241.38±17.84；对照组患者治疗前MMP-2和MMP-9表达水平分别为279.81±29.35、359.89±24.31，治疗结束后1周分别为213.53±34.26、283.53±22.19，2组治疗前与治疗结束后1周MMP-2和MMP-9表达水平比较差异均有统计学意义(P<0.05)，且观察组患者治疗结束后1周血清MMP-2和MMP-9表达水平均低于对照组患者，差异均有统计学意义(t＝8.093、10.468，P<0.05)。

供氧条件下VSD联合自体皮移植治疗难愈性糖尿病足溃疡疗效良好，且可以提高植皮存活率，缩短植皮痊愈时间，降低血清MMP-2和MMP-9表达水平。

To explore the clinical effect of vacuum sealing drainage (VSD) combined with autologous skin grafting under oxygen supply in the treatment of refractory diabetic foot ulcer.

A total of 100 patients with refractory diabetic foot ulcers who were admitted to People′s Hospital of Xinjiang Uygur Autonomous Region from March 2018 to March 2020 were selected as the research objects. According to the random number table method, they were divided into observation group and control group, with 50 patients in each group. Patients in the observation group were given anti-infection, dressing change, blood glucose control, and symptomatic supportive treatment, and debridement was given as scheduled after the improvement of relevant examinations. After debridement, the Vacuseal material was cut according to the size of the patient′s wound and then attached to the wound. An opening was made at a distance of 3 cm from the normal skin of the wound, and a drainage tube was drawn out. The attached material was sutured intermittently with the edge of the wound. The biological semipermeable membrane was tightly attached to the entire skin wound of the patient. After the attachment was completed, the drainage tube was connected to the central negative pressure device to maintain continuous negative pressure suction. The negative pressure suction pressure value was maintained at about 40 kPa, and the daily negative pressure suction time was about 6 h. VSD oxygen supply was performed in the order of pure oxygen first and then ozone every day, the oxygen flow rate of pure oxygen was 5 L/min for 1 h/d and the oxygen flow rate of ozone was 10 mL/min, 30 min/d. The wound surface of the patient was evaluated when the dressing was changed every day. When the wound surface had less secretions, the granulation tissue was bright and ruddy, the texture was firm without edema, and there was no inflammation, and the blood glucose control reached the standard, autologous skin grafting was performed. After the operation, the patients were required to rest in bed absolutely, and the affected limb was elevated and immobilized. The first dressing change was performed 4 d after the operation, and then the dressing change was performed according to the growth of the grafted skin on the wound surface, with an interval of 2 to 3 d. Insulin was used to control blood glucose during treatment. The patients in the control group were not given oxygen and ozone treatment, and the rest of the treatments were the same as those in the observation group. The clinical efficacy of the two groups at 1 week after the end of treatment; the wound pruritus score, granulation tissue morphology score, and visual analogue scale (VAS) score before and 1 week after the end of treatment; the amputation rate and skin graft survival rate and healing time of skin grafting at 1 month after the end of treatment and the changes of matrix metalloproteinase (MMP)-2 and MMP-9 levels 1 week after the end of treatment were compared. Data were compared with t test and chi-square test.

One week after the end of treatment, the total effective rate of treatment in the observation group was 98.00% (49/50), which was significantly higher than that in the control group [82.00% (41/50)], and the difference was statistically significant (χ²=7.111, P<0.05). The wound pruritus score, granulation tissue morphology score and VAS score of the observation group before treatment were (2.18±0.34), (2.10±0.29), (5.49±0.87) points, respectively, and 1 week after the end of treatment were (1.03±0.26), (1.07±0.18), (2.43±0.41) points; the wound pruritus score, granulation tissue morphology score and VAS score of the control group before treatment were (2.21±0.39), (2.13±0.32), (5.53±0.98) points, respectively, 1 week after the end of treatment, the scores were (1.64±0.31), (1.58±0.23), (3.39±0.53) points, respectively. There were significant differences in the scores of each index between the two groups before treatment and 1 week after the end of treatment, the differences were statistically significant (P<0.05). And the wound pruritus score, granulation tissue morphology score and VAS score of the observation group were significantly lower than those of the control group 1 week after the end of treatment, and the differences were statistically significant (t=10.661, 12.348, 10.131; P<0.05). There was no statistically significant difference in the amputation rate between the two groups (P>0.05). The survival rate of skin grafting in the observation group was 98.00% (49/50), which was significantly higher than that in the control group [84.00% (42/50)], and the difference was statistically significant (χ²=4.396, P=0.039). The recovery time of skin grafting in the observation group was (14.73±1.42) d, which was shorter than that in the control group [(18.32±1.81) d], and the difference was statistically significant (t=11.034, P<0.05). The expression levels of MMP-2 and MMP-9 in the observation group were 285.34±28.19 and 363.29±20.81 before treatment, and 167.49±21.08 and 241.38±17.84 1 week after the end of treatment, respectively; the expression levels of MMP-2 and MMP-9 in the control group were 279.81±29.35 and 359.89±24.31 before treatment, and 213.53±34.26 and 283.53±22.19 1 week after the end of treatment, respectively, there were statistically significant differences in the expression levels of MMP-2 and MMP-9 between the two groups before treatment and 1 week after the end of treatment (P<0.05), and the expressions level of MMP-2 and MMP-9 in the observation group 1 week after the end of treatment were lower than that of the control group, and the differences were statistically significant (t=8.093, 10.468; P<0.05).

Under oxygen supply, VSD combined with autologous skin grafting has a good effect on refractory diabetic foot ulcer, and can improve the survival rate of skin grafting, shorten the healing time of skin grafting, and reduce the expression levels of serum MMP-2 and MMP-9.