探讨自体真皮移植联合负压封闭引流(VSD)在胫骨前区骨外露创面治疗中的应用及临床效果。

选择2014年8月至2018年9月昆山市第一人民医院烧伤整形外科收治的符合入选标准的13例胫骨前区骨外露需手术修复的患者，按照随机数字表法分为2组，对照组6例，试验组7例。2组患者入院均行创面细菌培养及药物敏感试验。创面予0.1%苯扎氯铵溶液湿敷。对照组予清除创面坏死组织后采用邻近旋转皮瓣修复创面，供瓣区移植自体刃厚皮片，4-0丝线间断缝合固定，无菌敷料覆盖包扎，术后根据药物敏感试验结果选择敏感抗生素防治术区感染。试验组予彻底去除创面坏死组织，凿除外露骨皮质至渗血活跃，使用电动取皮刀于创面所在肢体的同侧大腿取超薄皮片，面积与胫骨前区创面相同，保持皮片蒂部不离断，向上翻转并保护皮片，使用电动取皮刀切取厚度为0.3 mm的真皮组织，离断取得的真皮组织后对供皮区止血，原位回植未离断的超薄皮片，4-0丝线间断缝合，无菌敷料加压包扎。VSD装置覆盖移植区，贴膜封闭，连接管路，将负压设定为75 mmHg(1 mmHg＝0.133 kPa)。术后根据入院创面细菌培养及药物敏感试验结果选择敏感抗生素防治术区感染。2组均于术后5 d首次更换术区敷料，后每3天消毒创面并更换无菌敷料1次，直至创面愈合。术后5 d，观察并计算2组患者皮片及皮瓣存活优良率；统计2组患者术后第1天至出院之日的床位日；术后6个月，采用温哥华瘢痕量表评定2组患者术区瘢痕生长情况并统计患者满意度。数据比较采用t检验、χ²检验。

试验组皮片及皮瓣存活优良率为100.0%(7/7)，高于对照组[83.3%(5/6)]，但2组比较差异无统计学意义(χ²＝1.264, P>0.05)；试验组术后床位日(12.9±1.3) d，短于对照组[(14.5±1.1) d]，差异有统计学意义(t＝2.472, P<0.05)；术后6个月，试验组患者术区温哥华瘢痕评分(7.1±1.3)分，显著低于对照组[(13.5±1.0)分]，差异有统计学意义(t＝9.564, P<0.05)；术后6个月试验组患者满意率为85.7%(6/7)，显著高于对照组[16.7%(1/6)]，差异有统计学意义(χ²＝6.198, P<0.05)。

自体真皮移植联合VSD应用于胫骨前区骨外露创面的治疗有其可行性，临床效果总体不亚于传统皮瓣移植法。

To explore the clinical effect of autologous dermal transplantation combined with vacuum sealing drainage (VSD) in the treatment of anterior tibial bone exposure wound.

From August 2014 to September 2018, 13 patients with exposed bones in the anterior tibial region who were admitted to the Department of Burns and Plastic Surgery, First People′s Hospital of Kunshan who met the selection criteria and required surgical repair were selected. The patients were divided into two groups according to the random number table method, with 6 cases in the control group and 7 cases in the experimental group. Wound bacterial culture and drug sensitivity test were performed on both groups of patients after admission. The wound was wet compressed with 0.1% benzalkonium chloride solution. In the control group, the necrotic tissue on the wound was removed and the wound was repaired with an adjacent rotating skin flap. The donor area was transplanted with an autologous blade thick skin, fixed with 4-0 silk thread intermittently, and covered with a steriled dressing. After the operation, sensitive antibiotics were selected to prevent and treat infections in the operation area according to the drug susceptibility test. In the experimental group, the necrotic tissue on the wound surface was completely removed, and the exposed cortex was excised until the blood oozing was active. Electric dermatome was used to take an ultra-thin skin graft from the thigh on the same side of the limb where the wound was located. Kept the pedicle of the skin graft intact, turned it upwards to protect the skin graft, the electric dermatome was used to cut the dermal tissue with a thickness of 0.3 mm, cut off the obtained dermal tissue to stop the bleeding in the donor site, and replanted the uncut ultra-thin skin flaps in situ, 4-0 silk thread was used to interrupt sutures, and sterile dressings was used to compression bandage. The VSD device was used to cover the transplant area, and the film was closed, the pipeline was connected, the negative pressure was set to 75 mmHg (1 mmHg=0.133 kPa). After operation, sensitive antibiotics were selected to prevent infection in the surgical area according to the results of bacterial culture and drug sensitivity test on the admission wound. On the 5th day after the surgery, the dressing of the operation area in the two groups were changed for the first time, and then the wound were disinfected and steriled dressing once every 3 days until the wound healed. Five days after operation, the survival of skin flap and skin flap in the two groups were observed and calculated. The bed days from the first day after operation to the day of discharge in the two groups were counted. Six months after operation, Vancouver scar scale was used to evaluate the scar growth in the operation area of the two groups, and the patient satisfaction was counted. Data were compared with t test and chi-square test.

The excellent and good rate of skin graft survival in the experimental group was 100.0%(7/7), which was higher than that of the control group [83.3%(5/6)], but the difference was not statistically significant (χ²=1.264, P>0.05); the experimental group′s postoperative bed days were (12.9±1.3) d, which was lower than the control group′s [(14.5±1.1) d], the difference was statistically significant (t=2.472, P<0.05); six months after surgery, the Vancouver scar score in the operation area in the experimental group was (7.1±1.3) points, which was significantly lower than that in the control group [(13.5±1.0) points], the difference was statistically significant (t=9.564, P<0.05); six months after surgery, the satisfaction rate in the experimental group was 85.7%(6/7), which was significantly higher than that in the control group [16.7%(1/6)], the difference was statistically significant(χ²=6.198, P<0.05).

Autologous dermal transplantation combined with VSD for the treatment of bone exposed wounds in the anterior tibial area has its feasibility. The overall clinical effect is no less than that of traditional flap transplantation.