胸大肌肌瓣移位治疗开胸术后慢性胸骨骨髓炎

目的总结采用胸大肌肌瓣移位治疗开胸术后慢性胸骨骨髓炎的治疗方法及效果。方法2006年1月-2009年2月,收治11例开胸术后并发慢性胸骨骨髓炎患者。男6例,女5例;年龄6～62岁,中位年龄34岁。冠状动脉搭桥术2例,二尖瓣换瓣术6例,心室缺损修补术3例。单纯胸骨骨髓炎6例;胸骨骨髓炎伴纵隔内感染2例,胸骨骨髓炎伴肋软骨炎3例。术中彻底扩创后胸骨缺损4cm×3cm～7cm×4cm。在一侧胸部设计胸大肌肌瓣8cm×5cm～10cm×6cm,移位修复胸骨缺损。术后持续负压吸引,应用敏感抗生素预防感染。结果术后10例切口Ⅰ期愈合;1例引流管切口处拆线时见少许分泌物,经换药1周后愈合。患者均获随访,随访时间3～10个月,平均6个月。8例胸部正中切口瘢痕平整,质软,轻度充血;3例略高于皮肤,质韧,充血,但未超出切口范围。胸骨区疼痛消失,无切口再次感染及慢性窦道形成,胸骨骨髓炎无复发。供区上肢功能正常。结论胸大肌肌瓣移位可有效治疗开胸术后慢性胸骨骨髓炎。     

双侧胸大肌内侧头转移术治疗心脏术后胸骨哆开

目的 探讨双侧胸大肌内侧头转移术治疗心脏术后并发胸骨哆开的方法. 方法 2005年5月至2010年10月首都医科大学附属北京安贞医院收治21例心脏外科术后并发胸骨骨髓炎和纵隔感染的胸骨哆开患者,其中男13例,女8例;年龄为53～72 (64.5±7.8)岁.施行冠状动脉旁路移植术(CABG)19例,心瓣膜置换术2例.采用清创、剔除坏死胸骨、保留部分或全部拔除胸骨固定钢丝、游离双侧胸大肌内侧头使之形成肌瓣并拉至中线位置无张力缝合,完全覆盖胸骨,放置负压吸引引流管,适时拔除,皮肤间断缝合. 结果 21例患者胸大肌肌瓣全部成活,均于术后2周内出院;20例术后愈合顺利,1例拔除引流管后引流口形成窦道并感染,再次手术局部切除窦道后愈合.术后6个月随访,全组患者均胸骨固定,胸廓外形正常,无反常呼吸,未发现再发或迁延性感染. 结论 双侧胸大肌内侧头转移术是治疗心脏外科手术后并发难治性胸骨哆开的一种确切、有效的手术方式.     

放射性胸部溃疡胸骨骨髓炎的外科治疗

目的：探讨放射性胸骨骨髓炎并胸部难治性溃疡的手术治疗方法。方法：7例胸腺瘤或乳腺癌术后术区放疗病人，于放疗后8－32个月出现前胸放疗区溃疡，胸骨感染外露，长期换药治疗不愈，经术后准备后行病灶胸骨，肋软骨及瘢痕组织切除，胸大肌肌瓣和腹直肌肌瓣充填缺损，局部皮瓣覆盖创面，1例部分创面尚需辅以皮片覆盖，术后加压包扎。结果：术后肌瓣成活良好，皮瓣无坏死，6例治愈；1例术后术区感染，伤口恶化，4个月后死于腐蚀性大出血。结论：放射性胸部感染胸骨骨髓炎时应尽早手术治疗，彻底切除炎症坏死的胸骨组织及受累的肋软骨，尽可能地切除放射性瘢痕，以带蒂肌瓣充填创面，皮瓣或加皮片覆盖创面是较好的治疗方法。     

胸腹壁随意皮瓣联合腹直肌肌瓣修复胸壁缺损

目的探讨胸腹壁随意皮瓣联合腹直肌肌瓣移位修复胸壁缺损的临床应用价值。方法2002年1月～2005年6月,对5例胸壁缺损患者行胸腹壁随意皮瓣联合腹直肌肌瓣移位修复术。其中胸骨骨髓炎术后、胸骨肿瘤刮除术后、胸骨结核病灶清除术后各1例,心脏手术术后2例;均因感染致胸骨及内置物外露,病程6个月～2年。先行病灶清除,视创面大小设计切取15cm×10cm的胸腹壁随意皮瓣,然后切取腹直肌肌瓣移位修复胸壁缺损。结果术后4例皮瓣期愈合,1例皮瓣延期愈合,无并发症。皮瓣外观良好,无臃肿及色素沉着,X线片显示胸骨死骨阴影消失。随访1～3年,平均1年6个月,无复发。腹部供区皮肤愈合良好,无腹壁疝发生。结论胸腹壁随意皮瓣联合腹直肌肌瓣移位修复术是治疗胸骨体周围胸壁缺损的一种简单、有效方法,值得推广应用。     

肌瓣成形新技术治疗胸骨切口深部感染23例

目的探讨胸大肌瓣翻转、伤口内无异物存留技术成形治疗胸骨切口深部感染的安全性与有效性。方法纳入我院2016年6~12月胸骨切口深部感染患者23例,男13例、女10例,年龄4~73(54.5±19.5)岁。8例合并糖尿病,1例合并慢性阻塞性肺疾病和脑梗塞。分型:Ⅱ型18例,Ⅲ型5例;5例纵隔残存脓腔。彻底清创伤口后,采用肌瓣成形新技术治疗胸骨切口感染:游离胸大肌将其外侧切断制备成肌瓣,向内翻转填充于胸骨缺损处,用减张缝合法将肌瓣填充并固定,切口全层缝合皮下皮肤。结果胸骨清创后胸骨缺损成形使用双侧胸大肌瓣17例、单侧6例,切口Ⅰ期愈合21例(91.3%),切口皮肤延迟愈合2例,均自行愈合。胸廓无反常呼吸22例,因合并症致多器官衰竭死亡1例。平均住院时间10.6 d。术后1个月胸部CT检查切口愈合良好。术后随访5.9(3~9)个月,患者未诉不适。结论胸大肌瓣翻转、伤口内无异物存留技术成形治疗胸骨切口深部感染技术独特,有Ⅰ期愈合率高、并发症少、住院时间短的优势。     

开放性骨水泥技术结合胸大肌推进肌瓣治疗冠脉搭桥术后慢性胸骨骨髓炎

目的:分析开放性骨水泥技术结合胸大肌推进肌瓣分期治疗冠脉搭桥术(CABS)后慢性胸骨骨髓炎的疗效,总结分期手术、综合治疗的临床经验。方法:回顾性分析2017年10月至2020年6月收治的CABS后胸骨慢性骨髓炎开放性骨水泥技术治疗的患者5例,年龄54~72岁,冠心病病史5~12年,入院时慢性胸骨骨髓炎时间3周~3个月。...     

应用背阔肌与胸大肌联合肌瓣及假体置入即刻乳房再造

目的探讨经乳房外侧弧形切口皮下乳腺切除术后,带蒂转移背阔肌肌瓣,与胸大肌肌瓣形成联合肌瓣覆盖乳房假体,进行即刻乳房再造术的治疗效果。方法选择临床分期为Ⅰ期或Ⅱ期．肿瘤未侵及皮肤和胸肌的乳腺癌患者共30例,经乳房外侧弧形切口皮下切除乳腺腺体并清扫腋窝淋巴结,利用同一切口,切取背阔肌肌瓣带蒂转移,分离胸大肌下间隙,切断胸大肌下缘与胸壁附着处直至胸骨边缘,将转移的背阔肌肌瓣与胸大肌断缘缝合,组成联合肌瓣,形成宽大的包裹假体的腔隙．置入假体。结果30例再造乳房外形及手感良好,其中优22例（73．3％）,良8例（26．7％）。术后所有患者均随访半年以上,均无瘤生存。结论再造乳房形态美观,能够置入较大的假体,不增加背部的切口,适合于无淋巴结转移、对侧乳房无明显下垂的早期青年乳腺癌患者的即刻乳房再造。     

带蒂肌瓣转移联合负压吸引一期重建治疗心脏术后复杂性纵隔感染

目的总结心脏术后复杂性纵隔感染的外科治疗经验,探讨最佳治疗策略。方法回顾性分析首都医科大学附属北京安贞医院心外科2006年6月至2012年12月期间,应用带蒂肌瓣转移填充及负压吸引一期重建治疗心脏直视术后复杂性纵隔感染18例的临床资料。其中男12例、女6例,平均年龄（65．5±8．2）岁。心脏手术与肌瓣重建时间间隔（12．5±5．8）d。彻底清创,拔除全部钢丝,游离双侧胸大肌瓣向中线牵拉,填充胸骨间隙并覆盖胸骨,无张力缝合肌瓣,纵隔及皮下置引流管负压吸引,关闭创口。胸骨缺损较大者,需游离一侧腹直肌瓣上提填充缺损,再按上述方法一期重建。结果1例患者术后早期死于纵隔感染复发,脓毒血症及多器官功能衰竭。17例患者术后过程顺利,创口一期愈合。重建术后住院时间（18．6±7.2）d,创口愈合时间（4．5±2．4）周。17例患者随访6个月以上未见纵隔感染复发,工作生活质量良好。结论带蒂肌瓣转移联合负压吸引一期重建治疗心脏术后复杂性纵隔感染效果确切,手术简单,易于推广。     

开胸术后肋软骨炎的整形外科治疗

目的探讨开胸术后肋软骨炎的治疗方法。方法对单根的肋软骨炎,在压痛最明显处直接切除受累的肋软骨;对胸上部多根肋软骨炎,可在胸部正中(开胸之瘢痕处)切开,切除受累的肋软骨;对胸下部、肋弓处肋软骨炎,除在胸部正中切开外,再向外下沿肋弓切开,形成以上部为蒂的胸部皮瓣,再切除受累的肋软骨;对肋软骨炎伴胸锁关节炎者,在胸部正中切开,形成一侧的胸部皮瓣,将受累的肋软骨及胸锁关节切除,应用胸大肌瓣转移填塞胸锁关节缺损处。术后行滴注引流,应用敏感抗生素。结果本组7例,2周后伤口愈合,效果良好。结论彻底清除感染的肋软骨是治疗开胸术后肋软骨炎的有效方法。     

经胸骨正中手术切口感染创面的修复

目的对比观察不同方法修复经胸骨正中手术切口感染创面的治疗效果。方法1997年12月～2006年12月,分别用胸大肌内侧头肌瓣、胸大肌瓣、上蒂腹直肌瓣及大网膜移位修复经胸骨手术切口感染创面13例。男8例,女5例;年龄28～72岁,平均52岁。合并糖尿病8例,肺炎及心力衰竭4例,脓胸3例,慢性肺功能不全4例,恶性肿瘤1例,严重肥胖6例。11例为较新鲜裂开创面,2例为慢性创面。创面范围10cm×5cm～22cm×10cm。结果3例分别于术后3d因血管吻合处破裂大出血、肺炎及癌转移死亡。其余10例伤口期愈合6例,随访6个月～5年,均无复发;2例切口皮肤拉拢缝合处部分皮肤坏死,经再次手术扩创植皮后愈合;2例创口引流处感染,经换药愈合。结论创面较小且位于手术切口上端者适合用胸大肌内侧头肌瓣修复;创面较大且位于切口上端者适合用全胸大肌瓣修复;创面较小且位于切口下端的适合用上蒂腹直肌瓣修复;创面较长可联合应用胸大肌瓣、上蒂腹直肌瓣修复创面;创面巨大合并重要脏器外露时,可用大网膜移位修复创面。残余创面可经植皮及换药愈合。     

Chest wall reconstruction with rectus abdominis musculocutaneous flap for sternum osteomyelitis after radiation

We report a case of reconstruction of radiation ulcer on the chest wall and sternum osteomyelitis using a rectus abdominis musculocutaneous flap. A case of 67-year-old woman, Halsted operation was performed for right breast cancer, 23 years ago. After 4 years, transcatheter arterial injection and radiation therapy was performed to treat recurrence of parasternal lymph nodes. Since then, she had been without recurrence of the tumor, but suffered from repeated scabbing of parasternal skin. In 2009, she suffered from pain, redness and purulent discharge of the wound, and diagnosed with sternum osteomyelitis. She was admitted to our hospital and underwent debridement of sternum, and the resection of surrounding skin. Sixteen days later, reconstruction using a rectus abdominis musculocutaneous flap was performed. Twenty months after the operation, she is well without any evidence of recurrence.     

Surgical treatment of chronic osteomyelitis of the sternum

The efficacy of surgical rehabilitation of patients with chronic osteomyelitis of the sternum is shown. Surgical treatment was divided in most cases into two stages: removal of the involved areas of the sternum and adjoining ribs and fixed muscular or musculocutaneous plastics. The obtained results are reassuring and promote further development of surgery of this region.     

Reconstruction of an emergency thoracotomy wound with free rectus abdominis flap: Anatomic and radiologic basis for the surgical technique

An alcoholic 50-year-old male patient with a history of schizophrenia sustained stab wounds into both ventricles and left lung, and survived following an emergency department thoracotomy. The EDT wound, however became infected requiring serial debridements of soft tissue, rib cartilage and sternum. Regional flap options such as pectoralis major and latissimus dorsi muscle flaps could not be employed due to inadequate reach of these flaps. Additionally, bilateral transection of the internal mammary arteries during emergency thoracotomy eliminated the use of rectus abdominis muscles as pedicled flaps based on the superior epigastric vasculature. Therefore, the EDT wound was reconstructed by using the right rectus abdominis muscle as a free flap. The deep inferior epigastric vessels of the flap were anastomosed to the right internal mammary vessels proximal to their transection level in the third-forth intercostal space. The flap healed with no further wound complications.     

A case of post-upper lobectomy empyema treated by serratus anterior muscle and pedicled latissimus dorsi musculocutaneous flaps plombage via open-window thoracostomy.

A 62-year-old male was admitted to our hospital for operation for Aspergillus empyema with a fungus ball in the right upper lobe. We performed a right upper lobectomy and decortication of the middle and lower lobes through a standard posterolateral thoracotomy with dissection of the latissimus dorsi and serratus anterior muscles, in October 2000. Twenty-one days postoperatively (POD), he developed an empyema and a bronchopleural fistula. We performed open-window thoracostomy through the axilla with removal of the third and fourth ribs at 41 POD, and sterilized the open drainage cavity in the out-patient clinic 11 months after discharge. Although the condition of the bronchopleural fistulas was not improved, and methicillin-resistant Staphylococcus aureus (MRSA) was found in the purulent discharge, the discharge decreased. Finally, a pedicled latissimus dorsi musculocutaneous and serratus anterior muscle flap plombage was performed 11 months after initial operation. The patient is now well and works as a driver 21 months after discharge. We conclude that muscle flaps of the pedicled latissimus dorsi and serratus anterior muscles can be useful for plombage of the cavity in cases of post-standard thoracotomy.     

A case report of radiation osteomyelitis 9 years after irradiation for thymoma]

Radiation osteomyelitis of the sternum is rare and usually difficult to cure. A 75-year-old man, who had undergone an exploratory sternotomy for a mediastinal tumor, not resected after all, 9 years earlier and received radiation therapy successively for the histological diagnosis of malignant thymoma, was admitted to our hospital with the chief complaint of fever and pus discharge of the anterior chest wall. He also suffered from diabetes mellitus. The skin around the fistula was dark-red and atrophic due to irradiation dermatitis and the manubrium was fissured in the midline. Open drainage and two-stage operation of direct closure was tried in vain. This case was treated successfully by resection of necrosed portion of sternum and pectoral muscle flap closure.     

胫骨平台骨折术后感染原因分析及治疗对策

目的 分析胫骨平台骨折钢板固定术后伤口感染的原因,探讨总结应用小腿近侧蒂肌皮瓣治疗方法的疗效.方法 2005年1月至2009年5月,经治胫骨平台骨折钢板内固定术后并发伤口感染不愈、软组织缺损、钢板外露、创伤性骨髓炎52例.彻底扩创、清理死骨、对髓腔开放者清理髓腔,并取不同层次炎性肉芽组织送实验室细菌学及药敏测试,对钢板固定失效者更换外固定架.创腔内放置载万古霉素或妥布霉素硫酸钙人工骨,骨缺损较大者,取自体髂骨混合植骨,选取小腿近侧蒂皮瓣填充覆盖修复创面.放置引流,抗生素静脉注射3至4周,定期拍摄X线片直至骨折愈合.结果 52例组织缺损均得到满意修复.随访时间最长5年,最短1年,骨折愈合最快4个月,最长1年.2例术后分别于第3、4个月骨髓炎复发再次手术治愈.3例术后6个月骨折不愈再次手术植骨后4～6个月愈合.结论 胫骨平台骨折钢板内固定术后并发伤口感染不愈软组织缺损、创伤性骨髓炎的治疗需要综合措施,应用小腿近侧蒂相应肌皮瓣填充创腔、覆盖闭合修复缺损创面、改善局部血供、促进骨折愈合是取得治疗成功不可或缺的方法之一.

Abstract：

Objective To analyze the reason of post-operative infection of tibial plateau fracture, the therapeutic effect of using pedicle musculocutaneous flaps of proximal leg was researched and summarized. Methods There were 52 patients of tibial plateau fracture after internal fixation complicated by disunion of infected wound and soft tissue defects, traumatic osteomyelitis from January 2005 to May 2009. After pre-operative physical examination, laboratory examination, X-ray, CT scan and bacterial culture of the secretion,the operation, such as debridement, dead bone moving, medullary cavity cleaning, transferring to the external fixation when the internal fixation lost efficacy and bacterial culture of granulation tissue of different levels. The cavity was filled with RBK combined with vancomycin or tobramycin. If the cavity was rather large, autografts from the iliac bone were combined. The tissue defects were covered with pedicle musculocutaneous flaps of proximal leg, and the wound had effective drainage. The antibiotic was used for 3-4 weeks, and the X-rays were given at fixed period until the fracture was cured. Results The soft tissue defects of all 52 patients were repaired well. They were followed from 1 year to 5 years, and the time of bone union ranged from 4 months to 1 year. Two patients of osteomyelitis had a relapse after 3,4 months, then they were cured by the second operation. Three patients had unhealed fracture after 6 months, then they were cured by bone grafting again after 4-6 months. Conclusion Patients of tibial plateau fracture after internal fixation complicated by disunion of infected wound and soft tissue defects, traumatic osteomyelitis should be cured by comprehensive treatments, one of the crucial treatment for success is using pedicle musculocutaneous flaps of proximal leg to fill in lacuna, close wound, improve the local blood supply and promote bone union.     

腓肠神经营养血管远端蒂肌皮瓣治疗慢性跟骨骨髓炎

目的探讨应用腓肠神经营养血管远端蒂肌皮瓣治疗慢性跟骨骨髓炎的方法。方法2002年1月-2005年10月治疗7例跟骨骨折所致慢性跟骨骨髓炎,其中男4例,女3例;年龄15-68岁。均为跟骨开放性骨折或跟骨闭合性骨折切开复位内固定或植骨致切口感染、跟骨外露,骨髓炎发生,病程3-12个月。手术彻底清创后采用腓肠神经营养血管远端蒂肌皮瓣移位治疗,肌皮瓣范围为8cm×4cm-12cm×7cm,其中肌瓣范围为4cm×3cm-6cm×5cm。供区直接缝合5例,植皮覆盖2例。结果术后移位肌皮瓣完全成活,切口期愈合。7例均获2-6个月随访,皮瓣质地,外形良好。骨髓炎未见复发,无并发症发生,所有患者均恢复正常行走。结论腓肠神经营养血管远端蒂肌皮瓣治疗慢性跟骨骨髓炎是完全可行的,给跟骨骨髓炎的治疗带来了一种新方法。     

Value of V.A.C.-therapy in the treatment of sternal infections

Osteomyelitis of the sternum is a dreaded complication after sternotomy and is related to high mortality. Control of infection by radical debridement is the key to successful treatment. Instability of the thoracic cage can lead to a high complication rate. 16 Patients with an infected and unstable sternum underwent radical debridement with resection of the sternum and adjacent ribs. 6 Patients (group A) received an immediate defect coverage with a pedicled muscle flap. 10 Patients (group B) were treated with a vacuum-assisted closure (V.A.C.)-therapy until stabilization of their general condition and underwent defect coverage in a second operation. Healing of the flaps was uneventful in all cases despite minor problems. 5 patients of group A had severe complications with pulmonary or cardiac failure and thoracic instability which lead to prolonged periods of mechanical ventilation. 2 patients of this group died due to multi organ failure. All patients of group B survived and there were no major complications. All of the patients were free of recurrence from their osteomyelitis during follow-up. V.A.C.-therapy after radical resection of sternum osteomyelitis proved to be an effective measure to bridge time while optimizing the status of the patient and it's wound. With this approach we believe to have lowered the rate of major complications in this multi-morbid patient group by reducing the burden of one large operation and by improving thoracic stability.     

The dynamic properties of tissue oxygen in healing flaps

Oxygen delivery to random pattern and musculocutaneous flaps was investigated in a canine model. Oxygen tension was measured in the proximal and distal portions of each flap and in adjacent normal skin by means of a recently developed technique. The effect of delay techniques on tissue oxygen tension was also examined with modifications of the same flap model. All measurements were made over a range of inspired oxygen concentrations (21% to 100%) both before operation and at intervals up to 15 days after operation. Tissue oxygen tensions were significantly higher in the musculocutaneous flaps than in random pattern flaps up to 6 days after operation. They were higher in the proximal portions than in the distal portions in each flap type. This difference was greater in the random pattern flap. Delay techniques prevented the early dramatic decrease in postoperative oxygen tension seen in random pattern flaps. Differences in the pattern of oxygen delivery to random pattern and musculocutaneous flaps may in part explain the greater reliability of musculocutaneous flaps when transposed in the presence of infection.