延期皮肤移植术在烧伤后重度关节畸形整复中的应用

目的　探索治疗重度瘢痕挛缩性关节畸形简便有效的整复技术。方法　Ⅰ期手术整复关节畸形 ,创面延期 3～ 5天 ,Ⅱ期手术植大片中厚皮。观察皮片成活质量及远期整复效果。结果　延期植皮法皮片成活率达 1 0 0 % ,关节畸形经分期整复可达到完全复位 ,远期整复效果良好。结论　延期植皮技术是一种简单有效的重度关节畸形整复方法。     

Reconstructive hand surgery for scleroderma joint contractures

Systemic scleroderma can cause significant hand deformity and functional impairment. Surgery is often avoided due to the perceived risks of wound healing. The most common surgical procedures have been digital sympathectomy, arthrodesis or arthroplasty of the proximal interphalangeal (PIP) or both, and metacarpophalangeal (MCP) joints. We describe herein successful soft tissue hand surgery in 2 patients for treatment of scleroderma claw deformities without the use of arthrodesis or arthroplasty. At the MCP joint, the tight capsules were excised, and the collateral ligaments and volar plates were released. At the PIP joints, the volar plates were released and the tight palmar skin was released, resulting in marked improvement of joint position. Intensive hand therapy was used to maximize function. In these 2 patients with claw deformity, we found that tight volar skin was the main contributor to flexion contracture at the PIP level. In contrast, joint capsule contracture was the main contributor to hyperextension deformity at the MCP level.     

Severe Post-Burn Hyperextension of Metatarsophalangeal Joints in a Child With Bilateral Foot Contracture

Achieving a stable plantigrade foot after repair of complex post-burn deformities poses a particularly difficult challenge for the foot and ankle surgeon. We report an unusual case of a child with severe bilateral forefoot contracture deformities treated by soft tissue release and lengthening, and conventional wound coverage with split-thickness skin grafting.     

自体皮源奇缺条件下瘢痕挛缩畸形的晚期临床修复

目的寻找对烧伤后畸形伴自体皮源奇缺患进行晚期修复的新方法。方法5例特重度、特大面积烧伤患治愈后伴较严重畸形，且自体皮源奇缺。采用柔软成熟的瘢痕皮肤作为修复的皮源，用扩张器扩张瘢痕皮肤后，切取中厚瘢痕皮片进行修复；不宜行瘢痕皮肤扩张术时，切取刃厚瘢痕皮片与异体脱细胞真皮基质组成复合皮进行修复。观察两种方法的疗效。结果所移植的扩张瘢痕皮片和复合皮均成活，功能和外形恢复良好，远期疗效近似正常自体中厚皮移植。结论采用不同厚度的瘢痕皮片修复烧伤畸形是可行的，可扩大自体皮源。此法对于皮源奇缺的瘢痕患尤其适用。     

微创牵拉技术治疗小腿缺血性肌挛缩后遗重度踝足畸形

目的探讨用llizarov微创牵拉技术,治疗小腿缺血性肌挛缩后遗重度踝足畸形的疗效。方法根据llizarov张力-应力法则,自行研制了可调式具有三维矫形功能的踝足关节牵拉外固定器。2002年4月至2004年3月,应用微创牵拉技术治疗因下肢创伤、骨折等原因并发的小腿缺血性肌挛缩后遗固定性踝足畸形患者8例。其中男4例,女4例;年龄13—31岁,平均23岁。左下肢5例,右下肢3例。术前畸形类型：马蹄内翻足6例,马蹄足2例,伴有小腿广泛性瘢痕挛缩,其中5例既往行软组织松解手术矫正足畸形失败。术后牵拉时间29—60d,平均46d。结果8例患者均获得随访,随访时间10-29个月,平均13个月。畸形足皆获得满意矫正,能全足持重行走,功能良好,未发生针道感染、皮瓣坏死、血管、神经损伤等并发症。结论微创牵拉技术矫正缺血性肌挛缩后遗踝足畸形,具有安全、微创、效果满意的优点,为缺血性肌挛缩后遗僵硬性踝足畸形的外科治疗开辟了一条有效途径。     

Z成形术治疗重度臀肌筋膜挛缩症及其所致腰臀部畸形

目的探索重度臀肌筋膜挛缩症及其所致臀腰部畸形的最佳治疗方法。方法对25例重度臀肌筋膜挛缩症及其所致臀腰部畸形患者,依Z成形术原则进行挛缩带和挛缩瘢痕的松解后,将局部皮肤进行重新分配和塑形加以治疗。结果25例双侧髋关节功能完全恢复,步态正常,腰臀部形态基本平整,无坐骨神经损伤。术后随访6个月至3年,平均1．6年,无畸形复发。结论Z成形术既解除了挛缩带对关节功能的牵制,又可对局部皮肤进行重新分配,矫正挛缩造成的凹陷畸形,术后功能和外形效果均佳,是治疗重度臀肌筋膜症及其所致臀腰部畸形的良好方法。     

烧伤后畸形的整形外科治疗

烧伤后畸形既包括瘢痕增生与挛缩畸形也包括组织器官的缺损与畸形，是整形外科最常见的病种，占住院患者的４０％以上，治疗难度也最大。大面积深度烧伤后遗畸形常是多部位、多器官受累，同时修复材料缺乏，供皮（瓣）区不足。１９５７年～１９９７年收治各种烧（烫）伤后畸形患者共３４０１例，１９７８年后收治了２４９６例烧伤后畸形患者，其中皮肤软组织扩张术、持续牵引技术及新型皮瓣在治疗中的应用及器官再造等方面均有一定改进和创新，取得了较好的临床效果。     

Breast reconstruction by tissue expander after radiotherapy: When the skin does not expand,the rib cage is at risk

Background

Expander-based breast reconstructions in irradiated chest walls have been documented to result in an increased risk of complications including skin necrosis, extrusion, displacement, and capsule contracture. In this article, thoracic cage deformity and rib fractures were investigated following breast reconstruction by tissue expansion.

Methods

A prospective series of 89 immediate postmastectomy tissue expander breast mound reconstructions in 81 patients, the patients were divided into two groups, reconstruction with radiotherapy (n?=?37) and without radiotherapy (n?=?52). The patients were observed for any sudden severe pain and development of capsule contracture; intraoperative assessment was done first during expander insertion then after exchange of expander with implant to detect any deformity of the chest wall. CT scans were done as an objective way to support the clinical findings in patients who developed flat or concave chest wall deformities.

Results

Patients who had reconstructions with radiotherapy developed severe capsular contractures causing severe pain and limitation in breast expansion in 35 % of reconstructions compared with 5.7 % in the control group. Twenty-six reconstructions (70.2 %) in the study group developed chest wall deformities; in four of them, the deformity was concave, and two patients (5.4 %) developed multiple rib fractures at the expander site. The overall rate of ribcage deformities in the control group was 32.6 %; all of them were simple flattening with no concave deformities. No fractures were noted in the control group.

Conclusions

Expander-based breast reconstruction in combination with radiotherapy and tight unyielding overlying skin and capsule can redirect the expansion force toward the thoracic ribcage rather than the skin causing rib deformities and possible fractures. Level of Evidence: Level IV, risk/prognostic study     

腋部烧伤瘢痕挛缩畸形的防治

目的探讨腋部瘢痕挛缩的防治方法。方法1996年5月~2006年5月对57例64侧腋部瘢痕挛缩患者切除瘢痕彻底松解挛缩,应用整形原则行五瓣法、局部皮瓣法、轴型皮瓣法、皮片移植法治疗。结果64侧皮瓣全部成活,优53侧,良8侧,差3侧,优良率95.3%。3侧植断层皮患者发生不同程度的挛缩,其中1侧再次手术。结论对腋部烧伤瘢痕挛缩畸形应根据病情不同,选择不同的方法,首先考虑应用皮瓣修复;术后要加强康复训练。     

Juvenile linear scleroderma with unique forms of renal involvement

Linear scleroderma is the most common type of juvenile localized scleroderma, which usually involves the limbs. The linear lesions may extend through the dermis, subcutaneous tissue, muscles, and the underlying bone, leading to significant functional and cosmetic deformities. Renal involvement in juvenile localized scleroderma is a rare manifestation. Here we report two cases with juvenile linear scleroderma and unique renal manifestations, including unilateral renal arterial stenosis and immunoglobulin M nephropathy.     

An algorithmic approach for the management of hand deformities in dystrophic epidermolysis bullosa

Treatment of hand deformities in epidermolysis bullosa patients represents a challenging field in hand surgery practice, thus a systematic approach by a team is mandatory for a successful result. A simple and practical algorithm for the surgical treatment of hand deformities in EB was employed by the authors where the deformities of each digit in EB patients was categorized according to pseudosyndactyly and interphalangeal joint contracture severity for guidance during the surgical treatment. The current study retrospectively reviewed the medical records and photographic data of 13 EB patients followed in our department, for whom a systematic approach to the management and treatment was used. Mild cases were treated by surgical release and secondary healing with non-adhesive dressing while moderate cases were treated with autologous dermal grafts harvested with a special technique that were fixed on denuded areas on the proximal interphalageal joints after release. The remaining areas were treated similarly to the mild group. Additional K-wires were applied for two weeks in severe cases. A total of 21 procedures were performed on 13 EB patients with hand deformities according to the proposed treatment strategy. Functional recovery was satisfactory for each patient and the outcomes were dependent upon the severity of deformity. A multidisciplinary and conscious approach followed by an algorithmic surgical treatment protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.     

矩形皮瓣联合肌腱延长术治疗小儿手掌瘢痕挛缩

目的 探讨利用矩形皮瓣联合肌腱延长术治疗小儿手掌瘢痕挛缩的可行性及优势.方法 自2014年9月至2019年9月,辽宁省人民医院整形美容外科对26例(31侧)手掌瘢痕挛缩的患儿行手术治疗及功能性修复.以矩形皮瓣修复蹼状畸形,以肌腱延长术修复严重的屈曲畸形,其余瘢痕松解部位以游离皮片移植或邻近皮瓣转移的方式修复,术后配合功...     

治疗大面积深度烧伤后瘢痕挛缩致膝髋关节严重畸形15例

目的回顾性分析躯干、下肢大面积深度烧伤患者增生性瘢痕挛缩致膝、髋关节屈曲畸形的治疗方法，并总结其经验。方法笔者将1960年12月-1995年12月收治的15例躯干及下肢深度烧伤后瘢痕挛缩患者屈曲畸形的膝、髋关节（共21个）按畸形程度分为A、B、C3组。A组瘢痕切除后关节能直接复位，立即用大张自体皮覆盖创面，缝合后包扎固定。B组瘢痕切除后关节不能立即恢复到伸直位，根据供区条件选择大张自体皮或小片头皮覆盖创面，再用踝套进行牵引治疗（力量逐渐加大），直至关节恢复到伸直位。C组关节瘢痕挛缩伴残余肉芽创面，创面较大者先用异体皮覆盖，待其成活后再切除瘢痕，并按B组方法治疗；肉芽创面较小者在无菌条件下直接与瘢痕一起切除，再按B组方法治疗。结果14例患者膝、髋关节屈曲畸形均被矫正至伸直位，关节功能恢复良好，仅1例患者关节未完全复位。结论瘢痕松解术及踝套牵引的治疗方法可在较短时间内最大限度地矫正关节畸形，恢复患者下肢功能，减少局部溃疡形成，并且较节省皮源。     

腋窝瘢痕挛缩畸形植皮术后包扎方法的改进

目的:改进传统的腋窝瘢痕挛缩畸形植皮术后包扎技术。方法:分析腋窝形态结构的特殊性而对基于普通弹性绷带的传统"8"字包扎技术进行2方面改进:①加一段弹性绷带在腋下水平缠绕胸、背部一圈,而使腋窝内侧壁包扎到;②在肩峰、上臂上端外侧、腋窝前、下、后侧用7号丝线将绷带相邻边缘缝扎固定一起,形成全腋窝弹性加压包扎法,并将此法用于13例(16侧)腋窝因广泛瘢痕增生并挛缩或粘连畸形而进行全厚皮片移植的患者。结果:手术切口均一期愈合,无血肿及皮片坏死发生,畸形改善明星,每次包扎后可维持7天不松散。全腋窝弹性加压包扎法使对术区包扎达到全方位、长久牢靠。结论:基于对腋窝结构特殊性而新创的全腋窝弹性加压包扎法牢固可靠,其用于腋窝植皮包扎预防皮片坏死效果确切有效。     

Tissue expansion in reconstruction of postburn contracture of the first web space of the hand

The successful release of severe contracture of the first web space depends on addition of a sufficient amount of skin. Because local skin is limited, skin grafts tend to contract, and free and pedicle flaps are bulky, further procedures are often obligatory. Expansion of the tissues of the dorsum of the hand offers an effective and relatively simple approach to generate the excess skin needed. We present a patient in whom an inflatable silicone implant was used to correct recurrent first web space contracture after burns.     

颈部瘢痕挛缩整复术中颌颈角形成的技巧与美学意义

目的：探讨颈部瘢痕整复术中形成颌颈角的技巧与美学意义。方法：128例颈部瘢痕挛缩患者,在彻底松解瘢痕挛缩的基础上,根据患者的具体情况,分别采用颈阔肌软组织瓣加深颌颈角、游离植皮、局部皮瓣、扩张皮瓣转移等方法修复创面,重塑颈部曲线。结果：手术效果良好,术后颌颈角明显,颈部曲线恢复,其中116例患者术后6个月～7年随访,颌颈角仍然明显,无再次挛缩出现。结论：形成颌颈角是颈部瘢痕挛缩松解术成功的关键,其对维持颈部外形和功能有重要作用。     

Surgical management of hand contractures and pseudosyndactyly in dystrophic epidermolysis bullosa

The term epidermolysis bullosa refers to a group of disorders characterized by skin blistering following minor trauma. The hands, because of constant use during normal daily activity, are especially exposed to blistering, with secondary scarring leading to pseudosyndactyly, adduction contracture of the thumb, and flexion or extension contracture of the fingers. The standard surgical approach for the correction of these deformities is based on the incisional release of pseudosyndactyly and contractures, and split skin grafting of the secondary wounds. A simplified approach without skin grafting is presented in this paper. Four children (8 hands) underwent 25 operations over two decades. The results, in terms of postoperative healing and recurrence, were comparable with those of the standard approach involving skin grafting.     

Linear scleroderma and foot deformity in children

Linear scleroderma is a subtype of localized scleroderma generally observed in children, and may produce secondary bone and joint deformities. Its localization at the foot or ankle is rarely reported. A complete review of the literature reveals 21 cases of foot or ankle deformity due to linear scleroderma to which we add one case. The clinical and radiological aspects of the deformity, its pathogenesis, histological findings as well as orthopaedic management are presented and discussed.     

Prevention of deformities using thick split-thickness skin grafts to repair infected wounds. Report of 22 cases

Previously, split-thickness skin graft was used as coverage for the infected wounds in special site. Because severe contracture and deformities occurred later due to thin skin graft, further plastic surgery was needed, yet the results still were unsatisfactory in some cases. In 22 patients, large pieces of thick split-thickness graft were used to cover the excised granulation wounds where the plate of collagen fibers were relaxed. All the grafts were 100% taken. The functions and appearances were satisfied after one year follow-up. The authors recommended that thick split-thickness skin graft possesses the properties of full-thickness skin graft. It will be taken well, if the infection of wound can be controlled and adequate blood supply of wound is provided.     

外伤性拇指指蹼挛缩的临床分型与治疗

目的介绍外伤性拇指指蹼挛缩的临床分型与用不同皮瓣覆盖虎口挛缩处皮肤缺损的疗效。方法根据虎口挛缩的病理机制分为5种类型。Ⅰ型拇指指蹼皮肤无挛缩而拇内收肌群挛缩。Ⅱ型拇指指蹼仅有皮肤挛缩。Ⅲ型皮肤挛缩及拇内收肌群挛缩。Ⅳ型皮肤、拇内收肌群挛缩伴拇外展功能严重障碍。Ⅴ型软组织挛缩合并骨、关节损伤。针对不同类型在充分解除其挛缩因素后,为69例采用8种皮瓣转位或游离移植重建拇指指蹼。对合并拇内收肌群挛缩、拇外展功能障碍及骨、关节损伤患者,一期同时行拇对掌功能重建或矫形手术。结果67例皮瓣全部成活,2例皮瓣远端坏死。术后经3至24个月(平均7.5个月)的随访,虎口开大的优良率为85.5%。结论采用皮瓣转位或游离移植是修复严重外伤性拇指指蹼挛缩的有效方法。