颜面深度烧伤早期痂治疗

目的:探讨颜面深度烧伤早期切痂植皮的优越性和可行性。方法:伤后3～7d手术,术前、术中各使用立止血1ku,4例手术使用M-200氩气增强电刀,正确掌握切痂平面,同期做睑缘粘连术。结果:10例手术切痂后植皮全部成活,弹性较好,瘢痕较轻,眼睑无睑外翻畸形。结论:如病人全身条件允许,早期手术切痂积极开展。     

烧伤后早期一次大面积切痂改善大鼠心肌损伤机制的研究

目的观察烧伤后早期一次大面积切痂对大鼠心肌损伤的改善状况,并探讨其分子机制。方法将66只SD大鼠随机分为非切痂组(30只)、切痂组(30只)与正常对照组(6只)。将前两组大鼠造成30%TBSAⅢ度烫伤(以下称烧伤,切痂组伤后20 min切除全部焦痂组织),并于伤后1、3、6、12、24 h(每时相点6只)检测大鼠心肌线粒体中腺苷三磷酸(ATP)含量、血清中肌钙蛋白Ⅰ(TnI)含量以及心肌线粒体DNA(mtDNA)4．8 kb大片段缺失情况。正常对照组大鼠不作处理,同样检测上述指标。结果(1)两致伤组大鼠心肌线粒体中ATP含量均有下降,但伤后1、6b切痂组该值分别为(0．90±0．27)、(0．66±0．19)μg/mg蛋白,较非切痂组的(0．74±0．18)、(0．46±0．21)μg/mg蛋白有显著改善(P＜0．05)。(2)与正常对照组比较,切痂组大鼠伤后1、3h血清中TnI含量变化不明显,但伤后1、3、6h与非切痂组比较差异有统计学意义(P＜0．05或0．01)。(3)非切痂组大鼠在伤后1、3、24h发生了mtDNA 4．8kb的部分或全部大片段缺失,切痂组大鼠仅在伤后1、12h发生缺失,且平均缺失率较非切痂组低。结论烧伤后早期一次大面积切痂能显著减轻伤后心肌受损程度,其机制可能与降低伤后早期心肌mtDNA缺失率有关。     

伤后即行切痂对烧伤大鼠心肌损伤的防治作用

目的 探讨早期一次性切痂对烧伤后心肌损伤的防治作用。方法 建立30％ TBSAⅢ度烧伤大鼠立即切痂模型，动物随机正常对照组、未切痂组和切痂组，于伤后1，3，6，12和24h检测血浆肌钙蛋白T（TnT)和肿瘤坏死因子（TNF）等指标。结果 烧伤后3h血浆TnT即显著升高，伤后6h血浆TNF显著高于伤前，心肌组织中TNF也在伤后12h显著升高。未切痂组与切痂组比较，伤后1－3h未切且TnT、TNF略低于切痂组。TNF与TnT存在显著正相关关系。结论 TNF是引起烧伤后心肌损伤的重要因素，且与心肌损伤程度密切相关。伤后即行一次性切痂可以减少炎症介质的生成和释放，这可能是其对烧伤后并发心肌损伤具有防治作用的机理之一。     

伤后即行切痂对烧伤大鼠心肌损伤的防治作用

目的探讨早期一次性切痂对烧伤后心肌损伤的防治作用。方法建立30% TBSAⅢ度烧伤大鼠立即切痂模型,动物随机分为正常对照组、未切痂组和切痂组,于伤后1,3,6,12和24h 检测血浆肌钙蛋白 T(TnT)和肿瘤坏死因子(TNF)等指际。结果烧伤后3h 血浆 TnT 即显著升高,伤后6h 血浆 TNF 显著高于伤前,心肌组织中 TNF 也在伤后12h 显著升高。未切痂组与切痂组比较,伤后1～3h 未切痂组 TnT、TNF 略低于切痴组,烧伤6h后,未切痂组 TnT 显著高于切痂组,烧伤12h 后,未切痂组 TNF 显著高于切痂组。TNF 与 TnT 存在显著正相关关系。结论 TNF是引起烧伤后心肌损伤的重要因素,且与心肌损伤程度密切相关。伤后即行一次性切痂可以减少炎症介质的生成和释放,这可能是其对烧伤后并发心肌损伤具有防治作用的机理之一。     

全颜面部深度烧伤的临床治疗

目的探讨提高患者全颜面部深度烧伤创面修复质量的处理方式。方法将54例全颜面部深度烧伤患者分为延期植皮组(48例)和早期切痂组(6例)。伤后3周对延期植皮组患者实施剥、削痂或手术刀柄刮除新生肉芽组织至基底层,在全颜面部分区进行自体中厚皮片移植术;早期切痂组患者于伤后1周行切痂术,其他处理同延期植皮组。观察两组患者首次手术时间、面部手术时间、手术总次数、手术前后血红蛋白(Hb)浓度、术中输血量及出血量,随访观察患者治愈后的情况。结果两组患者的首次手术时间、手术总次数、手术前后Hb浓度及术中输血量比较,差异无统计学意义(P>0．05)。延期植皮组患者面部手术时间为(21．9±3．2)d,较早期切痂组(12．6±1．3)d晚 (P<0．05);延期植皮组术中出血量(98±52)ml/100 cm2,明显少于早期切痂组(331±121)ml/100 cm2(P<0．01)。延期植皮组患者创面愈合后较早期切痂组面部外观丰满,皮肤弹性好,表情丰富。术后两组患者均出现不同程度小口畸形、双眉缺失,80％的患者出现睑外翻,皮片缝接处遗有增生性瘢痕等,经多次整形手术予以矫正。结论全颜面部深度烧伤患者行自体中厚皮片分区移植,创面无论采用早期切痂,还是延期剥、削痂或完全清除新生肉芽组织至基底层,均可取得较为满意的治疗效果;与前者相比,后者术中出血少,术后外观、功能恢复好;同时术后有效的物理治疗和有计划地进行后遗畸形整形手术,也是保障其治疗效果的重要因素。     

瘢痕瓣在烧伤整形手术中的应用

在烧伤整形外科手术中,常因皮肤大面积深度烧伤,造成正常皮肤不足以及局部瘢痕组织广泛,而需使用瘢痕瓣修复创面。笔者自1993年以来,利用瘢痕瓣整复治疗烧伤后期瘢痕畸形29例,疗效较满意。1　临床资料　本组29例中,男性17例,女性12例,年龄4～53岁。四肢关节部位14例,会阴部5例,面颈部10例;瘢痕挛缩切开局部瘢痕皮瓣转移12例,瘢痕瓣转移加植皮14例,瘢痕皮肤扩张整复3例;术后皮瓣成活24例,部分坏死3例,全部坏死2例;外观及功能恢复满意21例,较满意2例。2　讨论　瘢痕瓣应尽可能选择稳定性瘢痕,这时瘢痕组织与皮下分界清楚,无论在皮瓣成活率、外…     

伤后即行切痂对烧伤大鼠心肌损伤的防治作用

目的探讨早期一次性切痂对烧伤后心肌损伤的防治作用。方法建立３０％ＴＢＳＡⅢ度烧伤大鼠立即切痂模型,动物随机分为正常对照组、未切痂组和切痂组,于伤后１,３,６,１２和２４ｈ检测血浆肌钙蛋白Ｔ（ＴｎＴ）和肿瘤坏死因子（ＴＮＦ）等指标。结果烧伤后３ｈ血浆ＴｎＴ即显著升高,伤后６ｈ血浆ＴＮＦ显著高于伤前,心肌组织中ＴＮＦ也在伤后１２ｈ显著升高。未切痂组与切痂组比较,伤后１～３ｈ未切痂组ＴｎＴ、ＴＮＦ略低于切痂组,烧伤６ｈ后,未切痂组ＴｎＴ显著高于切痂组,烧伤１２ｈ后,未切痂组ＴＮＦ显著高于切痂组。ＴＮＦ与ＴｎＴ存在显著正相关关系。结论ＴＮＦ是引起烧伤后心肌损伤的重要因素,且与心肌损伤程度密切相关。伤后即行一次性切痂可以减少炎症介质的生成和释放,这可能是其对烧伤后并发心肌损伤具有防治作用的机理之一。     

烧伤后瘢痕的预防及后期瘢痕整形的治疗方法

目的探讨烧伤后瘢痕的预防及后期各种部位瘢痕的治疗。方法总结对90例烧烫伤患者的治疗经验。结果（1）对各种功能位深度烧伤患者早期采取各种治疗方法防止瘢痕。（2）对后期不同部位的瘢痕采取不同手术方法进行治疗。结论（1）对患者功能部位的深度烧伤应早期进行切除痂皮可防止后期瘢痕挛缩及后期功能，可尽可能减少后期整形的麻烦。（2）烧伤创面愈合后，3—6个月后即应进行烧伤瘢痕的整形治疗，均达到较满意效果。     

腹部合页式皮瓣修复手指烧伤

我院自 1996年以来应用腹部合页式皮瓣修复手指背 °烧伤 12例 30指 ,效果良好 ,报告如下。1　临床资料本组 12例 30指 ,男 7例 ,女 5例。指背创面均为 °烧伤。术后将指背痂皮及痂下坏死组织切除 ,若指骨坏死 ,给予适当凿除 ,彻底止血 ,于下腹部适当位置切取合页式皮瓣 ,皮瓣与创面比例为 1.2∶ 1,腹部供瓣区行游离植皮或直接拉拢缝合 ,术后 3周断蒂。本组 2 8指皮瓣全部成活 ,2指皮瓣部分坏死 ,经换药后愈合。2　手术方法以第 2～ 5指指背热压伤创面为例 ,术中切痂后 ,将 2与3指、4与 5指分成两组 ,皮瓣蒂部设计在每组的两指之间 ,皮瓣蒂…     

一例大面积特重度烧伤的救治及后期畸形修复

目的探寻特重度烧伤后早期救治及后期畸形修复、功能重建的新措施。方法对1例火焰烧伤总面积99.5%TBSA(Ⅲ度80.0%、深Ⅱ～Ⅲ度混合度14.5%、浅Ⅱ度5.0%)合并高钠、高氯血症的患者,入院后及早切痂,用异体皮覆盖创面;因自体皮源奇缺,根据皮源量分次移植自体皮或异体皮封闭创面。晚期采用瘢痕皮、瘢痕瓣、复合皮移植修复30多处瘢痕挛缩畸形。结果患者伤后早期经上述治疗病情逐渐稳定,未发生明显的并发症,手术7次,历时106 d,创面完全愈合。晚期进行15次整形手术,各部位功能均恢复良好,容貌得以改善。伤后26个月患者完全康复,重返工作岗位。结论对自体皮源奇缺的大面积烧伤患者,早期切痂用异体皮覆盖创面,待有少量自体皮源时分次行微粒皮移植,可稳定病情,减少并发症;溶痂创面用异体皮覆盖.可保护未受损的皮肤附件细胞,促进再上皮化,有利于创面及早愈合。晚期采用瘢痕皮、瘢痕瓣及复合皮进行畸形修复,能达到重建功能的目的。     

Transposition of the dorsal fascio-cutaneous flap of foot in treatment of talipes equinovarus]

For the purpose of one stage correction of severe congenital Talipes equinovarus, a new technique was designed to fashion a fascio-cutaneous flap from the redundant tissue on dorsolateral area of the foot, and it is then transposed to cover the defect left on the posteromedial part of the same foot following complete releasing and correcting the contractured soft tissue and lengthening the shortened tendons. This newly designed method was applied to 26 feet of severe congenital talipes equino-varus in 16 children aged 3/4-4 years. The foot deformity has been beautifully corrected and the transposed flap soundly healed in every foot without complication of any kind. The surgical procedures are fully described in the paper.     

伊氏外固定架治疗烧伤后瘢痕挛缩性足下垂畸形

目的 了解应用伊氏外固定架治疗瘢痕挛缩性足下垂的疗效. 方法 2004年6月-2007年10月,笔者应用伊氏外固定架治疗烧伤后瘢痕挛缩性足下垂患者6例,将组装好的伊氏外固定架按照穿针固定原则安装在患侧小腿和足部.术后3 d开始转动螺纹杆上的螺母,第1周旋转螺母2～4圈/次,4次/d;1周后旋转螺母1～2圈/次,4次/d,逐渐缩短或延长前后螺纹杆,矫正马蹄足畸形.在此基础上,再将踝关节固定在中立位2～3个月.去除外固定架后让患者逐渐增加负重量直至完全负重,不负重时穿戴支具保持踝关节处于中立位至少3个月.随访患者5～10个月.结果 6例患者应用伊氏外固定架4～6周后,踝关节可恢复到中立位.穿戴固定架时间12～15周,去除支架后患足畸形能达到0°位全足底负重,行走功能良好. 结论伊氏外固定架操作简单安全,手术创伤小,可作为矫治患者瘢痕挛缩性足下垂的选择方法.     

股前外侧皮瓣和腓肠神经营养血管皮瓣联合修复足部套状撕脱伤

目的 探讨吻合神经的股前外侧皮瓣和腓肠神经营养血管皮瓣联合修复足部套状逆行撕脱伤的临床效果。方法 足部套状逆行撕脱伤患者14例，男10例，女4例；年龄16-58岁，平均31岁。切取带股前外侧皮神经的股前外侧皮瓣移植至足部，将股前外侧皮神经与足底内侧神经吻合，并将足底外侧神经植人股前外侧皮瓣的足底修复区；转移腓肠神经营养血管皮瓣修复足外侧部。将腓浅神经及其分支分别与腓肠内、外侧皮神经吻合。按照Swanson等制定的周围神经损伤临床疗效评定方法，将感觉分成S1-S55级，将感觉恢复范围分为R1（〈25％）、R2（25％-50％）、R3（50％-75％）与R4（75％～100％）4级。结果 14例移植皮瓣均成活，术后外形良好。术后6个月足部感觉恢复分级：足内侧，S26足，S38足；足底，S29足，S35足；足外侧，S23足，S311足。足部感觉恢复范围：足内侧，R14足，R210足；足底，R18足、R26足；足外侧，R14足、R210足。术后9个月足部感觉恢复分级：足内侧，S37足，S47足；足底，S22足，S36足，S46足；足外侧，S38足，S46足。足部感觉恢复范围：足内侧，R25足，R38足，R41足；足底，R28足，R34足，R42足；足外侧，R25足，R37足，R42足。结论 吻合神经的股前外侧皮瓣和腓肠神经营养血管皮瓣联合修复足部套状逆行撕脱伤具有供区隐蔽、实用，受区感觉恢复理想的特点。     

Burn scar contractures of the feet: efficacy of bilateral simultaneous surgical correction

Children who sustain large total body surface area (TBSA) burns with involvement of the lower extremities frequently sustain injuries to the dorsum of the feet. Burn scar contractures of the feet can develop as a sequela of the burn injury. Such contractures frequently require surgical correction. Many surgeons proceed with staged unilateral corrections when both feet are equally in need of operative intervention. The purpose of the study is to determine if the morbidity for correction of bilateral dorsal foot contractures is different from that for the correction of unilateral dorsal foot contractures.

A retrospective review from January 1994 to July 1999 was undertaken. Forty-five patients with photographic record of burn scar contracture of the feet were identified. Twenty-five patients underwent staged unilateral surgical correction and twenty patients underwent simultaneous bilateral correction of the feet. All patients underwent surgical correction with split thickness skin grafts (STSG). No statistical difference was found in terms of mortality, development of contracture, or number of reconstructive procedures. However, the length of stay revealed the efficacy of the bilateral simultaneous release of the dorsal feet.     

Recurrence rates of burn contracture ankle equinus and other foot deformities in children treated with Ilizarov fixation

The purpose of this study was to determine recurrence rates of pediatric foot and ankle burn deformities treated with the Ilizarov method. A total of 19 patients with 29 foot and ankle deformities were studied. The most common deformity treated was equinus (23). Rocker-bottom and cavus foot deformities were each treated three times. The average age of the patient at the time of the burn injury was 3.2 years, and the average age at the time of fixation was 9.4 years. Equinus contractures averaged -34 degrees (34 degrees of plantarflexion) before surgery and +7 degrees (7 degrees of dorsiflexion) after treatment with the Ilizarov fixator. The recurrence rate for all 29 ankles and feet was 69% (20/29). The recurrence rate for equinus contractures was 74% (17/23). The average time to recurrence was 17.3 months. Only short-term follow-up was available on four of the six feet and ankles that did not recur. Deformity correction in burned feet and ankles is difficult to obtain by any means. The authors recommend using the Ilizarov method to obtain correction of moderate to severe foot and ankle deformities in pediatric burn patients, but the correction obtained is not stable and deformity will likely recur. Parents and patients should anticipate adjunctive nonoperative and operative procedures to keep their feet plantigrade as they grow. In young children, the possibility of having additional surgeries, including repeat Ilizarov procedures, should be discussed. Even older children should expect additional surgeries to prevent recurrent deformities.     

Our preferred surgical approach to cicatricial cryptotia

Background

Adhesions between the auricle and retroauricular cranial wall and mastoid occur after burns to this area due to cicatricial contracture, leading to the distortion of the otocranial angle and obscuring the remnant auricle in the scar. A definition of cicatricial cryptotia was devised to describe the ear deformity after burn by the authors, and a novel surgical approach to cicatricial cryptotia was employed to reconstruct the auricle.

Patients and methods

A total of 33 ears in 26 adult patients were operated upon. As many as 19 cases of cicatricial cryptotia were unilateral, seven cases bilateral. The patients’ age ranged from 19 to 31 years. Because of a lack of normal tissues surrounding the remnant ear, a periauricular cicatricial flap was designed to repair the helix and antihelix defect and a horizontal bifoliate skin flap for earlobe reconstruction. Two triangular cicatricial flaps located at the cephalic or caudal direction of the survival ear were used for shaping the otocranial angle and auriculotemporal sulci, combined with zoned transplantation of a full-thickness skin graft.

Results

All cicatricial flaps demonstrated nearly 100% survival and the take rate of transplanted skin grafts was approximately 95%. The main structures were visible and cosmetically acceptable; the otocranial angle and auriculotemporal sulci were acceptably restored. The function of wearing eye glasses or a mask was regained. The patients were followed up from 3 months to 6 years after surgery; the mean follow-up period was 3.2 years. The contour of the reconstructed auricle was maintained well, and the scar contracture was acceptable.

Conclusion

Periauricular cicatricial flaps combined with skin grafting is a new approach to cicatricial cryptotia when auricle reconstruction after burn is limited by a scarcity of supple, elastic local skin and fascia.     

Soft Tissue Management and Tibialis Posterior Tendon Transfer in Acute Correction for Neglected Drop Foot Deformity

Acute correction of rigid drop foot deformity can be problematic due to the skin defect that may occur in the medial part of the ankle. The purpose of this study is to present an innovative solution for this problem. We hypothesized that acute correction for rigid ankle contractures without arthrosis might be possible if the medial skin defect could be closed. Therefore, we described a surgical technique for acute functional correction of rigid drop foot deformities. The closure of the medial defect was performed by applying a flap and partial-thickness skin graft. We have retrospectively evaluated the results of 18 patients who were treated between 2010 and 2016 with this technique. The mean age of the patients was 37 ± 9.5 (22-56) years. Foot drop etiology was firearm-related nerve injury. Corrections were performed after 14.6 ± 7.9 (8-38) months following the injury. At the end of an average follow-up period of 44.4 ± 6.2 (37-60) months, 14 of 18 patients (78%) recovered without complications, 3 patients experienced partial loss in the medial skin graft region, and 1 patient developed a superficial infection. None of the patients have developed pes planus. We observed that the ankle flexion contracture, which was 34° ± 9.2° (20°-50°) preoperatively, could reach an average of 2.2° ± 2.5° (0°-6°) dorsiflexion after surgery. We suggest that acute correction and tibialis posterior tendon transfer in the treatment of rigid foot drop deformity can be performed with an effective skin closure with low soft tissue complications.     

神经端侧吻合的腓肠神经营养血管皮瓣修复足踝部缺损的临床研究

目的利用腓肠神经皮瓣所带的腓肠神经内侧支和外侧支与创面周围的腓深神经或胫神经端侧吻合，重建皮瓣的感觉以及恢复足背外侧感觉。以解决患者足踝部感觉缺失的痛苦。方法从2000年1月至2003年5月，收治足踝部软组织缺损40例(43足)，其中A组20例(22足)直接进行腓肠神经营养血管皮瓣移植，B组20例(21足)在切取皮瓣时，在腓肠神经近端多取1～2cm腓肠神经内侧支和外侧支，在覆盖创面时，先分离出创面周围的腓浅神经或胫神经，把腓肠神经断端与腓浅神经或胫神经作端侧吻合，再按腓肠神经营养皮瓣处理。两组都在术后3、6、9个月分别进行随访，按照感觉检查分级标准把皮瓣和足背外侧感觉恢复情况分成S1～S5 5级，并按感觉恢复范围分成R1：小于25％；R2：25％～50％，R3：50％～75％，R4：75％～100％。结果术后3个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 18足、S2 4足、R1 22足，B组，S1 17足、S2 4足，R1 21足；两组皮瓣和足背外侧皮肤感觉恢复情况无差别、术后6个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 15足、S2 6足、S3 1足，R1 18足、R24足，B组，S16足、S36足、S49足，R2 4足、R3 12足、R4 5足；B组无论皮瓣及足背外侧感觉恢复的等级还是感觉恢复的范围都比A组好。术后9个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 14足、S2 7足、S3 1足，R1 17足、R2 5足，B组，S3 2足、S44足、S5 15足，R35足、R416足；B组皮瓣及足背外侧感觉基本恢复正常，A组感觉恢复进展不大。供体神经功能无明显影响。结论作腓肠神经营养皮瓣移植时行腓肠神经与创面周围胫神经或腓浅神经端侧吻合手术简单，对胫神经或腓浅神经无不良影响，而皮瓣和足背外侧感觉恢复较好。     

McKay手术矫治僵硬型先天性马蹄内翻足畸形

为了总结ＭｃＫａｙ手术矫治僵硬型先天性马蹄内翻足畸形的手术效果，对术后７１例１０３只足进行了２年～９年随访。根据足部功能恢复、外观形态及Ｘ线片检查评定结果，优５５例７８只足，良１１例１６只足，可５例９只足，无一例复发。术后７例１２只足出现跟、舟骨形态改变，９例踝关节活动受限，５例７只足出现平足。认为，手术年龄以６个月～１８个月为佳。详细讨论了影响足部功能恢复的因素，手术年龄与疗效的关系等     

脊髓神经源性足部畸形的分类和治疗

[目的]研究脊髓神经源性足部畸形的发病机理、分类和手术治疗方案.[方法]1988年10月～2006年6月,回顾性分析脊髓病变、脊髓和脊神经因被牵拉或压迫引起的足部畸形167例258足,根据脊髓损伤的性质和发病机理,将足部畸形分为上运动神经元损伤型和下运动神经元损伤型两大类,两类足部畸形采用不同的治疗方案.上运动神经元损伤型足部畸形,手术方案以选择性脊神经后根切断术或周围神经缩窄术为主;下运动神经元损伤型足部畸形,手术方案以软组织松解、肌腱转位术和截骨术为主,其中僵硬性足部畸形使用Ilizarov外固定器缓慢矫正.[结果]得到至少5年随访的147例228足进行总结分析,上运动神经元损伤型足部畸形42足,下运动神经元损伤型足部畸形186足.采用Laaveg-Ponseti足功能评分系统:优94足,良84足,可32足,差18足;优良率78.1％.第1次术后复发36足,复发率15.8％.第2次术后复发8足.[结论]根据脊髓神经源性足部畸形的分类,采用不同的手术治疗方案,可提高治疗效果,减少术后畸形复发.