烧伤后膝关节伸直位僵硬的治疗与康复

【摘要】目的探讨烧伤后合并膝关节伸直位僵硬的手术松解方式及术后康复方法。方法2007年6月至2011年12月，收治的11例（16膝）烧伤后合并膝关节僵硬患者，男9例，女2例，年龄19～54（平均33．2）岁。僵硬时间8～26（平均12．6）个月。术前屈曲度5°-50°（平均26．2±11．9）°。术前HSS膝关节功能评分46—72（平均55．8±6．9）分。对僵硬膝关节实施关节松解术，分离关节内粘连，切断挛缩和纤维化的股中间肌，游离深浅筋膜层增加皮肤延展性。术中将膝关节松解至屈曲角度90。以上，用翻转的筋膜瓣在屈膝90°位缝合深筋膜层，皮下组织和皮肤原位缝合，不行植皮手术。术后将膝关节固定在不导致髌前皮肤发白缺血的最大屈曲位，固定72h，积极进行早期康复治疗，观察治疗前后皮肤覆盖、关节活动度和关节功能恢复情况。术后随访18～36（平均25．7）个月。结果膝关节屈曲度110°～135°（平均122．2±11．0）°，和手术前相比增加96．0°（P〈O．01），皮肤延展性增加，可以满足关节屈曲度增加的需要。随访结束时HSS膝关节功能评分93—100（平均97．5）分，比术前增加41．7分（P〈0．01），关节功能明显改善。结论对于烧伤后膝关节伸直位僵硬的关节松解术，可以采取挛缩带松解和深浅筋膜间游离但不予植皮的方式进行，术后短期屈曲位固定和积极的康复治疗是改善皮肤延展性和关节功能的关键措施。

Treatment and rehabilitation of postburn extension contracture of the knee

Objective To investigate the methods of release surgery and postoperative rehabilitation of postburn extension contracture of the knee. Methods From June 2007 to December 2011, 11 patients with 16 postburn stiffknees were adopted, including 9 males and 2 females. Their mean age was 33.2 years old （ range; 19-54 years ）, and the average stiffness period was 12.6 months （ range; 8-26 months ）. The mean range of flexion was （ 26.2-11.9 ） degrees preoperatively （ range; 5-50 degrees ）. The Hospital for Special Surgery （ HSS ） knee function score was （ 55.8-6.9 ） points preoperatively （ range; 46-72 points ）. Release surgery was performed in all stiff knees. The intra- articular adhesion was totally released, and the contractural and fibrous vastus intermedius was cut off. The deep and superficial fascias were freed to increase the skin ductility. More than 90 degrees of flexion was observed in all the knees during the operation, and the reversed fascial flap was used to suture the deep fascia in the position of flexion of 90 degrees. The skin was sutured with subcutaneous tissues in situ, and skin transplantation was not performed. After the operation the knee joint was immobilized in the maximum flexion position for 72 hours, and meanwhile the pre-patellar skin would not become pale or ischemic. All the patients actively started early rehabilitation. The skin coverage, range of motion and functional restoration of the joint were observed before and after the treatment. All the patients were followed up for a mean period of 25.7 months （ range; 18-36 months ）. Results The range of flexion was （ 122.2±11.0 ） degrees on average after the treatment, （ range; 110-135 degrees ）, which was increased by 96.0 degrees when compared with that preoperatively （ P〈0.01 ）. The range of flexion was increased to meet the demand after the increase of skin elongation. The mean HSS knee function score was 97.5 points in the latest follow-up （ range; 93-100 points ）, which was increased by 41.7 points when compared with that preoperatively （ P〈0.01 ）. The knee function was obviously improved. Conclusions For the patients with postbum extension contracture of the knee, release surgery is a good choice with the contractural tissues released and the deep and superficial fascias separated. However, skin transplantation is not performed. The short-term immobilization in the flexion position and active rehabilitation after the operation may be the crucial measures to improve the skin elongation and the knee function.