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封闭式负压引流技术在下肢毁损伤中的应用

目的 总结封闭式负压引流（vacuum sealing drainage，VSD）技术在下肢毁损伤早期治疗中的应用效果。 方法 2008 年7 月－ 12 月，收治13 例下肢毁损伤患者。男10 例，女3 例；年龄4 ～ 40 岁，中位年龄37.3 岁。致伤原因：机器损伤5 例，交通事故伤8 例。软组织缺损范围35 cm × 10 cm ～ 40 cm × 20 cm。下肢损伤程度采用四肢损伤分级标准评分平均10.7 分。伴膝关节周围骨折9 例，股骨中段骨折2 例，胫、腓骨中段骨折2 例。受伤至入院时间为6 ～ 20 h，平均10 h。采用VSD 治疗后，4 例保肢失败，截肢术后创面直接缝合；9 例保肢成功，其中8 例游离植皮修复，1 例采用腓肠神经营养血管蒂皮瓣修复，供区游离植皮修复。 结果 患者应用VSD 治疗 1 ～ 3 次。术后植皮及皮瓣均顺利成活，创面均Ⅰ期愈合。供区切口Ⅰ期愈合，植皮成活。患者均获随访，随访时间10 ～ 17 个月，平均14 个月。植皮创面均愈合良好，未出现破溃、感染。皮瓣色泽正常，无臃肿。X 线片检查示骨折均愈合，愈合时间7 ～ 12 个月。 结 论 VSD 技术可降低下肢毁损伤创面感染几率，促进创面内肉芽生长，为植皮及皮瓣移位修复提供良好的组织条件。

皮肤回植联合封闭式负压引流技术治疗四肢皮肤脱套伤

目的 总结封闭式负压引流技术（vaccum sealing drainage，VSD）联合一期皮肤回植治疗四肢皮肤脱套伤的临床效果。 方法 2009 年3 月－ 2010 年3 月，采用VSD 联合一期皮肤回植修复25 例四肢皮肤脱套伤患者。男16 例，女9 例；年龄9 ～ 53 岁，中位年龄32 岁。致伤原因：交通事故伤19 例，高处坠落伤3 例，重物砸伤3 例。部位：手背3 例，前臂6 例，小腿10 例，足踝及足背 6 例。脱套范围为14 cm × 9 cm ～ 42 cm × 23 cm。合并骨折8 例，血管、神经损伤2 例。受伤至入院时间4 ～ 8 h。 结果　 22 例经7 ～ 10 d VSD 治疗后，回植皮肤顺利成活；3 例经VSD 治疗10 d 后仍有点状坏死，经换药后愈合。25 例均获随访，随访时间3 ～ 12 个月，平均9 个月。全厚皮片回植后颜色接近正常皮肤，弹性良好，质地柔软，小腿两点辨别觉2 ～ 3 cm；中厚皮回植后部分颜色发暗，质地较硬，小腿两点辨别觉6 ～ 8 cm。8 例合并骨折者骨折愈合时间3 ～ 8 个月，平均5 个月；1 例尺神经断裂者6 个月后骨间肌萎缩，另1 例血运、感觉、运动均较好。 结 论 急诊VSD 在治疗四肢皮肤脱套伤中能充分引流、均匀加压、改善血循环、促进脱套皮肤成活。

REPAIR OF SKIN AND SOFT TISSUE DEFECTS OF LOWER LIMBS WITH VACUUM SEALING DRAINAGE COMBINED WITH FLAPS

Objective To explore the feasibil ity, indications, and effects of vacuum seal ing drainage (VSD) combined with flaps for repairing skin and soft tissue defects of lower l imbs. Methods From June 2006 to November 2009, 15 patients with skin and soft tissue defects of lower l imbs were treated with VSD combined with flaps (VSD group, n=5) and only flaps (non-VSD group, n=10). In VSD group, there were 3 males and 2 females with an average age of 46 years (range, 32-69 years), including 3 cases of traffic accident injury, 1 case of skin necrosis after amputation, and 1 case of plate exposureafter operation. The locations were lower leg in 1 case, ankle in 2 cases, dorsum of foot in 1 case, and forefoot in 1 case. The defect size ranged from 6.5 cm × 6.0 cm to 23.0 cm × 17.0 cm. The disease course ranged from 2 hours to 2 months. In non- VSD group, there were 5 males and 5 females with an average age of 50 years (range, 23-58 years), including 6 cases of traffic accident injury, 1 case of crush injury in earthquake, 1 case of osteomyel itis, and 2 cases of plate exposure after operation. The locations were lower leg in 1 case, ankle in 3 cases, forefeet and dorsum of feet in 4 cases, and heel in 2 cases. The defect size ranged from 4 cm × 4 cm to 20 cm × 12 cm. The disease course ranged from 1 hour to 2 months. There was no significant difference in general data between 2 groups (P gt; 0.05). Results In VSD group, the preoperative hospital ization days, postoperative hospital ization days, and total hospital ization days were (11.8 ± 9.5), (35.4 ± 28.3), and (47.2 ± 35.8) days, respectively; the size of flap was (232.8 ± 142.0) cm2; and the infection rate after VSD-use was 0. In non-VSD group, the preoperative hospital ization days, postoperative hospital ization days, and total hospital ization days were (25.8 ± 12.4), (33.9 ± 28.1), and (59.7 ± 32.4) days, respectively; the size of flap was (97.3 ± 93.6) cm2; and the infection rate after 8 to 14 days of regular therapy was 80%. There were significant differences in the preoperative hospital ization days and the size of flap between 2 groups (P lt; 0.05). All flaps were al ive except 3 partial necrosis (1 case in VSD group, 2 cases in non-VSD group). The 3 flaps healed by skin grafting and suturing. The donor sites healed by first intention. All patients were followed up 5-41 months (22.1 months on average). All flaps were good in color, texture, and wear abil ity. Conclusion It is effective to apply VSD combined with proper flap to repair skin and soft tissue defects of lower l imbs, which can cut down infection rate, improve blood supply, shorten the preoperative hospital ization days, and facil itate heal ing, but whether it can shorten the postoperative hospital ization days and total hospital ization days need further research.

CONDUCTION OF INJECTABLE CARTILAGE USING FIBRIN SEALANT AND HUMAN BONE MARROW MESENCHYMAL STEM CELLS IN VIVO

Objective To investigate the feasibility of the complex of the fibrin sealant (FS) and the bone marrow mesenchymal stem cells（MSCs） to createanew cartilage in the nude mice by the issue engineering technique. Methods T he MSCs were isolated from healthy humans and were expanded in vitro. And then the MSCs were induced by the defined medium containing the transforming growth factor β1 (TGF-β1), dexamethasone, and ascorbic acid. The biomechanical properties of the chondrocytes were investigated at 7 and 14 days. The MSCs induced for 7days were collected and mixed with FS. Then, the FSMSCs mixture was injectedby a needle into the dorsum of the nude mice in the experimental group. In the tw o control groups, only FS or MSCs were injected respectively. The specimens were harvested at 6 and 12 weeks，and the ability of chondrogenesis in vivo was inve stigated by the gross observation, HE, Alcian Blue staining, and type Ⅱ collagen immunohistochemistry. Results The MSCs changed from a spindlel ike fibroblastic appearance to a polygonal shape when transferred to the defined medium, and couldbe induced to express the chondrocyte matrix. After an injection of the mixture , the cartilage-like tissue mass was formed, and the specimens were harvested from the mass at 6 and 12 weeks in the experimental group. The tissue mass at 6 we eks was smaller and relatively firm in texture, which had a distinct lacuna structure. And glycosaminoglycan (GAG) and Type II Collagen expressions were detecte d. The tissue mass at 12 weeks was bigger, firmer and glossier with the mature c hondrocytes lying in the lacuna structure. The positive Alcian blue and Collagen II immunohistochemistry stainings were ber at 12 weeks than at 6 weeks. But there was no cartilage-like tissue mass formed in the two control groups. Conclusion This study demonstrates that the fibrin sealant and the bone marrow mesenchymal stem cells can be successfully used in a constructing technique for the tissue engineered injectable cartilage.

严重创伤后腹腔间隙综合征行腹腔扩容术1例报道

目的总结腹腔扩容术（IAVI）治疗创伤后腹腔间隙综合征（ACS）的效果及其关键技术。 方法回顾性分析2011年5月笔者所在医院收治的1例严重创伤后ACS患者的临床资料。 结果该例患者先行IAVI，手术时间为80 min，术中出血50 mL，手术顺利。术后监测膀胱压（1次/4 h），于IAVI后14 d行腹壁创面植皮以形成计划性腹疝。该例患者术后无出血、感染等并发症发生，恢复顺利，于术后20 d出院。于出院后9个月再行改良双侧腹直肌推徙术治疗巨大计划性腹疝。行改良双侧腹直肌推徙术后该患者获访24个月，随访期间腹壁疝无复发，未见其他不适。 结论IAVI能够有效防治ACS，提高严重创伤患者的生存率。

TREATMENT OF TRAUMATIC SOFT TISSUE DEFECT BY VACUUM SEALING

OBJECTIVE: To investigate the clinical effect of vacuum sealing in treatment of traumatic soft tissue defect. METHODS: From 1998. 8 to 2001. 2, 49 patients with 55 traumatic soft tissue defects were treated by vacuum sealing after debridement. Among them, there were 39 males and 10 females with mean age 38. 4 years. The wound area varied from 10 cm x 10 cm to 30 cm x 30 cm. In the experimental group, the wound surfaces or cavities were filled with polyvinyl alcohol foams with embedded drainage tubes connected with vacuum bottle (negative pressure of 50-60 kPa). Wound closure was performed with secondary suturing, or skin transplantation, or local flap grafting after 5-7 days. Besides, 126 patients were managed by traditional dressing as the control group. RESULTS: Out of 51 traumatic soft tissue defects (45 patients), the wound closure was performed with a free flap in 4, with local flap in 8, with skin grafting in 27, with secondary suturing in 6, and with vacuum sealing directly in the other 6 defects. Forty-five patients recovered and no complications (systemic and located) occurred. There were significant differences in time of secondary suturing, times of dressing, wound shrink and total therapeutic cost between two groups (P lt; 0.01). CONCLUSION: Vacuum sealing can protect the wound against contamination, evacuate the wound exudates completely, stimulate the growth of granulation tissue, and facilitate the wound healing; so vacuum sealing is a simple and effective method in treatment of traumatic soft tissue defect.

封闭式负压引流技术联合腓肠神经营养血管皮瓣治疗跟腱部软组织缺损

目的 总结封闭式负压引流技术（vacuum sealing drainage，VSD）联合腓肠神经营养血管皮瓣治疗跟腱部软组织缺损的临床疗效。 方法 2008 年1 月－ 2010 年6 月，收治14 例跟腱中下部软组织缺损患者。男9 例，女5 例；年龄18 ～ 67 岁，平均46 岁。交通事故伤6 例，重物砸伤4 例，炸伤2 例。受伤至入院时间为2 ～ 6 h，平均3.5 h；外院清创缝合后感染致皮肤坏死2 例。软组织缺损部位：跟腱部软组织缺损11 例，其中4 例伴跟腱断裂；跟腱及跟骨结节处软组织缺损3 例。创面范围为3 cm × 3 cm ～ 8 cm × 6 cm。入院后先行VSD 治疗，待创面有新鲜肉芽组织后，采用大小为4.5 cm × 4.0 cm ～ 10 cm × 8 cm 的腓肠神经营养血管皮瓣修复创面。供区直接缝合或植皮修复。 结果 采用VSD 治疗1 次11 例，2 次2 例，3 次1 例。术后第8 天1 例发生皮瓣远端周缘坏死，经换药后10 d 愈合；其余皮瓣及植皮均顺利成活，创面Ⅰ期愈合。患者术后均获随访，随访时间6 ～ 20 个月，平均12 个月。皮瓣外形、质地良好，无臃肿，局部无明显瘢痕挛缩，耐磨性良好。术后6 个月踝关节功能采用美国足踝外科学会（AOFAS）评分系统，获优9 例，良3 例，可1 例，差1 例，优良率为85.7%。 结论 VSD 能有效预防和控制感染，促进肉芽生长，为皮瓣修复提供良好条件；腓肠神经营养血管皮瓣是修复跟腱中下部软组织缺损的有效方法。

Litmus Paper and Fibrin Sealant Help Prevent Potential Pancreatoenterostomy Leakage (Report of 47 Cases)

目的总结降低胰十二指肠切除术后胰空肠吻合口漏发病率的经验体会。 方法切除胰头后，将胰腺残端游离2.5～3.0 cm，利用红色石蕊试纸遇碱性胰液变蓝的特性，帮助寻找胰腺断面被横断的小导管，丝线贯穿缝扎。将空肠袢断端2.0～2.5 cm浆肌层剥除后施行套叠式胰空肠端端吻合，距浆肌层游离缘1.0～1.5 cm 处空肠上下壁各缝1针固定，最后用纤维蛋白胶封闭吻合口。结果47例患者中无一例发生胰空肠吻合口漏。结论该法操作较简便，适用于胰腺残端各种情况的处理。

负压封闭技术治疗骨筋膜室综合征

封闭式负压引流技术应用于植皮术的临床疗效

目的 通过与传统打包加压植皮法比较，分析封闭式负压引流技术（vaccum sealing drainage，VSD）应用于骨科植皮手术的临床效果。 方法 2006 年8 月－ 2010 年6 月，收治106 例四肢各种组织损伤合并皮肤缺损者，其中57 例采用VSD 联合植皮术治疗（试验组），49 例采用传统打包加压植皮法治疗（对照组）。试验组：男31 例，女26例；年龄18 ～ 52 岁，平均35.6 岁；植皮部位：上臂1 例，前臂8 例，手背8 例，大腿3 例，小腿25 例，足踝12 例；创面范围7 cm × 6 cm ～ 25 cm × 20 cm；伤后至植皮术时间8 ～ 26 d，平均12.7 d。对照组：男28 例，女21 例；年龄16 ～ 59 岁，平均38.3 岁；植皮部位：上臂1 例，前臂5 例，手背7 例，大腿2 例，小腿25 例，足踝9 例；创面范围5 cm × 5 cm ～ 15 cm ×13 cm；伤后至植皮术时间7 ～ 38 d，平均14.6 d。两组患者一般资料比较，差异均无统计学意义（P gt; 0.05），具有可比性。 结果 试验组：术后植皮均成活，成活率100%；植皮愈合时间（8.8 ± 3.2）d。对照组：术后9 d 11 例出现皮片局部感染，5 例出现皮片缺血性坏死，成活率67.3%；植皮愈合时间（15.9 ± 5.8）d。两组植皮成活率比较，差异有统计学意义（χ2=19.440，P=0.000）；植皮愈合时间比较，差异有统计学意义（t=1.730，P=0.000）。患者均获随访，随访时间3 ～ 18 个月， 平 均7.6 个月。试验组植皮区外观良好，瘢痕组织较对照组少。 结论 VSD 可使皮片与创面充分、紧密接触，加压均匀，提高了植皮术后皮片成活率。