脱细胞异体真皮联合自体刃厚皮修复大面积烧伤后关节部位瘢痕挛缩

目的探讨脱细胞异体真皮联合自体刃厚皮移植在大面积烧伤患者关节部位瘢痕挛缩修复中的疗效。 方法选取2017年4月至2020年4月空军军医大学第一附属医院烧伤与皮肤外科收治的12例大面积烧伤后瘢痕挛缩患者，男9例，女3例，年龄为23.0~67.0岁，烧伤面积为70.0%~95.0%总体表面积(TBSA)。患者入院完善相关术前检查后，明确拟手术切除部位，行Ⅰ期关节部位瘢痕松解，完整切除功能受限的关节部位瘢痕，使其恢复最大功能位。瘢痕切除后创面面积为10.0 cm×5.0 cm~20.0 cm×15.0 cm。脱细胞异体真皮覆盖创面，可吸收线缝合固定，封闭负压吸引7 d后行Ⅱ期手术，取自体刃厚皮覆盖于脱细胞异体真皮上缝合固定，并行封闭负压吸引。术后7 d观察皮片成活情况；创面愈合后6个月，参照《实用烧伤康复治疗学》中关于关节活动功能评定标准，采用量角器测量关节活动度，同时观察患肢肌力、感觉、外形、遗留症状、关节区域功能及供受区外观；创面愈合后6个月，根据患者情况进行临床疗效评估，同时采用自制外观满意度评分表对患者进行满意度评估。 结果术后7 d，10例患者皮片全部成活，2例患者皮片移植区域有残余创面，经换药处理后1个月内愈合。术后随访6~24个月，平均随访12个月。创面愈合后6个月，12例患者关节活动度分别最大可达：肘关节屈曲130°、伸展0、腕关节掌屈60°、背伸65°、尺偏25°、桡偏20°。所有患者患肢肌力正常、感觉良好、外形较术前有很大改观，关节区域功能较术前明显改善，受区皮肤质地柔软，颜色与周围正常皮肤接近，供皮区毛发发育未见异常。创面愈合后6个月，10例患者痊愈，2例有效。创面愈合后6个月，10例患者非常满意，2例患者满意。 结论脱细胞异体真皮联合自体刃厚皮修复大面积烧伤后关节部位瘢痕挛缩畸形，解决了患者自体中厚皮源不足的问题，术后效果好，值得推广。

Repair of joint scar contracture after extensive burn with acellular allogeneic dermis and autologous split-thickness skin graft

ObjectiveTo investigate the efficacy of acellular allogeneic dermis combined with autologous split-thickness skin graft in the repair of joint scar contracture after extensive burn. MethodsFrom April 2017 to April 2020, 12 patients with joint scar contracture after extensive burn were selected in the Department of Burn and Gutaneous Surgery, First Affiliated Hospital of Air Force Military Medical University, including 9 males and 3 females, aged 23.0-67.0 years, with burn area ranging from 70.0%-95.0% total body surface area (TBSA). After the patients were admitted to the hospital and the relevant preoperative examination were completed, the site of surgical resection was determined, the stage I joint scar release was performed, and the joint scar with limited function was completely removed to restore its maximum functional position. The wound area after scar resection was 10.0 cm×5.0 cm-20.0 cm×15.0 cm. Acellular allogeneic dermis was used to cover the wound. Stage Ⅱ operation was performed after 7 days of closed negative pressure suction, autologous split-thickness skin was covered on the acellular allogeneic dermis. The wound was sutured and fixed, closed negative pressure suction was performed. The survival of skin graft was observed 7 days after surgery. Six months after wound healing, according to the evaluation standard of joint motion function in Practical Burn Rehabilitation Therapy, the range of motion of the joint was measured with a protractor, and the muscle strength, sensation, appearance, residual symptoms, joint area function and the appearance of the donor and recipient area of the affected limb were observed. Six months after wound healing, the clinical efficacy was evaluated according to the patient′s situation, and the satisfaction of patients was evaluated by self-made appearance satisfaction rating scale. ResultsSeven days after surgery, all the skin grafts of 10 patients survived, and 2 patients had residual wounds in the skin graft area, which healed within 1 month after dressing change. Postoperative follow-up was 6-24 months, with an average follow-up of 12 months. Six months after wound healing, the maximum range of motion was 130° elbow flexion, 0 extension, 60° wrist palmar flexion, 65° dorsiflexion, 25° ulnar deviation and 20° radial deviation in 12 patients. The muscle strength of the affected limb was normal, the feeling was good, the appearance was greatly improved, the function of the joint area was significantly improved, the skin texture of the recipient area was soft, the color was similar to the surrounding normal skin, and the hair development in the donor area was not abnormal for all patients. Six months after wound healing, 10 patients were cured and 2 were effective; and 10 patients were very satisfied and 2 were satisfied. ConclusionRepair of joint scar contracture after extensive burn with acellular allogeneic dermis and autologous split-thickness skin graft has solved the problem of insufficient autologous inter-mediate thickness skin source, with good postoperative effect and worth being popularized.