One-Stage Reconstruction with Meshed Acellular Dermal Matrix Plus Split Thickness Skin Graft and Negative Pressure Wound Therapy on A Large Knee Skin Defect - A Simple and Effective Method

以一階段去細胞真皮基質與分層皮膚移植配合負壓傷口療法重建大面積合併深部膝關節皮膚組織缺損－一個簡單且有效的方法

謝松育(Sung-Yu Hsieh) ； 顏毓秀(Yu-Hsiu Yen) ； 蒲啟明(Chi-Ming Pu)

《臺灣整形外科醫學會雜誌》 30卷2期 (2021/06) Pp. 109-117

摘要

Background: In the past decade, acellular dermal matrices (ADMs) have been widely used to treat soft-tissue defects, providing reasonable coverage for wounds that may not be suited for the traditional reconstructive ladder. The knee is one of the largest joints in the human body, and in case of a knee defect, the range of motion and elasticity after reconstruction must be considered. Aim and Objectives: Although free flap reconstruction can adequately cover the affected portion of a knee when addressing soft-tissue defects, donor-side comorbidity cannot be prevented. With a skin graft alone, the high incidence of secondary contracture may restrict the range of knee movement in the future. We simultaneously used an ADM and skin graft combined with negative pressure wound therapy (NPWT) for a large knee defect reconstruction. Materials and Methods: A 59-year-old woman with a severe blunt injury on her right knee developed a severe hematoma with a 10 × 10 cm^2 deep soft-tissue defect. After debridement and NPWT, the wound bed became well granulated, and we performed reconstruction by simultaneously using ADM, meshed at a 1:1.5 ratio, and an unmeshed split-thickness skin graft (STSG). NPWT was applied for graft fixation for 7 days. Results: Four weeks after the operation, the skin graft and ADM perfectly grafted onto the wound. The thickness and elasticity of the composite skin graft with ADM were satisfactory. Within 2 months after surgery, the patient's knee achieved full flexion and extension without restriction. Conclusion: For knee reconstruction, there are some factors may interfere the post-reconstruction function, including contracture and tissue thickness and elasticity. A free flap is a viable option, but donor-site comorbidity is inevitable. Combining an ADM with skin grafts can provide wound coverage with adequate tissue thickness compared with a skin graft alone. One-stage ADM application combined with an STSG covering plus NPWT achieved a satisfactory result with rapid procedure, good defect coverage, excellent tissue flexibility and thickness, and preserved range of motion in the knee.

關鍵字

acellular dermal matrix ； split thickness skin graft ； knee reconstruction

並列摘要

背景：去細胞真皮基質在近十年被廣泛運用在軟組織缺損上，且它能提供在某些傳統重建階梯上並沒有那麼好治療的傷口提供令人滿意的覆蓋。膝蓋是人體最大的關節之一，在重建它的軟組織時我們並須考慮到它的活動度與彈性。目的及目標：雖然游離皮瓣重建手術可以提供夠大的組織給膝蓋軟組織缺損，皮瓣供給處的傷害是不可避免的。單純的皮膚移植會有高機率的次級攣縮，這對未來的關節活動度風險很大。我們結合了去細胞真皮基質與分層皮膚移植配合負壓傷口療法一階段完成膝蓋區域軟組織的重建。材料及方法：59歲女性病人遭遇過撞擊意外導致她的右膝嚴重鈍擊而造成嚴重血腫，併發一個約十公分大小的深部軟組織傷口。在清創與負壓裝置吸引療法之後，傷口肉芽組織形成良好，我們就執行一階段以一比一點五網狀化的去細胞真皮基質與非網狀化的分層皮膚移植。結果：在手術四週後，皮膚移植配合去細胞真皮基質存活良好。移植皮膚的厚度與彈性度都令人滿意。病人的膝蓋在術後兩個月之後依然可以達成全角度的屈曲與伸展，並且沒有任何活動限制。結論：在膝蓋重建中，必須考量術後攣縮、組織的厚度與彈性，因為會影響到術後的活動功能。游離皮瓣重建是可行的選項，但供應皮瓣處的傷害是不可避免的。結合去細胞真皮基質與植皮比單純植皮提供足夠的組織厚度。一階段的去細胞真皮基質結合分層皮膚移植配合負壓傷口療法可達成令人滿意的成果，包括手術時間短、良好組織覆蓋、優質的組織彈性與厚度、保留膝蓋的完整活動度。