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Title: [Limb salvage strategies for patients with high voltage electric burns of extremities on the verge of amputation].
Author: Shen YM, Qin FJ, Du WL, Wang C, Zhang C, Chen H, Ma CX, Hu XH.
Journal: Zhonghua Shao Shang Za Zhi; 2019 Nov 20; 35(11):776-783. PubMed ID: 31775465.
Abstract:
Objective: To explore the limb salvage strategies for patients with high voltage electric burns of extremities on the verge of amputation. Methods: From January 2003 to March 2019, 61 patients with high voltage electric burns of extremities on the verge of amputation were treated in our hospital. All of them were male, aged 15-58 years, including 49 cases of upper limbs and 12 cases of lower limbs. The wound area after thorough debridement ranged from 15 cm×11 cm to 35 cm×20 cm. Emergency surgery for reconstruction of the radial artery with saphenous vein graft under eschar was performed in 5 cases. The arteries of 36 patients (including 7 cases with simultaneous ulnar artery and radial artery reconstruction) were reconstructed with various forms of blood flow-through after debridement, among them, the radial artery of 13 cases, the ulnar artery of 8 cases, the brachial artery of 8 cases, and the femoral artery of 2 cases were reconstructed with saphenous vein graft; the radial artery of 3 cases and the ulnar artery of 7 cases were reconstructed with the descending branch of the lateral circumflex femoral artery graft; the radial artery of 2 cases were reconstructed with greater omentum vascular graft; the reflux vein of 3 cases with wrist and forearm annular electric burns were reconstructed with saphenous vein graft. According to the actual situation of the patients, 12 cases of latissimus dorsi myocutaneous flap, 6 cases of paraumbilical flap, 28 cases of anterolateral thigh flap, 10 cases of abdominal combined axial flap, 5 cases of greater omentum combined with flap and/or skin grafts were used to repair the wounds after debridement and cover the main wounds as much as possible. Some cases were filled with muscle flap in deep defect at the same time. The area of tissue flaps ranged from 10 cm×10 cm to 38 cm×22 cm. For particularly large wounds and annular wounds, the latissimus dorsi myocutaneous flap, the paraumbilical flap, the abdominal combined axial flap, and the greater omentum combined with flap and/or skin grafts were used more often. Donor sites of three patients were closed directly, and those of 58 patients were repaired with thin and medium split-thickness skin or mesh skin grafts. The outcome of limb salvage, flap survival, and follow-up of patients in this group were recorded. Results: All the transplanted tissue flaps survived in 61 patients. Fifty-six patients had successful limb salvage, among them, 31 limbs were healed after primary surgery; 20 limbs with flap infection and tissue necrosis survived after debridement and flap sutured in situ; 5 limbs with flap infection, radial artery thrombosis, and hand blood supply crisis survived after debridement and radial artery reconstruction with saphenous vein graft. Five patients had limb salvage failure, among them, 3 patients with wrist electric burns had embolism on the distal end of the transplanted blood vessels, without condition of re-anastomosis, and the hands gradually necrotized; although the upper limb of one patient was salvaged at first, due to the extensive necrosis and infection at the distal radius and ulna and the existence of hand blood supply under flap, considering prognostic function and economic benefits, amputation was required by the patient; although the foot of one patient was salvaged at first, due to the repeated infection, sinus formation, extensive bone necrosis of foot under flap, dullness of sole and dysfunction in walking for a long time, amputation was required by the patient. During the follow-up of 6 months to 5 years, 56 patients had adequate blood supply in the salvaged limbs, satisfied appearance of flaps, and certain recovery of limb function. Conclusions: Timely revascularization, early thorough debridement, and transplantation of large free tissue flap, combined tissue flap, or blood flow-through flap with rich blood supply are the basic factors to get better limb preservation and recovery of certain functions for patients with high voltage electric burns of limbs on the verge of amputation. 目的： 探讨濒临截肢的四肢高压电烧伤患者的保肢策略。 方法： 2003年1月—2019年3月，笔者单位收治61例濒临截肢的四肢高压电烧伤患者，均为男性，年龄15～58岁，其中上肢49例、下肢12例，彻底清创后创面面积15 cm×11 cm～35 cm×20 cm。5例患者急诊在焦痂下行大隐静脉移植重建桡动脉；36例患者(其中7例同时进行尺桡动脉重建)在清创后采用各种形式的血流桥接方式重建动脉，其中大隐静脉移植重建桡动脉13例、尺动脉8例、肱动脉8例、股动脉2例，旋股外侧动脉降支移植重建桡动脉3例、尺动脉7例，大网膜血管移植重建桡动脉2例；3例患者腕及前臂环状电烧伤采用大隐静脉移植重建回流静脉。结合患者的实际情况，采用背阔肌肌皮瓣12例、脐旁皮瓣6例、股前外侧皮瓣28例、腹部联合轴型皮瓣10例、大网膜联合皮瓣和/或皮片5例，修复清创后创面，尽量一次覆盖主要创面，部分病例同时用肌肉瓣填充深在缺损，组织瓣面积10 cm×10 cm～38 cm×22 cm。对特别巨大的创面、环状创面更多采用背阔肌肌皮瓣、脐旁皮瓣、腹部联合轴型皮瓣及大网膜联合皮瓣和/或皮片修复。3例患者供瓣区直接缝合，58例患者供瓣区采用薄中厚断层皮或网状皮修复。记录本组患者术后保肢情况、皮瓣存活情况及随访情况。 结果： 61例患者移植的组织瓣全部成活。56例患者保肢成功，其中31例患者创面Ⅰ期术后愈合；20例患者皮瓣下感染、组织坏死，经扩创、皮瓣原位缝合保肢；5例患者发生皮瓣下感染、桡动脉栓塞、手血供危象，经扩创、大隐静脉移植重建桡动脉保肢。5例患者保肢失败，其中3例腕部电烧伤患者移植的血管远端栓塞，没有再吻合条件，手逐渐坏死；1例患者由于皮瓣下尺桡骨远端广泛坏死、感染、手血运存在，虽已保肢，考虑预后功能及经济条件，患者要求截肢；1例患者足虽保肢，但由于皮瓣下足部反复感染、窦道形成、骨广泛坏死，足底感觉迟钝，长期不能行走，患者后期要求截肢。随访6个月～5年，56例患者保肢四肢血运好，皮瓣外形良好，四肢功能有一定恢复。 结论： 及时的血管重建，早期的彻底清创，采用血运丰富的大型游离组织瓣、联合组织瓣或血流桥接皮瓣移植是濒临截肢四肢高压电烧伤患者得以较好保肢并恢复一定功能的根本。.

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