带蒂皮瓣移植修复手术诱发冻结肩的预防和治疗研究
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摘要
目的探讨手、腕部或前臂皮肤缺损进行腹部皮瓣(带蒂)修复术时诱发冻结肩的预防和治疗。方法选择手、腕部或前臂腹部皮瓣断蒂术患者60例,分为研究组和对照组,每组30例。研究组患者采用臂丛神经阻滞(肌间沟入路)+硬腰联合麻醉,腹部皮瓣断蒂术时兼顾对肩关节进行被动手法松解治疗和术后主动肩关节功能锻炼。对照组患者采用局麻或臂丛神经阻滞(肌间沟入路)+硬腰联合麻醉进行腹部皮瓣断蒂术。术后两组患者均进行患者静脉自控镇痛。断蒂术后2周对两组患者肩关节疼痛、Constant肩关节功能评分及肩关节活动度进行临床评估。结果术后2周,研究组患者Constant肩关节功能评分高于对照组(P<0.01),研究组患者肩关节疼痛及活动功能的改善情况显著优于对照组(P<0.05),研究组患者临床治愈率、显效率明显优于对照组(P<0.05),研究组患者麻醉效果优于对照组。结论利用术中臂丛阻滞(肌间沟入路)复合硬腰联合麻醉提供的无痛及肌松条件,行肩关节的手法松解并且于术后配合主动的肩关节功能锻炼,能够预防和治疗带蒂皮瓣修复术后继发冻结肩,促进手及肩关节功能全面恢复,减轻术后痛苦,提高患者的生活质量。
Objective To discuss the prevention and treatment of frozen shoulder induced by abdominal pedicle flaps transplantation to repair the skin defect of the hand,wrist or forearm. Methods Sixty patients admitted in our center undergoing elective abdominal pedicle flaps transplantation for skin defect were enrolled in this study. They were prospectively divided into the observation group and control group B,with 30 cases in each group. The patients in the observation group were treated with brachial plexus block( interscalene approach) and intraspinal anesthesia. When the pedicle of the abdominal flap was broken,the shoulder joint was treated with passive manipulation under anaesthesia and active shoulder joint function exercise after the operation. The patients in the control group were treated with local anesthesia or brachial plexus block( interscalene approach) and intraspinal anesthesia when the pedicle of the abdominal flap was broken. All patients in the 2 groups received patient-controlled intravenous analgesia( PCIA) postoperatively.In 2 weeks after surgery,the pains,range of motion( ROM) of shoulder joint and the score of Constant were evaluated to assess the function of the shoulder in both groups. Results In 2 weeks after operation,the Constant score was significantly higher in the observation group than the control group( P < 0. 01). The former group had better pain relief and ROM of shoulder joint( P < 0. 05),higher cure rate and effective rate( P <0. 05),and better anesthetic effect when compared with the latter group. Conclusion When the pedicle of the abdominal flap is broken,we should give consideration to the prevention and treatment of frozen shoulder caused by operation,which can promote the full recovery of hand and shoulder joint function,relieve postoperative pain and improve the quality of life in the patients.
Objective To discuss the prevention and treatment of frozen shoulder induced by abdominal pedicle flaps transplantation to repair the skin defect of the hand,wrist or forearm. Methods Sixty patients admitted in our center undergoing elective abdominal pedicle flaps transplantation for skin defect were enrolled in this study. They were prospectively divided into the observation group and control group B,with 30 cases in each group. The patients in the observation group were treated with brachial plexus block( interscalene approach) and intraspinal anesthesia. When the pedicle of the abdominal flap was broken,the shoulder joint was treated with passive manipulation under anaesthesia and active shoulder joint function exercise after the operation. The patients in the control group were treated with local anesthesia or brachial plexus block( interscalene approach) and intraspinal anesthesia when the pedicle of the abdominal flap was broken. All patients in the 2 groups received patient-controlled intravenous analgesia( PCIA) postoperatively.In 2 weeks after surgery,the pains,range of motion( ROM) of shoulder joint and the score of Constant were evaluated to assess the function of the shoulder in both groups. Results In 2 weeks after operation,the Constant score was significantly higher in the observation group than the control group( P < 0. 01). The former group had better pain relief and ROM of shoulder joint( P < 0. 05),higher cure rate and effective rate( P <0. 05),and better anesthetic effect when compared with the latter group. Conclusion When the pedicle of the abdominal flap is broken,we should give consideration to the prevention and treatment of frozen shoulder caused by operation,which can promote the full recovery of hand and shoulder joint function,relieve postoperative pain and improve the quality of life in the patients.
引文
[1]高华伟,雷英,田超,等.腹部股动脉穿支双叶真皮下血管网皮瓣修复手部多处电烧伤创面疗效观察[J].中华烧伤杂志,2016,32(9):566-568.DOI:10.3760/cma.j.issn.1009-2587.2016.09.011.GAO H W,LEI Y,TIAN C,et al.Repair of electric burn by flaps with subdermal vascular network of femoral artery[J].Chin J Burns,2016,32(9):566-568.DOI:10.3760/cma.j.issn.1009-2587.2016.09.011.
[2]熊远洪,黄冰,姚明,等.CT引导下臂丛阻滞技术用于冻结肩的松解治疗[J].中华全科医学,2015,13(7):1160-1162.XIONG Y H,HUANG B,YAO M,et al.CT-guided supraclavicular brachial plexus block technique for surgical capsular release of frozen shoulder[J].Chin J Gen Prac,2015,13(7):1160-1162.
[3]芦丹,汪亚群,叶苏,等.综合康复治疗肩关节周围炎的疗效观察[J].中华物理医学与康复杂志,2017,39(3):211-213.DOI:10.3760/cma.j.issn.0254-1424.2017.03.013.LU D,WANG Y Q,YE S,et al.Synthetic rehabilitation of periarthritis of shoulder[J].Chin J Phys Med Rehabil,2017,39(3):211-213.DOI:10.3760/cma.j.issn.0254-1424.2017.03.013.
[4]仇申强,孙文海,孙法威,等.髂腹部带蒂皮瓣结合VSD技术在上肢创面修复中的应用[J].中华显微外科杂志,2016,39(2):165-167.DOI:10.3760/cma.j.issn.1001-2036.2016.02.017.QIU S Q,SUN W H,SUN F W,et al.Clinical application of ilioinguinal abdominal bilobate flap combining VSD on the hand or elbow skin defect[J].Chin J Microsurg,2016,39(2):165-167.DOI:10.3760/cma.j.issn.1001-2036.2016.02.017.
[5]张宁,宿晓雷,贺椿媛,等.“W”形腹部皮瓣修复手部梭形皮肤软组织缺损[J].中华手外科杂志,2017,33(1):24-25.DOI:10.3760/cma.j.issn.1005-054X.2017.01.011.ZHANG N,SU X L,HE C Y,et al.Repair of skin and hand spindle soft tissue defect with W shape abdominal flap[J].Chin J Hand Surg,2017,33(1):24-25.DOI:10.3760/cma.j.issn.1005-054X.2017.01.011.
[6]孙乐天,侯书健,刘亚平,等.(拇)甲皮瓣加腹部瓦合皮瓣修复全手皮肤套脱伤[J].中华手外科杂志,2016,32(3):238-239.DOI:10.3760/cma.j.issn.1005-054X.2016.03.034.SUN L T,HOU S J,LIU Y P,et al.Repair of whole hand degloving injuries with great toe-nail flap combining abdominal flaps[J].Chin J Hand Surg,2016,32(3):238-239.DOI:10.3760/cma.j.issn.1005-054X.2016.03.034.
[7]LEHMANN L J,SCHOLLMEYER A,STOEVE J,et al.Biochemical analysis of the synovial fluid of the shoulder joint in patients with and without rotator cuff tears[J].Z Orthop Unfall,2010,148(1):90-94.DOI:10.1055/s-0029-1186112.
[8]CLEMENT R G,RAY A G,DAVIDSON C,et al.Frozen shoulder:long-term outcome following arthrographic distension[J].Acta Orthop Belg,2013,79(4):368-374.
[9]HAND G C,ATHANASOU N A,MATTHEWS T,et al.The pathology of frozen shoulder[J].J Bone Joint Surg Br,2007,89(7):928-932.DOI:10.1302/0301-620X.89B7.19097.
[10]汪秋柯,张厉,杨春喜.冻结肩的炎症纤维化机制研究进展[J].中华关节外科杂志(电子版),2017,11(3):289-292.DOI:10.3877/cma.j.issn.1674-134X.2017.03.014.WANG Q K,ZHANG L,YANG C X.Update of mechanism of fibrosis of the frozen shoulder[J].Chin J Joint Surg(Electr Ed),2017,11(3):289-292.DOI:10.3877/cma.j.issn.1674-134X.2017.03.014.
[11]贺纯静,罗依然,陈黔.肩关节粘连松解术后气压弹道式冲击波治疗冻结肩的疗效观察[J].中国疼痛医学杂志,2013,19(9):562-564.DOI:10.3969/j.issn.1006-9852.2013.09.013.HE C J,LUO Y R,CHEN Q.Efficiency of shock wave after arthrolysis for frozen shoulder[J].Chin J Pain Med,2013,19(9):562-564.DOI:10.3969/j.issn.1006-9852.2013.09.013.
[12]郭越.肩周炎的临床康复治疗进展[J].医学综述,2014,20(15):2752-2754.DOI:10.3969/j.issn.1006-2084.2014.15.024.GUO Y.Recent advances in the rehabilitation treatment of periarthritis of shoulder[J].Med Recapitulate,2014,20(15):2752-2754.DOI:10.3969/j.issn.1006-2084.2014.15.024.
[13]李俊,银燕,肖红,等.超声引导臂丛阻滞下肩关节松解术治疗粘连性肩关节囊炎的有效性及安全分析[J].中国疼痛医学杂志,2017,23(1):70-73.LI J,YIN Y,XIAO H,et al.Efficiency of ultrasound guided brachial plexus block in arthrolysis for adhesive capsulitis of shoulder[J].Chin J Pain Med,2017,23(1):70-73.
[14]钱洪,赵建宁,包倪荣.冻结肩的治疗进展[J].颈腰痛杂志,2017,38(1):69-72.DOI:10.3969/j.issn.1005-7234.2017.01.004.QIAN H,ZHAO J N,BAO N R.Update of the treatment of the frozen shoulder[J].J Cervicodynia Lumbodynia,2017,38(1):69-72.DOI:10.3969/j.issn.1005-7234.2017.01.004.
[15]CADOGAN A,MOHAMMED K D.Shoulder pain in primary care:frozen shoulder[J].J Prim Health Care,2016,8(1):44-51.DOI:10.1071/HC15018.
[2]熊远洪,黄冰,姚明,等.CT引导下臂丛阻滞技术用于冻结肩的松解治疗[J].中华全科医学,2015,13(7):1160-1162.XIONG Y H,HUANG B,YAO M,et al.CT-guided supraclavicular brachial plexus block technique for surgical capsular release of frozen shoulder[J].Chin J Gen Prac,2015,13(7):1160-1162.
[3]芦丹,汪亚群,叶苏,等.综合康复治疗肩关节周围炎的疗效观察[J].中华物理医学与康复杂志,2017,39(3):211-213.DOI:10.3760/cma.j.issn.0254-1424.2017.03.013.LU D,WANG Y Q,YE S,et al.Synthetic rehabilitation of periarthritis of shoulder[J].Chin J Phys Med Rehabil,2017,39(3):211-213.DOI:10.3760/cma.j.issn.0254-1424.2017.03.013.
[4]仇申强,孙文海,孙法威,等.髂腹部带蒂皮瓣结合VSD技术在上肢创面修复中的应用[J].中华显微外科杂志,2016,39(2):165-167.DOI:10.3760/cma.j.issn.1001-2036.2016.02.017.QIU S Q,SUN W H,SUN F W,et al.Clinical application of ilioinguinal abdominal bilobate flap combining VSD on the hand or elbow skin defect[J].Chin J Microsurg,2016,39(2):165-167.DOI:10.3760/cma.j.issn.1001-2036.2016.02.017.
[5]张宁,宿晓雷,贺椿媛,等.“W”形腹部皮瓣修复手部梭形皮肤软组织缺损[J].中华手外科杂志,2017,33(1):24-25.DOI:10.3760/cma.j.issn.1005-054X.2017.01.011.ZHANG N,SU X L,HE C Y,et al.Repair of skin and hand spindle soft tissue defect with W shape abdominal flap[J].Chin J Hand Surg,2017,33(1):24-25.DOI:10.3760/cma.j.issn.1005-054X.2017.01.011.
[6]孙乐天,侯书健,刘亚平,等.(拇)甲皮瓣加腹部瓦合皮瓣修复全手皮肤套脱伤[J].中华手外科杂志,2016,32(3):238-239.DOI:10.3760/cma.j.issn.1005-054X.2016.03.034.SUN L T,HOU S J,LIU Y P,et al.Repair of whole hand degloving injuries with great toe-nail flap combining abdominal flaps[J].Chin J Hand Surg,2016,32(3):238-239.DOI:10.3760/cma.j.issn.1005-054X.2016.03.034.
[7]LEHMANN L J,SCHOLLMEYER A,STOEVE J,et al.Biochemical analysis of the synovial fluid of the shoulder joint in patients with and without rotator cuff tears[J].Z Orthop Unfall,2010,148(1):90-94.DOI:10.1055/s-0029-1186112.
[8]CLEMENT R G,RAY A G,DAVIDSON C,et al.Frozen shoulder:long-term outcome following arthrographic distension[J].Acta Orthop Belg,2013,79(4):368-374.
[9]HAND G C,ATHANASOU N A,MATTHEWS T,et al.The pathology of frozen shoulder[J].J Bone Joint Surg Br,2007,89(7):928-932.DOI:10.1302/0301-620X.89B7.19097.
[10]汪秋柯,张厉,杨春喜.冻结肩的炎症纤维化机制研究进展[J].中华关节外科杂志(电子版),2017,11(3):289-292.DOI:10.3877/cma.j.issn.1674-134X.2017.03.014.WANG Q K,ZHANG L,YANG C X.Update of mechanism of fibrosis of the frozen shoulder[J].Chin J Joint Surg(Electr Ed),2017,11(3):289-292.DOI:10.3877/cma.j.issn.1674-134X.2017.03.014.
[11]贺纯静,罗依然,陈黔.肩关节粘连松解术后气压弹道式冲击波治疗冻结肩的疗效观察[J].中国疼痛医学杂志,2013,19(9):562-564.DOI:10.3969/j.issn.1006-9852.2013.09.013.HE C J,LUO Y R,CHEN Q.Efficiency of shock wave after arthrolysis for frozen shoulder[J].Chin J Pain Med,2013,19(9):562-564.DOI:10.3969/j.issn.1006-9852.2013.09.013.
[12]郭越.肩周炎的临床康复治疗进展[J].医学综述,2014,20(15):2752-2754.DOI:10.3969/j.issn.1006-2084.2014.15.024.GUO Y.Recent advances in the rehabilitation treatment of periarthritis of shoulder[J].Med Recapitulate,2014,20(15):2752-2754.DOI:10.3969/j.issn.1006-2084.2014.15.024.
[13]李俊,银燕,肖红,等.超声引导臂丛阻滞下肩关节松解术治疗粘连性肩关节囊炎的有效性及安全分析[J].中国疼痛医学杂志,2017,23(1):70-73.LI J,YIN Y,XIAO H,et al.Efficiency of ultrasound guided brachial plexus block in arthrolysis for adhesive capsulitis of shoulder[J].Chin J Pain Med,2017,23(1):70-73.
[14]钱洪,赵建宁,包倪荣.冻结肩的治疗进展[J].颈腰痛杂志,2017,38(1):69-72.DOI:10.3969/j.issn.1005-7234.2017.01.004.QIAN H,ZHAO J N,BAO N R.Update of the treatment of the frozen shoulder[J].J Cervicodynia Lumbodynia,2017,38(1):69-72.DOI:10.3969/j.issn.1005-7234.2017.01.004.
[15]CADOGAN A,MOHAMMED K D.Shoulder pain in primary care:frozen shoulder[J].J Prim Health Care,2016,8(1):44-51.DOI:10.1071/HC15018.