Dedmond Barnaby T, Davids Jon R
Shriners Hospital for Children, Greenville, South Carolina 29605, USA.
J Bone Joint Surg Am. 2005 May;87(5):1054-8. doi: 10.2106/JBJS.D.01832.
Investigators have recommended aggressive use of skin-grafting in order to preserve length and proximal joint function following an acquired amputation in children. However, there is little objective evidence to either support or refute that recommendation.
We performed a retrospective review of the cases of all children for whom a skin graft had been applied to the residual limb following an acquired lower-extremity amputation at our Limb Deficiency Clinic between 1984 and 2002. Skin graft dysfunction, defined as breakdown, contracture, and/or pain, was considered to be clinically relevant if it required the child to discontinue use of the prosthesis for any period of time or if it required revision surgery to facilitate continued prosthetic fitting.
Twenty-three children (mean age at amputation, 4.4 years) with a total of thirty-one acquired lower-extremity amputations had been treated with skin-grafting. At a mean of 6.3 years after the operation, sixteen (52%) of the thirty-one extremities had had no episodes of skin graft dysfunction. The remaining fifteen extremities (48%) had had clinically relevant skin graft dysfunction (breakdown in thirteen and contracture and pain in one extremity each). Nine of the ten extensive skin grafts underwent clinically relevant breakdown, as did thirteen of the twenty-four grafts that were located distally on the residual limb. Subsequent surgical revision of the residual limb because of inadequate function of the skin graft was performed on seven extremities (23%), with revision to a more proximal limb-segment level required in five.
Focal skin-grafting (involving < or = 25% of the surface area) of partial-thickness soft-tissue defects in order to optimize the length of the residual limb at the time of an amputation is an effective option for children with an acquired lower-extremity amputation. Limited skin-grafting (involving 26% to 50% of the surface area) is more likely to result in skin graft breakdown, particularly when it is done distally. Extensive skin-grafting, while technically possible, frequently requires revision and rarely results in an optimally functioning limb. Alternative treatment strategies should be considered for extremities that would require extensive, distal skin-grafting.
研究人员建议积极采用皮肤移植术，以在儿童后天性截肢后保留肢体长度和近端关节功能。然而，几乎没有客观证据支持或反驳这一建议。
我们对1984年至2002年间在我们肢体缺陷诊所接受后天性下肢截肢后对残肢进行皮肤移植的所有儿童病例进行了回顾性研究。皮肤移植功能障碍定义为破溃、挛缩和/或疼痛，如果需要儿童在任何时间段停用假肢，或者需要进行翻修手术以促进假肢的持续适配，则被认为具有临床相关性。
23名儿童（截肢时平均年龄4.4岁）共接受了31次后天性下肢截肢手术，并接受了皮肤移植治疗。术后平均6.3年时，31个肢体中有16个（52%）未出现皮肤移植功能障碍。其余15个肢体（48%）出现了具有临床相关性的皮肤移植功能障碍（13个肢体出现破溃，1个肢体出现挛缩和疼痛）。10个大面积皮肤移植中有9个出现了具有临床相关性的破溃，残肢远端的24个移植中有13个也出现了破溃。因皮肤移植功能不足而对残肢进行后续手术翻修的有7个肢体（23%），其中5个需要翻修至更靠近近端的肢体节段水平。
对于后天性下肢截肢的儿童，为了在截肢时优化残肢长度而对部分厚度软组织缺损进行局部皮肤移植（涉及表面积≤25%）是一种有效的选择。有限的皮肤移植（涉及表面积的26%至50%）更有可能导致皮肤移植破溃，尤其是在远端进行时。大面积皮肤移植虽然在技术上可行，但经常需要翻修，很少能使肢体功能达到最佳状态。对于需要大面积远端皮肤移植的肢体，应考虑替代治疗策略。
