Kruppa C, Königshausen M, Gessmann J, Dudda M, Schildhauer T, Seybold D
Chirurgische Klinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-Universität Bochum.
Z Orthop Unfall. 2015 Dec;153(6):648-51. doi: 10.1055/s-0041-106787. Epub 2015 Dec 15.
Benign subcutaneous emphysema caused by a valve mechanism and subsequent air entrapment is rare. Less invasive treatment can be performed, but acute life-threatening infectious diseases should be ruled out before treatment; these include gas gangrene or other infections caused by gas producing bacteria.
We retrospectively report on three patients with chronic wounds who developed benign subcutaneous extremity emphysema caused by valve mechanisms with subsequent air entrapment. Patient 1 had a chronic wound at his stump after a lower leg amputation years ago. Due to weight loading and unloading of the lower leg prosthesis while walking, air was sucked in and triggered subcutaneous emphysema. Patient 2 had a persistent fistula at his lateral thigh due to a chronic osteomyelitis and Girdlestone hip. Caused by the up-and-down movements of the femur during walking air was entrapped and led to emphysema. Patient 3 had a drain in his knee for development of a chronic fistula because of a persistent infection of his knee prosthesis. In extension of the knee, the drain was clamped in and air was entrapped during knee flexion and then seeped into the surrounding subcutaneous tissue. No signs of infection in the blood samples were present in two of the patients. None of the patients had fever and no gas producing bacteria were identified in the microbiological cultures. Only multisensitive Staphylococcus aureus was present in the wounds of patients 1 and 2.
Two patients were treated surgically. One patient was treated by fasciotomy plus debridement and irrigation of the wound. A second patient was treated by debridement of the Girdlestone hip, air evacuation and insertion of a drain. No sign of infection - such as necrosis or gangreneous tissue - was seen during these operations. In patient 3, the drain was removed in flexion of the knee and air was removed from the subcutaneous tissue through a separate, sterile needle punction.
There have been few published reports on benign subcutaneous emphysema caused by a valve mechanism. No standardised treatments exist, as it is initially difficult to distinguish this condition from an acute life-threatening infection. If a patient has a chronic wound at the location of the endoprosthesis or stump prosthesis after amputation, the possibility of benign air entrapment should be routinely considered.
由瓣膜机制及随后的空气潴留引起的良性皮下气肿较为罕见。可采用侵入性较小的治疗方法，但在治疗前应排除急性危及生命的感染性疾病；这些疾病包括气性坏疽或由产气细菌引起的其他感染。
我们回顾性报告了3例慢性伤口患者，他们因瓣膜机制导致良性下肢皮下气肿并伴有随后的空气潴留。患者1多年前小腿截肢后残端有慢性伤口。行走时小腿假肢的负重和卸载导致空气吸入，引发皮下气肿。患者2因慢性骨髓炎和吉氏髋关节成形术，大腿外侧有持续性瘘管。行走时股骨的上下运动导致空气潴留并引发气肿。患者3因膝关节假体持续感染，膝关节处有引流管以形成慢性瘘管。膝关节伸展时，引流管被夹住，膝关节屈曲时空气被潴留，然后渗入周围皮下组织。两名患者的血液样本中均未出现感染迹象。所有患者均无发热，微生物培养中未鉴定出产气细菌。患者1和2的伤口中仅存在多药敏感金黄色葡萄球菌。
两名患者接受了手术治疗。一名患者接受了筋膜切开术加伤口清创和冲洗。另一名患者接受了吉氏髋关节成形术清创、空气排出及引流管置入。这些手术过程中均未发现感染迹象，如坏死或坏疽组织。对于患者3，在膝关节屈曲时移除引流管，并通过单独的无菌针头穿刺从皮下组织排出空气。
关于由瓣膜机制引起的良性皮下气肿的已发表报告较少。由于最初难以将这种情况与急性危及生命的感染区分开来，因此不存在标准化的治疗方法。如果患者在截肢后假体或残端假体部位有慢性伤口，应常规考虑良性空气潴留的可能性。
