1.Pathogenesis.
In the literature of Chinese medicine, there is no exact record of the name of traumatic infected bony skin defect. Chronic infected trauma is also called “ulcer” in ancient times, which belongs to the category of ulcerative diseases. It is a tissue defect that takes more than 4 weeks to heal and has no obvious tendency to heal. When the body is injured and the veins are broken, the blood from the meridians accumulates in the muscles and couples and becomes blood stasis.
In addition, if there is a wound, evil toxins can invade from the wound and cause evil toxin infection. In mild cases, the wound is locally red, swollen, and painful; in severe cases, blood stasis blocks the meridians, causing local congestion, and the meridians are not smooth. The “Ling Shu” says: “If the blood is not flowing through the channels and veins, the blood is not flowing, and if the blood is not flowing, the Qi is not flowing through the channels and veins. Professor Cheng Chunsheng, the supervisor, believes that the disease belongs to the category of “ulcer disease”, which belongs to the category of ulcer disease.
The cause of the disease is mostly due to open injuries to the limbs caused by trauma, such as car accidents, machine strangulation, pressure injuries, and decortication injuries, which are prone to secondary infection due to necrosis of the traumatic tissue and soft tissue loss of the skin. In addition, it is also closely related to the thoroughness of debridement, the thoroughness of disinfection of internal fixation materials, the strictness of aseptic principle during surgical operation, and the presence of tension sutures in the wound. According to the ancestral medicine, wound infection is the result of external wind, dryness, dampness and fire, internal growth of dampness, heat and fire poison, and internal invasion of poisonous evil, resulting in disharmony of the camp health and stagnation of qi and blood.
2.Diagnosis method.
With the rapid development of modern industry and transportation, its high-energy and high-violence injuries are becoming more and more frequent, and its extremity trauma is becoming more and more serious, and consequently serious extremity trauma has become a common disease in orthopedics and traumatology, and infection is one of the most difficult problems to deal with. The instructors believe that timely and correct diagnosis of the disease and prevention of infection are the prerequisite and key to treatment. Clinical management of open fractures with severe soft tissue injury should be strictly mastered to achieve early and thorough debridement, simple and effective internal and external fixation, and timely superficial skin slice or flap graft surgery, which will reduce and minimize the occurrence of open infection.
In general, the primary goal of serious trauma patients after surgery is to control and prevent tissue liquefaction necrosis of the limb tissue due to infection, which leads to soft tissue defects, bone exposure, local lack of its blood nutrient supply after bone exposure, with the extension of time, the exposed bone gradually appears blackened and necrotic, coupled with repeated clearing treatment, the result is a (long segment) bone defect, followed by limb The result is a (long) bone defect, followed by limb dysfunction and even the risk of amputation. Cases like the one above are more prominent in primary hospitals.
The instructor believes that traumatic infected bone skin defect is mainly caused by severe trauma, early failure or misdiagnosis of open comminuted fracture, ischemia-reperfusion injury of distal limb after limb severance or fracture combined with vascular injury, etc. The prevention and treatment method mainly lies in reasonable diagnosis and treatment at the early stage of trauma. The most common site is calf, which is mainly related to the anatomical structure of calf, followed by foot, hand, forearm, thigh and arm.
3.Treatment method
The instructor believes that the diagnosis of the disease is relatively easy, but the key lies in the selection and rational use of treatment methods. At present, many patients with bone and skin defects of the extremities due to their various causes are gradually becoming one of the common diseases in the field of orthopaedics and traumatology, which are quite tricky and difficult to deal with. The early repair treatment method is still the focus of debate in the field of orthopaedic traumatology. Through the clinical experience of the supervisor for so many years, the method of using both internal and external treatment with TCM to complete the lesion removal and bony skin defect repair surgery in one phase is reliable and satisfactory.
3.1 Perioperative application of Chinese herbal medicine The instructor believes that with the rapid development of modern industry and transportation, the occurrence of such diseases is quite common in clinical practice, and most of the patients are in heavy condition, with long duration of illness, having undergone multiple surgeries, as well as long-term wound infection, chronic consumption, malnutrition, anemia, and lingering. The pus is caused by a long period of time, and the deficiency is unable to support the evil to go out, and the evil loves but does not go. The medical practitioners of the past generations have attached great importance to the treatment of supporting the righteousness, such as Zhang Jegu in the Treatise on Traumatic Injury and Confusion, which points out that “nourishing the righteousness will eliminate itself. In “The Essentials of the Living Method”, it is clearly proposed that “Therefore, those who treat accumulation should first nurture the righteousness, then the accumulation will be removed.”
Li Shizhen also strongly advocates “nourishing the righteousness to break the hard accumulation.” In the Nei Jing, it is suggested that “the tangible accumulation is difficult to be cut down, but the invisible qi cheng should be supported.” The instructor believes that the Chinese medical evidence of this disease mostly belongs to the deficiency of spleen and kidney, deficiency of both qi and blood, and the yongheng of evil toxins. Therefore, when treating this disease, the mentor also believes that the treatment rule of supporting the righteousness and eliminating the evil, attacking and supplementing at the same time should be established. Therefore, during the perioperative period, in addition to strengthening nutrition and systemic antibiotics, the treatment should be guided by a holistic concept and dialectical treatment, using the principle of warming the qi and blood, detoxifying the toxins in the torso, and supplementing with the principle of tonifying the spleen and kidneys, and using Naito Tang with extra reduction.
The treatment of open infected wounds is a major problem in orthopaedics and traumatology, and Western medicine has formed a relatively mature routine and effective treatment method. However, due to the widespread use of antibiotics in recent years. However, due to the widespread use of antibiotics in recent years, drug-resistant strains are expanding, and open infections are not caused by a single pathogenic bacteria. It is difficult to screen out effective antibiotics. The temperature, mechanics and chemical action of the drug. The therapeutic effect on the local area occurs when the decoction of Chinese medicine compound is fumigated locally. Due to the effect of warmth, it can make the blood vessels in the affected area dilate. It promotes local blood circulation and lymphatic circulation, and promotes the regulating effect of meridians.
Therefore, the instructor believes that while applying Chinese medicine for internal treatment, bacterial culture and drug sensitivity test should be performed on the local wound secretions, and the effective heat-clearing and detoxifying Chinese medicine should be applied locally, and the “self-controlled Chinese medicine wet and hot compress” should be used for local irrigation treatment. 50g, 50g for Staphylococcus aureus, 50g for forsythia, 50g for dandelion; 30g for E. coli, 30g for cypress, 30g for scutellaria; 50g for rhubarb, 50g for chuanxiong; 50g for bacillus aerogenes, 50g for umeboshi) to control infection.
The instructor believes that there are many methods of external treatment such as ointment, poultice, medicine dispersal compress and hot compress, but all of these methods are not conducive to local necrotic tissue exudation and drainage, and do not play a role in purifying the wound, while the external use of Chinese herbal medicine wet and hot compress is conducive to the drainage of secretions, reduce the absorption of toxins in the trauma face, and also play a role in local physical flushing and cleaning of the trauma.
3.2 Surgical treatment With the introduction and development of microsurgical techniques, various vascularized flaps, osteocutaneous flaps, and periosteal flap grafts have provided effective treatment for patients with this type of injury. Since 1982, our hospital has applied the Luoyang flap and osteocutaneous flap technology invented by Zhang Shancai, Li Jinming and Cheng Chunsheng to complete complete complete lesion removal and osteocutaneous tissue repair in one phase is an effective way to treat traumatic infected osteocutaneous defect, so as to avoid the disadvantages of staging multiple surgeries to treat the disease.
The instructor believes that the treatment of traumatic infective osteocutaneous defects should follow the principle of simplicity rather than complexity, and for the repair of tissue defects, if the problem can be solved by skin flap grafting, flap grafting repair is not needed; if the tissue defect can be repaired by local rotation flap, then distant flap repair is not needed. Therefore, we must strictly and reasonably utilize the indications and contraindications of Luoyang flap and bony flap in the treatment of traumatic infected bony skin defect, and also have to understand and master the precautions and solutions of this method for the treatment of traumatic infected bony skin defect as follows.
(1) Pre-operative local application of heat-clearing and detoxifying herbal medicines for local flushing and systemic application of effective antibiotics for active infection control treatment, as well as the use of internal herbal medicines to support and dispel evil, improve the patient’s general condition and enhance the body resistance;
(2) Examine the affected limb and the donor limb, and take X-ray films to understand the extent of osteocutaneous defects in the affected area and whether the skin and bone in the donor area are intact; at the same time, Allen’s test, angiography, MRI vascular digital subtraction, or Doppler measurement should be performed to determine whether the blood vessels are normal and to design the surgical plan carefully;
(3) For limb shortening greater than 5 cm, preoperative bone traction is used to correct part of the limb shortening deformity;
(4) For those with extensive skin scarring in the recipient area, poor superficial venous conditions, and a history of vascular injury for cross-tissue transplantation, the two lower extremities should be fixed together with bandages one week before surgery for adaptation training;
(5) Lesion removal in the recipient area must be thorough;
(6) Donor area wound treatment: if the area of the cut flap is small (width less than 5 cm), the donor area can be directly sutured, and the bone flap donor area is compressed with gelatin sponge to stop bleeding on the cut bone surface; the flounder muscle is sutured to establish a skin graft bed at the beginning, and a medium-thickness thigh skin slice is taken for skin graft;
(7) The donor area was fixed with plaster support for 4-6 weeks after surgery to facilitate tissue repair; then it was protected with external fixation support for 2-3 months to prevent fracture, and the recipient area was fixed firmly with plaster or external fixation support until the fracture healed as usual after bone grafting;
(8) In the case of cross grafting, a blocking test should be performed about 2 months after surgery to break the tip;
(9) Continue to apply effective antibiotics and antipyretic herbs to prevent infection;
(10) Treat the fracture according to the postoperative three-stage principle of Pingle Orthopaedic Technique, taking San Qi Bone Setting Pill to invigorate blood stasis in the early stage, using Blood Nourishing and Pain Relieving Pill in the middle stage, and taking Jia Wei Yi Qi Pill to nourish blood in the late stage;
(11) For free graft, apply anticoagulant and antispasmodic drugs such as low-molecular dextran, heparin, toltrazurin and blood-stasis activating herbs such as salvia, safflower and Chuanxiongzin injection to prevent vascular crisis;
(12) Intraoperative management of vascular variants in the donor area and treatment of muscle starting and stopping point reconstruction are important.
4.Summary
The instructor believes that postoperative infection and recurrence of distant inflammation are important factors affecting the efficacy of traumatic infected osteochondral defects, therefore, it is a question worth exploring how to avoid or reduce infection and improve the treatment effect. Thorough removal of dead bone, pus, unhealthy granulation tissue, sclerotic bone and unstable scar tissue from the lesion area is the basis of successful treatment.
Meanwhile, using Luoyang flap and osteocutaneous flap techniques to provide a larger volume of conforming tissue flap grafts with rich blood supply can repair bone and soft tissue defects in time, improve blood supply to the recipient area, enhance local resistance to infection, and create conditions for accelerating tissue repair and lesion healing is the key to successful treatment.
Pre-operative local application of heat-clearing and detoxifying Chinese herbal wet and hot compress treatment can play a role in controlling infection, purifying the wound, improving local blood circulation, and promoting the limitation of surrounding inflammation; at the same time, systemic application of Chinese herbal medicines to nourish the qi and blood, support the righteousness and dispel the evil to improve their immunity is also an important measure to ensure successful treatment. The instructor believes that the combination of both internal and external treatment with TCM and Luoyang flap and bony flap techniques is a safe, reliable and irreplaceable method of choice for treating infected bony skin defects in extremity trauma that can achieve good results.