Abstract
OBJECTIVE: To evaluate the clinical effect of antibiotic-loaded bone cement implantation combined with free chimeric tissue flap transplantation in the sequential treatment of severe gouty wounds. METHODS: This study was a retrospective observational study. From July 2019 to July 2022, 11 male patients with severe gouty wounds who were aged 33 to 71 years and met the inclusion criteria were admitted and treated at the Affiliated Hospital of Zunyi Medical University. The wounds were located on the hands in 2 cases, the ankles in 5 cases, and the feet in 4 cases. After debridement, the wound area ranged from 5.0 cm×4.0 cm to 22.0 cm×6.0 cm. All wounds were sequentially repaired with antibiotic-loaded bone cement implantation combined with free chimeric tissue flaps transplantation. Two cases were repaired by free perforating branch of superficial circumflex iliac artery with chimeric osseous flaps, with the areas of harvested skin flaps being 5.5 cm×4.0 cm and 8.0 cm×6.0 cm, respectively, and the volumes of iliac bone flaps being 2.0 cm×2.0 cm×1.5 cm and 3.5 cm×2.0 cm×2.0 cm, respectively. Two cases were repaired by free perforating branch of deep circumflex iliac artery with chimeric osseous flaps, with the areas of harvested skin flaps being 6.0 cm×4.0 cm and 7.5 cm×5.0 cm, respectively, and the volumes of iliac bone flaps being 2.0 cm×1.5 cm×1.5 cm and 2.5 cm×2.0 cm×1.5 cm, respectively. Seven cases were repaired by free chimeric myocutaneous flaps based on the descending branch of the lateral circumflex femoral artery. The areas of harvested skin flaps ranged from 9.5 cm×6.0 cm to 25.0 cm×6.5 cm, and the volumes of muscle flaps ranged from 4.0 cm×3.0 cm×2.0 cm to 6.0 cm×5.0 cm×2.5 cm. The donor site wounds were directly sutured. The chimeric tissue flap was freely transplanted to the recipient wound site, of which the iliac bone graft was used to fill the bone defect, the muscle flap was utilized to fill the wound cavity, and the skin flap was employed to cover the wound surface; the arteries and veins in the vascular pedicle were anastomosed with those in the recipient area. At admission and 3 days post antibiotic-loaded bone cement implantation, the changes in white blood cell count, neutrophil and hypersensitive C-reactive protein level, as well as the bacterial culture of wound secretions specimen, and the growth of granulation tissue were observed. After stage Ⅱ surgery, the survival of transplanted chimeric tissue flaps, the occurrence of vascular crisis, and the healing of wounds in donor and recipient sites were observed. During follow-up, the blood supply, appearance, and texture of the transplanted tissue flaps in the recipient sites, the function and appearance of the affected limbs and fingers, and the complications in the donor and recipient sites were observed. RESULTS: Three days post antibiotic-loaded bone cement implantation, white blood cell count, hypersensitive C-reactive protein level, and neutrophil significantly decreased compared with those at admission (with Z values of -2.93 and -2.93 respectively, t=8.63, P<0.05). At admission, all patients exhibited bacterial infections with redness and swelling around the wounds. Three days post antibiotic-loaded bone cement implantation, bacterial cultures of wound secretions specimen were negative, local redness resolved, and granulation tissue showed good growth. After stage Ⅱ surgery, all chimeric flaps survived without vascular crises. The wound healing in the recipient site of the dorsum of the foot in one patient was poor and delayed but healed after dressing changes; all the other recipient sites in remaining patients healed successfully. The donor incision healed well in all patients. During 6 to 24 months of follow-up, the flaps in the recipient area demonstrated good blood circulation, texture, and appearance. Bone healing was achieved in 4 patients with iliac grafts. Nine patients with lower limb wounds were able to bear weight, and the functions including gripping, palm alignment, and finger alignment were significantly improved in 2 patients with hand wounds. No significant complications were observed in donor or recipient sites. CONCLUSIONS: In treating patients with severe gouty wounds, the sequential strategy of stage Ⅰ debridement with antibiotic-loaded bone cement implantation followed by stage Ⅱ free chimeric osseous flaps or myocutaneous flaps repair can achieve effectively control of postoperative wound infection, promote wound healing, and well restore the functions of affected finger or limb with no obvious complications, which is worthy of promotion for clinical application.