Clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound on the wrist
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摘要: 目的 探讨游离股前外侧皮瓣联合动脉血管重建修复腕部Ⅱ、Ⅲ型高压电烧伤创面的临床效果。 方法 2016年5月—2019年2月,郑州市第一人民医院收治腕部高压电深度烧伤患者25例,其中男23例、女2例,年龄11~63岁,4例为双侧腕部电烧伤、21例为单侧腕部电烧伤,共29个患肢29个创面,创面深度为Ⅲ~Ⅳ度,其中Ⅱ型17个、Ⅲ型12个。术前24例患者行上肢CT血管造影,1例患者因海鲜过敏未行该项检查。7个患肢尺桡动脉均无明显损伤,6个患肢单纯尺动脉损伤,7个患肢单纯桡动脉损伤,9个患肢尺桡动脉均有损伤。清创后创面面积为10 cm×7 cm~36 cm×17 cm,切取面积为11 cm×8 cm~37 cm×18 cm的游离股前外侧皮瓣进行修复。尺桡动脉均无损伤患者,皮瓣旋股外侧动脉降支主干或其主干联合携带的较粗肌肉穿支或外侧支与创面尺或桡动脉吻合;单一的尺或桡动脉损伤患者,皮瓣旋股外侧动脉降支主干、外侧支或内侧支与创面尺或桡动脉吻合;尺桡动脉均长段损伤患者,采用上述方法重建创面尺或桡动脉,未与皮瓣动脉吻合的损伤动脉移植大隐静脉进行重建,并将移植的血管用股外侧肌包埋。皮瓣旋股外侧动脉降支的伴行静脉与创面尺或桡动脉的伴行静脉和/或头静脉吻合。供瓣区直接拉拢缝合或移植大腿中厚皮封闭。术后和随访观察皮瓣和患肢成活情况,随访时根据上肢周围神经损伤修复后评定标准评定患肢手功能。 结果 15个创面因组织液化于皮瓣修复术后14~28 d再次行清创手术后愈合。最终29个皮瓣均成活。1例患者患肢尺桡动脉长段损伤,术后1周因血管再次栓塞致手坏死;其余患肢均成活。术后随访6~30个月,皮瓣稍臃肿,患肢手温暖,血运正常,屈指、屈腕功能及手部感觉不同程度恢复。成活患肢功能评定为优者8个、良9个、中5个、劣6个,优良率为60.71%。 结论 游离股前外侧皮瓣联合动脉血管重建修复腕部高压电烧伤创面临床效果较好,Ⅰ期恢复上肢尺、桡动脉的通畅有助于提高保肢的成功率。Abstract: Objective To explore the clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction on repairing high-voltage electrical burn wound of type Ⅱ and Ⅲ on the wrist. Methods From May 2016 to February 2019, 25 patients with deep high-voltage electrical burn wounds on the wrist were admitted to Zhengzhou First People′s Hospital, including 23 males and 2 females, aged 11-63 years. Among them, 4 cases had bilateral electrical burns on the wrist, and 21 cases had unilateral electrical burns on the wrist. There were 29 wounds in 29 affected limbs with depth of full-thickness to full-thickness with tendon and bone exposure, and 17 wounds were type Ⅱ and 12 wounds were type Ⅲ. Twenty-four patients underwent CT angiography of the upper extremities before surgery, while the other one patient did not undergo the examination due to seafood allergy. There were no obvious injury to the ulnar and radial arteries in 7 affected limbs, simple ulnar artery injury in 6 affected limbs, simple radial artery injury in 7 affected limbs, and both ulnar and radial arteries injury in 9 affected limbs. The wound areas after debridement were 10 cm×7 cm-36 cm×17 cm, and the free anterolateral thigh flaps were obtained with area of 11 cm×8 cm-37 cm×18 cm for repairing the wounds. For patients with no damage of ulnar artery and radial artery, the trunk of descending branch of lateral circumflex femoral artery of the flap or combined with the thick muscle perforating branch or lateral branch was anastomosed with the ulnar or radial artery of the wound. For patients with simple ulnar artery or radial artery injury, the trunk, lateral branch, or medial branch was anastomosed with the ulnar artery or radial artery of the wound. For patients with long injury of ulnar artery and radial artery, the ulnar artery or radial artery of the wound was reconstructed with one of the above-mentioned methods, the injured artery that was not anastomosed was reconstructed with great saphenous vein, and the transplanted blood vessel was embedded in the lateral femoral muscle. The accompanying vein of the descending branch of the lateral circumflex femoral artery of the flap was anastomosed with the accompanying vein of the ulnar artery or radial artery of the wound and/or the cephalic vein. The donor sites of flaps were sutured directly or repaired with split-thickness skin graft from the thigh. The survival condition of flap and affected limb after operation and during follow-up was observed, and hand function of the affected limb during follow-up was evaluated according to the evaluation standard after repair of peripheral nerve injury in upper limbs. Results Fifteen affected limb wounds had tissue liquefaction but healed after second debridement on 14-28 days after flap repair operation. All 29 flaps survived in the end. One patient had long ulnar artery and radial artery injuries in affected limbs and the hand was necrotic due to second embolism of the blood vessel in 1 week post operation, and the remaining affected limbs survived. During the follow-up of 6 to 30 months after operation, the flaps were slightly bloated, the affected limbs were warm with normal blood flow, and finger flexion, wrist flexion, and sensory function of hand recovered to varying degrees. The functions of the survived affected limbs were evaluated as excellent in 8 affected limbs, good in 9 affected limbs, medium in 5 affected limbs, and poor in 6 affected limbs, with an excellent and good rate of 60.71%. Conclusions The clinical effect of free anterolateral thigh flap combined with arterial vascular reconstruction is good for repairing high-voltage electrical burn wound on the wrist, and the patency restoration of the ulnar artery and/or radial artery of the upper limb in stage Ⅰ is helpful for improving the success rate of limb salvage.
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