游离腓浅动脉穿支皮瓣修复拇趾皮肤软组织缺损的临床效果

张韬; 柳志锦; 刘胜哲; 程俊楠; 杨林; 周荣; 郭礼平; 杨亮; 熊胜; 巨积辉

doi:10.3760/cma.j.cn501120-20210604-00211

游离腓浅动脉穿支皮瓣修复拇趾皮肤软组织缺损的临床效果

doi: 10.3760/cma.j.cn501120-20210604-00211

张韬¹,
柳志锦¹,
刘胜哲¹,
程俊楠¹,
杨林¹,
周荣²,
郭礼平²,
杨亮²,
熊胜³,
巨积辉^1, ,

1.
苏州大学附属瑞华医院手外科，苏州　215104
2.
苏州大学附属瑞华医院足踝外科，苏州　215104
3.
苏州大学附属瑞华医院小儿骨科，苏州　215104

基金项目:

江苏省青年医学人才项目 QNRC2016224

苏州市姑苏卫生人才计划项目 2020075

苏州市民生科技项目关键技术应用研究 SS202092

苏州市卫生科教临床重点病种诊疗技术专项 LCZX202026

苏州市企业工程技术研究中心专项 SZS2019263

详细信息

通讯作者:
巨积辉，Email：jjh2006@263.net

计量
- 文章访问数: 240
- HTML全文浏览量: 106
- PDF下载量: 30
- 被引次数: 0
出版历程
- 收稿日期: 2021-06-04

Clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux

1.
Department of Hand Surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou 215104, China
2.
Department of Foot and Ankle Surgery, Ruihua Affiliated Hospital of Soochow University, Suzhou 215104, China
3.
Department of Pediatric Orthopedics, Ruihua Affiliated Hospital of Soochow University, Suzhou 215104, China

Funds:

Youth Medical Talent Project of Jiangsu Province of China QNRC2016224

Health Talents Program of Suzhou Gusu District 2020075

Key Technology Application Research of Suzhou MinSheng Science and Technology Project SS202092

Special Project on Diagnosis and Treatment Technology of Clinical Key Disease Species of Suzhou LCZX202026

Special Project of Suzhou Enterprise Engineering Technology Research Center SZS2019263

More Information

Corresponding author: Ju Jihui, Email: jjh2006@263.net

摘要

摘要: 目的探讨游离腓浅动脉穿支皮瓣修复拇趾皮肤软组织缺损的临床效果。方法采用回顾性观察性研究方法。2020年1月—2021年1月，苏州大学附属瑞华医院足踝外科收治13例符合入选标准的拇趾皮肤软组织缺损患者，其中男12例、女1例，年龄16~53岁。术前于患趾同侧小腿行彩色多普勒超声定位腓浅动脉穿支穿出点并于体表标记。手术于脊椎麻醉+连续硬膜外麻醉下进行，扩创后皮肤软组织缺损面积为4.5 cm×2.5 cm~12.0 cm×3.0 cm。根据创面的大小、形状，以腓骨小头与外踝尖连线向胫侧平移2 cm为皮瓣轴心线，以轴心线中点附近穿支穿出点为中心，设计腓浅动脉穿支皮瓣。皮瓣切取面积为5.0 cm×3.0 cm~13.0 cm×4.0 cm，游离蒂部时切取部分深筋膜。供区创面直接缝合。术中记录穿支数目、类型及皮瓣切取时间，测量穿支血管蒂长度及穿支直径。术后记录皮瓣成活情况、供受区愈合时间及愈合情况。随访记录皮瓣的色泽、质地、弹性，患者站立及行走功能，供区恢复情况以及患者对供受区恢复情况的满意度。末次随访，采用英国医学研究会感觉功能评定标准评定皮瓣感觉，采用美国足踝外科学会评分系统评价患肢功能并计算优良率。结果术中共探及腓浅动脉穿支13条，均为肌间隔穿支，穿支直径0.3~0.5 mm；血管蒂长度2~5 cm。皮瓣切取时间11~26 min。13例患者术后皮瓣均完全成活。术后9~18 d，供受区创面均愈合良好。随访6~14个月，皮瓣色泽、质地、弹性良好；11例患者外形无明显臃肿，另外2例患者因外观臃肿，Ⅱ期行皮瓣修薄整形；所有患者均恢复正常行走、站立功能；供区仅遗留一条线状瘢痕，无明显瘢痕增生或色素沉着；所有患者对供受区恢复情况表示满意。末次随访，皮瓣感觉功能评定为S₃级者2例、S₂级者9例、S₁级者2例；患肢功能评定为优者7例、良者6例，优良率为100%。结论游离腓浅动脉穿支皮瓣血管解剖较为恒定，皮瓣薄且耐磨，皮瓣切取后供区损伤小，可以最大限度保留拇趾外形及功能，是一种修复拇趾皮肤软组织缺损的有效方法。
- 外科皮瓣 /
- 显微外科手术 /
- 创伤和损伤 /
- 拇趾 /
- 腓浅动脉穿支皮瓣
Abstract: Objective To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux. Methods A retrospective observational study was conducted. From January 2020 to January 2021, 13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 12 males and 1 female, aged 26 to 53 years. Before operation, the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface. The operation was performed under spinal anesthesia combined with continuous epidural anesthesia. The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm. According to the size and shape of the wound, the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line, and the perforating point of the perforator near the midpoint of the axis line as the center. The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm, and part of the deep fascia was cut when the pedicle was freed. The donor site wound was sutured directly. During the operation, the number and type of the perforator and the cutting time of the flap were recorded, and the length of the perforator pedicle and diameter of the perforator were measured. The survival of the flap, the healing time and the healing condition of the donor and recipient areas were recorded after operation. The color, texture, elasticity of the flap, standing and walking functions of patients, the recovery of the donor area, and the patients' satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up. At the last follow-up, the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard, the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system, and the excellent and good rate of the function of the affected limb was calculated. Results A total of 13 perforators of the superficial peroneal artery were detected during the operation, all of which were septocutaneous perforators, and the perforator diameter was 0.3 to 0.5 mm. The vascular pedicle length was 2 to 5 cm. Flap cutting time was 11 to 26 minutes. The flaps of 13 patients all survived completely. The wounds at the donor and recipient sites healed well 9 to 18 days after operation. During follow-up of 6 to 14 months, the flaps had good color, texture, and elasticity; 11 patients had no obvious bloated appearance, and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance; all the patients returned to normal walking and standing functions. There was only one linear scar left in the donor site, with no obvious scar hyperplasia or hyperpigmentation. All the patients were satisfied with the recovery of the donor and recipient areas. At the last follow-up, the sensation of the flap was evaluated as grade S₃ in 2 cases, grade S₂ in 9 cases, and grade S₁ in 2 cases; the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases, with an excellent and good rate of 100%. Conclusions The free superficial peroneal artery perforator flap has relatively constant vascular anatomy, which is thin and wear-resistant, with less damage to the donor site after flap excision, and can preserve the shape and function of the hallux to the greatest extent. It is an effective method for repairing skin and soft tissue defect of the hallux.
- Surgical flaps /
- Microsurgery /
- Wounds and injuries /
- Hallux /
- Superficial peroneal artery perforator flap
张韬：酝酿和设计研究、手术实施、采集资料、分析数据与论文撰写；柳志锦、刘胜哲：手术实施、采集资料、分析数据与修改文章；程俊楠、杨林：手术实施与采集资料；周荣、郭礼平、杨亮：手术实施与采集资料；熊胜：采集资料；巨积辉：酝酿和设计研究、手术实施、分析数据、修改文章与获取研究经费

所有作者均声明不存在利益冲突

HTML全文

参考文献(37)

[1]	LimthongthangR,EamsobhanaP.First dorsal metatarsal artery perforator flap to cover great toe defect[J].J Orthop Surg (Hong Kong),2017,25(3):2309499017739497.DOI: 10.1177/2309499017739497.
[2]	LeeY,LeeYH,KimMB,et al.The innervated distally based first dorsal metatarsal artery flap with a wide pedicle for reconstruction of a great toe defect[J].Clin Orthop Surg,2019,11(3):325-331.DOI: 10.4055/cios.2019.11.3.325.
[3]	NikiH,AokiH,InokuchiS,et al.Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders I: development of standard rating system[J].J Orthop Sci,2005,10(5):457-465.DOI: 10.1007/s00776-005-0936-2.
[4]	KitaokaHB,AlexanderIJ,AdelaarRS,et al.Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes[J].Foot Ankle Int,1994,15(7):349-353.DOI: 10.1177/107110079401500701.
[5]	ChanJK,SongM,ShirleyR,et al.Free dorsal toe flap for reconstruction of the hallux[J].Plast Reconstr Surg Glob Open,2020,8(9):e3117.DOI: 10.1097/GOX.0000000000003117.
[6]	BargA,HarmerJR,PressonAP,et al.Unfavorable outcomes following surgical treatment of hallux valgus deformity: a systematic literature review[J].J Bone Joint Surg Am,2018,100(18):1563-1573.DOI: 10.2106/JBJS.17.00975.
[7]	ZeidermanMR, PuLLQ. Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma[J/OL]. Burns Trauma, 2021,9:tkab024[2022-07-06]. https://pubmed.ncbi.nlm.nih.gov/34345630/.DOI: 10.1093/burnst/tkab024.
[8]	李攀登,沈国良.携带腓肠肌的腓动脉穿支腓肠神经营养血管双血供复合组织瓣修复足踝部腔隙性缺损的临床效果[J].中华烧伤杂志,2019,35(5):392-394.DOI: 10.3760/cma.j.issn.1009-2587.2019.05.013.
[9]	李海,张程,邓呈亮,等.腓动脉中低位穿支皮瓣带蒂转移修复足踝部皮肤软组织缺损的临床效果[J].中华烧伤杂志,2017,33(10):607-610.DOI: 10.3760/cma.j.issn.1009-2587.2017.10.004.
[10]	秦建忠,朱振华,周聚普,等.腓动脉外踝前终末穿支降支蒂岛状皮瓣修复中足和前足软组织缺损[J].中华显微外科杂志,2020,43(1):20-23.DOI: 10.3760/cma.j.issn.1001-2036.2020.01.016.
[11]	曹胜军,丰波,王凌峰,等.足底内侧岛状皮瓣修复足底负重区创面11例[J].中华烧伤杂志,2017,33(7):455-457.DOI: 10.3760/cma.j.issn.1009-2587.2017.07.016.
[12]	黎斌,徐长春,刘志强,等.足内侧远端筋膜蒂岛状皮瓣修复(拇)趾创面缺损[J].中华手外科杂志,2016,32(1):73-74.DOI: 10.3760/cma.j.issn.1005-054X.2016.01.031.
[13]	杨英才,李养群,叶永奇,等.(拇)横动脉分支皮瓣修复(拇)趾皮肤缺损[J].中华整形外科杂志,2017,33(3):224-225.DOI: 10.3760/cma.j.issn.1009-4598.2017.03.015.
[14]	王国伟,王静,焦玉坤,等.逆行第1跖背动脉皮瓣在(足母)趾软组织缺损中的应用[J].中华显微外科杂志,2019,42(3):282-284.DOI: 10.3760/cma.j.issn.1001-2036.2019.03.019.
[15]	张海永,王宝英,牛军,等.跗外侧动脉皮瓣修复足拇趾末节皮肤软组织缺损13例[J].郑州大学学报(医学版),2017,52(2):223-225.DOI: 10.13705/j.issn.1671-6825.2017.02.030.
[16]	裴少琨,李卫海,崔留超,等.不同形式足内侧皮瓣修复前足软组织缺损[J].中国美容整形外科杂志,2019,30(11):651-654.DOI: 10.3969/j.issn.1673-7040.2019.11.004.
[17]	李楚炎,李文庆,姚海波,等.足内侧皮神经营养血管远端蒂皮瓣修复前足软组织缺损[J].中国临床解剖学杂志,2017,35(4):445-447.DOI: 10.13418/j.issn.1001-165x.2017.04.018.
[18]	杨洪涛,齐杰,李雯,等.足背内侧皮神经内侧支皮瓣修复足拇趾电击伤创面[J].中国美容整形外科杂志,2016,27(10):616-618.DOI: 10.3969/j.issn.1673-7040.2016.10.012.
[19]	窦金兰,田振欣,郑珊珊,等.三维CT血管造影辅助设计足内侧隐神经营养血管皮瓣修复足远端软组织缺损[J].中华整形外科杂志,2020,36(2):175-179.DOI: 10.3760/cma.j.issn.1009-4598.2020.02.012.
[20]	胡长青,连勇,白晓亮,等.游离胸背动脉穿支皮瓣修复小腿远端及足踝部创面九例[J].中华烧伤杂志,2018,34(4):240-242.DOI: 10.3760/cma.j.issn.1009-2587.2018.04.009.
[21]	潘冬经,姚志伟,姜魏,等.腓肠内侧动脉穿支皮瓣修复四肢及面部皮肤软组织缺损六例[J].中华烧伤杂志,2017,33(12):772-775.DOI: 10.3760/cma.j.issn.1009-2587.2017.12.010.
[22]	董建峰,史光华,王建国,等.游离腓肠内侧动脉穿支皮瓣修复(足母)𧿹甲瓣供区创面七例[J].中华显微外科杂志,2019,42(3):300-302.DOI: 10.3760/cma.j.issn.1001-2036.2019.03.027.
[23]	胡朝波,邱勋永,林晶,等.腓动脉穿支皮瓣游离移植修复前足皮肤缺损13例[J].中华显微外科杂志,2017,40(5):486-488.DOI: 10.3760/cma.j.issn.1001-2036.2017.05.019.
[24]	杜伟力,沈余明,胡骁骅,等.供瓣区美学修复方法的探讨[J].中华烧伤杂志,2020,36(2):97-105.DOI: 10.3760/cma.j.issn.1009-2587.2020.02.004.
[25]	韩军涛,王洪涛,谢松涛,等.供瓣区选择与修复策略的初步探讨[J].中华烧伤杂志,2020,36(2):85-90.DOI: 10.3760/cma.j.issn.1009-2587.2020.02.002.
[26]	刘毅.重视供区的美容修复[J].中华烧伤杂志,2020,36(2):81-84.DOI: 10.3760/cma.j.issn.1009-2587.2020.02.001.
[27]	陈珺,章一新.章氏超减张缝合在闭合高张力创面中的临床应用效果[J].中华烧伤杂志,2020,36(5):339-345.DOI: 10.3760/cma.j.cn501120-20200314-00163.
[28]	YangX,ZhangG,LiuY,et al.Vascular anatomy and clinical application of anterolateral leg perforator flaps[J].Plast Reconstr Surg,2013,131(4):534e-543e.DOI: 10.1097/PRS.0b013e3182827675.
[29]	秦向征,刘鹏,许东元,等.腓浅动脉皮支链的应用解剖[J].中华显微外科杂志,2015,38(1):66-69.DOI: 10.3760/cma.j.issn.1001-2036.2015.01.016.
[30]	徐永清.小腿穿支皮瓣在中国的临床应用及进展[J].中华显微外科杂志,2020,43(6):521-534.DOI: 10.3760/cma.j.cn441206-20200527-00243.
[31]	熊胜,巨积辉,金光哲,等.游离同侧多块小腿腓浅动脉穿支皮瓣修复手部多发创面效果观察[J].中华烧伤杂志,2019,35(9):655-660.DOI: 10.3760/cma.j.issn.1009-2587.2019.09.003.
[32]	程贺云,张韬,巨积辉,等.Flow-through腓浅动脉皮瓣修复手指伴指掌侧固有动脉缺损创面[J].中华显微外科杂志,2021,44(4):369-373.DOI: 10.3760/cma.j.cn441206-20210111-00011.
[33]	熊胜,巨积辉,金光哲,等. 彩超定位下游离腓浅动脉穿支皮瓣修复手足部创面[J]. 中华手外科杂志,2018,34(6):418-420. DOI: 10.3760/cma.j.issn.1005-054X.2018.06.007.
[34]	石岩,何晓清,杨曦,等. CT血管造影检查结合三维重建辅助设计腓浅动脉穿支皮瓣修复手部创面的疗效[J]. 中华创伤杂志,2021,37(6):501-507. DOI: 10.3760/cma.j.cn501098-20210202-00105.
[35]	StoccoC,MurphyDC,GargiuloM,et al.Superficial peroneal nerve accessory artery (SPNAA) flap for head and neck reconstruction: a cadaveric anatomical study and retrospective case series review[J].J Plast Reconstr Aesthet Surg,2021,74(7):1524-1533.DOI: 10.1016/j.bjps.2020.11.012.
[36]	张威凯,龚永清,尹绍猛,等. 游离腓浅动脉穿支双叶皮瓣修复双指皮肤缺损[J]. 中华手外科杂志,2016,32(5):397-398. DOI: 10.3760/cma.j.issn.1005-054X.2016.05.035.
[37]	徐永清,何晓清,陈雪松,等. 手和足部创面修复时四种吻合血管的皮神经营养血管穿支皮瓣的选择[J]. 中华显微外科杂志,2020,43(4):331-337. DOI: 10.3760/cma.j.cn441206-20200218-00068.

下载: 全尺寸图片幻灯片

1 游离腓浅动脉穿支皮瓣修复患者右足拇趾皮肤软组织缺损。1A.急诊术后12 d，拇趾末节甲床处皮肤坏死；1B.急诊术后 12 d，坏死组织清创后；1C.急诊术后12 d，以腓骨小头与外踝尖连线（图中直线）向胫侧平移2 cm为轴心线，以轴心线中点附近穿支穿出点为中心，设计面积为8.0 cm×3.0 cm的皮瓣；1D.皮瓣断蒂前；1E.供瓣区直接缝合后即刻；1F.皮瓣覆盖创面并缝合后即刻；1G.皮瓣修复术后8个月随访，皮瓣存活良好，拇趾外形恢复良好，无明显色素沉着；1H.皮瓣修复术后8个月随访，右小腿供区仅遗留线状瘢痕，无明显瘢痕增生或色素沉着

注：黄色箭头指示腓浅神经，黑色箭头指示腓浅动脉穿支

下载: 全尺寸图片幻灯片