无神经吻合的股前外侧皮瓣修复手腕及手背部创面后感觉恢复规律

周耀; 巨积辉; 唐林峰; 王凯; 周荣; 郭礼平; 杨亮

doi:10.3760/cma.j.cn501120-20211014-00350

无神经吻合的股前外侧皮瓣修复手腕及手背部创面后感觉恢复规律

doi: 10.3760/cma.j.cn501120-20211014-00350

周耀¹,
巨积辉^2, ,,
唐林峰²,
王凯²,
周荣²,
郭礼平²,
杨亮²

1.
常熟市海虞卫生院，常熟　　215500
2.
苏州瑞华骨科医院，苏州　　215104

基金项目:

苏州市姑苏卫生人才计划 2020075

苏州市民生科技项目 SS202092

苏州市卫生科教临床重点病种诊疗技术专项 LCZX202026

详细信息

通讯作者:
巨积辉，Email：jjh2006@263.net

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出版历程
- 收稿日期: 2021-10-14

The regularity of sensory recovery after wound repair on the wrist and back of hand with anterolateral femoral flap without nerve anastomosis

1.
Changshu Hai Yu Health Centre, Changshu 215500, China
2.
Suzhou Ruihua Orthopedic Hospital, Suzhou 215104, China

Funds:

Health Talents Program of Suzhou Gusu District 2020075

Suzhou MinSheng Science and Technology Project SS202092

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

More Information

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

摘要

摘要: 目的探讨无神经吻合的股前外侧皮瓣修复手腕及手背部创面后感觉恢复规律。方法采用横断面研究方法。将2018年1月—2020年12月在江苏省常熟市海虞卫生院和苏州瑞华骨科医院采用无神经吻合的股前外侧皮瓣游离移植修复手腕及手背部创面的且符合入选标准的患者纳入本研究。根据患者手术日与横断面调查日之间的时间间隔，将80例患者分为6个月组（男15例、女5例，年龄22~63岁）、12个月组（男16例、女4例，年龄21~65岁）、18个月组（男15例、女5例，年龄25~61岁）、24个月组（男14例、女6例，年龄20~65岁），每组20例。患者清创后的皮肤软组织缺损面积为6.0 cm×4.5 cm~18.0 cm×9.0 cm，股前外侧皮瓣切取面积为7 cm×5 cm~20 cm×10 cm、厚度为1.0~2.5 cm。将移植后皮瓣分为A区（近心端）、B/D区（两侧）、C区（远端）和E区（中央区域）。测试并比较前述5个区的痛觉、触觉、冷觉、温觉和两点辨别觉（2-PD）及整个皮瓣5种感觉的差异。对数据行单因素方差分析、Fisher确切概率法检验、 χ ²检验或McNemar检验。结果无神经吻合的股前外侧皮瓣A区中，与6个月组相比，12个月组患者皮瓣的痛觉、触觉、冷觉、温觉均恢复明显（ χ ²值分别为10.10、14.55、12.13、4.29， P<0.05或 P<0.01）；与12个月组相比，18个月组患者皮瓣的温觉恢复明显（ χ ²=5.23， P<0.05）。B区中，与6个月组相比，12个月组患者皮瓣的痛觉、触觉、冷觉均恢复明显（ χ ²值分别为5.58、3.96、4.29， P<0.05）；与12个月组相比，18个月组患者皮瓣的痛觉、触觉、冷觉、温觉均恢复明显（ χ ²值分别为5.58、3.96、7.03、12.38， P<0.05或 P<0.01）。C区中，与6个月组相比，12个月组患者皮瓣的痛觉恢复明显（ χ ²=4.80， P<0.05）；与12个月组相比，18个月组患者皮瓣的温觉恢复明显（ χ ²=10.16， P<0.01）。D区中，与6个月组相比，12个月组患者皮瓣的痛觉、触觉、冷觉均恢复明显（ χ ²值分别为5.58、4.29、3.96， P<0.05）；与12个月组相比，18个月组患者皮瓣的痛觉、触觉、冷觉、温觉均恢复明显（ χ ²值分别为5.58、4.29、3.96、10.10， P<0.05或 P<0.01）。E区中，与6个月组相比，12个月组患者皮瓣的冷觉恢复明显（ χ ²=4.80， P<0.05）；与12个月组相比，18个月组患者皮瓣的痛觉、触觉、温觉均恢复明显（ χ ²值分别为6.47、4.91、9.23， P<0.05或 P<0.01）。24个月组患者皮瓣5个区的5种感觉与18个月组均相似（ P>0.05）。各相邻2组间，患者皮瓣5个区的2-PD恢复情况均近似（ P>0.05）。12个月组患者皮瓣A区的痛觉、触觉、冷觉恢复均明显优于其他4个区（ P<0.05或 P<0.01），温觉恢复明显优于B区、C区、E区（ P<0.05或 P<0.01）；18个月组患者皮瓣A区的痛觉、触觉、冷觉、温觉恢复明显优于C区（ P<0.05）。与6个月组相比，12个月组患者整个皮瓣的痛觉、触觉、冷觉均恢复明显（ χ ²值分别为7.62、7.03、5.58， P<0.05或 P<0.01）；与12个月组患者整个皮瓣的痛觉、触觉、冷觉、温觉恢复者分别有10、11、10、4例相比，18个月组患者的17、17、16、14例均明显增多（ χ ²值分别为5.58、4.29、3.96、10.10， P<0.05或 P<0.01）。24个月组患者整个皮瓣的5种感觉与18个月组均相似（ P>0.05）。结论在修复手腕及手背部创面的无神经吻合的股前外侧皮瓣中，感觉从近端逐渐向远端恢复；其中整个皮瓣的触觉、痛觉、冷觉从术后6个月即开始恢复，至术后18个月进入恢复稳定期；温觉从术后12个月开始恢复，至术后18个月进入恢复稳定期；而大多数皮瓣的2-PD在术后2年仍未恢复。
- 外科皮瓣 /
- 显微外科手术 /
- 手 /
- 感觉 /
- 腕部 /
- 神经吻合 /
- 创面修复
Abstract: Objective To investigate the regularity of sensory recovery after repairing the wounds on the wrist and back of hand with anterolateral femoral flap without nerve anastomosis. Methods A cross-sectional study was conducted. From January 2018 to December 2020, patients who underwent free anterolateral femoral flaps without nerve anastomosis to repair wounds on the wrist and back of hand and met the inclusion criteria in Changshu Hai Yu Health Centre and Suzhou Ruihua Orthopedic Hospital were included in this study. Depending on the time interval between the day of the patient's surgery and the day of the cross-sectional survey, 80 patients were divided into 6-month group (15 males and 5 females, aged 22-63 years), 12-month group (16 males and 4 females, aged 21-65 years), 18-month group (15 males and 5 females, aged 25-61 years), and 24-month group (14 males and 6 females, aged 20-65 years), with 20 patients in each group. The area of skin and soft tissue defects after debridement ranged from 6.0 cm×4.5 cm to 18.0 cm×9.0 cm. Anterolateral femoral flaps were cut with areas of 7 cm×5 cm to 20 cm×10 cm and a thickness of 1.0 to 2.5 cm. Each transplanted flap was divided into A (proximal), B/D (bilateral), C (distal), and E (central) regions. The pain sensation, touch sensation, cold sensation, warmth sensation, and two-point discrimination (2-PD) in the aforementioned five regions and the differences in the five senses of the whole flap were tested and compared. Data were statistically analyzed with one-way analysis of variance, Fisher's exact probability test, chi-square test, or McNemar test. Results In A region of anterolateral femoral flap without nerve anastomosis, compared with those in 6-month group, the pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in 12-month group were significantly recovered (with χ ² values of 10.10, 14.55, 12.13, and 4.29, respectively, P<0.05 or P<0.01); compared with that in 12-month group, the warmth sensation of flap of patients in 18-month group recovered significantly ( χ ²=5.23, P<0.05). In B region, compared with those in 6-month group, the pain sensation, touch sensation, and cold sensation of flap of patients in 12-month group recovered significantly (with χ ² values of 5.58, 3.96, and 4.29, respectively, P<0.05); compared with those in 12-month group, the pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in 18-month group recovered significantly (with χ ² values of 5.58, 3.96, 7.03, and 12.38, respectively, P<0.05 or P<0.01). In C region, compared with that in 6-month group, the pain sensation of flap of patients in 12-month group recovered significantly ( χ ²=4.80, P<0.05); Compared with that in 12-month group, the warmth sensation of flap of patients in 18-month group recovered significantly ( χ ²=10.16, P<0.01). In D region, compared with those in 6-month group, the pain sensation, touch sensation, and cold sensation of flap of patients in 12-month group recovered significantly (with χ ² values of 5.58, 4.29, and 3.96, respectively, P<0.05); compared with those in 12-month group, the pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in 18-month group recovered significantly (with χ ² values of 5.58, 4.29, 3.96, and 10.10, respectively, P<0.05 or P<0.01). In E region, compared with that in 6-month group, the cold sensation of flap of patients in 12-month group recovered significantly ( χ ²=4.80, P<0.05); compared with those in 12-month group, the pain sensation, touch sensation, and warmth sensation of flap of patients in 18-month group recovered significantly (with χ ² values of 6.47, 4.91, and 9.23, respectively, P<0.05 or P<0.01). The five senses in the 5 regions of flap of patients in 24-month group were similar to those in 18-month group ( P>0.05). The recovery of 2-PD in the 5 regions of flap of patients was similar between the two adjacent groups ( P>0.05). In 12-month group, the recoveries of pain sensation, touch sensation, and cold sensation of flap of patients in A region were better than those in the other 4 regions ( P<0.05 or P<0.01), the recovery of warmth sensation was better than that of B region, C region, and E region ( P<0.05 or P<0.01); in 18-month group, the recovery of pain sensation, touch sensation, cold sensation, and warmth sensation of flap of patients in A region of was better than those in area C region ( P<0.05). Compared with those in 6-month group, the pain sensation, touch sensation, and cold sensation of the whole flap of patients in 12-month group recovered significantly (with χ ² values of 7.62, 7.03, and 5.58, respectively, P<0.05 or P<0.01). Compared with the 12-month group in which 10, 11, 10, and 4 patients had a recovery of pain, touch sensation, cold sensation, and warmth sensation in the whole flap, the 18-month group had significantly more patients with sensations recovered, which were 17, 17, 16, and 14, respectively (with χ ² values of 5.58, 4.29, 3.96, and 10.10, respectively, P<0.05 or P<0.01). The five senses of the whole flap of patients in 24-month group were similar to those in 18-month group ( P>0.05). Conclusions In the anterolateral femoral flap without nerve anastomosis for repairing wounds on the wrist and back of hand, the sensation gradually recovered from the proximal end to the distal end. The sensation of touch, pain, and cold began to recover from 6 months after operation, and entered the stable recover period at 18 months after operation. Warmth sensation began to recover from 12 months after operation, and entered the stable recovery period at 18 months after operation. The 2-PD of most flaps was still not recovered 2-year after operation.
- Surgical flap /
- Microsurgery /
- Hand /
- Feeling /
- Wrist /
- Nerve anastomosis /
- Wound repair
周耀：病例收集、查找文献并确定感觉测试方法、进行感觉测试、数据整理和分析、论文撰写；巨积辉：撰写指导、论文修改；唐林峰、王凯：统计分析；周荣、郭礼平、杨亮：数据整理

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参考文献(29)

[1]	唐茂林,刘元波.穿支皮瓣的解剖学研究进展[J].中华整形外科杂志,2018,34(9):785-790.DOI: 10.3760/cma.j.issn.1009-4598.2018.09.022.
[2]	周征兵, 唐举玉, 吴攀峰, 等. 双侧旋股外侧动脉降支穿支皮瓣组合移植治疗上肢大面积组织缺损[J].中华手外科杂志,2019,35(3):183-185.DOI: 10.3760/cma.j.issn.1005-054X.2019.03.008.
[3]	顾荣, 王海文, 江新民, 等. 髂腹股沟联体穿支皮瓣移植修复上肢较大面积皮肤缺损[J].中华显微外科杂志,2017,40(5):433-437. DOI: 10.3760/cma.j.issn.1001-2036.2017.05.005.
[4]	金光哲, 巨积辉, 熊胜, 等. 单叶或双叶带阔筋膜的股前外侧皮瓣在手足背皮肤肌腱缺损中的应用[J].中华手外科杂志,2019,35(4):241-243. DOI: 10.3760/cma.j.issn.1005-054X.2019.04.001.
[5]	刘胜哲, 巨积辉, 柳志锦, 等. 串并联双侧股前外侧超长穿支皮瓣修复四肢大面积创面的临床效果[J].中华烧伤杂志,2021,37(3):250-256. DOI: 10.3760/cma.j.cn501120-20200226-00096.
[6]	柳志锦, 巨积辉, 刘胜哲, 等. 股前外侧区双叶穿支皮瓣的血供方式及临床应用[J].中华骨科杂志,2021,41(4):211-218. DOI: 10.3760/cma.j.cn121113-20200415-00259.
[7]	宋达疆, 李赞, 周晓, 等. 分叶股前外侧穿支皮瓣修复口腔复杂洞穿缺损[J].中华整形外科杂志,2019,35(10):978-985. DOI: 10.3760/cma.j.issn.1009-4598.2019.10.006.
[8]	巨积辉, 周荣, 刘跃飞, 等. 超长股外侧区内增压型穿支皮瓣修复足踝部创面的临床效果[J].中华烧伤杂志,2019,35(7):495-500. DOI: 10.3760/cma.j.issn.1009-2587.2019.07.004.
[9]	邢培朋, 郭海娜, 狄海萍, 等. 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的临床效果[J].中华烧伤杂志,2020,36(6):419-425. DOI: 10.3760/cma.j.cn501120-20200219-00067.
[10]	刘会仁, 刘家寅. 对《MBCMA股前外侧皮瓣临床应用指南(2016征求意见稿)》的浅见[J].中华显微外科杂志,2017,40(2):205-206. DOI: 10.3760/cma.j.issn.1001-2036.2017.02.031.
[11]	唐举玉, 魏在荣, 张世民, 等. 穿支皮瓣的临床应用原则专家共识[J].中国临床解剖学杂志,2016(1):4-5. DOI: 10.13418/j.issn.1001-165x.2016.01.002.
[12]	徐磊, 巨积辉, 侯瑞兴, 等. 双足第二趾胫侧皮肤两点分辨觉的比较研究及其临床意义[J].中华手外科杂志,2016,32(6):460-462. DOI: 10.3760/cma.j.issn.1005-054X.2016.06.027.
[13]	吴昌盛, 潘振宇, 李平华, 等. 缝合神经的游离股前外侧皮瓣修复前足皮肤缺损皮瓣感觉恢复情况的中期随访[J].中华显微外科杂志,2018,41(4):371-373. DOI: 10.3760/cma.j.issn.1001-2036.2018.04.014.
[14]	周荣, 巨积辉, 唐林峰, 等. 带感觉神经的股前外侧穿支皮瓣修复足底皮肤软组织缺损的临床效果[J].中华烧伤杂志,2021,37(5):453-459. DOI: 10.3760/cma.j.cn501120-20200309-00136.
[15]	葛占洲, 陈秀民, 李晓良, 等. 应用有感觉功能的股前外侧穿支皮瓣修复足踝部创面[J].中华显微外科杂志,2019,42(4):385-388. DOI: 10.3760/cma.j.issn.1001-2036.2019.04.018.
[16]	李有斌, 刘少华, 丁治红, 等. 带感觉神经的股前外侧穿支皮瓣修复足底软组织缺损九例[J].中华显微外科杂志,2021,44(2):194-197. DOI: 10.3760/cma.j.cn441206-20200419-00207.
[17]	胡孔和, 吴强, 靳安民, 等. 神经端侧吻合重建游离皮瓣感觉功能的临床效果[J].中华显微外科杂志,2012,35(3):237-239. DOI: 10.3760/cma.j.issn.1001-2036.2012.03.025.
[18]	杨何平, 张洪武, 杨书雄, 等. 带感觉神经与失神经的股前外侧穿支皮瓣在头颈部感觉重建的对比研究[J].中华显微外科杂志,2016,39(3):225-229. DOI: 10.3760/cma.j.issn.1001-2036.2016.03.005.
[19]	刘芳, 常增林. 失神经皮瓣移植术后感觉神经再生的研究[J].中国现代医学杂志,2002,12(7):28-31. DOI: 10.3969/j.issn.1005-8982.2002.07.011.
[20]	贺倩茹, 丁斐. 周围神经趋化性再生研究新进展[J].解剖学杂志,2021,44(1):1-6. DOI: 10.3969/j.issn.1001-1633.2021.01.001.
[21]	肖飞鹏, 柳志锦, 刘胜哲, 等. 综合评价量表在股前外侧皮瓣修复术后疗效评价中的应用[J].中国美容整形外科杂志,2021,32(6):348-351. DOI: 10.3969/j.issn.1673-7040.2021.06.010.
[22]	唐举玉, 李康华, 谢松林, 等. 股前外侧皮瓣修复足跟大面积软组织缺损的感觉重建探讨[J].中华显微外科杂志,2012,35(4):267-271,后插1. DOI: 10.3760/cma.j.issn.1001-2036.2012.04.002.
[23]	牟勇, 黎路根, 胡春兰, 等. 削薄分叶股前外侧穿支皮瓣修复四肢复杂软组织缺损[J].中华显微外科杂志,2019,42(3):218-222. DOI: 10.3760/cma.j.issn.1001-2036.2019.03.003.
[24]	HastingsH. Dual innervated index to thumb cross finger or island flap reconstruction[J]. Microsurgery, 1987,8(3):168-172. DOI: 10.1002/micr.1920080312.
[25]	Torres-Ortíz ZermeñoCA, López MendozaJ. Aesthetic and functional outcomes of the innervated and thinned anterolateral thigh flap in reconstruction of upper limb defects[J]. Plast Surg Int, 2014,2014:489012. DOI: 10.1155/2014/489012.
[26]	吴包金, 江华. 失神经皮瓣移植感觉功能恢复的研究进展[J].中华整形外科杂志,2004,20(3):231-233. DOI: 10.3760/j.issn:1009-4598.2004.03.022.
[27]	沈余明, 覃凤均, 杜伟力, 等. 濒临截肢四肢高压电烧伤患者的保肢策略[J].中华烧伤杂志,2019,35(11):776-783. DOI: 10.3760/cma.j.issn.1009-2587.2019.11.003.
[28]	陈毅, 林平, 吴咏军, 等. 神经生长因子和第10号染色体同源丢失性磷酸酶-张力蛋白基因双基因修饰骨髓间充质干细胞促进周围神经再生[J].中华手外科杂志,2020,36(4):290-295. DOI: 10.3760/cma.j.cn311653-20190822-00233.
[29]	丁文龙, 温蔚, 谢志新. bFGF对同种异体神经移植后周围神经再生的影响[J].解剖学杂志,2002,25(2):141-145. DOI: 10.3969/j.issn.1001-1633.2002.02.010.

下载: 全尺寸图片幻灯片

1 无神经吻合的股前外侧皮瓣分区示意图

注：A区为皮瓣的近心端，C区为皮瓣的远端，B/D区为皮瓣两侧区域，E区为皮瓣中央区域

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2 无神经吻合的股前外侧皮瓣修复患者手腕及手背创面过程及术后皮瓣感觉测试。2A.急诊伤情；2B.左股前外侧皮瓣设计；2C.左股前外侧皮瓣的切取；2D.术后2周，患者出院时皮瓣成活；2E.术后6个月皮瓣感觉测试的分区；2F.皮瓣痛觉测试；2G.皮瓣触觉测试；2H.皮瓣冷觉测试；2I.皮瓣温觉测试；2J.皮瓣两点辨别觉测试

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表表1 4组手腕及手背部创面患者采用无神经吻合的股前外侧皮瓣修复后5个区的感觉恢复情况（例）

组别	例数	A区					B区					C区
组别	例数	痛觉	触觉	冷觉	温觉	2-PD	痛觉	触觉	冷觉	温觉	2-PD	痛觉	触觉	冷觉	温觉	2-PD
6个月组	20	6	5	5	3	0	3	4	3	2	0	2	3	3	1	0
12个月组	20	16 ^a	17 ^a	16 ^a	9 ^b	1	10 ^bd	10 ^bd	9 ^bd	3 ^d	0	8 ^bf	5 ^f	7 ^f	1 ^f	0
18个月组	20	19	18	19	16 ^c	1	17 ^c	16 ^c	17 ^e	14 ^e	1	12 ^d	11 ^d	13 ^d	10 ^de	1
24个月组	20	19	19	19	17	2	18	16	18	14	2	13	12	13	10	1
P值		<0.001	<0.001	<0.001	<0.001	0.899	<0.001	<0.001	<0.001	<0.001	0.611	0.001	0.006	0.002	<0.001	1.000
注：分组依据为患者手术日与横断面调查日之间的间隔；A区为皮瓣的近心端，C区为皮瓣的远端，B/D区为皮瓣两侧区域，E区为皮瓣中央区域；2-PD为两点辨别觉； P值为各指标总体比较所得；12个月组各指标与6个月组比较， ^a P<0.01, ^b P<0.05;18个月组各指标与12个月组比较， ^c P<0.05， ^e P<0.01；与A区相比， ^d P<0.05， ^f P<0.01

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表表2 4组手腕及手背部创面患者采用无神经吻合的股前外侧皮瓣修复后整体感觉恢复情况（例）

组别	例数	痛觉	触觉	冷觉	温觉	两点辨别觉
6个月组	20	2	3	3	2	0
12个月组	20	10 ^a	11 ^a	10 ^c	4	0
18个月组	20	17 ^b	17 ^b	16 ^b	14 ^d	1
24个月组	20	17	17	17	14	2
P值		<0.001	<0.001	<0.001	<0.001	0.611
注：分组依据为患者手术日与横断面调查日之间的间隔；12个月组各指标与6个月组比较， ^a P<0.01， ^c P<0.05；18个月组各指标与12个月组比较， ^b P<0.05， ^d P<0.01