以膝降动脉为蒂的游离股前外侧穿支皮瓣修复小腿保肢术后创面的临床效果

李雷; 周正虎; 鞠文; 邓伟; 陈鲁成; 李昌松; 夏宇航; 巨积辉

doi:10.3760/cma.j.cn501225-20220725-00308

以膝降动脉为蒂的游离股前外侧穿支皮瓣修复小腿保肢术后创面的临床效果

doi: 10.3760/cma.j.cn501225-20220725-00308

苏州瑞华骨科医院创伤骨科，苏州　　215104

基金项目:

苏州市卫生科教临床重点病种诊疗技术专项 LCZX202130

详细信息

通讯作者:
巨积辉，Email：jjh2006@263.net

计量
- 文章访问数: 186
- HTML全文浏览量: 68
- PDF下载量: 13
- 被引次数: 0
出版历程
- 收稿日期: 2022-07-25

Clinical effects of free anterolateral thigh perforator flap pedicled with descending genicular artery in repairing wounds after lower leg limb-sparing surgery

Department of Orthopaedics Trauma, Suzhou Ruihua Orthopedic Hospital, Suzhou 215104, China

Funds:

Special Project on Diagnosis and Treatment Technology of Clinical Key Disease Species of Health Science and Education in Suzhou LCZX202130

More Information

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

摘要

摘要: 目的探讨以膝降动脉为蒂的游离股前外侧穿支皮瓣修复小腿保肢术后创面的临床效果。方法采用回顾性观察性研究方法。2019年1月—2021年6月，苏州瑞华骨科医院收治12例符合入选标准的小腿保肢术后创面患者，其中男6例、女6例，年龄17~74岁，原始创面面积为17 cm×9 cm~40 cm×15 cm，5例患者创面有感染。创面均采用对侧游离大腿股前外侧穿支皮瓣（面积为18 cm×10 cm~37 cm×9 cm）修复，皮瓣动脉均吻合于膝降动脉，供区创面直接缝合；7例患者另移植对侧大腿刃厚皮片覆盖皮瓣无法覆盖的剩余创面，供区创面予油纱覆盖。术中记录皮瓣携带的穿支类型、受区动静脉类型。术后记录皮瓣成活和血管危象发生情况、皮片成活情况、供受区创面愈合情况、皮瓣移植术后患者住院时间。随访记录皮瓣色泽和质地、小腿再次感染情况及骨折愈合情况。末次随访时根据陈中伟断肢再植的功能评定标准评价患者的保肢效果。结果皮瓣携带的穿支类型：仅携带旋股外侧动脉降支者6例，仅携带旋股外侧动脉斜支者3例，携带旋股外侧动脉降支+旋股外侧动脉斜支并吻合穿支进行内增压者3例。皮瓣受区动脉类型：膝降动脉主干者1例，膝降动脉隐支者8例，膝降动脉关节支者3例；受区静脉类型：1条膝降动脉伴行静脉+1条大隐静脉分支者8例、2条大隐静脉分支者4例。术后皮瓣均成活且无血管危象，皮片也均成活；供受区创面均愈合。皮瓣移植术后患者住院时间为13~79 d。随访6~23个月，12例患者皮瓣色泽、质地均良好，小腿创面均无感染；5例患者术后骨折愈合后去除内/外固定，7例患者术后骨折未愈合再次行植骨内固定后切口均愈合无感染。末次随访时，患者的保肢效果评价：优者7例、良者4例、可者1例。结论以膝降动脉为蒂的游离股前外侧穿支皮瓣可有效修复小腿保肢术后创面、控制感染，不增加远端肢体血管再次损伤风险，患者住院时间短，可获得较佳保肢效果，值得临床推广。
- 外科皮瓣 /
- 腿损伤 /
- 膝降动脉 /
- 股前外侧穿支皮瓣 /
- 创面修复
Abstract: Objective To explore the clinical effects of free anterolateral thigh perforator flap pedicled with descending genicular artery in repairing wounds after lower leg limb-sparing surgery. Methods A retrospective observational study was conducted. From January 2019 to June 2021, 12 patients with wounds after lower leg limb-sparing surgery who met the inclusion criteria were admitted to Suzhou Ruihua Orthopedic Hospital, including 6 males and 6 females, aged 17 to 74 years, with original wound area ranging from 17 cm×9 cm to 40 cm×15 cm. Five patients had infection in wounds. The wounds were all repaired by free anterolateral thigh perforator flap from contralateral thigh, with area of 18 cm×10 cm to 37 cm×9 cm. The artery of flap was anastomosed with the descending genicular artery, and the wounds in donor areas were sutured directly. Seven patients were transplanted with split-thickness skin grafts from the contralateral thigh to cover the remaining wounds that can not be covered by flap and the wounds in donor areas were covered with gauze. During the operation, the types of perforating branch carried by flap and the types of arteries and veins in recipient areas were recorded. The survival and occurrence of vascular crisis of flap, the survival of skin graft, the wound healing in donor and recipient areas, and the length of hospital stay after flap transplant surgery were recorded. During follow-up, the color and texture of flap, reinfection in lower leg, and fracture healing were recorded. At the last follow-up, the limb salvage function of patients was evaluated according to the functional evaluation criteria of Chen Zhongwei's amputated limb replantation. Results The types of perforating branches carried by flaps were as follows: 6 cases of only carrying the descending branch of the lateral circumflex femoral artery, 3 cases of only carrying the oblique branch of the lateral circumflex femoral artery, and 3 cases of carrying the descending branch of the lateral circumflex femoral artery and oblique branch of the lateral circumflex femoral artery after internal pressurization anastomosis. The types of arteries in the recipient area of flap were as follows: one case of main trunk of the descending genicular artery, 8 cases of the saphenous branch of the descending genicular artery, and 3 cases of the articular branch of the descending genicular artery. The types of veins in the recipient area of flap were as follows: 8 cases of one accompanying vein of the descending genicular artery and one branch of the great saphenous vein, and 4 cases of two branches of the great saphenous vein. All the flaps survived without vascular crisis, and all the skin grafts also survived. The wounds in the donor and recipient areas were all healed. The length of hospital stay of patient after flap transplant surgery ranged from 13 to 79 days. During the follow-up of 6 to 23 months, the color and texture of flap were both good, with no infection in lower leg wound. Internal or external fixation were removed after fracture healing in 5 patients, and bone graft internal fixation was performed in 7 patients whose fractures were not healed after surgery and all the incisions healed without infection. At the last follow-up, the limb salvage effect of patients was evaluated as followings: excellent in 7 patients, good in 4 patients, and fair in one patient. Conclusions Free anterolateral thigh flap pedicled with descending genicular artery can effectively repair the wounds after lower leg limb-sparing surgery and control infection with short length of hospital stay, while not increasing the risk of secondary injury of distal limb vessels. Thus, it can obtain satisfactory limb salvage effect which is worthy of clinical promotion.
- Surgical flaps /
- Leg injuries /
- Descending genicular artery /
- Anterolateral thigh perforator flap /
- Wound repair
李雷：酝酿和设计研究、实施手术、采集资料、分析数据、撰写论文；周正虎、鞠文、邓伟、陈鲁成：实施手术、采集资料；李昌松、夏宇航：采集资料；巨积辉：酝酿和设计研究、实施手术、采集资料、分析数据、修改论文

所有作者均声明不存在利益冲突

HTML全文

参考文献(30)

[1]	魏在荣,王达利,黄广涛.毁损性创面的治疗进展[J/CD].中华损伤与修复杂志:电子版,2019,14(2):85-90.DOI: 10.3877/cma.j.issn.1673-9450.2019.02.002.
[2]	李绍光,何红英,张建政.肢体毁损伤要截肢还是保肢[J].中国骨与关节杂志,2021,10(12):881-884.DOI: 10.3969/j.issn.2095-252X.2021.12.001.
[3]	魏在荣,常树森.穿支皮瓣简述[J].中华烧伤杂志,2019,35(7):481-485.DOI: 10.3760/cma.j.issn.1009-2587.2019.07.001.
[4]	唐举玉,徐达传,徐永清,等.特殊形式穿支皮瓣及其衍生术式命名专家共识[J].中华显微外科杂志,2022,45(1):5-13.DOI: 10.3760/cma.j.cn441206-20220114-00010.
[5]	刘元波,朱珊,臧梦青,等.穿支皮瓣研究领域的新技术、新方法[J].中华整形外科杂志,2019,35(9):835-846.DOI: 10.3760/cma.j.issn.1009-4598.2019.09.001.
[6]	柳志锦,巨积辉,周荣,等.带阔筋膜血流桥接型股前外侧穿支皮瓣修复伴伸肌腱缺损的手、足背侧创面[J].中华创伤杂志,2021,37(10):894-899.DOI: 10.3760/cma.j.cn501098-20210326-00204.
[7]	梁尊鸿,潘云川,林志琥,等.游离股前外侧皮瓣及头皮扩张术序贯治疗头皮大面积缺损并颅骨外露感染创面[J].中华显微外科杂志,2018,41(2):186-189.DOI: 10.3760/cma.j.issn.1001-2036.2018.02.024.
[8]	杨力,蔡斌,薛君荣,等.个体化股前外侧皮瓣游离移植修复复杂难愈性创面的临床效果[J].中华烧伤杂志,2020,36(8):730-734.DOI: 10.3760/cma.j.cn501120-20190621-00281.
[9]	顾凡彬,刘小林,朱庆棠.陈氏标准在断肢再植术后功能评价的研究进展[J].中华显微外科杂志,2020,43(1):97-100.DOI: 10.3760/cma.j.issn.1001-2036.2020.01.027.
[10]	JuJH,LiL,ZhouR,et al.Combined application of latissimus dorsi myocutaneous flap and iliac bone flap in the treatment of chronic osteomyelitis of the lower extremity[J].J Orthop Surg Res,2018,13(1):117.DOI: 10.1186/s13018-018-0824-z.
[11]	李雷,巨积辉,周正虎,等.开槽灌洗序贯Flow-through型股前外侧嵌合肌皮瓣治疗胫骨慢性骨髓炎[J].中华显微外科杂志,2019,42(3):223-227.DOI: 10.3760/cma.j.issn.1001-2036.2019.03.004.
[12]	滕云升,刘重,杨亚龙,等.膜诱导技术结合股前外侧皮瓣移植修复小腿复合组织缺损[J].中华显微外科杂志,2018,41(1):14-17.DOI: 10.3760/cma.j.issn.1001-2036.2018.01.004.
[13]	李海,肖顺娥,邓呈亮,等.游离分叶穿支皮瓣修复四肢复杂创面[J].中国修复重建外科杂志,2022,36(1):98-101.DOI: 10.7507/1002-1892.202108084.
[14]	郭永明,刘重,滕云升,等.Flow-through股前外侧皮瓣移植结合骨搬运技术治疗下肢节段性毁损伤[J].中华显微外科杂志,2018,41(4):319-323.DOI: 10.3760/cma.j.issn.1001-2036.2018.04.002.
[15]	周荣,巨积辉,柳志锦,等.多穿支超长股前外侧皮瓣修复足踝部环形创面[J].中华整形外科杂志,2021,37(11):1244-1250.DOI: 10.3760/cma.j.cn114453-20200309-00130.
[16]	钱汉根,黄春辉,沈国良,等.微型筋膜蒂皮瓣在修复小腿骨及内固定外露创面中的应用[J].中华显微外科杂志,2018,41(3):283-284.DOI: 10.3760/cma.j.issn.1001-2036.2018.03.024.
[17]	朱跃良,殷作明,范新宇,等.小腿受区血管缺乏时重建梯的研究[J].中华显微外科杂志,2017,40(4):328-332.DOI: 10.3760/cma.j.issn.1001-2036.2017.04.005.
[18]	周洪翔,何亮,尹东,等.桥式交叉“Y”形血管吻合ALTF移植修复小腿复杂软组织缺损33例[J].中华显微外科杂志,2022,45(1):28-32. DOI: 10.3760/cma.j.cn441206-20210928-00226.
[19]	张净宇,孙文弢,高顺红,等.介绍一种小腿严重创伤后游离皮瓣修复受区血管选择方式[J].中国骨与关节损伤杂志,2017,32(12):1316-1318.DOI: 10.7531/j.issn.1672-9935.2017.12.032.
[20]	KimKN,KimSI,HaW,et al.Popliteal fossa reconstruction with a medial sural artery perforator free flap using the medial sural vessel as the recipient[J].J Plast Surg Hand Surg,2017,51(6):387-392.DOI: 10.1080/2000656X.2017.1279622.
[21]	刘军,黎逢峰,吴永伟,等.以膝降动脉为受区血管的股前外侧皮瓣在膝关节周围创面的临床应用[J].中华显微外科杂志,2018,41(4):324-328.DOI: 10.3760/cma.j.issn.1001-2036.2018.04.003.
[22]	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.
[23]	张万锋,高秋芳,张小锋,等.膝降动脉隐支穿支皮瓣修复老年烧伤患者膝部深度创面的效果[J].中华烧伤杂志,2017,33(7):444-447.DOI: 10.3760/cma.j.issn.1009-2587.2017.07.012.
[24]	柳志锦,巨积辉,刘胜哲,等.内增压型股前外侧双叶皮瓣修复四肢创面的临床应用[J].中华创伤杂志,2020,36(10):920-925.DOI: 10.3760/cma.j.cn501098-20200615-00445.
[25]	周正虎,巨积辉,李雷,等.DSA在膝降动脉-隐动脉链式穿支蒂皮瓣修复膝关节周围创面中的临床应用[J].中华显微外科杂志,2021,44(3):298-300.DOI: 10.3760/cma.j.cn441206-20190702-00227.
[26]	李雷,巨积辉,周正虎,等.DSA技术结合多普勒彩超在股前外侧皮瓣穿支定位中的应用[J].中国临床解剖学杂志,2020,38(3):331-334.DOI: 10.13418/j.issn.1001-165x.2020.03.017.
[27]	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.
[28]	常树森,何春念,金文虎.股前外侧皮瓣的供区并发症[J].中华显微外科杂志,2018,41(1):101-104.DOI: 10.3760/cma.j.issn.1001-2036.2018.01.030.
[29]	张世民.皮瓣远侧血液循环增强技术:外增压、内增压和超回流[J].中华显微外科杂志,2016,39(6):524-525.DOI: 10.3760/cma.j.issn.1001-2036.2016.06.002.
[30]	张皖侠,巨积辉,汪朝平,等.血流桥接型股前外侧皮瓣修复小腿创面的围手术期护理[J].实用手外科杂志,2019,33(4):474-476.DOI: 10.3969/j.issn.1671-2722.2019.04.036.

下载: 全尺寸图片幻灯片

1 以膝降动脉为蒂的游离股前外侧穿支皮瓣修复左小腿保肢术后近端内侧半环形创面。1A.术前X线片显示左胫骨上段粉碎性骨折；1B.急诊见左小腿近端离断，内侧皮肤挫伤重；1C.左小腿再植术后小腿近端内侧半环形创面形成；1D.急诊保肢术后造影复查显示腘动脉通畅、膝降动脉存在；1E.术中于右大腿设计股前外侧穿支皮瓣；1F.选择膝降动脉隐支作为皮瓣受区动脉，选择2条大隐静脉分支作为皮瓣受区静脉；1G.皮瓣覆盖后剩余部分创面切取右大腿刃厚皮片移植覆盖；1H.右大腿供区创面愈合好；1I.皮瓣移植术后13个月随访，骨折愈合；1J.皮瓣移植术后18个月随访，皮瓣色泽良好，无破溃或感染

下载: 全尺寸图片幻灯片