精准皮瓣外科理念下逆行股前外侧皮瓣修复膝关节前方创面的临床效果

何晓清; 杨曦; 石岩; 段家章; 董凯旋; 徐月仙; 徐永清; 苏踊跃

doi:10.3760/cma.j.cn501225-20221020-00461

精准皮瓣外科理念下逆行股前外侧皮瓣修复膝关节前方创面的临床效果

doi: 10.3760/cma.j.cn501225-20221020-00461

1.
解放军联勤保障部队第九二〇医院骨科，昆明　　650032
2.
云南省第二人民医院急诊外科，昆明　　650021
3.
云南省第一人民医院骨科，昆明　　650034

基金项目:

云南省创伤骨科临床医学中心 ZX2019-10-01

云南省骨科与运动康复临床医学研究中心 202102AA310068

云南省科技厅科技计划项目 202101AY070001-298, 202201AY070001-288, 202201AY70001-292

联勤保障部队第九二〇医院院内科技计划 2019YGB05, 2020YGD08, 2020YGC02

详细信息

通讯作者:
苏踊跃，Email：drsuyy@qq.com

计量
- 文章访问数: 347
- HTML全文浏览量: 110
- PDF下载量: 62
- 被引次数: 0
出版历程
- 收稿日期: 2022-10-20

Clinical effects of retrograde anterolateral thigh flaps in repairing anterior knee joint wounds under the concept of precise flap surgery

1.
Department of Orthopedic Surgery, the 920th Hospital of Joint Logistic Support Force of PLA, Kunming 650032, China
2.
Department of Emergency Surgery, the Second People's Hospital of Yunnan Province, Kunming 650021, China
3.
Department of Orthopedic Surgery, the First People's Hospital of Yunnan Province, Kunming 650034, China

Funds:

Yunnan Provincial Clinical Orthopaedic Trauma Medical Center ZX2019-10-01

Yunnan Orthopedics and Sports Rehabilitation Clinical Medicine Research Center 202102AA310068

Science and Technology Planning Program of Yunnan Province Science and Technology Department 202101AY070001-298, 202201AY070001-288, 202201AY70001-292

In-hospital Science and Technology Program of the 920th Hospital of Joint Logistic Support Force of PLA 2019YGB05, 2020YGD08, 2020YGC02

More Information

Corresponding author: Su Yongyue, Email: drsuyy@qq.com

摘要

摘要: 目的介绍在精准皮瓣外科理念下用逆行股前外侧皮瓣修复膝关节前方创面的方法并探讨其临床效果。方法采用回顾性观察性研究方法。2014年8月—2022年3月，解放军联勤保障部队第九二〇医院在精准皮瓣外科理念的指导下，用逆行股前外侧皮瓣修复7例患者膝关节前方创面，患者中男6例、女1例，年龄36~66岁，清创后创面面积7 cm×5 cm~15 cm×11 cm。所有病例均行术前CT血管造影（CTA）检查，按照精准皮瓣外科方法评估皮瓣供、受区，选择最佳的皮瓣血管蒂、穿支和旋转点，皮瓣面积为10 cm×6 cm~20 cm×9 cm。将所有皮瓣供区直接缝合。观察术中探查情况与术前CTA情况是否一致。术后观察皮瓣成活情况及并发症发生情况。随访观察皮瓣色泽、外形、质地及并发症发生情况。末次随访时，采用中华医学会手外科学分会断指再植功能评定试用标准的血液循环评价指标评估皮瓣血液循环状态，采用特种外科医院膝关节评分系统评估膝关节功能。结果所有皮瓣术中探查情况与术前CTA情况完全吻合。6例患者术后皮瓣完全成活；1例患者皮瓣末端坏死，经换药后愈合。术后所有皮瓣过度充盈，1周后皮瓣色泽逐渐趋于正常。术后随访7~44个月，所有患者皮瓣色泽、外形、质地良好；1例患者胫骨近端出现局部骨髓炎。末次随访时，7例患者血液循环均为优；膝关节功能评分为69~91分，评定为优者3例、良者3例、中者1例。结论逆行股前外侧皮瓣变异大，应用精准皮瓣外科的方法能在术前精准了解变异情况，从而指导皮瓣设计和切取，实现膝关节前方创面的精准修复，且修复效果良好。
- 外科皮瓣 /
- 软组织损伤 /
- 膝关节 /
- 计算机体层摄影血管造影术 /
- 精准外科 /
- 创面修复
Abstract: Objective To introduce the methods of retrograde anterolateral thigh flaps in repairing anterior knee joint wounds under the concept of precise flap surgery and to explore the clinical effects. Methods A retrospective observational study was conducted. From August 2014 to March 2022, 7 patients with anterior knee joint wounds were treated with retrograde anterolateral thigh flap under the guidance of the concept of precise flap surgery in the 920 ^th Hospital of Joint Logistic Support Force of PLA. Among them, 6 were males and 1 was female, aged 36 to 66 years. The sizes of wounds were 7 cm×5 cm to 15 cm×11 cm after debridement. All the patients were performed with computed tomography angiography (CTA), the donor and recipient sites were evaluated according to the precise flap surgery method, and the optimal pedicle, perforator, and pivot of flaps were chosen. The flap sizes were 10 cm×6 cm to 20 cm×9 cm, and all the donor sites of flaps were sutured directly. The consistency of the intraoperative exploration with preoperative CTA was observed. The flap survival and occurrence of complications were observed after surgery. The color, appearance, texture, and occurrence of complications were followed up. At the last follow-up, the blood supply of flaps was evaluated using the blood circulation evaluation indicators of Chinese Medical Association Hand Surgery Branch's trial criteria for digital replantation function evaluation, and the function of knee joint was evaluated using knee joint scoring system of hospital for special surgery. Results The flap condition of the intraoperative exploration was completely consistent with that of preoperative CTA. The flaps survived completely after surgery in 6 patients, while necrosis at the edge of the flap occurred in 1 patient, which healed after dressing change. All the flaps were hyperperfused after surgery, and the color of the flaps gradually became normal after 1 week. Follow-up of 7 to 44 months showed that the color, appearance, and texture were well in all the patients, while local osteomyelitis at the proximal tibia occurred in 1 patient. At the last follow-up, all the 7 patients had excellent blood circulation; the function score of knee joint was 69 to 91, which was evaluated as excellent in 3 cases, good in 3 cases, and fair in 1 case. Conclusions The retrograde anterolateral thigh flap has large variations, and the application of precise flap surgery method can accurately understand the variations before surgery, guide the design and cutting of the flaps, thus achieving precise repair of anterior knee joint wounds, with good repair outcome.
- Surgical flaps /
- Soft tissue injuries /
- Knee joint /
- Computed tomography angiography /
- Precise surgery /
- Wound repair
何晓清：提出理念，手术操作，论文写作；杨曦、石岩：完善理念，手术操作；段家章、董凯旋：手术操作，资料收集；徐月仙、徐永清：手术操作；苏踊跃：课题设计，手术操作，经费支持

所有作者均声明不存在利益冲突

HTML全文

参考文献(30)

[1]	张功林,葛宝丰,姜世平,等.逆行股前外侧岛状皮瓣和肌皮瓣移植术[J].中华医学杂志,1990,70(12):676-678.
[2]	赵书明,刘亚明,刘娜,等.CT血管造影辅助下逆行股前外侧穿支皮瓣修复膝周或小腿近端皮肤及软组织缺损的临床效果[J].中华烧伤杂志,2021,37(4):356-362.DOI: 10.3760/cma.j.cn501120-20200905-00401.
[3]	BotaO,MeierF,GarzarolliM,et al.Lower leg reconstruction after resection of a squamous cell carcinoma on necrobiosis lipoidica with a pedicled fibula and an extended anterolateral thigh flap-a case report[J].World J Surg Oncol,2023,21(1):38.DOI: 10.1186/s12957-023-02923-z.
[4]	PanSC,YuJC,ShiehSJ,et al.Distally based anterolateral thigh flap: an anatomic and clinical study[J].Plast Reconstr Surg,2004,114(7):1768-1775.DOI: 10.1097/01.prs.0000142416.91524.4c.
[5]	JeongSH,BaikSH,NamgoongS,et al.An algorithmic approach to soft-tissue reconstruction around the knee using anterolateral thigh perforator flap in patients with post-traumatic knee osteomyelitis[J].Front Surg,2023,10:982669.DOI: 10.3389/fsurg.2023.982669.
[6]	ZhangYX,HayakawaTJ,LevinLS,et al.The economy in autologous tissue transfer: part 1. The kiss flap technique[J].Plast Reconstr Surg,2016,137(3):1018-1030.DOI: 10.1097/01.prs.0000479971.99309.21.
[7]	何晓清,杨曦,段家章,等.基于CTA精准皮瓣外科的理念与初步实践[J].中华骨科杂志,2022,42(6):365-373.DOI: 10.3760/cma.j.cn121113-20211119-00669.
[8]	徐永清,何晓清,朱跃良.股前外侧皮瓣顺行切取方法介绍[J].中华显微外科杂志,2016,39(6):621-623.DOI: 10.3760/cma.j.issn.1001-2036.2016.06.037.
[9]	潘生德,顾玉东,侍德.中华医学会手外科学会上肢部分功能评定试用标准[J].中华手外科杂志,2000(3):130.DOI: 10.3760/cma.j.issn.1005-054X.2000.03.003.
[10]	InsallJN,RanawatCS,AgliettiP,et al.A comparison of four models of total knee-replacement prostheses[J].J Bone Joint Surg Am,1976,58(6):754-765.
[11]	LiuWC,ChangCH,LuCC,et al.Reconstruction of massive knee defects with extensor mechanism deficiency through concurrent anterolateral thigh flap and autogenous hamstring tendon: a report of two cases[J].J Orthop Surg (Hong Kong),2020,28(2):2309499020935994.DOI: 10.1177/2309499020935994.
[12]	郑健雄,卓灵剑,胡稷杰.膝降动脉穿支皮瓣的临床应用及解剖研究进展[J].中华创伤骨科杂志,2017,19(9):817-821.DOI: 10.3760/cma.j.issn.1671-7600.2017.09.016.
[13]	张净宇,胡宏宇,高顺红,等.膝上外侧动脉穿支皮瓣逆行修复膝关节周围软组织缺损的临床观察[J].中华解剖与临床杂志,2016,21(6):570-572.DOI: 10.3760/cma.j.issn.2095-7041.2016.06.023.
[14]	于吉文,刘建,张成安,等.膝降动脉隐支岛状皮瓣修复膝关节周围皮肤缺损[J].中华创伤骨科杂志,2008,10(2):194-195.DOI: 10.3760/cma.j.issn.1671-7600.2008.02.027.
[15]	AlshomerF,AlhujayriA,AlthubaitiG.Pedicled peroneal artery perforator flap for knee defect reconstruction: case presentation and literature discussion[J].Plast Reconstr Surg Glob Open,2018,6(11):e2034.DOI: 10.1097/GOX.0000000000002034.
[16]	ChiangIH,WuCC,ChenSG,et al.Pedicled medial sural perforator flap for the reconstruction of knee defects[J].Int Wound J,2017,14(4):673-677.DOI: 10.1111/iwj.12668.
[17]	AminNH,SpeirsJN,SimmonsMJ,et al.Total knee arthroplasty wound complication treatment algorithm: current soft tissue coverage options[J].J Arthroplasty,2019,34(4):735-742.DOI: 10.1016/j.arth.2018.12.016.
[18]	徐达传, 钟世镇, 刘牧之,等. 股前外侧部皮瓣的解剖学一个新的游离皮瓣供区[J]. 临床应用解剖学杂志, 1984,2(3): 158-160.DOI: 10.13418/j.issn.1001-065x.1984.03.012.
[19]	高秋芳,牛雪涛,马彬,等.股前外侧带蒂皮瓣修复坏死性筋膜炎所致会阴部皮肤软组织缺损的效果[J].中华烧伤杂志,2020,36(8):738-742.DOI: 10.3760/cma.j.cn501120-20190528-00257.
[20]	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.
[21]	郑和平,张发惠,陈秀清,等.股前外侧逆行皮瓣的应用解剖学[J].福建医学院学报,1994,28(1):14-16.
[22]	WeiFC,JainV,CelikN,et al.Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps[J].Plast Reconstr Surg,2002,109(7):2219-2226; discussion 2227-2230.DOI: 10.1097/00006534-200206000-00007.
[23]	LakhianiC,LeeMR,Saint-CyrM.Vascular anatomy of the anterolateral thigh flap: a systematic review[J].Plast Reconstr Surg,2012,130(6):1254-1268.DOI: 10.1097/PRS.0b013e31826d1662.
[24]	张驰,游兴,吕美娟,等.超回流技术在逆行股前外侧斜支皮瓣修复小腿上段软组织缺损的应用[J].中华显微外科杂志,2019,42(3):209-212.DOI: 10.3760/cma.j.issn.1001-2036.2019.03.001.
[25]	ShiehSJ,ChiuHY,YuJC,et al.Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation[J].Plast Reconstr Surg,2000,105(7):2349-2357; discussion 2358-2360.DOI: 10.1097/00006534-200006000-00006.
[26]	刘磊,王燕妮,于静,等.增强CT及三维重建技术在扩张皮瓣整复小儿烧伤后瘢痕中的应用效果[J].中华烧伤杂志,2019,35(10):715-719.DOI: 10.3760/cma.j.issn.1009-2587.2019.10.003.
[27]	王成德,王爱,孙继玲,等.三维CT血管造影辅助下游离腓动脉穿支皮瓣修复前足皮肤软组织缺损创面的临床效果[J].中华烧伤与创面修复杂志,2022,38(7):661-666.DOI: 10.3760/cma.j.cn501120-20210914-00317.
[28]	朱国明,何涛,徐朝,等.基于美学理念的逆行股前外侧穿支皮瓣修复膝关节周围软组织缺损[J].中华整形外科杂志,2019,35(6):584-587.DOI: 10.3760/cma.j.issn.1009-4598.2019.06.013.
[29]	MinK,HongJP,SuhHP.Risk factors for partial flap loss in a free flap: a 12-year retrospective study of anterolateral thigh free flaps in 303 lower extremity cases[J].Plast Reconstr Surg,2022,150(5):1071e-1081e.DOI: 10.1097/PRS.0000000000009646.
[30]	HallockGG.Musculoseptocutaneous perforator of anterolateral thigh flap: a clinical study[J].Plast Reconstr Surg,2022,149(1):148e-149e.DOI: 10.1097/PRS.0000000000008642.

下载: 全尺寸图片幻灯片

1 术前CT血管造影（CTA）断层及三维重建确定逆行股前外侧皮瓣的血管蒂。1A.术前CTA显示旋股外侧动脉降支发出穿支（红色箭头）位置；1B.术前CTA显示旋股外侧动脉与股深动脉终末支吻合点（黄色箭头），即逆行股前外侧皮瓣的旋转点；1C.术前CTA显示创面（蓝色箭头）位置；1D.皮瓣穿支（红色箭头）、旋转点（黄色箭头）及创面（蓝色箭头）在旋股外侧动脉降支三维重建影像上的对应位置

下载: 全尺寸图片幻灯片

2 精准皮瓣外科理念下逆行股前外侧皮瓣修复患者右膝关节骨折脱位内固定术后严重感染创面。2A.清创后膝关节前方创面；2B.术前右腿CT血管造影三维重建影像；2C.术前精确设计皮瓣，标记血管蒂走行、穿支位置、皮瓣大小和旋转点；2D.术中切取逆行股前外侧皮瓣；2E.皮瓣覆盖创面并缝合后即刻；2F.术后11个月复查，皮瓣色泽及外形良好

下载: 全尺寸图片幻灯片