足踝部高压电烧伤创面修复的带蒂轴型皮瓣选择策略

仲海燕; 陈勇; 杜轩宇; 王倩; 王慜; 邹鸣立; 袁斯明

doi:10.3760/cma.j.cn501225-20230613-00212

足踝部高压电烧伤创面修复的带蒂轴型皮瓣选择策略

doi: 10.3760/cma.j.cn501225-20230613-00212

东部战区总医院烧伤整形科，南京　　210002

基金项目:

江苏省333工程科研项目 BRA2020416

详细信息

通讯作者:
袁斯明，Email：yuansm@163.com

计量
- 文章访问数: 94
- HTML全文浏览量: 24
- PDF下载量: 10
- 被引次数: 0
出版历程
- 收稿日期: 2023-06-13

Selection strategy of pedicled axial flaps for repairing high-voltage electric burn wounds in foot and ankle

Department of Burn and Plastic Surgery, General Hospital of Eastern Theater Command, Nanjing 210002, China

Funds:

The 333 Project Scientific Research Program of Jiangsu Province of China BRA2020416

More Information

Corresponding author: Yuan Siming, Email: yuansm@163.com

摘要

摘要: 目的探讨足踝部高压电烧伤创面修复的带蒂轴型皮瓣选择策略。方法采用回顾性观察性研究方法。2017年1月—2022年12月，东部战区总医院收治16例高压电烧伤后足踝部皮肤软组织缺损患者，其中单侧缺损者11例、双侧缺损者5例。所有患者均为男性，年龄为25~75岁。彻底清创后拟用皮瓣修复的创面面积为5.0 cm×4.0 cm~12.0 cm×8.0 cm。术前采用彩色多普勒超声、CT血管造影、数字减影血管造影等充分评估患肢血管损伤程度，明确血管网的分布和交通吻合情况，及早应用具有可靠血运的带蒂轴型皮瓣修复创面，皮瓣面积为3.0 cm×2.0 cm~13.0 cm×8.0 cm。供瓣区创面采用头部刃厚皮或大腿中厚皮修复。统计足踝部各区创面采用的皮瓣情况，术后观察皮瓣和皮片成活情况。术后随访观察皮瓣外观、患者行走功能。末次随访，采用美国足踝外科协会踝-后足评分系统评估足踝部功能并评级。结果采用逆行足背皮瓣修复2个趾区创面，采用足底内侧皮瓣修复3个内踝区创面、2个足跟区创面，采用逆行足底内侧皮瓣修复2个足底前区合并趾区创面，采用逆行足内侧皮瓣修复2个足底前区合并趾区创面、5个足底前区创面，采用趾足底固有动脉皮瓣修复1个趾区创面，采用外踝上穿支皮瓣修复1个足背区创面、1个外踝区创面，采用腓肠神经营养血管皮瓣修复1个外踝区创面、1个足背区创面。1例患者术后皮瓣出现静脉回流障碍，经治疗后成活；其余皮瓣和皮片术后完全成活。术后随访6~24个月，皮瓣外观较佳，患者行走功能正常。末次随访时，患者足踝部功能评分为76~95分，评级为优者11例、良者5例。结论根据足踝部高压电烧伤情况，早期彻底清创，术前采用影像学检查方法评估患肢血管情况，选择血运可靠的带蒂轴型皮瓣是修复足踝部高压电烧伤创面及重建相关功能的较好方法。
- 烧伤，电 /
- 足 /
- 踝 /
- 带蒂轴型皮瓣 /
- 皮肤软组织缺损 /
- 创面修复
Abstract: Objective To explore the selection strategy of pedicled axial flaps for repairing high-voltage electric burn wounds in foot and ankle. Methods The retrospective observational research method was used. From January 2017 to December 2022, 16 patients with skin and soft tissue defects in foot and ankle after high-voltage electric burns were treated in General Hospital of Eastern Theater Command, including 11 cases of unilateral defect and 5 cases of bilateral defect. All patients were male, aged from 25 to 75 years. After thorough debridement, the area of the defect to be repaired with the flap was 5.0 cm×4.0 cm to 12.0 cm×8.0 cm. Before operation, the color Doppler ultrasound, computed tomography angiography, or digital subtraction angiography was used to fully evaluate the degree of vascular injury in the affected limb and to identify the distribution and traffic anastomosis of vascular network. Pedicled axial flaps with reliable blood supply were used to repair the wounds as soon as possible, and the area of flaps ranged from 3.0 cm×2.0 cm to 13.0 cm×8.0 cm. The wound in the donor area of flaps was repaired with split-thickness skin graft from head or medium-thickness skin graft from thigh. The flap repair of wounds in various areas of the ankle and foot was recorded. The postoperative survivals of the flaps and skin grafts were observed after surgery. The postoperative appearance of flaps and walking function of patients were followed up. At the last follow-up, the foot and ankle function was evaluated and rated using the American Association of Foot and Ankle Surgeons Ankle Posterior Foot Scoring System. Results Two wounds in toe area were repaired with reverse dorsal pedis flaps, 3 wounds in medial ankle area and 2 wounds in heel area were repaired with medial plantar flaps, 2 wounds in anterior plantar area combined with toe area were repaired with reverse medial plantar flaps, 2 wounds in anterior plantar area combined with toe area and 5 wounds in anterior plantar area were repaired with reverse medial pedis flaps, 1 wound in toe area was combined with proper plantar digital artery flap, 1 dorsal pedis wound and 1 lateral malleolus wound were repaired with lateral supramalleolar perforator flaps, and 1 lateral malleolus wound and 1 dorsal pedis wound were repaired with sural neurovascular flap. One flap had venous reflux disorder after surgery and survived after treatment, while the other flaps and skin grafts survived completely after surgery. During the follow-up of 6 to 24 months after operation, the appearance of the flaps was good, and the walking function of patients was normal. At the last follow-up, the functional score of foot and ankle was 76 to 95, which was evaluated as excellent in 11 cases and good in 5 cases. Conclusions According to the condition of high-voltage electric burn in foot and ankle, early and thorough debridement, preoperative imaging examination to evaluate blood vessels of the affected limb, and selection of pedicled axial flap with reliable blood supply are good methods for wound repair and related functional reconstruction of high-voltage electric burn in foot and ankle.
- Burns, electric /
- Foot /
- Ankle /
- Pedicled axial flap /
- Skin and soft tissue defect /
- Wound repair
仲海燕：实施手术、采集资料、分析数据、撰写论文；陈勇、杜轩宇、王倩、王慜、邹鸣立：实施手术、采集资料；袁斯明：酝酿和设计研究、实施手术、修改论文

所有作者均声明不存在利益冲突

HTML全文

下载: 全尺寸图片幻灯片

1 不同血供基础的足踝部高压电烧伤创面修复的皮瓣选择策略及皮瓣修复区域

下载: 全尺寸图片幻灯片

2 逆行足底内侧皮瓣修复例1患者右足足底前区合并趾区高压电烧伤创面。2A.入院时可见右足拇趾及跖趾关节电烧伤创面基底苍白、部分肌腱外露；2B.术前数字减影血管造影显示足部血管网，足底内侧动脉深支与足底深弓在足底前端吻合；2C.清创后可见右足拇趾趾骨、跖趾关节暴露及皮瓣设计；2D.术中切取皮瓣后；2E.术后14 d，移植皮瓣及皮片成活，皮瓣外观略显臃肿；2F.术后18个月，皮瓣外观良好

下载: 全尺寸图片幻灯片

3 逆行足背皮瓣修复例2患者右足趾区高压电烧伤创面。3A.入院时可见右足跖趾关节和足弓内侧电烧伤创面有黑褐色焦痂，部分炭化；3B.术前CT血管造影显示足背动脉的足底深支与足底深弓吻合；3C.清创后可见跖趾关节处骨与关节腔暴露；3D.逆行足背皮瓣修复跖趾关节创面及头部刃厚皮修复供瓣区后7 d，皮瓣及皮片均成活；3E、3F.分别为术后12个月随访时右足左侧及背侧，皮瓣外观好，供瓣区无明显瘢痕增生

下载: 全尺寸图片幻灯片

4 外踝上穿支皮瓣修复例3患者右足足背区高压电烧伤创面。4A.入院时可见右侧小腿下段、足踝部黑色焦痂创面，部分肌腱、肌肉组织炭化；4B.数字减影血管造影（DSA）显示胫后动脉、腓动脉存在，胫前动脉闭塞，腓动脉在外踝上发出2条穿支；4C.第1次清创后可见右小腿远端、足背区、外踝区大面积软组织缺损，伴有胫骨下段骨外露；4D.设计外踝上穿支皮瓣；4E.术中显露外踝上腓动脉的2条穿支，与术前DSA情况一致；4F.术后6个月随访时，皮瓣外观好

下载: 全尺寸图片幻灯片

参考文献(25)

[1]	魏伟,张庆富.电烧伤和热力烧伤皮肤的组织学观察[J].中华烧伤杂志,2020,36(6):425.DOI: 10.3760/cma.j.issn.1009-2587.2020.06.102.
[2]	杜伟力,沈余明,胡骁骅,等.巨大腹壁下动脉脐旁穿支皮瓣修复腕部环状高压电烧伤创面的临床效果[J].中华烧伤与创面修复杂志,2023,39(6):527-533.DOI: 10.3760/cma.j.cn501225-20220719-00296.
[3]	贾伟,刘建龙,覃凤均,等. 高压电烧伤合并肢体血管损伤治疗10年回顾性分析[J]. 中国普通外科杂志,2022,31(6):760-766. DOI: 10.7659/j.issn.1005-6947.2022.06.008.
[4]	狄海萍,李永林,邢培朋,等.皮瓣修复腕部高压电烧伤创面的手术时机选择[J].中华显微外科杂志,2019,42(2):166-169.DOI: 10.3760/cma.j.issn.1001-2036.2019.02.016.
[5]	AggarwalS,MaitzP,KennedyP.Electrical flash burns due to switchboard explosions in New South Wales--a 9-year experience[J].Burns,2011,37(6):1038-1043.DOI: 10.1016/j.burns.2011.01.017.
[6]	刘军,刘建云,余小平. 足踝部高压电烧伤的手术治疗[J]. 临床医学,2020,40(10):10-12. DOI: 10.19528/j.issn.1003-3548.2020.010.004.
[7]	KohD,LimJ,ChenJY,et al.Flexor hallucis longus transfer versus turndown flaps augmented with flexor hallucis longus transfer in the repair of chronic Achilles tendon rupture[J].Foot Ankle Surg,2019,25(2):221-225.DOI: 10.1016/j.fas.2017.10.019.
[8]	QianW,WangS,WangY,et al.Epidemiological and clinical characteristics of burns in the older person: a seven-year retrospective analysis of 693 cases at a burn center in south-west China[J/OL].Burns Trauma,2020,8:tkz005[2023-06-13].https://pubmed.ncbi.nlm.nih.gov/32346542/.DOI: 10.1093/burnst/tkz005.
[9]	张丕红. 加强规范化诊治　改善电烧伤预后 [J] . 中华烧伤杂志,2019,35 (11): 772-775. DOI: 10.3760/cma.j.issn.1009-2587.2019.11.002.
[10]	赵黎君,周琴,邹小梅. 鼠神经生长因子联合腹部超薄皮瓣修复手部深度电烧伤创面[J]. 中国美容医学,2022,31(10):31-34. DOI: 10.15909/j.cnki.cn61-1347/r.005286.
[11]	李利根,柴家科.肢体高压电烧伤软组织及血管损伤的影像学判断及临床意义[J].中华烧伤杂志,2020,36(11):1009-1012.DOI: 10.3760/cma.j.cn501120-20190904-00371.
[12]	朱志祥,王松柏.足解剖分区和修复方法[J].实用美容整形外科杂志,1997(3):46-48.
[13]	亢向辉,赵建强,孙杰,等.Flow-through足背皮瓣在拇指撕脱离断伤再植术中的应用[J].中华手外科杂志,2022,38(2):157-158.DOI: 10.3760/cma.j.cn311653-20210511-00159.
[14]	王晓东,魏杰,曹鑫杰,等.腓肠神经营养血管皮瓣修复跟腱周围软组织缺损的临床疗效[J].中华显微外科杂志,2020,43(1):81-85.DOI: 10.3760/cma.j.issn.1001-2036.2020.01.022.
[15]	KarimiH,AkhoondinasabMR,Kazem-ZadehJ,et al.Comparison of the results of early flap coverage with late flap coverage in high-voltage electrical injury[J].J Burn Care Res,2017,38(2):e568-e573.DOI: 10.1097/BCR.0000000000000422.
[16]	SauerbierM,OferN,GermannG,et al.Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity[J].Plast Reconstr Surg,2007,119(2):605-615.DOI: 10.1097/01.prs.0000246512.47204.da.
[17]	JanisJE,KhansaI,LehrmanCR,et al.Reconstructive management of devastating electrical injuries to the face[J].Plast Reconstr Surg,2015,136(4):839-847.DOI: 10.1097/PRS.0000000000001619.
[18]	ZeidermanMR,PuLLQ.Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma[J/OL].Burns Trauma,2021,9:tkab024[2023-06-13].https://pubmed.ncbi.nlm.nih.gov/34345630/.DOI: 10.1093/burnst/tkab024.
[19]	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修复下肢大面积软组织缺损[J].中华显微外科杂志,2020,43(6):535-539.DOI: 10.3760/cma.j.cn441206-20200314-00150.
[20]	OuQ,WuP,PanD,et al.Combined transfer by several perforator skin flaps to cover an extensive and multiplanar wound on the foot and ankle[J].J Plast Reconstr Aesthet Surg,2022,75(10):3751-3760.DOI: 10.1016/j.bjps.2022.06.081.
[21]	夏成德,狄海萍,邢培朋,等.游离股薄肌肌瓣联合腓肠神经移植重建腕部电烧伤患者手屈指和感觉功能的效果[J].中华烧伤与创面修复杂志,2023,39(3):228-233.DOI: 10.3760/cma.j.cn501225-20221203-00525.
[22]	CastroJC, ColtroPS, MillanLS, et al. Early application of microsurgical flaps in the electric burns of extremities: a two institutional case series[J]. J Burn Care Res, 2018,39(6):1037-1042. DOI: 10.1093/jbcr/irx010.
[23]	赵学刚,张庆富.电烧伤截肢的预测因子和重建管理[J].中华烧伤与创面修复杂志,2023,39(8):730.DOI: 10.3760/cma.j.issn.2097-1109.2023.08.101.
[24]	仓正强,倪小冬,王慜,等.足底内侧皮瓣在踝周软组织缺损修复中的应用[J].组织工程与重建外科杂志,2019,15(1):29-31.DOI: 10.3969/j.issn.1673-0364.2019.01.008.
[25]	徐强,张锡平,王镖,等.远端蒂腓肠神经营养血管皮瓣的解剖及临床应用[J].实用骨科杂志,2020,26(3):228-231.