基于多层CT血管成像的穿支皮瓣设计和切取的三维导航流程的建立及其临床应用效果

尹其翔; 糜菁熠; 蔡华忠; 周峰; 姚群; 华雍

doi:10.3760/cma.j.cn501225-20240407-00123

基于多层CT血管成像的穿支皮瓣设计和切取的三维导航流程的建立及其临床应用效果

doi: 10.3760/cma.j.cn501225-20240407-00123

尹其翔¹,
糜菁熠^2, ,,
蔡华忠¹,
周峰¹,
姚群²,
华雍²

1.
江苏大学附属医院急诊中心,镇江　　212001
2.
无锡市第九人民医院运动医学科,无锡　　214062

基金项目:

上海市周围神经显微外科重点实验室/卫健委手功能重点实验室 20DZ2270200

镇江市科技创新资金 SH2021051, SH2023033

无锡市卫生健康委重大科研项目 Z202108

无锡市卫生健康委员会推广应用项目 T202346

无锡市科技发展基金项目面上项目 Y20232020

镇江市科技计划 SH2024043

详细信息

通讯作者:
糜菁熠,Email：mijingyi@suda.edu.cn

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出版历程
- 收稿日期: 2024-04-07

Establishment and clinical application effects of a three-dimensional navigation process for design and resection of perforator flaps based on multi-detector computed tomography angiography

1.
Department of Emergency, Affiliated Hospital of Jiangsu University, Zhenjiang 212001, China
2.
Department of Sports Medicine, Wuxi No. 9 People's Hospital, Wuxi 214062, China

Funds:

Shanghai Key Laboratory of Peripheral Nerve and Microsurgery/Key Laboratory of Hand Reconstruction of National Health Commission 20DZ2270200

Zhenjiang Science and Technology Innovation Fund SH2021051, SH2023033

Major Scientific Research Project of Wuxi Municipal Health Commission Z202108

Promotion and Application Project of Wuxi Municipal Health Commission T202346

Wuxi Science and Technology Development Fund Project Y20232020

Zhenjiang Science and Technology Plan SH2024043

More Information

Corresponding author: Mi Jingyi, Email: mijingyi@suda.edu.cn

摘要

摘要: 目的建立基于多层CT血管成像（MDCTA）的穿支皮瓣设计和切取的三维导航流程,探讨其临床应用效果。方法该研究为回顾性观察性研究。2021年1月—2023年10月,江苏大学附属医院收治7例、无锡市第九人民医院收治6例符合入选标准的创伤后四肢皮肤软组织缺损患者,其中男8例、女5例,年龄21~68岁。创面位于手部者9例、足部者4例。清创后创面面积为8.0 cm×6.0 cm~18.0 cm×17.0 cm。通过基于MDCTA的三维导航流程,设计并切取14块穿支皮瓣,包括11块游离股前外侧穿支皮瓣、3块含腓肠神经营养血管链的腓动脉穿支带蒂皮瓣,皮瓣面积9.0 cm×6.0 cm~20.0 cm×15.0 cm。6块皮瓣供区创面直接缝合,8块皮瓣供区创面行皮片移植。比较术前导航显示的穿支位置、类型及其来源动脉同术中实际探查的一致性。术后即刻,按照自定义标准评价皮瓣覆盖创面情况。观察术后皮瓣成活情况。观察并记录随访期间并发症发生情况。末次随访时,观察皮瓣外观,参照中华医学会手外科学会上肢部分功能评定试用标准评定皮瓣血运和9例手部创伤者手部功能,采用美国矫形足踝外科协会踝-后足评分系统评定4例足部创伤者足部功能。结果术前导航显示的穿支位置、类型及其来源动脉与术中实际探查结果一致。术后即刻,11块皮瓣覆盖创面情况为优、3块为中。术后,13块皮瓣完全成活；1块皮瓣部分坏死,经移植大腿全厚皮后愈合。患者术后获得4~24个月随访,1例患者发生皮瓣下血肿、1例患者发生局部感染。末次随访时,所有患者皮瓣色泽、质地均良好,5例术后皮瓣臃肿者行修薄手术后外观良好；12块皮瓣血运为优、2块皮瓣血运为良；手部创伤者中手部功能为优者2例、良者4例、差者3例,足部创伤者中足部功能为优者3例、良者1例。结论基于MDCTA的穿支皮瓣设计和切取的三维导航流程,实现了对皮瓣供区穿支血管及受区皮肤软组织缺损的精准评估。在该三维导航流程指导下,应用游离股前外侧穿支皮瓣和含腓肠神经营养血管链的腓动脉穿支带蒂皮瓣修复四肢皮肤软组织缺损,实现了精准手术,减少了皮瓣供区损伤,临床疗效好。
- 穿支皮瓣 /
- 血管造影术 /
- 成像,三维 /
- 术前导航流程 /
- 创面修复
Abstract: Objective To establish a three-dimensional navigation process for design and resection of perforator flaps based on multi-detector computed tomography angiography (MDCTA) and to explore its clinical application effects. Methods This study was a retrospective observational study. From January 2021 to October 2023, 7 patients and 6 patients with post-traumatic skin and soft tissue defects in extremity and conformed to the inclusion criteria were admitted to the Affiliated Hospital of Jiangsu University and Wuxi No. 9 People's Hospital, respectively. There were 8 males and 5 females, aged 21 to 68 years. Nine patients had wounds on the hand and 4 patients had wounds on the foot. The wound area after debridement ranged from 8.0 cm×6.0 cm to 18.0 cm×17.0 cm. Through the three-dimensional navigation process based on MDCTA, 14 perforator flaps were designed and resected, including 11 free anterolateral thigh perforator flaps and 3 pedicled peroneal artery perforator flaps with sural nerve nutritional vessel chain, with flap size ranging from 9.0 cm×6.0 cm to 20.0 cm×15.0 cm. Six wounds in the flap donor sites were directly sutured, and eight wounds in the flap donor sites were transplanted with skin grafts. The consistency of the location, type, and source of the perforators was compared between the preoperative navigation display and actual intraoperative detection. Immediately after surgery, the coverage of wound by the flap was evaluated according to the self-made criteria. The postoperative flap survival was observed. The occurrence of complications was observed during follow-up. At the last follow-up, the appearance of the flaps was observed, the blood supply of the flaps and the hand function of the 9 patients with hand trauma were evaluated according to the trial standards for evaluation of partial function of upper extremity by the Hand Surgery Society of Chinese Medical Association, and the foot function of the 4 patients with foot trauma was assessed using the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scoring System. Results The location, type, and source of the perforators displayed in preoperative navigation were consistent with the actual intraoperative detection. Immediately after surgery, the coverage of the wounds by 11 flaps was rated as excellent, and that of 3 flaps was rated as moderate. Postoperatively, 13 flaps survived completely, and 1 flap had partial necrosis, which healed after a full-thickness skin grafting from the thigh. Patients were followed up for 4 to 24 months postoperatively, one patient developed a hematoma under the flap, and one patient had local infection. At the last follow-up, the flaps of all patients were good in color and texture, and 5 patients with bloated flaps post operation had good appearance after thinning surgery; the blood supply was excellent in 12 flaps and was good in 2 flaps; among patients with hand trauma, the hand function was rated as excellent in 2 cases, good in 4 cases, and poor in 3 cases; among patients with foot trauma, the foot function was rated as excellent in 3 cases and good in 1 case. Conclusions The three-dimensional navigation process for design and resection of perforator flaps based on MDCTA realizes precise evaluation of perforator vessels in flap donor sites and skin and soft tissue defects in the recipient sites. Guided by the three-dimensional navigation process, the application of free anterolateral thigh perforator flaps and pedicled peroneal artery perforator flaps with sural nerve nutritional vessel chain in repairing skin and soft tissue defects in extremity realizes precise surgery, reducing flap donor site injury and achieving excellent clinical outcomes.
- Perforator flap /
- Angiography /
- Imaging, three-dimensional /
- Preoperative navigation process /
- Wound repair
尹其翔：酝酿和设计研究、实施研究、设计和实施手术、采集数据、分析数据和论文撰写；糜菁熠：直接参与并指导研究,对文章的知识性内容进行审阅,行政、技术或材料支持；蔡华忠、周峰：参与研究、实施手术、采集数据；姚群、华雍：设计、指导、实施手术

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尹其翔：酝酿和设计研究、实施研究、设计和实施手术、采集数据、分析数据和论文撰写；糜菁熠：直接参与并指导研究,对文章的知识性内容进行审阅,行政、技术或材料支持；蔡华忠、周峰：参与研究、实施手术、采集数据；姚群、华雍：设计、指导、实施手术

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图 1 在基于MDCTA的三维导航流程指导下设计并切取游离股前外侧穿支皮瓣修复例1患者手部皮肤软组织缺损的效果。1A.清创后创面伴有肌腱、肌肉外露；1B、1C、1D、1E.分别为行MDCTA后重建出创面模型、在皮瓣供区定位到3条Ⅰ级穿支（箭头所示）、以最左侧穿支为目标穿支设计皮瓣、模拟切取皮瓣并旋转完全覆盖创面后；1F.按术前设计在体表标记皮瓣切取范围及目标穿支的深筋膜穿出点；1G.术中切取皮瓣；1H.术后即刻,皮瓣血运良好、外观稍臃肿；1I.逐层减张缝合供区创面后即刻；1J、1K.分别为术后16个月随访时,手指屈伸功能良好、供区遗留线性瘢痕；1L.术后21个月末次随访时,经2次皮瓣修薄手术后,手部外观良好

注：MDCTA为多层CT血管成像

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图 2 在基于MDCTA三维导航流程指导下设计并切取的含腓肠神经营养血管链的腓动脉穿支带蒂皮瓣修复例2患者足部皮肤软组织缺损的效果。2A.清创后创面伴有骨外露；2B、2C、2D、2E.分别为行MDCTA后重建出创面模型、在皮瓣供区定位到1条腓动脉穿支（箭头所示）、设计皮瓣、模拟切取皮瓣并旋转完全覆盖创面后；2F.术中依据术前设计切开皮瓣蒂部皮肤；2G.术中探查到腓动脉穿支进入皮瓣蒂部；2H.术中完全切开皮瓣,旋转覆盖创面前；2I.术后5 d,皮瓣大部分血运良好,边缘少许淤血； 2J、2K.分别为术后24个月随访时,皮瓣正面观、侧面观,可见皮瓣存活良好,外观稍臃肿；2L.术后24个月随访时,供区愈合良好

注：MDCTA为多层CT血管成像

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