以旋股外侧动脉斜支为蒂并携带阔筋膜的股前外侧穿支皮瓣修复手足毁损性创面并重建功能的效果

葛成伟; 蒋国栋; 程俊楠; 郭礼平; 车志刚; 袁松; 巨积辉

doi:10.3760/cma.j.cn501225-20240508-00163

以旋股外侧动脉斜支为蒂并携带阔筋膜的股前外侧穿支皮瓣修复手足毁损性创面并重建功能的效果

doi: 10.3760/cma.j.cn501225-20240508-00163

苏州瑞华骨科医院手外科,苏州　　215104

基金项目:

苏州市重点学科 SZXK202127

苏州市科技发展计划 SKYD2023026

详细信息

通讯作者:
巨积辉,Email：gkswk2013@163.com

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出版历程
- 收稿日期: 2024-05-08

Effects of anterolateral femoral perforator flaps pedicled with oblique branch of lateral circumflex femoral artery and carrying fascia lata in repairing destructive wounds and rebuilding function of hands or feet

Department of Hand Surgery, Suzhou Ruihua Orthopaedic Hospital, Suzhou 215104, China

Funds:

Key Discipline of Suzhou City SZXK202127

Suzhou Science and Technology Development Plan SKYD2023026

More Information

Corresponding author: Ju Jihui, Email: gkswk2013@163.com

摘要

摘要: 目的探讨采用以旋股外侧动脉斜支为蒂并携带阔筋膜的股前外侧穿支皮瓣修复手足毁损性创面并重建功能的效果。方法该研究为回顾性观察性研究。2022年1月—2023年3月,苏州瑞华骨科医院收治16例符合入选标准的合并伸肌腱缺损的手足毁损性创面患者,其中男12例、女4例,年龄3~63岁。创面位于手部者12例、足部者4例。伸肌腱缺损根数为1~5根,缺损长度为2.5~6.0 cm。清创后创面面积为11.0 cm×5.5 cm~29.0 cm×9.5 cm,采用以旋股外侧动脉斜支为蒂并携带阔筋膜的股前外侧穿支皮瓣修复,皮瓣面积为12.0 cm×6.5 cm~30.0 cm×11.0 cm；用阔筋膜修复缺损伸肌腱,阔筋膜切取面积为8.0 cm×3.0 cm~12.0 cm×8.0 cm。将15例患者皮瓣供区创面直接缝合,1例患者皮瓣供区创面采用下腹部中厚皮片覆盖。术后1周内,观察皮瓣成活情况及皮瓣供受区创面愈合情况。术后随访,统计行修薄整形术或肌腱松解术的患者数。末次随访时,评定手部及足部移植皮瓣感觉功能恢复情况,采用皮瓣综合评价量表评定皮瓣修复疗效,依据中华医学会手外科学分会上肢部分功能评定试用标准评定手部功能。比较术前及末次随访时测量的伤指总主动活动度及采用Maryland足部功能评分标准评定的足部功能。结果 2例患者术后出现皮瓣动脉危象,经及时探查后皮瓣成活,其余患者术后皮瓣存活良好；供受区术后未见明显瘢痕增生或破溃。所有患者获得随访8~16个月,其中6例患者于术后6~7个月行皮瓣修薄整形术,4例患者于术后3~6个月行肌腱松解术。末次随访时,皮瓣感觉功能恢复达S1级者5例、S2级者11例,两点辨别觉仅有1个点；皮瓣修复疗效评分为80~91分,评定为优者5例、良者9例、可者2例；手部功能评定为优者5例、良者5例、可者2例。所有患者均成功重建伤指/趾主动伸直功能,末次随访时的伤指总主动活动度为（225±22）°,明显高于术前的（117±20）°（t=119.59,P<0.05）；末次随访时的足部功能评分为（86±7）分,明显高于术前的（29±7）分（t=222.68,P<0.05）,足部功能评定为优者2例、良者1例、可者1例。结论以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣切取操作相对简单,修复手足创面后外观和功能良好,皮瓣供受区均无明显瘢痕增生。皮瓣携带的阔筋膜可同期修复伸肌腱缺损,改善指/趾体活动。
- 外科皮瓣 /
- 阔筋膜 /
- 手 /
- 足 /
- 斜支 /
- 股前外侧穿支皮瓣 /
- 毁损性创面 /
- 创面修复
Abstract: Objective To investigate the effects of anterolateral femoral perforator flaps pedicled with oblique branch of lateral circumflex femoral artery and carrying fascia lata in repairing destructive wounds and rebuilding function of hands or feet. Methods This study was a retrospective observational study. From January 2022 to March 2023, 16 patients with destructive wounds in hands or feet combined with extensor tendon defects who met the inclusion criteria were admitted to Suzhou Ruihua Orthopedic Hospital, including 12 males and 4 females, aged 3 to 63 years. The wounds were located on the hands in 12 cases and on the feet in 4 cases. The number of defective extensor tendon ranged one to five, and the length of the defect ranged from 2.5 to 6.0 cm. The wound area was 11.0 cm×5.5 cm to 29.0 cm×9.5 cm after debridement. The wounds were repaired with anterolateral femoral perforator flaps pedicled with oblique branch of lateral circumflex femoral artery and carrying fascia lata, and the flap area was 12.0 cm×6.5 cm to 30.0 cm×11.0 cm. The fascia lata was used to repair the extensor tendon defects, and the harvesting area of fascia lata was 8.0 cm×3.0 cm to 12.0 cm×8.0 cm. The wounds in flap donor areas in 15 patients were sutured directly, and the wound in flap donor area in 1 patient was covered with medium-thickness skin graft from lower abdomen. The survival of flaps and the wound healing in donor and recipient areas of flaps were observed within 1 week after operation. The number of patients who underwent thinning and plastic surgery or tenolysis was recorded during postoperative follow-up. At the last follow-up, the recovery of sensory function of the transplanted flaps on hands or feet was evaluated, the efficacy of flap repair was evaluated according to the comprehensive flap evaluation scale, and the function of hands was evaluated according to the trial standards for evaluation of partial function of upper extremity by the Hand Surgery Society of Chinese Medical Association. The following two indexes were compared, including the measured total active motion of the injured fingers and the foot function assessed using Maryland foot function scale between before surgery and at the last follow-up. Results Arterial crisis occurred in flaps in 2 patients after operation, and the flaps survived after timely exploration; the flaps in the rest patients survived well after operation. No obvious scar hyperplasia or ulceration was observed in donor and recipient areas of flaps after operation. All patients were followed up for 8 to 16 months, of which 6 patients underwent flap thinning and plastic surgery 6 to 7 months after operation, and 4 patients underwent tenolysis 3 to 6 months after operation. At the last follow-up, the recovery of sensory function of flaps reached S1 level in 5 cases and S2 level in 11 cases, and the two-point discrimination only had 1 point. The efficacy of flap repair scored 80 to 91, which were evaluated as excellent in 5 cases, good in 9 cases, and acceptable in 2 cases. The hand function was evaluated as excellent in 5 cases, good in 5 cases, and acceptable in 2 cases. The active extension function of the injured finger/toe was reconstructed successfully, and the total active motion of the injured finger was (225±22)° at the last follow-up, which was significantly higher than (117±20)° before surgery (t=119.59,P<0.05); the foot function score was 86±7 at the last follow-up, which was significantly higher than 29±7 before surgery (t=222.68,P<0.05), and the foot function was evaluated as excellent in 2 cases, good in 1 case, and acceptable in 1 case. Conclusions The operation of harvesting the anterolateral femoral perforator flap pedicled with oblique branch of lateral circumflex femoral artery is relatively simple. After the wounds on hands or feet being repaired with the flaps, the appearance and function are good, with no obvious scar hyperplasia in donor and recipient areas of flaps. The fascia lata carried by the flap can repair the extensor tendon defect at the same time and improve the movement of the finger/toe.
- Surgical flaps /
- Fascia lata /
- Hand /
- Foot /
- Oblique branch /
- Anterolateral femoral perforator flaps /
- Destructive wounds /
- Wound repair
葛成伟：酝酿、设计并实施研究,采集、分析并解释数据,起草文章,统计分析；蒋国栋：对文章的知识性内容作批评性审阅；程俊楠、郭礼平、车志刚、袁松：实施研究,采集数据,统计分析；巨积辉：实施研究,对文章的知识性内容作批评性审阅,支持性贡献

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参考文献(32)

[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]	胡雷鸣,段虹昊.同种异体肌腱移植修复手部肌腱缺损及指功能重建的疗效[J].实用骨科杂志,2020,26(1):23-26.
[3]	郭峭峰,张春,黄凯,等.同种异体肌腱移植修复多条指伸肌腱缺损的疗效观察[J].中华手外科杂志,2014,30(6):475-476.DOI: 10.3760/cma.j.issn.1005-054X.2014.06.033.
[4]	郭礼平,柳志锦,周荣,等.带血供阔筋膜瓣修复KuwadaⅢ~Ⅳ型跟腱断裂伴止点撕脱的疗效观察[J].中华解剖与临床杂志,2023,28(12):799-805.DOI: 10.3760/cma.j.cn101202-20230417-00106.
[5]	孙燕琨,张友乐,李祥,等.异体肌腱移植术后粘连原因分析[J].中国修复重建外科杂志,2008,22(3):346-348.
[6]	杨文龙,王丹,徐旭纯,等.95%乙醇浸泡异体肌腱移植的实验研究[J].中华手外科杂志,1997,13(2):119-121.DOI: 10.3760/cma.j.issn.1005-054X.1997.02.018.
[7]	熊胜,巨积辉,金光哲,等.游离带阔筋膜的股前外侧皮瓣修复手背伸肌腱及软组织缺损[J].中华显微外科杂志,2019,42(2):132-135.DOI: 10.3760/cma.j.issn.1001-2036.2019.02.008.
[8]	张宜之,张子清,肖春生,等.带阔筋膜的股前外侧穿支皮瓣修复合并伸肌腱缺损的手足创面[J].中华整形外科杂志,2021,37(8):899-906.DOI: 10.3760/cma.j.cn114453-20200612-00355.
[9]	芮永军.股前外侧皮瓣在中国的研究进展[J].中华显微外科杂志,2020,43(4):313-325.DOI: 10.3760/cma.j.cn441206-20200628-00277.
[10]	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].中华显微外科杂志,2016,39(2):105-106.DOI: 10.3760/cma.j.issn.1001-2036.2016.02.001.
[11]	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.
[12]	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.
[13]	高秋芳,张小锋,张万锋,等.股内侧肌穿支皮瓣修复游离股前外侧穿支皮瓣供区继发创面的临床效果[J].中华烧伤杂志,2019,35(1):65-68.DOI: 10.3760/cma.j.issn.1009-2587.2019.01.012.
[14]	李锦,金光哲,武海波,等.带血供阔筋膜重建兔腱骨连接的组织学和生物力学研究[J].中华手外科杂志,2023,39(4):367-371.DOI: 10.3760/cma.j.cn311653-20220912-00240.
[15]	LiuZ,YangL,ChengJ,et al.Is the oblique branch of the lateral circumflex femoral artery a common variant?[J].J Plast Reconstr Aesthet Surg,2023,84:540-546.DOI: 10.1016/j.bjps.2023.06.024.
[16]	廖瑞真,刘倚河,刘舜辉,等.彩色多普勒超声在旋股外侧动脉穿支皮瓣的临床应用价值[J].中国临床医学影像杂志,2018,29(3):206-208.DOI: 10.3969/j.issn.1008-1062.2018.03.015.
[17]	徐万林,卢浩,吴一凡,等.携血管化阔筋膜的股前外侧皮瓣动力性修复下唇大型缺损[J].中华整形外科杂志,2022,38(1):52-57.DOI: 10.3760/cma.j.cn114453-20210104-00001.
[18]	KuoYR,YehMC,ShihHS,et al.Versatility of the anterolateral thigh flap with vascularized fascia lata for reconstruction of complex soft-tissue defects: clinical experience and functional assessment of the donor site[J].Plast Reconstr Surg,2009,124(1):171-180.DOI: 10.1097/PRS.0b013e3181a80594.
[19]	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.
[20]	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.
[21]	潘达德,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,2000,16(3):130-135.DOI: 10.3760/cma.j.issn.1005-054X.2000.03.003.
[22]	SandersR, FortinP, DiPasqualeT, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification[J].Clin Orthop Relat Res,1993(290):87-95.
[23]	WongCH,WeiFC,FuB,et al.Alternative vascular pedicle of the anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery[J].Plast Reconstr Surg,2009,123(2):571-577.DOI: 10.1097/PRS.0b013e318195658f.
[24]	程俊楠,柳志锦,杨林,等.基于解剖学研究的三级命名法在旋股外侧动脉主要分支命名中的应用探讨[J].中华解剖与临床杂志,2022,27(1):13-18.DOI: 10.3760/cma.j.cn101202-20210410-00093.
[25]	杨林,程俊楠,刘胜哲,等.基于DSA的旋股外侧动脉斜支的形态学研究及其临床意义[J].中华显微外科杂志,2021,44(6):642-646.DOI: 10.3760/cma.j.cn441206-20210604-00142.
[26]	柳志锦,巨积辉,程俊楠,等.以旋股外侧动脉斜支为源动脉的股前外侧双叶穿支皮瓣修复四肢创面[J].中华显微外科杂志,2021,44(2):152-156.DOI: 10.3760/cma.j.cn441206-20210111-00012.
[27]	杨林,柳志锦,程俊楠,等.以肌间隔主干型旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣解剖特点与临床应用[J].中华烧伤与创面修复杂志,2022,38(12):1133-1139.DOI: 10.3760/cma.j.cn501225-20220227-00039.
[28]	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.
[29]	唐举玉.特殊形式穿支皮瓣及其衍生术式的分型与命名[J].中华显微外科杂志,2021,44(3):245-254.DOI: 10.3760/cma.j.cn441206-20210530-00193.
[30]	刘族安,黄志锋,马亮华,等.股前外侧皮瓣斜支血管的认识及斜支“陷阱”的处理[J].中华显微外科杂志,2021,44(2):146-151.DOI: 10.3760/cma.j.cn441206-20200724-00299.
[31]	刘晓春,赵鹏,孙大炜,等.股前外侧皮瓣供区并发症分析及预防策略[J].中华显微外科杂志,2022,45(6):680-683.DOI: 10.3760/cma.j.cn441206-20220601-00109.
[32]	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.

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图 1 以旋股外侧动脉斜支为蒂并携带阔筋膜的股前外侧穿支皮瓣修复例1患者右足皮肤软组织及肌腱缺损的效果。1A.术中清创后右足背毁损性创面,可见骨质外露合并第1~5趾肌腱缺损；1B.术中设计皮瓣；1C.术中切取皮瓣,显露穿支,黄色箭头指示旋股外侧动脉斜支,蓝色箭头指示旋股外侧动脉降支；1D.术中阔筋膜同期桥接修复缺损肌腱；1E.术后即刻,右足皮瓣血运良好；1F.左大腿供区直接缝合后即刻,张力适中；1G.术后8个月,左大腿供区愈合良好,仅遗留线性瘢痕；1H.术后8个月,右足足趾背伸活动良好

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图 2 以旋股外侧动脉斜支为蒂并携带阔筋膜的股前外侧穿支皮瓣修复例2患者右手背皮肤软组织及肌腱缺损的效果。2A.术中清创后右手背毁损性创面,可见骨质外露合并示指、中指、环指、小指伸肌腱缺损；2B.术中设计皮瓣；2C.术中切取皮瓣,显露穿支,黄色箭头指示旋股外侧动脉斜支,蓝色箭头指示旋股外侧动脉降支；2D.术中皮瓣游离后即刻；2E.术中阔筋膜桥接修复右手示指、中指、环指、小指伸肌腱缺损；2F.术后即刻,皮瓣血运良好；2G.右大腿供区创面直接缝合后即刻,张力适中；2H.术后8个月,右大腿供区仅有线性瘢痕,无明显瘢痕增生；2I.术后8个月,右手示中环小指主动伸直力量可；2J.术后8个月,右手关节屈曲活动良好,掌指关节屈曲约60°

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