Clinical application of lobulated transplantation of free anterolateral thigh perforator flap in the treatment of electric burns of limbs
-
摘要:
目的 探讨采用游离股前外侧穿支皮瓣分叶移植修复四肢电烧伤创面的临床疗效。 方法 2014年8月—2019年4月,笔者单位收治19例四肢电烧伤患者,其中男18例、女1例,年龄20~58岁。共37个Ⅳ度创面,面积3.0 cm×2.0 cm~40.0 cm×8.0 cm。设计并切取股前外侧多穿支皮瓣,以旋股外侧动脉各穿支为轴心将皮瓣分叶后移植于扩创后四肢创面,将血管干或分叶后皮瓣穿支血管与受区血管分别吻合。一次手术修复多处创面时,使用各皮瓣分叶分别修复;一次手术修复单个较大不规则创面时,将各皮瓣分叶拼接或错开摆放覆盖创面以适合创面形状。针对伴远端血运障碍患肢,利用皮瓣供血分支重建血运,必要时另取适当长度静脉移植。观察重建血运改善情况;统计手术次数、股前外侧穿支皮瓣数、皮瓣分叶数与面积、每次手术吻合血管数、供瓣区处理情况、每次手术时长、术后皮瓣分叶并发症及存活情况;随访时,采用Carroll上肢功能测试量表评价上肢功能,按李克特量表5级评分调查患者对每次手术效果的满意度。将手术分为一次修复1个创面的单创面组和一次修复2个及以上创面的多创面组,比较2组手术中每次手术吻合血管数、供瓣区处理情况、每次手术时长、术后皮瓣分叶存活情况;另将手术分为伤后7 d内手术的早期组和伤后7 d及以后手术的晚期组,比较2组手术术后皮瓣分叶并发症及存活情况、末次随访时上肢功能评分和患者对每次手术效果的满意度。对数据行独立样本
t 检验、Mann-Whitney
U 检验、Fisher确切概率法检验。 结果 5例伴手或手指远端血运障碍患者行血管移植后血供恢复或明显改善。19例患者共行21次手术,切取21个股前外侧穿支皮瓣,形成46个分叶,每个皮瓣分成(2.2±0.4)叶,皮瓣分叶面积4.0 cm×3.0 cm~24.0 cm×13.0 cm。每次手术吻合动脉2.0(1.5,3.0)条、静脉3.0(2.0,3.0)条。6个供瓣区取刃厚头皮移植修复,15个供瓣区直接缝合。每次手术时长(8.9±1.7)h。术后2个皮瓣分叶发生出血及血肿,5个皮瓣分叶发生局部感染,处理后好转;4个皮瓣分叶出现血管危象,经探查治疗后2叶存活,另2叶坏死改行其他方法修复;其余皮瓣分叶均存活良好。每次术后随访3~60个月,四肢皮瓣覆盖区域均恢复良好。末次随访时,20个受累上肢功能评分为85(63,90)分,患者对每次手术效果的满意度评分为(4.4±0.7)分。多创面组14次手术共获得30个皮瓣分叶,分别修复30个创面;单创面组7次手术共获得16个皮瓣分叶,拼接后修复7个较大不规则创面。多创面组与单创面组手术中每次手术动脉或静脉吻合数、每次手术时长比较,差异无统计学意义(
Z =0.240、0.081,
t =0.180,
P >0.05),供瓣区植皮情况、术后皮瓣分叶存活情况相似(
P >0.05)。早期组10次手术共获得22个皮瓣分叶,修复18个创面;晚期组11次手术共获得24个皮瓣分叶,修复19个创面。早期组和晚期组手术术后皮瓣分叶血肿、感染、血管危象发生情况以及存活情况相似(
P >0.05);末次随访时患者对每次手术效果的满意度比较,差异无统计学意义(
t =0.701,
P >0.05)。早期组手术末次随访时9个上肢功能评分为90(85,97)分,明显高于晚期组11个上肢的80(40,85)分(
Z =2.431,
P <0.05)。 结论 游离股前外侧穿支皮瓣分叶后适合用于四肢多个电烧伤创面的同时修复,以及单个较大不规则创面的修复,具有供区损伤小,修复质量好的临床优点;早期皮瓣移植手术有利于改善电烧伤患肢功能。
Abstract:Objective To explore the clinical efficacy of lobulated transplantation of free anterolateral thigh perforator flap in repairing electric burn wounds of limbs. Methods From August 2014 to April 2019, 19 patients with electric burns in the limbs were hospitalized in our unit, including 18 males and 1 female, aged 20-58 years. There were 37 wounds deep to bone. The area of wounds ranged from 3.0 cm×2.0 cm to 40.0 cm×8.0 cm. Multiple-perforator-based anterolateral thigh flap was designed and resected. Then the flap was lobulated taking the respective perforators of the lateral circumflex femoral artery as the axial vessels before being transplanted to the debrided wounds in the limbs. The blood vessel trunk or the perforator vessels of flap lobes were anastomosed with the respective vessels in the recipient sites. The wounds were repaired with respective lobes of the flap when repairing multiple wounds in one surgical procedure, whereas the lobes were spliced or staggered to cover the wound to fit the shape of wound when repairing a single irregular wound in one surgical procedure. For the limb with distal blood supply disorder, the blood supply branch of flap was used to reconstruct the blood supply. If necessary, an appropriate length of vein was taken for transplantation. The improvement of reconstructed blood supply was observed. The number of surgeries, the number of anterolateral thigh perforator flaps, the number and size of flap lobes, the number of anastomosed vessels in each surgery, the treatment of the donor sites, the length of each surgery, the postoperative complications and survival condition of flap lobes were recorded. The upper extremity function was evaluated with the Carroll′s Upper Extremity Function Test Scale, and the patients′ satisfaction degree with the therapeutic effect of each surgery was investigated with a 5-point Likert Scale during follow-up. Surgeries were divided into single wound group of repairing one wound at one time and multiple wounds group of repairing two or more wounds at one time. The number of anastomosed vessels in each surgery, the treatment of the donor sites, the length of each surgery, and the postoperative survival condition of the flap lobes were compared between the two groups. Surgeries were divided into early group of performing surgery within post burn day 7 and late group of performing surgery on post burn day 7 and beyond. The postoperative complications and survival condition of flap lobes, the evaluation score of upper limb function and the patients′ satisfaction degree with the therapeutic effect of each surgery at the last follow-up were compared between the two groups. Data were processed with independent sample
t test, Mann-Whitney
U test, or Fisher′s exact probability test. Results The blood supply of 5 patients with distal hand or finger blood supply disorder recovered or improved significantly after vascular transplantation. A total of 46 lobes [(2.2±0.4) lobes per flap] were obtained from 21 anterolateral thigh perforator flaps in 19 patients with 21 surgeries. The area of flap lobes ranged from 4.0 cm×3.0 cm to 24.0 cm×13.0 cm. In each surgery, 2.0 (1.5, 3.0) arteries and 3.0 (2.0, 3.0) veins were anastomosed. Six donor sites were repaired by thin split-thickness scalp, and 15 donor sites were closed directly. The duration of each surgery was (8.9±1.7) h. After surgery, bleeding and hematoma occurred in 2 flap lobes and local infection occurred in 5 flap lobes, which were improved after management. Vascular crisis occurred in 4 flap lobes, and exploratory surgeries were performed, after which 2 lobes survived, while the other 2 lobes necrotized and were repaired by other methods. The rest flap lobes survived well. After each postoperative follow-up of 3 to 60 months, the flap covering areas of the limbs were well-recovered. At the last follow-up, the function evaluation score of 20 affected upper limbs was 85 (63, 90) points, and the score of patients′ satisfaction degree with the therapeutic effect of each surgery was (4.4±0.7) points. A total of 30 flap lobes were obtained in 14 surgeries and repaired 30 wounds respectively in multiple wounds group, and 16 flap lobes were obtained in 7 surgeries and were spliced to repair 7 large irregular wounds in single wound group. There were no statistically significant differences in the number of anastomosed artery or vein in each surgery, and the duration of each surgery between multiple wounds group and single wound group (
Z =0.240, 0.081,
t =0.180,
P >0.05), and the condition of skin grafting in the donor sites and the postoperative survival of the flap lobes in multiple wounds group were similar to those in single wound group (
P >0.05). A total of 22 flap lobes were obtained in 10 surgeries and repaired 18 wounds in early group, and 24 flap lobes were obtained in 11 surgeries and repaired 19 wounds in late group. The incidence of postoperative hematoma, infection, vascular crisis, and survival of flap lobes in early group were similar to those in late group (
P >0.05). There were no statistically significant differences in the patients′ satisfaction degree with the therapeutic effect of each surgery at the last follow-up between early group and late group (
t =0.701,
P >0.05). At the last follow-up, the function evaluation score of 9 upper limbs in early group was 90 (85, 97) points, significantly higher than 80 (40, 85) points of 11 upper limbs in late group (
Z =2.431,
P <0.05). Conclusions Free lobulated anterolateral thigh perforator flap is suitable for simultaneous repair of multiple electric burn wounds of limbs, as well as the repair of a single large irregular wound. It has the clinical advantages of less damage to the donor site and good repair quality. The early flap transplantation is beneficial to improve the function of limbs with electric burns.
-
Key words:
- Burns, electric /
- Surgical flaps /
- Microsurgery /
- Arteriovenous anastomosis /
- Hand function
-
参考文献
(0) 期刊类型引用(25)
1. 周荣,刘禹城,巨积辉,张韬,程俊楠,杨亮,郭礼平,刘跃飞. 股前外侧肌皮瓣治疗足踝部慢性骨髓炎9例治疗体会. 足踝外科电子杂志. 2023(01): 41-46+66 . 百度学术
2. 谢钦赐. 游离分叶穿支皮瓣术修复手部多处创面的治疗进展. 实用手外科杂志. 2023(02): 260-264 . 百度学术
3. 覃凤均,王成,张颖,杜伟力,贾伟,田轩,沈余明,刘建龙. 游离皮瓣联合血管重建在上肢毁损性创面合并血管损伤修复中的应用. 中国普通外科杂志. 2023(06): 840-849 . 百度学术
4. 张韬,程俊楠,杨林,孙丰文,高钦锋,黄永涛,杨成鹏,曹阳,柳志锦,巨积辉. 腓浅动脉穿支双叶皮瓣修复手指相邻2处创面的效果. 中华烧伤与创面修复杂志. 2023(07): 655-661 . 本站查看
5. 薛继东,狄海萍,梁琰,邢培朋,郭海娜,赵孝开,王丽敏,夏成德. 足部微型皮瓣游离移植修复手指Ⅳ度电烧伤创面的疗效. 中华烧伤与创面修复杂志. 2023(08): 724-730 . 本站查看
6. 张伟,陈斓,杨飞,张卫东,刘峰,谢卫国. 上肢毁损性电烧伤的救治方法及其临床疗效. 中华烧伤与创面修复杂志. 2023(08): 731-737 . 本站查看
7. 闫征,郝瑞峥,霍永鑫. 不同时期游离股前外侧穿支皮瓣分叶移植术对四肢电烧伤后关节滑膜内神经生长因子与Carroll评分的影响. 临床和实验医学杂志. 2023(18): 1968-1972 . 百度学术
8. 徐军辉,张伟,周锦秀,陈斓,张卫东,龚翔,谢卫国. 游离移植腹股沟皮瓣修复四肢电烧伤创面的临床效果. 中华烧伤与创面修复杂志. 2023(11): 1030-1037 . 本站查看
9. 李海,肖顺娥,邓呈亮,吴必华,张天华,刘志远,聂开瑜,魏在荣. 游离分叶穿支皮瓣修复四肢复杂创面. 中国修复重建外科杂志. 2022(01): 98-101 . 百度学术
10. 郭鹏飞,王旭,魏爱周,孟庆楠,周健,高娅,崔正军. 基于供区保护理念的游离股前外侧分叶穿支皮瓣在头部电烧伤创面修复中的临床应用效果. 中华烧伤与创面修复杂志. 2022(01): 77-80 . 本站查看
11. 杨飞,谢卫国,张伟,王德运,刘淑华,余刚,张卫东,席毛毛. 放射性溃疡严重程度分型及临床治疗分析. 组织工程与重建外科. 2022(01): 62-66 . 百度学术
12. 杨薇,王前,齐一侠,王天龙. 不同神经阻滞方案在大隐静脉射频消融联合点式剥脱术的麻醉疗效分析. 北京医学. 2022(09): 844-846 . 百度学术
13. 刘胜哲,巨积辉,柳志锦,周荣,唐林峰. 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. 中华烧伤杂志. 2021(03): 250-256 . 百度学术
14. 豆倩影,黄立新. 股前外侧穿支皮瓣修复治疗四肢严重烧伤的效果及安全性. 河南医学研究. 2021(06): 1030-1032 . 百度学术
15. 赵书明,刘亚明,刘娜,张宏亮,宋占锋,高文华,蓝悦辉,樊安未,刘学亮. 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. 中华烧伤杂志. 2021(04): 356-362 . 百度学术
16. 李雪峰,梁帅. 四肢难治性感染创面患者皮瓣移植术治疗临床疗效. 中国现代医生. 2021(14): 63-65+69 . 百度学术
17. 周望高,张振伟,余少校,李东扬,叶学浪,林慧鑫,柯于海. 带肌瓣的旋股外侧动脉降支穿支皮瓣修复合并死腔的小腿软组织缺损. 中国美容整形外科杂志. 2021(07): 411-414 . 百度学术
18. 廖宗生,巫家晓,毛远科,刘卿,邹高健,于慧珍. 股前外侧皮瓣移植修复口腔颌面部恶性肿瘤切除后组织缺损疗效研究. 中国美容医学. 2021(06): 151-154 . 百度学术
19. 张颖,沈余明. 腕部高压电烧伤诊治的研究进展. 中华创伤杂志. 2021(05): 467-472 . 百度学术
20. 覃凤均,沈余明,杜伟力,程琳,张颖,马春旭. 带腹壁下血管的脐旁穿支皮瓣在毁损性创面修复中的应用策略及临床效果. 中华烧伤杂志. 2021(07): 606-613 . 百度学术
21. 张丕红. 毁损伤的成因与评估及其修复策略优化探讨. 中华烧伤杂志. 2021(07): 601-605 . 百度学术
22. 梁鹏飞,张丕红,张明华,曾纪章,周捷,黄覛韬,崔旭,郭乐,鄢卓贤,冉艳钦,周思拓,何志友,黄晓元. 手指Ⅳ度烧伤创面的修复方法与临床效果. 中华烧伤杂志. 2021(07): 614-621 . 百度学术
23. 邢培朋,郭海娜,狄海萍,薛继东,曹大勇,梁占岭,梁琰,夏成德. 游离股前外侧皮瓣联合动脉血管重建修复腕部高压电烧伤创面的临床效果. 中华烧伤杂志. 2020(06): 419-425 . 百度学术
24. 柳志锦,巨积辉,刘胜哲,周荣,蒋国栋. 内增压型股前外侧双叶皮瓣修复四肢创面的临床应用. 中华创伤杂志. 2020(10): 920-925 . 百度学术
25. 张丕红. 加强规范化诊治 改善电烧伤预后. 中华烧伤杂志. 2019(11): 772-775 . 百度学术
其他类型引用(4)
-
计量
- 文章访问数: 212
- HTML全文浏览量: 49
- PDF下载量: 18
- 被引次数: 29