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

王成德; 王爱; 孙继玲; 马文国; 王建国

doi:10.3760/cma.j.cn501120-20210914-00317

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

doi: 10.3760/cma.j.cn501120-20210914-00317

1.
潍坊市益都中心医院介入治疗科，潍坊　　262550
2.
潍坊市益都中心医院烧伤整形外科，潍坊　　262550
3.
潍坊市益都中心医院示教室，潍坊　　262550
4.
青州市中医院骨科，潍坊　　262500

基金项目:

潍坊市卫生健康委员会科研项目 wfwsjk_2019_145

详细信息

通讯作者:
王建国，Email：wjg3389@126.com

计量
- 文章访问数: 1199
- HTML全文浏览量: 132
- PDF下载量: 30
- 被引次数: 0
出版历程
- 收稿日期: 2021-09-14

Clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography

1.
Interventional Therapy Department, Yidu Central Hospital of Weifang, Weifang 262550, China
2.
Department of Burn and Plastic Surgery, Yidu Central Hospital of Weifang, Weifang 262550, China
3.
Demonstration Classroom, Yidu Central Hospital of Weifang, Weifang 262550, China
4.
Orthopaedic Department, Chinese Medicine Hospital of Qingzhou City, Weifang 262500, China

Funds:

Scientific Research Program of Health Commission of Weifang City wfwsjk_2019_145

More Information

Corresponding author: Wang Jianguo, Email: wjg3389@126.com

摘要

摘要: 目的探讨在三维CT血管造影（3D-CTA）辅助下采用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疗效。方法采用回顾性观察性研究方法。2017年3月—2019年9月，潍坊市益都中心医院烧伤整形外科收治15例前足皮肤软组织缺损创面患者，其中男12例、女3例，年龄18~60岁。入院时创面面积为3.0 cm×3.0 cm~9.0 cm×8.0 cm。术前行3D-CTA检查，选择血管蒂长度合适、血流灌注好的腓动脉穿支血管。根据创面面积及3D-CTA检查定位的腓动脉穿支血管情况，设计及切取大小为3.5 cm×3.5 cm~9.5 cm×8.5 cm腓动脉穿支皮瓣，皮瓣携带腓肠外侧皮神经并与创面的神经吻合。供区创面直接拉拢缝合或取大腿中厚皮覆盖。观察术前3D-CTA检查拟切取的腓动脉穿支血管类型、管径、穿出位置与术中实际探测情况是否一致，记录皮瓣切取时长和术后皮瓣成活情况。术后12个月随访，指导患者按照Maryland足功能评分标准评定足部功能，观察供区创面愈合情况及影响肢体运动功能的并发症发生情况。对数据行配对样本t检验。结果该组患者术中探测到拟切取的腓动脉穿支血管类型为肌间隔穿支者12例、肌皮穿支者2例、肌肉-肌间隔穿支者1例，与术前3D-CTA检查结果一致。术前3D-CTA测量的腓动脉穿支血管管径为（1.38±0.17）mm，与术中测量的（1.40±0.19）mm相近（t=0.30，P>0.05）；术前3D-CTA测量的穿支起始点至小腿外缘水平距离为（42±6）mm，穿支起始点至外踝尖水平的垂直距离为（219±14）mm，分别与术中测量的（43±6）、（221±15）mm相近（t值分别为0.46、0.38，P>0.05）。皮瓣切取时长为（31±6）min，术后皮瓣全部成活，无血管危象出现。术后12个月随访，足功能评定为优者11例、良者3例、中者1例；供区创面愈合良好，瘢痕不明显，无挛缩，肢体运动功能无影响。结论游离腓动脉穿支皮瓣是重建前足皮肤软组织缺损创面的有效方法之一，术前3D-CTA明确了穿支血管解剖位置，降低了手术风险。
- 伤口愈合 /
- 穿支皮瓣 /
- 血管造影术 /
- 足前段，人
Abstract: Objective To investigate the clinical effects of free peroneal artery perforator flaps in repairing forefoot skin and soft tissue defect wounds assisted with three-dimensional computed tomography angiography (3D-CTA). Methods A retrospective observational study was conducted. From March 2017 to September 2019, 15 patients with skin and soft tissue defect wounds in the forefoot were treated in the Department of Burn and Plastic Surgery of Yidu Central Hospital of Weifang, including 12 males and 3 females, with age of 18-60 years. The wound area on admission was 3.0 cm×3.0 cm-9.0 cm×8.0 cm. The 3D-CTA examination before operation was performed to select the peroneal artery perforating vessels with appropriate length of vascular pedicle and good blood perfusion. According to the wound area and the perforating vessels of the peroneal artery located by 3D-CTA, the peroneal artery perforator flaps of 3.5 cm×3.5 cm-9.5 cm×8.5 cm carried with lateral sural cutaneous nerve was designed and cut, and the nerve was anastomosed with the nerve of the wound. The wound in the donor site of the flap was directly sutured or covered with medium-thickness skin graft from the thigh. The consistencies of type, diameter, and perforating position of perforating vessel of the peroneal artery detected by 3D-CTA before the operation with those of the actual measurement during operation were observed. The length of time for flap cutting and the survival of the flap after operation were recorded. During follow-up of 12 months after the operation, the patients were instructed to evaluate the foot function according to the Maryland foot function score standard, and the wound healing in the donor area and the occurrence of complications affecting the motor function of limb were observed. Data were statistically analyzed with paired sample t test. Results The types of peroneal artery perforating vessels in patients measured during the operation were septocutaneous perforator of 12 cases, musculocutaneous perforator of 2 cases, and musculomuscular septal perforator of 1 case, which were consistent with those measured by preoperative 3D-CTA. The diameter of the peroneal artery perforating vessel measured by preoperative 3D-CTA was (1.38±0.17) mm, which was close to (1.40±0.19) mm measured during the operation (t=0.30, P>0.05). The horizontal distance from the starting point of the perforating vessel to the outer edge of the shank was (42±6) mm, and the vertical distance from the starting point of the perforating vessel to the level of the lateral ankle tip was (219±14) mm measured by preoperative 3D-CTA, which were respectively close to (43±6) and (221±15) mm of intraoperative measurement (with t values of 0.46 and 0.38, respectively, P>0.05). The length of time for cutting flap was (31±6) min. All flaps survived post operation without vascular crisis. During follow-up of 12 months after the operation, the foot function was evaluated as excellent in 11 cases, good in 3 cases, and fair in 1 case, the donor site wound healed well, the scar was not noticeable with no contracture, and the motor function of joints was not affected. Conclusions Free peroneal artery perforator flap is one of the effective methods to reconstruct skin and soft tissue defect wounds in the forefoot, and the risk of surgery can be reduced when the anatomical location of the perforating vessels is confirmed by 3D-CTA.
- Wound healing /
- Perforator flap /
- Angiography /
- Forefoot, human
王成德：研究设计、手术操作、实施研究、撰写论文；王爱、孙继玲：病例随访、资料整理；马文国、王建国：数据整理、论文修改

所有作者均声明不存在利益冲突

HTML全文

参考文献(35)

[1]	袁野,邱俊涛,李辉,等. 应用超引流技术的腓动脉穿支皮瓣修复四肢皮肤缺损[J].中华整形外科杂志,2021,37(5):534-540.DOI: 10.3760/cma.j.cn114453-20200407-00204.
[2]	OgawaR. Surgery for scar revision and reduction: from primary closure to flap surgery[J/OL]. Burns Trauma, 2019,7:7 [2022-02-21]. https://pubmed.ncbi.nlm.nih.gov/30891462/. DOI: 10.1186/s41038-019-0144-5.
[3]	梅良斌,吕乾,范新宇,等.腓动脉低位穿支螺旋桨皮瓣转位修复足跟部软组织缺损[J].中华创伤杂志,2021,37(9):793-798.DOI: 10.3760/cma.j.cn501098-20210202-00101.
[4]	吴学仁,魏盼杰,赵耀华,等.髂腹股沟复合组织瓣修复手足部皮肤软组织缺损的效果[J].中华烧伤杂志,2020,36(8):722-725.DOI: 10.3760/cma.j.cn501120-20190408-00171.
[5]	徐永清,何晓清,陈雪松,等.手和足部创面修复时四种吻合血管的皮神经营养血管穿支皮瓣的选择[J].中华显微外科杂志,2020,43(4):331-337. DOI: 10.3760/cma.j.cn441206-20200218-00068.
[6]	李振峰,杨瑞甫,江小萌,等.游离腓肠内侧动脉穿支皮瓣修复前臂及足部软组织缺损[J].中华显微外科杂志,2020,43(2):132-135.DOI: 10.3760/cma.j.cn441206-20190610-00205.
[7]	陈雪松,徐永清,杨黎,等.超薄游离腓动脉穿支皮神经营养血管皮瓣修复手、足皮肤软组织缺损[J].中华创伤杂志,2017,33(4):355-361. DOI: 10.3760/cma.j.issn.1001-8050.2017.04.014.
[8]	刘兴盛,刘兴旺,张永明,等.逆行足背外侧皮神经营养血管皮瓣修复第5足趾皮肤软组织缺损八例[J].中华烧伤杂志,2017,33(8):508-509.DOI: 10.3760/cma.j.issn.1009-2587.2017.08.012.
[9]	许操,王书芹,胡恺,等.3D-CTA在腓动脉穿支皮瓣修复舌癌术后软组织缺损中的应用[J].中华全科医学,2021,19(6):936-939,978.DOI: 10.16766/j.cnki.issn.1674-4152.001954.
[10]	郭晓峰,强力,薛明宇,等.CT血管造影和彩色多普勒在腓肠内侧动脉穿支皮瓣的定位比较[J].中华手外科杂志,2021,37(4):248-250.DOI: 10.3760/cma.j.cn311653-20200625-00268.
[11]	苟中坤,吴泉玲,赵崇伟,等.腓动脉穿支皮瓣修复趾腓侧皮瓣供区九例[J].中华显微外科杂志,2021,44(6):653-656.DOI: 10.3760/cma.j.cn441206-20210309-00072.
[12]	刘勇,康彦忠,李文龙,等.游离腓动脉穿支皮瓣修复手足软组织缺损[J].中华创伤骨科杂志,2015,17(7):579-583.DOI: 10.3760/cma.j.issn.1671-7600.2015.07.006.
[13]	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.
[14]	于承祺,刘勇,王剑利,等.以腓血管为蒂跨供区皮瓣的解剖学研究及临床应用[J].中华显微外科杂志,2022,45(1):71-76.DOI: 10.3760/cma.j.cn441206-20211013-00240.
[15]	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.
[16]	欧阳阳钢,姜宗圆,梁海,等.应用小腿穿支皮瓣修复足趾移植后供区的软组织缺损[J].中华手外科杂志,2018,34(3):164-166.DOI: 10.3760/cma.j.issn.1005-054X.2018.03.002.
[17]	田振欣,时丹萍,姜宁宁,等.三维CT血管造影辅助下游离腓骨复合组织瓣修复下肢复合组织缺损[J].中华手外科杂志,2019,35(5):373-376.DOI: 10.3760/cma.j.issn.1005-054X.2019.05.019.
[18]	王伟,艾合买提江·玉素甫.腓动脉穿支皮瓣的术前3D可视化研究[J].中华显微外科杂志,2022,45(2):157-161.DOI: 10.3760/cma.j.cn441206-20211217-00300.
[19]	石岩,何晓清,杨曦,等.CT血管造影检查结合三维重建辅助设计腓浅动脉穿支皮瓣修复手部创面的疗效[J].中华创伤杂志,2021,37(6): 501-507.DOI: 10.3760/cma.j.cn501098-20210202-00105.
[20]	杨涛,陈佳,成贝贝,等.穿支皮瓣联合足趾移植术修复拇指毁损伴手部软组织缺损的临床疗效[J].中华烧伤杂志,2021,37(9):875-879.DOI: 10.3760/cma.j.cn501120-20200727-00360.
[21]	KhoongYM, HuangX, GuS, et al. Imaging for thinned perforator flap harvest: current status and future perspectives[J/OL]. Burns Trauma, 2021, 9: tkab042[2021-12-17]. https://pubmed.ncbi.nlm.nih.gov/34926708/. DOI: 10.1093/burnst/tkab042.
[22]	熊颖杰,幸超峰,胡智玉,等.腓动脉终末穿支外踝上皮瓣修复足跟外侧创面[J].中华显微外科杂志,2019,42(5):459-462. DOI: 10.3760/cma.j.issn.1001-2036.2019.05.010.
[23]	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.
[24]	刘春,杨学林,胡福兴,等.三维CT血管造影辅助血管定位设计游离腓动脉穿支皮瓣修复前足背软组织缺损[J].中华创伤杂志,2021,37(9):786-792.DOI: 10.3760/cma.j.cn501098-20201219-00730.
[25]	俞学子,张龙,王殷红.游离穿支皮瓣修复足背软组织缺损[J].中华整形外科杂志,2019,35(4):376-380.DOI: 10.3760/cma.j.issn.1009-4598.2019.04.010.
[26]	MinP, LiJ, BrunettiB, et al. Pre-expanded bipedicled visor flap: an ideal option for the reconstruction of upper and lower lip defects postburn in Asian males[J/OL]. Burns Trauma, 2020, 8: tkaa005[2022-02-21]. https://pubmed.ncbi.nlm.nih.gov/32341918/. DOI: 10.1093/burnst/tkaa005.
[27]	郑晓飞,江起庭,胡小峰,等.携带穿支血管推进皮瓣在肢体软组织缺损创面修复中的应用[J].中华解剖与临床杂志,2020,25(6):695-697. DOI: 10.3760/cma.j.cn101202-20200118-00013.
[28]	JiaoX, CuiC, NgSK, et al.The modified bilobed flap for reconstructing sacral decubitus ulcers[J/OL]. Burns Trauma, 2020,8:tkaa012[2022-02-21]. https://pubmed.ncbi.nlm.nih.gov/33335930/. DOI: 10.1093/burnst/tkaa012.
[29]	秦建忠,朱振华,周聚普,等.腓动脉外踝前终末穿支降支蒂岛状皮瓣修复中足和前足软组织缺损[J].中华显微外科杂志,2020,43(1):20-23.DOI: 10.3760/cma.j.issn.1001-2036.2020.01.006.
[30]	张兴,郭峰松,苏凯华,等.穿支皮瓣修复四肢创面临床应用56例[J].中华显微外科杂志,2020,43(2):141-144.DOI: 10.3760/cma.j.cn441206-20190918-00314.
[31]	任远飞,钟声,尚耀华,等.应用腓动脉双穿支螺旋桨皮瓣修复跟腱区大面积软组织缺损一例[J].中华显微外科杂志,2020,43(3):309-310.DOI: 10.3760/cma.j.cn441206-20190224-00059.
[32]	ZeidermanMR, PuLLQ. Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma[J]. Burns Trauma, 2021, 9:tkab024[2022-02-21]. https://pubmed.ncbi.nlm.nih.gov/34345630/. DOI: 10.1093/burnst/tkab024.
[33]	宋家林,黄腾立,高涛,等. 游离腓动脉穿支皮瓣在足踝部软组织缺损中的临床应用[J]. 中国修复重建外科杂志,2021,35(6):756-760. DOI: 10.7507/1002-1892.202101069.
[34]	方杰,肖军杰,张威,等.两组不同源血管穿支供养的腓肠内侧动脉穿支体区皮瓣修复手挤压伤创面一例[J].中华显微外科杂志,2022,45(2):218-220.DOI: 10.3760/cma.j.cn441206-20211228-00306.
[35]	GuillierD, CampisiC, KrähenbühlSM, et al. Bipedicled distally based medial plantar artery perforator flap for forefoot reconstruction: a case report[J]. Microsurgery, 2020,40(4):497-500. DOI: 10.1002/micr.30583.

下载: 全尺寸图片幻灯片

1 腓动脉主干及穿支血管类型。1A.肌间隔穿支；1B.肌皮穿支；1C.肌肉-肌间隔穿支

下载: 全尺寸图片幻灯片

2 于三维CT血管造影（3D-CTA）辅助下行腓动脉穿支皮瓣游离移植修复交通伤患者右前足内侧皮肤软组织缺损创面。2A.术前右前足创面；2B.术前双小腿3D-CTA容积再现图像，显示腓动脉穿支血管类型为肌肉-肌间隔穿支；2C.术前设计皮瓣；2D.术中切取皮瓣；2E.皮瓣覆盖创面并缝合后即刻；2F.术后12个月随访，皮瓣外观较好，无臃肿

下载: 全尺寸图片幻灯片