Clinical effects of free bilateral turbocharged anterolateral thigh flaps in tandem in repairing extensive wounds in the foot and ankle
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摘要:
目的 探讨采用游离双侧股前外侧内增压型串联皮瓣修复足踝部大面积创面的临床疗效。 方法 该研究为回顾性观察性研究。2020年4月—2023年6月,苏州瑞华骨科医院创面修复科收治12例符合入选标准的足踝部大面积创面患者,其中男8例、女4例,年龄21~65岁,清创后创面面积为27 cm×14 cm~37 cm×20 cm。根据创面面积和形状,设计并切取双侧以旋股外侧动脉斜支或降支为蒂的穿支皮瓣,其中单块皮瓣切取面积为16 cm×9 cm~34 cm×12 cm。先将一侧皮瓣的非同源穿支与该皮瓣的旋股外侧动脉斜支或降支的粗大肌支或主干血管进行内增压,然后将该皮瓣的旋股外侧动脉斜支或降支及其伴行静脉近端与受区胫前动静脉、胫后动静脉或足背动静脉端端吻合,该皮瓣的旋股外侧动脉斜支或降支及其伴行静脉远端与另一侧皮瓣的源血管端端吻合。将皮瓣供区创面直接缝合。统计皮瓣携带穿支数量和穿支来源、皮瓣修复手术用时,术后观察皮瓣成活情况、是否发生血管危象、供受区创面愈合情况。随访观察皮瓣情况、患肢外观及功能情况。末次随访时,采用英国医学研究会感觉评级标准评定皮瓣感觉功能,采用美国矫形足踝协会评分标准评定患肢足踝部功能。 结果 成功切取24块皮瓣,共携带60条穿支,其中来源于旋股外侧动脉斜支者34条、来源于旋股外侧动脉降支者24条、来源于旋股外侧动脉横支者1条、来源于股动脉直接分支者1条。皮瓣修复手术用时4.2~9.0 h。术后12例患者的皮瓣均完全成活。2例患者共2块皮瓣术后发生静脉危象,经急诊探查后均成活。1例患者术后一侧皮瓣供区创面愈合不良,经换药、清创缝合后愈合；其余患者供区创面均愈合。2例患者受区创面愈合不良,经换药、切除残余死骨后愈合；其余患者受区创面顺利愈合。随访4~26个月,患者皮瓣色泽、质地良好,外形略臃肿,皮瓣恢复部分感觉,患肢外观良好、功能恢复较佳。末次随访时,皮瓣感觉功能评定为S2级者9例、S3级者3例,患肢足踝部功能评定为优者2例、良者9例、可者1例。 结论 双侧股前外侧内增压型串联皮瓣穿支来源多,通过皮瓣内非同源穿支内增压,增加了皮瓣血供,降低了大面积皮瓣坏死风险,是修复足踝部大面积创面的有效方法,修复后患肢功能良好。 Abstract:Objective To explore the clinical effects of free bilateral turbocharged anterolateral thigh flaps in tandem in repairing extensive wounds in the foot and ankle. Methods The study was a retrospective observational study. From April 2020 to June 2023, 12 patients with extensive wounds in the foot and ankle who met the inclusion criteria were admitted to the Department of Wound Repair Surgery of Suzhou Ruihua Orthopedic Hospital, including 8 males and 4 females, aged 21 to 65 years. The wound area after debridement ranged from 27 cm×14 cm to 37 cm×20 cm. The bilateral perforator flaps pedicled with either oblique or descending branches of the lateral circumflex femoral artery were designed and harvested based on the size and shape of the wounds. The individual flap incision area ranged from 16 cm×9 cm to 34 cm×12 cm. The non-homologous perforator of the flap on the one side was turbocharged by anastomosing it with the gross muscular branch or main vessel of the oblique or descending branch of the lateral circumflex femoral artery from the flap. Subsequently, the proximal end of the oblique or descending branch of the lateral circumflex femoral artery and its accompanying vein from the flap on the one side were connected end-to-end with either the anterior tibial artery and vein, posterior tibial artery and vein, or dorsal foot artery and vein in the recipient area, the distal end of the oblique or descending branch of the lateral circumflex femoral artery and its accompanying vein from the flap on the one side were anastomosed end-to-end with a source vessel originating from flap on the other side. The wounds in the flap donor areas were sutured directly. The number and source of perforators carried by the flaps and the duration of the flap repair surgery were recorded. The survival of the flap, the occurrence of vascular crisis, and the wound healing at both donor and recipient areas were observed after surgery. The flap condition, appearance and function of the affected limb were observed during follow-up. At the last follow-up, the sensory function of the flap was assessed using the British Medical Research Council's sensory rating standard, the foot and ankle function of the affected limb was evaluated according to the American Orthopedic Foot and Ankle Society scoring standard. Results A total 24 flaps were successfully harvested, carrying 60 perforators, including 34 perforators from the oblique branch of the lateral circumflex femoral artery, 24 perforators from the descending branch of the lateral circumflex femoral artery, one perforator from the transverse branch of the lateral circumflex femoral artery, and one perforator from the direct branch of the femoral artery. The duration of the flap repair surgery ranged from 4.2 to 9.0 hours. The flaps of 12 patients exhibited complete survival after surgery. A total of two flaps of two patients experienced venous crisis after surgery but survived through emergency exploration. One patient encountered undesirable wound healing at the donor area of flap on the one side after surgery, which healed after dressing change, debridement, and suturing. The remaining patients' donor area wounds healed. Two patients displayed impaired wound healing in the recipient area, which improved after dressing change and resection of residual sequestrum, and the wounds in the recipient area of other patients healed successfully. During the follow-up of 4-26 months, the flaps demonstrated favorable color and texture, slight edematous appearance, and partial sensory recovery, as well as good aesthetic and functional restoration of the affected limbs. At the last follow-up, the sensory function of the flap was assessed as grade S2 in 9 cases and grade S3 in 3 cases; the foot and ankle function of the affected limb was evaluated as excellent in two cases, good in 9 cases, and fair in one case. Conclusions The bilateral turbocharged anterolateral thigh flaps have numerous sources of perforators. By implementing supercharging of non-homologous perforators within the flap, the vascular supply to the flap is turbocharged, thereby mitigating the risk of extensive flap necrosis. The flap is an effective approach for repairing extensive wounds in the foot and ankle, resulting in improved function of the affected limb after repair. -
Key words:
- Wounds and injuries /
- Perforator flap /
- Foot /
- Ankle /
- Microsurgery /
- Anterolateral thigh flap /
- Wound repair
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参考文献
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图 1 双侧股前外侧内增压型串联皮瓣血管吻合方式示意图。1A.皮瓣A的旋股外侧动脉斜支或降支先与该皮瓣的粗大肌支行内增压,再与皮瓣B的源血管行端端吻合；1B.皮瓣A的旋股外侧动脉斜支或降支先与该皮瓣的主干血管内增压,再与皮瓣B的源血管端端吻合
注：1为切取的皮瓣A,2为切取的皮瓣B,3为皮瓣A的旋股外侧动脉斜支或降支,4为皮瓣B的旋股外侧动脉斜支或降支,5为受区血管；箭头指示血管吻合口
图 2 游离双侧股前外侧内增压型串联皮瓣修复例1患者右足踝部大面积创面的效果。2A.清创后,右足踝部前侧创面可见足背肌腱、骨外露；2B.清创后,右足踝部内侧创面可见胫骨远端外露；2C.清创后,右足踝部外侧创面可见外踝及跟骨外露；2D.术中探查到右侧股前外侧皮瓣携带1条穿支,来源于旋股外侧动脉斜支；2E.术中探查到左侧股前外侧皮瓣携带4条穿支,其中皮瓣近端1条穿支来源于旋股外侧动脉斜支,皮瓣远端3条穿支来源于旋股外侧动脉降支；2F.术中将左侧皮瓣的旋股外侧动脉斜支与该皮瓣的旋股外侧动脉降支粗大肌支进行内增压；2G、2H.分别为皮瓣修复术后2年随访右足踝部背侧、内侧,皮瓣存活良好,略臃肿,未见明显色素沉着
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