携带神经的腓动脉穿支皮瓣修复腕部电烧伤后期神经缺损的临床效果

周健; 郑玉岑; 陈伟; 常树森; 魏在荣; 聂开瑜; 张芳

doi:10.3760/cma.j.cn501225-20240520-00187

携带神经的腓动脉穿支皮瓣修复腕部电烧伤后期神经缺损的临床效果

doi: 10.3760/cma.j.cn501225-20240520-00187

遵义医科大学附属医院烧伤整形外科,遵义　　563003

基金项目:

国家自然科学基金地区科学基金项目 82360445

详细信息

通讯作者:
魏在荣,Email：zairongwei@163.com

计量
- 文章访问数: 51
- HTML全文浏览量: 7
- PDF下载量: 56
- 被引次数: 0
出版历程
- 收稿日期: 2024-05-20

Clinical effects of nerve-carrying peroneal artery perforator flaps in repairing nerve defects in the late stage of wrist electric burns

Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, China

Funds:

Regional Science Fund Project of National Natural Science Foundation of China 82360445

More Information

Corresponding author: Wei Zairong, Email: zairongwei@163.com

摘要

摘要: 目的探讨携带神经的腓动脉穿支皮瓣修复腕部电烧伤后期神经缺损的临床效果。方法该研究为回顾性观察性研究。2019年12月—2023年5月,遵义医科大学附属医院收治5例符合入选标准的腕部电烧伤后期神经缺损致手部感觉功能障碍患者,其中男4例、女1例,年龄7~48岁。正中神经、尺神经均缺损者4例,仅正中神经缺损者1例,神经缺损长度为5~12 cm。对4例患者行携带腓肠神经和腓浅神经的腓动脉穿支皮瓣移植,1例患者行仅携带腓肠神经的腓动脉穿支皮瓣移植。将皮瓣供区创面直接拉拢缝合。1例患者合并肌腱粘连,同期行肌腱粘连松解；3例患者合并腕屈肌肌群缺损,其中同期行自体肌腱移植者2例、Ⅱ期行股薄肌肌皮瓣屈指功能重建者1例；1例患者合并腕关节屈曲挛缩,Ⅱ期行挛缩松解。术后随访观察皮瓣成活情况,记录皮瓣供受区切口/缝合口愈合时间及手部感觉恢复时间。末次随访时,观察皮瓣供区瘢痕形成情况及足部感觉缺失情况；根据中华医学会手外科学分会上肢部分功能评定试用标准中手部肌腱、神经修复评定标准,分别评价屈指肌力和手指感觉功能。结果患者术后获随访12~24个月,所有患者皮瓣均成活,皮瓣供受区切口/缝合口愈合时间均约为2周,手部感觉在术后6个月内恢复。末次随访时,小腿供区遗留线性瘢痕,足背遗留部分皮肤感觉障碍,无皮肤破溃,不影响穿鞋及行走；屈指肌力评定为4级者1例、3级者3例、2级者1例；手部感觉功能评定为S3⁺级者4例,皮肤两点辨别觉距离为8~11 mm；手部感觉功能评定为S3级者1例,皮肤两点辨别觉距离为13 mm。结论采用携带神经的腓动脉穿支皮瓣修复腕部电烧伤后期神经缺损,手部感觉在6个月内恢复,皮瓣供区仅遗留线性瘢痕,足背仅有部分区域感觉减退；结合屈指功能重建,能有效改善手部整体功能。
- 烧伤,电 /
- 腕 /
- 穿支皮瓣 /
- 腓肠神经 /
- 腓浅神经 /
- 神经缺损 /
- 功能重建
Abstract: Objective To explore the clinical effects of nerve-carrying peroneal artery perforator flaps in repairing nerve defects in the late stage of wrist electric burns. Methods This study was a retrospective observational study. From December 2019 to May 2023, five patients with sensory dysfunction in hands due to nerve defects in the late stage of wrist electric burns were treated in the Affiliated Hospital of Zunyi Medical University and met the inclusion criteria. There were 4 males and 1 female, aged 7 to 48 years. Four patients had defects in both median nerve and ulnar nerve, one patient had a defect solely in median nerve, and the length of nerve defects ranged from 5 to 12 cm. Four patients underwent transplantation of peroneal artery perforator flaps carrying sural nerve and superficial peroneal nerve, and 1 patient underwent transplantation of peroneal artery perforator flap only carrying sural nerve. The wounds in flap donor sites were all directly sutured. One patient had tendon adhesion and release of tendon adhesion was performed during the same surgery; 3 patients had combined defects in the wrist flexor muscle group, including 2 patients received autologous tendon grafting during the same surgery, and one patient received reconstruction of finger flexion function with a gracilis myocutaneous flap in the second stage; 1 patient had combined wrist flexion contracture which was surgically released in the second stage. During follow-up after surgery, the survival of the flaps was observed, and the healing time of the incisions or sutures in flap donor and recipient sites and the recovery time of hand sensation were recorded. At the last follow-up, the scar formation and loss of sensation in the foot were observed, and flexor strength and sensory function of the fingers were evaluated based on the evaluation criteria for tendon and nerve repair standards of hands in the trial standards for evaluation of partial function of the upper extremity by the Hand Surgery Society of Chinese Medical Association. Results All patients were followed up after surgery for 12 to 24 months, and all flaps of patients survived. The healing time for the incisions or sutures in flap donor and recipient sites was about 2 weeks, and the hand sensation recovered in 6 months after surgery. At the last follow-up, linear scar was left in the donor site on the lower leg; patients had partial sensory impairment on the dorsum of the foot, but there was no skin ulceration, which did not affect wearing shoes or walking; finger flexor strength was rated as grade 4 in 1 patient, grade 3 in 3 patients, and grade 2 in 1 patient; the sensory function of hands was evaluated as S3⁺ level in 4 patients, with the two-point discrimination distance of the skin ranging from 8 to 11 mm, while the sensory function of hands was evaluated as S3 level in 1 patient, with the two-point discrimination distance of the skin of 13 mm. Conclusions Using the nerve-carrying peroneal artery perforator flaps to repair the nerve defects in the late stage of wrist electric burns, the sensation of hands can be restored in 6 months after surgery, with only linear scar in the flap donor sites and hypoesthesia in some areas of the dorsum of the foot. When combined with the reconstruction of finger flexion function, the overall function of hands can be effectively improved.
- Burns, electric /
- Wrist /
- Perforator flap /
- Sural nerve /
- Superficial peroneal nerve /
- Nerve defects /
- Functional reconstruction
周健、陈伟、常树森：手术设计和操作、论文撰写、病历资料整理及分析；郑玉岑、聂开瑜、张芳：患者管理、手术操作、病历资料收集；魏在荣：资金支持、手术设计和操作、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(30)

[1]	杜伟力,沈余明,胡骁骅,等.巨大腹壁下动脉脐旁穿支皮瓣修复腕部环状高压电烧伤创面的临床效果[J].中华烧伤与创面修复杂志,2023,39(6):527-533.DOI: 10.3760/cma.j.cn501225-20220719-00296.
[2]	曹大勇,狄海萍,邢培朋,等.股前外游离皮瓣在腕部高压电击伤创面修复中的临床疗效分析[J].中国医疗美容,2019,9(9):39-42.DOI: 10.19593/j.issn.2095-0721.2019.09.011.
[3]	邢培朋,郭海娜,狄海萍,等.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[J].中华烧伤杂志,2020,36(6):419-425.DOI: 10.3760/cma.j.cn501120-20200219-00067.
[4]	狄海萍,李永林,邢培朋,等.皮瓣修复腕部高压电烧伤创面的手术时机选择[J].中华显微外科杂志,2019,42(2):166-169.DOI: 10.3760/cma.j.issn.1001-2036.2019.02.016.
[5]	夏成德,狄海萍,邢培朋,等.游离股薄肌肌瓣联合腓肠神经移植重建腕部电烧伤患者手屈指和感觉功能的效果[J].中华烧伤与创面修复杂志,2023,39(3):228-233.DOI: 10.3760/cma.j.cn501225-20221203-00525.
[6]	TaylorGI, HamFJ. The free vascularized nerve graft. A further experimental and clinical application of microvascular techniques[J]Plast Reconstr Surg,1976,57(4):413-426.
[7]	顾玉东,吴敏明,郑忆柳,等.静脉蒂动脉化游离腓肠神经移植[J].中华外科杂志,1985,23(6):338-340.
[8]	顾玉东.周围神经缺损的基本概念与治疗原则[J].中华手外科杂志,2002,18(3):129-130.DOI: 10.3760/cma.j.issn.1005-054X.2002.03.001.
[9]	ToiaF,MattaD,De MicheleF,et al.Animal models of vascularized nerve grafts: a systematic review[J].Neural Regen Res,2023,18(12):2615-2618.DOI: 10.4103/1673-5374.358604.
[10]	潘生德,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.
[11]	郑玉东,李卫,何藻鹏,等.腓浅动脉皮支蒂V-Y推进皮瓣修复小腿小面积软组织缺损9例[J].中华显微外科杂志,2023,46(3):330-332.DOI: 10.3760/cma.j.cn441206-20221222-00250.
[12]	史宸硕,唐修俊,王达利,等.跨关节顺行腓浅神经营养血管皮瓣修复足踝部小面积软组织缺损[J].中华创伤杂志,2020,36(3):269-271.D0I:10.3760/cma.j.issn.1001-8050.2020.03.015.
[13]	熊胜,巨积辉,金光哲,等.游离同侧多块小腿腓浅动脉穿支皮瓣修复手部多发创面效果观察[J].中华烧伤杂志,2019,35(9):655-660.DOI: 10.3760/cma.j.issn.1009-2587.2019.09.003.
[14]	张韬,程俊楠,杨林,等.多穿支腓浅动脉穿支皮瓣修复手足创面的疗效[J].中华烧伤与创面修复杂志,2023,39(3):234-240.DOI: 10.3760/cma.j.cn501225-20220723-00305.
[15]	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.
[16]	李攀登,沈国良.携带腓肠肌的腓动脉穿支腓肠神经营养血管双血供复合组织瓣修复足踝部腔隙性缺损的临床效果[J].中华烧伤杂志,2019,35(5):392-394.DOI: 10.3760/cma.j.issn.1009-2587.2019.05.013.
[17]	PolatkanS,OrhunE,PolatkanO,et al.Evaluation of the improvement of sensibility after primary median nerve repair at the wrist[J].Microsurgery,1998,18(3):192-196.DOI: 10.1002/(sici)1098-2752(1998)18:3<192::aid-micr13>3.0.co;2-t.
[18]	王萍,李沅衡,李大宇,等.上肢感觉神经功能重建技术研究现状[J].中国临床解剖学杂志,2020,38(3):359-362,366.DOI: 10.13418/j.issn.1001-165x.2020.03.024.
[19]	尹凯,程琳,杜伟力,等.169例腕部高压电烧伤住院患者流行病学调查[J].中华烧伤杂志,2020,36(6):433-439.DOI: 10.3760/cma.j.cn501120-20200304-00119.
[20]	沈余明,覃凤均,杜伟力,等.濒临截肢四肢高压电烧伤患者的保肢策略[J].中华烧伤杂志,2019,35(11):776-783.DOI: 10.3760/cma.j.issn.1009-2587.2019.11.003.
[21]	WangC, ShenYM, QinFJ, et al. Free flow-through anterolateral thigh flaps for wrist high-tension electrical burns: a retrospective case series[J]. Biomed Environ Sci, 2020,33(7):510-517. DOI: 10.3967/bes2020.064.
[22]	范启申,周祥吉,钟世镇.吻合腓动静脉腓肠神经移植的应用[J].中华显微外科杂志,1998,21(2):97-99.DOI: 10.3760/cma.j.issn.1001-2036.1998.02.007.
[23]	顾玉东.周围神经缺损的治疗现状与进展[J].中华创伤杂志,2002,18(9):517-519.DOI: 10.3760/j:issn:1001-8050.2002.09.001.
[24]	褚晓朝,陆裕朴,殷琦.等.正中神经断裂伤晚期修复58例远期疗效[J].中华显微外科杂志,1996,19(1):15-17.
[25]	钟世镇,徐达传,丁自海.显微外科临床解剖学[M].济南:山东科学技术出版社,2000:345-400.
[26]	李绍光,顾立强,邵岩.尺神经功能束组走行模式的三维重建[J].中华创伤骨科杂志,2004,12(6):1358-1361. DOI: 10.3760/cma.j.issn.1671-7600.2004.12.013.
[27]	赖柏安,李慧,杨胜波.基于Sihler's技术的踝和足背皮神经的整体分布模式研究[J].中国临床解剖学杂志,2022,40(4):387-393.DOI: 10.13418/j.issn.1001-165x.2022.4.03.
[28]	付秀利,吕辉,刘雪峰.足背皮神经的显微断层解剖及其临床意义[J].齐齐哈尔医学院学报,2000,21(4):361-363.
[29]	张伯勋,卢世璧,朱盛修,等.腓肠神经的解剖类型及其切取后供区感觉变化的观察[J].中华显微外科杂志,1986,9(3):144-145,143,C1.DOI: 10.3760/cma.j.issn.1001-2036.1986.03.107.
[30]	BaiL,HanYN,ZhangWT,et al.Natural history of sensory nerve recovery after cutaneous nerve injury following foot and ankle surgery[J].Neural Regen Res,2015,10(1):99-103.DOI: 10.4103/1673-5374.150713.

下载: 全尺寸图片幻灯片

图 1 携带腓肠神经和腓浅神经的腓动脉穿支皮瓣联合腕关节瘢痕挛缩松解治疗例1患儿腕部电烧伤后期手指感觉和屈指功能障碍的效果。1A.术前左腕部可见腕关节瘢痕挛缩畸形；1B.术中探查见正中神经（红色箭头）、尺神经（白色箭头）缺损；1C.术中皮瓣设计；1D.术中皮瓣离体后；1E.皮瓣移植于腕部后即刻；1F、1G.分别为皮瓣移植术后7个月,腕关节瘢痕挛缩背侧观和掌侧观；1H、1I.分别为皮瓣移植术后7个月,行腕关节瘢痕挛缩松解术中及术后即刻；1J、1K.分别为皮瓣移植术后17个月,腕关节得以矫正,屈指、伸指功能良好；1L.皮瓣移植术后18个月,小腿皮瓣供区遗留线性瘢痕

下载: 全尺寸图片幻灯片

图 2 携带腓肠神经和腓浅神经的腓动脉穿支皮瓣联合游离股薄肌肌皮瓣移植修复例2患者腕部电烧伤后期手指感觉和屈指功能障碍的效果。2A.右腕部术前情况；2B.术中探查见正中神经（红色箭头）、尺神经（白色箭头）缺损；2C.术中皮瓣设计；2D.术中皮瓣离体后；2E.术中皮瓣移植于腕部后即刻；2F.供区缝合后即刻；2G.术后6个月皮瓣存活好；2H.术后6个月供区遗留线性瘢痕；2I、2J、2K.分别为腓动脉穿支皮瓣移植术后6个月,股薄肌肌皮瓣设计、切取后、移植于前臂后即刻；2L.腓动脉穿支皮瓣移植术后24个月随访时,股薄肌肌皮瓣成活,屈指功能良好

下载: 全尺寸图片幻灯片