腓肠内侧动脉穿支皮瓣游离移植修复手足电烧伤创面的效果

张卫东; 张伟; 余刚; 陈斓; 龚翔; 谢卫国; 茹天峰

doi:10.3760/cma.j.cn501225-20240611-00226

腓肠内侧动脉穿支皮瓣游离移植修复手足电烧伤创面的效果

doi: 10.3760/cma.j.cn501225-20240611-00226

武汉大学同仁医院暨武汉市第三医院烧伤科,武汉　　430060

基金项目:

湖北省自然科学基金 2024AFB470

武汉市卫生和计划生育委员会科研项目 WX18Q44

武汉市知识创新专项曙光计划项目 2022020801020553

详细信息

通讯作者:
谢卫国,Email：wgxie@hotmail.com

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出版历程
- 收稿日期: 2024-06-11

Efficacy of free medial sural artery perforator flap transplantation in repairing electrical burn wounds on hands and feet

Department of Burns, Tongren Hospital of Wuhan University ＆ Wuhan Third Hospital, Wuhan 430060, China

Funds:

Natural Science Foundation of Hubei Province of China 2024AFB470

Research Project of Wuhan Municipal Health and Family Planning Commission WX18Q44

Knowledge Innovation Program of Wuhan-Shuguang Project 2022020801020553

More Information

Corresponding author: Xie Weiguo, Email: wgxie@hotmail.com

摘要

摘要: 目的探讨腓肠内侧动脉穿支皮瓣游离移植修复手足电烧伤创面的效果。方法该研究为回顾性观察性研究。2017年11月—2023年9月,武汉大学同仁医院暨武汉市第三医院收治21例符合入选标准的年龄28~51岁手足电烧伤男性患者。共有23个创面,其中14个创面位于手部,9个创面位于足部；9个创面伴肌腱损伤外露,6个创面伴骨外露或坏死,8个创面伴关节损伤。清创后创面面积为4.0 cm×2.5 cm~14.0 cm×10.0 cm。对于2个较宽创面和2个相邻指/趾创面,设计并切取以2条腓肠内侧动脉穿支为中心的分叶皮瓣进行修复；对于其他创面,设计并切取腓肠内侧动脉穿支皮瓣进行修复。皮瓣面积为5.0 cm×3.0 cm~16.0 cm×11.0 cm。将皮瓣动静脉与受区动静脉行端端吻合；将10个皮瓣的皮神经与手部创面神经吻合,另切取腓肠神经束修复1处指神经缺损。减张缝合供区创面。记录术后皮瓣成活情况、供区创面愈合情况。随访时,记录皮瓣后期整复情况,观察皮瓣质地、外观,观察小腿供区瘢痕及功能恢复情况。末次随访时,观测手部皮瓣感觉恢复情况,采用利克特量表调查患者对每次手术治疗效果的满意度,采用中华医学会手外科学会上肢部分功能评定试用标准评估手部创面患者患手功能,使用Holden步行能力分级评估足部创面患者的患足负重行走能力。结果术后1个皮瓣远端存在少许坏死,经换药后愈合。23个皮瓣全部成活。2个供区缝合口因局部张力过高愈合不良,经清创、引流后行二次缝合,愈合良好；其余21个供区创面愈合良好。术后随访6~26个月显示,3个皮瓣稍臃肿,行皮瓣整复术后外观改善；其余皮瓣未行后期整复。所有皮瓣质地软且与周围组织形态相近。小腿供区存留线状瘢痕,行走功能正常。末次随访时,手部皮瓣均恢复保护性感觉；患者对21次手术治疗效果表示非常满意,对2次手术治疗效果表示比较满意；14例手部创面患者中患手功能评定为优者10例、良者3例、可者1例,7例足部创面患者的患足负重行走能力分级均为Ⅴ级。结论腓肠内侧动脉穿支皮瓣具有血供可靠、厚度适宜且平整等优点,可分叶或根据创面形状切取,用该皮瓣修复手足电烧伤创面时,受区的外形和功能恢复效果均较佳,患者对手术治疗效果满意度较高。
- 烧伤,电 /
- 显微外科手术 /
- 外科皮瓣 /
- 腓肠内侧动脉穿支皮瓣 /
- 手足创面 /
- 游离皮瓣 /
- 创面修复
Abstract: Objective To explore the efficacy of free medial sural artery perforator flap transplantation in repairing electrical burn wounds on hands and feet. Methods This study was a retrospective observational study. From November 2017 to September 2023, 21 male patients aged 28-51 years with electrical burns on hands and feet who met the inclusion criteria were admitted to Tongren Hospital of Wuhan University ＆ Wuhan Third Hospital. There were 23 wounds, of which 14 were on the hand and 9 on the foot; 9 were associated with exposed tendon injury, 6 were associated with bone exposure or necrosis, and 8 were associated with joint injury. The wound area after debridement was 4.0 cm×2.5 cm-14.0 cm×10.0 cm. For 2 relatively wide wounds and 2 adjacent fingers/toes wounds, the lobulated flaps centered on 2 medial sural artery perforators were designed and incised for repair. For other wounds, medial sural artery perforator flaps were designed and incised. The flap area was 5.0 cm×3.0 cm-16.0 cm×11.0 cm. The arteriovenous vessels of flap were anastomosed end-to-end with the arteriovenous vessels of the recipient area; the cutaneous nerves of 10 flaps were anastomosed with the nerves in hand wound, and the sural nerve bundle was cut to repair one digital nerve defect. The donor site wound was closed with tension-relieving sutures. Postoperative flap survival and wound healing at donor site were recorded. During follow-up, subsequent flap revision was recorded, the texture and appearance of the flap, as well as the scarring and functional recovery of the donor area of the lower leg, were observed. At the last follow-up, the recovery of hand flap sensation was observed, the satisfaction of patients with the treatment effect of each operation was investigated by using Likert scale, the hand function of the affected hand in patients with hand wounds was evaluated by using the trial standards for evaluation of partial function of upper extremity by the Hand Surgery Society of Chinese Medical Association, and the weight-bearing walking ability of the affected foot in patients with foot wounds was evaluated by Holden walking ability grading. Results There was a slight necrosis at the distal end of one flap after surgery, which healed after dressing change. All 23 flaps survived. The sutures of the two donor areas were poorly healed due to high local tension, and the second sutures were performed after debridement and drainage, and the healing was good. The wounds of the remaining 21 donor sites healed well. Follow-up of 6-26 months after surgery showed that 3 flaps were slightly bloated, and the appearance was improved after flap reconstruction; the other flaps did not undergo subsequent revision. All flaps were soft and similar to the surrounding tissue morphology. Linear scar remained in the donor site of the lower leg, and walking function was normal. At the last follow-up, the protective sensation of the hand flap was restored; the patients were very satisfied with the results of 21 surgeries and were relatively satisfied with the results of 2 surgeries. Among the 14 patients with hand wounds, the affected hand function was rated as excellent in 10 cases, very good in 3 cases, and acceptable in one case, and the weight-bearing walking ability of the affected foot in 7 patients with foot wounds was all rated as grade Ⅴ. Conclusions The medial sural artery perforator flap has the advantages of reliable blood supply, appropriate thickness and smoothness, and can be lobulated or cut according to the shape of the wound. The flap demonstrates superior aesthetic and functional restoration in repairing electrical burn wounds on hands and feet, achieving high patient satisfaction with the surgical treatment effect.
- Burns, electric /
- Microsurgery /
- Surgical flaps /
- Medial sural artery perforator flap /
- Wounds on hands and feet /
- Free flap /
- Wound repair
张卫东：手术操作、数据整理、论文撰写与修改、经费支持；张伟、余刚、陈斓、龚翔、茹天峰：手术操作、数据整理、论文修改；谢卫国：论文修改、研究指导、经费支持

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图 1 腓肠内侧动脉穿支皮瓣游离移植修复例1患者右手示指电烧伤创面的效果。1A.术前右手示指关节桡侧创基凹陷并形成干痂；1B.右手示指清创后即刻；1C.术前,于左侧小腿设计皮瓣；1D.完全游离皮瓣术中；1E.皮瓣血管蒂离断后即刻,显露动静脉及神经；1F.克氏针固定示指关节于伸直位,将皮瓣移植到创面后即刻；1G、1H.分别术后12个月随访时右手侧面及掌面观,显示皮瓣外形良好

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图 2 腓肠内侧动脉穿支分叶皮瓣游离移植修复例2患者左足电烧伤创面的效果。2A.左足术前创面情况；2B.左足创面清创后基底残余肌腱、趾骨外露；2C.术前探查左小腿腓肠内侧动脉穿支为2条,将皮瓣设计成2叶；2D.皮瓣切取完成即刻；2E.皮瓣分叶后移植到创面即刻；2F.术后6个月随访时,第1、2趾皮瓣存活良好,分趾后外形良好

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图 3 腓肠内侧动脉穿支皮瓣游离移植修复例3患者双足电烧伤创面的效果。3A、3B.分别为右、左足伤后1 d,用磺胺嘧啶银乳膏护痂；3C.右足伤后22 d,创面行负压治疗后形成部分肉芽组织,第1跖趾关节开放及趾间关节囊部分坏死；3D.术中设计左小腿腓肠内侧动脉穿支皮瓣；3E.皮瓣切取完毕,携带2条穿支；3F.右足皮瓣移植术后14 d情况；3G.伤后37 d,左足创面清创后,近节趾骨部分坏死变黑,趾间关节腔开放；3H.切取右小腿腓肠内侧动脉穿支皮瓣（携带1条穿支）；3I.皮瓣移植到左足创面后即刻；3J、3K、3L.分别为随访26个月,右、左足及双下肢情况,双足皮瓣形态良好,双小腿供区愈合良好

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