Clinical application value of color Doppler ultrasound in the repair of skin and soft tissue defects in the extremities using the anterolateral thigh perforator flaps pedicled with the oblique branch of the lateral circumflex femoral artery
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摘要:
目的 探讨彩色多普勒超声在以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣（ALTPF）修复四肢皮肤软组织缺损中的临床应用价值。 方法 该研究为回顾性队列研究。将2018年3月—2020年11月东营市中医院收治的符合入选标准且采用根据术者临床经验设计、切取的以旋股外侧动脉斜支为蒂的ALTPF修复四肢皮肤软组织缺损的30例患者作为对照组,将2020年12月—2023年5月该院收治的符合入选标准且采用根据术前彩色多普勒超声结果设计、切取的以旋股外侧动脉斜支为蒂的ALTPF修复四肢皮肤软组织缺损的30例患者作为超声组。患者中男49例、女11例,年龄19~60岁。清创后创面面积为6.0 cm×3.0 cm~13.0 cm×11.0 cm,切取的ALTPF面积为7.0 cm×4.0 cm~18.0 cm×8.0 cm。将供区创面直接拉拢缝合。分析超声组患者术前彩色多普勒超声检查的旋股外侧动脉斜支的分型及其穿支血管数量与术中探查结果的一致性,比较术前彩色多普勒超声检查及术中探查测量的旋股外侧动脉斜支起始处管径及其穿支穿出点血管管径、血管蒂长度。术后1、3、5、7、14 d,采用皮瓣血运评估量表对2组患者皮瓣血运状况进行评分；统计皮瓣手术时长、术中出血量、住院时长；统计术后1周内皮瓣受区张力性水疱、静脉危象及术后2周内皮瓣坏死发生情况,统计术后2周内供区切口裂开及术后1年内瘢痕异常增生、感觉异常、运动功能减退等发生情况；术后1年,通过利克特5级量表评估患者对治疗效果的满意度。 结果 超声组患者术前彩色多普勒超声检查显示旋股外侧动脉斜支为1型者17例、2型者5例、3型者3例、4型者3例、5型者2例,与术中探查情况完全一致（Kappa系数为1.00,P<0.05）；旋股外侧动脉斜支的穿支血管数量与术中探查结果具有高度一致性（Kappa系数为0.08,P<0.05）。术前彩色多普勒超声检查测量的旋股外侧动脉斜支起始处管径、穿支穿出点血管管径、血管蒂长度与术中实际测量结果比较,差异均无统计学意义（t值分别为0.60、0.85、0.78,P>0.05）。术后1、3、5、7、14 d,超声组患者皮瓣血运状况评分均明显高于对照组（t值分别为8.64、10.41、10.84、8.99、6.37,P<0.05）。超声组患者皮瓣手术时长及住院时长均明显短于对照组（t值分别为5.34、3.73,P<0.05）,术中出血量明显少于对照组（t=18.37,P<0.05）。超声组患者术后各时间点皮瓣供受区并发症发生率均明显低于对照组（P<0.05）。术后1年,超声组患者对治疗效果的满意率明显高于对照组（P<0.05）。 结论 术前彩色多普勒超声检查可明确旋股外侧动脉斜支的类型及分布。基于此设计及切取以旋股外侧动脉斜支为蒂的ALTPF修复四肢皮肤软组织缺损,术后皮瓣血运明显改善,手术时长及住院时长均明显缩短,术中出血量减少,术后并发症发生率降低,患者对治疗效果的满意度更高。 -
关键词:
- 超声检查,多普勒,彩色 /
- 创伤和损伤 /
- 穿支皮瓣 /
- 四肢 /
- 创面修复
Abstract:Objective To investigate the clinical application value of color Doppler ultrasound in the repair of skin and soft tissue defects in the extremities using the anterolateral thigh perforator flaps (ALTPF) pedicled with the oblique branch of the lateral circumflex femoral artery. Methods This study was a retrospective cohort study. A total of 30 patients admitted to Dongying Traditional Chinese Medicine Hospital from March 2018 to November 2020 who met the inclusion criteria were selected as the control group. The patients underwent repair of skin and soft tissue defects in the extremities using the ALTPF which pedicled with the oblique branch of the lateral circumflex femoral artery and designed and harvested based on the surgeon's clinical experience. Another 30 patients admitted to the same hospital from December 2020 to May 2023 who met the inclusion criteria were selected as the ultrasound group. The patients underwent repair of skin and soft tissue defects in the extremities using the ALTPF pedicled with the oblique branch of the lateral circumflex femoral artery and designed and harvested according to preoperative color Doppler ultrasound results. Among the patients, there were 49 males and 11 females, aged 19-60 years. After debridement, the wound areas ranged from 6.0 cm×3.0 cm to 13.0 cm×11.0 cm, and the harvested areas of ALTPF ranged from 7.0 cm×4.0 cm to 18.0 cm×8.0 cm. The donor site wounds were directly sutured. For patients in the ultrasound group, the consistency between the classification of the oblique branches of the lateral circumflex femoral artery and the number of its perforating vessels determined by the preoperative color Doppler ultrasound examination and the intraoperative exploration results was analyzed; the diameters of the oblique branches of the lateral circumflex femoral artery at its origin, the diameters of the vessels at the perforation points of its perforating branches, as well as the length of the vascular pedicle were compared between the preoperative color Doppler ultrasound examination and the intraoperative exploration. For patients in the two groups, the blood supply status of the flaps on postoperative days 1, 3, 5, 7, and 14 was scored using a flap blood supply assessment scale; the duration of flap surgery, intraoperative blood loss, and length of hospital stay were recorded; the incidence of tension blisters and venous crisis in the flap recipient areas within one week after surgery and flap necrosis within two weeks after surgery were recorded, and the incidence of incision dehiscence in the flap donor areas within two weeks after surgery and abnormal scar hyperplasia, sensory abnormalities, and decreased motor function within one year after surgery were recorded. One year after surgery, the satisfaction of patients in the two groups with the treatment outcomes was evaluated using a Likert 5-point scale. Results For patients in the ultrasound group, the preoperative color Doppler ultrasound examination revealed that the oblique branch of the lateral circumflex femoral artery was type 1 in 17 cases, type 2 in 5 cases, type 3 in 3 cases, type 4 in 3 cases, and type 5 in 2 cases, which was completely consistent with the intraoperative exploration findings (with Kappa coefficient of 1.00, P<0.05). The number of perforating vessels of the oblique branch of the lateral circumflex femoral artery detected by the preoperative color Doppler ultrasound examination showed a high degree of consistency with the intraoperative exploration results (with Kappa coefficient of 0.80, P<0.05). There were no statistically significant differences in the diameters of the oblique branches of the lateral circumflex femoral artery at its origin, the diameters of the vessels at the perforation points of its perforating branches, as well as the length of the vascular pedicle between the preoperative color Doppler ultrasound examination and the intraoperative exploration (with t values of 0.60, 0.85, and 0.78, respectively, P>0.05). On postoperative days 1, 3, 5, 7, and 14, the scores of flap blood supply status in the ultrasound group of patients were significantly higher than those in the control group (with t values of 8.64, 10.41, 10.84, 8.99, and 6.37, respectively, P<0.05). The duration of flap surgery and length of hospital stay in the ultrasound group of patients were significantly shorter than those in the control group (with t values of 5.34 and 3.73, respectively, P<0.05), and the intraoperative blood loss was significantly less than that in the control group (t=18.37, P<0.05). The incidence of complications in the flap donor and recipient areas in the ultrasound group of patients at different time points after surgery was significantly lower than that in the control group (P<0.05). One year after surgery, the satisfaction rate of patients with the treatment outcomes in the ultrasound group was significantly higher than that in the control group (P<0.05). Conclusions The color Doppler ultrasound was used to clarify the classification and distribution of the oblique branch of the lateral circumflex femoral artery preoperatively. Based on this, the ALTPF pedicled with the oblique branch of the lateral circumflex femoral artery was designed and harvested to repair the skin and soft tissue defects in the extremities, which can significantly improve the postoperative flap blood supply, effectively shorten surgical duration and length of hospital stay, reduce intraoperative blood loss and the incidence of complications, and enhance patients' satisfaction with treatment outcomes. -
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图 1 旋股外侧动脉斜支分型示意图及其术前彩色多普勒超声检查图。1A.1型示意图；1B.2型示意图；1C.3型示意图；1D.4型示意图；1E.5型示意图；1F.1型检查图；1G.2型检查图；1H.3型检查图；1I.4型检查图；1J.5型检查图
注：1为股动脉,2为股深动脉,3为旋股外侧动脉,4为旋股外侧动脉横支,5为旋股外侧动脉斜支,6为旋股外侧动脉降支；图1F~1J中白色箭头指示旋股外侧动脉斜支主干
图 2 根据术前彩色多普勒超声检查结果设计、切取以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣修复患者左足足跟部位皮肤软组织缺损的效果。2A.术前通过彩色多普勒超声探测旋股外侧动脉斜支情况,明确其分型为1型；2B.清创后创面,可见骨质外露；2C.皮瓣设计；2D.术中显露旋股外侧动脉斜支及其穿支血管；2E.术中皮瓣切取后即刻；2F.术中将皮瓣分为双叶皮瓣；2G.术中用皮瓣覆盖创面并缝合后即刻；2H.术后1年,皮瓣外形较好
注：图2A中白色箭头为旋股外侧动脉斜支主干；图2D中白色箭头为旋股外侧动脉斜支主干,黑色箭头为斜支的穿支血管
Table 1. 2组四肢皮肤软组织缺损患者一般资料比较
组别 例数 性别（例） 年龄（岁, 受伤侧（例） 身体质量指数（kg/m2, 清创后创面大小（ 皮瓣大小（ 男 女 左 右 长（cm） 宽（cm） 长（cm） 宽（cm） 对照组 30 25 5 40±6 13 17 22±3 10.9±2.5 7.3±1.2 12.6±3.2 6.8±0.5 超声组 30 24 6 38±5 16 14 23±3 11.7±2.9 7.6±1.9 14.1±3.7 7.0±0.6 统计量值 — t=1.40 — t=1.29 t=1.14 t=0.73 t=1.68 t=1.40 P值 <0.999 0.166 0.606 0.202 0.257 0.468 0.098 0.166 注：对照组、超声组患者分别采用根据术者临床经验、术前彩色多普勒超声结果设计、切取的以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣修复创面；“—”表示无此项 
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Table 2. 2组四肢皮肤软组织缺损患者术后不同时间点皮瓣血运状况评分比较（分,
组别 例数 1 d 3 d 5 d 7 d 14 d 对照组 30 3.59±0.08 3.49±0.11 3.47±0.13 3.49±0.15 3.61±0.16 超声组 30 3.78±0.09 3.76±0.09 3.82±0.12 3.85±0.16 3.89±0.18 t值 8.64 10.41 10.84 8.99 6.37 P值 <0.001 <0.001 <0.001 <0.001 <0.001 注：对照组、超声组患者分别采用根据术者临床经验、术前彩色多普勒超声结果设计、切取的以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣修复创面；处理因素主效应,F=11.97,P<0.001；时间因素主效应,F=12.02,P<0.001；两者交互作用,F=9.91,P<0.001
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Table 3. 2组四肢皮肤软组织缺损患者手术时长和术中出血量及住院时长比较（
组别 例数 手术时长（min） 术中出血量（mL） 住院时长（d） 对照组 30 80±23 317±21 24±6 超声组 30 54±15 228±16 19±3 t值 5.34 18.37 3.73 P值 <0.001 <0.001 <0.001 注：对照组、超声组患者分别采用根据术者临床经验、术前彩色多普勒超声结果设计、切取的以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣修复创面
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Table 4. 2组四肢皮肤软组织缺损患者术后皮瓣受区并发症发生情况比较[例（%）]
组别 例数 术后1周内 术后2周内皮瓣坏死 张力性水疱 静脉危象 对照组 30 9（30.00） 8（26.67） 6（20.00） 超声组 30 1（3.33） 1（3.33） 0（0） P值 0.012 0.026 0.024 注：对照组、超声组患者分别采用根据术者临床经验、术前彩色多普勒超声结果设计、切取的以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣修复创面
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Table 5. 2组四肢皮肤软组织缺损患者术后供区并发症发生情况比较[例（% ）]
组别 例数 术后2周内切口裂开 术后1年内 瘢痕异常增生 感觉异常 运动功能减退 对照组 30 6（20.00） 9（30.00） 8（26.67） 6（20.00） 超声组 30 0（0） 1（3.33） 1（3.33） 0（0） P值 0.024 0.012 0.026 0.024 注：对照组、超声组患者分别采用根据术者临床经验、术前彩色多普勒超声结果设计、切取的以旋股外侧动脉斜支为蒂的股前外侧穿支皮瓣修复创面
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