股前外侧穿支皮瓣游离移植联合骨搬运序贯治疗小腿大面积皮肤软组织损伤伴大段胫骨缺损的临床效果

赵海磊; 孙志刚; 赵晓慧; 杨彬; 史明; 沈余明

doi:10.3760/cma.j.cn501225-20240926-00350

股前外侧穿支皮瓣游离移植联合骨搬运序贯治疗小腿大面积皮肤软组织损伤伴大段胫骨缺损的临床效果

doi: 10.3760/cma.j.cn501225-20240926-00350

1.
北京大望路急诊抢救医院烧伤整形与创面修复科,北京　　100122
2.
首都医科大学附属北京积水潭医院烧伤科,北京　　100035

基金项目:

北京市自然科学基金-昌平创新联合基金项目 L234067

详细信息

通讯作者:
沈余明,Email：shenyuming1963@163.com

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出版历程
- 收稿日期: 2024-09-26

Clinical effects of sequential treatment of extensive skin and soft tissue injuries of the lower leg accompanied by large segmental tibial defects by free transplantation of anterolateral thigh perforator flap combined with bone transport

1.
Department of Burns and Plastic Surgery and Wound Repair, Beijing Dawanglu Emergency Rescue Hospital, Beijing 100122, China
2.
Department of Burns, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China

Funds:

Beijing Natural Science Foundation-Changping Innovation Joint Fund Project L234067

More Information

Corresponding author: Shen Yuming, Email: shenyuming1963@163.com

摘要

摘要: 目的探讨股前外侧穿支皮瓣游离移植联合骨搬运序贯治疗小腿大面积皮肤软组织损伤伴大段胫骨缺损的临床效果。方法该研究为回顾性观察性研究。2020年4月—2024年1月,北京大望路急诊抢救医院收治8例符合入选标准的小腿大面积皮肤软组织损伤伴大段胫骨缺损患者,其中男6例、女2例,年龄17~58岁。清创后,小腿创面面积为17 cm×8 cm~30 cm×12 cm,胫骨缺损长度为9~12 cm。行Ⅰ期手术：游离移植股前外侧穿支皮瓣修复小腿大面积皮肤软组织损伤；对遗留创面,采用大腿自体皮片移植修复。待创面愈合后行Ⅱ期手术：拆除外固定支架并换用Orthofix单边外固定延长架（以下简称外固定延长架）搬运胫骨近端截骨修复大段骨缺损。记录Ⅰ期术中动静脉吻合情况及皮瓣供血方式,术后供受区皮瓣/皮片成活情况,受区创面愈合时间。记录Ⅱ期术后完成骨搬运耗时和外固定延长架保留时间及其间并发症发生情况。随访时,记录受区创面及患肢是否有不良事件发生。末次随访时,依据Paley评分对患肢骨折愈合情况进行评价并观察患肢功能。结果 2例患者旋股外侧动脉降支及伴行静脉与胫前或胫后动、静脉近端行端端吻合顺行供血、顺行回流；2例患者旋股外侧动脉降支与胫前动脉远端行端端吻合逆行供血,旋股外侧动脉降支伴行静脉与胫前静脉近端行端端吻合顺行回流；3例患者旋股外侧动脉降支与胫后动脉远端行端端吻合逆行供血,旋股外侧动脉降支伴行静脉与胫后静脉远端行端端吻合逆行回流；1例患者采用健肢血管桥式交叉供血游离皮瓣修复患侧小腿损伤。8例患者供受区皮瓣/皮片均成活,受区创面愈合时间为14~30 d。该组患者完成骨搬运耗时93~125 d,停止搬运后外固定延长架继续保留7~14个月；骨搬运期间,仅1例患者出现针道感染,经换药及加强护理后得到控制。随访时,受区创面未发生破溃,患肢未发生骨髓炎及骨折。末次随访时,骨折愈合情况评定均为优；患肢行走姿势及功能基本正常。结论应用股前外侧穿支皮瓣游离移植联合骨搬运序贯治疗小腿大面积皮肤软组织损伤伴大段胫骨缺损,可实现创面愈合及骨缺损功能性重建,有较大临床应用价值。
- 显微外科手术 /
- 下肢 /
- 穿支皮瓣 /
- 股前外侧穿支皮瓣 /
- 骨搬运 /
- 骨缺损 /
- 软组织缺损 /
- 创面修复
Abstract: Objective To explore the clinical effects of sequential treatment of extensive skin and soft tissue injuries of the lower leg accompanied by large segmental tibial defects by free transplantation of anterolateral thigh perforator flap combined with bone transport. Methods This study was a retrospective observational study. From April 2020 to January 2024, 8 patients with extensive skin and soft tissue injuries of the lower leg accompanied by large segmental tibial defects who met the inclusion criteria were admitted to Beijing Dawanglu Emergency Rescue Hospital. Among them, there were 6 males and 2 females, aged 17 to 58 years. After debridement, the area was 17 cm×8 cm to 30 cm×12 cm, and the length of tibial defect was 9 to 12 cm. Stage Ⅰ surgery was performed by free transplantation of anterolateral thigh perforator flap to repair the extensive skin and soft tissue injuries of the lower leg and using autologous skin graft from the thigh to repair the remaining wound. Stage Ⅱ surgery was performed after wound healing, the external fixation bracket was removed and replaced with an Orthofix unilateral external fixation lengthening frame (hereinafter referred to as external fixation lengthening frame) to transport the proximal tibial osteotomy for repairing the large segmental bone defects. The intraoperative arteriovenous anastomosis and the blood supply of the flap during stage Ⅰ surgery were documented, along with the survival status of the flap/skin graft in the donor and recipient areas postoperatively, and the wound healing time in the recipient area. The time required for bone transport completion, the duration of external fixation retention, and the occurrence of complications during this period were recorded after stage Ⅱ surgery. During follow-up, the occurrence of adverse events in the recipient area was recorded. At the final follow-up, fracture healing of the affected limb was evaluated according to the Paley score, and limb function was observed. Results In 2 patients, the descending branch of the lateral circumflex femoral artery and the accompanying vein were end-to-end anastomosed with the proximal anterior tibial or posterior tibial artery and vein for antegrade blood supply and antegrade reflux; in 2 patients, the descending branch of the lateral circumflex femoral artery was end-to-end anastomosed with the distal anterior tibial artery for retrograde blood supply, and the accompanying vein of the descending branch of the lateral circumflex femoral artery was end-to-end anastomosed with the proximal anterior tibial vein for antegrade reflux; in 3 patients, the descending branch of the lateral circumflex femoral artery was end-to-end anastomosed with the distal posterior tibial artery for retrograde blood supply, and the accompanying vein of the descending branch of the lateral circumflex femoral artery was end-to-end anastomosed with the distal posterior tibial vein for retrograde reflux; one patient underwent repair of the injury in the affected lower leg using a free cross-leg vascular pedicle flap from the healthy limb. The flaps/skin grafts in the donor and recipient areas of all 8 patients survived, and the wound healing time in recipient area was 14 to 30 days. The bone transport duration of the patients in this group was 93 to 125 days, and the external fixation lengthening frame was continuously retained for 7 to 14 months after the bone transport was stopped; during the bone transport period, 1 patient had pin tract infection, which was controlled after dressing change and enhanced nursing. During the follow-up, there was no ulceration of the wound surface in recipient area, and no osteomyelitis or fracture developed in the affected limb. At the last follow-up, the bone healing evaluation was all excellent; the walking posture and function of the affected limb were basically normal. Conclusions The application of free transplantation of anterolateral thigh perforator flap combined with bone transport in the sequential treatment of extensive skin and soft tissue injuries of the lower leg accompanied by large segmental tibial defecst can achieve wound healing and functional reconstruction of bone defects, and has great clinical application value.
- Microsurgery /
- Lower extremity /
- Perforator flap /
- Anterolateral thigh perforator flap /
- Bone transport /
- Bone defect /
- Soft tissue defect /
- Wound repair
赵海磊：酝酿设计、论文撰写与修改、实施手术；孙志刚：论文修改、实施手术：赵晓慧、杨彬、史明：实施手术、采集与分析资料；沈余明：研究指导、论文修改、经费支持

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图 1 股前外侧穿支皮瓣游离移植联合骨搬运序贯治疗例1患者左小腿大面积皮肤软组织损伤伴大段胫骨缺损的效果。1A.入院时,小腿大面积皮肤软组织损伤,骨质外露,颜色灰暗；1B.入院时,X线检查显示胫腓骨粉碎性骨折+外固定支架固定；1C.入院后第10天,Ⅰ期术前对皮瓣供区进行血管造影；1D.入院后第12天,行清创后去除坏死组织及骨质；1E.入院后第12天,Ⅰ期术中,设计股前外侧穿支皮瓣；1F.Ⅰ期术中,游离股前外侧降支穿支皮瓣；1G.Ⅰ期术中,将游离皮瓣移植覆盖小腿创面；1H.Ⅰ期术中,设计阔筋膜张肌肌皮瓣；1I.Ⅰ期术中,将阔筋膜张肌肌皮瓣推进覆盖供区创面；1J.Ⅰ期术后第14天,股前外侧穿支皮瓣成活,行拆线；1K.Ⅰ期术后第14天,覆盖供区创面的阔筋膜张肌肌皮瓣完全成活,行拆线；1L.Ⅱ期术中,X线检查显示胫骨近端被截骨,并用Orthofix单边外固定延长架固定,准备骨搬运；1M.Ⅱ期术后8个月完成骨搬运,CT三维重建图像显示骨折断端完全矿化,予以拆除Orthofix单边外固定延长架；1N、1O.分别显示Ⅱ期术后5个月双下肢基本等长、患肢站立单独负重功能良好

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图 2 股前外侧穿支皮瓣游离移植联合骨搬运序贯治疗例2患者右小腿大面积皮肤软组织损伤伴大段胫骨缺损的效果。2A.入院时,X线检查显示小腿胫腓骨粉碎性骨折伴骨缺损,采用外固定支架固定；2B.入院后,清创后显示小腿大面积皮肤软组织损伤伴大段胫骨缺损；2C.Ⅰ期术前,进行双下肢血管造影；2D.入院后第13天,解剖股前外侧穿支皮瓣；2E.Ⅰ期术中,切取股前外侧穿支皮瓣；2F.Ⅰ期术中,将旋股外侧动脉降支与胫前动脉远端端端吻合逆行供血；2G、2H.分别为Ⅰ期术中,设计、切取23 cm×11 cm腹股沟皮瓣接力修复供瓣区创面；2I、2J.分别为Ⅰ期术中,采用自体皮片移植修复股前外侧穿支皮瓣覆盖右小腿胫前创面后剩余创面前、后；2K.Ⅰ期术后第14天,股前外侧穿支皮瓣及自体皮均成活,创面愈合；2L.Ⅰ期术后第14天,覆盖供区创面的腹股沟皮瓣完全成活,创面愈合；2M.Ⅰ期术后第21天,X线检查显示Orthofix单边外固定延长架固定患肢情况；2N.Ⅱ期术后8个月,CT三维重建显示骨折断端完全矿化,拆除Orthofix单边外固定延长架；2O.Ⅱ期术后8个月,患肢单独站立负重,功能良好；2P、2Q、2R.分别为拆除Orthofix单边外固定延长架后6个月,双下肢基本等长的X线检查结果、患肢站立位功能、患肢单独负重功能情况

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