Clinical efficacy of free anterolateral thigh flap supplied by non-major artery in the recipient area based on gradient selection in repairing wounds formed after lower limb salvage surgery
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摘要:
目的 探讨基于梯度选择的受区非主干动脉供血游离股前外侧皮瓣修复小腿保肢术后形成创面的临床效果。 方法 该研究为回顾性观察性研究。2020年1月—2024年6月,苏州瑞华骨科医院创伤骨科收治66例符合入选标准的小腿保肢术后形成创面患者,其中男46例、女20例,年龄19~76岁,8例患者皮瓣移植前创面分泌物标本微生物培养结果阳性。创面均位于单侧小腿,清创后创面面积为9 cm×6 cm~40 cm×30 cm,采用面积为10 cm×8 cm~35 cm×11 cm的游离股前外侧皮瓣修复创面,对巨大创面辅以刃厚皮片移植或行双股前外侧皮瓣移植修复。根据解剖位置由低到高将受区与创面邻近的腓肠内侧动脉、膝降动脉、旋股外侧动脉降支这3条非主干动脉进行梯度分级,选择最低级未损伤动脉作为覆盖创面游离皮瓣供血动脉。将供瓣区创面直接缝合或者用腹部全厚皮片覆盖。记录术前数字减影血管造影（DSA）检查确认的受区最低级可用非主干动脉类型,术中使用的受区非主干动脉类型、吻合的受区非主干动脉与皮瓣血管口径比值、血管吻合类型、皮瓣血管蒂长度、创面修复方式、双股前外侧皮瓣动静脉串联方式,术后至出院前皮瓣成活及血管危象发生情况、供受区创面愈合情况、供区特殊并发症发生情况。随访记录皮瓣色泽及质地、创面感染控制情况。末次随访时,根据综合评价量表评价皮瓣移植效果。 结果 术前DSA检查确认受区最低级可用非主干动脉为腓肠内侧动脉者35例、膝降动脉者24例、旋股外侧动脉降支者7例,同术中使用的受区非主干动脉一致。术中吻合的受区腓肠内侧动脉、膝降动脉、旋股外侧动脉降支与皮瓣血管口径比值分别为0.5~1.0、0.5~0.8、0.5~0.7,行血管端端直接吻合者20例、血管端端鱼嘴状吻合者46例,皮瓣血管蒂长度为8~18 cm,对创面行单纯皮瓣移植修复者57例、皮瓣+皮片移植修复者9例,双股前外侧皮瓣中主皮瓣动静脉主干与副皮瓣动静脉主干串联者2例、主皮瓣动静脉分支与副皮瓣动静脉主干串联者1例。术后,67块皮瓣顺利成活,2块皮瓣发生血管危象,经手术探查重新吻合血管后成活；55例患者术前无感染创面与4例患者术前感染创面术后顺利愈合,3例患者术前无感染创面术后出现感染而延迟愈合,4例患者术前感染创面术后延迟愈合；供区创面均顺利愈合,未发生感染、肌肉坏死等特殊并发症。随访6~24个月显示,69块皮瓣色泽、质地均良好,创面均未发生感染。末次随访时,皮瓣移植效果评价为优者39例、良者21例、可者6例。 结论 基于梯度选择的受区非主干动脉供血游离股前外侧皮瓣血供丰富,可用其一次性修复小腿保肢术后形成创面,不增加远端肢体血管再次损伤风险,有效控制感染,值得临床推广。 Abstract:Objective To investigate the clinical efficacy of free anterolateral thigh flap supplied by non-major artery in the recipient area based on gradient selection in repairing wounds formed after lower limb salvage surgery. Methods This study was a retrospective observational study. From January 2020 to June 2024, 66 patients with wounds formed after lower limb salvage surgery were admitted to the Department of Orthopaedics Trauma of Suzhou Ruihua Orthopedic Hospital, including 46 males and 20 females, aged 19-76 years. The microbiological culture results of wound secretion specimens from 8 patients were positive before flap transplantation. The wounds were all located on unilateral lower leg, with a wound area of 9 cm×6 cm to 40 cm×30 cm after debridement, which were repaired with free anterolateral thigh flaps measuring from 10 cm×8 cm to 35 cm×11 cm. Large wounds were repaired with additional split-thickness skin grafting or double anterolateral thigh flap transplantation. According to the anatomical location form low to high, the three non-major recipient arteries adjacent to the wound, namely the medial sural artery, the descending genicular artery, and the descending branch of the lateral circumflex femoral artery, were graded in a stepwise manner, and the lowest-grade uninjured artery was selected as the blood supply artery for the free flap covering the wound. Wounds in flap donor area were closed directly or covered with full-thickness skin grafts from the abdomen. Data recorded included the type of the lowest-grade usable non-major artery in the recipient area confirmed by preoperative digital subtraction angiography (DSA) examination, intraoperatively used type of non-major artery in the recipient area, the ratio of the calibers of the non-major artery in the recipient area to the flap vessel, type of vascular anastomosis, flap pedicle length, wound repair method, and arterial and venous connection method for double anterolateral thigh flaps, as well as flap survival and vascular crisis occurrrence, wound healing in recipient and donor areas, and occurrrence of specific donor-site complications after surgery before discharge. The flap's color, texture, and wound infection control were followed up. The outcome of the flap transplantation was evaluated using a comprehensive assessment scale at the final follow-up. Results Preoperative DSA examination identified the lowest-grade usable non-major recipient artery as the medial sural artery in 35 cases, the descending genicular artery in 24 cases, and the descending branch of the lateral circumflex femoral artery in 7 cases, which were consistent with the non-major artery in the recipient area used intraoperatively. The caliber ratio of recipient artery-to-flap vessel that were anastomosed intraoperatively was 0.5-1.0 for the medial sural artery, 0.5-0.8 for the descending genicular artery, and 0.5-0.7 for the descending branch of the lateral circumflex femoral artery. End-to-end direct anastomosis was performed in 20 cases, and end-to-end "fish-mouth" anastomosis was performed in 46 cases. The flap pedicle length was 8-18 cm. Wounds were repaired with flap transplantation alone in 57 cases and transplantation of flap combined with skin graft in 9 cases. For double anterolateral thigh flaps, the main arterial and venous trunk of the primary flap was connected to the main arterial and venous trunk of the secondary flap in 2 cases, and the arterial and venous branches of the primary flap was connected to the main arterial and venous trunk of the secondary flap in 1 case. Postoperatively, 67 flaps survived successfully, while vascular crisis occurred in 2 flaps, which survived after surgical exploration and re-anastomosis. Preoperatively non-infected wounds in 55 cases and infected wounds in 4 cases healed successfully postoperatively, while preoperatively non-infected wounds in 3 cases developed postoperative infection leading to delayed healing, and preoperatively infected wounds in 4 cases healed with delay. All donor site wounds healed well without specific complications like infection or muscle necrosis. Follow up for 6-24 months showed that all 69 flaps exhibited good color and texture with no wound infection. At the final follow-up, the outcome of the flap transplantation was evaluated as excellent in 39 cases, good in 21 cases, and fair in 6 cases. Conclusions The free anterolateral thigh flap supplied by non-major artery in the recipient area based on gradient selection demonstrates abundant blood supply, which can be used to repair wounds formed after lower limb salvage surgery in one time, without increasing the risk of further damage to the distal limb blood vessels, and can effectively control infections. This technique merits clinical promotion. -
参考文献
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图 1 受区腓肠内侧动脉供血的游离股前外侧皮瓣修复例1患者左小腿保肢术后胫前形成不规则创面的效果。1A.保肢术后15 d左小腿胫前皮肤坏死；1B.皮瓣移植术前数字减影血管造影（DSA）显示受区腓肠内侧动脉存在且未损伤（图中箭头指示）；1C.切除坏死组织后,左小腿胫前形成不规则创面；1D.设计右股前外侧皮瓣；1E.将皮瓣动脉同受区腓肠内侧动脉吻合中；1F.皮瓣移植术后15 d,供区创面顺利愈合；1G.皮瓣移植术后5个月,DSA造影显示腓肠内侧动脉吻合口通畅（图中箭头指示）；1I.皮瓣移植术后21个月随访时,皮瓣色泽良好,未见破溃或感染
图 2 受区旋股外侧动脉降支接力左小腿大隐静脉供血的游离股前外侧皮瓣修复例2患者右小腿保肢术后胫前形成创面的效果。2A.保肢术后14 d右小腿胫前皮肤坏死；2B.皮瓣移植前数字减影血管造影显示受区旋股外侧动脉存在且未损伤（图中箭头指示）；2C.切除右小腿坏死组织后,可见钢板及骨关节组织外露；2D.设计左股前外侧皮瓣修复创面；2E.设计左小腿大隐静脉皮瓣进行皮瓣血管接力；2F.股前外侧皮瓣断蒂前血运良好；2G.皮瓣移植术毕即刻皮瓣血运良好；2H.皮瓣移植术后14 d供区创面顺利愈合；2I.皮瓣移植术后14 d,皮瓣血运好,顺利成活；2J.皮瓣移植术后21个月随访时,皮瓣色泽良好,未见破溃或感染
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