不同类型嵌合穿支皮瓣移植治疗下肢骨外露创面的临床效果

王晶; 黄书清; 刘婧怡; 雷泽源; 杨智斌

doi:10.3760/cma.j.cn501225-20250527-00245

不同类型嵌合穿支皮瓣移植治疗下肢骨外露创面的临床效果

doi: 10.3760/cma.j.cn501225-20250527-00245

陆军军医大学（第三军医大学）第二附属医院整形外科,重庆　400015

基金项目:

陆军军医大学第二附属医院青年博士人才孵化计划项目 2024YQB090, 2022YQB084

详细信息

通讯作者:
杨智斌,Email：yanzhibin321@163.com

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出版历程
- 收稿日期: 2025-05-27
- 网络出版日期: 2026-09-28

Clinical effects of different types of chimeric perforator flap transplantation in the treatment of lower extremity wounds with bone exposure

Department of Plastic Surgery, the Second Affiliated Hospital of Army Medical University (the Third Military Medical University), Chongqing 400015, China

Funds:

The Young PhD Talents Cultivation Project of the Second Affiliated Hospital of Army Medical University 2024YQB090, 2022YQB084

More Information

Corresponding author: Yang Zhibin, Email: yanzhibin321@163.com

摘要

摘要: 目的探讨不同类型嵌合穿支皮瓣移植治疗下肢骨外露创面的临床效果。方法该研究为回顾性病例系列研究。2019年1月—2024年8月,陆军军医大学（第三军医大学）第二附属医院整形外科收治15例符合入选标准的下肢骨外露创面患者,其中12例患者合并骨髓炎。15例患者中男8例、女7例,年龄27~66岁,末次清创后创面面积为3.0 cm×2.0 cm~22.0 cm×4.5 cm。根据创面面积、深度、缺损组织成分、解剖部位及患肢血管条件等,应用嵌合肌瓣、肌瓣与髂骨瓣、肌瓣与筋膜瓣的穿支皮瓣,包括旋髂动脉嵌合穿支皮瓣、旋髂浅动脉联合腹壁浅动脉嵌合穿支皮瓣、旋股外侧动脉嵌合穿支皮瓣、胸背动脉嵌合穿支皮瓣,进行下肢骨外露创面修复,嵌合穿支皮瓣面积为4.0 cm×3.0 cm~25.0 cm×5.0 cm。对嵌合穿支皮瓣供区创面进行直接拉拢缝合、游离皮片移植或局部皮瓣转移修复。观察术后早期移植嵌合穿支皮瓣成活情况。随访观察所有患者移植嵌合穿支皮瓣存活情况与外观、供受区创面愈合情况与并发症发生情况、供区瘢痕形成情况、负重活动情况,合并骨髓炎患者骨髓炎有无复发迹象。结果 1例行嵌合肌瓣与筋膜瓣的旋股外侧动脉降支穿支皮瓣移植患者,在术后24 h内出现皮瓣静脉血管危象,皮瓣淤紫,行急诊血管探查+静脉二次吻合再通后皮瓣成活；1例行嵌合肌瓣的旋股外侧动脉斜支穿支皮瓣移植患者术后10 d皮瓣远端部分坏死,经换药+游离皮片移植修复后皮瓣成活；其余13例患者移植嵌合穿支皮瓣均顺利成活。术后随访3~6个月显示,15例患者移植嵌合穿支皮瓣均存活良好,其中7例患者皮瓣臃肿；15例患者供受区创面愈合良好,未发生感染及窦道形成、持续性疼痛等并发症,且供区仅遗留线性瘢痕,但有3例患者供区遗留皮肤感觉异常；15例患者均能负重活动；12例合并骨髓炎患者均未见骨髓炎复发迹象。结论采用不同类型嵌合穿支皮瓣修复下肢骨外露创面,具有并发症少、皮瓣存活率高、骨髓炎治愈率高、下肢功能恢复佳等优点,是下肢骨外露损伤时修复创面、重建下肢功能的可靠临床方案。
- 下肢 /
- 穿支皮瓣 /
- 显微外科手术 /
- 骨髓炎 /
- 骨外露 /
- 嵌合皮瓣 /
- 创面修复
Abstract: Objective To investigate the clinical effects of different types of chimeric perforator flap transplantation in the treatment of lower extremity wounds with bone exposure. Methods This study was a retrospective case series study. From January 2019 to August 2024, 15 patients with lower extremity wounds with bone exposure who met the inclusion criteria were admitted to the Department of Plastic Surgery of the Second Affiliated Hospital of Army Medical University (the Third Military Medical University), among whom 12 patients were combined with osteomyelitis. Among the 15 patients, there were 8 males and 7 females, aged 27-66 years, and the wound area after the last debridement ranged from 3.0 cm×2.0 cm to 22.0 cm×4.5 cm. According to the wound area, depth, composition of defective tissue, anatomical site, and vascular conditions of the affected limb, chimeric perforator flaps containing muscle flaps, muscle flaps and iliac bone flaps, or muscle flaps and fascial flaps were used, including circumflex iliac artery chimeric perforator flaps, superficial circumflex iliac artery combined with superficial inferior epigastric artery chimeric perforator flaps, lateral circumflex femoral artery chimeric perforator flaps, and thoracodorsal artery chimeric perforator flaps, to repair lower extremity wounds with bone exposure. The area of the chimeric perforator flaps ranged from 4.0 cm×3.0 cm to 25.0 cm×5.0 cm. The donor site wounds of the chimeric perforator flaps were repaired by direct suture, free skin grafting, or local flap transfer. The survival of the transplanted chimeric perforator flaps in the early postoperative period was observed. Follow-up was conducted to observe the survival and appearance of the transplanted chimeric perforator flaps, wound healing and complications in both donor and recipient sites, scar formation in the donor site, and weight-bearing activity of all patients, and signs of osteomyelitis recurrence in patients combined with osteomyelitis. Results One patient who underwent transplantation of a chimeric perforator flap based on the descending branch of the lateral circumflex femoral artery containing a muscle flap and a fascial flap developed venous vascular crisis within 24 hours after surgery, with the flap becoming dark purple; the flap survived after emergency vascular exploration and secondary venous anastomosis and recanalization. One patient who underwent transplantation of a chimeric perforator flap based on the oblique branch of the lateral circumflex femoral artery containing a muscle flap developed partial necrosis of the distal end of the flap 10 days after surgery, and the flap survived after dressing changes and free skin grafting. The transplanted chimeric perforator flaps in the remaining 13 patients survived smoothly. Postoperative follow-up of 3-6 months showed that the transplanted chimeric perforator flaps in 15 patients all survived well, among whom 7 patients had bulky flaps; all the wounds in both donor and recipient sites healed well in 15 patients, with no complications such as infection, sinus tract formation, or persistent pain, and only linear scars remained in the donor sites, but 3 patients had abnormal skin sensation in the donor sites; all 15 patients were able to perform weight-bearing activities; no signs of osteomyelitis recurrence were observed in the 12 patients combined with osteomyelitis. Conclusions The use of different types of chimeric perforator flap to repair lower extremity wounds with bone exposure has the advantages of fewer complications, high flap survival rate, high cure rate of osteomyelitis, and good recovery of lower extremity function, and is a reliable clinical regimen for repairing wounds and reconstructing lower extremity function in lower extremity injuries with bone exposure.
- Lower extremity /
- Perforator flap /
- Microsurgery /
- Osteomyelitis /
- Bone exposure /
- Chimeric flap /
- Wound repair
王晶：采集资料,撰写文章；黄书清：采集资料,分析数据；刘婧怡：采集资料,核对数据；雷泽源：指导手术,修改文章；杨智斌：设计研究,实施部分手术,修改文章

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参考文献(37)

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图 1 嵌合肌瓣的旋股外侧动脉降支穿支分叶皮瓣游离移植联合抗生素骨水泥填充修复例1患者左下肢骨外露创面的效果。1A.骨科予以左侧胫骨及外踝切开复位内固定+骨水泥置入术后第2天CT三维重建（左图）及X线片（右图）表现；1B、1C.分别为入整形外科（后续均为该科室处理）第1次清创术前外踝、胫前区创面,外踝骨质、肌腱、肌肉及内固定钢板外露,胫骨、肌肉、肌腱及内固定钢板外露；1D.第1次清创术中留取骨髓腔内组织行病理检查,可见大量中性粒细胞、淋巴细胞及浆细胞浸润,伴纤维组织增生苏木精-伊红 ×100；1E.皮瓣移植术前胫前及外踝骨水泥外露创面；1F.皮瓣移植术前左内侧踝骨外露创面；1G.皮瓣移植术前左侧胫前区创面；1H.嵌合肌瓣的旋股外侧动脉降支穿支分叶皮瓣设计；1I.切取皮瓣并离断血管蒂后即刻；1J、1K.分别为皮瓣游离移植+抗生素骨水泥填充术后即刻侧面观、正面观,皮瓣血运良好；1L.供区创面直接拉拢缝合后即刻；1M、1N.分别为皮瓣修复术后6个月胫前、外踝皮瓣,均存活良好,轻度臃肿；1O.皮瓣修复术后6个月,X线检查显示骨髓腔内无明显感染征象（右侧图为左侧图放大1.6倍后图像）

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图 2 嵌合肌瓣的胸背动脉穿支皮瓣游离移植联合抗生素骨水泥填充修复例2患者右下肢骨外露创面的效果。2A.入院时右小腿中段前内侧填塞骨水泥并部分外露；2B.入院时X线片显示,右侧胫骨内固定术后改变,右小腿软组织肿胀；2C.第2次清创术前创面,右侧胫骨外露；2D.第2次清创术中留取骨髓腔内组织行病理检查,大量中性粒细胞、淋巴细胞及浆细胞浸润,伴纤维组织增生苏木精-伊红 ×100；2E.背部嵌合肌瓣的胸背动脉穿支皮瓣设计；2F.胸背动脉穿支血管走行；2G.皮瓣移植手术前创面情况；2H.切取嵌合肌瓣的胸背动脉穿支皮瓣并离断血管蒂后即刻；2I.皮瓣游离移植+抗生素骨水泥填充术后即刻,皮瓣血运良好；2J.皮瓣修复术后3个月,皮瓣成活良好,轻度臃肿；2K.皮瓣修复术后3个月,供区遗留线性瘢痕；2L.皮瓣修复术后3个月,CT检查显示骨髓腔未见明显感染征象

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