ALTF联合“Y”形大隐静脉移植修复小腿近中段大面积软组织缺损的临床效果

钟硕; 王云鹏; 徐婵军; 刘林峰

doi:10.3760/cma.j.cn501225-20260130-00055

ALTF联合“Y”形大隐静脉移植修复小腿近中段大面积软组织缺损的临床效果

doi: 10.3760/cma.j.cn501225-20260130-00055

1.
山东第一医科大学附属省立医院手足与显微重建外科,济南　250021
2.
山东省公共卫生临床中心影像科,济南　250100

详细信息

通讯作者:
刘林峰,Email：sdslsz2024@163.com

计量
- 文章访问数: 8
- HTML全文浏览量: 4
- PDF下载量: 2
- 被引次数: 0
出版历程
- 收稿日期: 2026-01-30
- 网络出版日期: 2026-05-14

Clinical efficacy of ALTF combined with "Y"-shaped great saphenous vein graft for the repair of large soft tissue defects in the proximal-middle segment of the lower leg

1.
Department of HandFoot and Reconstructive Microsurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
2.
Department of Radiology, Shandong Public Health Clinical Center, Jinan 250100, China

More Information

Corresponding author: Liu Linfeng, Email: sdslsz2024@163.com

摘要

摘要: 目的探讨应用股前外侧皮瓣（ALTF）联合“Y”形大隐静脉移植修复小腿近中段大面积软组织缺损的临床效果。方法该研究为回顾性病例系列研究。2019年1月—2023年12月,山东第一医科大学附属省立医院手足与显微重建外科收治8例符合入选标准的小腿近中段大面积软组织缺损患者,其中男7例、女1例,年龄15~63岁。待创面清洁、感染控制后,小腿软组织缺损面积为18 cm×7 cm~30 cm×14 cm。采用ALTF联合“Y”形大隐静脉移植修复小腿软组织缺损,皮瓣切取面积为19 cm×8 cm~31 cm×15 cm。术中将“Y”形大隐静脉分叉端分别与膝降动脉、股内侧肌支（MFMB）行端端吻合,主干端与旋股外侧动脉降支（LFCA-DB）行端端吻合,构建“双入单出”的静脉桥接方式。将LFCA-DB优势伴行静脉与受区大隐静脉端端吻合；若小腿受区无合适静脉可与LFCA-DB优势伴行静脉吻合,则另截取对侧小腿大隐静脉段并将其桥接至LFCA-DB优势伴行静脉后与膝上大隐静脉行端端吻合。皮瓣供区创面直接缝合者3例,取同侧腹股沟区全厚皮片修复者5例。记录皮瓣蒂部血管长度、皮瓣蒂部血管与拟吻合膝降动脉和MFMB之间的缺损长度。术后观察皮瓣成活情况、皮瓣供区创面愈合情况。随访时,观察皮瓣外观、质地、感觉恢复情况,皮瓣供区恢复情况及静脉供区所在肢体肿胀情况。末次随访时,参照利克特5级量表调查患者对皮瓣供受区治疗效果的满意度。结果该组患者皮瓣蒂部血管长度为12~17 cm,平均14.1 cm；皮瓣蒂部血管与拟吻合膝降动脉和MFMB之间的缺损长度为9~16 cm,平均12.3 cm。术后皮瓣均完全成活,未发生血管危象；皮瓣供区创面均愈合良好。随访12~40个月显示,6例患者皮瓣无臃肿；2例患者因后期胫骨骨搬运治疗导致皮瓣局部受压臃肿,其中1例患者经修整手术后改善,1例患者未行修整治疗。皮瓣质地柔软,张力适中,无溃疡,均恢复保护性感觉。皮瓣供区均恢复良好,其中直接拉拢缝合区遗留轻微线性瘢痕,植皮区遗留轻微瘢痕；静脉供区所在肢体无肿胀。末次随访时,患者对供受区治疗效果满意度评分均为4、5分。结论利用ALTF联合“Y”形大隐静脉移植吻合膝降动脉和MFMB修复小腿近中段大面积软组织缺损,能有效实现供受区血管口径的生理性匹配,通过双重供血保障大面积皮瓣血运,规避创周炎症以降低血管危象风险,患者对供受区治疗效果满意。
- 创伤和损伤 /
- 下肢 /
- 显微外科手术 /
- 血管移植术 /
- 外科皮瓣 /
- 穿支皮瓣 /
- 膝降动脉 /
- 创面修复
Abstract: Objective To explore the clinical efficacy of using the anterolateral thigh flap (ALTF) combined with "Y"-shaped great saphenous vein graft in repairing large soft tissue defects in the proximal-middle segment of the lower leg. Methods This study was a retrospective case series study. From January 2019 to December 2023, 8 patients with large soft tissue defects in the proximal-middle segment of the lower leg meeting the inclusion criteria were admitted to the Department of Hand & Foot and Reconstructive Microsurgery of Shandong Provincial Hospital Affiliated to Shandong First Medical University, including 7 males and 1 female, aged 15 to 63 years. After the wounds were cleaned and the infection was controlled, the areas of soft tissue defects in the lower leg ranged from 18 cm×7 cm to 30 cm×14 cm. The ALTF combined with "Y"-shaped great saphenous vein graft was conducted to repair the soft tissue defects in the lower leg. The flap harvest areas were 19 cm×8 cm to 31 cm×15 cm. Intraoperatively, the bifurcated ends of the "Y"-shaped great saphenous vein were end-to-end anastomosed with the descending genicular artery and the medial femoral muscle branch (MFMB) respectively, and the main trunk end was end-to-end anastomosed with the descending branch of lateral circumflex femoral artery (LFCA-DB), constructing a "dual-in, single-out" venous bridging mode. The dominant concomitant vein of LFCA-DB was end-to-end anastomosed with the recipient great saphenous vein. If there was no suitable vein in the recipient area of the lower leg for anastomosis with the dominant concomitant vein of LFCA-DB, another segment of the great saphenous vein from the contralateral lower leg was harvested for venous bridging and end-to-end anastomosed with the above-knee great saphenous vein. The flap donor site wounds were directly sutured in 3 cases, and repaired with full-thickness skin grafts from the ipsilateral inguinal region in 5 cases. The length of the flap pedicle vessels and the defect distance between the flap pedicle vessels and the planned anastomotic descending genicular artery and MFMB were recorded. Postoperatively, the flap survival and the wound healing in the donor sites were observed. During follow-up, the appearance, texture, and sensory recovery of the flaps, the recovery of flap donor sites, and the limb swelling in the vein donor sites were observed. At the last follow-up, the 5-point Likert scale was used to investigate the satisfaction of patients with the treatment effects in the flap recipient and donor sites. Results The lengths of the flap pedicle vessels were 12 to 17 cm, with an average of 14.1 cm. The defect distances between the flap pedicle vessels and the planned anastomotic descending genicular artery and MFMB were 9 to 16 cm, with an average of 12.3 cm. Postoperatively, all flaps survived completely, without vascular crisis; all flap donor site wounds healed well. During follow-up of 12 to 40 months, the flaps of 6 patients showed no bulkiness; two flaps developed local bulkiness due to compression during the subsequent tibial bone transport treatment, of which one case improved after surgical debulking, and one case received no modification treatment. The flaps were soft in texture, with moderate tension and no ulcer, and all regained protective sensation. The flap donor sites all recovered well. The direct suture areas left slight linear scars, the skin grafted areas left slight scars, and the limbs in the vein donor sites showed no swelling. At the last follow-up, the satisfaction scores of patients with the treatment effects in the recipient and donor sites were all 4 and 5. Conclusions In specific complex cases with severe injury of the main vessels of the lower leg and a lack of reliable recipient vessels around the wound, the application of ALTF combined with "Y"-shaped great saphenous vein graft bridging and anastomosing the descending genicular artery and MFMB to repair large soft tissue defects in the proximal-middle segment of the lower leg can effectively achieve the physiological caliber matching of the donor and recipient vessels, ensure the blood supply of the large-area flaps through dual blood supply, and bypass the periwound inflammatory areas to reduce the risk of vascular crisis. The patients are satisfied with the treatment effect of the donor and recipient sites.
- Wounds and injuries /
- Lower extremity /
- Microsurgery /
- Vascular grafting /
- Surgical flaps /
- Perforator flap /
- Descending genicular artery /
- Wound repair
钟硕：研究设计、资料收集和整理、手术实施、论文撰写；王云鹏：研究设计、手术实施、指导论文修改；徐婵军：资料收集和整理、指导论文修改；刘林峰：研究设计、手术实施、指导论文修改

所有作者声明不存在利益冲突

HTML全文

参考文献(39)

[1]	邵卓恒,李雷,李昌松,等.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[J].中华烧伤与创面修复杂志,2025,41(12):1183-1191.DOI: 10.3760/cma.j.cn501225-20250225-00085.
[2]	VenkatramaniH,SabapathySR,NayakS.Free-flap cover of complex defects around the knee using the descending genicular artery as the recipient pedicle[J].J Plast Reconstr Aesthet Surg,2014,67(1):93-98.DOI: 10.1016/j.bjps.2013.09.011.
[3]	SorkinA,ChangC,MarcascianoM,et al.Algorithmic recipient vessel selection for vessel-depleted lower limbs[J].J Plast Reconstr Aesthet Surg,2026,113:121-128.DOI: 10.1016/j.bjps.2025.11.011.
[4]	KozuskoSD,LiuX,RiccioCA,et al.Selecting a free flap for soft tissue coverage in lower extremity reconstruction[J].Injury,2019,50Suppl 5:S32-S39.DOI: 10.1016/j.injury.2019.10.045.
[5]	HongJP, ParkCJ, SuhHP. Importance of vascularity and selecting the recipient vessels of lower extremity reconstruction[J]. J Reconstr Microsurg,2021,37(1):83-88.DOI: 10.1055/s-0040-1708835.
[6]	刘军,黎逢峰,吴永伟,等.以膝降动脉为受区血管的股前外侧皮瓣在膝关节周围创面的临床应用[J].中华显微外科杂志,2018,41(4):324-328.DOI: 10.3760/cma.j.issn.1001-2036.2018.04.003.
[7]	胡宏宇,高顺红,于俊,等.膝降动脉顺行或逆行供血的游离组织瓣移植修复小腿大面积皮肤软组织缺损[J].中国骨与关节损伤杂志,2022,37(10):1092-1094.DOI: 10.7531/j.issn.1672-9935.2022.10.025.
[8]	李雷,周正虎,鞠文,等.以膝降动脉为蒂的游离股前外侧穿支皮瓣修复小腿保肢术后创面的临床效果[J].中华烧伤与创面修复杂志,2023,39(5):450-455.DOI: 10.3760/cma.j.cn501225-20220725-00308.
[9]	YazarS,LinCH.Selection of recipient vessel in traumatic lower extremity[J].J Reconstr Microsurg,2012,28(3):199-204.DOI: 10.1055/s-0032-1306366.
[10]	刘军,吴永伟,王建兵,等.四种膝周非主干血管作为游离组织瓣受区血管的选择探讨[J].中华整形外科杂志,2021,37(6):659-665.DOI: 10.3760/cma.j.cn114453-20200313-00140.
[11]	赵海磊,孙志刚,赵晓慧,等.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[J].中华烧伤与创面修复杂志,2025,41(3):242-250.DOI: 10.3760/cma.j.cn501225-20240926-00350.
[12]	张浩,李文军,郑宪友,等.开放性小腿皮肤撕脱伤临床诊疗指南(2024版)[J].中华创伤杂志,2024,40(12):1071-1081.DOI: 10.3760/cma.j.cn501098-20240719-00439.
[13]	TiongcoRFP, RezwanSK, AlahmadiS, et al. Early flap reconstruction and infection rates in open lower extremity fractures: a systematic review and meta-analysis[J]. Plast Reconstr Surg Glob Open,2025,13(6):e6829.DOI: 10.1097/GOX.0000000000006829.
[14]	LeELH, McNamaraCT, ConstantineRS, et al. The continued impact of Godina's principles: outcomes of flap coverage as a function of time after definitive fixation of open lower extremity fractures[J]. J Reconstr Microsurg,2024,40(8):648-656.DOI: 10.1055/a-2273-4075.
[15]	中华医学会显微外科学分会,中国医师协会骨科医师分会创伤学组,中国医师协会骨科医师分会外固定学组,等.中国下肢软组织损伤修复指南(2023)[J].中华创伤骨科杂志,2023,25(3):193-201.DOI: 10.3760/cma.j.cn115530-20230110-00015.
[16]	ParkS,EomJS.Selection of the recipient vessel in the free flap around the knee: the superior medial genicular vessels and the descending genicular vessels[J].Plast Reconstr Surg,2001,107(5):1177-1182.DOI: 10.1097/00006534-200104150-00012.
[17]	钱汉根,黄春辉,沈国良,等.微型筋膜蒂皮瓣在修复小腿骨及内固定外露创面中的应用[J].中华显微外科杂志,2018,41(3):283-284.DOI: 10.3760/cma.j.issn.1001-2036.2018.03.024.
[18]	牛峰,张朝,郭永明,等.交腿桥式供血的游离股前外侧穿支皮瓣修复伴有主干血管缺损的小腿感染性创面7例[J].中华显微外科杂志,2024,47(4):416-422.DOI: 10.3760/cma.j.cn441206-20240225-00053.
[19]	GhamariBT, RadSB, SadighiM, et al. Limb salvage using reverse sural cross-leg flap in complex lower limb injury: a case series[J]. J Clin Orthop Trauma,2025,70:103156.DOI: 10.1016/j.jcot.2025.103156.
[20]	张演基,李海,吴祥奎,等.游离股前外侧嵌合皮瓣的临床应用与遵义分型[J].中华烧伤与创面修复杂志,2025,41(5):447-453.DOI: 10.3760/cma.j.cn501225-20241108-00438.
[21]	杨亮,周荣,巨积辉,等.游离双侧股前外侧内增压型串联皮瓣修复足踝部大面积创面的临床疗效[J].中华烧伤与创面修复杂志,2025,41(1):61-69.DOI: 10.3760/cma.j.cn501225-20240508-00164.
[22]	蔡杰,张小锋,许清华,等.双叶游离股前外侧皮瓣在四肢创面修复中的个性化运用[J].中华显微外科杂志,2026,49(1):14-19.DOI: 10.3760/cma.j.cn441206-20251112-00185.
[23]	黎章灿,郑大伟,潘勇,等.超长联体皮瓣联合股前外侧皮瓣修复下肢巨大创面1例[J].中华显微外科杂志,2025,48(5):569-572.DOI: 10.3760/cma.j.cn441206-20250207-00028.
[24]	AlharbiZ, QariS, ZafarT, et al. Anterior lateral thigh perforator (ALTP) flaps: literature review and technical experience to pushing the limits toward aesthetical reconstruction[J]. Medicina (Kaunas),2025,61(12):2154.DOI: 10.3390/medicina61122154.
[25]	HongJP, KimHB, ParkCJ, et al. Using duplex ultrasound for recipient vessel selection[J]. J Reconstr Microsurg,2022,38(3):200-205.DOI: 10.1055/s-0041-1740218.
[26]	ParkS,HanSH,LeeTJ.Algorithm for recipient vessel selection in free tissue transfer to the lower extremity[J].Plast Reconstr Surg,1999,103(7):1937-1948.DOI: 10.1097/00006534-199906000-00019.
[27]	LinCH,MardiniS,LinYT,et al.Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts[J].J Trauma,2004,56(5):1107-1117.DOI: 10.1097/01.ta.0000114637.29779.ab.
[28]	HadjiandreouM, KimYH, KaartinenI, et al. Microvascular stigmata in lower extremity trauma: step-by-step dissection of the zone of injury[J]. Microsurgery,2026,46(1):e70168.DOI: 10.1002/micr.70168.
[29]	CepasA, KiiskiJ, MajavaM, et al. Myth-busting the zone-of-injury concept: a prospective study on the vascular response to high-energy lower extremity trauma[J]. Plast Reconstr Surg,2024,154(1):190e-198e.DOI: 10.1097/PRS.0000000000010980.
[30]	StranixJT, BorabZM, RifkinWJ, et al. Proximal versus distal recipient vessels in lower extremity reconstruction: a retrospective series and systematic review[J]. J Reconstr Microsurg,2018,34(5):334-340.DOI: 10.1055/s-0037-1621746.
[31]	童德迪,吴乐昊,朱珊,等.长段血管移植在游离组织瓣修复小腿大面积软组织缺损中的临床应用[J].中华整形外科杂志,2019,35(9):868-873.DOI: 10.3760/cma.j.issn.1009-4598.2019.09.005.
[32]	ZavalaA,MachacaL,TorneroR,et al.Use of retrograde dorsalis pedis as recipient vessels for pediatric free flap lower leg reconstruction[J].Microsurgery,2024,44(3):e31158.DOI: 10.1002/micr.31158.
[33]	HigginsJP. Vascularized medial femoral condyle flap reconstruction for osseous defects of the hand and wrist[J]. Hand Clin,2024,40(1):151-159.DOI: 10.1016/j.hcl.2023.06.003.
[34]	孙丰坤,王立民,宋兴华,等.彩色多普勒超声探测下应用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临床效果[J].中华烧伤与创面修复杂志,2026,42(1):81-90.DOI: 10.3760/cma.j.cn501225-20240623-00247.
[35]	张迪,齐耀东,仇申强,等.Force CT微细血管解剖成像技术及其临床应用[J].中华显微外科杂志,2022,45(6):650-655.DOI: 10.3760/cma.j.cn441206-20220327-00059.
[36]	张路,李栋,樊安未.血管成像技术在旋髂浅动脉穿支皮瓣游离移植修复四肢创面中的临床应用效果[J].中华烧伤与创面修复杂志,2025,41(9):877-886.DOI: 10.3760/cma.j.cn501225-20250228-00100.
[37]	HayashiK, FutamuraK, TsuchidaY, et al. The influence of the level of injury on the selection of recipient vessels in severe open fractures of the tibia and foot[J]. J Reconstr Microsurg,2026,42(2):132-144.DOI: 10.1055/a-2576-0389.
[38]	ChuongB, KatiraK, RamsayT, et al. Reliability of long vein grafts for reconstruction of massive wounds[J]. J Clin Med,2023,12(19):6209.DOI: 10.3390/jcm12196209.
[39]	LaiCS,ChangYT,ShenCH,et al.The role of vein grafts in reconstructive head and neck microsurgery[J].Braz J Otorhinolaryngol,2022,88 (Suppl 4):S81-S88.DOI: 10.1016/j.bjorl.2021.09.004.

下载: 全尺寸图片幻灯片

图 1 ALTF+“Y”形大隐静脉移植修复例1患者左小腿近中段软组织缺损的效果。1A.皮瓣修复术前创面情况；1B.皮瓣切取前,探查膝降动脉和MFMB；1C.术前皮瓣设计；1D.术中皮瓣切取后；1E.术中“Y”形大隐静脉切取后；1F.术中将“Y”形大隐静脉分叉端（V端）与膝降动脉、MFMB行端端吻合,“Y”形大隐静脉主干端（I端）与LFCA-DB行端端吻合,LFCA-DB优势伴行静脉与小腿大隐静脉行端端吻合；1G.皮瓣修复术后即刻；1H.术后24个月,皮瓣外形良好

注：ALTF为股前外侧皮瓣,MFMB为股内侧肌支,LFCA-DB为旋股外侧动脉降支

下载: 全尺寸图片幻灯片

图 2 ALTF+“Y”形大隐静脉移植修复例2患者左小腿近段软组织缺损的效果。2A.皮瓣修复术前创面情况；2B.皮瓣切取前,探查膝降动脉和MFMB；2C.术前皮瓣设计；2D.术中皮瓣切取后；2E.术中“Y”形大隐静脉分叉端（V端）与膝降动脉、MFMB行端端吻合,“Y”形大隐静脉主干端（I端）与LFCA-DB行端端吻合,LFCA-DB优势伴行静脉与小腿大隐静脉行端端吻合；2F.皮瓣修复术后即刻；2G.皮瓣修复术后12个月,拆除外固定架后即刻；2H.术后40个月,皮瓣外形良好

注：ALTF为股前外侧皮瓣,MFMB为股内侧肌支,LFCA-DB为旋股外侧动脉降支

下载: 全尺寸图片幻灯片