远端蒂腓肠神经营养血管皮瓣与肌皮瓣的临床应用与改进

Modification and clinical application of distally based sural nerve nutrition blood vessel flap and myocutaneous flap

目的:报道应用远端蒂腓肠神经营养血管皮瓣,肌皮瓣修复小腿下段及足踝部软组织缺损的可行性安全性和临床效果。方法:对42例以远端蒂腓肠神经营养血管(肌)皮瓣修复小腿下段及足踝部不同原因所致软组织缺损病例进行总结分析。本组男36例,女6例;年龄最大75岁、最小6岁;皮瓣最大面积17.0cm×15.0cm,最小6.0cm×5.0cm,其中12例皮瓣面积在10.0cm×10.0cm以上;6例设计为肌皮瓣(腓肠肌外侧头),肌瓣最大为10.0cm×7.0cm×2.0cm,最小为6.0cm×5.0cm×1.0cm。结果:所有病例术后皆出现不同程度的皮瓣肿胀,暗道较明道者明显。2例大皮瓣经行小隐静脉远端结扎仍出现肿胀、色暗,皮瓣近侧1/3坏死。皮瓣边缘坏死3例,换药治愈。部分坏死需行植皮者3例。36例术后伤口I期愈合,骨外露软件组织缺损覆盖修复满意,6例II期愈合,其中糖尿病,地中海贫血各一例。结论:(1)远端蒂腓肠神经营养血管皮瓣转位修复小腿下1/3及足踝部缺损创面,极有临床实用价值;(2)设计切取腓肠神经营养血管肌皮瓣修复小腿及足踝填充感染创腔是可行的;(3)但对其皮瓣及所携带的肌瓣究竟切取多大面积是安全的、肌瓣的血运机理以及远端蒂筋膜皮瓣中小隐静脉干是否结扎,何处结扎等问题仍有待进一步研究。

Objective: To report the clinical effects and discuss the safety of distally based sural nerve nutrition blood vessel flap and musculocutaneous flap for repairing the soft tissue defects in the distal one third of anterior tibia, ankle and heel. Methods: Forty two patients with soft tissue defects in the distal one third of anterior tibia, ankle and heel were treated with distally based sural nerve nutrition blood vessel flap or musculocutaneous flap.There were 36 males and 6 females with age ranged from 6 to 75 years. The size of largest flap was about 17.0 cm×15.0 cm, while the smallest one was 6.0 cm×5.0 cm. The size of twelve flaps was larger than 10.0 cm×10.0 cm. There were six sural nerve musculocutaneous flaps with the size from 6.0 cm×5.0 cm×1.0 cm to 10.0 cm×7.0 cm×2.0 cm. Results: Swelling occurred in all flaps after operation, especially in those used subcutaneous transportation. Two large flaps appeared swell and proximal partial necrosis despite of ligating the distal end of saphenous vein. Fringe necrosis happened in three flaps and healed by dressing change.Three flaps had distal partial necrosis and cured by dermoplasty. For 36 cases, incision healed primarily, however, 6 cases belonged to secondary healing which included one case of diabetes and thalassanemia seperately. Conclusions: The distally based sural nerve nutrition blood vessel flap is an ideal and effective flap for reconstruction the soft tissue defect around the heel,malleolus,and the low 1/3 part of anterior tibia.The sural nerve musculocutaneous flap is feasible for packing infective wound with bone defect in the heel,malleolus,and tibia, whereas it is necessary to investigate the blood vessel communication between sural flap and lateral head of gastrocnemius muscle .Also it is essential to resolve some problems, such as how big size of sural musculocutaneous flap should be dissected and whether the distal end of saphenous vein should be ligated.