游离腓骨瓣轴向截骨术在下颌角重建中的应用

Axial split osteotomy of free fibular flap for mandibular angle reconstruction: A clinical study

目的:介绍一种下颌角成形术中,应用腓骨瓣轴向截骨的技术,探讨该方法的适应证和优缺点。方法:16例患者中,良性肿瘤11例(成釉细胞瘤8例,牙源性角化囊肿3例),放射性骨坏死3例,术后继发下颌骨缺损畸形2例,所用游离腓骨瓣长度为10～17cm(平均14.6cm),血管蒂长5～11cm(平均8.2cm)。轴向截骨手术步骤:①按改良方法制备腓骨瓣后,剥离肌袖,解剖分离腓骨瓣截骨线旁血管蒂组织及骨膜,加以保护。摆动锯首先切开腓骨肌面,垂直于骨长轴切至骨髓腔平面;②在伸肌面或屈肌面(肌袖面)沿长轴切割,长度为2～3cm;最后在伸肌面与屈肌面交界处,垂直于骨长轴于内侧面切至骨髓腔平面。③进行骨断端塑形,其2个截骨面骨髓腔接触面的大小依其所成角度而改变,通常塑形角度为120°,使修复下颌角2个腓骨骨块即可成角,又使之轴向截骨片间与钛支架紧密接触,并将钛钉固定在预成钛板支架上。结果:16例患者术后经超声Doppler动态监测,移植骨血供良好,术后3、6个月摄片示移植骨段愈合理想,角部外形恢复满意。结论:应用轴向截骨法重建下颌角缺损,由于增大了骨段间接触面,从而提高了骨的愈合能力,且能减少腓骨骨量的损失,并可在一定范围内延长移植骨的长度。

PURPOSE： To introduce an axial split osteotomy of free fibular flap for mandible angle reconstruction and discuss its indications and surgical technique. METHODS： 16 patients underwent axial split osteotomy of free fibular flap（12 males and 4 females, aged from 23 to 62）. 11 patients with benign tumors （8 ameloblastomas and 3 odontogenic keratocyst）, 3 patients with osteoradionecrosis, and 2 patients with secondary mandibular deformity were included. The length of free fibular flap ranged from 10-17 cm （mean 14.6 cm）. The length of the vascular pedicel ranged from 5-11cm （mean 8.2cm）. The fibular flap harvested was performed in routine manner. After elevating the periosteum and performing minimal dissection at osteotomy site only, axial splitting was performed using an oscillating saw. The first osteotomy was made on the external surface of the fibula, perpendicular to the main axis of the bone down to the level of the medullary canal. The second osteotomy was made along the main axis of the bone. The length of this osteotomy was between 2 and 3cm. The last osteotomy was made perpendicular to the internal surface at one junction of the anterolateral and posteromedial surfaces down to the medullary canal, as was done for the first osteotomy. Then the harvested flap was contoured, which was achieved by raising the two bone segments and fitting them together. The angulation was 120 degrees. RESULTS： 16 flaps were monitored by Doppler ultrasound postoperatively and examined by colored ultrasound 3 months, 6 months after operation. The results revealed that the recipient sites healed primarily without complications. CONCLUSIONS： Axial split osteotomy is a reliable technique with maximum contact surface for bone union, and less bone loss,which can lengthen the transplanted bone to a certain extent. It is suitable especially for reconstruction of the defect of the angle of the mandible. Supported by Shanghai Leading Academic Discipline Project （Y0203）.