腓肠神经营养血管腓肠肌外侧头复合瓣转移治疗胫骨骨髓炎

Treatment of tibial osteomyelitis by transfer of distally based sural nerve compound flaps

目的探讨腓肠神经营养血管皮瓣与腓肠肌外侧头一同切取成复合瓣的可行性，观察应用复合瓣转移治疗胫骨骨髓炎的疗效。方法在尸体标本上观察腓肠神经营养血管蒂与深层的腓肠肌外侧头之间的血管比邻关系。对15例胫骨骨髓炎的患者采用窦道切除、胫骨开槽的方法进行彻底清创，采用远端蒂腓肠神经营养血管与腓肠肌外侧头的复合瓣转移覆盖窦道切除后的皮肤缺损区，将肌肉部分尽量填塞入胫骨骨槽内，置负压引流；3例骨不连患者拆除内固定后更换外固定支架。结果腓肠神经营养血管筋膜蒂与腓肠肌外侧头之间有5—6支血管穿支，可以一同切取为复合皮瓣；临床治疗15例患者转移复合瓣全部成活，14例胫骨骨髓炎完全治愈，1例患者经过第二次清创后完全愈合，3例骨不连者经二期髂骨植骨后6个月完全愈合，平均随访18个月（10～26个月）无复发。结论腓肠神经营养血管蒂与深层的腓肠肌外侧头有血管穿支存在，二者可以切取成远端蒂的复合瓣，可有效治疗胫骨骨髓炎。

Objective To explore the possibility of treating tibial osteomyelitis with transfer of a compound flap composed of the sural nerve fasciocutaneous flap and the lateral gastrocnemius muscle. Methods We observed in cadaver specimens the anatomical structure of the sural nerve fasciocutaneous flap and the lateral gastrocnemius muscle to design a compound flap. Fifteen cases of tibial osteomyelitis were treated with sinus excision and thorough debridement before the skin defect area was covered with a sural nerve compound flap whose muscle was stuffed into the tibial channel. Plates were replaced with unilateral fixators in 3 cases of tibial nonunion. Results We observed 5 to 6 perforating branches of blood vessels between the sural nerve fasciocutaneous flap and the lateral gastrocnemius muscle, indicating that the two can be harvested simultaneously in one compound flap. The transferred compound flaps survived in 15 cases. Tibial osteomyelitis was completely cured in 14 cases, 1 case healed after second debridement, and 3 cases of tibial nonunion healed 6 months later after a second stage iliac bone graft. No recurrence was found after a mean follow-up of 18 （10 to 26） months. Conclusion A compound flap composed of the sural nerve fasciocutaneous flap and the lateral gastrocnemius muscle can be used to treat tibial osteomyelitis effectively.