腓骨头复合瓣重建内踝缺损的应用解剖

APPLIED ANATOMY OF COMPOUND FLAP BASED ON FIBULAR HEAD TO REBUILD DEFECTS OF INTERNAL MALLEOLUS

目的为带血供腓骨头复合瓣移植重建内踝提供解剖学依据。方法观察供区与受区血管及骨的形态学。成人干燥胫骨40侧(左右各20侧),测量内踝底部宽度、内踝前部长度、内踝后部长度、内踝中部厚度及内踝与前踝的夹角。成人干燥腓骨40侧(左右各20侧),测量腓骨头中部宽度、厚度,腓骨头内侧关节面的外倾斜角。成人下肢截肢自愿捐献的新鲜标本30侧,经股动脉内灌注红色乳胶,重点观测胫前返动脉与腓骨头的血供关系及受区的内踝前动脉。结果内踝呈前低后高向下突出,内踝底部宽(2.6±0.2)cm,内踝中部厚(1.3±0.2)cm,内踝前部长(1.4±1.9)cm,内踝后部长(0.6±0.1)cm,内踝与前踝夹角为(11.89±3.60)°。腓骨头中部厚(1.8±0.6)cm,中部宽(2.7±0.4)cm。腓骨头内侧面有一圆形浅凹的关节面,朝向内上方,与胫骨外侧髁外下的关节面构成胫腓关节,其关节面外倾角为(39.2±1.3)°。胫前返动脉直接起始于胫前动脉占93.3%,与腓浅动脉共干起始于胫前动脉占6.7%。胫前返动脉起始点距腓骨头尖下(4.5±0.7)cm;主干经胫骨前肌深面,贴胫骨近端外侧面向前外上走行,主干长为(0.5±0.2)cm,外径为(2.0±0.4)mm。伴行静脉2支注入胫前静脉,外径分别为(2.1±0.5)mm和(2.6±0.4)mm;在距其起始点(1.0±0.4)cm处较为恒定地发出腓骨头支1～2支,外径为(1.7±1.3)mm。内踝前动脉起自胫前动脉或足背动脉,外径(1.6±0.4)mm,伴行静脉2支,外径分别为(1.3±0.5)mm和(1.1±0.4)mm。结论带血供腓骨头复合瓣移植修复内踝缺损具有可行性,其关节面结构是重建内踝的重要解剖学基础。

Objective To provide anatomical evidences for the blood supply compound flap based on fibular head to rebuild internal malleolus. Methods The morphology of vessels and bones in donor site and in recipient site was observed. The materials for the study were listed as follows： ① Forty desiccative adult tibias （20 left and 20 right respectively） were used to measure the basilar width, middle thickness, anterior length, posterior length and introversion angle of internal malleolus; ② Forty desiccative adult fibulas （20 left and 20 right respectively） were used to measure the middle width and thickness, as well as the extraversion angle of articular surface of fibular head; ③ Thirty adult lower limb specimens which perfused with red rubber were used to observe the blood supply relationships between the anterior tibial recurrent vessels and fibular head, and internal anterior malleolar vessels inside recipient site. Results The internal malleolus had a basilar width of （2.6 ± 0.2） cm, a middle thickness of （1.3 ± 0.2） cm, an anterior length of （1.4 ± 1.9） cm and a posterior length of （0.6 ± 0.1） cm. Its articular facet was half-moon. Its introversion angle was （11.89 ± 3.60）°. The fibular head had a middle thickness of （ 1.8 ± 0.6） cm, a middle width of （2.7 ± 0.4） cm. Its articular facet was toroid, superficial and cavate in shape, and exposed inwardsly and upwardsly, and had a extraversion angel of （39.2 ± 1.3）°. The anterior tibial recurrent artery directly began from anterior tibial artery, accounting for 93.3%. Its initiation point was （4.5 ± 0.7） cm inferior to apex of fibular head, Its main trunk ran through the deep surface of anterior tibial muscle, and ran forwards, outwards and upwards with sticking to the lateral surface of proximal tibia. Its main trunk had a length of （0.5 ± 0.2） cm and a outer diameter of （2.0 ± 0.4） mm. Its accompanying veins, which had outer diameters of （2.1 ± 0.5） mm and （2.6 ± 0.4） ram, entry into anterior tibial vein. It constantly gave 1-2 fibular head branches which had a outer diameter of （1.7 ± 1.3） mm at （ 1.0 ± 0.4） cm from the initiation point. The internal anterior malleolar artery which began from anterior tibial artery or dorsal pedal artery had a outer diameter of （1.6 ± 0.4） mm. Its accompanying veins had outer diameters of （1.3 ± 0.5） mm and （1.1 ± 0.4） mm. Conclusion The blood supply compound flap based on fibular head had a possibility to rebuild internal malleolus. Its articular facet was characterized as the important anatomical basis to rebuild internal malleolus.