吻合血管腓骨移植的数字化设计与初步临床应用

Digital design and preliminary clinic application of vascularized fibular graft

目的探讨吻合血管腓骨移植数字化设计修复长段骨和（或）软组织缺损的临床应用价值。方法选择四肢长段骨缺损患者9例，术前血管造影后行螺旋CT供区小腿扫描。将扫描数据输入计算机，应用Amira3．1软件对腓骨及其营养血管行三维重建。术前根据患者骨缺损长度、形态及软组织缺损面积，利用三维重建图像进行精确测量和个性化设计，并模拟手术关键操作。术中仔细核对腓动脉与重建血管走行，并依术前设计切取腓骨（皮）瓣，移植于骨缺损受区进行固定。参照Enneking系统对患肢功能进行评价，以达到正常肢体功能的百分数表示，参照国际挽救肢体专题讨论会制定的“同种及带血管移植的放射学评价方法”对移植腓骨的转归进行影像学评价。结果三维重建图像直观地体现了腓骨、营养血管及腓动脉穿支皮瓣的三维结构及空间毗邻关系。通过数字化设计和模拟手术操作，可避免术中因小腿血管损伤或血管变异致切取失败和供区意外损伤。9例移植的腓骨（皮）瓣全部成活。术后随访6～30个月，平均15．8个月。骨缺损均修复，骨性愈合时间平均为4．5个月，肢体功能恢复率90．4％。结论数字化设计可为修复长段骨缺损手术方案的选择提供科学依据，方便术前模拟及术中指导，降低手术风险。

Objective To explore the clinical value of the digital design of vascularized cutaneous fibular flap to repair defects of long bones and/or soft tissues. Methods Nine patients with long bone and/or soft tissue defects were sleeted. Each of the donor site＇s leg was scaned by the spiral CT angiography. After the scanned data had been inputted into the computer, image segmentation and three-dimensional surface reconstruction were generated from these data using Amira 3.1 software. Then the 3D reconstruction image was measured and designed according to the length and morphology of bone and the range of soft tissue defeet of patient, simulated surgery can be realized. Noticed and compared the blood vessel＇s orientation between the fibula artery and 3D reconstruction artery in the operation. When fibular flap based on the preop- erative design was harvested, it can be transplanted and reliably fixed on the recipient site. Limb function was graded with Enneking＇s system, and presented as percentage of normal limb function. The changes of the vascularized fibular graft were evaluated radiographicaiiy according to the International Symposium on Limb Salvage. Results 3D reconstructed visualization cutaneous fibular flap could perfectly display the spatial relationship of the fibular, nutrient vessel and the fibular artery perforator flap. Through digital design and surgical simulation, we can effective avoided the operation failure and unintentional injury caused by the vascular injury or variation before operation. All the fibular flap survived well. All patients were followed up for an average of 15.8 months （range, 6 to 30 months）, All of the fractures healed up, the average time for fracture union was 4.5 months. Nine patients had the average limb function restored in 90.4%. Conclusion Digital design offers scientific ground for selecting surgical plan, and provides much convenience to surgical sim- ulation before operation and guide manipulation in operation, and greatly decreases operation risk.