腓动脉穿支筋膜蒂腓肠神经营养血管皮瓣修复足背皮肤软组织缺损

REVERSED FASCIA PEDICLED PERONEAL PERFORATING BRANCH SURAL NEUROFASCIOCUTANEOUS FLAP FOR REPAIRING SOFT TISSUE DEFECT IN DORSAL PEDIS

目的总结腓动脉穿支筋膜蒂腓肠神经营养血管皮瓣修复足背皮肤软组织缺损的临床经验,探讨其手术注意事项及预防皮瓣坏死的措施。方法 2000年8月-2009年4月,应用腓动脉穿支筋膜蒂腓肠神经营养血管皮瓣修复足背皮肤软组织缺损31例。男23例,女8例;年龄3～65岁,中位年龄34岁。病因:交通事故伤20例,机器绞伤2例,压砸伤2例,受伤至入院时间1～32d,平均15d;慢性溃疡及不稳定性瘢痕6例,病程6个月～10年;鳞癌1例,病程5个月。创面部位:足背偏内侧12例,足背偏外侧19例;跖骨中点以近14例,跖骨中点以远17例,其中10例达跖趾关节。创面均伴骨、肌腱外露,其中5例伴趾长伸肌腱断裂缺损,1例伴距骨骨折,1例伴距骨和第3跖骨骨折。创面范围为6.0cm×4.5cm～17.0cm×10.0cm,术中皮瓣切取范围为8.0cm×5.5cm～20.0cm×12.0cm;供区植皮修复。结果术后皮瓣完全成活17例,创面Ⅰ期愈合。术后5～12d皮瓣远端表皮及表浅坏死6例,经换药或植皮后愈合;术后7～14d皮瓣远端部分坏死及大部分坏死8例,其中1例位于足背偏外侧,7例位于足背偏内侧,3例经二期缝合、3例经植皮、1例经局部皮瓣移位、1例经交腿皮瓣移位修复愈合。供区植皮均成活,切口Ⅰ期愈合。术后29例获随访,随访时间6～29个月,平均19个月。术后皮瓣稍臃肿,但均不影响穿鞋,质地软,色泽良好,无色素沉着。患者步态均正常。术前感染创面术后均无复发。5例重建趾长伸肌腱患者踝关节无跖屈及锤状趾畸形。2例骨折患者术后3个月均达骨性愈合。结论腓动脉穿支筋膜蒂腓肠神经营养血管皮瓣适于修复足背偏外侧皮肤软组织缺损,修复足背偏内侧缺损时应注意确保皮瓣及筋膜蒂无明显张力,以保证皮瓣成活。

Objective To summarize the clinical experience of repairing soft tissue defect in dorsal pedis with reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flap,and to explore surgery matters needing attention and measures to prevent flap necrosis.Methods Between August 2000 and April 2009,31 patients with soft tissue defects in dorsal pedis were treated with reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flaps.There were 23 males and 8 females with a median age of 34 years（range,3-65 years）.Defects were caused by traffic accident in 20 cases,by machine in 2 cases,and by crush in 2 cases.The time from injury to admission was 1-32 days（mean,15 days）.And 6 cases had chronic ulcer or unstable scar excision with disease duration of 6 months to 10 years,and 1 case had squamous carcinoma with disease duration of 5 months.The wounds were located in medial dorsal pedis in 12 cases and lateral dorsal pedis in 19 cases;including 14 wounds near the middle metatarsal and 17 wounds beyond the middle metatarsal（up to the metatarsophalangeal joint in 10 cases）.All cases accompanied with bone or tendon exposure.Five cases accompanied with long extensor muscle digits tendon rupture and defect,1 case accompanied with talus fracture,1 case accompanied with talus fracture and third metatarsal fracture.The size of the wounds ranged from 6.0 cm × 4.5 cm to 17.0 cm × 10.0 cm.The size of the flaps ranged from 8.0 cm × 5.5 cm to 20.0 cm × 12.0 cm.The donor sites were resurfaced by skin graft.Results Seventeen flaps survived uneventfully,wounds healed by first intention.Distal epidermal or superficial necrosis occurred in 6 flaps at 5-12 days after operation,wounds healed by dressing change or skin graft.Distal partial necrosis occurred in 8 flaps（7 in medial dorsal pedis and 1 in lateral dorsal pedis） at 7-14 days after operation,wounds healed by skin graft in 3 cases,by secondary suture in 3 cases,by local flap rotation in 1 case,and by cross leg flap in 1 case.All skin grafts at donor sites survived uneventfully,wounds healed by first intention.Twenty-nine patients were followed up 6-29 months（mean,19 months）.The appearance was slightly overstaffed,but wearing shoe function and gait were normal.The texture and color of the flaps in all cases were good.There was no pigmentation and suppuration relapse.There was neither ankle plantar flexion deformity nor hammer toe deformity in 5 cases accompanied with long extensor muscle digits tendon rupture and defect.All fractures healed at 3 months after operation in 2 cases.Conclusion The reversed fascia pedicled peroneal perforating branch sural neurofasciocutaneous flaps are suitable to repair most soft tissue defects in lateral dorsal pedis.When the flaps are used to repair soft tissue defects in medial dorsal pedis,avoiding tension in flaps and fascia pedicles should be noted so as to improve flap survival.