内踝后穿支筋膜皮下瓣的解剖与临床研究

Medial retromalleolar perforator adipofascial flap:anatomical and clinical study

目的介绍内踝后穿支筋膜皮下瓣的血管解剖基础与初步临床应用效果。方法解剖24侧新鲜下肢灌注标本,观察内踝后间隙内胫后动脉发出的穿支血管情况。临床切取内踝后穿支筋膜皮下瓣,翻转修复跟内侧创伤缺损5例。结果内踝后间隙长约4cm,前界为内踝及趾长屈肌腱,后方为跟腱,表面为深筋膜覆盖,间隙内有疏松脂肪组织。在内踝后间隙内走行的胫后动脉发出2-3条皮肤穿支血管,口径0.1～0.7 mm,一般小于0.5 mm,但数量恒定。内踝后穿支与上方的胫后动脉最远侧肌间隔穿支血管间有互补性,在筋膜表面和皮下组织中有丰富血管吻合。临床上以内踝后穿支血管为轴点（内踝最下缘上方1～2 cm）,设计切取远端蒂筋膜皮下瓣,面积5～6 cm×6～12 cm,修复5例跟骨开放性骨折的内侧创面,筋膜瓣均成活。结论内踝后穿支筋膜皮下瓣相对传统的肌间隔穿支血管组织瓣,其旋转轴点下移,减少小腿供区损伤,无静脉回流障碍,受区组织柔软活动度好,更适合修复足跟内侧的创面。

Objective To introduce the anatomical study and clinical experience of medial retromalleolar perforator adipofascial flap.Methods Microsurgical anatomic study was carried out on 24 fresh cadaver limbs,and was focused on the distal perforators of the posterior tibial artery.Then five clinical cases of distally based medial retromalleolar perforator flaps were raised for medial wound coverage of the calcaneus after open fracture.Results The terminal part of posterior tibial artery run distally in the medial retromalleolar space.The space was usually 4cm long,with its anterior border of medial malleolus and flexor digitorum longus tendon,medial border of Achilles tendon,covered by deep fascia,and filled with areolar fatty tissue.In the space,there were about 2~3 fasciocutaneous perforators with caliber ranged 0.1~0.7 mm,usually less than 0.5mm with an average 0.47mm.The perforating artery usually had one partner veins.These perforators showed apparent link-anastomosis with the mostdistal septal perforator of posterior artery.In clinic,the five flaps,measured 5-6cm×6-12cm with pivot point 1-2 cm above the tip of medial malleolus,survived completely and smoothly.This adipofascial flap,compared to distally based faciocutaneous flap,has obvious advantages of reducing the morbidity to lower leg donor site,releasing venous drainage load,improving survived quality.Conclusions The retromalleolar perforator adipofascial flap is a thin reliable,pliable flap with an easy and simple surgical process.It should be considerated for medial aspect of the foot and heel.