穿支皮瓣修复跟周软组织缺损

Perforator flaps for soft tissue defects around the heel

目的探讨穿支皮瓣修复跟刷软组织缺损的疗效，并比较游离和带带穿支皮瓣的优缺点。方法2009年1月至2011年12月共收治9例跟周软组织缺损患肴，男5例，女4例；平均年龄为35．4岁（18～51岁）。合并损伤：跟腱断裂或缺损3例，跟骨结节骨折、缺失4例，跟骨骨髓炎1例。，缺损面积为4cm×1cm～17cm×9cm，均采用穿支皮瓣覆盖创面，皮瓣面积为5cm×2cm～18cm×10cm。其中游离穿支皮瓣5例（旋股外侧动脉降支穿支皮瓣3例，横支穿支皮瓣1例，胸背动脉穿支皮瓣1例），带蒂穿支皮瓣4例（腓动脉穿支皮瓣3例，胫后动脉穿支皮瓣1例）。同时修补合并的跟腱断裂，术中复位内固定跟骨骨折．结果9例患者术后获6～39个月（平均21个月）随访。9例患者皮瓣完全存活．其中1例穿支皮瓣患者术后发生静脉危象，经探查存活；1例带蒂穿支皮瓣患者远端回流障碍，经持续按摩后存活。9例患者术后小腿肌力均达到5级，、游离穿支皮瓣较带蒂穿支皮瓣厚，患者穿鞋时有后跟摩擦。1例患者术后1年随访时走路有轻度跛行，其余患者步态正常。结论对于小面积跟周软组织缺损者，应优先采用带蒂穿支皮瓣覆盖；对于缺损面积大、尤其足缺损宽度大的患者，心采用游离穿支皮瓣修复，并注意治疗并发的跟腱和跟骨损伤，以减少后遗症。

Objective To compare free pertbrator and pedieled perforator flaps in repair of soft tissue defects around the heel. Methods From January 2009 to December 2011, 9 patients with soft tissue defects around tile heel wre treated in our center with perforator flaps. They were 5 men and 4 women, with an average age of 35.4 years （from 18 to 51 years）. The concomitant injuries included Achilles tendon rupture or defect in 3 cases, caleaneus tubercle fracture or defect in 4 cases, and caleaneus osteomyelitis in one case. The defect sizes ranged from 4 cmx 1 em to 17 cm × 9 cm. Tire perforator flaps ranged from 5 cm × 2 em to 18 cmx 10 em. There were 5 free perforator flaps （3 ones with the descending branch of the lateral circumflex femoral arter3, one with the transverse branch of the lateral cireunfflex femoral artery and one with the thoracodorsal artery） and 4 pedicled pedbrator flaps （3 ones with the fibular artery and one with the posterior tibial artery） . The concurrent Achilles tendon rupture was repaired and the caleaneus fracture re- duced and internally fixated. Results The 9 patients were fiollowed for 6 to 39 months （average, 21 months）. All the flaps survived emnpletely. One free perforator flap experienced postoperative vein congestion which was resoked after surgical exploration. One pedieled perforatnr flap had the problem of distal vein reflux but survived after continuous massage. The postoperative leg myodynamia reached level V in each case. Generally the free perforator flaps were thicker than the pedieled ones so that tbe patients with a thicker heel flap had a grinding feeling against the back collar of the shoe. All the patients regained a normal gait except one who had a cripple heel. Conclusions For small skin defects around the heel, pedicled perforator flaps may be the first choice while free perforator flaps are more suitable for large and wide skin defects around the heel. In any cases, the concurrent injuries to the Achilles tendon and the caleaneus should be repaired cautiously to minimize postoperative complications.