肩胛骨背阔肌复合组织瓣移植一期修复小腿外伤后胫骨伴软组织缺损

The use of free scapula latissimus dorsi muscle compound flap for the repair of traumatic defect of the tibia and soft tissue at one setting

目的应用肩胛骨背阔肌复合组织瓣移植一期修复小腿外伤后胫骨伴软组织缺损。方法8例小腿创伤后胫骨伴局部软组织缺损，其中胫骨完全性节段缺损6例，蝶形缺损2例；胫骨缺损长度5－8cm，平均6.3cm。局部软组织缺损面积6cmx8cm～8cmx12cm。受伤部位：小腿近段2例，中段3例，下段3例。按Gustilo分级：ⅢB型6例，ⅢC型2例。所有病例均有局限性感染，其中2例伴有胫骨断端局限性骨髓炎。应用游离胸背血管肩胛骨背阔肌复合组织瓣一期修复。结果移植组织瓣全部成活。背阔肌皮瓣面积9cmx10cm～20cmx14cm；骨瓣长7．0～9．5cm，平均8．3cm。受区血管5例为胫前动静脉，3例为胫后动静脉；动脉端端吻合6例，“T”形嵌入2例。经术后1～5年，平均2年7个月随访，骨瓣于术后3～6个月愈合。随着部分负重移植肩胛骨瓣迅速增粗，术后1年其宽度平均增加49．6％，厚度平均增加73．3％。5例恢复原工作，另3例改换工种。结论肩胛骨背阔肌复合组织瓣游离移植适合于修复小腿外伤后局部软组织伴中等长度的胫骨缺损。

Objective To observe the long term result of the transplantation of scapula latissimus dorsi muscle compound flap to repair the defect of the tibia and the soft tissue after trauma at the same setting.Methods 6 patients with complete segmental defect of the tibia with 2 butterfly defects of the tibia were reconstructed by the transfer of scapula latissimus dorsi muscle compound flap pedicle based on thoracodorsal vessels at one stage. The age of the patients ranged from 18 to 46 years with an average of 31. There were 7 males and 1 female. All had traumatic injuries. The wounds involved the proximal segments of the tibia in 2 cases, the middle segments in 3 cases and the distal in 3 cases. The lengths of the tibial defects were 5 to 8 cm, averaged 6. 3 cm. The extent of the soft tissue defects varied from 6 cm x 8 cm to 8 cm x 12 cm. 6 patients were classified as Gustilo grade Ⅲ B, 2 patients as grade Ⅲ C; all the patients had developed local infec tion. Results All of the flaps survived postoperatively. The sizes of the myocutaneous flap varied from 9 cm x 10 cm to 2o cm x 14 cm, and the lengths of the bone graft were 7. 0 to 9. 5 cm respectively, averaged 8. 3 cm. Tibialis anterior or posterior were used for an astomosis with the flap. Follow-up period lasted from 1 - 5 years; the time of bony union ranged from three to six months; hypertrophy of the bone grafs procured from the lateral border of the scapula was remarkable, with a rate of 49. 6% in width and 73. 3% in thickness one year afer operation. Five patients returned to original work, three did not. Conclusion The latissimus dorsiscapular myoosteo-cutaneous nap can be used for the reconstruction of lower extremity involving moderate tibial and soft tissue defects and the lateral board of the scapula can provide a length of about 10 cm bone graff with adequate blood supply from the branches of the thoracodorsal vessels; hypertrophy of the transferred bone was seen shortly afer the lower limb began weight bearing.