腓肠神经营养血管远端蒂皮瓣修复足前部软组织缺损

The distally based sural neurouascular flap for reconstruction of the forefoot soft tissue defect

目的探讨腓肠神经营养血管远端蒂皮瓣转位修复足前部软组织缺损的临床效果。方法在解剖学研究的基础上，2004年1月—2013年1月采用腓肠神经营养血管远端蒂皮瓣转位修复足前部软组织缺损21例，致伤原因：车祸伤8例，砸伤9例，机器伤3例，爆炸伤1例。软组织缺损范围为7．0cm×5．0cm-22．0cm×11．0cm。旋转点位于外踝上1～3cm。皮瓣切取范围8．0cm×6．0cm～25．0cm×12．0cm。部分病例将腓肠神经与受区可供吻合的神经行端端或端侧吻合，以重建皮瓣感觉。结果所有皮瓣成活。术后皮瓣虽出现不同程度皮瓣肿胀，但在旋转点远侧结扎浅静脉干者肿胀程度明显轻于未结扎者。术后3—4d出现皮瓣边缘坏死2例，经换药后皮瓣成活，创口Ⅱ期愈合。其余皮瓣及供区植皮均顺利成活，创口I期愈合。患者均获随访，随访时间5—27个月，皮瓣外形满意，足的行走负重功能均恢复，供区外观及运动正常。本组5例行皮神经端侧吻合的患者，患处触痛觉功能多在术后1年得到不同程度的恢复，两点辨别觉在8～10mm。结论腓肠神经营养血管远端蒂皮瓣旋转点低，可以修复足前部软组织缺损创面，手术操作简便，创伤小，成活率高。将腓肠神经近端与足背皮神经吻合，可改善皮瓣感觉功能。

Objective To investigate the clinical effect of the distally based sural neurouascular flap for the reconstruction of the anterior soft tissue defect of foot. Methods Based on anatomy research, the distally based sural neurouascular flap was used in 21 consecutive patients with the forefoot soft tissue defect from January 2004 to lanuary 2013. The cause of trauma as follows： 8 cases were traffic accident injury, 9 eases were crushing injury, 3 cases were machine injury, and 1 case was explosion injury. The area of defect varied from 7.0 cm × 5.0 cm to 22.0 cm× 11.0 cm. The rotation point located 1 - 3 cm above the lateral malleolus, and flap size varied from 8.0 cm×6.0 cm to 25.0 cm × 12.0 cm. We anastomosed sural nerve with recipient site nerve to reconstruct the sense of this flap in some cases. Results Although, the different degrees of swelling were found after the operation, all flaps survived. Flaps whose trunk of the superficial vein were ligated distally at the rotation point swelled less serious than those unligated. In 2 cases of flap necrosis occurred at the edge in 3 - 4 days after the surgery, and phase II healing was acquired after dressing change. The other flaps and all donor sites acquired Phase I healing. All clinical results were satisfactory after 5 to 27 months of follow-up. Not only appearance and function of foot-such as walking and loading-were reconstructed, but also all donor sites recovered with no complications. In 5 cases of this group which were conducted anastomosis of cutaneous nerve, sense of touch and pain restored in different degrees 1 year after the surgery, and the two-point discrimination was 8 - 10 mm. Conclusions The distally based sural neurouascular flap, with a lower rotation point, can be used to reconstruct the front of the foot soft tissue defect and has a high survival rate. The sense of flap can be restored by anastomosing the sural nerve with the dorsal cutaneous nerve of foot.