足踝软组织重建的皮瓣选择策略：14种皮瓣226例分析

Foot and ankle reconstruction：an experience on the use of 14 different flaps in 226 cases

目的总结大样本足踝软组织重建病例使用不同皮瓣的经验，提出皮瓣的选择策略。方法从2007年3月至2012年10月，使用14种不同皮瓣对226例足踝软组织缺损进行重建。男162例，女64例。带蒂皮瓣62例，游离皮瓣164例。带蒂皮瓣包括腓肠神经营养血管皮瓣、隐神经营养血管皮瓣、足背皮神经营养血管皮瓣、带蒂腓动脉穿支皮瓣、带蒂胫后动脉穿支皮瓣、足内侧皮瓣；游离皮瓣包括背阔肌皮瓣、股前外侧肌皮瓣、腹股沟皮瓣、臂前外侧皮瓣、股前外穿支皮瓣、腓动脉穿支皮瓣、胸背动脉穿支皮瓣、臂内侧穿支皮瓣。所有皮瓣未进行感觉神经重建。226例中194例合并足踝部骨折，162例合并肌腱断裂。结果带蒂皮瓣62例中有11例发生远端部分坏死。164例游离皮瓣中8例全部坏死，局部坏死5例，创面二期处理后愈合。覆盖足底的57例皮瓣（带蒂25例，游离32例）在负重后，11例（带蒂5例，游离6例）出现了足底溃疡，14例出现了感染。56例恢复了足底的保护性感觉，恢复时间为3～12个月。所有术后随访4～48个月，平均16．7个月，均保肢成功并恢复了日常行走功能。结论目前临床常用的皮瓣中，腓肠神经营养血管皮瓣、隐神经营养血管皮瓣是覆盖内外踝、后足背、中足背的良好选择；足底、前足、大面积的缺损应首选游离股前外侧穿支皮瓣；对于伴有感染、死腔的创面，游离背阔肌皮瓣为最佳选择。

Objective To present the experience on the use and choice of different flaps for soft tissue reconstruction of the foot and ankle. Methods From March 2007 to October 2012, the soft tissue defects of traumatic injuries on foot and ankle were reconstructed by using 14 different flaps in 226 cases （ 162 males and 64 females）. There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, and medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety-four cases were combined with open fractures. One hundred and sixty-two cases had tendon ruptures. Results Of the 62 pedieled flaps, 11 had partial loss. Among 164 free flaps, 8 flaps were completely lost, and 5 were partly lossed. The resiudal defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage （25 pedicled flaps and 32 free flaps） , ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. All of limbs were preserved and the patients regained walking and daily activities. Conclusion Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead space, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice.