儿童足后跟Ⅲ级轮辐伤后跟腱重建中带蒂皮瓣选择

Selection of pedicled flaps in Achilles tendon reconstruction for grade Ⅲ spoke heel injuries in children

目的探讨儿童足后跟Ⅲ级轮辐伤带蒂皮瓣选择与跟腱重建的临床效果。方法回顾性分析2007年1月-2013年6月收治的儿童足后跟Ⅲ级轮辐伤31例，其中男19例，女12例；年龄3-12岁，平均5．2岁。均为摩托车致伤。软组织缺损为8．0cm×4．5cm～3．5cm×2．5cm。跟腱缺损长度为1．5～4．4cm。患者受伤至入院时间2h～26d，平均4．4d。Ⅰ期重建18例，Ⅱ期重建13例。16例行复合腓肠肌皮瓣V-Y推进＋跟腱止点重建术，11例行隐神经营养血管皮瓣（7例）或胫后动脉穿支皮瓣（4例）＋跟腱止点重建术，4例行腓肠神经营养血管皮瓣（3例）或腓动脉穿支皮瓣（1例）＋跟腱止点重建术。术后观察皮瓣成活和并发症情况，随访观察踝关节屈伸活动度、步态和主观症状。结果术后皮瓣末端部分坏死3例，跟腱部分感染1例。本组患者随访6个月～4年，平均13个月。术后6个月踝关节背伸受限，平均背伸角度为95．4°。随着随访时间延长踝关节背伸功能逐渐改善，18个月踝关节平均背伸角度为87．3°，所有患儿步态正常。结论儿童足后跟Ⅲ级轮辐伤采用带蒂皮瓣＋带血运肌腱或筋膜进行跟腱修复和重建可获得满意的临床疗效。

Objective To investigate the selection of pedicled flaps and Achilles tendon reconstruction for grade Ⅲ spoke heel injuries in children. Methods Thirty-one children with grade m spoke heel injuries in motorcycle accidents treated from January 2007 to June 2013 were reviewed retrospectively. There were 19 males and 12 females, aged of 3-12 years （mean, 5.2 years）. According to the injury time, systemic condition, and size and location of Achilles tendon defect, different surgical options were adopted. Soft tissue defect ranged in size from 8.0 cm× 4.5 cm-3.5 cm × 2.5 cm. Length of Achilles tendon defect was 1.5-4.4 cm. Time from injury to operation was 2 h-26 d （mean, 4.4 d）. Eighteen cases were reconstructed in one stage and the others in second stage. Sixteen cases received combined gastrocnemius musculocutaneous V-Y advancement flap repair and reconstruction of Achilles tendon insertion. Eleven cases underwent saphenous neurocutaneous vascular flap （7 cases） or posterior tibial artery perforator flap repair （4 cases） and reconstruction of Achilles tendon insertion. Four cases received sural neurocutaneous vascular flap （ 3 cases） or peroneal artery perforator flap repair （ 1 case） and reconstruction of Achilles tendon insertion. Flap conditions and complications were recorded. Ankle flexion-extension motion, gait and subjective symptoms were followed up. Results Postoperatively, 3 cases presented partial necrosis of the flap end, and one case presented local infection of the Achilles tendon. Mean duration of follow-up was 13 months （range, 6 months-4 years）. Dorsiflexion of the ankle was limited at postoperative 6 months, and mean dorsiflexion was 95.4°. Dorsiflexion function of the an- kle was improved over time, and mean dorsiflexion was 87.3°at postoperative 18 months. All acquired normal gait. Conclusion The pedicled flap plus vascular tendon or fascia result in satisfactory effect in treatment of grade III spoke heel injuries in children.