带腓肠腱膜的腓肠神经营养皮瓣修复KuwadeⅣ型跟腱缺损

Repair of Kuwade Type Ⅳ Achilles Tendon Defect with Sural Neurocutaneous Flap Combined Gastrocnemius Aponeurosis

目的：回顾性分析带腓肠肌腱膜的腓肠神经营养皮瓣修复KuwadeⅣ型跟腱缺损的临床病例,探讨其手术注意事项及治疗经验。方法：总结2008年5月-2013年8月收治的KuwadeⅣ型跟腱缺损19例,应用带腓肠肌腱膜的腓肠神经营养皮瓣进行一期修复。7例为新鲜损伤,12例为陈旧性缺损。19例跟腱缺损均伴有皮肤及软组织坏死,皮肤缺损范围为4.0 cm×6.0 cm-6.0cm×12.0 cm,跟腱缺损长度为5-9 cm,术中皮瓣切取范围为6.0 cm×5.5 cm-12.0 cm×8.0cm,腓肠腱膜切取范围5.5 cm×6.0cm-10.0 cm×6.0 cm;供区游离植皮修复。客观性评价指标包括关节跖屈、背伸动度及形态学,主观性评价采用AOFAS评分。结果：术后17例跟腱功能重建良好,2例感染控制不良,跟腱移植体部分坏死。皮瓣完全成活13例,创面Ⅰ期愈合。2例术后6天皮瓣远端表皮坏死,经换药后愈合。2例术后10天皮瓣远端部分坏死,经局部皮瓣移位修复愈合,2例感染控制不良者,皮瓣未愈合,移植跟腱部分坏死,经再次清创后,行阔筋膜条修复术,局部皮瓣移位修复。术后19例均获随访,随访时间6~24个月,平均18个月。术后皮瓣略臃肿,但不影响穿鞋,行走功能恢复良好,术后1年AOFAS评分平均80.31分。结论：带腓肠肌腱膜的腓肠神经营养皮瓣用于治疗KuwadeⅣ型跟腱缺损,可以同时修复皮肤及跟腱缺损,是一种较为理想的一期修复方法。

Objective： To retrospectively analyze the clinical experience of repairing Kuwade type IV Achilles tendon defect with Sural neurocutaneous flap combined gastrocnemius aponeurosis and to explore the surgery matters needing attention and treatment experience. Methods： Between 2008 May and 2014 February, 19 cases of Kuwade type IV Achilles tendon defects were repaired with Sural neurocutaneous flap combined gastrocnemius aponeurosis. 7 cases were fresh injury, 12 cases were old defects. 19 cases of Achilles tendon defects were accompanied by skin and soft tissue necrosis. The size of the wounds ranged from 4.0 cm×6.0 cm to 6.0 cm×12.0 cm.The length of tendon defect ranged from 5 cm to 9 cm. The size of the flaps ranged from 6 cm×5.5 cm to 12 cm ×8 cm. The size of gastrocnemius aponeurosis ranged from 5.5 cm ×6 cm to 10 cm ×6 cm. The donor sites were covered with intermediate split thickness skin grafts. The objective evaluated indexes included range of plantar flexion and dorsal flexion and morphology. The subjective evaluation was obtained by AOFAS scores. Results： 17 cases reconstructive achilles tendon survived well. 2 cases experience recurrent infection and partial necrosis of Achilles tendon transplantation. 13 flaps survived uneventfully, wounds healed by first intention. 2 cases with skin necrosis of distal epidermis were healed by wound care. Operative revision was required for 2 cases with delayed-onset soft tissue infections and 2 cases with donor site necrosis. Nineteen patients were followed up 6-24 months（mean, 18 months）. The appearance was slightly overstaffed, but wearing shoe function and gait were normal. The average score of AOFAS in 1 year was 80.31 points. Conclusions： For Kuwade type IV Achilles tendon defect, Sural neurocutaneous flap with gastrocnemius aponeurosis can repair skin and tendon defects in one stage. It is a kind of ideal repair method.