足背外侧血管神经的解剖及足背外侧逆行筋膜蒂皮瓣的临床应用研究

Study on Anatomy of Vessels and Nerves of Lateral Dorsum of Foot and Clinical Application of Retrograde Fascia Pedicle Skin Flap of Lateral Dorsum of Foot

目的:研究带腓肠神经供应血管的逆行筋膜蒂皮瓣(FPSF)在足背皮肤软组织缺损移植修复中的临床应用。方法:选取本院2013年7月-2015年7月期间25例足背部皮肤软组织缺损患者临床资料、9例健康体检者临床资料、成人尸体标本6具共12侧肢体。足背部皮肤软组织缺损患者采用FPSF移植修复,9例健康体检者以彩超血管探测仪对体检者小腿部远端后外侧腓动脉的肌间隔支、终支进行探测,并对成人尸体标本6具共12侧肢体予腓肠神经及其供应血管的解剖观察。结果:(1)25例足背部皮肤软组织缺损患者皮瓣修复全部成活。皮瓣最大(18.0×13.0)cm^2,最小(3.0×2.5)cm^2。其中1例由于静脉回流受阻有小部分坏死出现,其余24例均无并发症。经18个月随访,复诊时患者足背部皮瓣弹性良好、均未见畸形。(2)标本解剖所见,小隐静脉由足背静脉弓及其中外侧缘的汇合处发起,自外踝的后缘与跟腱直接上行,至腘窝下角穿过深筋膜,再经腓肠肌的两头间上行,注入腘静脉。小腿后部、足外侧部浅层结构静脉血汇至小隐静脉,且小隐静脉伴行腓肠神经,相距1~10 mm。(3)体检彩超组腓动脉终支、肌间隔支距外踝距离与尸检标本组比较,差异均无统计学意义(P>0.05)。结论:带腓肠神经供应血管的逆行FPSF,不仅具有皮瓣血运佳、血管神经蒂长、变异小、旋转范围大、易成活等特点,而且兼具充分的静脉回流、可靠的动脉供血、切取皮瓣时操作简单、无需血管吻合、不影响主干动脉等多方面优势,适用于足背皮肤软组织缺损的移植修复,效果显著,应予推广。

Objective： To study the clinical application of retrograde FPSF （ fascia pedicle skin flap ） with nutrient vessels of gastrocnemius nerve in transplantation of instep skin and soft tissue defect.Method： From July 2013 to July 2015, the clinical data of 25 cases with instep skin and soft tissue defect and 9 health cases and 12 lower limbs of 6 adult cadavers in our hospital were selected.25 cases with instep skin and soft tissue defect were treated by transplantation of FPSF.Intermuscular septum branches and end branches of peroneal arteries of distal posteroiateral shanks of 9 health cases were detected by vascular ultrasound detector.Anatomies of gastrocnemius nerves and its nutrient vessels of 12 sides of limbs of 6 adult cadaver specimens were observed.Result： （ 1 ） All flap survived, maximum was （ 18.0 ×13.0 ）cm^2 and minimum was （ 3.0×2.5 ） cm^2.There were 1 cases with a small part of necrosis due to the obstruction of venous reflux and 24 cases without complications.After 18 months of follow-up, the elasticity of flaps were good and there were no deformity. （ 2 ） According to the anatomical, small saphenous vein originated in the confluence of foot dorsal venous arch and its lateral border, ran up along the lateral malleolus trailing edge and the achilles tendon directly, was through the deep fascia in popliteal fossa, passed between the heads of the gastrocnemius muscle and drained into the popliteal vein.Shallow venous blood of the back of shank and the lateral of foot was remitted to the small saphenous vein, small saphenous vein accompanied with sural nerve and distance was about 1-10 ram. （ 3 ） Compared distance from peroneal artery end branch and intermuscular septum branch to lateral malleolus of medical ultrasound group with those of autopsy specimens group, the differences had no statistical significance （P〉0.05） .Conclusion： Retrograde FPSF with nutrient vessels of gastrocnemius nerve not only has the advantages of good flap blood, long neurovascular pedicle, little variation, wide rotation range and easy to survive, but also possess enough venous reflux, reliable artery, simple operation to cut flap, no need to anastomose vessels, no effect on the main artery and many other advantages, so it is suitable for transplantation of instep skin and soft tissue defect, whose effect is significant and which should be popularized.