穿支蒂足背中间皮神经营养血管皮瓣修复前足软组织缺损

Perforator-based intermediate dorsal pedal flap with vessels of cutaneous nerve nutrition for repair of soft tissue defects of the forefoot

目的探讨穿支蒂足背中间皮神经营养血管皮瓣修复前足软组织缺损的可行性。方法采用回顾性病例系列研究分析2013年2月～2017年1月收治的7例前足软组织缺损患者。其中男5例，女2例；年龄18～73岁，平均38岁。损伤部位：前足底外侧皮肤缺损3例，第3趾蹼背侧皮肤缺损2例，第4足趾近节背侧皮肤缺损2例。缺损面积2．5cm×1．5cm～4．5cm×2．0cm。根据术式解剖学基础，在足背外侧设计并切取穿支蒂足背中间皮神经营养血管皮瓣转位修复前足创面。记录手术时间及术中出血量。术后常规观察皮瓣感觉、外观、质地、术区血供、皮瓣成活情况及皮瓣是否存在臃肿、增生性瘢痕、瘙痒、皮肤移植区麻痹等。术后运动功能恢复情况采用美国足踝外科协会（AOFAS）评分。结果手术时间1．0～1．5h，平均1h；术中出血量30～100ml，平均50ml。7例穿支蒂足背中间皮神经营养血管皮瓣全部成活，创面Ⅰ期愈合。经过2～15个月随访，皮瓣两点辨别觉为9～15mm，平均12．5mm。皮瓣质地优良，不臃肿，色泽接近正常，外观较好，术后足部未发生骨质吸收、创面感染、肌腱粘连、局部留有线条或片状瘢痕等并发症，下肢行走功能无障碍，供、受区未发现穿鞋不适。患足AOFAS评分95～98分，患者对供、受区功能和外形满意。结论穿支蒂足背中间皮神经营养血管皮瓣具有术后皮瓣成活率高、外形满意、术区恢复快等特点，且无明显足部疼痛、关节活动受限等并发症，是修复前足软组织缺损创面的可靠方法。

Objective To explore the feasibility of the perforator-based intermediate dorsal pedal flap with vessels of cutaneous nerve nutrition for repair of soft tissue defects of the forefoot. Methods A retrospective case series study was performed for seven cases of soft tissue defects of the forefoot hospitalized between February 2013 and January 2017. There were five males and two females, with a mean age of 38 years （range, 18-73 years）. Injury regions were lateral plantar skin defect in the forefoot in three cases, dorsal skin defect in the third webbed toe in two cases and proximal dorsal skin defect in the fourth toe in two cases. The defect area was about 2. 5 cm ×1. 5 em-4. 5 cm × 2.0 cm. The perforator-based intermediate dorsal pedal flap with vessels of cutaneous nerve nutrition was designed on the lateral dorsum of the foot and then was incised and transferred to repair the forefoot wound based on its surgical anatomy. The time of surgery and the amount of intraoperative blood loss were recorded. An observation was done on feeling, appearance, texture, blood supply and survival of the flap as well as swelling, hypertrophic scar, itching, paralysis of the skin grafting area. The recovery of the activity function was assessed by American Orthopedic Foot ＆ Ankle Society （AOFAS） score. Results The surgery time was 1.0-1.5 h （mean, 1 h）, and intraoperative bleeding was about 50 ml （range, 30-100 ml）. Seven cases of perforator-based dorsal medial skin flap with vessels of cutaneous nerve nutrition all survived, with early wound healing. After 2 to 15 months follow-up, two-point discrimination of flaps was 9-15 mm （average, 12.5 mm）. Skin flaps were with excellent texture and without swelling, the color of which was close to normal color with good appearance. The postoperative foot did not have bone resorption, wound infection, tendon adhesion, line-type or flaky scar left locally, lower limb walking dysfunction or other complications. Patients were satisfied with the functions of donor and recipient sites and the appearance of the flap. Conclusions Perforation-based dorsal flap with vessels of cutaneous nerve nutrition has high survival rate, satisfaction of appearance and fast recovery of recipient site, with no obvious foot pain, limitation of joint movement or other complications, and therefore is a reliable method to repair soft tissue defects in forefoot.