小腿下段穿支蒂螺旋桨皮瓣术后严重并发症的原因分析及对策

Analysis of the causes and the countermeasures for the serious complications after perforating pedicle flap of lower leg

目的分析小腿下段穿支蒂螺旋桨皮瓣术后各种严重并发症的发生原因，并探讨相应的处理对策。方法回顾性分析2012年6月至2016年8月运用小腿下段穿支蒂螺旋桨皮瓣修复足踝部软组织缺损60例的临床资料，软组织缺损面积3.0 cm×2.0 cm^19.0 cm×9.0 cm，均伴骨外露。外伤性组织缺损2例，胫骨远端慢性骨髓炎7例，踝关节骨折及Pilon骨折术后切口感染、坏死13例，跟骨骨折术后单纯软组织坏死、感染10例，跟骨骨髓炎18例；足踝部肿瘤术后软组织缺损伴感染1例；跟腱断裂术后软组织坏死6例，单纯软组织缺损伴感染3例。采用胫后动脉穿支蒂螺旋桨皮瓣18例，血管蒂距离内踝6.0~18.0 cm，皮瓣旋转135°~180°；腓动脉穿支蒂螺旋桨皮瓣42例，血管蒂距离外踝5.0~18.0 cm，皮瓣旋转120°~180°；皮瓣切取面积9.0 cm×3.0 cm^34.0 cm×18.0 cm。供瓣区直接缝合32例，游离植皮28例。结果术后观察皮瓣颜色、肿胀、弹性、毛细血管反应及供瓣区愈合情况，60例患者术后无皮瓣缺血发生，发生静脉回流障碍14例，均出现II°以上肿胀，其中8例出现Ⅲ°肿胀并伴明显瘀紫，最终导致皮瓣部分坏死4例，全部坏死1例，其中另行游离植皮4例，皮瓣移植修复1例。供瓣区植皮后坏死3例，均为部分坏死；供区创面直接缝合后切缘坏死1例，拆线后皮肤崩裂1例，创面均予以换药以及血竭粉外用处理后愈合。出院后均获得12~30（平均24.5）个月随访，皮瓣成活及供区瘢痕愈合良好，踝关节活动度背伸-10°~10°（平均5.6°），跖屈20°~50°（平均37.8°）。其中发生静脉回流障碍的14例随访15~28（平均22.3）个月，皮瓣及植皮成活良好，踝关节背伸为-10°~10°（平均2.4°），跖屈为20°~45°（平均35.6°），均无明显跛行。结论小腿下段穿支蒂螺旋桨皮瓣修复足踝部软组织缺损虽总体效果满意，但仍存在各种严重并发症，其发生原因以医源性居多。医者应从术前准备、术中操作及术后管理中从始至终严格遵循皮瓣外科基本原则，减少并发症发生。

ObjectiveTo analysis causes of the serious complications after the operation of the lower leg perforator pedicle screw flap, and to explore the corresponding countermeasures.MethodsFrom June, 2012 to August, 2016, 60 cases of soft tissue defect of ankle and foot were repaired with propeller flaps pedicled with perforator of lower legs. with the area were soft tissue defect ranged from 3.0 cm×2.0 cm to 19.0 cm×9.0 cm, and all with bone exposure. Two cases of traumatic tissue defect, 7 cases were chronic osteomyelitis of the distal tibia, 13 cases were incision infection and necrosis after the operation of ankle joint fracture and Pilon fracture, 10 cases were simple incision necrosis after calcaneal fracture, 18 cases were calcaneal osteomyelitis, 1 case were soft tissue defect after the ankle tumor operation, 6 cases were soft tissue necrosis after the Achilles tendon rupture, and 3 cases were soft tissue defect of the dorsum with infection. The posterior tibial artery perforator pedicled propeller flap was used in 18 cases. The pedicle of the vascular pedicle was 6.0-18.0 cm from the medial malleolus, the flap rotation was 135°-180°. There were 42 cases of the perforator pedicle propeller flap of the peroneal artery, 5.0-18.0 cm from the pedicle of the vascular pedicle and 120°-180° rotation in the flap. The area of the flap was 9.0 cm×3.0 cm-34.0 cm×18.0 cm. There were 32 cases of direct suture in the donor site and 28 cases of free skin grafting.ResultsThe color, swelling, elasticity, capillary reaction and healing of donor site were observed after operation. There was no flap ischemia occurred in 60 patients. Fourteen cases had venous reflux obstruction, all of which had swelling above II degree, 8 cases had swelling above Ⅲ degree with obvious purple blood stasis, resulting in partial flap necrosis in 4 cases, all necrosis in 1 case, including 4 cases of free skin grafting, 1 case of flap transplantation and repair. There were 3 cases of necrosis after skin grafting in the flap area, all of which were partial necrosis. There was case of necrosis of the wound surface after direct suture of the donor site and 1 case of skin disintegration after disassembly, and all wounds healed after the replacement of the wound and the external use of the dried blood powder. All the 60 patients were followed-up for 12 to 30 （mean, 24.5）months. The flaps survived and the donor site scars healed well. The range of motion of the ankle was from -10°to 10°（mean, 5.6 °） and the flexion of the plantar was from 20 °to 50 °（mean, 37.8 °）. Fourteen patients with venous reflux disorder were followed up for 15 to 28（mean, 22.3）months. The flap and skin graft survived well. Ankle dorsiflexion ranged from -10° to 10 °（mean, 2.4 °） and plantar flexion from 20° to 45 °（mean, 35.6 °）. There was no obvious limp in walking.ConclusionAlthough the overall effect of the lower leg perforator pedicle propeller flap to repair the soft tissue defect of the foot and ankle is satis-factory, there are still various serious complications, which are mainly due to iatrogenic. Doctors should strictly follow the basic principles of skin flap surgery from preoperative to postoperative, and during operation and postoperative man-agement, so as to reduce the incidence of complications.