带腓骨长短肌的游离腓骨复合组织瓣在复杂肢体创伤中的应用

Free fibular composite tissue flap with peroneus longus and brevis for complicated extremity trauma

目的探讨应用带腓骨长短肌的游离腓骨复合组织瓣治疗复杂肢体创伤的可行性。方法回顾性研究2014年8月至2017年9月上海交通大学附属第六人民医院骨科采用带腓骨长短肌的游离腓骨复合组织瓣治疗的5例复杂肢体损伤患者资料。患者男4例,女1例;年龄23~52岁,平均35.1岁;桡骨缺损1例,尺骨缺损1例,胫骨缺损3例;骨缺损长度7~18 cm,软组织缺损面积10 cm×5 cm^18 cm×8 cm。彻底清创后根据损伤区域软组织条件及缺损面积,设计复合组织瓣修复骨缺损并固定,覆盖创面,功能重建。术后观察皮瓣存活情况、受区相应肌腱功能恢复情况、腓骨愈合时间。观察供区伤口愈合情况,供区踝关节活动功能,是否存在供区并发症。结果所有患者术后均获随访,时间为18~38个月(平均25.2个月)。所有皮瓣均存活,未出现血管危象,且均未出现感染。移植腓骨愈合时间为4~16个月(平均8.4个月)。3例胫骨缺损患者背伸最大角度为0~10°,未出现足下垂;前臂骨缺损患者均重建屈拇及屈指功能,仅能对示指,不能握拳。5例皮瓣供区均采用负压封闭引流后二期缝合伤口,伤口愈合良好,其中1例瘢痕增生明显。供侧未见明显足内翻,患者踝关节活动功能满意。随访过程中未出现腓骨瓣再骨折。患者对治疗结果满意。结论带腓骨长短肌的游离腓骨复合组织瓣治疗存在肌肉肌腱缺损的复杂肢体创伤可行,可以作为治疗的备选方案。

Objective To report our clinical application of free fibular composite tissue flap with peroneus longus and brevis in the treatment of complicated extremity trauma. Methods From August 2014 to September 2017, 5 patients with complicated extremity trauma were treated using a free fibular composite tissue flap with peroneus longus and brevis at Department of Orthopaedics, The Sixth People's Hospital of Shanghai. They were 4 men and one woman, aged from 23 to 52 years (average, 35.1 years). All of them had tendon defects;one had a radius defect, one an ulnar defect and three a tibial defect. The length of bone defects ranged from 8 cm to 18 cm;the size of soft tissue defects ranged from 10 cm × 5 cm to 18 cm ×8 cm. A fibular composite tissue flap was designed according to the soft tissue condition and defect area to repair and fixate the bone defect after thorough debridement and cover the wound before functional reconstruction. Postoperatively, survival of the flap and functional recovery of the corresponding tendon at the recipient site, healing time of the tibia, and wound healing, ankle motion and complications at the donor site were all observed. Results The 5 patients were followed up for 18 to 38 months (average, 25.2 months). All flaps survived without any vascular crisis or infection. The union time for the fibular graft ranged from 4 to 16 months (average, 8.4 months). In the 3 patients with a tibial defect, the maximum angle of dorsal extension ranged from 0° to 10° and no foot drop was observed. Thumb and digital flexion was reconstructed in the patients with a forearm bone defect only to achieve opposition of index finger and thumb but we failed to make them have a fist. At the 5 flap donor sites, the wound was sutured by the second stage after vacuum suction and healed well;obvious scar formed in one of them. No obvious foot varus was observed at the donor site. The patients were satisfactory with their ankle joint motion. No refracture of the fibular graft occurred during follow-up. Conclusion A free fibular composite tissue flap with peroneus longus and brevis is a good choice for complicated extremity trauma.