三种不同形式的小腿内侧岛状皮瓣临床应用分析

Clinical application of 3 types of the medial shank island flaps

目的比较分析胫后动脉中下1/3穿支皮瓣、隐神经营养血管皮瓣及胫后动脉-隐神经双套血供皮瓣在内踝及小腿中下段创面中的临床应用及疗效。方法门诊随访2015年8月至2018年12月期间治疗的内踝及小腿中下段创面60例,其中采用胫后动脉中下1/3穿支皮瓣25例,隐神经营养血管皮瓣15例,胫后动脉-隐神经双套血供皮瓣20例。对3组皮瓣的手术方法、皮瓣成活情况、皮瓣的外形质地及肿胀度、患者的满意度及美国足踝协会踝与后足功能(AOFAS)评分进行研究。结果术后随访6~24个月,平均13.4个月,3组中采用胫后动脉中下1/3穿支蒂皮瓣共25例,其中1例皮瓣术后肿胀度欠佳,出现供血不足情况,对症处理后皮瓣逐渐好转,皮瓣外形、质地良好;采用隐神经营养血管皮瓣修复15例,2例术后皮瓣远端坏死,二期植皮修复,皮瓣蒂部略臃肿;采用胫后动脉穿支-隐神经双套血供皮瓣20例,皮瓣术后血运良好,2例术后出现瘀紫,拆除蒂部缝线后好转,3例皮瓣外观臃肿,蒂部膨隆,二期皮瓣整形。3组在AOFAS平均评分分别为93.8、93.3和92.8分,患者满意度调查优良比例均较高。结论3种皮瓣均能较好修复内踝及小腿下段软组织缺损创面,术中应根据穿支是否存在及穿支的粗细决定是否携带隐神经。如果穿支可靠,使用胫后动脉穿支皮瓣进行创面修复,在皮瓣血运及外观上更满意;对于较大面积的创面,携带胫后动脉穿支及隐神经营养血管的双套血供皮瓣更安全。

Objective To compare the application and results in repairing wounds on shank and medial malleolus by perforator pedicled middle and lower third of posterior tibial flap, saphenous neurovascular flap and posterior tibial artery perforator plus saphenous neurovascular (double blood supply) flap.Methods Clinical data of 60 patients with wounds on shank and medial malleolus and treated between August, 2015 and December, 2018 were analyzed. Among the patients, 25 were treated with perforator pedicled middle and lower third of posterior tibial flaps, 15 with saphenous neurovascular flaps, and 20 with double blood supply flaps. The data of surgery, survival of the flaps, texture and swelling of the flaps, patient satisfaction and scores set by American Orthopaedic Foot and Ankle Society(AOFAS) were collected. Statistic analysis was carried out to compare observations among the 3 groups.Results Postoperative followed-up was 6 to 24(average 13.4) months. One flap suffered insufficient blood supply in the group of perforator pedicled middle and lower third of posterior tibial flaps, 2 flaps suffersd necrosis and skin graft was carried out in reverse saphenous nerve neurocutaneous flaps group. In double blood supply flaps group, 2 flaps appeared purple after surgery, and improved after removing the pedicle sutuer, and flaps became swelling and received secondary repair. All AOFAS scores (93.8, 93.3 and 92.8, respectively) and patient satisfaction were high in all 3 groups.Conclusion All 3 types of flap are able to be used in repairing the soft tissue defect on shank and medial malleolus. The inclusive of saphenous nerve should be determined in intraoperation according to the presence and size of the perforator. If artery perforation is reliable, the use of posterior tibial artery perforator flap in wound repairing will deliver satisfactory outcomes in terms of blood supply and appearance of the flap. For the wider area of wound, a flap with double blood supply is preferred.