带神经股前外侧皮瓣与腓肠神经营养血管皮瓣修复足踝部软组织缺损效果比较

Comparison of the effects of anterolateral thigh flap with nerve and sural neurovascular flap in repairing soft tissue defect of foot and ankle

目的:比较带神经股前外侧皮瓣与腓肠神经营养血管皮瓣在足踝部软组织损伤修复中的效果,为临床选择提供参考。方法:回顾性分析2016年5月至2019年5月西南医科大学附属中医医院显微外科修复重建中心收治的以皮瓣修复的足踝部软组织损伤患者资料,根据手术方法分为带神经股前外侧皮瓣组(A组)和腓肠神经营养血管皮瓣组(B组)。统计2组皮瓣的一期存活率;参照中华医学会手外科学会上肢部分功能评定试用标准将皮瓣按评分设为优、良、可3个等级,计算优良率;统计2组皮瓣供区并发症发生率。采用SPSS 26.0进行分析,计量资料行 t检验,用均值±标准差表示,分类变量行卡方检验或Fisher确切概率法, P<0.05表示差异有统计学意义。 结果:共纳入38例足踝部软组织缺损患者,其中A组21例,男12例,女9例,平均年龄42.1岁,缺损面积4 cm× 6 cm^11 cm×16 cm,术后平均随访12.3个月;B组17例,男11例,女6例,平均年龄45.3岁,缺损面积5 cm×5 cm^10 cm×14 cm,术后平均随访11.3个月。2组患者年龄、性别、受伤原因等差异无统计学意义( P<0.05)。A组和B组皮瓣切取面积分别为(53.0±12.2) cm 2和(46.4±9.62) cm 2, 2组比较差异无统计学意义( t=1.824, P=0.076)。2组皮瓣均成活,其中A组术后2例皮瓣远端部分坏死,后期处理后愈合;B组皮瓣1例术后发生血管危象,探查减压后皮瓣存活。A组皮瓣一期存活率90.5%(19/21),B组皮瓣一期存活率94.1%(16/17),差异无统计学意义( P=1.000)。A组皮瓣优10例,良7例,可4例,优良率81.0%(17/21);B组皮瓣优3例,良3例,可11例,优良率35.3%(6/17),差异有统计学意义( P=0.007)。A组皮瓣供区愈合良好,无相关并发症出现,B组2例(11.8%)皮瓣供区术后出现瘢痕挛缩畸形,影响小腿功能,二期瘢痕松解后功能恢复,2组供区并发症发生率比较,差异无统计学意义( P=0.193)。 结论:带神经的股前外侧皮瓣与腓肠神经营养血管皮瓣均能修复足踝部软组织缺损,成活率高,但带神经股前外侧皮瓣较腓肠神经营养血管皮瓣优良率高,对供区影响更小。

Objective To evaluate the effect of the free anterolateral thigh flap with nerve and the sural neurocutaneous flap on ankle and foot tissue defect,and to provide guidance for clinical selection.Methods From May 2016 to May 2019,we reviewed and analyzed the data of patients with soft tissue injury of ankle and foot repaired by flap from Microsurgery Repair and Reconstruction Center,Traditional Chinese Medicine Hospital Affiliated to Southwest Medical University.According to the surgical method,they were divided into the free anterolateral thigh flap with nerve group and the sural neurocutaneous flap group.The survival rate of the 2 groups of skin flaps were calculated.According to the trial standard for evaluation of upper limb function in Chinese Medical Association Hand Surgery Society,the flaps were rated as excellent,good,and acceptable.And the excellent and good rates were counted.The incidence of regional complications of the 2 groups were counted.SPSS 26.0 software was used for analysis,the measurement data were subjected to t-test,expressed as mean±standard deviation;the categorical variables were subjected to chi-square test or Fisher’s exact probability method,and P<0.05 indicated that the difference was statistically significant.Results A total of 59 patients with soft tissue defects in the foot and ankle were included.Among them,21 cases were repaired with free anterolateral thigh flaps with nerve(group A),12 males and 9 females,with an average age of 42.1 years,and the defect area was 4 cm×6 cm-11 cm×16 cm,followed up for an average of 12.3 months after surgery;17 cases of sural neurocutaneous flap repair(group B),11 males and 6 females,average age 45.3 years,defect area 5 cm×5 cm-10 cm×14 cm,the average follow-up was 11.3 months.There were no statistically significant differences in age,gender and cause of injury between the two groups(P<0.05).The area of the flaps in group A and group B were(53.0±12.2)cm2 and(46.4±9.62)cm2,respectively.There was no significant difference between the two groups(t=1.824,P=0.076).The flaps were all survived in both groups.Among them,2 cases of group A had partial necrosis at the distal end of the flaps and healed after post-treatment;1 case of group B had vascular crisis after operation,and the flaps survived after exploratory decompression.The first-stage survival rate of skin flaps in group A was 90.5%(19/21),and the first-stage survival rate of skin flaps in group B was 94.1%(16/17).The difference was not statistically significant(P=1.000).According to the trial standard of upper limb function evaluation of the Chinese Medical Association Hand Surgery Society,the skin flaps in group A were excellent in 10 cases,good in 7 cases,and fair in 4 cases,with an excellent and good rate of 81.0%(17/21).In group B,skin flaps were excellent in 3 cases and good in 3 cases.Of the 11 cases,the excellent and good rate was 35.3%(6/17),and the difference was statistically significant(P=0.007).The flap donor area in group A healed well without related complications.In group B,2 patients(11.8%)developed scar contracture deformity after the flap donor area,which affected calf function,and the function recovered after the second-stage scar was released.The incidence of complications in the region was not statistically significant(P=0.193).Conclusions Both the free anterolateral thigh flap with nerve and the sural neurocutaneous flap can repair the soft tissue defect of foot and ankle with high survival rate.But the sural neurocutaneous flap has a higher good rate than the free anterolateral thigh flap with nerve,and the donor site is affected smaller.