带肋下神经外侧皮支旋髂浅动脉穿支削薄皮瓣修复足踝部软组织缺损

Free thin sensate superficial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve for repair of soft tissue defect in the foot and ankle

目的探讨以带肋下神经外侧皮支旋髂浅动脉穿支削薄皮瓣修复足踝部软组织缺损的疗效方法采用回顾性病例系列研究分析2017年12月至2019年12月解放军第八十集团军医院收治的9例足踝部软组织缺损患者临床资料,其中男8例,女1例;年龄28〜63岁[(47.3±12.3)岁]。体重指数(BMI)为16.7~27.8 kg/m^(2)[(23.9±3.9)kg/m^(2)]。皮肤缺损面积为10 cm× 6 cm~20 cm × 12 cm均采用带肋下神经外侧皮支旋髂浅动脉穿支削薄皮瓣修复。在清创或肿瘤切除后,从浅、深脂肪层间切取带感觉神经的皮瓣,皮瓣面积为13 cm × 8 cm~13 cm × 10cm,Ⅰ期削薄后皮瓣厚度3〜6 mm肋下神经外侧皮支跨越髂嵴处距离髂前上棘的距离7.5~10.0cm.术后评估皮瓣存活、并发症、再手术情况。采用Tmel征及九宫格法测量皮瓣的单丝触觉、振动觉、疼痛觉、温度觉和静态两点辨别觉的恢复.评估患足踝关节活动度、穿鞋行走情况末次随访时采用美国足踝外科协会(AOFAS)踝-后足评分对患足功能进行评估观察供区副损伤情况。结果患者均获随访6~35个月[(21.1±10.1)个月]。皮瓣均存活,无感染或肿瘤复发1例修复足跟患者因溃疡行多余皮肤切除,1例Ⅱ期再削薄、取内固定。3〜6个月后可首次测到皮瓣9个区域内单丝触觉、振动、疼痛、温度觉不同程度恢复。随访12个月以上者单丝触觉、振动、疼痛、温度觉堪本均匀恢复,仅1例的1个区域内可测到25 mm的静态两点辨別觉。2例同时行骨韧带复合体重建的患者踝关节活动略受限患足均可穿鞋无痛行走。末次随访时AOFAS踝-后足评分78~97分[(86.4±7.4)分],较术前的10~70分[(44.2±18.4)分]显著提高(P<0.01)。供区无疼痛,残留略增宽的线性瘢痕.结论对于足踝部中等大小的软组织缺损,采用带肋下神经外侧皮支旋髂浅动脉穿支削薄皮瓣修复,皮瓣可适当削薄,术后外形可,感觉恢复可靠;患足可穿普通鞋,无痛行走,功能恢复良好;供区副损伤小。

Objective To investigate1 the efficacy of free thin sensate superficial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve for repair of soft tissue defect in the foot and ankle.Methods A retrospective case series study was made on clinical data of 9 patients with soft tissue defect in the loot and ankle admitted to 80th Group Military Hospital from December 2017 to December 2019.There were 8 males and 1 females,with the age of 28-63 years[(47.3±12.3)years]and the body mass index(BMI)of 16.7-27.8 kg/m^(2)[(23.9±3.9)kg/m^(2)].The size of soft tissue defect ranged from 10 cm ×6 cm to 20 cm × 12 cm.All patients were treated with the free thin sensate superfic ial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve.After debridement or tumor resection,a thin sensate flap was harvested by intraadipose tissue dissection between the superficial and deep fat layers.The size of flap ranged from 13 cm ×8 cm and 13 cm× 10 cm.The thickness of the defatted flap ranged from 3-6 ram.The distance from the anterosuperior iliac spine to the point where the lateral cutaneous branch of the subcostal nerve crossed the iliac crest ranged from 7.5-10.0 cm.The flap survival,complications,and reoperation were observed after operation.The sensory recovery of the flap was evaluated using Tinel sign and nine-grid method including monofilament touch perception,vibration j^rception,pinprick perception,temperature perception,and static two-point discrimination test.The joint range of motion,and shoewear and walking problems were recorded.At the last follow-up,the American Orthopedic Foot and Ankle Society(AOFAS)ankle-hindfoot score was used to assess the affected foot and ankle.The injury at ihe donor site was detected as well.Results All palients were followed up for 6-35 months[(21.1±10.1)months].All flaps survived without infection or tumor reoccurrence.One patient developed ulceration,then surplus skin on the reconstructed heel was resected.One patient underwent flap debulking and removal of internal fixation.One or more sensory modalities within the nine areas in each flap could he detected at postoperative 3-6 months.The monofilament touch,vibration,pinprick,and temperature perception were presented in almost all regions of each flap at postoperative 12 months.However,only one patient in one region was noted with the static two-point discrimination,in which the distance of the two points was set as 25 mm.The range of ankle motion was slightly limited in 2 patients who underwent osseoligamentous complex reconstruction.All patients were able to wear normal shoes and walk without pain.At the last follow-up,the AOFAS ankle-hindfoot score ranged from 78 to 97 points[(86.4±7.4)points],significantly improved from preoperative 10-70 points[(44.2±18.4)points](P<0.01).No patients complained of pain at the donor site,but the widening linear scar was noted.Conclusion For medium-sized soft tissue defect of the foot and ankle,the free thin sensate superficial circumflex iliac artery perforator flap based on lateral cutaneous branch of the subcostal nerve can he defatted with the requirement and has advantages in defect site appearance,sensory restoration,wearing ordinary shoes,painless walking,good functional recovery,and minimal donor site morbidity.