带阔筋膜血流桥接型股前外侧穿支皮瓣修复伴伸肌腱缺损的手、足背侧创面

Flow-through anterolateral thigh perforator flap with fascia lata for repairing dorsal wounds of the hand and foot with extensor tendon defects

目的探讨带阔筋膜血流桥接型股前外侧穿支皮瓣修复伴伸肌腱缺损的手、足背侧创面的疗效。方法采用回顾性病例系列研究分析2015年1月至2019年12月苏州大学附属瑞华医院收治的14例伴伸肌腱缺损的手、足背侧创面患者临床资料,其中男13例,女1例;年龄10~57岁[(39.2±13.4)岁]。手背部创面8例,足背创面6例。均为单个创面,创面面积为10 cm×4 cm~23 cm×12 cm。1例肌腱缺损1条,10例肌腱缺损4条,3例肌腱缺损5条,肌腱缺损长度为2.0~6.0 cm[(3.8±1.4)cm]。均切取带阔筋膜的股前外侧穿支皮瓣,皮瓣切取面积为12 cm×5 cm~23 cm×13 cm,血管蒂以血流桥接方式吻合至受区,阔筋膜切取面积为11 cm×5 cm~20 cm×7 cm,修整后同期修复缺损伸肌腱。11例为单叶皮瓣,3例设计为双叶皮瓣,所有供区直接缝合。观察皮瓣成活情况和供区愈合情况。末次随访时评估受区肢体末端血运、皮瓣外形及感觉恢复情况。术前及末次随访时采用中华医学会手外科学会上肢部分功能评定试用标准及Maryland足部功能评分评价手足功能。记录供区并发症及是否行Ⅱ期松解或皮瓣修薄术。结果患者均获随访8~30个月[(15.3±6.2)个月]。本组14例皮瓣均顺利成活,皮瓣周缘及大腿供区均Ⅰ期愈合。末次随访时受区肢体末梢血运无影响,皮瓣色泽质地良好,温、痛、触觉部分恢复。末次随访时修复手背创面者,见伸指功能存在,手指屈曲活动无明显受限,伤指总主动活动度为180°~250°[(226.3±21.7)°],较术前110°~170°[(145.6±13.2)°]明显改善(P<0.01)。依据中华医学会手外科学会上肢部分功能评定试用标准,优4例,良2例,可2例。修复足背创面者,踝关节伸屈功能良好,足趾无明显下垂畸形,末次随访时Maryland足部功能评分为60~92分[(76.0±12.7)分],较术前18~45分[(27.4±7.8)分]明显增加(P<0.01),优2例,良3例,中1例。大腿供区仅遗留线性瘢痕,无瘢痕挛缩或疼痛等不适。14例患者均未行Ⅱ期肌腱松解,其中4例因皮瓣外形臃肿于术后4~8个月行修薄术。结论带阔筋膜血流桥接型股前外侧皮瓣修复伴肌腱缺损的手、足背侧创面,可减少对受区血供干扰,在覆盖创面的同时修复伸肌腱缺损,伸屈功能恢复良好,供区损伤小。

Objective To investigate the clinical effect of flow-through anterolateral thigh perforator flap with fascia lata for repairing dorsal wounds of the hand and foot with extensor tendon defects.Methods A retrospective case series study was conducted to analyze the clinical date of 14 patients with hand and foot wounds associated with extensor tendon defects admitted to Kuihua Affiliated Hospital of Soochow University from January 2015 to December 2019.There were 13 males and 1 fem ale,aged 10-57 years[(39.2±13.4)years].The wounds were all single with the area of 10 cm×4 cm~23 cm×12 cm cm,including 8 wounds on the back of the hand and 6 wounds on the back of the foot.There was 1 patient accompanied with 1 tendon defect,10 with 4 tendon defects and 3 with 5 tendon defects,with the length of tendon defects ranging from 2.0 to 6.0 cm[(3.8±1.4)cm].The dimension of flaps ranged from 12 cm×5 cm to 23 cm×13 cm,with the fascia lata from 11 cm×5 cm to 20 cm×7 cm.The deficient extensor tendons were repaired with the fascia lata and vascular pedicles were anastomosed by flow-though.A bilobed flap was harvested in 3 patients and a single flap in 11 patients.Donor sites were sutured directly.The survival of the flap and healing of the donor area were detected after operation.The extremity revascularization and shape and sensation recovery of the flap were measured at the last follow-up.The upper extremity functional evaluation standard set up by Hand Surgery Society of the Chinese Medical Association and Maryland foot functional score were used to evaluate the hand and foot function before operation and at the cast follow-up,respectively.The donor site complications and performance of tendon release or flap thinning in the second stage were recorded.Results All patients were followed up for 8-30 months[(15.3±6.2)months].All flaps survived successfully,with wounds and thigh donor areas healed by first intension.No significant effect of revascularization was observed on recipient sites,and acceptable cosmetic outcomes and sensation recovery of the flap were achieved at the final follow-up.For patients with dorsal wounds of the hand,the extensor function recovered in different degrees,and the flexion activities of the fingers were not limited.The total active movement was 180°-250°[(226.3±21.7)°]at the last follow-up,compared to preoperative 110°-170°[(145.6±13.2)°](P<0.01).According to the upper extremity functional evaluation standard,the function was excellent in 4 patients,good in 2 and fair in 2.For patients with wounds of the foot,the flexion and extension function was good,with no obvious deformity of toes,and the Maryland foot functional score ranged from 60 to 92 points[(76.0±12.7)points]at the last follow-up,significantly improved from preoperative 18-45 points[(27.4±7.8)points](P<0.01),including excellent results in 2 patients,good n 3 and fair in 1.Only linear scars were left in the thigh donor area,and there was no discomfort such as scar contracture or pain.Four patients underwent skin flap thinning at 4-8 months after operation and none underwent a tenolysis.Conclusion Repair of dorsal wounds with extensor tendon defects of the hand and foot by flow-through anterolateral thigh perforator flap with fascia lata can reduce interference to recipient sites and repair wounds and extensor tendons simultaneously,which can obtain good flexion and extension function and minor damage to the donor area.