带阔筋膜游离股前外侧皮瓣修复糖尿病足溃疡伴骨外露

Application of free anterolateral thigh flap with fascia lata for diabetic foot ulcers with bone exposure

目的探讨带阔筋膜游离股前外侧皮瓣(anterolateral thigh flap,ALTF)修复糖尿病足溃疡(diabetic foot ulcers,DFUs)伴骨外露的疗效。方法2019年1月—2021年1月,收治20例DFUs伴骨外露患者。男17例,女3例;年龄48~76岁,中位年龄57.5岁。糖尿病足Wagner分级3级10例,4级10例。足部溃疡形成时间1~14个月,中位时间3个月。CT血管造影检查示患者均存在双下肢动脉粥样硬化表现;其中6例严重狭窄或闭塞,行经皮血管腔内成形术。入院后一期彻底清创联合封闭式负压引流处理,清创后创面范围为7 cm×6 cm~27 cm×10 cm;二期采用带阔筋膜游离ALTF修复创面及部分缺损肌腱,皮瓣切取范围为8 cm×5 cm~28 cm×11 cm。供区创面直接缝合。记录皮瓣成活情况、创面愈合时间以及并发症发生情况。术后2周及6个月使用激光散斑血流成像系统检测皮瓣及其周围皮肤血流灌注情况。术后6个月以美国矫形足踝协会(AOFAS)评分评价足部功能。结果术后6例出现皮瓣下积液,对症处理后愈合。最终14例皮瓣完全成活;3例皮瓣边缘部分坏死,经换药后愈合;3例皮瓣出现静脉危象,探查后1例皮瓣完全坏死,另2例皮瓣部分成活,经清创换药后植皮修复。皮瓣成活率95.0%,保肢率100%。皮瓣移植术后创面愈合时间14~30 d,平均19.1 d。2例患者愈合后1个月内再发皮瓣外周皮肤溃疡,经换药后愈合。供区切口18例Ⅰ期愈合;2例局部皮肤坏死,经清创缝合后愈合。患者均获随访,随访时间6~30个月,中位时间11个月。皮瓣质地、外观及弹性良好。患者均能独自行走,无行走时疼痛。术后6个月13例门诊随访患者AOFAS评分为(75.9±11.9)分,与术前(44.7±18.4)分比较差异有统计学意义(t=-7.025,P=0.000);患者皮瓣外周正常皮肤血流灌注值由术后2周(38.1±7.8)PU升高至(42.7±10.3)PU,差异有统计学意义(t=-4.680,P=0.001)。结论带阔筋膜ALTF血供丰富、成活率高,可用于修复DFUs伴骨外露创面。皮瓣愈合后可促进患足血运重建,降低溃疡复发风险,避免截肢。

Objective To investigate the effectiveness of free anterolateral thigh flap(ALTF)with fascia lata in repairing diabetic foot ulcers(DFUs)with bone exposure.Methods Between January 2019 and January 2021,20 patients with DFUs with bone exposure were admitted.There were 17 males and 3 females with a median age of 57.5 years(range,48-76 years).There were 10 cases of Wagner grade 3 and 10 cases of grade 4.The DFUs formed 1 to 14 months,with a median time of 3 months.The patients underwent CT angiography,which showed extensive atherosclerosis in both lower limbs;6 of them were severely narrowed or occluded and underwent percutaneous transluminal angioplasty.The size of wound ranged from 7 cm×6 cm to 27 cm×10 cm after applied first-stage debridement combined with vacuum sealing drainage treatment.In the second-stage,free ALTF with fascia lata was used to repair wounds and partial defects of tendons.The size of flap ranged from 8 cm×5 cm to 28 cm×11 cm.The wound of the donor site was sutured directly.The survival of the flap,the healing time of the wound,and the complications were recorded.The laser speckle blood flow imaging system was used to detect the blood perfusion of the flap and the skin around the flap at 2 weeks and 6 months after operation.The foot function was evaluated by American Orthopaedic Foot and Ankle Society(AOFAS)score at6 months after operation.Results After operation,effusion under the flap happened in 6 cases,which cured after symptomatic treatment.Flaps survived completely in 14 cases.The tissue necrosis at the edges of the flaps occurred in3 cases and healed after dressing changes.Venous crisis of flaps occurred in 3 cases,of which 1 case was completely necrotic after exploration,and the other 2 cases were partially alive.The wounds of 3 cases were repaired with skin grafts after debridement and dressing.The flap survival rate was 95.0%,and the limb salvage rate was 100%.The wound healing time after flap transplantation was 14-30 days,with an average of 19.1 days.Two patients had recurrence of peripheral skin ulcers of the flaps within 1 month after healing,which healed after conservative dressing changes.Eighteen cases of incisions at donor site healed by first intention,2 cases had local skin necrosis and healed by debridement and suture.All patients were followed up 6-30 months,with a median time of 11 months.The texture,appearance,and elasticity of the flaps were good.All patients could walk alone without pain.At 6 months after operation,the AOFAS score was 75.9±11.9,which was significantly different from that(44.7±18.4)before operation(t=-7.025,P=0.000).The blood perfusion value increased from(38.1±7.8)PU at 2 weeks to(42.7±10.3)PU,and the difference was significant(t=-4.680,P=0.001).Conclusion Free ALTF with fascia lata has a rich blood supply and a high survival rate.It can be used to repair DFUs with bone exposure.After the free skin flap healed,it can promote revascularization of the affected foot,reduce the probability of ulcer recurrence,and avoid amputation.