游离腓浅动脉穿支皮瓣修复拇趾皮肤软组织缺损的临床效果

Clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux

目的探讨游离腓浅动脉穿支皮瓣修复拇趾皮肤软组织缺损的临床效果。方法采用回顾性观察性研究方法。2020年1月—2021年1月,苏州大学附属瑞华医院足踝外科收治13例符合入选标准的拇趾皮肤软组织缺损患者,其中男12例、女1例,年龄16~53岁。术前于患趾同侧小腿行彩色多普勒超声定位腓浅动脉穿支穿出点并于体表标记。手术于脊椎麻醉+连续硬膜外麻醉下进行,扩创后皮肤软组织缺损面积为4.5 cm×2.5 cm~12.0 cm×3.0 cm。根据创面的大小、形状,以腓骨小头与外踝尖连线向胫侧平移2 cm为皮瓣轴心线,以轴心线中点附近穿支穿出点为中心,设计腓浅动脉穿支皮瓣。皮瓣切取面积为5.0 cm×3.0 cm~13.0 cm×4.0 cm,游离蒂部时切取部分深筋膜。供区创面直接缝合。术中记录穿支数目、类型及皮瓣切取时间,测量穿支血管蒂长度及穿支直径。术后记录皮瓣成活情况、供受区愈合时间及愈合情况。随访记录皮瓣的色泽、质地、弹性,患者站立及行走功能,供区恢复情况以及患者对供受区恢复情况的满意度。末次随访,采用英国医学研究会感觉功能评定标准评定皮瓣感觉,采用美国足踝外科学会评分系统评价患肢功能并计算优良率。结果术中共探及腓浅动脉穿支13条,均为肌间隔穿支,穿支直径0.3~0.5 mm;血管蒂长度2~5 cm。皮瓣切取时间11~26 min。13例患者术后皮瓣均完全成活。术后9~18 d,供受区创面均愈合良好。随访6~14个月,皮瓣色泽、质地、弹性良好;11例患者外形无明显臃肿,另外2例患者因外观臃肿,Ⅱ期行皮瓣修薄整形;所有患者均恢复正常行走、站立功能;供区仅遗留一条线状瘢痕,无明显瘢痕增生或色素沉着;所有患者对供受区恢复情况表示满意。末次随访,皮瓣感觉功能评定为S3级者2例、S2级者9例、S1级者2例;患肢功能评定为优者7例、良者6例,优良率为100%。结论游离腓浅动脉穿支皮瓣血管解剖较为恒定,皮瓣薄且耐磨,皮瓣切取后供区损伤小,可以最大限度保留拇趾外形及功能,是一种修复拇趾皮肤软组织缺损的有效方法。

Objective To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux.Methods A retrospective observational study was conducted.From January 2020 to January 2021,13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University,including 12 males and 1 female,aged 26 to 53 years.Before operation,the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface.The operation was performed under spinal anesthesia combined with continuous epidural anesthesia.The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm.According to the size and shape of the wound,the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line,and the perforating point of the perforator near the midpoint of the axis line as the center.The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm,and part of the deep fascia was cut when the pedicle was freed.The donor site wound was sutured directly.During the operation,the number and type of the perforator and the cutting time of the flap were recorded,and the length of the perforator pedicle and diameter of the perforator were measured.The survival of the flap,the healing time and the healing condition of the donor and recipient areas were recorded after operation.The color,texture,elasticity of the flap,standing and walking functions of patients,the recovery of the donor area,and the patients'satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up.At the last follow-up,the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard,the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system,and the excellent and good rate of the function of the affected limb was calculated.Results A total of 13 perforators of the superficial peroneal artery were detected during the operation,all of which were septocutaneous perforators,and the perforator diameter was 0.3 to 0.5 mm.The vascular pedicle length was 2 to 5 cm.Flap cutting time was 11 to 26 minutes.The flaps of 13 patients all survived completely.The wounds at the donor and recipient sites healed well 9 to 18 days after operation.During follow-up of 6 to 14 months,the flaps had good color,texture,and elasticity;11 patients had no obvious bloated appearance,and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance;all the patients returned to normal walking and standing functions.There was only one linear scar left in the donor site,with no obvious scar hyperplasia or hyperpigmentation.All the patients were satisfied with the recovery of the donor and recipient areas.At the last follow-up,the sensation of the flap was evaluated as grade S3 in 2 cases,grade S2 in 9 cases,and grade S1 in 2 cases;the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases,with an excellent and good rate of 100%.Conclusions The free superficial peroneal artery perforator flap has relatively constant vascular anatomy,which is thin and wear-resistant,with less damage to the donor site after flap excision,and can preserve the shape and function of the hallux to the greatest extent.It is an effective method for repairing skin and soft tissue defect of the hallux.