游离旋股外侧动脉降支组织瓣修复Wagner 3级或4级糖尿病足创面的临床效果

Clinical effects of free descending branch tissue flap of lateral circumflex femoral artery in repairing Wagner grade 3 or 4 diabetic foot wounds

目的探讨游离旋股外侧动脉降支组织瓣修复Wagner 3级或4级糖尿病足创面的临床效果。方法采用回顾性观察性研究方法。2019年10月—2022年1月, 玉林市第一人民医院收治12例符合入选标准的糖尿病足创面患者, 其中男10例、女2例;年龄38~66岁, 平均52岁;Wagner 3级者5例、Wagner 4级者7例。对创面行清创+负压封闭引流控制感染, 清创后创面面积为13 cm×6 cm~28 cm×11 cm。然后采用旋股外侧动脉降支组织瓣游离移植修复创面, 其中采用旋股外侧动脉降支肌皮支或肌间隙支单块皮瓣修复者4例、分叶皮瓣修复者1例、双侧皮瓣串联修复者1例、嵌合股外侧肌肌瓣修复者6例, 组织瓣切取面积为9 cm×7 cm~21 cm×10 cm;供受区血管吻合方式均为端端吻合, 必要时进行增压处理。对10例患者的供区创面行美容减张缝合, 对2例患者供区创面采用头部刃厚皮修复。术后, 记录创面修复情况。于创面愈合后, 检测患者餐后2 h血糖水平。随访时, 观察供区创面愈合情况与受区瘢痕形成情况。术前及术后6个月, 采用CT血管造影检测患肢血流灌注情况并进行对比。末次随访时, 记录患者行走能力情况。结果 9例患者术后创面愈合良好;2例患者受区皮瓣在术后第5天发生感染, 对创面行敞开引流、控制炎症后进行Ⅱ期缝合修复;1例患者移植的串联皮瓣远端于术后第4天逐渐出现组织变紫样坏死, 清创后行植皮修复。创面愈合后, 所有患者的餐后2 h血糖值均控制在8~12 mmol/L。随访6个月~1年, 3例患者足底受压区出现局部破溃, 经减压+换药或移植皮瓣修复后愈合, 其余9例患者受区未出现破溃;患足创面愈合后, 局部外观饱满, 移植皮瓣血运良好, 与周围组织契合良好, 耐磨, 但感觉迟钝。随访期间, 10例患者行直接缝合的供区仅遗留线性瘢痕;2例患者行植皮修复的供区皮片完全成活。与术前患肢足踝关节段主干血管通畅相比, 术后6个月患足皮瓣移植区血管网形成。末次随访时, 8例患者能自主行走, 4例患者能拄拐行走。结论采用游离旋股外侧动脉降支组织瓣修复Wagner 3级或4级糖尿病足创面能缩短病程、改善局部血流, 效果良好。

Objective To investigate the clinical effects of free descending branch tissue flap of lateral circumflex femoral artery in repairing Wagner grade 3 or 4 diabetic foot wounds.Methods A retrospective observational study was conducted.From October 2019 to January 2022,12 patients(10 males and 2 females,aged 38-66 years,with an average of 52 years)with diabetic foot wounds who met the inclusion criteria were admitted to the First People's Hospital of Yulin,of whom 5 cases being Wagner grade 3 and 7 cases being Wagner grade 4.Wound debridement and vacuum sealing drainage were performed to control infection,and the wound area after debridement was between 13 cm×6 cm and 28 cm×11 cm.The wounds were repaired with free descending branch tissue flaps of lateral circumflex femoral artery.Among them,the wounds of 4 cases were repaired with single flap of musculocutaneous branch or intermuscular branch of descending branch tissue flap of lateral circumflex femoral artery,1 case with lobulated flap,1 case with bilateral tandem flap,and 6 cases with chimeric lateral femoral muscle flap.The area of resected tissue flap was 9 cm×7 cm to 21 cm×10 cm;end-to-end anastomosis was selected between vessels in the donor sites and the recipient sites,and pressurized treatment should be performed if necessary.The donor site wounds of 10 patients were treated with cosmetic tension-relieving suture,and the donor site wounds of 2 patients were repaired with split-thickness skin graft from head.After operation,the condition of wound repair was recorded.After wound healing,the level of 2-hour postprandial blood glucose of patients was measured.During follow-up,the wound healing of the recipient site and scar formation of the donor site were observed.Before and 6 months after operation,computer tomography angiography was used to detect and compare the blood perfusion of the affected limb.At the last follow-up,the walking ability of the patients was recorded.Results The wounds of 9 patients healed well after operation;the flaps in the recipient site of 2 patients were infected on postoperative day 5 after surgery and were repaired by suturing in stageⅡafter open drainage and inflammation control;the distal end of the grafted tandem flap in 1 patient gradually developed purple necrosis on postoperative day 4 and was repaired with a skin graft after debridement.After wound healing,the 2-hour postprandial blood glucose value of all patients was controlled in the range of 8-12 mmol/L.During Follow-up of 6 months to 1 year,3 patients had partial ulceration in the plantar compression area,which healed after decompression combined with dressing change or flap repair,while the other 9 patients had no ulceration in the recipient area;the appearance of the affected foot was plump after wound healing,the transplanted flaps had good blood supply and good fit with the surrounding tissue,and were wear-resistant,but insensitive.During follow-up,only linear scar remained in the donor area of direct suture in 10 cases,and the skin grafts in the donor area were completely survived in 2 cases.Compared with the patency of the main blood vessels of the ankle joint segment of the affected limb before operation,the vascular network of the flap transplantation area in the affected foot was formed 6 months after operation.At the last follow-up,8 patients could walk independently,and 4 patients could walk with crutches.Conclusions The free descending branch tissue flap of lateral circumflex femoral artery is effective in repairing Wagner grade 3 or 4 diabetic foot wounds,which can shorten the course of disease and improve local blood flow.