增强现实技术在胫后动脉穿支皮瓣修复下肢软组织缺损中的应用

Application of augmented reality technique in repairing soft tissue defects of lower limbs with posterior tibial artery perforator flap

目的 探讨胫后动脉穿支皮瓣修复下肢软组织缺损术中,采用增强现实(augmented reality,AR)技术定位胫后动脉穿支血管的准确性。方法 2019年6月—2022年6月,采用胫后动脉穿支皮瓣修复10例足踝周围皮肤软组织缺损。男7例,女3例;年龄33~69岁,平均53.7岁。致伤原因:交通事故伤5例,重物压伤4例,机器伤1例。创面范围5 cm×3 cm~14 cm×7 cm。受伤至皮瓣修复手术时间为7~24 d,平均12.8 d。术前行下肢CT血管造影,将获得的数据以Mimics软件构建穿支血管、骨骼三维图像;术中运用AR技术将上述图像投影叠加至患肢体表,实施精准定位下的皮瓣设计和切取。皮瓣切取范围6 cm×4 cm~15 cm×8 cm。供区直接拉拢缝合或植皮修复。结果 术前AR定位10例患者胫后动脉穿支1~4支,平均3.4支;术中穿支血管定位位置与术前AR技术定位基本一致,两者距离0~16 mm,平均12.2 mm。按照术前设计顺利切取皮瓣并完成创面修复。术后9例皮瓣顺利成活,无血管危象发生;2例供区植皮局部感染,1例皮瓣远端边缘坏死,经换药后愈合;其余植皮均成活,切口均Ⅰ期愈合。患者均获随访,随访时间6~12个月,平均10.3个月。皮瓣质地柔软,无明显瘢痕增生及挛缩发生。末次随访时,踝关节功能根据美国矫形足踝协会(AOFAS)评分,达优8例、良1例、差1例。结论 在胫后动脉穿支皮瓣术前规划中可应用AR技术确定穿支血管位置,降低皮瓣坏死风险,手术操作简便。

Objective To investigate the accuracy and reliability of augmented reality(AR) technique in locating the perforating vessels of the posterior tibial artery during the repair of soft tissue defects of the lower limbs with the posterior tibial artery perforator flap. Methods Between June 2019 and June 2022, the posterior tibial artery perforator flap was used to repair the skin and soft tissue defects around the ankle in 10 cases. There were 7 males and 3 females with an average age of 53.7 years(mean, 33-69 years). The injury was caused by traffic accident in 5 cases, bruising by heavy weight in 4 cases, and machine injury in 1 case. The size of wound ranged from 5 cm×3 cm to 14 cm×7 cm. The interval between injury and operation was 7-24 days(mean, 12.8 days). The CT angiography of lower limbs before operation was performed and the data was used to reconstruct the three-dimensional images of perforating vessels and bones with Mimics software. The above images were projected and superimposed on the surface of the affected limb using AR technology, and the skin flap was designed and resected with precise positioning. The size of the flap ranged from 6 cm×4 cm to 15 cm×8 cm. The donor site was sutured directly or repaired with skin graft. Results The 1-4 perforator branches of posterior tibial artery(mean, 3.4 perforator branches) in 10 patients were located by AR technique before operation. The location of perforator vessels during operation was basically consistent with that of AR before operation.The distance between the two locations ranged from 0 to 16 mm, with an average of 12.2 mm. The flap was successfully harvested and repaired according to the preoperative design. Nine flaps survived without vascular crisis. The local infection of skin graft occurred in 2 cases and the necrosis of the distal edge of the flap in 1 case, which healed after dressing change. The other skin grafts survived, and the incisions healed by first intention. All patients were followed up 6-12 months, with an average of 10.3 months. The flap was soft without obvious scar hyperplasia and contracture. At last follow-up, according to the American Orthopedic Foot and Ankle Association(AOFAS) score, the ankle function was excellent in 8 cases, good in 1 case, and poor in 1 case. Conclusion AR technique can be used to determine the location of perforator vessels in the preoperative planning of the posterior tibial artery perforator flap, which can reduce the risk of flap necrosis, and the operation is simple.