吻合高位穿支的内增压大面积游离股前外侧皮瓣修复四肢大面积软组织缺损6例

Turbocharged large free anterolateral thigh flap by anastomosing a superior perforator of the flap in reconstruction of large soft tissue defect of limbs:a report of 6 cases

目的:探讨吻合高位穿支的内增压大面积游离股前外侧皮瓣(ALTF)修复四肢大面积软组织缺损的临床应用效果。方法:2017年6月-2021年6月,青岛大学附属医院手足外科共收治四肢大面积软组织缺损伴骨关节、肌腱外露的患者6例,均应用吻合高位穿支的内增压大面积游离ALTF修复。其中男4例,女2例,年龄32~60(46.0±8.1)岁,损伤原因:5例交通事故损伤,1例机器挤压伤。4例下肢软组织缺损中,2例伴开放性胫、腓骨骨折,1例伴髌骨缺损及腓骨骨折,1例伴腓骨骨折;2例上肢软组织缺损均伴骨和肌腱外露,无骨折;创面面积为25.0 cm×12.0 cm~35.0 cm×19.0 cm。一期行VSD处理,二期采用游离ALTF覆盖创面,采用吻合高位穿支的方式来增大皮瓣切取面积,皮瓣面积为26.0 cm×13.0 cm~36.0 cm×15.0 cm。6例供区直接拉拢缝合缩小创面,剩余创面游离皮片植皮覆盖。术后1、2、3、6个月门诊复查,随后门诊、电话或微信随访。根据皮瓣外观、质地、感觉恢复评价手术效果。结果:6例皮瓣全部成活,术后无皮瓣近端部分坏死。随访6~24(16.7±5.0)个月,皮瓣外观、质地满意,无磨损破溃。皮瓣感觉按照英国医学研究会(BMRC)评定标准,4例恢复到S 3,2例恢复到S 2。2例上肢损伤患者术后肘关节Mayo功能评分为良;4例下肢损伤患者术后膝关节按照美国特种外科医院(HSS)功能评分,3例为优,1例为良,按照美国足踝外科学会(AOFAS)踝-后足功能评分,2例为优,2例为良。供区均无感染,无功能缺失。结论:游离ALTF穿支较恒定,皮瓣修复时可重建部分感觉,利用吻合高位穿支的方式增大皮瓣切取面积,穿支血管可靠,是四肢大面积软组织缺损较好的修复方式。

Objective To investigate the clinical effect of turbocharged large free anterolateral thigh flaps(ALTF)by anastomosis with a superior perforator of the flap in reconstruction of large soft tissue defects of limbs.Methods From June 2017 to June 2021,6 patients with large soft tissue defects of limbs with exposed joints and tendons were treated in the Department of Hand and Foot Surgery of the Affiliated Hospital of Qingdao University with turbocharged large free ALTFs.The pressurised blood supply of ALTF was achieved by anastomosing a superior perforating branch carried in the flap.Such large and turbocharged ALTFs were used to repair large soft tissue defects with exposed joints and tendons in limbs.Of the 6 patients,there were 4 males and 2 females,and aged 32-60(46.0±8.1)years old.Cause of injury:5 by traffic accident and 1 by machine crush.Four patients had soft tissue defects in lower limbs:2 with open tibia and fibula fractures,1 had patellar defect and fibula fracture,and 1 associated with fibula fracture.The other 2 patients had soft tissue defect in upper limbs with bone and tendon exposed but without fracture.The sizes of wound were 25.0 cm×12.0 cm-35.0 cm×19.0 cm.In the primary surgery,Vacuum sealing drainage(VSD)was applied.In the second stage,free ALTFs were used to cover the wound.The area of flap incision was increased by anastomosing the superior perforators and as the consequence,the size of flaps was achieved to 26.0 cm×13.0 cm-36.0 cm×15.0 cm.Donor site of 6 cases were reduced by direct suture,and the remaining wound was covered by free skin graft.Postoperative follow-ups were conducted at outpatient clinic reviews at 1,2,3 and 6 months after surgery,and followed by telephone or WeChat interviews.The results of the operation were evaluated according to the appearance,texture and sensory recovery of the flap.Results All 6 flaps survived and the patients completed the postoperative follow-up that lasted for 6-24(16.7±5.0)months.No necrosis of flap occurred after surgery.The appearance and texture of the flaps were satisfactory without wear and tear.Sensation recover was evaluated by the standered of British Medical Research Council(BMRC),4 patients recovered to S3 and 2 patients to S2.The Mayo score of the elbow joint was good in 2 patient with upper extremity injuries.Of the other 4 patients with lower limb injuries,the knee function evalued by Hospital for Special Surgery(HSS)score were excellent in 3 patients and good in 1 patient,and the American Orthopedic Foot and Ankle Societ(AOFAS)ankle-hind foot function score was excellent in 2 patients and good in 2 patients.There was no infection or function loss at all donor sites.Conclusion The perforator of an ALTF is relatively constant,and the flap can partially restore sensation.The superior perforator is reliable and the incision area of the flap can be enlarged by anastomosing the superior perforator vessels.It is a better way to reconstruct a large soft tissue defects in limbs.