彩色多普勒超声辅助下超薄胸背动脉穿支皮瓣的切取方案及临床应用效果

Cutting scheme and clinical application effects of ultrathin thoracodorsal artery perforator flap assisted by color Doppler ultrasound

目的探讨彩色多普勒超声辅助下超薄胸背动脉穿支皮瓣的切取方案及临床应用效果。方法该研究为回顾性历史对照研究。将2017年2月—2019年10月华北医疗健康集团邢台总医院骨三科(以下简称本科室)收治的20例符合入选标准且采用根据术者临床经验设计、切取的超薄胸背动脉穿支皮瓣修复四肢皮肤软组织缺损的患者作为对照组,其中男16例、女4例,年龄(37±5)岁;将2019年11月—2022年12月本科室收治的21例符合入选标准且采用在彩色多普勒超声辅助下设计、切取的超薄胸背动脉穿支皮瓣修复四肢皮肤软组织缺损的患者作为超声辅助组,其中男15例、女6例,年龄(38±6)岁。清创后,四肢皮肤软组织缺损范围5.0 cm×4.0 cm~19.0 cm×8.0 cm,胸背动脉穿支皮瓣面积为6.0 cm×5.0 cm~20.0 cm×9.0 cm。将供瓣区创面直接拉拢缝合。统计超声辅助组患者彩色多普勒超声检查耗时、费用,比较术前彩色多普勒超声探查到的胸背动脉穿支血管数量、类型、位置和术中实际探查情况是否一致。记录2组患者皮瓣完整切取耗时。术后1、3、5、7、14 d,采用皮瓣血运评估量表评估2组患者皮瓣血运情况。术后14 d,观察2组患者皮瓣成活情况并计算皮瓣成活面积百分比。术后6个月,采用利克特5级量表评估2组患者对治疗效果的满意度并计算满意率。结果超声辅助组患者术前彩色多普勒超声检查耗时为(10.5±2.3)min、费用为120元;术前通过彩色多普勒超声探查并标记出21条胸背动脉穿支血管,其中8条(38.10%)1型穿支血管,10条(47.62%)2型穿支血管和3条(14.29%)3型穿支血管,术前探查到的胸背动脉穿支血管数量、类型、位置与术中探查情况一致。超声辅助组患者皮瓣完整切取耗时(41±10)min,明显短于对照组的(63±12)min(t=6.32,P<0.05)。术后1、3、5、7、14 d,超声辅助组患者皮瓣血运评分均明显优于对照组(t值分别为6.67、7.48、8.03、8.75、7.99,P<0.05)。术后14 d,超声辅助组仅1例患者皮瓣部分坏死,对照组6例患者皮瓣全部或部分坏死;超声辅助组患者皮瓣成活面积百分比为(99±8)%,明显高于对照组的(87±8)%(t=4.57,P<0.05)。术后6个月,2组患者对治疗效果的满意率无明显差异(P>0.05)。结论术前行彩色多普勒超声探测穿支血管的数量、类型及位置等的准确率高;根据不同穿支血管类型设计超薄胸背动脉穿支皮瓣切取方案,能缩短手术时间,提高皮瓣的成活率。

Objective To explore the cutting scheme and clinical application effects of ultrathin thoracodorsal artery perforator flap assisted by color Doppler ultrasound.Methods This study was a retrospective historical control study.From February 2017 to October 2019,20 patients who were admitted to the Third Department of Orthopedics of Xingtai General Hospital of North China Medical and Health Group(hereinafter referred to as our department),met the inclusion criteria,and underwent repair of skin and soft tissue defects of extremities with ultrathin thoracodorsal artery perforator flap designed and harvested based on the surgeon's clinical experience were selected as control group,including 16 males and 4 females,aged(37±5)years.From November 2019 to December 2022,21 patients who were admitted to our department,met the inclusion criteria,and underwent repair of skin and soft tissue defects of extremities with ultrathin thoracodorsal artery perforator flap designed and harvested under the assistance of color Doppler ultrasound were selected as ultrasound-assisted group,including 15 males and 6 females,aged(38±6)years.After debridement,the area of skin and soft tissue defects of extremities ranged 5.0 cm×4.0 cm to 19.0 cm×8.0 cm,and the area of thoracodorsal artery perforator flaps ranged 6.0 cm×5.0 cm to 20.0 cm×9.0 cm.The wounds in flap donor sites were closed directly.For patients in ultrasound-assisted group,the time and cost required for color Doppler ultrasound examination were recorded,and the number,type,and location of thoracodorsal artery perforator vessels detected by preoperative color Doppler ultrasound were compared with those of intraoperative actual detection.The time required for complete flap harvest of patients in 2 groups was recorded.On postoperative day(POD)1,3,5,7,and 14,the blood perfusion of flaps in the 2 groups of patients was assessed using a flap perfusion assessment scale.On POD 14,flap survival of patients in 2 groups was observed,and the percentage of flap survival area was calculated.In postoperative 6 months,satisfaction of patients with the treatment outcome in the 2 groups was assessed using 5-grade Likert scale,and the satisfaction rate was calculated.Results For patients in ultrasound-assisted group,the time required for preoperative color Doppler ultrasound examination was(10.5±2.3)min,and the cost was 120 yuan;21 thoracodorsal artery perforator vessels were detected and marked using preoperative color Doppler ultrasound,including 8(38.10%)type 1 perforator vessels,10(47.62%)type 2 perforator vessels,and 3(14.29%)type 3 perforator vessels;the number,type,and location of thoracodorsal artery perforator vessels detected preoperatively were consistent with those detected intraoperatively.The time required for complete flap harvest of patients in ultrasound-assisted group was(41±10)min,which was significantly shorter than(63±12)min in control group(t=6.32,P<0.05).On POD 1,3,5,7,and 14,the blood perfusion scores of flaps of patients in ultrasound-assisted group were significantly better than those in control group(with t values of 6.67,7.48,8.03,8.75,and 7.99,respectively P<0.05).On POD 14,only one patient in ultrasound-assisted group had partial flap necrosis and 6 patients in control group had complete or partial necrosis of the flap;the percentage of flap survival area of patients in ultrasound-assisted group was(99±8)%,which was significantly higher than(87±8)%in control group(t=4.57,P<0.05).In postoperative 6 months,there was no significant difference in the satisfaction rate of patients with the treatment outcome between the two groups(P>0.05).Conclusions Preoperative color Doppler ultrasound is highly accurate in detecting the number,type,and location of perforator vessels.The cutting scheme of ultrathin thoracodorsal artery perforator flaps can be designed according to the different types of perforator vessels,with shorted flap cutting time and improved flap survival rate.