三种皮瓣修复开放性踝关节骨折脱位软组织缺损

Three kinds of flaps for repairing soft tissue defect complicated with open ankle fracture dislocation

[目的]比较三种皮瓣修复开放性踝关节骨折脱位软组织缺损的临床效果。[方法]回顾性分析2015年1月—2021年2月本科收治的开放性踝关节骨折脱位51例患者的临床资料。根据医患沟通结果,29例采用胫后动脉穿支螺旋桨皮瓣组(perforating artery perforator flap, PAPF),15例采用腓动脉穿支-腓肠神经皮瓣组(sural neurocutaneous flap, SNCF),7例采用股前外侧游离皮瓣(anterolateral thigh flaps, ALTF)。比较三组围手术期及随访结果。[结果] ALTF组手术时间[(165.5±26.4) min vs (125.3±13.8) min vs (120.8±11.3) min, P<0.001]、皮瓣面积[(62.7±6.7) cm~2vs (55.3±6.4) cm2vs (54.9±8.2) cm~2, P=0.038]、术中失血量[(298.6±30.7) ml vs (238.9±38.9) ml vs (229.6±30.7) ml, P<0.001]均显著大于PAPF组和SNCF组,PAPF组和SNCF组差异无统计学意义(P>0.05)。三组患者与初次手术间隔时间、供区闭合形式、供区愈合情况、住院时间的差异均无统计学意义(P>0.05)。随访时间平均(14.7±2.0)个月。三组完全负重活动时间的差异无统计学意义(P>0.05)。术后随时间推移,三组VAS评分、踝背伸-跖屈ROM、AOFAS评分、供区瘢痕评分均显著改善(P<0.05),PAPF组受区感觉功能分级显著改善(P<0.05),而SNCF组和ALTF组无显著变化(P>0.05)。末次随访,PAPF组、 SNCF组的踝背伸-跖屈ROM均显著优于ALTF组[(62.1±5.1)°vs (61.7±6.2)°vs (54.9±5.3)°, P=0.010],PAPF组和ALTF组的受区感觉功能分级[优/良/可/差:(17/7/3/2) vs (4/1/1/1) vs(2/3/7/3), P=0.046]、供区瘢痕评分[(3.9±0.9) vs (4.2±1.3) vs (5.1±0.9), P<0.001]显著优于SNCF组。[结论] PAPF逆行皮瓣修复开放性踝关节骨折脱位术后皮肤缺损并发症少,皮瓣外观及感觉功能恢复满意度高。

[Objective] To compare the clinical outcomes of three kinds of flaps in repairing soft tissue defect complicated with open ankle joint fracture and dislocation. [Methods] A retrospective study was conducted on 51 patients who received surgical treatment for soft tissue defect complicated with open ankle fracture and dislocation in our department from January 2015 to February 2021. According to doctor-patient communication, 29 cases received perforating artery perforator flap(PAPF), 15 cases received sural neurocutaneous flap(SNCF), and 7 cased underwent anterolateral thigh flaps(ALTF). The documents of perioperative period and follow-up were compared among the three groups. [Results] The ALTF group proved significantly greater than the PAPF and SNCF in terms of operation time of[(165.5±26.4) min vs(125.3±13.8) min vs(120.8±11.3) min, P<0.001], flap area [(62.7±6.7) cm~2 vs(55.3±6.4) cm2vs(54.9±8.2) cm~2, P=0.038], intraoperative blood loss [(298.6±30.7) ml vs(238.9±38.9) ml vs(229.6±30.7) ml, P<0.001], whereas there were no statistical significances between PAPF and SNCF groups in abovesaid items(P>0.05). However, there were no significant differences among the three groups in terms of the time interval of two stage operations, the closure form of donor area, the healing of donor area, and the hospital stay(P>0.05). All the patients in the 3 groups were followed up for a mean of(14.7±2.0) months, and there was no significant difference in the time to resume full weight-bearing activity among the three groups(P>0.05). The VAS score, ankle dorsal-plantar flexion ROM, AOFAS score and donor scar score were significantly improved over time(P<0.05). The PAPF group got significant improvement in sensory function with time(P<0.05), while the SNCF group and ALTF group had it remained unchanged(P>0.05). At the last follow-up, the ankle dorsalplantar flexion ROM in PAPF and SNCF groups was significantly better than that in ALTF group [(62.1±5.1)° vs(61.7±6.2)° vs(54.9±5.3)°,P=0.010]. The PAPF and ALTF group were significantly better than SNCF in terms of sensory function [excellent/good/fair/poor:(17/7/3/2)vs(4/1/1/1) vs(2/3/7/3), P=0.046], and the donor scar score [(3.9±0.9) vs(4.2±1.3) vs(5.1± 0.9), P<0.001]. [Conclusion] PAPF retrograde skin flap for the repairing soft tissue defect complicated with open ankle fracture and dislocation has advantages of few complications, more satisfactory flap appearance and better sensory function recovery.