顺行带蒂股前外侧皮瓣和腹部带蒂皮瓣瓦合修复前臂大面积软组织缺损

Antegrade pedicled anterolateral thigh flap combined with pedicled abdominal flap in reconstruction of large soft tissue defect of forearm

目的探讨顺行带蒂股前外侧皮瓣(ALTF)和腹部带蒂皮瓣瓦合修复前臂大面积软组织缺损的效果及临床体会。方法2015年1月至2020年1月,台州骨伤医院手足外科采用顺行带蒂ALTF和腹部带蒂皮瓣瓦合修复前臂大面积软组织缺损35例,其中男28例,女7例,年龄22~63岁,平均37岁。创面面积13.0 cm×28.0 cm~18.0 cm×46.0 cm,根据创面大小设计样布增大约10%为所需的皮瓣面积,皮瓣大小为15.0 cm×30.0 cm~20.0 cm×49.0 cm,供瓣区创面直接缝合或取中厚、全厚皮片覆盖并加压包扎。35例患者均在术后4周进行手术断蒂。术后定期门诊及上门随访,观察皮瓣成活、外观、创面愈合及并发症等情况。术后12个月,根据张浩等标准对患者皮瓣外观及愈合情况进行评价,根据Johner-Wruhs标准对患肢功能恢复情况进行评价。结果35例患者均获得12~27(平均18)个月的随访。皮瓣二期手术断蒂后均完全成活,21例创面Ⅰ期愈合,14例创面延期愈合;28例皮瓣臃肿,7例接近正常;21例皮瓣温度正常,14例稍低;21例皮瓣感觉部分存在,14例无感觉;21例供区瘢痕明显,14例为轻度瘢痕;术后12个月,根据张浩等标准,术后总评分为6~9分;根据患肢功能恢复Johner-Wruhs评定方法,患肢功能恢复优14例,良14例,可7例,优良率为80%。结论顺行带蒂ALTF和腹部带蒂皮瓣瓦合修复前臂大面积软组织缺损短中期效果满意,值得临床进一步观察和研究。

Objective To discuss the outcomes and clinical experience in reconstruction of large soft tissue defects in forearm with a filed flap that antegrade pedicled anterolateral thigh flap(ALTF)combined with pedicled abdominal flap.Methods From January 2015 to January 2020,the Department of Hand and Foot Surgery of Taizhou Orthopaedic and Traumatic Hospital carried out surgery for reconstruction of large soft tissue defects in forearm using the tiled pedicled flaps which were created by combination of antegrade pedicled ALTF with pedicled abdominal flap in 35 patient.The patients were 28 males and 7 females,aged 22 to 63 years old with an average of 37 years old.The defect sizes were 13.0 cm×28.0 cm-18.0 cm×46.0 cm.According to the size of the wound,the required flap area should be increased by about 10%.The flaps were 15.0 cm×30.0 cm to 20.0 cm×49.0 cm in size.Flap donor sites were sutured directly or covered with medium-thickness or full-thickness skin grafts with pressurised wrapping.All patients received pedicle dissection at 4 weeks after surgery.Flap survival,flap appearance,wound healing and postoperative complications were observed by either scheduled reviews at outpatient clinics or by home visits.Twelve months after surgery,flap appearance and wound healing were evaluated according to the flap satisfaction criteria proposed by Zhang Hao et al.and the function recoveries of the affected limbs were assessed according to Johner-Wruhs criteria.Results All 35 patients were included in the postoperative follow-up for 12 to 27(mean 18)months.All flaps survived after pedicle dissection.Twenty-one patients achieved primary wound healing while 14 had delayed wound healing.The appearances of 7 flaps were close to normal but 28 were bloated.Normal temperature was recorded from 21 flaps and 14 with slightly lower temperature.Partial sensation recovery was found in 21 flaps and no sensation at all in 14 flaps.Twenty-one patients had obvious scars in the donor site and 14 with mild scars;At 12 months after surgery,the overall postoperative rating was 6 to 9 indicating that all patients were satisfactory with the flaps,according to the assessment criteria for flap satisfaction proposed by Zhang Hao et al.According to the Johner-Wruhs assessment for functional recovery of the affected limb,the functional recovery of the affected limbs was excellent in 14 patients,good in 14,and fair in 7,with an excellent and good rate of 80%.Conclusion Reconstruction of a large soft tissue defect in forearm with a tiled flap that antegrade pedicled ALTF combines with a pedicled abdominal flap offers an outcome with short-to-medium term satisfactory.Further clinical observations are necessary to verify the surgical procedure.