并联组合血流桥接穿支皮瓣治疗伴血运障碍肢体环形热压伤的临床效果

Clinical effects of parallel combined flow-through perforator flaps in the treatment of circular hot crush injuries in limbs with blood supply disorder

目的探讨应用并联组合血流桥接穿支皮瓣治疗伴血运障碍肢体环形热压伤的临床效果。方法该研究为回顾性观察性研究。2016年4月-2022年12月,解放军联勤保障部队第九八八医院烧伤整形科收治4例符合入选标准的伴血运障碍的肢体环形热压伤患者,其中男3例、女1例,年龄24~48岁,累及小腿者2例、前臂者2例。急诊清创后,皮肤软组织缺损面积为20 cm×20 cm~44 cm×20 cm。患者胫前、后动脉缺损长度为13~18 cm,尺、桡动脉缺损长度为9~12 cm。设计并切取血流桥接旋股外侧动脉降支穿支皮瓣(面积为20 cm×9 cm~24 cm×21 cm,携带旋股外侧动脉降支及其伴行静脉长度为8~18 cm)、血流桥接胫后动脉穿支皮瓣(面积分别为21 cm×13 cm、20 cm×14 cm,携带旋股外侧动脉降支及其伴行静脉长度分别为14、17 cm,大隐静脉长度分别为22、21 cm)。采用血流桥接旋股外侧动脉降支穿支皮瓣与血流桥接胫后动脉穿支皮瓣并联组合修复伴血运障碍小腿环形热压伤创面,采用双侧血流桥接旋股外侧动脉降支穿支皮瓣并联组合修复伴血运障碍前臂环形热压伤创面,同时重建损伤的主干血管。将皮瓣供区创面直接缝合或移植腹部中厚皮片修复。术后观察皮瓣及远端患肢血运、成活情况,供受区创面愈合、皮片成活情况。随访观察皮瓣情况,患肢外观、血运及功能情况。末次随访时,根据美国矫形足踝协会评分标准进行足、踝功能评价,按中华医学会手外科学会上肢断肢再植功能评定试用标准进行腕、手功能评价。结果4例患者术后皮瓣及远端患肢均血运良好并顺利成活。3例患者受区创面顺利愈合,但1例前臂环形热压伤患者受区创面后期出现渗出,经再次清创、缝合后愈合;供区创面均愈合,皮片均顺利成活。术后随访12~24个月,患者皮瓣稍臃肿,肢体外观良好、血运正常、功能恢复较佳。末次随访时,2例小腿环形热压伤患者足、踝功能评定为良者1例、可者1例,2例前臂环形热压伤患者腕、手功能评定为优者1例、良者1例。结论并联组合血流桥接穿支皮瓣可同时重建受损主干血管及修复创面,既可有效保肢,又能恢复患肢部分功能,是治疗伴有血运障碍的肢体环形热压伤的有效方法之一。

Objective To explore the clinical effects of parallel combined flow-through perforator flaps in the treatment of circular hot crush injuries in limbs with blood supply disorder.Methods The study was a retrospective observational study.From April 2016 to December 2022,4 cases with circular hot crush injuries in limbs with blood supply disorder were admitted to the Department of Burns and Plastic Surgery of the 988 th Hospital of Joint Logistics Support Force of PLA,including 3 males and 1 female,aged from 24 to 48 years.Among them,2 cases were injured in the calf and 2 cases were injured in the forearm.After emergency debridement,the area of skin and soft tissue defects was from 20 cm×20 cm to 44 cm×20 cm.The patients had defects in tibialis anterior and posterior tibial arteries with a length of 13 to 18 cm,and in ulnar and radial arteries with a length of 9 to 12 cm.Flaps were designed and cut,including a flow-through anterolateral thigh perforator flap with area of 20 cm×9 cm to 24 cm×21 cm carrying the descending branch of the lateral circumflex femoral artery and the accompanying veins of 8 to 18 cm in length;and a flow-through posterior tibial artery perforator flap with area of 21 cm×13 cm and 20 cm×14 cm carrying the posterior tibial artery,the accompanying veins with a length of 14 and 17 cm respectively,and the great saphenous vein with a length of 22 and 21 cm.The circular hot crush injury wounds in the calf with blood supply disorder were repaired by a parallel combination of flow-through posterior tibial artery perforator flap and flow-through anterolateral thigh perforator flap,and the circular hot crush injury wounds in the forearm with blood supply disorder were repaired by a parallel combination of bilateral flow-through anterolateral thigh perforator flap,and the injured main vessels were reconstructed.The donor site wounds of flap were closed directly or treated with split-thickness skin grafts from abdomen.After surgery,the blood supply and survival of the flap and distal affected limb,the healing of wounds in the donor and recipient sites,the survival of the skin graft in the flap donor site were observed.During follow-up,the condition of flaps,the appearance,blood supply,and function of affected limbs were observed.At the last follow-up,the foot and ankle functions were evaluated according to the scoring standards of American Orthopedic Foot and Ankle Association,and the wrist and hand function was evaluated according to the trial standard of replantation of amputated upper limb function assessment of the Hand Surgery of Chinese Medical Association.Results The flaps and distal affected limbs of 4 patients had good blood circulation and successfully survived after surgery.The wounds of 3 cases successfully healed,while one patient with circular hot crush injury in the forearm experienced exudation in the recipient site in the later stage,and the wound healed after re-expansion and suturing.The donor site wounds healed smoothly,and the skin grafts successfully survived.During follow-up of 12 to 24 months after surgery,the flaps were slightly swollen,the limbs had good appearance,normal blood circulation,and fine functional recovery.At the last follow-up,the foot and ankle function of 2 patients with circular hot crush injuries in the calf was evaluated as good in 1 case and commonly in 1 case;the wrist and hand function of 2 patients with circular hot crush injuries in the forearm was evaluated as excellent in 1 case and good in 1 case.Conclusions The parallel combined flow-through perforator flap can reconstruct the damaged main blood vessels and repair the wound at the same time.It can not only effectively save the limb,but also restore part of the function of the affected limb.It is one of the effective methods to treat the circular hot crush injuries in limbs with blood supply disorder.