以旋髂深动脉为蒂的髂骨肌皮瓣修复合并空腔的下肢复合缺损创面

Clinical application of iliac myocutaneous flap pedicled with deep circumflex iliac artery in repair of complex defect of lower limb with cavity

目的探讨以旋髂深动脉(deep circumflex iliac artery,DCIA)为蒂的髂骨肌皮瓣修复合并空腔的下肢复合缺损创面的临床疗效。方法回顾分析2017年3月—2020年9月收治的7例下肢复合缺损创面患者临床资料,男4例,女3例;年龄24~58岁,中位年龄37岁。致伤原因:机器绞伤2例,高处坠落伤2例,交通事故伤3例。创面污染严重,根据Gustilo-Anderson分型:Ⅲa型1例,Ⅲb型4例,Ⅲc型2例(合并胫前动脉断裂);骨折国际内固定研究协会/美国骨创伤协会(AO/OTA)分型:42-C3型2例,43-A2型2例,43-B1型3例。受伤至入院时间为2~10 h,平均6 h。一期急诊清创后均遗留胫骨骨缺损及周围软组织缺损,伴深部空腔形成;二期根据创面特征设计DCIA嵌合髂骨肌皮瓣三维立体修复复合缺损,髂骨瓣切取范围为2.0 cm×2.0 cm×2.0 cm~7.0 cm×3.0 cm×2.5 cm,皮瓣切取范围为12.0 cm×8.0 cm~21.0 cm×13.0 cm,腹内斜肌肌瓣切取范围为3.0 cm×2.0 cm×2.0 cm~5.5 cm×4.0 cm×4.0 cm。供区直接一期闭合。结果术后除1例皮瓣边缘部分坏死,经二期植皮后愈合外,其余皮瓣全部成活;供、受区创面均Ⅰ期愈合。7例患者均获随访,随访时间16~24个月,平均18个月。骨缺损断端愈合良好,愈合时间8~10个月,平均7.3个月。末次随访时,皮瓣外形满意,质地柔软,未出现异常毛发生长、色素沉着等。供区仅遗留线性瘢痕,未出现腹壁疝等并发症。根据Paley骨折愈合评分标准评价骨愈合情况,优5例、良2例。肢体功能重建满意,术后12~16个月实现完全负重,根据下肢功能评定标准(LEFS)评价,优6例、良1例。结论以DCIA为蒂的髂骨肌皮瓣设计灵活,组织成分高度自由,能立体修复合并深部空腔的下肢复合缺损创面,最大程度修复肢体外形及重建负重功能。

Objective To explore the effectiveness of iliac myocutaneous flap pedicled with deep circumflex iliac artery(DCIA)on the repair of lower limb composite defect wounds with cavity.Methods A retrospective analysis of 7 patients with lower limb composite defect wounds treated between March 2017 and September 2020 was conducted,including 4 males and 3 females,aged 24-58 years,with a median age of 37 years.The causes of injury were machine twisting injury in 2 cases,fall from height injury in 2 cases,and traffic accident injury in 3 cases.According to Gustilo-Anderson classification,there were 1 case of typeⅢa,4 cases of typeⅢb,and 2 cases of typeⅢc(combined with anterior tibial artery rupture);according to AO/Orthopaedic Trauma Association(AO/OTA)classification,there were 2 cases of type 42-C3,2 cases of type 43-A2,and 3 cases of type 43-B1.The time from injury to admission ranged from 2 to 10 hours,with an average of 6 hours.Tibial bone defect and surrounding soft tissue defect with deep cavity were left after primary emergency debridement.In the second stage,according to the characteristics of the wound,the three-dimensional repair of the composite defect was designed with DCIA embedded iliac myocutaneous flap.The size of the iliac flap was 2.0 cm×2.0 cm×2.0 cm to 7.0 cm×3.0 cm×2.5 cm,and the size of the flap was 12.0 cm×8.0 cm to 21.0 cm×13.0 cm.The internal oblique muscle flap was harvested in size of 3.0 cm×2.0 cm×2.0 cm to 5.5 cm×4.0 cm×4.0 cm.The donor site was primarily closed.Results All the flaps survived after operation,except for 1 case of partial necrosis of the flap edge,which healed after secondary skin grafting,and the donor and recipient wounds healed by first intention.All patients were followed up 16-24 months,with an average of 18 months.The broken end of the bone defect healed well,and the healing time was 8-10 months,with an average of 7.3 months.At last follow-up,the shape of the flap was satisfactory,the texture was soft,and there was no abnormal hair growth,pigmentation,and so on.Only linear scar was left in the donor site,and no complication such as abdominal hernia occurred.According to Paley fracture healing scoring system,bone healing was rated as excellent in 5 cases and good in 2 cases.The limb function was satisfactory,and full weight bearing was achieved at 12-16 months after operation.According to the lower extremity functional scale(LEFS),6 cases were excellent and 1 case was good.Conclusion The iliac myocutaneous flap pedicled with DCIA is flexible in design and highly free in tissue composition,which can repair the composite defect wound of lower limbs with deep cavity in a three-dimensional way,and repair the limb shape and reconstruct weight-bearing function to the greatest extent.