交腿桥式供血的游离股前外侧穿支皮瓣修复伴有主干血管缺损的小腿感染性创面7例

Free anterolateral thigh perforator flap with cross-leg vessel bridging in reconstruction of infected wounds in lower leg with major vessel defects:a report of 7 cases

目的探讨交腿桥式供血的游离股前外侧穿支皮瓣(ALTPF)修复伴有主干血管缺损的小腿感染性创面的临床效果。方法本文采用回顾性研究。自2020年1月至2021年12月,兵器工业521医院创伤骨科收治小腿大面积感染性创面需行皮瓣移植修复的患者7例,其中男5例,女2例,年龄23~50岁,平均37岁,致伤原因:车祸伤5例,机器挤压伤1例,重物砸压伤1例,经清创、敏感抗生素使用控制感染后修复创面,软组织缺损面积11.0 cm×15.0 cm~20.0 cm×32.0 cm,均经血管造影检查或CDU检查证实胫前动脉损伤6例,胫后损伤1例,患肢仅余胫前动脉或胫后动脉单一动脉供血,且损伤的动脉无法作为皮瓣移植供血动脉,采用交腿桥式供血的游离ALTPF修复,即在吻合皮瓣血管蒂时对血管蒂供区采用VSD敷料覆盖,延期至血管蒂断蒂时将胫后动脉及皮管回植,皮瓣切取面积13.0 cm×17.0 cm~22.0 cm×32.0 cm(单侧ALTPF 6例,双侧ALTPF 1例)。供区张力不大的2例直接拉拢缝合,张力较大无法直接缝合的5例行植皮修复。术后观察皮瓣成活情况、并发症情况,并定期采用门诊复诊、微信、上门随访等方式进行随访。结果7例患者均成功修复,并全部获得随访,时间12~24个月,平均16个月。本组皮瓣全部成活,一期愈合6例,1例出现皮瓣远端部分坏死伴浅表感染,经换药治疗后愈合,愈合时间14~36 d,平均17.9 d,断蒂时间为皮瓣修复术后3~4周,平均3.6周。皮瓣及血管蒂供区愈合良好,经CDU证实健侧胫后动脉通畅,患侧肢体功能恢复满意,健侧肢体功能良好。结论交腿桥式供血的游离ALTPF修复伴有主干血管缺损的小腿感染性创面的临床效果满意,是一种切实有效的治疗方法。

ObjectiveTo explore the clinical effects of free anterolateral thigh perforator flap(ALTPF)with modified cross-leg vessel bridging in reconstruction of infected wounds in the lower leg combined with major vessel defects.MethodsA retrospective observational study was conducted on 7 patients who admitted to the Department of Trauma Orthopaedics,the 521 Hospital of Norinco Group from January 2020 to December 2021 for treatment of large infected wounds in lower leg with soft tissue defect by reconstructive surgery of flap transfer.The patients were 5 males and 2 females,aged 23-50 years old with an average age of 37 years old.The causes of injury were:5 patients were of car accidents,1 of machinery compression and 1 of heavy object crush.The wounds were reconstructed after debridement and infection control with sensitive antibiotics,where the soft tissue defects were found at 11.0 cm×15.0 cm to 20.0 cm×32.0 cm in size.All patients underwent vascular angiography or CDU examinations and it was confirmed that the affected calf had only an anterior tibial artery as the vessel left for blood supply in 6 patients and a posterior tibial artery as the blood supply vessel in one patient.Therefore application of vascular end-to-side anastomosis in free flap reconstruction of limb defects was impossible due to the damaged artery could not be salvaged as a blood supply artery for the transferred flap.Therefore,a modified cross-leg vessel bridging to the freed ALTPF in the affected lower leg was applied.The donor site of the pedicle was covered with VSD while the pedicle of the flap was anastomosed.It was remained until the posterior tibial artery and the tubular flap were ready for replantation after disconnection of the pedicle.The sizes of flap were 13.0 cm×17.0 cm to 22.0 cm×32.0 cm(unilateral ALTPFs for 6 patients and bilateral ALTPFs for 1 patient).Two donor sites in low tension were direct closed,and the rest of 5 donor sites that had great tensions and could not be directly sutured were reconstructed by skin grafting.The survival and complications of flaps were observed in the scheduled postoperative follow-ups at outpatient visits,WeChat reviews and home visits,etc.ResultsAll 7 patients were successfully treated and had 12-24 months postoperative follow-up,with an average of 16 months.All flaps survived,with primary healing in 6 patients and 1 patient had partial flap necrosis with surface infection,which healed after dressing changes.The wound healing time was 14-36 days with an average of 17.9 days.The time for disconnection of the cross-leg vessel bridging pedicle was 3-4 weeks with the flap transfer,with an average of 3.6 weeks.The donor sites of ALTPFs and vessel pedicles all healed well.CDU confirmed the patency of the contralateral posterior tibial artery.Satisfactory functional recovery was achieved in the affected lower limb and there was a good function of the contralateral healthy lower leg.ConclusionApplication of the transfer of a free ALTPF with modified cross-leg vessel bridging in reconstruction of infected wounds with major vessel defects in the lower leg has shown excellent clinical outcomes.It is a practical and effective method in treatment of large infective defect in lower leg.