多方式腓骨及皮瓣移植修复四肢骨及软组织缺损

目的 探讨带血管的腓骨及皮瓣移植修复四肢骨及软组织缺损的疗效.方法 用腓骨转位修复胫骨缺损4例;游离腓骨移植中折叠移植3例,其中修复股骨下端缺损2例、跟骨缺损1例;单根移植修复胫骨、桡骨、跖骨缺损11例;半面腓骨移植修复掌骨缺损2例.同时均带皮瓣修复骨及软组织缺损.结果 20例全部成活,骨愈合时间为6～ 10周,3～6个月后负重,15例随访6个月～4年,移植骨增粗,下肢正常行走,移植皮瓣弹性好,上肢及手部恢复抓握旋转功能.结论 多方式带血管的腓骨及皮瓣移植是治疗四肢及手术骨和软组织缺损的有效方法.     

游离腓骨复合移植重建上肢关节功能及骨缺损

目的：吻合血管的腓骨复合移植适用于一期修复上肢长骨骨缺损及重建关节功能。方法：自１９８５年以来，采用折叠腓骨段及复合组织瓣修复尺桡骨同时骨缺损４例；小儿肱骨近端肿瘤瘤段切除后采用吻合血管带腓骨小头的腓骨移植重建肩关节功能９例；桡骨远端肿瘤瘤段切除后取吻合血管带腓骨小头的腓骨移植重建桡腕关节６例。结果：经术后２～１０年随访，重建的肩关节、桡腕关节功能恢复令人满意，尺桡骨骨缺损一期修复，骨愈合良好。结论：复合的游离腓骨移植是扩大应用于关节功能重建的有效方法。     

带血管蒂腓骨骨皮瓣移植修复创伤性骨髓炎所致骨缺损

目的探讨带血管蒂腓骨骨皮瓣移植修复创伤性骨髓炎所致骨缺损的临床应用。方法采用带血管蒂腓骨骨皮瓣移植治疗创伤性骨髓炎所致骨缺损患者20例。随访观察患者骨及软组织缺损愈合和功能恢复情况。结果 20例患者术后随访12~24个月,创面术后2周均1期愈合,X线示移植腓骨约3~4个月愈合,患肢关节功能保留完好,骨髓炎病灶消除,无复发,移植腓骨12~18个月胫骨化。结论采用带血管蒂腓骨骨皮瓣移植是治疗创伤性骨髓炎所致软组织及骨缺损的一种有效方法。     

桡骨远端瘤段切除后单纯自体腓骨移植与吻合血管腓骨移植重建桡腕关节疗效比较

目的分析单纯自体腓骨移植与吻合血管腓骨移植在桡骨远端瘤段切除后修复桡骨远端缺损和重建桡腕关节远期效果.方法 1979年1月～2002年9月对15例桡骨远端肿瘤患者行瘤段切除后,6例行单纯自体腓骨移植,9例行吻合血管腓骨移植重建桡腕关节.随访1年,参照Enneking系统及国际肢体修复讨论会所制定的同种/带血管蒂骨移植的影像学评价方法,进行肢体功能、影像学及供区的功能评价.结果 8例吻合血管腓骨移植恢复肢体功能的80%,6个月内完成骨愈合;6例单纯自体腓骨移植恢复肢体功能的67%,其中4例移植骨在5 cm以内术后6个月骨愈合可,2例骨移植超过12 cm者愈合延迟,分别为13个月和16个月;1例术后2个月行肘下截肢术.结论应用腓骨头替代桡骨远端重建腕关节是合适的;吻合血管腓骨移植重建桡腕关节不受骨缺损长度影响,且植骨愈合率高、时间短,无骨吸收.可作为桡骨远端肿瘤手术治疗的一种有效手段.     

吻合血管的髂骨与腓骨移植修复四肢骨缺损疗效分析

目的探讨带血管腓骨和髂骨移植修复四肢骨缺损的临床效果。方法1992年1月～2004年1月,对49例四肢骨缺损患者采用带血管腓骨(33例)和带血管髂骨(16例)移植治疗。参照Enneking系统对患肢进行功能评价,移植骨转归参照国际挽救肢体专题讨论会制定的关于同种及带血管移植的放射学评价方法评定。结果所有患者术后随访1～12年,带血管腓骨移植组患肢功能恢复率为82.7%,移植腓骨愈合时间平均为16.8周,治愈率为87.9%。带血管髂骨移植组患肢功能恢复率为88%,移植髂骨愈合时间平均15.2周,治愈率为93.8%。两组骨愈合时间和患肢功能恢复率比较有统计学意义。结论带血管腓骨移植可用于修复下肢大段骨缺损和桡骨远端缺损,而带血管髂骨修复上肢骨缺损效果较好。     

静脉移植桥接血管蒂的游离腓骨瓣移植治疗长骨感染性骨缺损

目的：探讨静脉移植桥接血管蒂的游离腓骨瓣移植治疗长骨感染性骨缺损及软组织缺损的手术方法及临床疗效。方法回顾性分析自2008年6月至2014年1月收治的17例长骨感染性骨缺损患者病例资料,男11例,女6例;年龄1.5~55岁,平均31.3岁;股骨8例,胫骨5例,肱骨3例,桡骨1例;骨缺损长度为4~19 cm,平均9.4 cm;其中8例合并软组织缺损（5.0 cm×3.0 cm~17.0 cm×5.5 cm）。感染性骨缺损端彻底清创后,负压封闭灌洗引流2~3周,待肉芽生长新鲜,设计并切取腓骨瓣或腓骨皮瓣移植进行重建,移植自体静脉并端端吻合桥接受区血管与腓骨瓣的血管蒂。静脉移植桥接腓骨瓣的动、静脉血管蒂长度5~18 cm,平均9.6 cm;移植腓骨皮瓣面积6.5 cm×4.0 cm~18.0 cm×6.0 cm。结果17例腓骨瓣手术及术后恢复顺利,均无血管危象。伤口一期愈合11例,延期1~2周愈合6例。术后6~8周X线片示移植腓骨端骨痂形成。15例获得随访,随访9个月~6年,平均30个月,2例失访。13例骨缺损一期愈合,2例腓骨一端与受区未愈合,再次手术后愈合。1例移植腓骨术后7个月发生应力骨折,经外固定架治疗4个月后愈合。感染性骨缺损愈合时间4.2~9.8个月,平均5.9个月,末次随访时采用Enneking系统评分,优11例,良3例,可1例,优良率93.3%。手术后肢体功能恢复满意。结论静脉移植桥接游离腓骨（皮）瓣血管蒂,不仅能有效地修复长骨感染性骨缺损和局部软组织缺损,而且可以改善骨缺损局部血运,控制感染,明显缩短疗程,是治疗肢体长骨感染性骨缺损及合并软组织缺损的有效手段。     

急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

带血管蒂腓骨移植46例临床分析

目的 报道带血管蒂腓骨移植修复缺缺损的临床应用价值。方法 从1989年3月-2002年8月．应用血管蒂腓骨游离移植46例，其中腓骨骨皮瓣移植40例，同侧带血管蒂转移腓骨移植6例，修复外伤、骨肿瘤切除术后及先天性胫骨假关节造成的骨缺损。结果 46例中除1例胫骨巨细胞瘤术后复发而行大腿截肢外，余45例术后半年复查X线片示移植腓骨与宿主骨之间出现骨性连接。结论 带血管蒂腓骨移植是治疗骨缺损的有效方法之一。     

腓骨骨皮瓣移植修复肢体复合组织缺损

目的总结腓骨骨皮瓣移植修复肢体外伤性复合组织缺损的临床修复效果。方法依照患者肢体复合组织缺失情况及全身状况,采用腓骨骨皮瓣移植进行修复,其中男9例,女3例。年龄12～45岁。胫骨缺损伴腓骨骨折2例,单纯胫骨缺损2例,桡骨缺损2例,尺骨缺损3例,跟骨缺损1例,第1跖骨缺损2例;骨缺损长度4.2～10.6cm,平均7.8cm;皮肤缺损10.0cm×4.5cm～27.0cm×15.0cm。合并胫前和(或)胫后动脉损伤2例,胫后神经损伤2例,腓总神经损伤1例。一期修复4例,延期修复8例。骨皮瓣游离移植手术9例,推移手术2例,逆行移位手术1例。4例于术后3～6个月行二期肌腱移位动力重建术。行腕、踝关节融合术各1例。结果术后出现静脉危象及腓总神经牵拉性损伤各1例,经探查、大隐静脉移植等对症治疗,12例骨皮瓣全部成活。术后随访6～24个月,移植腓骨与受区断端均达骨性愈合,肢体功能均得到良好恢复。供区未出现膝及踝关节运动障碍。结论采用急诊或延期的腓骨骨皮瓣移植手术,可较好地修复肢体长管状骨干和软组织复合组织缺损。应注意受区移植腓骨皮瓣术后的感觉功能重建。     

带蒂游离腓骨骨皮瓣治疗创伤后胫骨大段缺损并胫前皮肤软组织缺损

目的探讨采用健侧带蒂游离腓骨骨皮瓣修复创伤后胫骨大段缺损并胫前皮肤软组织缺损的方法及疗效。方法自2007-05—2013-03采用彻底清创、清除死骨后一期健侧带蒂游离腓骨骨皮瓣治疗创伤后胫骨大段骨缺损并胫前皮肤缺损14例。结果术后14例均获得9~16个月随访,术后伤口18~25 d愈合拆线,皮瓣全部存活,X线示移植腓骨均愈合。术后3个月开始出现明显骨痂形成,完全愈合时间平均7.2(6~10)个月,移植腓骨增粗完全胫骨化平均14.6(12~16)个月。其中3例在术后9个月时行X线复查发现移植腓骨中段出现骨折,周围已有大量骨痂形成,未行外固定及局部制动。6例术后11~15个月取出克氏针内固定。术后9个月按Enneking评价系统,肢体术后功能恢复平均为正常功能的87%,6例克氏针内固定取出术后1个月肢体功能恢复平均为正常功能的96%。结论使用带蒂游离腓骨骨皮瓣能一次性修复创伤后胫骨大段缺损并胫前皮肤软组织缺损,可以明显减少手术次数并缩短愈合时间,肢体功能恢复满意。     

Free vascularized fibular grafts

Postoperative results in 21 patients with bone defects that had been treated with a free vascularized fibular graft (FVFG) were evaluated. Pathogeneses in 21 patients were bone defect or pseudarthrosis after trauma in eight, massive bone defect after resection of bone and soft tissue tumor in six, congenital pseudarthrosis of the tibia in six, and congenital arteriovenous fistula in the forearm in one patient. The follow-up ranged from 15 months to 12 years, with an average of four years and six months. At final review, 12 patients went on to primary bony union, and six additional patients obtained union following an additional conventional bone graft. Three FVFGs resulted in a non-vascularized fibular graft. However, two patients obtained union with additional bone graft. Only one patient failed to obtain bony union and eventually required an above-knee amputation. Bony union rates in congenital pseudarthrosis of the tibia treated with the FVFG were lower than those in other diseases. Variables related to the surgical procedures and other factors affecting results and complications were also evaluated.     

吻合血管腓骨移植的新术式

目的 探索扩大吻合血管腓骨移植修复骨缺损的应用范围。方法 应用吻合血管节段性腓骨移植修复骨肿瘤切除后骨缺损;吻合口管双节段腓骨或复合组织瓣移植－期修复尺,桡骨缺损;对于Ⅲ度胫骨粉碎性骨折,采用带血管或吻合血管腓骨移植,起到内夹板固定作用,并加速骨折的愈合。结果 所有被修复骨缺损均获良好愈合,其功能与外形均令人满意。结论 以上术式的开展,扩大了吻合血管腓骨移植的应用范围,为腓骨移植展示了良好的临床应     

吻合血管腓骨移植的数字化设计与初步临床应用

目的 探讨吻合血管腓骨移植数字化设计修复长段骨和(或)软组织缺损的临床应用价值.方法 选择四肢长段骨缺损患者9例,术前血管造影后行螺旋CT供区小腿扫描.将扫描数据输入计算机,应用Amira 3.1软件对腓骨及其营养血管行三维重建.术前根据患者骨缺损长度、形态及软组织缺损面积.利用三维重建图像进行精确测量和个性化没计,并模拟手术关键操作.术中仔细核对腓动脉与重建血管走行,并依术前设计切取腓骨(皮)瓣.移植于骨缺损受区进行固定.参照Enneking系统对患肢功能进行评价,以达到正常肢体功能的百分数表示,参照国际挽救肢体专题讨论会制定的"同种及带血管移植的放射学评价方法"对移植腓骨的转归进行影像学评价.结果 三维重建图像直观地体现了腓骨、营养血管及腓动脉穿支皮瓣的三维结构及空间毗邻关系.通过数字化设计和模拟手术操作,町避免术中因小腿血管损伤或血管变异致切取失败和供区意外损伤.9例移植的腓骨(皮)瓣全部成活.术后随访6～30个月,平均15.8个月.骨缺损均修复,骨性愈合时间平均为4.5个月,肢体功能恢复率90.4%.结论 数字化设计可为修复长段骨缺损手术方案的选择提供科学依据,方便术前模拟及术中指导,降低手术风险.     

股前外侧皮瓣串联腓骨皮瓣修复小腿大面积皮肤软组织伴骨缺损

目的 探讨吻合血管的股前外侧皮瓣串联腓骨皮瓣修复小腿大面积皮肤软组织伴骨缺损的临床效果.方法 2005年6月至2008年7月,将股前外侧皮瓣与腓骨皮瓣的轴心血管串联吻合后移植修复8例小腿大面积皮肤软组织伴大段胫骨缺损患者.皮肤软组织缺损面积为23 cm×12cm～34 cm×16 cm,骨缺损长度为7～16 cm.股前外侧皮瓣切取面积为16 cm×12 cm～28 cm×15cm,腓骨皮瓣切取面积为15 cm×6 cm～21 cm×10 cm,腓骨切取长度为10～18 cm.结果 7例串联组织瓣一期成活,1例术后皮瓣远端边缘坏死,经换药伤口逐渐愈合.8例患者术后获7～31个月(平均16个月)随访.3～6个月移植腓骨愈合,术后1年移植腓骨直径明显增粗.所有皮瓣质地柔软,形态及功能满意,供区无功能障碍.结论 应用股前外侧皮瓣串联腓骨皮瓣联合移植能有效修复小腿大面积皮肤软组织伴骨缺损,且缩短了病程,减少了肢体的伤残率.     

改进法腓骨移植治疗胫骨及周围皮肤软组织缺损

改进切取带血管腓骨及其复合组织瓣方法治疗合并胫前及周围皮肤软组织条件不良的胫骨骨缺损。方法：采用改进法行带血管腓骨及复合组织皮瓣的切取,术中先锯断两端腓骨再行带肌袖腓骨的切取和腓动静脉血管蒂的显露。为保障移植腓骨的血运,腓动脉两断端均与受区胫前动脉吻合。结果：术中无１例损伤腓动静脉,切取腓骨时间在２０～４０ｍｉｎ,１６例腓骨均一期骨愈合。结论：该改进法切取腓骨具有手术出血量少、解剖清晰、手术时间较常规方法极大缩短的优点。腓骨复合组织瓣移植法行植骨的同时可修复胫前皮肤软组织缺损,并可对移植腓骨的血运情况进行监测。     

Bone Propeller Flap: A Staged Procedure

The ideal reconstruction technique for complex defects of the lower limb consists of replacing tissue with similar tissue in an attempt to achieve a good functional result. A 23-year-old white male sustained a crush injury with a grade IIIB open ankle dislocation. After open reduction and fixation, the patient developed severe osteomyelitis at the tibiotalar joint requiring a staged and radical debridement with a substantial combined soft tissue and bony defect over the distal tibia, fibula, and talus area. The reconstructive approach consisted of a modified model of the propeller flap, implementing the spare part concept in a 2-stage procedure using a prefabricated and vascularized “double-barrel” fibular graft. At 17 months postoperatively, a plain radiograph showed bony union with complete and stable coverage of the soft tissue defect. The patient was fully weightbearing. In conclusion, there is evidence to suggest that the established concept of a soft tissue propeller flap can be implemented on bone.     

An intramedullary free vascularized fibular graft combined with pasteurized autologous bone graft in leg reconstruction for patients with osteosarcoma

The use of pasteurized autologous bone graft has been an innovation in limb-salvage surgery; however, its principal disadvantage is fracture, infection, pseudoarthrosis, and bone resorption. We present two cases in which an intramedullary free vascularized fibular graft combined with pasteurized autologous bone graft was performed for immediate femur or tibia reconstruction following osteosarcoma resection. The rationale of this method is to combine the mechanical strength of a pasteurized bone with the biological activity of a vascularized bone. The pasteurized bone graft provides bone stock and early stability and the addition of the vascularized bone graft substantially facilitates host-pasteurized bone union. This combination procedure may be a recommended option for reconstruction of the lower leg, preserving knee joint function for patients with osteosarcoma.     

Free vascularized fibula in traumatic long bone defects and in limb salvaging following tumor resection: Comparative study

In this retrospective analysis, we present our experience with two groups of patients who had long bone defects secondary to trauma or tumor resection and who were treated with a free vascularized fibular graft for skeletal reconstruction. Both groups were comparable in number and average age of patients, length of bone defect, and mean follow-up (average 3 years both groups). The number of surgical procedures prior to microvascular grafting was significantly higher for the traumatic defects. Primary bone union in a mean period of 6 months occurred at a higher rate in the tumor patients; the trauma patients had a significantly higher nonunion rate, which required multiple additional surgical procedures. The latter did not, significantly, improve the rate of success in the trauma group. Residual limb shortening was present in one-half of the patients with traumatic defects. On the basis of this review, it appears that the scarred and relatively avascular soft tissues surrounding the long bone defects secondary to trauma affect the course and the final outcome of the microvascular fibular grafting. A similar procedure applied for limb salvaging after tumor resection is better. © 1993 Wiley-Liss Inc.     

Vascularized fibula transplantation in orthopedic oncology. Personal experience and review of the literature

Primary malignant bone tumors can be treated predominantly with limb salvage. After resection of large articular segments adjacent to the dia- or metaphysis of long bones modular endoprosthetic devices are most commonly used for reconstruction. In case non-vascularized corticocancellous bone is transplanted in order to bridge extensive bone defects, the risk of pseudarthrosis and fracture of the donor bone is significantly higher in comparison to a free vascularized transplant. From 1988 until 1999 we treated 20 patients with extensive bone defects after resection of tumors affecting the upper and lower extremity using a vascularized fibular graft. In this retrospective analysis we collected the data focusing on bone integration and functional outcome. The graft union was classified according to the standards of the "International Symposium of Limb Salvage". Evaluation of the functional outcome was quantified using the Enneking-score. The stabilisation of the transplant was obtained exclusively by plate fixation in the upper extremity. In 10 in a total of 12 patients the reconstruction using a vascularized fibula transfer was reinforced with an allograft in the lower extremity. The functional evaluation score reached 73% of normal function at the last follow-up. After 18 months the radiographic evaluation of graft union was "excellent" in 75%, "good" in 11%, "fair" in 6% and "poor" in 9% according to the criteria of the ISOLS. Main complications were graft fracture in of 15% and pseudarthrosis in 14.3%. Reconstruction of extensive bone defects using free vascularized fibula grafts are a demanding operative procedure. The procedure combines a biologic form of reconstruction with a legitimate expectation of good long term outcome and a relatively low rate of complications.