腓肠神经-小隐静脉营养血管远端蒂复合瓣的解剖学研究

目的:为腓肠神经-小隐静脉营养血管远端蒂复合瓣设计提出解剖学依据.方法:30侧经动脉灌注红色乳胶成人下肢标本,解剖观测腓动脉肌间隔穿支、腓肠外侧动脉肌皮穿支与腓肠神经-小隐静脉、腓肠肌外侧头、比目鱼肌以及腓骨营养血管的关系;小隐静脉浅深交通支.结果:腓动脉肌间隔穿支6～10支,外径0.5～1.6 mm,最远的动脉穿支距外踝尖上(1.0±1.3)cm,外径(0.6±0.2)mm.穿支分出骨膜动脉、肌支,营养腓骨和比目鱼肌外侧半.穿支穿深筋膜时,发深筋膜支、皮支、皮神经浅静脉血管,构成腓肠神经-小隐静脉营养血管链.腓肠外侧动脉发2～5支外径0.2～1.2 mm肌皮穿支,营养腓肠肌外侧头及相应区域皮肤.小隐静脉浅深交通支距外踝尖上(3.4±0.9)cm,外径(1.7±0.5)mm.结论:腓肠神经-小隐静脉营养血管与肌、骨、皮营养血管同源,以腓动脉的肌间隔动脉终末穿支远端蒂复合瓣,旋转点近外踝尖平面,可覆盖前足创面.     

小隐静脉解剖和多普勒超声活体观察在远端蒂皮瓣的意义

目的:探讨小隐静脉与远端蒂皮瓣静脉回流.方法:以腓肠神经营养血管皮瓣为例.(1)解剖观察40侧小隐静脉.(2)用多普勒超声检查60侧人的小隐静脉.结果:解剖观察外踝尖水平上 3～4 cm小隐静脉体表投影与皮瓣轴线基本一致,两者相差(0.5±0.3)cm.40侧中有12侧各有1支与腓静脉的交通支,距外踝尖(3.0±0.7)锄,外径(1.2±0.5)mm;彩超检杳外踝尖水平上3～4cm小隐静脉内径为(2.3±0.7)mm,距体表(3.2±1.0)mm,78.3%正常人的小隐静脉能较显著将远侧的静脉血导入近侧.若足踝部大隐静脉回流障碍,小隐静脉引流将加剧.结论:(1)结扎小隐静脉消除了浅静脉干对远端蒂皮瓣的倒灌,可改善皮瓣静脉回流.(2)经超声定位,在外踝尖水平上3～4cm行0.5～1 cm的纵向小切口能准确结扎小隐静脉,操作简单,不会损伤蒂部穿支血管和血管网.     

The surgical anatomy of the sural nerve: An ultrasound study

The aim of this study was (a) to examine the anatomy of the sural nerve (SN) in a sample of 30 patients and (b) to analyze the incidence of different origins of the SN, and the distance of the SN from planned arthroscopic portals. An ultrasound (USG) examination of the SN was performed bilaterally on thirty healthy patients with no history of surgery or trauma of the lower limb. The SNs were classified into six main types of pattern, with an additional category for new and unclassified types. Each of Types 1 and 3 had two subdivisions. The distances from the superior border of the calcaneal tuberosity to the three simulated arthroscopy portal sites (Z1, Z1.5, Z2) to the SN were measured. A total of 30 patients (n = 60 limbs) with an average age of 27 ± 7.5 years were examined and the SN was visualized in all cases. The most common origin was Type 3A, accounting for 30% of limbs. Type 2 was the second most common seen in 18.3%. The distances of the SN from arthroscopic portal placement sites above the lateral malleolus were 2.07 ± 0.39 cm at the Z1 portal, 2.15 ± 0.38 cm at Z1.5, and 2.28 ± 0.33 cm at Z2. The variability in the anatomy of the SN warrants the use of USG to locate it accurately, thus preventing iatrogenic injury when portals are placed for arthroscopy, improving proper administration of anesthesia, and helping to localize the nerve for graft harvesting. Clin. Anat. 31:450–455, 2018. © 2017 Wiley Periodicals, Inc.     

Categorizing the distribution of the saphenous nerve in relation to the great saphenous vein

Saphenous donor site neuralgia is a cause of morbidity post‐coronary artery bypass surgery. Saphenous nerve damage during harvesting of the great saphenous vein is thought to be responsible. We dissected 37 cadaveric lower limbs from the knee fold to the dorsal venous arches, to study the spatial relations of the saphenous nerve and great saphenous vein to identify its distribution within the leg. Distribution of the saphenous nerve was categorized into Type A, where the nerve traveled inferiorly and split into an anterior and posterior branch during its course between the knee fold and medial malleolus, Type B, where the nerve traveled anterior to the vein with a small caliber branch traveling posteriorly at the proximal end, Type C where two main branches originated at the knee fold, one anterior to and one posterior to the vein. Overall the vein and nerve crossed in 27 out of the 37 cases (73%), occurring between 5 and 29 cm from the malleolus (60% occurred between 16 and 26 cm). In 32 (86%) of cases, the distal part of the nerve and vein were tightly adhered to each other within a common sheath. The length of adherence ranged from 3 to 26 cm with an average of 14 cm. The saphenous nerve is highly vulnerable during harvesting of the great saphenous vein due to its close relationship and crossing branches. Knowledge of the distribution categories of the nerve can help guide the surgeon to avoid damaging nerve branches during harvesting. Clin. Anat. Clin. Anat. 2013. © 2012 Wiley Periodicals, Inc.     

腓肠神经-小隐静脉营养血管远端蒂皮瓣临床应用的改进

目的:报道腓肠神经-小隐静脉营养血管远端蒂皮瓣临床应用的改进的效果.方法:在腓肠神经-小隐静脉营血管解剖学研究的基础上,采用远端蒂皮瓣旋转点降至外踝尖上2cm,术中结扎远端蒂小隐静脉以及复合瓣设计,临床应用15例.伤因及伤情:车祸伤6例,砸伤6例,机器绞伤3例.创面有骨与肌腱外露或在足跟负重区,其中足背创面5例,足跟创面3例,前足背4例,胫前创面2例,小腿远段创面伴胫骨缺损1例.皮瓣修复方式:低旋转点远端蒂皮瓣13例,远端蒂腓骨皮瓣1例,远端蒂腓肠肌皮瓣1例.结果:临床15例皮瓣全部一期成活,2例皮瓣边缘皮肤坏死,最大占皮瓣总面积的1/10,脱痂后自行愈合.经1月至8月的随访,皮瓣质地良好,厚薄均匀,颜色一致,供区无功能障碍.结论:腓肠神经-小隐静脉营养血管与邻近肌、骨、皮营养血管同源,临床对严重的外伤造成的骨不连、骨缺损和大的死腔,采用腓肠神经-小隐静脉营养血管远端蒂复合瓣修复是理想的选择.     

Injury to the infrapatellar branch of the saphenous nerve during tendon graft harvesting for knee ligament reconstruction: An ultrasound simulation study

The clinical anatomy of the infrapatellar branch of the saphenous nerve (IPBSN) is of particular importance during operations in the area of the knee, especially when material for anterior cruciate ligament reconstruction is harvested. The nerve can easily be injured during the harvesting procedure, leading to postoperative complications that reduce quality of life. Three different skin incisions are commonly used during hamstring tendon harvesting: horizontal, vertical, and oblique. The aim of this ultrasound simulation study was to assess the risk of IPBSN injury associated with the type of skin incision and the point‐of‐emergence of the IPBSN relative to the sartorius muscle. Thirty healthy volunteers (60 lower limbs) were recruited for identification of the IPBSN. When it was found, using a high‐frequency ultrasound probe, three different 3 cm skin incisions over the pes anserinus were simulated. Vertical, horizontal, or oblique lines simulating incisions were marked over the pes anserinus and ultrasound was used to visualize the structures that could be injured during the marked incisions. The IPBSN was visualized in 58 lower limbs (96.7%). The results of the simulation study indicated that the vertical incision should be avoided during hamstring tendon harvesting, as it is associated with a significantly higher risk of injury (25.9%) to the IPBSN than the horizontal (3.5%) or oblique (8.6%) incisions. We recommend that a preoperative ultrasound assessment of IPBSN anatomy be performed to minimize the risk of iatrogenic injury to the nerve and associated complications. Clin. Anat. 30:868–872, 2017. © 2017 Wiley Periodicals, Inc.     

腓肠神经及其两根的应用解剖学观测

目的观测人腓肠神经的构成类型,长、宽以及构成腓肠神经的两根的位置、长度、宽度,以补充国人腓肠神经的解剖学资料为临床腓肠神经的移植提供依据。方法利用直尺及游标卡尺（精确度0．02mm）对腓肠神经,腓肠内、外侧皮神经的长、宽进行测量,对腓肠内、外侧皮神经位置及腓肠神经的组成型式进行观测统计。结果腓肠神经的构成型式较前人的观察更为复杂,因此本文采用了新的分型方法。腓肠内、外侧皮神经的发出位置多变,腓肠神经起始部、中点及外踝平面宽度不同。结论腓肠神经及其两根型式复杂,临床选择移植体时应充分考虑其型式及长度、宽度,以便更加适应受区特征。     

Proximal great saphenous vein cut down: an evaluation of techniques and anatomical considerations

Cut-down techniques by which emergency venous access can be achieved are important, particularly, in the resuscitation of haemodynamically depleted patients where percutaneous access to collapsed veins is a problem. The aim was to evaluate the efficacy of different methods that are used to locate the proximal great saphenous vein in the thigh and to describe the vein's immediate course. A further component was to identify the position of the valves in the proximal great saphenous vein. Needles were placed in 42 cadaver thighs as defined by the techniques identified from the literature and surgical practice. After a detailed dissection, the vein's relation to these needles was measured and the course of the vein and number of valves noted in relation to easily identifiable landmarks. Landmarks in 2.5-cm intervals on a line from the pubic tubercle to the adductor tubercle of the femur were used. The rule of two's, an experimental method by one of the authors, along with Dronen's second method localized the vein most successfully. The course of the vein was scrutinized and found to have a rather direct course as it proceeded medially toward the saphenous hiatus. The largest population of valves could be found in the proximal 5 cm (76%) with a valve in the confluence of the great saphenous vein and the femoral vein being the most common. Valve populations were found to decrease in number from proximal to distal, which would have implications with the placement of catheters into the vein for fluid resuscitation.     

足踝部小隐静脉干与属支的解剖观测及其临床意义

目的为更好地处理远端蒂腓肠神经营养血管皮瓣中的小隐静脉以减轻皮瓣静脉血"倒灌"提供解剖依据。方法对40侧福尔马林液浸泡的成人尸体足踝区的小隐静脉干及其属支进行解剖。以踝关节线(经外踝尖的水平线)为基准观测小隐静脉的起始类型,以及足踝部外侧引流静脉汇入小隐静脉干的最高点至踝关节线的垂直距离。结果按足踝部小隐静脉各属支起源、行走路径及汇聚情况将小隐静脉的起始类型分为4类:单主支起始型出现率为47.5%(19侧)、双主支起始型27.5%(11侧)、3主支起始型10.0%(4侧)和4主支起始型15.0%(6侧);按足踝部外侧属支汇入小隐静脉干的最高点至踝关节线的垂直距离可分为3类,低位起始型占10.0%(4侧)、中位起始型35.0%(14侧)和高位起始型55.0%(22侧)。结论在足踝部小隐静脉属支汇聚成干的形式在各标本间均不相同,有些差异较大。故对远端蒂腓肠神经营养血管皮瓣,欲提高阻止静脉血"倒灌"的效果,不仅要结扎小隐静脉干,还必须结扎小隐静脉干结扎线以上且可回流至蒂部的小隐静脉的属支。     

腓肠外侧皮神经营养血管岛状筋膜皮瓣的解剖学基础

目的 :为腓肠外侧皮神经营养血管岛状筋膜皮瓣提供解剖学依据。方法 :采用巨微解剖、全身动脉放射显影及电脑图像分析技术 ,解剖观察了腓肠外侧皮神经及其营养血管的起始、走行、分支与分布情况。结果 :腓肠外侧皮神经于腓骨头上方 ( 7.1± 1.3 )cm ,中线外侧 ( 1.8± 0 .6)cm起自腓总神经 ,分支分布于小腿后外侧上 2 /3部 ,末端与腓肠内侧皮神经相吻合。其营养动脉主要为窝外侧皮动脉 ,于腓骨头水平面上方 ( 4 .6± 2 .3 )cm处发自动脉 ,并于腓骨头上 ( 4 .6± 1.2 )cm ,中线外侧 ( 2 .1± 0 .5 )cm处开始伴行腓肠外侧皮神经下降 ,下端主要与腓动脉穿支吻合 ,形成一营养血管链。结论 :以腓肠外侧皮神经及其营养血管链为蒂可以设计近端或远端蒂岛状筋膜皮瓣。     

Anatomic study of the superficial sural artery and its implication in the neurocutaneous vascularized sural nerve free flap

Combined extended nerve and soft tissue defects of the upper extremity require nerve reconstruction and adequate soft tissue coverage. This study focuses on the reliability of the free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap within this indication. An anatomical study was performed on 26 cadaveric lower extremities that had been Thiel fixated and color silicone injected. Dissection of the fasciocutaneous posterior calf flap involved the medial sural nerve and superficial sural artery (SSA) with its septocutaneous perforators, extended laterally to include the lateral cutaneous branch of the sural nerve and continued to the popliteal origin of the vascular pedicle and the nerves. The vessel and nerves diameter were measured with an eyepiece reticle at 4.5× magnification. Length and diameter of the nerves and vessels were carefully assessed and reported in the dissection book. A total of 26 flaps were dissected. The SSA originated from the medial sural artery (13 cases), the popliteal artery (12 cases), or the lateral sural artery (one case). The average size of the SSA was 1.4 ± 0.4 mm. The mean pedicle length before the artery joined the sural nerve was 4.5 ± 1.9 cm. A comitant vein was present in 21 cases with an average diameter of 2.0 ± 0.8 mm, in 5 cases a separate vein needed to be dissected with an average diameter of 3.5 ± 0.4 mm. The mean medial vascularized sural nerve length was 21.2 ± 8.9 cm. Because of inclusion of the vascularized part of the lateral branch of the sural nerve (mean length of 16.7 ± 4.8 cm), a total of 35.0 ± 9.6 cm mean length of vascularized nerve could be gained from each extremity. The free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap pedicled on the SSA offers a reliable solution for complex tissue and nerve defect. Clin. Anat. 26:903–910, 2013. © 2012 Wiley Periodicals, Inc.     

隐神经收肌管段的应用解剖学

在80侧成人下肢标本上观察了隐神经及其髌下支穿Hunter's管(收肌管)前壁的类型。其中隐神经除有93.8％穿该管前壁腱板浅出外,尚有6.3％未穿该管前壁腱板。神经穿出处之裂孔按形态分为3种:裂隙形(隐神经为74.7％;髌下支为65.0％)、近圆孔形(隐神经为14.7％;髌下支为20.0％)、狭窄形(隐神经为为10.7％;髌下支为15.0％。并测量了神经穿出点的位置距Hunter's管前壁腱板上缘的长度、裂孔的长度和横径,为临床探讨隐神经卡压症的病因和治疗提供应用解剖学资料。     

岩静脉及其与三叉神经关系的应用解剖

目的通过解剖国人尸体头颅标本,观察岩静脉起始与终止部位、形态、行程特点及其与三叉神经的毗邻关系,为三叉神经微血管减压术提供解剖学依据。方法用经10%福尔马林充分固定的成人尸头颅标本12例（24侧）,在手术显微镜下解剖岩静脉与三叉神经等结构,观察上述神经、血管的位置、走行方向及其相互关系,测量岩静脉长度、外径及其与三叉神经根最近距离等相关数据。结果在24例标本共发现岩静脉35支;其属支交汇处直径为（2.44±0.87）mm（1.15~4.10 mm）,汇入岩上窦处直径（2.60±0.93）mm（1.20~4.50 mm）;岩静脉主干长度为（5.05±3.53）mm（1.75~8.95 mm）;共有7支主干及2条束支与神经根接触或压迫,除7条主干接触者外,其主干与三叉神经根最近距离（7.09±4.48）mm（1.20~12.60 mm）。结论岩静脉与三叉神经关系密切,可与三叉神经接触并压迫神经,成为三叉神经痛发生的解剖学基础之一。岩静脉呈游离悬空状,其主干多粗短,术中易因过度牵拉而破裂出血导致严重的后果,对岩静脉影响手术者应提前将其分离后电凝切断。     

带蒂腓肠神经小隐静脉营养血管皮瓣的解剖与临床应用

目的:报道带蒂腓肠神经小隐静脉营养血管皮瓣修复小腿远端、踝足部软缺损的效果。方法:对18例小腿或足部不同部位软组织缺损,采用带腓肠神经血管蒂皮瓣逆行转移修复。皮瓣面积最大为13cm×5cm,最小为3cm×3cm。结果:17例全部成活,其中2例部分坏死,l例失败,随访效果满意。结论:此皮瓣是修复小腿远端、踝及足部软组织缺损的理想供区,具有切取方便,位置恒定,血供可靠。     

Cutaneous innervation of the ankle: An anatomical study showing danger zones for ankle surgery

Three nerves innervate the skin in the foot and ankle region: the saphenous, sural, and superficial peroneal nerves. Because they are close to the medial and lateral malleoli, these nerves are at significant risk during orthopedic interventions. The aims of this study were to investigate the distal courses of the three cutaneous nerves of the ankle and to determine their exact relationships with easily identifiable bony landmarks. Ten freshly frozen and 40 embalmed lower extremities of adults were dissected. The positions of the superficial peroneal, sural, and saphenous nerves were determined using reference lines based on easily palpable osseous landmarks. The frequencies and distributions of all three nerves and their branches were converted into absolute numbers. A danger zone for each nerve was established on the basis of the distribution of crossings between the nerves and the different reference lines. Determination of the exact orientation of the nerves around the ankle should help minimize the nerve injury rate during surgical approaches in this area. Using this easily translatable new grid system, the course and danger zones of each cutaneous nerve around the ankle can be estimated clinically. Clin. Anat. 653–658, 2014. © 2013 Wiley Periodicals, Inc.     

The relative contributions of the medial sural and peroneal communicating nerves to the sural nerve

The medial sural cutaneous nerve (MSCN) and peroneal communicating nerve (PCN) conjoin in the calf area to form the sural nerve (SN). In previous anatomic studies, there was unresolved debate as to the main contributor to the sural nerve, and the relative contributions of MSCN and PCN had not been studied. The purpose of this study is to determine their relative neurophysiologic contributions to the SN by nerve conduction study (NCS). A total of 47 healthy subjects (25 males and 22 females, mean age 29.6 +/- 10.4 yrs, range 20-59 yrs) participated in the study. This study employed the orthodromic nerve conduction technique: stimulation at the ankle and recording at the mid calf (SN); specifically, we preformed stimulation at the mid calf (MSCN, PCN) and recording at 14 cm proximal to the middle of the popliteal fossa (MSCN) and fibular head (PCN). The onset and peak latencies (ms) were SN 2.3 +/- 0.2 and 3.0 +/- 0.2; MSCN 2.1 +/- 0.2 and 2.8 +/- 0.2; and PCN 2.1 +/- 0.2 and 2.8 +/- 0.2. The peak-to-peak amplitudes (microV) and areas (nVsec) of the SN, MSCN, and PCN were 9.7 +/- 3.9, 7.0 +/- 4.7, and 5.0 +/- 3.2; and 7.2 +/- 2.9, 5.7 +/- 3.4, and 4.0 +/- 2.4, respectively. The side-to-side difference was not statistically significant. The main contributor to the SN was found to be the MSCN. The relative contribution ratio of the MSCN to the PCN was 1.37:1 by amplitude and 1.42:1 by area. However, in 32.9% of the subjects, the contribution of the PCN was greater than that of the MSCN.     

Clinicopathologic study of 43 patients with sural nerve vasculitis

Vasculitis is a relatively uncommon finding in sural nerve biopsy specimens and is associated with significant morbidity. This study retrospectively reviewed the clinicopathologic features of 43 patients (44 sural nerve biopsy specimens) with sural nerve vasculitis, defined as infiltration of vessel walls by inflammatory cells. These biopsy specimens were obtained over a 19-year period, during which 1503 nerve specimens were reviewed. The study group comprised 29 females and 14 males, ranging in age from 19 to 94 years (mean, 72.5 years) at the time of biopsy. The most frequent clinical presentations included paresthesias in 19 patients (61%), pain in 17 patients (57%), weakness in 10 patients (32%), and weight loss in 9 patients (29%). Histologically, 26 of 44 biopsy specimens (59%) demonstrated necrotizing vasculitis. The remaining 18 biopsy specimens demonstrated a nonnecrotizing lymphocytic vasculitis. Eosinophils were identified in 4 biopsy specimens, intravascular thrombi in 10 (22%) specimens, and granulomatous inflammation in 1 specimen. In 39 biopsy specimens (89%), multiple vessels were involved by vasculitis. Epineurial vessels were the most common target of vasculitis, (n = 42; 95%). Evidence of vascular wall scarring, indicative of healed vasculitis, was observed in 13 biopsy specimens (30%). All biopsy specimens showed evidence of axonopathy, with mild axonal loss noted in 14 specimens (32%), moderate loss in 18 specimens (41%), and severe loss in 12 specimens (27%). Concomitant muscle biopsy was performed in 31 patients. Fifteen muscle biopsy specimens demonstrated evidence of vasculitis (48%), which was necrotizing in 11 cases. All muscle biopsy specimens demonstrated features of neurogenic atrophy. Twenty-five out of 32 patients were known to have been treated with steroids and demonstrated some degree of clinical improvement. In conclusion, sural nerve vasculitis is a relatively uncommon pathological finding (prevalence of 2.9% in this study). In most cases, multiple vessels were involved. Concomitant vasculitis was also identified in about half of the muscle biopsy specimens obtained at the time of nerve biopsy. In most patients, the vasculitis appeared to be at least partially responsive to immunosuppressive therapy.     

Formation and distribution of the sural nerve based on nerve fascicle and nerve fiber analyses

The formation and distribution of the sural nerve are presented on the basis of an investigation of 31 legs of Japanese cadavers using nerve fascicle and fiber analyses. Nerve fibers constituting the medial sural cutaneous nerve were designated as 'T', whereas those constituting the peroneal communicating branch were designated as 'F'. In 74.2% of cases (23/31), the T and F fibers joined each other in the leg, whereas in 9.7% of cases (3/31) they descended separately. In 16.1% of cases (5/31), the sural nerve was formed of only the T fibers. The sural nerve gave off lateral calcaneal branches and medial and lateral branches at the ankle. The lateral calcaneal branches always contained T fibers. The medial branches consisted of only T fibers, whereas most of the lateral branches consisted of only F fibers (71.0%; 22/31). In addition to the T and F fibers, P fibers, which derived from the superficial and deep peroneal nerves, formed the dorsal digital nerves. The P fibers were entirely supplied to the medial four and one-half toes. However, they were gradually replaced by the T and F fibers in the lateral direction. The 10th proper dorsal digital nerve consisted of T fibers only (38.7%; 12/31), of F fibers only (19.4%; 6/31) or of both T and F fibers (38.7%; 12/31). These findings suggest that the T fibers are essential nerve components for the skin and deep structures of the ankle and heel rather than the skin of the lateral side of the fifth toe. The designation of the medial sural cutaneous nerve should be avoided and only the T fibers are appropriate components for naming as the sural nerve.     

小隐静脉旁淋巴管的应用解剖

目的　研究小隐静脉旁淋巴管的解剖特征,为临床应用提供解剖学基础。  方法　成人新鲜尸体3具,截取3对下肢。外踝后皮内注入少量双氧水,真皮下找到淋巴管,将显影剂经30G注射针注入,使其显影,追踪并显示小隐静脉旁淋巴管的走行,同时进行拍照及X线摄像,依次到达小腿及腘窝。  结果　小隐静脉旁均可见内侧支和外侧支集合淋巴管,有的始于外踝后区真皮下,有的始于小腿后下部。淋巴管沿小隐静脉两侧蜿蜒曲折向心性走行,管间有分支相连接。近腘窝时,淋巴管与小隐静脉一起穿过深筋膜进入腘窝,然后发出多个小分支汇入淋巴结。此组淋巴管管径在0.3~1.5 mm之间,近侧较粗,远侧稍细。  结论　精确描述了下肢小隐静脉旁淋巴管的分布与走行,为临床应用提供重要的解剖学参考。