神经端侧吻合的腓肠神经营养血管皮瓣修复足踝部缺损的临床研究

目的利用腓肠神经皮瓣所带的腓肠神经内侧支和外侧支与创面周围的腓深神经或胫神经端侧吻合，重建皮瓣的感觉以及恢复足背外侧感觉。以解决患者足踝部感觉缺失的痛苦。方法从2000年1月至2003年5月，收治足踝部软组织缺损40例(43足)，其中A组20例(22足)直接进行腓肠神经营养血管皮瓣移植，B组20例(21足)在切取皮瓣时，在腓肠神经近端多取1～2cm腓肠神经内侧支和外侧支，在覆盖创面时，先分离出创面周围的腓浅神经或胫神经，把腓肠神经断端与腓浅神经或胫神经作端侧吻合，再按腓肠神经营养皮瓣处理。两组都在术后3、6、9个月分别进行随访，按照感觉检查分级标准把皮瓣和足背外侧感觉恢复情况分成S1～S5 5级，并按感觉恢复范围分成R1：小于25％；R2：25％～50％，R3：50％～75％，R4：75％～100％。结果术后3个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 18足、S2 4足、R1 22足，B组，S1 17足、S2 4足，R1 21足；两组皮瓣和足背外侧皮肤感觉恢复情况无差别、术后6个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 15足、S2 6足、S3 1足，R1 18足、R24足，B组，S16足、S36足、S49足，R2 4足、R3 12足、R4 5足；B组无论皮瓣及足背外侧感觉恢复的等级还是感觉恢复的范围都比A组好。术后9个月，皮瓣及足背外侧皮肤感觉恢复情况：A组，S1 14足、S2 7足、S3 1足，R1 17足、R2 5足，B组，S3 2足、S44足、S5 15足，R35足、R416足；B组皮瓣及足背外侧感觉基本恢复正常，A组感觉恢复进展不大。供体神经功能无明显影响。结论作腓肠神经营养皮瓣移植时行腓肠神经与创面周围胫神经或腓浅神经端侧吻合手术简单，对胫神经或腓浅神经无不良影响，而皮瓣和足背外侧感觉恢复较好。     

足踝部外伤皮肤缺损常用带蒂皮瓣的选择

目的 探讨总结足踝部外伤皮肤缺损的特点和常用带蒂皮瓣的选择,并针对修复不同部位皮肤缺损的皮瓣供区选择提供建议和参考. 方法 采用足背皮瓣、足底内侧皮瓣、跖底皮瓣、(足母)趾腓侧皮瓣、第2趾胫侧皮瓣、胫前皮瓣、小腿内侧皮瓣、腓肠神经皮瓣、跗外侧皮瓣、踝前皮瓣、腓动脉皮瓣等行带蒂转移修复前足、足背、足底及踝部皮肤缺损. 结果 术后251例皮瓣除2例坏死外全部成活.5例术后第1天、2例第2天因植皮处包扎过紧,出现血管危象,探查后血运恢复正常.135例随访3～96个月,平均16个月,足底内侧皮瓣有4例、跖底皮瓣3例,转移后出现皮瓣和足底皮肤缝合处的磨损,二期皮瓣修整,改变负重点恢复正常行走.9例小腿内侧皮瓣、6例腓肠神经营养血管皮瓣,因为皮瓣臃肿行二期整形.其余皮瓣无明显臃肿,外形良好,不需要二期整形.其中足底内侧皮瓣和躅趾腓侧皮瓣、第2趾胫侧皮瓣顺行转移均带感觉神经,供区为非负重部位,不影响患者行走及负重功能,术后皮瓣感觉正常,两点辨别觉4 ～10 mm. 结论 足底内侧皮瓣、跖底皮瓣、(足母)趾腓侧皮瓣及第2趾胫侧皮瓣修复前足跖侧较好,皮肤耐磨,感觉好;足背皮瓣、胫前皮瓣、小腿内侧皮瓣、腓肠神经营养血管皮瓣、跗外侧皮瓣、踝前皮瓣、腓动脉皮支皮瓣、腓动脉皮瓣等皮瓣可以切取的面积较大,修复足背及踝关节周围皮肤缺损,具有皮瓣较薄、色泽接近和锯剖位置恒定等优点.以上皮瓣均操作简单,修复效果好,是修复足踝部皮肤缺损的良好方法.     

逆行腓肠神经营养血管皮瓣的感觉重建

目的 探讨逆行腓肠神经营养血管皮瓣切取后皮瓣与足外侧的感觉重建方法和临床疗效.方法 对足跟软组织缺损病例13例,应用逆行腓肠神经营养血管皮瓣修复的同时,将皮瓣内的腓肠神经近端与腓浅神经吻合,重建皮瓣和足外侧感觉,术后9～15个月随访,测试皮瓣和足外侧的痛觉、触觉、温度觉和两点辨别觉恢复情况.结果 13例皮瓣全部成活,皮瓣血运良好,修复创面一期愈合,随访9～15个月,皮瓣感觉恢复优良率为53.85%,足背外侧皮肤恢复保护性感觉,感觉恢复优良率61.54%.结论 应用逆行腓肠神经营养血管皮瓣修复足跟软组织缺损时,将腓肠神经近端与腓浅神经吻合,可改善皮瓣和足背外侧皮肤感觉功能恢复.

Abstract：

Objective To explore the method of sensory reconstruction after the operation of reversed island pedicled sural flap and evaluate its therapeutic effect of clinical application. Methods Thirteen clinical cases with traumatic soft tissue defects in heel had recepted the treatment of reversed island pedicled sural flap. All flaps were innervated by anastomosing the distal end of the sural nerve in the flaps and the recipient nerve (superficial peroneal nerve) in end to end or end to side. All patients were evaluated at 9-15 months on the postoperative follow-up parameters, including flap contour, flap stability, locomotor activity,touch sensation, pain sensation, static two-point discrimination, thermal sensibility, and the skin sensory recovery level in lateral dorsutn of foot. Results Thirteen cases flaps had good blood supply and primary healing. All cases were followed up 9-15 months, the rate of good sensory recovery was 53.85%. All pa tients had protective sensory in lateral dorsum of foot, the rate of good sensory recovery was 61.54%. Conclusion Anastomosing the proximal end of sural nerve and superficial peroneal nerve together will be good for the sensory recovery in flap and lateral foot in repairing soft tissue defects in heel with reversed island pedicled sural flap.     

腓肠神经营养血管逆行岛状皮瓣修复足踝部大面积软组织缺损

目的总结采用腓肠神经营养血管逆行岛状皮瓣修复足、踝、胫前区大面积皮肤软组织缺损的临床效果。方法2004年6月-2008年12月,收治12例足、踝及胫前区大面积皮肤软组织缺损患者。男8例,女4例;年龄21～63岁,平均44.8岁。交通伤9例,慢性溃疡、胫前区术后瘢痕、足背皮肤撕脱伤术后感染坏死创面各1例。缺损部位:足背6例,足跟、踝部、胫前区各2例。软组织缺损范围6cm×4cm～16cm×9cm。病程3d～18个月。采用大小为8cm×6cm～18cm×10cm的腓肠神经营养血管逆行岛状皮瓣修复缺损,将小隐静脉近端与创面周围的回流静脉吻合,腓肠神经近端与皮瓣受区供体神经端侧缝合。供区植皮修复。结果术后皮瓣均顺利成活,创面Ⅰ期愈合。供区2例植皮部分坏死,经换药后成活;其余植皮均顺利成活,切口Ⅰ期愈合。12例均获随访,随访时间6～14个月,平均9个月。术后16周根据英国医学研究会标准进行感觉功能评定,其中S23例,S2+5例,S34例。其中9例皮瓣两点辨别觉10～16mm,平均14mm。皮瓣色泽、质地、弹性良好,行走后无水疱及皮肤破溃损伤等。结论腓肠神经营养血管逆行岛状皮瓣修复足、踝及胫前区大面积皮肤软组织缺损时,将小隐静脉近端与受区回流静脉吻合,腓肠神经近端与皮瓣受区供体神经端侧缝合,利于皮瓣成活及感觉恢复,修复效果良好。     

腓肠神经营养血管皮瓣的临床应用

目的探讨腓肠神经营养血管皮瓣的优越性。方法用逆行腓肠神经营养血管皮瓣对15例患者的足背、内外踝、小腿中下段、胫前部皮肤缺损进行修复，同时观察腓肠神经及营养血管的走行特点。结果15例完全成活，无一例坏死或部分坏死。转移的皮瓣均于术后6个月恢复感觉。结论腓肠神经营养血管皮瓣切取简便，成功率高，最远可达足前中部，是修复足跟、足背、内外踝、及小腿中下段软组织缺损的理想供区。     

股前外侧游离皮瓣修复足跟大面积软组织缺损

目的探讨股前外侧游离皮瓣移植修复足跟大面积创伤性软组织缺损的临床效果。方法1997年10月至2005年3月，应用股前外侧游离皮瓣移植修复足跟大面积软组织缺损26例，将旋股外侧动脉降支及其伴行静脉分别与胫后动静脉吻合，并将股外侧皮神经与隐神经或腓肠神经吻合，使皮瓣具有感觉功能，并将阔筋膜缝合固定于跟骨以增加皮瓣稳定性。结果移植皮瓣全部成活，创面一期愈合，经3个月至4年的随访，皮瓣感觉部分恢复，足跟外形与稳定性良好。结论股前外侧游离皮瓣供区隐蔽，血供丰富，可切取范围大，特别是带有感觉神经和阔筋膜，修复足跟耐磨、稳定性好，是修复足跟大面积软组织缺损的理想皮瓣。     

保留腓肠神经的血管筋膜蒂皮瓣的解剖及临床研究

目的 研究保留腓肠神经的腓动脉穿支皮瓣的可行性、方法 及适应证,以改进常规腓肠神经营养血管皮瓣术后足外侧皮肤感觉障碍的缺陷. 方法 选择8具16个成人下肢标本,其中新鲜标本8个,经股动、静脉分别灌注红蓝色乳胶48 h后,解剖研究腓肠神经及小隐静脉伴行动脉的关系.临床应用保留腓肠神经主干或内、外侧支的血管筋膜皮瓣修复足踝皮肤缺损12例. 结果 腓肠神经及小隐静脉有各自的伴行血管,伴行血管与腓肠神经及小隐静脉的距离不恒定,在1～8哪之间,两条伴行血管相互交通.腓动脉最低穿支距踝尖12～32 min,平均22 mm,穿支直径1.0～1.5 mm,平均1.2mm.临床保留腓肠神经主干、内侧支或外侧支的皮瓣12例.术后4例腓肠神经支配区皮肤感觉正常;4例S2+～S3;2例外踝区域S0感觉消失,2例足外侧S1.经6～24个月的随访,4例S2+～S3于术后5～30 d恢复达基本正常. 结论 保留神经对保存足部皮肤感觉有积极的意义,腓肠神经及小隐静脉各有一条伴行动脉是保留神经的解剖基础.当营养血管绕过神经,很难分离神经时,可以术中放弃保留神经.     

腓肠神经营养血管逆行岛状筋膜皮瓣的解剖及临床应用

目的　了解分析腓肠神经及营养血管的解剖特性 ,为临床设计以腓肠神经营养血管为蒂的逆行岛状皮瓣提供依据。　方法　取 4只福尔马林浸泡的下肢标本 ,红色乳胶灌注 ;6只新鲜截肢小腿 ,采用中国墨汁自腓动脉和胫后动脉灌注后进行解剖学观察。临床应用皮瓣修复足部皮肤缺损 16例 ,皮瓣最大面积为 9cm× 18cm。　结果　腓肠浅动脉是腓肠神经营养血管 ,起源于动脉 ,在小腿中下段与来源腓动脉肌间隔皮支和 /或胫后动脉的肌皮支在深筋膜层有广泛吻合 ;营养血管呈节段性供血 ,深筋膜血管网供血范围上至小腿中上 1/3交界处 ,两侧在中线 ,腓动脉肌间隔皮支和 /或胫后动脉的肌皮支最远端位于外踝上 5 0～ 7 5cm。临床应用 16例 ,其中修复足背皮肤缺损 12例 ,修复足跟皮肤缺损 4例 ,皮瓣全部成活。　结论　以腓肠神经营养血管为蒂的逆行岛状筋膜皮瓣是一种修复足部皮肤缺损 ,具有不牺牲主要动脉 ,操作灵活优点的皮瓣 ;切取皮瓣面积较大时供瓣区难以直接缝合 ,需植皮修复是其缺点。     

股前外侧皮瓣移植修复足背皮肤缺损一例

股前外侧皮瓣移植修复足背皮肤缺损一例温晓阳患者男，３２岁。因车祸致右足背皮肤、皮下组织缺损，骨外露急诊入院。入障后即行左股前外侧皮瓣游离移植修复术。皮瓣面积２３×１８ｃｍ，旋股外动、静脉降支分别与胫前动脉、大隐静脉端侧吻合。股外侧皮神经与腓肠外侧皮神...     

带腓肠神经营养血管的逆行岛状皮瓣移植一例

患者女，６８岁，因车祸致右足跟足底大面积逆行皮肤撕脱伤入院。急诊清创将皮肤修成全厚皮片原位缝合，术后足底部分皮肤成活，遗留跟底及足背外侧１０ｃｍ×２５ｃｍ的创面。遂用带腓肠神经营养血管岛状皮瓣逆行转移修复。腓肠神经与足背内侧皮神经端端外膜吻合，皮瓣蒂...     

Anatomic study and clinical application of distally-based neuro-myocutaneous compound flaps in the leg

OBJECTIVE: Anatomical study on the anastomosis between the neurovascular axis and the musculocutaneous perforators in leg. The distally-based neuron-myocutaneous flap was used for repairing special patients with soft tissue defect in foot and ankle. METHODS: Systematical observation was carried out on 30 injected lower legs about the anastomosis between the neurovascular axis and the musculocutaneous perforators, and we summarized the clinical experiences from February 2004 on 12 cases using distally-based neuron-myocutaneous flap for repairing special patients with soft tissue defect in foot and ankle. RESULTS: The neuron-vessels of sural nerve anastomosed permanently with the musculocutaneous perforators of medial and lateral head of gastrocnemius. There were two to three anastomoses found, respectively. The medial anastomotic branches were found larger in caliber than the lateral ones. The spatium intermuscular branches of the posterior tibial artery gave off their junior branches and anastomosed with the vessels in or out of the soleus muscle. There were two to three muscular branches perforated out of the soleus muscle, with mean caliber 0.5 +/- 0.2 mm and accompanying with one to two veins. The neuron-vessels of the superficial fibular nerve gave off alone its course two to three muscular branches to the long extensor muscle digits and the long fibular muscle, and one to two fasciocutaneous to the skin. The diameter of the muscular branches was 0.4 +/- 0.2 mm in average. Accounting for the operating models in the 12 cases, we had distally-based sural neuron-myocutaneous flap in 7 cases, saphenous neuron-myocutaneous flap in 4 cases, and superficial fibular neuron-myocutaneous flap in 1 case. All these cases were followed up at least for 2-6 months and had the significant results of nice limb's shape and cured osteomyelitis. CONCLUSION: Distally-based neuro-myocutaneous flap in leg can live with reliable blood circulation. These flaps offer excellent donor sites for repairing special the soft tissue defect in foot and ankle.     

股前外侧皮瓣和腓肠神经营养血管皮瓣联合修复足部套状撕脱伤

目的 探讨吻合神经的股前外侧皮瓣和腓肠神经营养血管皮瓣联合修复足部套状逆行撕脱伤的临床效果。方法 足部套状逆行撕脱伤患者14例，男10例，女4例；年龄16-58岁，平均31岁。切取带股前外侧皮神经的股前外侧皮瓣移植至足部，将股前外侧皮神经与足底内侧神经吻合，并将足底外侧神经植人股前外侧皮瓣的足底修复区；转移腓肠神经营养血管皮瓣修复足外侧部。将腓浅神经及其分支分别与腓肠内、外侧皮神经吻合。按照Swanson等制定的周围神经损伤临床疗效评定方法，将感觉分成S1-S55级，将感觉恢复范围分为R1（〈25％）、R2（25％-50％）、R3（50％-75％）与R4（75％～100％）4级。结果 14例移植皮瓣均成活，术后外形良好。术后6个月足部感觉恢复分级：足内侧，S26足，S38足；足底，S29足，S35足；足外侧，S23足，S311足。足部感觉恢复范围：足内侧，R14足，R210足；足底，R18足、R26足；足外侧，R14足、R210足。术后9个月足部感觉恢复分级：足内侧，S37足，S47足；足底，S22足，S36足，S46足；足外侧，S38足，S46足。足部感觉恢复范围：足内侧，R25足，R38足，R41足；足底，R28足，R34足，R42足；足外侧，R25足，R37足，R42足。结论 吻合神经的股前外侧皮瓣和腓肠神经营养血管皮瓣联合修复足部套状逆行撕脱伤具有供区隐蔽、实用，受区感觉恢复理想的特点。     

腓浅神经营养血管远端蒂皮瓣感觉重建的解剖学基础

目的 为腓浅神经营养血管远端蒂皮瓣感觉功能重建提供解剖学依据. 方法 在40侧常规防腐的成人下肢标本上,解剖观测小腿外侧部感觉神经的来源、走行及分布规律.1例标本摹拟手术设计. 结果 ①腓肠外侧皮神经在腓骨头尖平面上方约7 cm处自腓总神经发出,向下随腓总神经行一短程后穿出胭筋膜至小腿外面,沿途发出1～3个终支,分布于小腿后外侧Ⅰ、Ⅱ区的皮肤.②腓浅神经在腓骨头下1.9 cm处起于腓总神经,先于腓骨长肌与腓骨之间向下向前行,继降于腓骨长肌与腓骨短肌之间并分支供应两肌,其主干(纯感觉支)径直下行于腓骨短肌与小腿前肌间隔之间,在小腿外侧Ⅱ、Ⅲ区交界处穿出深筋膜至皮下组织中分为足背内侧、中间皮神经,分布于小腿外侧Ⅲ区和足背的皮肤.结论 通过腓肠外侧皮神经主干与受区感觉神经分支吻合,可重建腓浅神经营养血管远端蒂皮瓣的感觉功能.     

神经端侧吻合重建足部皮瓣手术后感觉功能

目的 重建小腿部皮瓣移转术后足部皮肤感觉功能。方法 小腿内侧隐神经营养血管筋膜皮瓣移转后,将被切断的隐神经远侧段与腓肠神经端侧吻合。小腿逆行皮神经营养血管皮瓣（腓肠神经伴行血管供血）移转术后,将皮瓣近端携带的腓肠神经与足背皮神经端侧吻合。另可切取次要皮神经与足背皮神经端侧吻合,其远段植入移转至足部的失神经支配皮瓣的感觉功能等方法。结果 临床手术３例病人分别经２０、９和３６个月随诊,效果转好。结论     

逆行及顺行腓肠神经营养血管皮瓣的临床应用

目的探讨腓肠神经营养血管皮瓣逆行转移修复足背、足跟及踝部组织缺损,顺行转移修复膝部组织缺损的临床应用效果。方法在应用解剖及对成人小腿和足背长度测量基础上,设计带筋膜蒂的腓肠神经营养血管岛状皮瓣,逆行应用修复足背、足跟、足底及踝部软组织缺损,顺行应用修复膝部软组织的缺损。同时观察皮瓣的可切取范围、血液供应及静脉回流情况、营养血管在外踝上与腓动脉穿通支的位置及血管蒂隧道的处理方案。结果临床应用23例,其中修复足背组织缺损11例、足跟软组织缺损5例、膝软组织缺损3例、足底软组织缺损1例及外踝及足背联合缺损3例。皮瓣最大面积16cm×10cm,全部成活。结论腓肠神经营养血管皮瓣血液循环丰富,成活率高,是修复足背、足跟、踝部、足底及膝部软组织缺损的理想皮瓣。     

The distally based posterolateral supramalleolar neurofasciocutaneous island flap for coverage defects over the distal third of the leg and foot

A traditional-designed distally based sural flap centralized on the axis of the (medial) sural nerve and the lesser saphenous vein has been used widely for coverage of the distal third of the leg, ankle, malleoli, and foot. However, a variety of 5% to 47% of flap necrosis after the flap elevation and transposition were recorded in the literature. The unreliability of the distal part of the flap, especially when skin paddle located at the proximal third of the leg is at least partly due to their subfascial coursing of the median superficial sural artery and the medial sural nerve as well as the lesser saphenous vein. Based on the anatomic characteristics of the sural nerve and previous angiographic studies, a longitudinal chain-linked axial vascular network along with the sural nerve and the lateral sural nerve had been demonstrated on the posterolateral side of the leg from lateral retromalleolar gutter to the fibular head. A distally based posterolateral supramalleolar neurofasciocutaneous island flap centralized on this longitudinal neurovascular network was designed and used to reconstruct and cover the defects over the distal third of the leg, lateral malleolus, foot, and Achilles tendon. In this report we retrospectively review the clinical outcomes. This flap was used in 11 patients, including six young children aged 3 to 6 years. All flaps survived fully without complications except one flap which experienced postoperative infection which was controlled by dressing change and antibiotic application. Relevant surgical anatomy and detailed surgical techniques for elevation of the flap and its versatile usage are presented. Risks leading to flap necrosis, safe pedicle design, and manipulations etc. are discussed. In conclusion, this distally based posterolateral supramalleolar neurofasciocutaneous island flap is reliable and very useful for covering defects over the distal leg, ankle, heel, foot, and Achilles tendon, especially in young children.     

Anatomical study of medial and lateral sural cutaneous nerve: implications for innervated distally-based superficial sural artery flap

We report about reconstruction of the foot with an innervated distally-based superficial sural artery flap using the lateral sural cutaneous nerve. The sensation of the lateral part of the leg depends on the sural nerve (SN), and the medial part of the leg on the saphenous nerve. The border of the area between the SN and the saphenous nerve, however, is not clear. To elucidate the distribution of the medial and lateral sural cutaneous nerves, the origin, diameter, course, branches, and distributions were recorded in 40 adult cadaver lower legs. The medial and lateral nerves in all legs (n = 40) were identifiable. In one leg, the SN was a direct continuation of the medial branch, and the lateral branch ended in the middle of the lower leg. Thick (>1 mm) sub-branches from the lateral branch were identified in 26 legs. Most cutaneous branches from it ended in the middle of the sural area. We applied the innervated distally-based sural artery flap using the lateral branch in 2 cases and obtained good recovery of sensation. The lateral branch supplies most of the central sural area and is required for the innervation of the distally-based superficial sural artery flap.     

腓肠神经营养血管筋膜蒂岛状筋膜皮瓣修复足部皮肤缺损

目的:观察应用腓肠神经营养血管筋膜蒂岛状筋膜皮瓣修复足部皮肤缺损的临床效果方法:以腓肠神经营养血管筋膜蒂岛状筋膜皮瓣修复足部皮肤缺损16例,创面最大10cm×14cm,最小5cm×7cm,其中足背部皮肤缺损10例,足跟部皮肤缺损6例。结果:16例皮瓣均成活;1例远端边缘出现水疱,但无坏死;术后经4～24个月随访,皮瓣外形及足功能恢复均良好结论:应用腓肠神经营养血管筋膜蒂岛状筋膜皮瓣修复足部皮肤缺损切取方便,成活率高,疗效好,易于广大基层医院普及。     

吻合血管的足背三叶皮瓣的解剖学研究

目的对足背动脉进行解剖学研究，为设计并应用足背三叶皮瓣提供依据。方法１０只新鲜成人足标本，用乳胶灌注后对胫前动脉→足背动脉在足内侧区、第一跖背区、足外侧区的分支进行解剖学观察。结果足内侧区皮肤的血供由足背动脉发出内踝前动脉或跗内侧动脉支配，足外侧区皮肤的血供由足背动脉发出外踝前动脉或跗外侧动脉供应，第一跖背区皮肤的血供由足背动脉－第一跖背动脉的皮支营养，各区域供养血管互有代偿。结论以足背动脉及伴行静脉为血管蒂的足背三叶皮瓣，血供可靠，可用于修复多指皮肤缺损。