带监测皮岛的吻合血管腓骨移植修复下肢骨缺损

目的 观察带监测皮岛的吻合血管腓骨移植修复下肢大块骨缺损中监测皮岛血循环的可靠性与实用性。方法 以源于腓动脉的比目鱼肌肌皮支供血的小腿外侧皮肤设计监测皮岛的吻合血管的腓骨移植修复下肢长骨缺损,通过观察监则皮岛的血运监测移植腓骨的血供情况。结果 临床应用１６例,其中有６例监测皮岛于术后监测过程中准确提示了移植腓骨血循环障碍,并经及时手术处理而恢复血供,１６例腓骨游离移植均达早期骨性愈合。结论 监测皮     

Free vascularized osteocutaneous fibular graft to the tibia

We reviewed the clinical results of reconstruction performed for extensive tibial bone and soft tissue defect with a free vascularized osteocutaneous fibular graft in 46 patients (43 male and 3 female). The mean duration of follow-up was 30 months (range 13-76 months). The mean age at the time of reconstruction was 41 years (range 15-66 years). In the 46 consecutive procedures of free vascularized osteocutaneous fibular grafts, bony union was achieved in 43 grafted fibulae at an average of 3.75 months after operation. There were two delayed unions and one non-union. Forty-four cutaneous flaps survived, and two cutaneous flaps failed due to deep infection and venous insufficiency. One necrotized cutaneous flap was replaced with a latissimus dorsi free flap and the other with a soleus muscle rotational flap without replacing the grafted fibulae; unions were obtained without significance complications. All grafted fibulae hypertrophied during the follow-up periods. The most common complication was fracture of the grafted fibulae in 15 patients, and it occurred at an average of 9.7 months after the reconstruction. The fractured fibulae were treated with long leg above-the-knee cast immobilization or internal fixation with conventional cancellous bone graft. Free vascularized osteocutaneous fibular graft is a good treatment modality for the reconstruction of extensive bone and soft tissue defect in the leg. Fracture of the grafted fibula, one of the most common complications after this operation, can easily be treated with cast immobilization or internal fixation with conventional cancellous bone graft.     

带血管腓骨移植的远期疗效报告

目的分析带血管腓骨移植修复四肢长骨缺损的远期效果。方法对 19例应用带血管腓骨移植修复不同部位骨缺损患者进行 5～ 20年 (平均 10.79年 )远期随访,参照 Enneking系统对患肢功能进行评价,采用等级记分法,以达到正常肢体功能的百分数表示。对移植腓骨的转归,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”进行结果评定。结果应用带血管腓骨移植修复骨缺损的远期效果因缺损类型的不同而存在较大差异。 9例先天性胫骨假关节患者,术后肢体功能恢复 65％,其中移植腓骨骨不连 1例、骨折 3例 (7次 )、成角畸形 5例; 3例先天性桡骨缺如患者,术后肢体功能恢复 62％, 3例术后均出现移植腓骨骨骺线早闭,畸形复发; 5例骨髓炎、骨外露、骨缺损并软组织缺损患者,术后肢体功能恢复 94％,仅 1例发生移植腓骨骨折; 1例前臂软组织缺损并尺骨缺损,尺神经、正中神经损伤者,术后肢体功能恢复 67％,骨愈合顺利; 1例桡骨海绵状血管瘤者,术后肢体功能恢复 100％,骨愈合顺利。结论带血管腓骨移植是修复长骨缺损的好方法,与其他组织瓣联合应用,可一次完成骨支架重建与软组织覆盖,有利于肢体功能的尽早恢复。但对先天性胫骨假关节和桡骨缺如患者 ,远期效果不甚理想。     

Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula

Free vascularized fibular grafts were used to treat seventeen patients who had extensive defects and pseudarthroses in long bones of the extremities. Of the seventeen, thirteen had been followed for from eighteen months to five years and could be evaluated. All thirteen grafts healed with no radiographic evidence of bone necrosis or resorption. During the immediate postoperative period, the patency of the anastomoses was monitored by observing the color of the skin of an island pedicle (so-called buoy) skin graft whose blood supply was in continuity with that of the fibular graft. Preoperative Doppler measurements were used to determine the most favorable location for the island pedicle graft. In the presence of defects of both bone and skin, the skin defect can be covered by using a large buoy flap. The largest flap used in this series measured fifteen square centimeters.     

Simultaneous reconstruction of bone and skin defects by free fibular graft with a skin flap

It has been very difficult to accomplish simultaneous reconstruction of a massive defect of the long bone associated with a large skin defect. Yoshimura et al reported a new procedure using a vascularized free fibular transplant with a monitoring flap. This procedure was used in four cases that had resulted in massive bone and skin defects after wide resection of benign and malignant bone tumors occurring in the long bones. Our results using the composite vascularized fibular graft were gratifying.     

Reverse-flow vascularized fibular graft: a new method

The reverse-flow island flap is a relatively recent concept. We have applied this concept to the vascularized bone graft. We report a new method of the reverse-flow vascularized fibular graft for two patients with a pseudarthrosis and massive bone defect of the tibia. The peroneal artery and venae comitantes were severed proximally and elevated with the fibula while maintaining distal vascular continuity. The reverse-flow vascularized fibula was grafted to the posterior aspect of the bone defect of the tibia. Bony union was obtained in both cases. The reverse-flow vascularized fibular graft has many advantages compared with free vascularized fibular graft.     

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。     

带血管骨移植在四肢骨肿瘤治疗中的应用

目的临床观察带血管骨移植修复四肢骨肿瘤瘤段切除后骨缺损的治疗价值。方法对４８例不同类型的骨肿瘤行局部彻底切刮除,或骨膜外瘤段切除后所致的骨缺损分别采用带血管蒂髂骨瓣转位移植６例,游离移植３例;带血管胫骨瓣游离移植１例;带血管蒂腓骨瓣同侧顺逆行转位移植９例,游离腓骨移植２２例,双腓骨瓣组合移植４例,腓骨皮瓣游离移植３例进行修复治疗。结果移植骨与主骨均获得愈合,时间为２５～４２个月,平均３５个月。并经０５～１２年（平均４７年）的随访,４５例治愈,;３例复发,复发的３例病人中２例为骨肉瘤,１例为动脉瘤样骨囊肿恶性变,最终行了截肢术。结论证明带血管骨移植用于修复病变广泛的良性骨肿瘤或低变恶性骨肿瘤瘤段切除后的骨缺损疗效可靠,恶性肿瘤者较差。     

皮肤与骨骼复合缺损的修复

目的 探讨显微外科修复肢体骨与皮肤复合缺损的技术和效果。方法 39例肢体骨与皮肤复合缺损患者接受显微外科手术修复:游离移植背阔肌肌皮瓣,而后髂骨植骨4例,移植髂骨皮瓣7例,移植腓骨皮瓣6例,组合移植背阔肌肌皮瓣与游离腓骨20例,组合移植双侧背阔肌肌皮瓣与游离腓骨2例。结果 移植组织完全成活30例,9例移植的(肌)皮瓣远端皮肤发生局部浅表坏死,经换药后愈合。移植骨术后12～18周与宿主骨牢固连接。平均随访3年6个月,修复肢体均恢复有用功能。14例12岁以下儿童,修复后下肢生长正常,未发生肢体不等长现象。结论 严格手术指征,准确操作,酌情选择不同皮瓣与骨复合组织移植的显微外科修复是治疗骨与皮肤缺损的有效手段。     

Limb reconstruction with vascularized fibular grafts after bone tumor resection

Limb-salvage operations are being used with increasing frequency for patients with malignant bone tumors. For children, when a biologic reconstruction is desired, the choice is often between conventional and vascularized fibular grafts. An experimental study was performed in dogs to compare the two types of fibular grafts for bridging segmental defects in the radius and ulna. Twenty-six adult dogs were divided into two groups and studied at intervals of two, three, four, six, and 12 months after transplantation. The conventional grafts healed by creeping substitution i.e., they were first partially resorbed before new bone was laid down. In contrast, the vascularized fibulae maintained their normal structure and hypertrophied by subperiosteal new bone formation. The conventional fibulae eventually hypertrophied but much later than the vascularized grafts. The vascularized grafts were stronger at four and six months. Between six and 12 months, both grafts remodeled to resemble the size and shape of the forearm bones they were replacing. These experimental results have influenced the treatment of patients. Vascularized fibular grafts are ideal for diaphyseal defects greater than 10 cm long, especially in very young children, a poorly vascularized bed, or when bone healing is delayed by chemotherapeutic agents. To maximize hypertrophy, an external fixator is used to immobilize the graft rather than a plate, which acts as a stress shield.     

腓骨移植术33例分析

目的 介绍我院1981年8月至1999年10月采用吻合血管的游离腓骨移植术修复四肢长骨干骨缺损33例的手术治疗方法。方法 带血管蒂的游离腓骨移植至受区时,其动脉吻合采用动脉双口吻合法或叫“T” 嵌入端端吻合法;在带血管蒂的游离腓骨取材入路上作了简化。结果 经随访6个月至5年,平均2．5年,经X线摄片检查,术后移植骨临床愈合时间为2－5个月,平均3．5个月。肢体功能基本恢复正常。结论 带血管蒂的游离腓骨移植是修复四肢长骨长段骨缺损的有效方法;在血管吻合时采用动脉“T”形,嵌入端端吻合法,该法既保证移植骨的血供,又使受区供血动脉原供区血液供应不受影响,在带血管蒂的腓骨取材上,本术式入路操作简便。     

吻合血管腓骨移植48例报告

目的　探索吻合血管腓骨移植治疗长管骨大段骨缺损的方法与效果。方法　长管骨骨缺损６ ｃｍ 以上４８ 例,用对侧腓骨游离移植修复缺损,均携带供观察腓骨血供的“监测皮岛”或供修复皮肤软组织缺损的皮瓣。结果　１ 例失败,４４ 例于术后３ ～６ 个月、３ 例于１ 年内骨性愈合。随访３ 年以上３６ 例,移植腓骨均增粗、塑形,酷似受区长管骨。结论　吻合血管腓骨移植治疗长管骨大段骨缺损效果满意,“监测皮岛”是保证腓骨血供的有效监测手段     

Free vascularized osteocutaneous fibular graft to the tibia in 51 consecutive cases

The authors reviewed retrospectively the clinical results of 51 consecutive cases of vascularized osteocutaneous fibular graft to the tibia for the reconstruction of extensive tibial bone and soft-tissue defects. The mean duration of follow-up was 31 months (range: 13 to 76 months). In the 51 procedures of free vascularized osteocutaneous fibula graft from the contralateral side, bony union was achieved in 48 cases at an average of 3.74 months after the operation, except for two cases of non-union and two cases of delayed union. Forty-eight cutaneous flaps survived, and three cutaneous flaps failed due to deep infection and venous thrombosis. All united fibulae hypertrophied during the follow-up periods. Stress fracture of the grafted fibula was the most common complication (16 cases), and it was treated with above-the-knee cast immobilization or internal fixation with a conventional cancellous bone graft. The free vascularized osteocutaneous fibular graft is recommended as a useful treatment modality for the reconstruction of extensive tibial defects combined with soft tissue injury.     

Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.     

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.     

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.     

吻合血管的骨移植及钛板内固定修复下颌骨缺损

目的 探讨吻合血管的游离髂骨或腓骨移植及钛板坚强内固定在修复下颌骨缺损中的临床应用效果。方法 选择7例以旋髂深动静脉为蒂的游离髂骨肌瓣和2例以腓动静脉为蒂的游离腓骨肌瓣修复9例下颌骨缺损，并用钛板坚强内固定，血管的动静脉蒂分别与颌外动静脉吻合。结果 9例术后2～4周经放射性核素锝亚甲基二磷酸盐(^99mTc MDP)扫描证实血供良好，移植骨成活。经6个月至3年随访，移植骨固位稳定。结论 吻合血管的骨移植及钛板内固定是修复下颌骨缺损的最佳选择之一。     

A solution to the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur: Bridging with vein transplantation

PurposeThe present study aimed to evaluate the feasibility and clinical efficacy of bridging vein transplantation to deal with the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur.MethodsTwelve patients (aged 15–58 years) with infected bone defects of the femur (between 6.0 and 18.0 cm) were recruited in this study. Vacuum sealing drainage were applied after extensive debridement of the infected bone defects and irrigated with 0.9% sodium chloride solution for 1–2 weeks. After the drainage was clear and the focal infections were controlled, the free vascularized fibula was harvested for reconstructing the femoral bone defects. The vascularized fibula was grafted and fixated appropriately at the recipient site. The autogenous great saphenous vein was harvested, one end was anastomosed and bridged the vascular pedicles of the fibular grafts, and the other end anastomosed the artery and/or the vein in the recipient healthy site.ResultsMean length of vein transplantation with vascularized fibular graft was 10.2 cm (range 7–15 cm). All patients had good radiological healing without recorded nonunion or malunion. No patient developed deep infection or implant failure. Primary bone healing was achieved in 10 patients; however, 2 grafted fibular formed pseudarthrosis with the recipient femoral and then healed after a secondary surgery. One patient suffered from graft stress fracture after bone healing and healed after external fixation. After the mean follow-up of 30 months (9–72 months), according to the Enneking scoring system, clinical outcomes were excellent in 7 patients, good in 4 and fair in one. The functional recovery rate of the lesion limb was 89.4%.ConclusionsFree vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help control infection. It is a feasible and effective treatment for infected bone defects of the femur with poor soft tissue conditions, or blood supply vessel shortage.     

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.     

四肢火器伤骨缺损修复方法的选择

分析了５６例四肢火器伤骨缺损的发生原因，总结了２８例吻合旋髂深血管的髂骨移植的优点及１５例吻合腓血管的长段腓骨移植的适应证和９例肩胛骨皮瓣移植方法的经验。强调指出半环槽式外固定架在四肢长骨火器伤骨缺损治疗中具有独特的优越性，它将成为四肢火器伤骨折、骨不连及骨缺损治疗的首选方法。