腓浅血管蒂腓骨移植的应用解剖

在４０侧灌注红色乳胶的成人下肢标本上，对腓浅血管的起始、走行和分支进行了解剖观测，结果显示：腓浅动脉始于胫前动脉，外径１．４±０．４ｍｍ。在肌间隔内，动脉分出１～３支外径为０．９±０．２ｍｍ的肌骨支，分布腓骨头及颈以下腓骨体中上段骨膜，并与其它来源的腓骨膜支构成动脉网，有形成以腓浅血管为蒂的腓骨移植，从而为腓骨移植增加一种可供选择的新血管蒂。临床应用２例，全部成活。     

腓血管蒂腓骨嵌合组织瓣设计的解剖学基础

目的　为腓血管蒂腓骨嵌合组织瓣设计提供解剖学依据。 方法　用30侧成人下肢标本,以腓骨头和外踝为标志,将小腿分为上、中、下3区段解剖观测：①腓动脉起源、走行与分支;②腓动脉各区段肌（隔）穿支、骨膜支数目与分布。另1侧新鲜标本摹拟手术设计。  结果    腓动脉源于胫后动脉,移行为跟外侧动脉,中下段贴腓骨后面走行,沿途分支至邻近骨、肌肉和小腿外侧皮肤。其中：①腓骨骨膜支：（2~8）支、外径0.5~1.1 mm,分布腓骨中下1/3段骨膜：②胫骨骨膜支：（1~3）支、外径0.6~0.8 mm,营养胫骨中、下1/3段后面骨膜; ③肌（隔）穿支：（4~8）支、外径1.0~1.6 mm,支配小腿外侧中下段皮肤,并与胫前、胫后动脉皮支吻合。  结论　以腓动脉为蒂可设计腓骨嵌合组织瓣,依需要选择一种或多种嵌合组织瓣修复骨合并软组织缺损。     

以胫前返血管为蒂腓骨上段移植的应用解剖

目的:为胫前返血管蒂腓骨瓣的设计提供解剖学基础。方法:30侧经动脉红色乳胶灌注的成人下肢标本,解剖观测胫前返动脉的起始、走行、分支及分布。结果:胫前返动脉始于胫前动脉,起始点距腓骨头尖下(4.5±0.7)cm(3.0～6.0cm),动脉主干长(0.5±0.2)cm(0.2～1.2cm),外径(2.0±0.4)mm(1.3～3.0mm),伴行静脉2条,外径为(2.1±0.5)mm(1.5～3.0mm)和(2.6±0.4)mm(1.7～3.2mm)。胫前返动脉腓骨头支1～2支,外径(1.7±1.3)mm(0.6～2.1mm),分布于腓骨头的前内侧面骨膜,并与其它来源的腓骨上段骨膜支构成动脉网。腓骨头支起始点至胫前返动脉起始点长度为(1.0±0.4)cm(0.3～1.8cm),其中长度≥1.0cm者占46.7%。腓骨头支起始点以远1.5cm处的胫前返动脉外径为(1.4±0.5)mm(0.8～2.1mm)。结论:胫前返血管蒂腓骨瓣的的设计具有可行性,为临床带血管腓骨上段移植提供一种新的可供选择的血管蒂。     

双腓浅神经一例

解剖51侧腓浅神经,发现一男性尸体右侧为双腓浅神经(附图)。该例腓浅神经与腓深神经分开后,在腓骨头下方2.5cm处立即分为腓浅神经内侧支(横径2.0mm)和腓浅神经外侧支(横径1.8mm)。两条腓浅神经起始段均走行于趾长伸肌与腓骨长肌之间,继而在长伸肌和腓骨短肌浅面下行,至小腿下1/3段分别穿出深筋膜达皮下。两条神经并列下行,在腓骨头下方15cm以内最大距离为0.5cm,然后距离逐渐增大,在腓骨头上方20cm处两条神经相距1.0cm,在内踝连线上相距2.3cm。两条神经分出后没有吻合支,外侧支在足背有腓肠神经的一支加入,内侧支在第一跖骨间隙内分出一束加入腓深神经。腓浅     

腓骨头血供的应用解剖学

在30例成人、10例儿童、2例胎儿尸体下肢上,对腓骨头血供进行应用解剖学研究。胫前返动脉,旋腓骨支和膝下外侧动脉在腓骨头外形成动脉吻合网。腓骨滋养动脉上升支供养腓骨头内松质骨。研究结果认为:在成人作腓骨头移植时可以腓动脉为蒂:若在儿童作腓骨头移植时,除了吻合腓血管外,最好同时吻合膝下外侧动脉,以充分保证骨骺的血供。     

膝下外侧动脉腓骨上段骨皮瓣移植的应用解剖

目的:为膝下外侧动脉蒂腓骨上段骨皮瓣的设计提供应用解剖学基础。方法:在42侧经动脉内灌注红色乳胶的成人下肢标本上重点观测膝下外侧动脉的起始、走行、分支、分布和吻合。结果:膝下外侧动脉始于动脉,起点距腓骨头尖上方(1.9±0.7)cm,起始部外径(1.7±0.3)mm。从起点至第一下行骨膜支距离(3.2±0.8)cm,至第一皮支距离(3.9±0.2)cm。结论:膝下外侧动脉可携带腓骨上段骨皮瓣。皮瓣面积约为9.0cm×6.0cm。     

以腓骨短肌腓浅血管为蒂腓骨短肌皮瓣逆行转位术的应用解剖

目的:为远端蒂腓骨短肌皮瓣的临床应用提形态学学基础。方法:20例(40侧)尸体下肢标本,对腓浅神经、腓浅血管及腓动脉腓骨短肌的营养肌支进行解剖观测,并在3例下肢动脉灌注标本上观察腓动脉及其分支与周围血管吻合情况。结果:(1)腓浅血管、腓浅神经至小腿中下部走行于腓骨短肌与趾长伸肌间隙中,而后下行于腓骨短肌筋膜表面,在外踝上(10 2+1.9)cm浅出皮下。(2)腓动脉在腓骨中部发出数支弓状动脉,沿途发出2-4支腓骨短肌肌支,这些动脉分别向深部与胫前、胫后动脉,向后与跗外侧动脉、外踝前动脉有交通吻合。结论:以腓骨短肌及腓浅血管远端为蒂的肌皮瓣转位修复小腿下1／3及踝部软组织缺损,操作简便。     

膝降血管为蒂股骨胫骨联合骨膜瓣移位修复股骨骨不连的应用解剖

目的:为应用以膝降血管为蒂股骨胫骨联合骨膜瓣移位修复股骨中下段骨不连提供解剖学基础。方法:用30侧经动脉红色乳胶灌注的成人下肢标本,解剖观测膝降血管起点、走行、分支及分布,并测量30侧成人股骨干中段1/2处及中下1/3交界处的周径。结果:膝降动脉起自股动脉,下行于股内侧肌后内侧面,在距膝关节间隙水平上5.9±1.2cm处,分为横支及纵支(髌下支),横支紧贴股骨下端向前外侧走行,沿途发出骨膜支分布于股骨内侧髁;纵支继续沿收肌腱板及收肌结节前面下行至膝关节间隙水平,后折向前横行于膝关节囊表面,向下发出分支与周围动脉骨膜支在胫骨内侧上段吻合成血管网。结论:分别以膝降动脉横支及纵支为蒂切取股骨内侧髁骨膜瓣和胫骨骨膜瓣,向上移位修复股骨中下断骨不连,形态学上是可行。     

带血管腓骨干切取应用解剖的几点补充

目的:为临床带血管腓骨干切取补充解剖学基础。方法:在24侧防腐固定的成年小腿标本上,将腓骨全长平均分为4段,解剖观测腓骨肌肉的附着及部分肌肉的神经支配情况,观测腓骨营养血管的起始位置的特征。结果:腓骨干上附着肌肉的宽度从大到小依次为腓骨肌面、屈肌面、胫骨后肌面和伸肌面。腓骨短肌的肌支发出处距腓骨头尖(9.9±2.7)cm,于腓骨中2/4段和中3/4段的上半部分最贴近腓骨骨面,长伸肌的第1肌支起始位置距腓骨头尖(10.1±1.9)cm,于腓骨的中2/4段紧贴腓骨前缘,腓骨滋养动脉和第1￣3弓状动脉集中于腓骨中2/4段。结论:(1)带血管腓骨干所可能切取的“肌袖”主要为长屈肌和胫骨后肌;(2)腓骨肌面的中2/4段和中3/4段的上半部分为手术时容易损伤腓骨短肌肌支的部位;(3)腓骨中2/4段近腓骨前缘是长伸肌神经支最易损伤的部位;(4)近端截骨点位于腓骨上1/4段中点的切取可以最大程度地包含腓骨的营养血管。     

带骨骺的儿童腓骨移植应用解剖学

解剖观察了70侧的儿童腓骨上骨骺的动脉来源、分布和吻合情况。其血供来源共见7种,胫前返动脉和腓浅动脉的腓骨头支是营养骨骺的重要血管。带骨骺儿童腓骨移植应以胫前动脉为血管蒂,腓骨体移植仍以腓血管为蒂。     

Variations of the nutrient artery of the fibula

In this study the authors aimed to show variations of the nutrient artery of the fibula, which is important for more effective vascularized fibular grafts. Thirty intact legs were examined to determine the number, location, and diameter of the nutrient arteries in the shaft. In 27 of these specimens (90%) there was single nutrient artery; two legs (6.6%) had double nutrient artery. In one leg (3.3%) no nutrient artery was observed. The number of nutrient arteries found on each of the surfaces was summarized as follows. Most of the nutrient arteries pierced the fibula at its medial crest, while only one entered from the posterior surface. Most nutrient arteries were near the middle third of the fibula. The most frequent diameter of the nutrient artery was 0.9-1.5 mm. The authors think that their results about the variations of the nutrient artery supplying the fibula will contribute to the clinical and vascular anatomy knowledge.     

Transplantation of the proximal fibula based on the anterior tibial artery. Anatomical study and clinical application

The purpose of this study was to investigate the feasibility of microvascular transplantation, based on the anterior tibial artery, of the epiphysis and the proximal half of the diaphysis of the fibula. India ink injections into the anterior tibial artery were performed in 13 unembalmed adult cadavers, following which transverse frozen sections were taken. Dye was observed in the fibula, both within the intramedullary cavity and at the level of the periosteum, in all specimens. The average distal limit reached by the dye, measured from the tip of the epiphysis, was 10.4 cm in the intramedullary cavity and 11.8 cm in the periosteum. Based on these anatomical findings one case of humeral reconstruction has been performed with a fibular transplant, including both the epiphysis and a segment of diaphysis, vascularized solely by the anterior tibial artery.     

Transplantation of the proximal fibula based on the anterior tibial artery. Anatomical study and clinical application

The purpose of this study was to investigate the feasibility of microvascular transplantation, based on the anterior tibial artery, of the epiphysis and the proximal half of the diaphysis of the fibula. India ink injections into the anterior tibial artery were performed in 13 unembalmed adult cadavers, following which transverse frozen sections were taken. Dye was observed in the fibula, both within the intramedullary cavity and at the level of the periosteum, in all specimens. The average distal limit reached by the dye, measured from the tip of the epiphysis, was 10.4cm in the intramedullary cavity and 11.8cm in the periosteum. Based on these anatomical findings one case of humeral reconstruction has been performed with a fibular transplant, including both the epiphysis and a segment of diaphysis, vascularized solely by the anterior tibial artery.     

以前臂内侧皮神经及营养血管为蒂的前臂内侧皮瓣的应用解剖

目的　为带前臂内侧皮神经及其营养血管筋膜皮瓣提供形态学基础。方法　在 32侧成人上肢标本上 ,观测前臂内侧皮神经营养血管及其周围皮肤的血供情况。结果　前臂内侧皮神经近侧的血供来源于尺侧返动脉混合肌皮支 ,起始处外径为 0 .8mm ,穿出深筋膜前长度为 1.1cm ;中部主要来自尺动脉近中段和远中段的粗大皮支 ,起始处外径均为 0 .7mm ,穿出深筋膜前长度均为 1.0cm ;远侧有尺动脉腕上皮支 ,起始处外径为 0 .9mm ,穿出深筋膜前长度均为 1.0cm ;远侧有尺动脉腕上皮支 ,起始处外径为 0 .9mm ,穿出深筋膜前长为 2 .6cm。其神经旁血管网与神经皮穿支及神经内血管广泛吻合组成了皮神经血管轴。结论　可设计成带前臂内侧皮神经及营养血管为蒂筋膜上瓣 ,顺行或逆行转位修复邻近部位的软组织缺损。     

腓骨骨膜瓣移植在儿童四肢骨肿瘤瘤段骨射线灭活回植术中的应用观察

目的 探讨腓骨骨膜瓣移植覆盖灭活瘤段骨断端在儿童四肢骨肿瘤射线灭活再植术中应用的可行性和临床效果。方法 回顾性分析2016年6月—2017年6月郑州大学附属肿瘤医院骨与软组织科8例原发四肢恶性或侵袭性骨肿瘤患儿临床资料,男4例、女4例,年龄9~17(13.6±2.5)岁;骨肉瘤5例,尤文肉瘤、软骨肉瘤、反复复发的侵袭性朗格汉斯组织细胞增生症各1例。均采用瘤段骨扩大切除+术中灭活自体瘤段骨回植术治疗,回植的瘤段骨断端均应用带蒂或游离腓骨骨膜瓣覆盖。肿瘤位于胫骨中上段5例,应用同侧带腓血管蒂腓骨膜瓣逆行转位覆盖瘤段骨远侧断端;肿瘤位于股骨中下段2例、肱骨中段1例,应用游离腓血管蒂腓骨膜瓣移植覆盖近侧断端。瘤段骨为单纯骨干5例,包含关节面3例,长度13~26(18.1±3.9)cm。灭活方法均为术中离体射线灭活。术后定期随访,拍摄X线、CT观察记录瘤段骨体内愈合情况,并观察患肢长度变化。结果 本组8例患儿术后随访12~24(18.8±3.5)个月。8例患儿共有13处断端均获得骨愈合,腓骨膜覆盖的断端平均愈合时间6~10(7.3±1.3)个月,且骨膜覆盖区域可观察到成骨现象。末次随访时,5例骨干灭活和1例骨关节灭活的患儿未发生双侧肢体不等长,2例骨关节灭活患儿患侧下肢长度较对侧短缩1.5 cm和2.0 cm。结论 在儿童四肢骨肿瘤手术治疗中,应用腓骨骨膜瓣移植覆盖灭活瘤段骨断端的方法可行,能够有效促进瘤段骨的愈合和防止骨不愈合、骨不连发生,且操作简便,并发症较少,推荐临床开展应用。     

吻合血管腓骨及(足母)长屈肌移植的应用解剖学

在50具(100侧)成年人尸体标本上,对吻合血管的腓骨和(足母)长屈肌复合瓣移植的应用解剖学进行了研究。这个复合组织瓣以腓血管及其伴行的胫神经(足母)长屈肌支为吻接的血管神经蒂,腓动脉外径3.7mm,(足母)长屈肌神经支横径1.6mm。     

Congenital fibular dystrophisms conform to embryonic arterial dysgenesis

The congenital short limb (CSL) with fibular deficiency has traditionally been graded by plain radiography. The most popular orthopedic classification sorts the fibular dysmorphologies into three radiographic groupings: IA (thinned), IB (proximally truncated), or II (absent). In contrast, the soft tissues have been relatively neglected. Since bone formation of the fibula progresses from the anlage, a scaffolding cartilage mold intermediate, cartilage transformation to bone is dependent upon timely embryonic arterial invasion. Absences of the requisite arteries predicate specific skeletal dysmorphologies. The usual arterial supply of the fibula is comprised primarily of the anterior tibialis artery (ATA), which uniquely supplies the proximal portion of the fibula, and also joins the peroneal artery (PA) in supplying the mid to distal fibular shaft. Combinations of the two nutrient arteries allow four potential variations of fibular vascular supply, among which the ATA and PA conjoin to supply the normal fibula and variably supply the three dysmorphic fibular models. The IA and IB deformities conform, respectively, to the absences of the PA and the ATA. Combined ATA and PA absences present in the radiographically “absent” fibula. Thus, each of the four fibular (dys)morphologies conforms to a specific embryonic pattern of arterial development. The term “dystrophism” most accurately characterizes such malformed long bones.     

带腓肠外侧皮神经及其营养血管筋膜皮瓣的应用解剖

目的 为带腓肠外侧皮神经及其营养血管筋膜皮瓣的临床应用提供解剖学基础.方法 在32例成人下肢标本上,对腓肠外侧皮神经及其营养血管进行解剖观测.结果 腓肠外侧皮神经在腓骨头平面上方 7.1±2.4cm处起于腓总神经,分布于小腿后外侧上半或上2/3的皮肤.其营养动脉主要为:腓肠外侧皮动脉:起自腘动脉,在腓骨头平面上方5.0±1.5cm处浅出,外径为0.9±0.3mm;肌间隔筋膜皮支:起自胫后动脉和腓动脉,分别在腓骨头平面下方9.2±3.8cm和15.8±3.8cm处浅出,外径为0.7±0.3mm和0.9±0.4mm.该营养动脉除在腓肠外侧皮神经周围或其内呈链式吻合外,还发出筋膜皮支与邻位的皮动脉连接.静脉血可沿伴行静脉或小隐静脉及其属支回流至深静脉.结论 以腓肠外侧皮神经及其营养血管为蒂,可设计成顺行或逆行转位筋膜皮瓣,修复邻近部位的软组织缺损.     

吻合血管腓骨修复股骨颈骨折与股骨头坏死的解剖学

目的：对吻合血管腓骨移植修复股骨颈骨折与股骨头缺血性坏死进行解剖学再探讨。方法：成人下肢标本,观测供区、受区血管的解剖学。结果：(1)观测了腓动脉及其伴行静脉起点的位置和外径及腓骨滋养动脉的分布。(2)观测了旋股外侧动脉及其升支的起点位置、干长和外径及其伴行静脉的外径。结论：旋股外侧血管升支为术式首选的受区血管,将腓动脉与旋股外侧血管的升支吻合,有利于重建股骨头颈的血供。