足踝部皮肤缺损的修复

目的探讨足踝部皮肤缺损的修复方法及疗效。方法2000年1月~2005年10月,对36例足踝部皮肤缺损分别采用同侧外踝上皮瓣或逆行腓肠神经营养皮瓣修复,其中男35例,女1例。年龄6~62岁,平均38岁。损伤原因:机器伤12例,车祸伤22例,感染1例,冻伤1例。其中急诊行皮瓣修复24例,12例于伤后7 d~1个月手术,修复部位包括足背、足跟、前足和内、外踝,皮肤缺损范围5 cm×4 cm~20 cm×10 cm。其中外踝上皮瓣15例15个皮瓣,切取皮瓣范围5 cm×4 cm~15 cm×8 cm;逆行腓肠神经营养皮瓣21例22个皮瓣,切取皮瓣范围6 cm×4 cm~20 cm×10 cm。就其术后疗效及两种皮瓣的成活率进行比较。结果术后外踝上皮瓣完全成活10个,完全坏死3个,尖端部分坏死2个。逆行腓肠神经营养皮瓣完全成活21个,其中3个尖端出现表皮坏死;1个在术中即出现动脉供血不足,改行其他方法修复。术后经3周~6个月随访,两种皮瓣修复后的疗效相似,皮肤质地、厚度与足踝部相接近,皮瓣的痛、触觉为S0~S1。修复足跟跖侧的两种皮瓣术后均较臃肿,皮瓣与跟骨之间存在滑动,皮瓣表面出现压迫性表皮坏死。结论外踝上皮瓣适用于内外踝部、足背近侧等距皮瓣供区较近的部位,皮肤缺损面积相对较小的创面;对于缺损较大或距离踝关节较远的足部创面,应采用逆行腓肠神经营养皮瓣,但有踝关节动脉网破坏严重时需谨慎应用。     

Thirteen-Year Follow-Up Reverse Sural Artery Flap for Plantar Calcaneal Wound: A Case Report

Reconstruction of soft tissue defects in the lower leg and foot after traumatic injury is a challenging problem owing to lack of locally reliable flaps. The traditional options for wound coverage often do not provide feasible or adequate treatment for many of these wounds. The lack of skin laxity in the lower leg and foot often make local flaps unavailable. Split-thickness skin grafts will not be robust enough. Free tissue flaps have a litany of potential complications and guaranteed comorbidities. The present case reinforces that appropriately selected patients with significant open bony and soft tissue trauma to the foot and ankle can be treated with a reverse sural artery fasciocutaneous flap. The reverse sural artery flap allows for full-thickness skin coverage with its own blood supply, maximizing the healing potential and should be considered a viable first option for soft tissue coverage.     

Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: Patient selection and surgical refinement

In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The patient selection and surgical refinement are discussed. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the Chang Gung Memorial Hospital. The defects were located at the ankle (three cases), foot (two cases), and heel (six cases). Particular attention was paid to precise patient selection and surgical refinements. Patient selection was based on the lower limb vascular status by palpable distal pedal pulses and ankle brachial index ranging from 0.9 to 1.2. Surgical techniques were refined as precisely locating the perforators of peroneal artery, placing the skin paddle in upper third of leg for a distal region coverage, designing a 7‐cm‐wide adipofascial pedicle with a 2 cm skin paddle on it, preserving the mesentery structure of sural nerve and concomitant artery with or without including gastrocnemius muscles cuff, no tunneling when inset this flap and supercharging with lesser saphenous vein whenever needed. All the flaps survived completely. Only one patient required immediate anastomosis of lesser saphenous vein to local vein around defect in order to relieve the venous congestion during operation. Patients felt diminished but adequate recovery of sense of touch and temperature at the flap. Following the precise patient selection and surgical refinements, the modified reverse sural flap seemed to be a reliable and effective local flap for reconstruction of the soft tissue defects on ankle and foot. © 2013 Wiley Periodicals, Inc. Microsurgery 33:342–349, 2013.     

不同类型皮瓣修复足踝部软组织缺损的临床效果

目的探讨不同类型皮瓣修复足踝部软组织缺损的临床效果。方法对30例足踝部软组织缺损患者进行皮瓣修复,其中足底内侧皮瓣修复足跟部软组织缺损7例,股前外侧皮瓣修复足背、足内侧软组织缺损12例,腓肠神经营养血管皮瓣修复足踝部软组织缺损11例。结果患者均获得随访,时间1~5年。29例皮瓣完全成活,仅1例股前外侧皮瓣发生坏死,二次手术给予植皮。13例患者因皮瓣臃肿,二期行皮瓣修整术;2例患者因术后长期从事体力劳动足跟部发生溃疡;其余患者皮瓣质地柔软,踝关节功能恢复满意。供区均未出现并发症。足底内侧皮瓣修复患者皮瓣感觉功能完全恢复,股前外侧皮瓣修复患者感觉均部分恢复,5例吻合神经腓肠神经营养血管皮瓣患者于术后3~5个月感觉功能完全恢复,剩余患者感觉功能部分恢复。结论足底内侧皮瓣、股前外侧皮瓣、腓肠神经营养血管皮瓣各有优缺点,应根据足踝部软组织缺损面积、部位的不同选择合适的皮瓣,以提高皮瓣成活率,重建肢体功能。     

带蒂组合皮瓣修复足踝部严重组织缺损

目的探讨带蒂组合皮瓣修复足踝部严重创伤的临床疗效。方法2000年10月至2012年5月,对13例足踝部严重创伤,合并皮肤软组织缺损的患者,使用腓肠神经营养血管皮瓣和交腿皮瓣的组合皮瓣进行修复。结果术后皮瓣成活12例,坏死1例,成活皮瓣切口均一期愈合。术后随访6~12个月,患者功能恢复良好。结论组合皮瓣治疗下肢足踝部严重创伤,疗效明确,功能恢复良好,是治疗下肢足踝部严重创伤的理想方法。     

腓肠神经营养血管岛状皮瓣临床应用

目的探讨腓肠神经营养血管岛状皮瓣临床应用特点。方法应用腓肠神经营养血管岛状皮瓣对小腿、踝周、足部皮肤缺损伴骨肌腱外露21例进行修复，其中4例修复前足背顺行皮瓣5例，逆行皮瓣16例。同时观察和测量腓肠神经的走行及合成以及腓动脉穿支的发出部位。结果21例皮瓣全部存活。腓肠神经（18例）吻合型12例，单干型4例，双干型2例，腓肠内侧皮神经与腓肠外侧皮神经的交通支吻合点在踝上11～14cm者12例，其吻合点越低者，腓肠神经越短。腓动脉穿支18例其中15例在踝上4～7cm范围内，另3例最高分支点分别位于踝上10、11、11．5cm。结论腓肠神经营养血管岛状皮瓣，切取简单，不损伤主要血管，是修复小腿、踝周、足部皮肤缺损骨肌腱外露的理想供区，修复足跟时必须吻合神经。     

腓肠神经营养血管蒂逆行岛状皮瓣的临床应用

目的探讨应用腓肠神经营养血管蒂岛状皮瓣的临床效果。方法以小腿腓肠神经营养血管远端为蒂设计并切取皮瓣,逆行转移修复小腿下段、踝部及足跟部皮肤缺损16例。结果随访6个月～2年,16例皮瓣中除1例皮瓣远端边缘部分坏死外,其余皮瓣全部成活。结论腓肠神经营养血管蒂岛状皮瓣具有血供可靠、操作简单、成活率高以及不牺牲知名血管等特点,是修复小腿下段、踝部及足跟部皮肤软组织缺损的理想方法之一。     

两套血供的小腿外侧皮瓣逆行转位修复足踝部软组织缺损

目的 介绍两套血供的改良小腿外侧皮瓣逆行转位修复老年人足踝部软组织缺损的临床体会。 方法 对足踝部软组织缺损、创面骨肌腱外露、需作皮瓣修复的老年病例,在传统的小腿外侧逆行岛状皮瓣及穿支带腓肠神经营养血管逆行岛状皮瓣的基础上,利用小腿外侧皮瓣中下段穿出的骨皮动脉皮支及腓肠神经营养血管皮瓣的供血穿支均发自腓动脉的特点,将皮瓣设计于小腿后外侧,用兼顾传统小腿外侧皮瓣及腓肠神经营养血管皮瓣在供m范围的重叠区域而形成两套血供的改良小腿外侧逆行岛状皮瓣修复。结果临床共应用11例,所有皮瓣术后均顺利成活,供区植皮愈合良好,经3～9个月随访,6例皮瓣外观满意,踝关节伸屈功能正常,基本恢复行走功能;5例合并伸肌腱缺损者3个月后作肌腱移植重建后恢复行走功能。 结论 采用两套血供的改良小腿外侧皮瓣逆行转位是修复老年人足踝部软组织缺损的好方法。     

腓肠浅动脉逆行岛状筋膜皮瓣急诊修复下肢创伤性皮肤软组织缺损

目的探讨急诊一期修复小腿中下段及足部创伤性软组织缺损的方法. 方法 2000年2月～2003年12月,应用同侧腓肠浅动脉逆行岛状筋膜皮瓣急诊一期修复小腿及足部皮肤软组织缺损18例,并分析其可行性及手术注意点;切取皮瓣4 cm×5 cm～11 cm×12 cm. 结果除2例皮瓣远端1/3发绀并坏死经换药Ⅱ期愈合外,其余皮瓣均Ⅰ期愈合.随访1～2年,有2例皮瓣臃肿,其余外观满意,功能均恢复正常. 结论腓肠浅动脉逆行岛状筋膜皮瓣急诊修复创伤性皮肤软组织缺损,具有早期闭合创面、促进早期功能锻炼的优点,尤其适合于急诊修复小腿下1/3及其足踝部的皮肤软组织缺损.     

逆行腓动脉穿支蒂腓浅神经营养血管皮瓣修复足踝软组织缺损

目的评价逆行腓动脉穿支蒂腓浅神经营养血管皮瓣修复足踝软组织缺损的临床效果。方法对25例足踝部软组织缺损的患者采用逆行腓动脉穿支蒂腓浅神经营养血管皮瓣进行修复。其中,以腓动脉终末穿支的升支为蒂19例,以其降支为蒂6例。软组织缺损大小10cm×9cm～4cm×3cm,皮瓣面积11cm×9.5cm～6cm×5cm。结果 23例皮瓣完全存活,另2例皮瓣远端部分坏死,经换药后植皮修复。皮瓣术后轻度肿胀,无瘀血。术后随访6～18个月,皮瓣质地优良,蒂部无臃肿。结论以腓动脉穿支为蒂的腓浅神经营养血管皮瓣血供可靠、质地优良,是修复足、踝软组织缺损的良好选择。     

腓肠神经营养血管蒂逆行岛状皮瓣修复足部软组织缺损

目的　观察应用腓肠神经营养血管蒂逆行岛状皮瓣修复足部软组织缺损的临床效果。方法　对 1 8例足部软组织缺损患者 ,以其腓肠神经营养血管为蒂 ,于小腿后侧切取皮瓣逆行转移修复缺损区。观察术后患者皮瓣成活情况及供区创面愈合情况。　结果　术后皮瓣均成活 ,切取的最大皮瓣为 1 0 .5cm× 1 6.5cm。供区创面愈合良好 ,除外观略受影响外活动功能基本正常。　结论　腓肠神经营养血管蒂逆行岛状皮瓣切取简便 ,移植成活率高 ,是修复足部软组织缺损的较好方法。     

Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique

Background:

Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases.

Materials and Methods:

Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years.

Results:

Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management.

Conclusions:

RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.KEY WORDS: Distally based peroneal flaps, extended reverse sural flaps, foot reconstruction, peroneal artery, reverse peroneal flaps     

改良式腓肠神经滋养血管逆行岛状皮瓣的临床应用

目的:论证保留部分腓肠神经的小腿后侧筋膜皮瓣的成活可靠性和手术方法。方法:17例应用腓肠神经滋养血管逆行岛状皮瓣修复足、踝部创面,6例保留腓肠神经或部分腓肠神经,携带深筋膜保证皮瓣的血运供应。结果:17例皮瓣全部成活,6例保留腓肠神经的皮瓣成活良好,腓肠神经支配区域皮肤感觉正常或部分存在。结论:保留腓肠神经或部分腓肠神经的所谓腓肠神经滋养血管皮瓣完全成活,减少了神经损伤,有利于术后功能康复。     

逆行腓肠神经营养皮瓣修复足踝部软组织缺损体会

目的观察应用逆行腓肠神经营养皮瓣修复足踝部软组织缺损的临床效果。方法应用同侧逆行腓肠神经营养皮瓣修复足踝部皮肤软组织缺损11例,并观察皮瓣存活情况及术后效果。结果11例皮瓣全部存活,1例皮瓣出现淤青、水泡,经换药愈合;1例皮瓣远端部分皮肤坏死,使用中厚皮植皮愈合;随访1～6个月,患肢能正常步态行走,皮瓣耐磨。结论逆行腓肠神经营养皮瓣切取简单,存活率高,是修复足踝部软组织缺损的较理想方法。     

小腿或足部软组织缺损伴骨、肌腱外露的显微外科修复

目的 报道小腿或足部软组织缺损伴骨、肌腱外露应用显微外科修复的临床效果。方法 采用6种类型的皮瓣进行修复30例，其中吻合血管的背阔肌皮瓣12例包括采用胸背血管-小腿腓肠血管吻合的3例、吻合血管的阔筋膜张肌皮瓣3例、股前外侧皮瓣1例、小腿外侧逆行岛状皮瓣l例、小腿内侧岛状皮瓣l例、腓肠神经营养血管逆行岛状皮瓣12例。结果 吻合血管的肌皮瓣、皮瓣移植16例全部成活。14例岛状皮瓣除4例腓肠神经营养血管逆行岛状皮瓣远端小部分坏死外，其余均成活。术后随访l～4年，修复小腿软组织缺损10例的功能与外观均较满意。修复足部20例，其中涉及足跟、足底负重区12例包括4例全足皮肤脱套伤，均恢复了行走功能。结论 小腿、足部软组织缺损伴骨、肌腱外露、骨髓炎患，应用显微外科修复可取得较满意的效果。最佳手术方案的制定，精细熟练的显微手术，血管危象的防治是手术成功的关键。     

Distally Based Adipofascial Flaps for Dorsal Foot and Ankle Soft Tissue Defects

Soft tissue defects of the dorsal foot and ankle are difficult to reconstruct because the contour of the foot must be maintained for shoe fitting. The adipofascial flap, covered with a skin graft, is a suitable method of reconstruction that fulfills this important requirement. Twelve patients with soft tissue defects of the dorsal foot and at the ankle were treated in our unit with this method. Ten (83%) were children, 2 (17%) were adults. All defects were due to road traffic accidents. Three (25%) patients were women; 9 (75%) were men. The right foot was affected in 10 (83.4%) patients, with 2 (16.6%) patients having the left foot involved. The flaps used were the peroneal artery perforator flap (distally based lateral adipofascial flap) in 9 (75%) patients, the superficial sural artery flap in 2 patients (17%), and the posterior tibial artery perforator flap (distally based medial adipofascial flap) in 1 patient (8%). All flaps were successful, providing adequate contour of the foot for wearing ordinary shoes. There were 2 partial skin graft necroses, and, in 1 patient, the tips of the donor site skin flaps were necrosed. In conclusion, the distally based adipofascial flap, covered with skin graft, is a suitable method for reconstruction of soft tissue loss of the dorsal foot and ankle and provides optimum functional and aesthetic outcome with minimum donor site morbidity.     

逆行腓肠神经营养血管皮瓣治疗小腿及足踝部软组织缺损

目的：观察应用腓肠神经营养血管皮瓣修复小腿下段及足踝部创伤性软组织缺损的临床效果。方法：以逆行腓肠神经营养血管皮瓣修复小腿下段及足踝部因创伤致软组织缺损187例。皮瓣最大面积14cm×13cm,最小4cm×3cm。结果：修复小腿下段113例皆获成功,伤口1期愈合,11例皮肤边缘坏死,换药治愈,4例坏死面积较大,经换药,邮票植皮且治愈,足及踝部修复54例,伤口1期愈合,5例局部坏死,经换药后获治愈。结论：应用逆行腓肠肌神经营养血管皮瓣可以有效修复小腿及足踝部皮肤缺损,此皮瓣血运丰富,手术操作简便。     

Various applications of the medial plantar flap to cover the defects of the plantar foot,posterior heel,and ankle

The medial plantar fasciocutaneous flap provides structurally similar tissue to plantar foot, posterior heel, and ankle defects with its thick glabrous plantar skin, shock-absorbing fibrofatty subcutaneous tissue, and plantar fascia. During the past 4 years, 24 patients (20 men, 4 women) with skin and soft-tissue defects over the plantar foot, posterior heel, or ankle were treated. They ranged in age from 20 to 42 years (mean, 24 y). The medial plantar flap was transposed to the defects in four different ways: proximally pedicled sensorial island flaps (N = 18), reverse-flow island flaps (N = 2), free flaps (N = 2), and cross-foot flaps (N = 2). Flap size varied from a width of 2 to 5.5 cm and a length of 5 to 7.5 cm. The follow-up period ranged from 2 to 18 months (mean, 9 mo). Partial flap loss was observed in one free flap and one reverse-flow island flap. Partial skin graft lost in the donor site required regrafting in one patient. Durable, sensate coverage of the defects was achieved in all patients.     

Free medial sural artery perforator flap for ankle and foot reconstruction

Resurfacing shallow defects over the ankle and foot with an appropriately thin flap is a common but difficult task. This can be accomplished by harvesting the medial sural artery perforator flap from the medial aspect of the upper calf. Based on the musculocutaneous perforator of the medial sural artery, this flap preserves the medial gastrocnemius muscle and avoids unnecessary flap bulkiness. Between January 2002 and February 2004, we used 2 variants of the free medial sural artery perforator flap for ankle and foot reconstruction in 13 patients (10 fasciocutaneous flaps and 3 adipofascial flaps). In these patients, skin defects were combined with bone, joint, or tendon exposure. The main advantage of this flap is that it provides a thin and pliable coverage to achieve better accuracy in the reconstructive site. Other advantages include maintaining the function of the medial gastrocnemius muscle, providing a long vascular pedicle, and avoiding the need to sacrifice major arteries of the leg. The main disadvantages are the tedious process of intramuscular retrograde dissection of the perforator and the unsightly skin graft over the medial calf.     

改良带腓肠神经营养血管远端蒂逆行岛状皮瓣修复足踝部皮肤缺损

目的总结改进带腓肠神经营养血管远端蒂逆行岛状皮瓣修复足踝部皮肤缺损的临床效果。方法2004年8月~2005年4月,对15例足跟、踝关节和足前部皮肤缺损患者,应用以腓肠神经营养血管链为皮瓣提供血供,设计逆行岛状皮瓣进行修复,蒂部最远可达外踝平面。其中切取单纯皮瓣12例,复合皮瓣3例,皮瓣范围7cm×6cm~11cm×8cm。供区伤口直接缝合或游离植皮覆盖。结果术后15例皮瓣全部成活,无皮瓣肿胀或血运障碍,供、受区创面均期愈合。术后获随访3~6个月,皮瓣外形满意,质地柔软,色泽与受区近似,无局限性臃肿,能穿鞋正常行走,皮瓣受力处无破溃,足部功能恢复良好。结论带腓肠神经营养血管远端蒂逆行岛状皮瓣修复足、踝部皮肤缺损不需吻合血管,操作简便,安全可靠,是修复足踝部皮肤缺损的理想皮瓣。