双血管蒂髂骨皮瓣移植修复小腿骨软组织缺损

目的探讨双血管蒂髂骨皮瓣移植修复小腿骨及其周围软组织缺损的方法及临床效果。方法2001年5月至2006年3月，应用同时携带旋髂深及旋髂浅双血管蒂的髂骨皮瓣移植治疗23例胫骨骨软组织缺损，切取髂骨块大小4cm×3．5cm～9cm×3．5cm，皮瓣面积最小5cm×8cm，最大12cm×23cm。结果23例骨皮瓣全部存活，6周可见移植髂骨与受区胫骨断端间有少量骨痂形成，平均骨性愈合时间6个月。全部病例术后随访6个月～3年，行走负重良好，外形满意。结论此术式是治疗胫骨骨软组织缺损的一种良好方法，双血管蒂为骨皮瓣尤其是皮瓣的存活提供了可靠保障。     

髂骨皮瓣移植加外固定器固定修复胫骨缺损伴小腿软组织缺损

目的 探讨髂骨皮瓣移植加外固定器固定修复胫骨缺损伴小腿软组织缺损的方法和临床效果。方法1998年5月～2001年5月,应用Bastiani外固定器固定腔骨骨折及缺损端,同时行旋骼深血管为蒂的骼骨皮瓣移植,治疗腔骨缺损伴小腿软组织缺损共22例。男15例,女7例;年龄16～58岁,平均37岁。随访5～36个月,平均25.5个月。结果22例髂骨皮瓣均完全成活,胚骨及软组织缺损Ⅰ期修复,骨外固定器固定牢固,骨折愈合快,植骨与骨折端于术后2～4个月达临床愈合,术后3～6个月达骨性愈合。患肢功能恢复良好,无一例发生骨不连、骨坏死、关节僵直等并发症。结论 吻合旋骼深血管的髂骨皮瓣移植,可Ⅰ期修复胫骨缺损伴小腿软组织缺损。结合骨外固定器固定,可为植骨愈合创造便利条件,且固定牢靠,受区创伤小,可早期进行功能锻炼,避免应力遮挡,促进骨折愈合,是目前治疗胚骨缺损伴小腿软组织缺损的有效方法。     

A new flap model in rats: iliac osteomusculocutaneous flap

Although osteomusculocutaneous flaps are used frequently in clinical practice to repair defects involving soft tissue and bone, there are still many questions that remain to be answered regarding their basic physiology. To accomplish such basic science studies, simple and reliable animal osteomusculocutaneous flap models are needed. The purpose of this study was to describe a new flap model in rats--namely, the iliac osteomusculocutaneous flap. Thirty adult Wistar rats weighing 200 to 250 g were used in this experiment. In 15 rats, the vascular anatomy of the iliolumbar vessels and their relation with adjacent soft tissues and the iliac bone was determined by anatomic dissection. Based on this anatomic study, the iliac osteomusculocutaneous flap model was created in rats. The flap is comprised of a skin island (3 x 3 cm) in the flank region, a 1 x 1-cm segment of iliac bone, and an abdominal wall muscle cuff. In 10 rats, the flap was raised as an island flap based on its vascular pedicle of iliolumbar vessels, and was replaced in situ. In the remaining 5 rats, the flap was transferred to the groin region as a free flap. Direct observation on postoperative day 7 revealed that the skin island of all the flaps was completely viable. Bone scintigraphy performed on postoperative day 3 in free flaps demonstrated radionuclide uptake, indicating viability of the bony segment. The dye injection study revealed ink staining within blood vessels of the bone, confirming its viability. Microangiography of the flap demonstrated vascularity of each component of the flap by the iliolumbar vessels, including a distinct branch to the iliac bone. The authors conclude that the iliac osteomusculocutaneous flap of the rat is a simple and reliable flap model that offers the following advantages: (1) It is a true osteomusculocutaneous flap, (2) it can be used as a free flap without the need for an isogeneic rat, (3) the vascular pedicle is consistent, and (4) it is harvested from a small-animal species.     

骨外固定架与髂骨皮瓣移植联合应用治疗小腿骨及软组织缺损

目的探讨骨外固定架与髂骨皮瓣移植I期联合修复胫骨缺损伴小腿软组织缺损的方法和临床效果。方法对28例胫骨及其周围软组织缺损早期应用骨外固定架与髂骨皮瓣移植治疗。皮肤缺损面积：5cm×5cm～9cm×20cm;手术切除皮瓣面积：5cm×7cm～12cm×23cm;切取髂骨块5cm×3.5cm～10cm×3.5cm。对于较大面积的骨皮组织缺损,应用同时携带旋髂深及旋髂浅双血管蒂的髂骨皮瓣移植治疗。结果髂骨植骨骨性愈合时间31周,无不愈合病例。骨皮瓣全部存活,无感染、坏死,外形及功能恢复满意。结论早期应用单侧外固定支架与髂骨皮瓣移植联合是修复合并骨及软组织缺损的小腿严重创伤的一种良好方法,双血管蒂为骨皮瓣的存活提供了可靠保障。     

带血管蒂髂骨瓣移植修复下肢骨及其周围软组织缺损

目的探讨带血管蒂髂骨瓣移植在修复下肢骨及其周围软组织缺损中的作用。方法针对小腿、足解剖结构和伤后骨与软组织易缺损的特点,利用游离髂骨移植必须携带周围肌肉,设计带血管蒂的髂骨肌肉瓣,移植修复下肢骨及软组织缺损;髂骨肌肉瓣血管与受区血管吻合后于骨瓣周围肌肉表面皮片覆盖。结果手术后1周,移植皮片全部植在髂骨周围的肌肉表面,皮片成活间接证明移植骨瓣成活;皮片全部成活4例,大部分成活3例;术后1个月均可见髂骨瓣与受区断端间有少量的骨痂形成,修复足跖骨4个月后拔除克氏针,胫骨6～8个月拆除外固定架,扶拐行走2～4个月：术后随访经6～15个月(平均10个月),双下肢等长,无溃疡,行走负重良好,外形及功能满意。结论单纯髂骨游离移植修复骨及软组织缺损一次完成手术操作,解剖塑形及外观比传统术式更满意,是修复小腿及足外伤软组织和骨缺损的较好术式。     

髂骨股前外侧联合组织瓣修复小腿皮肤伴跟骨跟腱缺损

目的探讨髂骨股前外联合组织瓣在修复跟骨、跟腱及大面积皮肤缺损中的临床应用及临床效果。方法以旋髂深血管及旋股外侧动脉的横、升支为血管蒂设计超大复合组织瓣，与损伤的胫后动脉远近端吻合游离移植，修复小腿下段、足跟皮肤缺损的同时修复跟骨、跟腱缺损。结果16例组织瓣全部成活，其中10例获6～24个月的随访，平均12个月。术后小腿及足有良好外形和保护性感觉。经功能锻炼均保证行走功能。结论以旋髂深血管及旋股外侧动脉的横、升支为血管蒂设计超大复合组织瓣修复小腿下段、足跟皮肤缺损的同时修复跟骨、跟腱缺损是可行的，而且手术安全性高。     

Free compound rib-latissimus dorsi osteomusculocutaneous flap in reconstruction of the leg

The use of a free compound rib-latissimus dorsi osteomusculocutaneous flap is described, for reconstruction of the tibia and soft tissue of the leg. The entire flap depends on the thoracodorsal artery for its blood supply. Dye injection studies of the artery demonstrated continuity between it and the intercostal artery, which is the periosteal vessel of the rib, through a dense network of vascular communications. The longest follow-up reported is three years and ten months. Follow-up showed that the use of this compound flap produced uniformly well-contoured soft tissue coverage and bony structure that thickened almost to the same dimensions as the tibia. The transferred tissue was examined by x-ray and bone scintigraphy, and was found to be viable.     

游离髂腹部穿支皮瓣的临床应用

目的 介绍选择供血血管的游离髂腹部穿支皮瓣的临床应用体会.方法 设计选择供血血管及穿支为蒂的髂腹部游离皮瓣移植修复四肢软组织缺损,临床应用30例,其中以旋髂浅动脉为蒂12例,以旋髂深动脉及穿支为蒂14例,以旋髂浅深动脉共干为蒂4例.皮瓣切取面积最大22.0cm×10.0cm,最小8.0cm×6.0cm.结果 术后所有皮瓣均顺利存活,供区创面直接缝合.随访时间3～6个月.修复前臂及小腿(12例)皮瓣外观满意;修复手及足踝部(18例)皮瓣较臃肿,二期行整形术.供区仅遗留线条瘢痕,未出现任何并发症.结论 髂腹部皮瓣供区隐蔽,供皮量大,是修复四肢软组织缺损的良好供区;但供血血管有旋髂浅动脉及旋髂深动脉两类,且穿支或皮支的解剖有一定变异,具体手术时应根据供血血管的口径、走行灵活选择.     

Experience with free composite tissue transplantation based on the deep circumflex iliac vessels

Eight free iliac osteocutaneous flaps and three vascularized iliac bone grafts based on the deep circumflex iliac vessels were transferred in 11 cases of large skin and bone or bone defects. Seven of the eight osteocutaneous flaps took successfully. The eighth demonstrated partial necrosis. There was complete bone union in ten cases, and no union in one case as a result of persistent infection. Based on this experience, we conclude that free osteocutaneous flaps based on the deep circumflex iliac vessels have the following advantages over free osteocutaneous flaps based on the superficial circumflex iliac vessels: the pedicle is long (5 to 7 cm); the nutrient vessels are large (artery: 2.2 mm; vein: 2.5 mm); the anatomic course of the vessels is constant; and there is a large amount of bone available.     

以腓肠肌内侧血管供血的游离股前外侧皮瓣修复小腿皮肤软组织严重缺损

目的：探讨小腿严重软组织缺损的显微外科治疗方法及临床效果。方法采用患肢腓肠肌内侧血管供血的游离股前外侧皮瓣移植修复小腿胫前严重皮肤软组织缺损7例。结果7例皮瓣全部成活,效果良好。结论对小腿主干血管损伤伴骨外露、骨髓炎的大面积皮肤、软组织缺损患者,采用患肢腓肠肌内侧血管供血的游离股前外侧皮瓣可避免采用健侧血管供血的桥式皮瓣修复,有效地保护了健侧小腿的胫后动脉,缩短疗程,减少双腿固定的痛苦。     

Composite osteo-cutaneous groin flap for the reconstruction of wrist and forearm defects

Two patients with severe traumatic soft tissue and bone loss at the wrist and involving the ulnar compartment of the forearm have been successfully treated with a compound osteo-cutaneous groin flap. The bone scans of the iliac bone graft showed good vascularity 8 weeks after the operation.     

急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

Reconstruction of Massive Midfoot Bone and Soft Tissue Loss as a Result of Blast Injury

Lower extremity blast injuries represent a unique challenge to surgeons and often involve complex, limb-threatening wounds with extensive soft tissue and bone loss. Surgical treatment of these injuries can be difficult because of limited autogenous resources for reconstruction of the defect. In this article, we describe a technique for medial column reconstruction using iliac crest bone graft and soft tissue coverage with an abductor hallucis rotational flap combined with a split-thickness skin graft. This method addresses the extensive bone and soft tissue defects that frequently characterize blast injuries to the foot, and may be applicable in other situations where trauma or infection has caused extensive destruction of the medial column.     

隐神经-大隐静脉营养血管远端蒂复合瓣的临床应用

目的 研究设计隐神经-大隐静脉营养血管远端蒂复合瓣的方法和报道临床应用的疗效。方法利用隐神经-大隐静脉营养血管与肌、骨、皮营养血管同源的解剖学基础，形成小腿内侧隐神经一大隐静脉营养血管远端蒂复合瓣修复足踝部组织缺损8例。结果7例复合瓣创面Ⅰ期愈合，1例发生小面积皮肤坏死，经换药后创面Ⅱ期愈合。1例跟骨缺损Ⅱ期行髂骨植骨，术后12周X线片显示获得骨愈合。术后经3～12个月随访，复合组织瓣的质地、外观及功能良好。结论隐神经-大隐静脉营养血管远端蒂复合瓣血供可靠，不损伤主干血管，操作简单，肌瓣充填软组织缺损，骨膜瓣促进骨修复，皮瓣具有重建感觉的条件。     

带旋髂深动脉髂骨瓣与腓肠神经营养血管皮瓣修复跟骨及软组织缺损

目的探讨带旋髂深动脉髂骨瓣、腓肠神经营养血管皮瓣修复跟骨及软组织缺损的临床疗效。方法采用游离带旋髂深动脉髂骨瓣联合腓肠神经营养血管皮瓣修复6例跟骨及软组织缺损患者。结果 6例皮瓣骨瓣全部成活。3例皮瓣发生部分边缘性坏死,经换药后创面愈合;1例因跟腱修复失败,二期行踝关节融合术。患者均获得6~20个月随访。术后小腿及足部均有良好外形及部分感觉,部分患者经锻炼后恢复承重功能。结论以带旋髂深动脉髂骨瓣联合腓肠神经营养血管皮瓣修复跟骨及软组织缺损可行,临床疗效满意。     

胫骨平台骨折术后感染原因分析及治疗对策

目的 分析胫骨平台骨折钢板固定术后伤口感染的原因,探讨总结应用小腿近侧蒂肌皮瓣治疗方法的疗效.方法 2005年1月至2009年5月,经治胫骨平台骨折钢板内固定术后并发伤口感染不愈、软组织缺损、钢板外露、创伤性骨髓炎52例.彻底扩创、清理死骨、对髓腔开放者清理髓腔,并取不同层次炎性肉芽组织送实验室细菌学及药敏测试,对钢板固定失效者更换外固定架.创腔内放置载万古霉素或妥布霉素硫酸钙人工骨,骨缺损较大者,取自体髂骨混合植骨,选取小腿近侧蒂皮瓣填充覆盖修复创面.放置引流,抗生素静脉注射3至4周,定期拍摄X线片直至骨折愈合.结果 52例组织缺损均得到满意修复.随访时间最长5年,最短1年,骨折愈合最快4个月,最长1年.2例术后分别于第3、4个月骨髓炎复发再次手术治愈.3例术后6个月骨折不愈再次手术植骨后4～6个月愈合.结论 胫骨平台骨折钢板内固定术后并发伤口感染不愈软组织缺损、创伤性骨髓炎的治疗需要综合措施,应用小腿近侧蒂相应肌皮瓣填充创腔、覆盖闭合修复缺损创面、改善局部血供、促进骨折愈合是取得治疗成功不可或缺的方法之一.

Abstract：

Objective To analyze the reason of post-operative infection of tibial plateau fracture, the therapeutic effect of using pedicle musculocutaneous flaps of proximal leg was researched and summarized. Methods There were 52 patients of tibial plateau fracture after internal fixation complicated by disunion of infected wound and soft tissue defects, traumatic osteomyelitis from January 2005 to May 2009. After pre-operative physical examination, laboratory examination, X-ray, CT scan and bacterial culture of the secretion,the operation, such as debridement, dead bone moving, medullary cavity cleaning, transferring to the external fixation when the internal fixation lost efficacy and bacterial culture of granulation tissue of different levels. The cavity was filled with RBK combined with vancomycin or tobramycin. If the cavity was rather large, autografts from the iliac bone were combined. The tissue defects were covered with pedicle musculocutaneous flaps of proximal leg, and the wound had effective drainage. The antibiotic was used for 3-4 weeks, and the X-rays were given at fixed period until the fracture was cured. Results The soft tissue defects of all 52 patients were repaired well. They were followed from 1 year to 5 years, and the time of bone union ranged from 4 months to 1 year. Two patients of osteomyelitis had a relapse after 3,4 months, then they were cured by the second operation. Three patients had unhealed fracture after 6 months, then they were cured by bone grafting again after 4-6 months. Conclusion Patients of tibial plateau fracture after internal fixation complicated by disunion of infected wound and soft tissue defects, traumatic osteomyelitis should be cured by comprehensive treatments, one of the crucial treatment for success is using pedicle musculocutaneous flaps of proximal leg to fill in lacuna, close wound, improve the local blood supply and promote bone union.     

邻近非主干血管蒂(肌)皮瓣转移修复小腿中下段软组织缺损

目的探讨以邻近非主干血管为蒂皮瓣转移修复小腿中下段皮肤缺损的优化选择。方法分析42例病例，应用4种邻近非主干血管为蒂皮瓣进行修复。小腿中下段软组织缺损周围皮肤条件良好者，选择邻近的逆行腓肠神经、隐神经营养血管皮瓣或腓肠肌皮瓣；如周围皮肤有较轻损伤，用腓肠肌皮瓣；皮肤缺损范围大者，组合逆行腓肠神经营养血管皮瓣与肌瓣或腓肠肌皮瓣；创面较小，选用比目鱼肌肌瓣或腓骨短肌瓣。结果所有病例随访6～12个月，成活37例，5例远端少部分坏死，2例局部皮瓣转移修复，1例肌瓣转移，2例肉芽组织生长后植皮修复。结论邻近非主干血管为蒂皮瓣转移修复小腿中下段皮肤缺损是最佳修复方式，不同的术式可满足各种创面的要求。     

逆行供血的胸脐皮瓣游离移植修复胫骨外露创面

目的观察逆行供血的吻合血管胸脐皮瓣修复胫骨外露创面的临床效果.方法对44侧小腿动脉铸型标本进行了观测的基础上,于1993年5月～2000年7月,对临床收治的25例小腿中上段大面积软组织缺损,胫骨外露,其中18例有胫前或胫后血管长段受损栓塞,创面最大为28 cm×11 cm,最小为11 cm×9 cm.采用小腿远端胫前或胫后血管远端与腹壁下血管吻合的胸脐皮瓣移植修复创面.结果胫前动脉、胫后动脉和腓动脉三组主干型血管,三者彼此间在足踝部交通吻合十分丰富,有很好的相互代偿能力.术后移植皮瓣全部成活,皮瓣色泽、质地良好,创面完全修复.结论只要小腿胫前或胫后主要血管之一正常,受损血管远端正常,逆行供血良好,即可采用吻合血管的胸脐皮瓣修复小腿中上段大面积软组织缺损.     

Transposition of muscle flaps for covering exposed bone in the leg.

A muscle transposition technique for reconstruction of soft tissue loss and skin defects with exposed bone in the leg is described. Reconstruction with muscle flaps and freee skin grafts is a reliable and convenient one-stage operation. The gastrocnemius and soleus muscles were used to cover the upper and middle third of the leg. The method was used in 13 patients, and there were 3 failures in the series because of the impaired vascularity of the injuried leg. In 7 cases, including one failure, the soft tissue injury was associated with compound fractures. No functional disability was observed in the leg, ankle or foot after successful transposition of the muscle flap.     

Indications and long-term assessment of 10 cases of cross-leg free DCIA flaps

Compound fractures of the lower limb with skin and bone loss are difficult repair problems, especially in multiple level injuries. With bone loss between 6 and 12 cms, the deep circumflex iliac artery (DCIA) flap is usually the flap of choice in reconstruction; the aim is to carry out microvascular anastomosis of the flap vessels to vessels on the damaged leg. However, this may be difficult or even impossible. Experience of 10 cross-leg DCIA flaps is outlined, with indications and surgical technique. The long-term bone healing is compared with 13 cases with anastomosis based on the same leg. There appears to be no difference in callus formation and remodelling of bone, indicating that despite subsequently dividing the original main vascular supply the bone in the DCIA flap remains vascularized and behaves as such.