游离上臂外侧皮瓣在头颈肿瘤术后缺损修复的临床应用

目的 探讨以桡侧副动脉后支供血的游离上臂外侧皮瓣的设计和应用技术.方法 临床应用游离上臂外侧皮瓣修复头颈肿瘤术后缺损9例.结果 9例皮瓣均完全存活,效果良好.结论 上臂外侧皮瓣血管蒂恒定,皮瓣薄且质地佳,手术操作方便,供区隐蔽,适合修复头颈肿瘤尤其口腔术后缺损.     

上臂远端外侧肱骨骨皮瓣修复手部复合组织缺损

目的 探讨上臂远端外侧肱骨骨皮瓣在手外科的临床应用效果.方法 对8例手部复合组织缺损的患者,根据掌指骨缺损的情况,先设计骨瓣的切取位置和大小(骨瓣远端止于肱骨外上髁的上缘),然后再根据皮肤缺损的面积和骨缺损的相对位置设计皮瓣的大小.前臂后皮神经位于皮瓣的中轴线上,可以保留或一并切取使用,恢复受区感觉.皮瓣切取面积为4.0cm×8.0cm～6.0cm×8.0cm,骨瓣切取大小为4.0cm×1.5cm×1.0cm～6.0cm×1.5cm×1.0cm.结果 术后8例骨皮瓣全部存活,上臂供区创面直接闭合,愈合好,上臂功能无影响.术后随访4～24个月,皮瓣感觉恢复良好,移植骨完全愈合,手部外形满意.结论 上臂远端外侧肱骨骨皮瓣是修复手部创面和掌、指骨复合组织缺损的理想选择.     

游离肘外侧皮瓣修复手部皮肤缺损

目的 探讨以桡侧副动脉后支供血的游离肘外侧皮瓣的设计和应用技术。方法 以肱骨外上髁后缘与三角肌止点后缘连线为轴,在肘外侧部设计包含前臂后皮神经的皮瓣,以桡侧副动静脉为蒂,蒂长可达５～８ｃｍ。临床应用游离肘外侧皮瓣修复手部皮肤缺损７例。结果７例皮瓣均完全存活,效果良好,结论 肘外侧皮瓣血管蒂较长,皮瓣薄且质地佳,手术操作较方便,适合修复中等面积手部皮肤缺损。     

Reverse vascularized bone graft of the lateral distal humerus for non-union of the radial neck fracture: anatomical study and case report

A few treatment options for radial neck non-union have been reported, including radial head excision, radial head replacement, and internal fixation with a bone graft. We describe a new treatment for radial neck non-union using a reverse vascularized bone graft of the lateral distal humerus. In the anatomical study, the posterior radial collateral artery (PRCA) was dissected in eight fresh-frozen cadaver arms. The number of branches from the PRCA to the humerus was determined, and the distances from these branches to the lateral epicondyle of the humerus were measured. We then used this information to create a reverse vascularizedhumeral bone graft, which was used to treat non-union of a radial neck fracture in a 73-year-old female. There were two to four PRCA branches (mean: 3.3) entering the bone. The distance from the branches to the lateral epicondyle of the humerus ranged from 2.5 to 10.8?cm. The mean distances from the most proximal and distal PRCA branches to the lateral epicondyle of the humerus were 7.6?cm and 3.4?cm, respectively. The case of non-union of a radial neck fracture was successfully treated with a reverse vascularized humeral bone graft. There were no major complications, and radiographs showed bony union at 8?weeks postoperatively. This procedure may become a new option for the treatment of non-union of fractures of the radial head and neck, as it enables preservation of the radial head, which is an important structure in the elbow and proximal radioulnar joints.     

Posterior radial collateral artery as the basis of the lateral forearm flap

The lateral forearm flap is being increasingly used for covering minor-to-moderate-sized defects for which soft and thin skin is required. Within the framework of an anatomic study carried out on 28 cadaveric arms, the authors investigated the principal artery that supplies blood to this flap namely, the posterior radial collateral artery (PRCA). They found that distal to the lateral epicondyle, the PRCA lies in a constant axial line lateral to the brachioradialis muscle. The average length of the artery distal to the epicondyle is 8 cm. Distal to the epicondyle side branches of the PRCA build an arterial plexus 6 cm (+/-3.5 cm) long and 5 cm (+/-1.1 cm) wide. The posterior cutaneous antebrachii nerve lies close to the artery. This permits the harvesting of a flap that is both innervated and has adequate vascular supply.     

The composite lateral arm free flap: vascular relationship to triceps tendon and muscle.

We studied the vascular relationship of the lateral arm flap to triceps tendon and muscle in 16 dissected cadaver arms. We designed composite lateral arm free flaps containing fasciocutaneous components, triceps muscle, and/or triceps tendon. Vascular communication between the lateral arm fascia and triceps tendon was negligible. In contrast, a mean of 3.6 vessels passed through triceps muscle from the posterior radial collateral artery to the harvested triceps tendon; in each dissection at least 1 vessel entered the proximal 5 cm and 1 vessel entered the distal 5 cm of harvested tendon. Methylene blue injections confirmed that perfusion of the triceps tendon was through triceps muscle and not through lateral arm fascia. We used the composite lateral arm free flap in 6 patients, 3 with triceps muscle and 3 with triceps tendon. Baltimore Therapeutic Evaluation testing in those patients where triceps tendon was harvested showed no deficit in elbow extension. Complete coverage of composite defects was achieved with a single surgical procedure in all patients.     

上臂外侧骨皮瓣移植修复手部复合伤

目的 介绍应用游离上臂外侧骨皮瓣移植修复手部软组织并掌骨缺损的手术疗效。方法 对7例手部软组织及掌骨缺损的患者，设计带桡侧副动脉后支的肱骨下段骨皮瓣一期修复皮肤和骨缺损。结果 骨皮瓣全部存活，术后随访6～12个月，皮瓣质地优，移植骨块全部骨性愈合，手功能按手外科学会上肢功能评定标准，优6例，良1例。结论 本组骨皮瓣切取方便，血供可靠且不损伤主要血管，是修复手部软组织伴骨缺损的较好方法。     

带血管蒂骨膜瓣移位修复肱骨骨不连的解剖与临床研究

目的：探讨带不同血管蒂骨膜瓣移位修复肱骨骨不连的应用价值。方法：通过对旋肱前血管内、外侧降支、肱血管肌间隙支,桡侧副血管和骨间返血管的应用解剖学研究,创用了以上述血管为蒂的骨膜瓣移位术,并总结临床应用情况。结果：临床施术36例,效果满意。上述5种骨膜瓣移位术均各有其适用范围。结论：旋肱前血管外侧降支肱骨上段骨膜瓣适于修复肱骨近端;旋肱前血管内侧降支肱骨中段骨膜瓣是修复肱骨上段的理想供区,肱血管肌间隙支肱骨中段骨膜瓣供修复肱骨中下段,桡侧副血管肱骨下段骨膜瓣适于修复肱骨中段或中下段;骨间返血管尺骨上段骨膜瓣逆转移位则用于修复肱骨下段髁上部。     

Surgical anatomy of the medial sural artery perforator flap

Background?The medial sural (medial gastrocnemius) perforator flap is a thin flap with a long pedicle. It has tremendous potential for applications in a variety of soft-tissue defects. We aimed to further clarify the vascular anatomy of the medial sural region and establish a safe approach for elevation of this flap.Methods?Ten fresh cadaveric lower limbs were injected and used in this study. We identified the locations and courses of the medial sural artery perforators and correlated them to anatomic landmarks.Results?The medial sural artery divides into two branches, a medial and lateral branch. Correspondingly, musculocutaneous perforators supplying the overlying skin were oriented in two parallel vertical rows, along the course of the lateral or medial branch of the medial sural artery. Two to six perforators were located 6 cm to 22.5 cm from the popliteal crease. Perforators from the lateral row, nearer the posterior midline, were generally larger. In most cases, a large perforator with a superficial, straight intramuscular course could be identified a mean of 10 cm distal to the popliteal crease and an average of 2 cm from the posterior midline. Based on the above findings, we successfully used this flap in five clinical cases.Conclusion?Perforators of the medial sural artery were arranged in a medial and a lateral row. Use of perforators from the lateral row, nearer the posterior midline, is preferable as these are usually larger in size. A consistent major perforator could always be identified in all specimens. With increased safety and confidence in flap harvesting, the medial sural artery perforator flap may find wider clinical applications.Clinical question: TherapeuticLevel of Evidence: IV.     

吻合血管同种异体肱骨远段移植的解剖学研究

目的：为吻合血管同种异体肱骨远段移植提供解剖学依据。方法：在50侧动脉灌注红色乳胶的成人上肢标本,解剖观测了肱骨下段血管的来源、分支分布、长度及外径,结果：肱骨下段外侧骨膜血管来自桡侧副动脉,分布肱骨下1／3段外侧半前、后面骨膜,动脉外径1．6mm,伴行静脉多为2支。肱骨下段内侧内膜血管来自尺侧下副动脉,分布肱骨下1／3段内侧半前、后面和内上髁处骨膜,动脉起始处径1．8mm,伴行静脉1－2支。结论：以桡侧副血管或尺侧下副血管为蒂的肱骨下段移植,可用于肱骨大段缺损的重建。     

游离上臂外侧皮瓣在手部皮肤缺损中的应用

目的 探讨应用游离上臂外侧皮瓣修复手部中小面积软组织缺损的方法和临床效果.方法 2007年10月-2008年4月,对14例手部皮肤缺损患者,应用游离上臂外侧皮瓣进行修复.以桡侧副血管为蒂重建皮瓣血供,以皮神经重建感觉,皮肤缺损面积为5.0 cm×4.0 cm～9.0 cm×5.5cm.血管采用端端或端侧吻合法.结果 术后皮瓣全部存活.无血管危象发生.术后随访时间为3～8个月,3例皮瓣略臃肿(2例手背皮瓣3个月后行整形手术),皮瓣外观及弹性良好,感觉恢复至S3～S4.结论 以桡侧副血管为蒂的上臂外侧皮瓣血管解剖恒定,皮肤穿支丰富,感觉重建满意,是修复手部中小面积皮肤缺损的有效方法.     

The anconeus muscle flap: its anatomy and clinical application

The arterial anatomy, coverage area, and potential donor site morbidity of the anconeus muscle flap are described. Using 17 cadaveric upper extremities, we investigated the muscle's arterial anatomy in 12 specimens and defined the coverage area of the anconeus flap in 5 specimens. We also reviewed the records of 9 patients who underwent a pedicle anconeus muscle flap for elbow coverage to assess clinical results of the procedure. The anconeus muscle is supplied from 3 arterial pedicles: the recurrent posterior interosseus artery, the medial collateral artery, and the posterior branch of the radial collateral artery. The recurrent posterior interosseus artery and the medial collateral artery were present in all dissected cadavers and consistently anastomosed with each other underneath the anconeus muscle. By harvesting the muscle on the medial collateral artery, the anconeus muscle flap can be expected to cover a 7.3 cm2 defect over the radiocapitellar joint, a 6.1 cm2 defect over the distal triceps tendon, and a 7.2 cm2 defect over the olecranon. In this series, none of the patients experienced loss of elbow motion, stability, or extension strength. The results of this study indicate that the anconeus can be harvested with minimal risk of morbidity and provides effective coverage for soft tissue defects of the elbow.     

The extended lateral arm flap: a new modification

The lateral arm flap has been one of the mainstays in the armamentarium of microvascular reconstructive surgeons, especially in the cover of small to medium-sized defects. Despite its many advantages, its widespread application has been limited by its small skin paddle. As a result of detailed anatomic and dye-injection studies, it is possible to determine the actual extent of the cutaneous vascular supply of this flap, which is derived from the posterior radial collateral artery. This artery is found to extend significantly beyond the elbow and into the radial aspect of the upper forearm and, through clinical illustrations, it can be shown that a much larger flap can be harvested and used in a manner that is more versatile than the conventional lateral arm flap.     

Non-anatomical reconstruction of lateral ulnar collateral ligament of the elbow after tumor resection

We present the case of an 80-year-old man with a tumor recurrence on his right arm 6 years after initial treatment. The lateral aspect of the elbow joint, involving overlaying skin, muscles, tendons, joint capsule, lateral collateral ligament complex, the lateral 1/3 of the capitellum, and lateral epicondyle of humerus were excised in the tumor resection. Intraoperative assessment revealed multidirectional instability of the elbow, and joint stabilization was needed. Because the lateral epicondyle was resected, graft placement in an anatomical position was impossible to carry out. Therefore, non-anatomical reconstruction of lateral ulnar collateral ligament with palmaris longus tendon graft was performed. The skin was reconstructed using an antegrade pedicled radial forearm flap. For wrist extension reconstruction, the pronator quadratus tendon was transferred to the extensor carpi radialis brevis tendon. One year after the operation, elbow range of motion was 5–130°. The patient remains symptom free. The Mayo elbow performance score is good. The Musculoskeletal Tumor Society rating score is excellent. To our knowledge, this is the first report of an elbow lateral ulnar collateral ligament reconstruction after tumor resection.     

带感觉的上臂外侧皮瓣游离移植修复手部皮肤缺损

目的游离上臂外侧穿支感觉皮瓣修复手部皮肤缺损。方法2008年7月-2010年5月．急诊或择期行同侧上臂外侧穿支感觉皮瓣修复手部皮肤缺损11例．其中单纯皮肤缺损5例．合并肌腱伤或骨折6例。皮瓣切取面积为6．5cm×4．5cm-11cm×6．5cm,皮瓣包括上臂外侧皮神经．移至受区重建皮瓣感觉。结果术后皮瓣全部成活。随访5～12个月．皮瓣外观及弹性良好,单纯皮肤缺损行皮瓣移植后手部各关节主被动活动正常者5例,合并肌腱伤或骨折行皮瓣移植后手部各关节主动活动有不同程度影响者6例。按中华医学会手外科学会断指再植功能评定标准评定：优7指,良4指。结论带感觉上臂外侧皮瓣游离移植是修复手部皮肤缺损的一种较好方法。     

Reversed lateral upper arm flap with a vascularised fragment of the humerus for reconstruction of ulna shaft fracture after resection of malignant tumour: A case report

The lateral upper arm flap (LAF) is used for a pedicled flap with the vascular arcade at the elbow. There has been no report, however, with regard to the reverse lateral upper arm flap (R-LAF) with a vascularised humerus as an osteocutaneous flap. We describe the case of a 72-year-old woman with a fracture of the ulna after wide resection of a malignant tumour at the proximal half of the forearm, which was reconstructed with an R-LAF with a vascularised fragment of the distal humerus. The flap has successfully survived and the fracture was healed without any adverse event. The R-LAF with vascularised bone is a useful option for the simultaneous treatment of soft tissue and bone defects.     

肘肌肌瓣的解剖学研究

目的对营养肘肌的血管解剖和肘肌转移的覆盖范围进行初步的解剖学研究,设计肘肌肌瓣。方法选用新鲜尸体上肢10只,取8例在手术显微镜下解剖,观察肘肌营养血管的起始、走行、分布及吻合情况。在其余2例标本上进行模拟手术。结果所有标本均显示肘肌的血供来源于三组血管,它们分别是:骨间返动脉、中央副动脉和桡侧副动脉的后支。肘肌的平均面积为(6.5±0.8)cm2。结论可用以中副动脉为蒂的肘肌肌瓣覆盖尺骨鹰嘴、肱桡关节和肱骨下端的软组织缺损。     

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects.

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.     

游离腓骨头复合组织瓣重建儿童内踝骨与皮肤缺损的解剖学研究及临床应用

目的 探讨游离腓骨头复合组织瓣重建儿童内踝骨与皮肤缺损的解剖学依据及临床效果.方法 选取儿童下肢标本6具,男4具,女2具;采用大体解剖方法对腓骨头区域血供进行解剖学研究,观察腓骨头区域的血供情况及供血血管的解剖位置、走行并测量其长度和直径等.在此基础上设计了腓骨头复合组织瓣,并于2005年6月至2009年10月应用于8例儿童内踝骨与皮肤缺损患者,男6例,女2例;年龄3～11岁,平均4.6岁;右侧7例,左侧1例.开放性损伤7例,闭合性损伤1例;内踝缺损均累及骨骺,缺损大小2 cm×2 cm～4 cm×6 cm,皮肤缺损面积为3 cm×6 cm～8 cm×10cm.结果 解剖学研究发现膝下外侧动脉为腓骨头复合组织瓣的主要供血血管.膝下外侧动脉自腘动脉发出后,于腓肠肌外侧头起始处的深面走向外侧,在腓侧副韧带的深面,沿外侧半月板的前外侧缘走向内侧,沿股骨后侧水平向外走行.膝下外侧动脉从干骺端进入腓骨头,走行位置恒定,起始处直径平均为(1.0±0.2)mm,全长平均为(2.5±0.4)cm,并有2～4个分支进入腓骨头区域的皮肤.临床应用8例全部存活,术后获4～13个月(平均7个月)随访.8例患者骨端全部愈合,其中1例出现部分骨骺早闭,重建内踝形态良好,踝关节外形及功能恢复满意.结论 血供丰富腓骨头复合组织瓣是重建儿童内踝骨与皮肤缺损的一种有效方法.

Abstract：

Objective To explore clinical outcomes of reconstruction of bone and skin defects of medial malleolus with a free composite tissue flap of the fibular head in children.Methods First a gross anatomic observation was conducted to study the blood supply and anatomy of the blood vessels around the area of fibular head using 6 cadaveric specimens of children's lower limb (4 boys and 2 girls).Based on the gross observation, a free composite tissue flap of the fibular head was designed for the repair of bone and skin defects of medial malleolus in 8 children (6 boys and 2 girls, aged from 3 to 11 years).There were 7 cases of open injury and one case of closed injury.Seven right medial malleoli and one left medial malleolus were repaired.The osteoepiphysis was involved in all the cases.The bone defect area ranged from 2 cm×2 cm to 4 cm× 6cm, and the skin defect area from 3 cm× 6 cm to 8 cm× 10 cm.Results The gross anatomic observation revealed that the lateral inferior genicular artery is the principal blood supply to the free composite tissue flap of the fibular head.The lateral inferior genicular artery originates from the popliteal artery and runs to the fibular head by way of the lateral gastrocnemius muscle, collateral ligament, lateral meniscus and posterior aspect of the femoral bone.The artery course is constant.The initial diameter of the artery is 1.0±0.2mm, and its total length is 2.5 ± 0.4 cm.On average, the artery has 2 to 4 branches extending into the skin of the fibular head area.After clinical application, the flap survived in all the 8 cases.Follow-ups from 4 to 13 months showed bony union, fine shape of the medial malleolus reconstructed and satisfactory functional recovery of the ankle joint in all the 8 cases, with partial early closed osteoepiphysis in one case.Conclusion The free composite tissue flap of the fibular head has plentiful blood supply and is a good way to reconstruct bone and skin defects of the medial malleolus in children.     

Free thoracodorsal artery perforator flap in extremity reconstruction: 12 cases.

The need for thin flap coverage has increased, especially for contouring or covering shallow defects of extremities. The free thoracodorsal artery perforator flap harvested from the upper lateral back can be useful for this purpose. The thoracodorsal artery supplies the latissimus dorsi muscle and supplies perforating branches to the overlying skin. The flap is based upon the proximal perforator of the thoracodorsal artery, which usually emerges in an area approximately 8-10 cm below the posterior axillary fold and 2-3 cm posterior to the lateral border of the latissimus dorsi muscle. Between February of 2001 and April of 2003, we used the free thoracodorsal artery perforator flap for distal limbs reconstruction in 12 clinical cases, including three hands, two forearms and seven feet. The soft tissue defects resulted from trauma, scar release, chronic ulcer, or tumour ablation. The main advantages of the thoracodorsal artery perforator flap are that it contains no muscle, allowing more reconstructive precision, and morbidity is minimised by preserving the function of the latissimus dorsi muscle and hiding the donor scar. However, meticulous intra-muscular retrograde dissection of the perforator, to the thoracodorsal artery, is necessary in order to obtain suitable pedicle length and vessel diameter. The authors conclude that the free thoracodorsal artery perforator flap has greater potential for resurfacing large defects of distal limbs, because of its suitable thickness and hidden donor site.