旋髂深血管蒂髂骨瓣转位腰骶椎植骨的应用解剖

目的 :为带旋髂深血管蒂髂骨瓣转位腰骶段椎体植骨融合术提供应用解剖学基础。方法 :在3 0具共 60侧灌注红色乳胶的成年尸体上 ,解剖观察旋髂深动脉的起始、走行、分支、分布范围及其毗邻结构 ,测量有关数据 ;摹拟转位情况、测量旋髂深动脉的起点至S1椎体中部、L5～S1椎间、L5椎体中部的距离 ,并用量角器测量旋髂深动脉主干向内转位的角度。结果 :旋髂深动脉起于髂外动脉者占 63 .3 % ,起于股动脉者占 3 6.7%。起点外径 ( 2 .6± 0 .4)mm ,腹壁肌支外径 ( 1.4± 0 .4)mm ,旋髂深动脉的主干延续为髂嵴支 ,外径 ( 1.8± 0 .4)mm ,沿途发出许多小的分支进入髂嵴 ,以最后一个分支作为终点测量其蒂长为( 10 .7± 0 .7)cm ,旋髂深动脉起点至L5椎体中部距离为 ( 11.2± 0 .7)cm ,至L5～S1椎间距离为 ( 10 .1±0 .5 )cm ,至S1椎体中部距离为 ( 9.7± 0 .6)cm ,向内旋转角度为 ( 63 .5± 3 .5 )°。结论 :带旋髂深动脉蒂髂骨瓣转位腰骶段椎体植骨融合具有可行性。     

旋股外侧动脉旋髂浅动脉和旋髂深动脉起始变异1例

笔者在解剖一具成年男性尸体时,发现其右侧旋股外侧动脉、旋髂浅动脉和旋髂深动脉的起始变异,为积累资料和为临床提供参考,现报道如下：1.右旋股外侧动脉起于股动脉,起始处外径3.8 mm,距股深动脉起始处2.42cm发出,发出后行向外侧0.85 cm后继而行向下,分支分布于缝匠肌、股直肌、股外侧肌。2.右旋髂浅动脉起于旋股外侧动脉,距股动脉0.85 cm发出,起始处外径1.8mm,发出后行向外上,分布于缝匠肌、阔筋膜张肌。3.正常情况下：旋髂深动脉在距髂前上棘附近分为髂嵴支和腹壁肌支(升之),前者分布至髂嵴及附近肌及皮肤,后者分布至肌。本例右旋髂深动脉起于股动脉,起始处外径为3.0 mm,距腹股沟韧带1.22 cm,以短干发出后分为上、下两支,起始处外径分别为2.4 mm、2.2 mm。上支向上穿腹股沟韧带后行向外上,分布于髂肌和腹横肌的下份内面,上支起始段还发出两较大分支,分布于耻骨肌;下支行向外上于腹股沟深面入腹内斜肌和腹横肌之间,分布于此二肌的下份。     

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。     

股深动脉、腹壁下动脉及旋股外侧动脉罕见变异1例

股深动脉为股动脉的最大分支,于腹股沟韧带下方3～5 cm处起自股动脉后外侧,向内下,行于长收肌和大收肌之间,沿途发出旋股内、外侧动脉,数条穿动脉及肌支.腹壁下动脉在近腹股沟韧带中点处稍内侧发自髂外动脉,在腹股沟深环内直肌鞘后层之间[1].     

以旋髂深血管或腹壁主要升支为蒂腹膜瓣的应用解剖

在１２具灌注红色乳胶和墨汁的人尸体的显微解剖发现，旋髂深动脉的腹壁主要升支为腹前外侧壁层腹膜的主要营养血管。腹壁主要升支大多起旋髂深动脉的腹股沟段，走行于腹内斜肌和腹模肌之间，并向深面发支营养壁层腹膜。腹壁主要升起始处动脉口径１．４±０．４ｍｍ，伴行静脉口径２．０±３．４ｃｍ。结果提示：以旋髂深动脉或腹壁主要升支为蒂可形成腹膜组织瓣，可局部转位或游离移植用于修复尿道，输尿管，肝外胆道和中等口径血管     

膝上外侧血管髂胫束骨瓣移植的应用解剖

目的:为膝上外侧血管髂胫束骨瓣移植提供解剖学基础。方法:26例红色乳胶灌注的成人下肢标本,解剖观察髂胫束膝部和膝上外侧动脉。3例摹拟髂胫束骨瓣切取术。结果:(1)髂胫束膝部,长(6.7±0.5)cm,上端宽(2.1±0.1)cm,下端宽(5.9±0.2)cm,中部厚度(1.3±0.1)mm,下端可区分为髁束和髌束,分别止于胫骨外侧髁和髌骨。(2)膝上外侧动脉在距股骨外上髁上方(5.6±0.4)cm处发自胭动脉,起始处外径(2.2±0.3)mm,外上行(2.9±0.4)cm后分为升、降支。升支起始外径(1.5±0.3)mm,发出肌支和髂胫束穿支。降支起始外径(1.5±0.2)mm,发出肌支、骨膜支及髂胫束穿支。髂胫束穿支外径(1.1±0.2)mm,在距胫骨外侧髁近侧(6.6±0.4)cm处分上、中、下支入髂胫束。髂胫束骨瓣血管蒂长(5.8±0.2)cm。结论:以膝上外侧血管为蒂设计多种不同类型髂胫束骨瓣,用于移植修复组织缺损。     

前臂骨间后动脉穿支皮瓣的解剖学研究

目的:观测前臂中上段骨间后动脉穿支的相关解剖参数,为游离前臂骨间后动脉穿支皮瓣的临床应用提供解剖学依据.方法:红色乳胶灌注的上肢标本20侧,观测外径≥0.5 mm的前臂背侧骨间后动脉穿支(即有效穿支),自骨间后动脉发出点至肱骨外上髁间距离、发出点处外径、血管蒂长.结果:骨间后动脉在前臂中上段发出2～5支肌间隙穿支或肌穿支供应皮肤,其中有效穿支出现率为85%(17/20).最粗的骨间后动脉穿支发出点位于自肱骨外上髁至尺骨小头桡侧缘连线上、距肱骨外上髁 (9.6±3.2)cm范围内,余穿支依次相距3.0～6.0 cm发出,每个穿支斜行0.8～2.7 cm穿过肌间隙后穿入皮下,蒂长(2.5±0.2)cm,穿支外径(0.5±0.2)mm,均有两条伴行静脉.结论:以前臂背侧中上段骨间后动脉穿支为蒂的游离皮瓣,临床应用具有可行性.     

旋髂深动脉穿支皮瓣的数字解剖学研究

目的为旋髂深动脉穿支骨皮瓣的设计与安全截取提供解剖学基础。方法选6具未经固定处理的尸体,采用改良明胶/氧化铅灌注技术进行动脉灌注,层次解剖观测腰区外径≥0.5 mm的穿支,测量其管径及其走行、分支、分布情况并拍摄X线片。利用Photoshop与Scion Image软件分析穿支供血的趋向性及每个分支的供血面积等。另选1具未固定处理的男尸,采用羧甲基纤维素/氧化铅水凝胶行一次性全身动脉造影,并进行CT扫描与三维重建。结果旋髂深动脉穿支(DCIAP)的出现率为92%,平均每侧为1.6支,直径0.7mm,其穿支出现于髂前上棘后方5~10cm,髂嵴上方12~35mm之间,供血范围为31 cm2。结论旋髂深动脉起源、行程及其穿支较恒定,具备穿支骨皮瓣的解剖学基础,可截取穿支皮瓣(肌皮瓣或骨皮瓣)进行游离移植或转位,用于复合组织缺损的重建。     

旋股外侧动脉升支阔筋膜张肌支髂骨瓣的解剖学研究及临床意义

目的 :探讨带旋股外侧动脉升支阔筋膜张肌支髂骨瓣的解剖及应用要点。方法 :在 2 5侧经动脉灌注红色乳胶的成人下肢标本上 ,重点观测旋股外侧动脉升支阔筋膜张肌支的走行、分支、发出点和外径等。结果 :旋股外侧动脉升支的阔筋膜张肌支上行支发出点距髂前上棘平面 7.1± 2 .3cm ,外径 1.2± 0 .8mm ,该支又分出 2～ 3支外径在 0 .3mm～ 0 .5mm的小分支从阔筋膜张肌后份进入肌质 ,上行至肌起始处达髂骨 ;其下行支发出点距髂前上棘平面 7.9± 1.8cm ,外径 1.3± 0 .8mm。结论 :旋股外侧动脉升支阔筋膜张肌支髂骨瓣具有手术可行性和实际应用价值     

胫后动脉穿支皮瓣设计的应用解剖

目的　为临床设计以胫后动脉肌间隙穿支皮瓣提供解剖学基础。 方法　8例成人新鲜小腿标本,解剖观察胫后动脉肌间隙穿支血管及其分支的分布规律,设计以胫后动脉穿支为血管蒂的显微削薄穿支皮瓣、联体穿支皮瓣、穿支蒂嵌合穿支皮瓣及穿支分叶皮瓣,并模拟皮瓣切取。 结果　胫后动脉平均发出4.8支(3~7支)肌间隙穿支,有3支较恒定、外径较粗的穿支分别位于内踝上(6.7±1.1) cm、(15.8±1.8) cm和(22.6±1.7) cm处;在深筋膜下穿支可发出多支皮支、骨膜支、肌支,骨膜支的穿支主要集中在小腿中段,在同一分支点两皮支起始外径均≥0.5 mm的穿支主要集中在中、上段。 结论　在小腿中、上段的胫后动脉的第1、2穿支较恒定、外径较粗、蒂较长及可发出多种组织分支,适合切取胫后动脉穿支蒂显微削薄穿支皮瓣、联体穿支皮瓣、嵌合穿支皮瓣及穿支分叶皮瓣。     

轴型静脉皮瓣的解剖学基础及临床应用

在参照关于皮瓣静脉的一系列解剖学研究的基础上,设计了以静脉干为轴的轴型静脉皮瓣.经20例次临床病例的观察,较之传统的随机型皮瓣更易成活。手术设计时注意选择良好的知名的静脉干为轴,术中注意保护好轴型静脉是手术成功的关键。     

链型皮瓣的血管基础及临床意义

目的：探讨链型血供皮瓣类型的血管基础与临床意义。方法：从皮瓣的血管解剖和临床应用方面总结作者的研究和文献资料。结果：营养肢体被组织的穿支血管在浅出过程中，于深筋膜表面和皮神经、浅静脉周围，形成环环相扣的纵向链式吻合血管丛。临床将皮瓣的长轴与血管丛的轴向保持一致，成活的长宽比例可达5：1。结论：链型血供是随意型血供和轴型血供的中间过渡形式，对带皮神经浅静脉筋膜皮瓣的临床应用有指导意义。     

Sural flap vascularization in arteritic patients: an anatomic study of 24 amputation specimens

Obliterating arteriopathy of the lower limbs is a classic contraindication for neurocutaneous islands flaps, particularly the sural flap. But recent literature reports examples of its successful application in arteritic patients. The aim of this work was to study the vascular anatomy of the sural flap in patients suffering from arteriopathy and its possible clinical application. Twenty-four specimens of leg amputation were studied. The mean age of the amputated patients was 68.5 years. The clinical signs of arteriopathy had been present for 3–16 years. In 10 cases amputation was carried out directly, in 14 cases after failed revascularization. The results of the dissection showed the theoretical possibility of a sural flap in almost all the cases (23 of 24) despite certain anatomical peculiarities. In the upper part of the leg the arterial network of the sural communicating nerve dominates that of the sural nerve; this should allow the use of a sural flap centered on this vascular axis. In the lower part, the arterial network of the sural communicating nerve is sustained by the perforators of the peroneal artery, then by the branches of the calcaneal artery, and finally by the lateral tarsal artery, which should allow the use of a sural flap with a very distal pedicle. The authors propose a theory which suggests that the progressive evolution of arteriopathy and the concomitant development of a supply network involving the vascularization of the sensory nerves induces the "anticipation" of a sural flap.

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Vascularisation du lambeau sural chez les patients artéritiques. Etude anatomique sur 24 spécimens d'amputation

Résumé L'artériopathie oblitérante des membres inférieurs est une contre-indication classique des lambeaux loco-régionaux neuro-cutanés, en particulier du lambeau sural. La littérature récente rapporte cependant des succès dans son utilisation chez l'artéritique. Le but de ce travail était d'étudier l'anatomie vasculaire du lambeau sural chez le porteur d'une artériopathie et ses possibilités d'application chirurgicale. Vingt-quatre pièces d'amputation ont été étudiées. L'âge moyen des patients amputés était de 68,5 ans. Les manifestations cliniques de l'artériopathie étaient présentes depuis 3 à 16 ans. Dans 10 cas l'amputation fut réalisée d'emblée, dans 14 cas après échec de revascularisation. Les résultats de la dissection montraient la possibilité théorique de réalisation d'un lambeau sural dans la quasi-totalité des cas (23 sur 24) malgré la présence de certaines particularités anatomiques. A la partie supérieure de la jambe, le réseau artériel accompagnant le nerf cutané sural latéral prédomine sur celui accompagnant le nerf cutané sural médial, ce qui doit permettre la levée d'un lambeau sural décalé sur cet axe vasculaire. A la partie inférieure de la jambe, le réseau artériel périneural du nerf cutané sural médial est alimenté par les perforantes de l'artère péronière, puis par les branches de l'artère calcanéenne, et enfin par les branches de l'artère tarsienne latérale, ce qui doit permettre la levée d'un lambeau sural à pédicule très distal. Les auteurs proposent une théorie selon laquelle l'évolution progressive de l'artériopathie et le développement concomitant d'un réseau de suppléance, intéressant également la vascularisation des nerfs sensitifs, entraîne "l'anticipation" d'un lambeau.

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Vascular patterns of non-physiologic flaps

In order to improve the survival of non-physiologic flaps, the morphologic changes of the vessels that provide the circulation were studied in 178 rats by translucent, radiologic, and histologic methods. The flaps were divided into five groups: normal, simple venous, arterialized venous, simple arterial, and devascularized flaps. The differences of the survival area ratios among the normal, simple venous, and arterialized venous flaps were not statistically significant, and the revascularization of the flaps of these three groups was similar. Therefore, simple venous and arterialized venous flaps may be used in clinical practice. The arterial revascularization of the simple venous and arterialized venous flaps started on the fifth postoperative day, after which a normal circulation was reestablished. On the first postoperative day, the arterialized venous flap was nourished by the arterial blood passing through the anastomosed venous system in the flap. Before the fifth postoperative day in the simple venous flap, and by the third day in the arterialized venous flap, arteries have not been demonstrated but the veins appear distended. It is fair to assume that a true plasmatic circulation was present at this stage. The obstruction of the anastomosed segments of vessels in the arterialized venous flap group may permit a reduction of the edema and cyanosis of the flap.     

Lateral arm flap: analysis of its anatomy and modification using a vascularized fragment of the distal humerus

Soft tissue injuries with associated bone defects are difficult to manage and often require prolonged treatment with repeated interventions. Frequently, a free flap is applied as a first step and bone grafting is carried out in a second procedure. Ideally, these two procedures are combined in one operation, utilizing a soft tissue flap with an attached vascularized bone fragment. The lateral arm flap can provide such an osteoseptocutaneous flap and has been utilized clinically with success; however, the vascular anatomy of the flap, especially the humeral fragment, has not been described in detail previously, and there is broad disagreement concerning its innervation. In this study, the arteries and nerves of 24 fresh cadaver arms were dissected after injection of colored latex. The levels of origin of the periosteal arteries of the humerus were also documented. The lateral arm flap has a consistent arterial supply from three septocutaneous perforating branches that are arranged in a predictable pattern. The lateral supracondylar ridge of the humerus is vascularized by direct branches of the posterior branch of the radial collateral artery and by arteries that arise from muscular branches supplying adjacent muscles. The innervation of the lateral arm flap is by the inferior lateral cutaneous nerve of the arm. Knowledge of the consistent vascular anatomy of the lateral humerus and soft tissue of the donor site allows an osteoseptocutaneous flap to be raised safely with an appropriate technique. We recommend use of the lateral arm flap with a humeral fragment for the treatment of combined soft tissue and bone defects when a single step surgical solution is indicated.     

以旋股外侧动脉降支为蒂分叶股前外侧肌皮瓣设计的解剖学研究

目的为以旋股外侧动脉降支为蒂的分叶股前外侧肌皮瓣的设计与临床应用提供解剖学基础。方法新鲜下肢标本20侧,动脉灌注红色乳胶,重点观察动脉进入股外侧肌的部位,及其在股外侧肌内的分支、分布与吻合情况。结果 (1)80.8%的降支发自旋股外侧动脉,外径(3.7±0.9)mm,于股直肌深面,沿股外侧肌前缘下降,在起始下方(9.0±3.5)cm处分为内、外两侧支。(2)外侧支营养股外侧肌,肌外血管蒂长(8.1±3.3)cm,在股外侧肌中段肌内行走的全程发出6.6支口径1.0mm的肌支或肌皮支,平均支间距(1.9±0.9)cm。(3)股前外侧部出现皮支(2.5±1.2)支,外径(0.8±0.3)mm,其中肌间隙穿支占23.8%,而肌皮穿支占76.2%。57.7%(15侧)肢体有高位皮动脉出现。结论 (1)可以设计以旋股外侧动脉降支为蒂的分叶股前外侧肌皮瓣,并用不同部位的血管支的距离来调整肌瓣和肌皮瓣的叶间距离,修复不同的创面。(2)以旋股外侧动脉降支为蒂的分叶股前外侧肌皮瓣是临床修复复杂创面的一种极佳选择。     

足底内侧皮瓣和足内侧皮瓣的应用解剖

在42侧成年标本上解剖观察了足底内侧血管及其主要分支。结果表明足底内侧动脉可作为足底内侧和足内侧联合皮瓣的血管蒂;足底内侧动脉深支可作为足底内侧皮瓣的轴心血管;足底内侧动脉浅支作为足内侧皮瓣的轴心血管。     

全膝关节置换后创面的皮瓣转移修复

BACKGROUND: Wound complications probably result in severe soft tissue defects after total knee arthroplasty, which brings orthopedic surgeon a big challenge. Some treatment options, such as frequent sterile dressings changes, persistent drainage, minor or thorough debridement, negative pressure wound therapy and split-thickness skin grafts, fail to help those quite large and deep wounds around the knee, with exposed fascia or prosthesis, bone, joint, tendon, large vessels and nerve, heal by secondary intention. Under these situations, orthopedic surgeon should consult plastic surgery and propose flap re-construction.     

犬肋骨膜肌瓣食管成型术的应用解剖及实验研究

目的：为带血供的骨膜肋间肌瓣食管成型术提供解剖学和形态学基础。方法：取１０条犬的肋骨膜肌瓣标本,将其上的第７肋间血管灌注后观察分布情况。手术先切除部分第７肋骨,然后将保留的骨膜和上下肋间肌修整成一个带血管蒂的骨膜肌瓣。瓣上８．５～１２．５ｃｍ,宽４．５ｃｍ,以此肌瓣修复１／２直径４ｃｍ长的食管缺损。结果：带蒂的骨膜肌瓣由肋间动脉的两条主干分支供血,具有良好的血运。尽管处死犬检查手术修复部位轻度狭窄     

足内侧皮瓣血供的应用解剖学

目的：提供足内侧皮瓣血供来源、类型和临床应用资料。方法：用３０侧成人下肢和１５侧童尸下肢动脉铸型标本作观测。结果：皮瓣的轴心血管是内踝前血管、跗内侧血管及二者的前、后支与趾底内侧血管浅支和足底内侧血管浅支吻合成的血管弓。这些血管的皮支吻合丰富。内踝前动脉、跗内侧动脉和前、后支外径分别为１．５ｍｍ、１．２ｍｍ、０．７ｍｍ和０．８ｍｍ。结论：以上述轴心血管为蒂的足内侧皮瓣，可修复足背、足跟、足前部及踝周围皮肤缺损。临床应用７例，效果良好。