优化的外踝上皮瓣修复足踝部皮肤软组织缺损

目的总结应用优化的外踝上皮瓣逆行转移修复足踝部皮肤软组织缺损的临床效果。方法2016年1月至2019年6月,漯河医学高等专科学校第二附属医院显微骨科收治16例足踝部中小面积皮肤软组织缺损患者,其中男12例,女4例;年龄18~63岁,平均48岁。应用优化的外踝上皮瓣进行修复。术前测量创面宽度,在小腿中下部或中部前外侧利用"提捏法"评估供区,确认可直接闭合。多普勒超声血流仪探测外踝上腓动脉终末穿支及近侧穿支,两穿支标记点连线为皮瓣中轴线,旋转点在外踝平面或下胫腓联合上缘水平,旋转点至创面近侧缘距离作为血管组织蒂长度,术中注意保护皮瓣蒂内的穿支血管及腓动脉终末穿支降支血管,小血管夹夹闭外踝上腓动脉终末穿支近侧的穿支血管后,放松止血带,评估皮瓣血运,必要时可打开骨间膜携带腓动脉。经明道转移皮瓣,并将蒂部覆盖的皮瓣优化设计成钝弧形或半圆形。对踝周及足底皮肤缺损的4例患者,将皮瓣近心端腓浅神经与腓肠神经端侧吻合。供区直接拉拢缝合。术后观察皮瓣成活情况。结果本组16例,皮瓣切取面积3.0 cm×1.5 cm~14.0 cm×6.0 cm。仅1例术后24 h出现皮瓣淤血肿胀,远端血运差,给予拆除蒂部部分缝线,1周后皮瓣尖端仍出现小面积坏死,经换药后愈合,其余皮瓣未经特殊处理顺利成活。共12例患者得到有效随访,随访时间为4个月至2年,皮瓣外形及功能满意。吻合神经的4例患者中3例得到随访,随访时间8~13个月,皮瓣感觉恢复至S2级1例,S3级2例。结论通过对皮瓣供区优化选择、皮瓣血管蒂长度及明道转移的优化设计,以及术中对皮瓣血运的评估与优化处理,不但提高了皮瓣成活率,而且获得了良好的外形与功能,虽部分患者因切取腓浅神经后可遗留不同程度的足背皮肤感觉功能障碍,但仍不失为修复足踝部中小面积皮肤软组织缺损较为理想的方法之一。

The lateral supramalleolar perforator pedicle flap was optimized to repair the soft tissue defect of foot and ankle

Objective To summarize the clinical effect of the optimized lateral supramalleolar perforator pedicle flap in repairing the soft tissue defect of the foot and ankle.Methods From January 2016 to June 2019,the Microorthopaedics of the Second Affiliated Hospital of Luohe Medical College admitted 16 patients with small and medium area skin and soft tissue defects of the ankles,including 12 males and 4 females.The age ranged from 18 to 63,with an average age of 48.The defects was repaired with the optimized laterals uprmalleolus perforator pedicle flap.The width of the wound was measured preoperatively,and the anterolateral skin in the middle lower or middle part of the calf was evaluated by"lifting and kneading"according to the width of the wound.After the evaluation,the doner arear can be closed directly.The lateral supramalleolar perforating vessels and there proximal perforation of peroneal artery can be detected by Doppler ultrasound flowmeter.The line of two perforating points is used as the central axis of the flap.The rotation point of flap was at lateral malleolus plane or the superior edge of the inferior tibiofibular syndesmosis.The distance from the rotation point to the proximal edge of the wound was used as the pedicle length of the vsscular tissue.During the operation,the perforating branch in the pedicle of the flap and the descending branch in the terminal perforating branch of the peroneal artery should be protected.After the perforating vessels above the lateral supramalleolar perforating branch were clipped with vessel clips,the tourniquet was relaxed to evaluate the blood supply of the flap.If necessary,the interosseous membrane can be opened to carry the peronerl artery.The flap was transferred to the recipient area through the open channel which was optimized to cover the pedicle with a blunt curved or semicircular flap.In 4 patients with perimalleolar and plantar skin defects,the head end of the superficial peroneal nerve in the flap was anastomosed with the side of the recipient sural nerve.The donor area was closed directly.The survival of the flap was observed after operation.Results In this group of 16 cases,the area of the flap was 3.0 cm×1.5 cm-14.0 cm×6.0 cm.Only 1 case of flap showed blood stasis and swelling at 24 h after surgery,with poor blood flow at the distal end.Although the pedicle suture was removed,one week later,the tip of the flap still showed small area of necrosis.After dressing changes later,it gradually heals.The other flaps survived without special treatment.12 patients were followed up for 4 months to 2 years,and the flap shape and function were satisfactory.Among the 4 patients with nerve anastomosis,3 of them were followed up for 8-13 months,1 case recovered to grade S2,and 2 cases recovered to grade S3.Conclusions Through the optimal selection of the flap donor area,the optimal design of the open channel,the evaluation of the blood supply of the flap and the optimal treatment of the perforating vessels,the survival rate of flap was not only improved,but also a good shape and function was obtained.Although some patients may have different degrees of sensory dysfunction of the dorsal foot after excision of the superficial peroneal nerve,it can still be regarded as one of the ideal method to repair the skin and soft tissue in the middle and small area of foot and ankle.