应用穿支皮瓣治疗下肢远端慢性骨髓炎并皮肤缺损

目的 探讨游离或带蒂穿支皮瓣在治疗下肢远端慢性骨髓炎并皮肤缺损创面修复中的应用价值.方法 应用穿支皮瓣游离或带蒂移位修复胫前及足踝部慢性骨髓炎并皮肤缺损28例.游离移植13例:采用股前外侧穿支皮瓣修复胫前2例,踝前3例,足背2例,足跟2例;小腿外侧腓动脉穿支皮瓣修复足背4例.带蒂移位15例:胫后动脉穿支皮瓣修复胫前4例,修复内踝2例;腓动脉外踝后上穿支皮瓣修复足跟6例,外踝及足背各1例;第1跖背动脉穿支皮瓣修复近节(足母)趾背侧1例.抗生素液灌流伤口7例,万古霉素明胶海绵残腔填塞8例.结果 1例胫后动脉穿支皮瓣出现静脉回流不足,表浅坏死,自行愈合,其余皮瓣无坏死.随访6个月～2年,2例复发,分别经1次和2次手术后愈合,其余均一期愈合,皮瓣外形满意.3例行二期骨移植.最后一次随访时,患者可行走,患肢完全负重,按足部疾患治疗效果标准评定平均为84.5分.结论 游离或带蒂穿支皮瓣血供良好,可用于治疗残腔不大的慢性骨髓炎并皮肤缺损.

Application of perforator flaps to repair chronic osteomyelitis with soft tissue defect in the distal lower extremity

Objective To evaluate free or pedicled perforator flaps for repairing chronic osteemylitis with soft-tissue defect in the distal lower extremity. Methods From May of 2006 to October of 2007, 28 consecutive patients of chronic osteomylitis with soft-tissue defect in the distal lower extremity underwent surgical debridement and reconstruction with free or pedicled perforator flaps. There were 13 free flaps. The free anterolateral thigh flaps were used in 2 cases to repair the soft defects in the front of leg, 3 cases in the front of the malleolus, 2 cases in the dorsum of foot, 2 cases in the heel. The free lateral crural flaps nourished by perone al artery were used in 4 cases to repair the soft defects in the dorsum of foot. There were 15 pedicled flaps. Posterior tibial artery perforator flaps were used in 4 cases to repair the soft defects in the front of leg, and 2 cases in the medial malleolus. Lateral retromalleolar perforator flaps nourished by peroneal artery were used in 6 cases to repair the soft-defects in the heel, 1 case in the lateral malleolus and 1 case in the dorsum of foot, the first dorsal metatarsal artery perforator flap was used to repair the proximal dorsum of hallux. The wound was closed with irrigation-suction in 7 cases and with vancomycin-impregnated gelatin in 8 cases. Results All 27 flaps were successfully survived except insuffcient vein refluence in 1 posterior tibial artery perforator flap, which resulted in a superficial necrosis and healed spontaneously. The follow-up period from 6 months to 2 years revealed that recurrence developed in two diffuse type patients and both were treated once and twice with success, respectively. The others healed without any signs of recurrences. No debulking procedure was necessary in any case. Secondary bone graft was performed in 3 cases. All patients were ambulatory and fully weight-bearing with normal clinical parameters at the time of last review. According to the evaluating criteria for the treatment of foot disease, the mean score was 84.5. Conclusion Free or pedicled perforator flap has been shown to be well vascularised, and it is feasible for the treatment of chronic osteomyelitis with soft-tissue defect in the distal lower extremity.