游离髂骨瓣结合足底内侧皮瓣与游离股前外侧皮瓣结合腓骨瓣修复前足胫侧列缺损的疗效比较

目的比较游离髂骨瓣结合足底内侧皮瓣和游离股前外侧皮瓣结合腓骨瓣重建前足胫侧列缺损的疗效。 方法2013年1月至2016年12月，西安·兵器工业五二一医院手外二科共收治前足胫侧列缺损患者22例，其中11例采用游离髂骨瓣结合足底内侧皮瓣修复，设为观察组；另外11例采用股前外侧皮瓣结合腓骨瓣修复，设为对照组。一期手术2组均为清创后采用克氏针或钢板螺钉固定骨折及脱位，创面采用负压封闭引流装置覆盖。二期重建前足胫侧列缺损时，观察组采用游离髂骨瓣结合足底内侧皮瓣进行修复，对照组采用游离股前外侧皮瓣结合腓骨瓣进行修复。观察皮瓣是否成活、是否有血管危象和感染发生；通过定期门诊复查、微信、电话等方式对患者进行随访，术后24个月根据美国矫形足踝协会评分标准对2组患者足功能恢复情况进行评分比较，其中优：90～100分；良：75～89分；可：50～74分；差：50分以下，计算患者足功能恢复优良率；根据英国医学研究会提出的感觉功能恢复分级标准，分别在术后6、12、24个月对2组皮瓣感觉功能恢复情况进行评分比较。数据比较采用Wilcoxon符号秩和检验。 结果所有患者均获随访，平均随访时间31个月。术后所有皮瓣均成活。对照组1例分别于术后1、2 d出现静脉危象，经手术探查后缓解。观察组1例出现皮瓣伤口浅表感染，经换药、静脉滴注抗生素后缓解。术后24个月足功能恢复情况，观察组：优3例，良7例，可1例，优良率90.9%；对照组：优1例，良3例，可7例，优良率36.4%。观察组足功能恢复优良率高于对照组，差异有统计学意义(Z＝－2.598，P＝0.024)。术后6、12、24个月，观察组皮瓣感觉功能恢复评分分别为8.0(4.0, 8.0)、12.0(12.0, 16.0)和16.0(16.0, 16.0)分；对照组皮瓣感觉功能恢复评分分别为4.0(4.0, 4.0)、12.0(8.0, 12.0)和12.0(12.0, 12.0)分。相同时间点比较，观察组皮瓣感觉功能恢复评分均高于对照组，差异均有统计学意义(Z＝－2.165、－2.280、－3.031，P＝0.030、0.023、0.002)。 结论带血管的髂骨瓣及腓骨瓣为足部骨质缺损提供理想供骨；足底内侧皮瓣为修复前足足底皮肤软组织缺损提供良好的供区，修复后足部负重及行走功能恢复良好、外观满意、皮瓣感觉功能恢复良好，足底皮肤耐磨。股前外侧皮瓣修复足部皮肤软组织缺损虽能覆盖创面，但术后外观差，感觉恢复较差，易滑移及破溃。

Comparison of efficacy of free iliac bone flap combined with medial plantar flap and free anterolateral thigh flap combined with fibula flap in the repair of tibial row defect of forefoot

ObjectiveTo compare the efficacy of free iliac bone flap combined with medial plantar flap and free anterolateral thigh flap combined with fibula flap in repair of tibial row defect of forefoot. MethodsFrom January 2013 to December 2016, a total of 22 patients with tibial row defect of forefoot were admitted to Department of Hand Surgery Ⅱ of 521 Hospital of Norinco Group, Xi′an. Among them, 11 cases were repaired with free iliac bone flap combined with medial plantar flap and set as the observation group; the other 11 cases were repaired with anterolateral thigh flap and fibula flap and set as the control group. The fracture and dislocation were fixed with Kirschner wires or plates and screws after debridement in both groups in the first stage of operation, and the wounds were covered with vacuum sealing drain. In the second stage of operation for reconstruction of tibial row defect of forefoot, the observation group was reconstructed with free iliac bone flap combined with medial plantar flap, while the control group was reconstructed with free anterolateral thigh flap combined with fibular flap. The survival of the flap and the occurrence of vascular crisis and infection were observed, the patients were followed up by regular outpatient review, WeChat, telephone, etc. According to the American Orthopedic Foot and Ankle Society scoring standard, the patients′ foot function recovery was scored at 24 months after surgery, with excellent: 90-100 points; good: 75-89 points; acceptable: 50-74 points; poor: 50 points or less, the excellent rate of foot function recovery of patients were calculated and compared. According to the classification standard of sensory function restoration proposed by the British Medical Research Council, the sensory functional recovery of the two groups of flaps was scored and compared at 6, 12, and 24 months after surgery. Data were compared with Wilcoxon signed rank sum test. ResultsAll patients were followed up, with an average follow-up time of 31 months. All flaps survived after surgery. One patient in the control group developed venous crisis on the 1, 2 day after the operation, which was relieved after surgical exploration. One patient of superficial infection of flap wound in the observation group was relieved after dressing change and intravenous antibiotic infusion. According to the American Orthopedic Foot and Ankle Society scoring standard at 24 months after surgery, the observation group: excellent in 3 cases, good in 7 cases, acceptable in 1 case, the excellent and good rate was 90.9%; control group: excellent in 1 case, good in 3 cases, acceptable in 7 cases, the excellent and good rate was 36.4%, the difference of the excellent rate between the two groups was statistically significant (Z=-2.598, P=0.024). At 6, 12, and 24 months after operation, the scores of sensory function recovery in the observation group were 8.0 (4.0, 8.0), 12.0 (12.0, 16.0), and 16.0 (16.0, 16.0) points; the sensory function recovery scores in the control group were 4.0 (4.0, 4.0), 12.0 (8.0, 12.0) and 12.0 (12.0, 12.0) respectively. At the same time point comparison, the sensory function recovery score of the observation group was higher than that of the control group, the differences were statistically significant (Z=-2.165, -2.280, -3.031; P=0.030, 0.023, 0.002). ConclusionsThe vascularized iliac bone flap and fibula flap provide the ideal bone supply for the foot bone defect; the medial plantar flap is a good donor site for the repair of the plantar skin and soft tissue defect of foot. Good the weight-bearing and walking functions, satisfactory appearance, ideal sensory functional recovery and wear-resistant plantar skin can be achieved by it. Although the anterolateral thigh flap can also cover the skin and soft tissue defect of the foot, it has poor appearance, poor sensory recovery and is prone to slip and break.