带大隐静脉的胫后动脉穿支皮瓣修复前臂脱套伤创面并重建手背静脉回流  

Application of posterior tibial artery perforator flap with great saphenous vein in treatment of forearm degloving injury and reconstruction of venous circulation of dorsal hand

作　　者：于胜军[1] 马振杰[1] 付胜强 李晓[1] 王志龙[1] 徐俊涛 李英 YU Shengjun;MA Zhenjie;FU Shengqiang;LI Xiao;WANG Zhilong;XU Juntao;LI Ying(Department of Hand Surgery,Yantaishan Hospital,Yantai,Shandong Province 264001,China)

机构地区：[1]烟台市烟台山医院手外科,山东烟台264001

出　　处：《中华显微外科杂志》2022年第4期372-376,共5页Chinese Journal of Microsurgery

摘　　要：目的探讨带大隐静脉(GSV)的胫后动脉穿支皮瓣在前臂严重脱套伤治疗中的临床应用。方法自2015年6月至2020年10月, 烟台市烟台山医院手外科共应用带GSV的胫后动脉穿支皮瓣修复5例前臂脱套伤部分创面并重建手背静脉回流, 其中男4例, 女1例;年龄20~46岁, 平均37岁。均为前臂掌背侧完全脱套伤, 合并尺、桡骨骨折3例, 尺、桡动脉损伤2例, 手指血运障碍2例, 软组织缺损面积26 cm×18 cm~32 cm×25 cm。切取胫后动脉穿支皮瓣覆盖前臂部分创面, 皮瓣面积12 cm×5 cm~33 cm×6 cm, 穿支与桡动脉吻合,GSV桥接吻合头静脉远、近端, 重点重建手背静脉回流, 前臂其余创面4例联合股前外侧皮瓣(ALTF)修复,1例联合腹部带蒂皮瓣修复。小腿皮瓣供区直接缝合, 将上肢脱套皮肤修薄成中厚皮覆盖大腿皮瓣供区, 打包加压包扎。术后采用门诊、电话、微信、上门等方式随访, 复查皮瓣成活情况、伤肢远端肿胀程度、功能恢复及供区愈合情况等, 并参照中华医学会手外科学会上肢部分功能评定试用标准评定功能恢复情况。结果本组5例皮瓣全部成活,1例小腿皮瓣远、近端表皮坏死, 换药4周后愈合, 其余皮瓣未发生血管危象。术后4~8周手部肿胀消退, 皮纹明显, 患手拇、手指周径与健侧相比无明显增大。随访8~20个月, 平均11个月, 皮瓣弹性、颜色良好, 质地饱满, 皮瓣无色素沉着, 小腿皮瓣供区为线形瘢痕, 供区足部及伤肢手部无肿胀, 手指伸、屈良好, 手关节活动度正常, 手指感觉均恢复至S4, 胫后动脉穿支皮瓣感觉恢复S3 2例,S2 3例。按中华医学会手外科学会上肢功能评定试用标准进行评定, 结果属优3例, 良2例。结论带GSV的胫后动脉穿支皮瓣血运可靠, 供区损伤小, 是修复前臂严重脱套伤部分创面并重建手背静脉回流的理想皮瓣。Objective To explore the clinical application of the posterior tibial artery perforator flap with the great saphenous vein(GSV)in the treatment of severe degloving injury of the forearm.Methods From June 2015 to October 2020,5 patinets(4 males and 1 female,aged 20-46 years old,mean age 37 years old)were treated in the Department of Hand Surgery of Yantaishan Hospital in Yantai.Aposterior tibial artery perforator flap with GSV was used to repair the partial wound of the injured forearm,together with the establishment of venous circulation of dorsal hand for all 5 patients.All the patients suffered from severe forearm degloving injury.Of which,3 accompanied with ulna radius fracture,2 with ulnar and radial artery injury and 2 with blood supply insufficiency in the injured fingers.The sizes of soft-tissue defect were 26 cm×18 cm-32 cm×25 cm.The sizes of the posterior tibial artery perforator flap with GSV ranged from 12 cm×5 cm to 33 cm×6 cm.The anastomoses were performed on the perforating artery and the radial artery.The GSV was anastomosed with cephalic vein with bridging anastomosis to re-establish the venous circulation of dorsal hand.Combined anterolateral thigh flaps(ALTF)were used to repair the rest wound of injured limbs in 4 patients,and the combined pedicled abdominal flap was used in 1 patient.The donor site of calf flap was sutured directly,and the skin of upper limb was thinned into medium thick to cover the thigh flap donor site,which was packed with pressure dressing.Regular follow-up reviews were carried out by outpatient clinic,telephone,WeChat APP or home-visit after the operation to observe the survival of flaps,the swelling of the distal end of injured limb,functional recovery and healing at the donor site.Functional recovery was evaluated according to the Evaluation Standard of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association.Results All the grafted flaps in 5 patients survived.Necrosis at epidermal edge occurred in 1 calf flap,and achieved secondary healing afte

关 键 词：脱套伤 胫后动脉穿支皮瓣 前臂 大隐静脉 移植 修复 

分 类 号：R658.2[医药卫生—外科学]