改良胫骨横向骨搬移技术的解剖学观察与治疗重度糖尿病足  

Modified tibial transverse transport technique:anatomical observation and treatment of severe diabetic foot

作　　者：吴攀峰[1] 唐举玉[1] 卿黎明[1] 曹哲明 袁剑 WU Panfeng;TANG Juyu;QING Liming;CAO Zheming;YUAN Jian(Department of Hand Microsurgery,Xiangya Hospital of Central South University,Changsha 410008,China;Department of Hand Microsurgery,Xiangya Boai Rehabilitation Hospital,Changsha 410100,China)

机构地区：[1]中南大学湘雅医院手显微外科,长沙410008 [2]湘雅博爱康复医院手显微外科,长沙410100

出　　处：《中华显微外科杂志》2023年第5期487-493,共7页Chinese Journal of Microsurgery

基　　金：国家自然科学基金(81871577,81901978,82072194);湖南省自然科学基金(2022JJ30970)。

摘　　要：目的探讨改良胫骨横向骨搬移(TTT)技术治疗重度糖尿病足的可行性与临床效果。方法2015年11月至2017年11月,中南大学湘雅医院手显微外科用红色乳胶经股动脉灌注10侧成人下肢标本,观测胫骨结节下方6.0~10.0 cm以内在胫骨内后缘胫后动脉发出骨筋膜皮支的出现率,以及其所发出的皮支和骨膜支的数目、分布、外径等指标。结合解剖学观察结果设计带胫骨后内侧骨筋膜皮支的嵌合瓣,改良TTT治疗糖尿病足。2016年2月至2018年11月,收治按Wagner诊断标准确诊为Ⅲ~Ⅳ期糖尿病足的糖尿病患者,临床应用12例,采用改良TTT进行治疗,其中截骨骨瓣大小为10.0 cm×2.5 cm。术后5例患者坏疽足趾于拆除骨搬移外固定架时行不同程度足趾残端修整,2例患者足跟、足底创面行拱顶石皮瓣修复,3例患者创面自行愈合,2例WagnerⅣ期患者行小腿近端截肢。术后通过门诊随访,并总结该方法的初步应用效果。结果10侧标本中,在胫骨结节远端6.0~10.0 cm以内从胫骨内后缘共发出骨筋膜皮支11条(1例为2条,9例为1条),距离胫骨结节为(9.23±0.62)cm,外径为(1.10±0.10)mm,骨筋膜皮支穿出深筋膜后发出皮支营养小腿内侧皮肤,外径为(0.59±0.09)mm,同时也发出营养胫骨内侧骨膜的骨膜支,外径为(0.85±0.10)mm。所有患者手术顺利,与术前比较,术后所有患者足部皮温显著升高、术后视觉模拟评分(VAS)显著降低,差异有统计学意义(P<0.05)。12例患者随访时间24~36(29.33±4.36)个月,术后10例患者患肢疼痛及麻木症状得到明显改善甚至消失,足部创面均完全愈合,小腿TTT创面均得到I期愈合,胫骨骨搬运节段完全愈合,愈合时间为(6.17±0.83)个月。2例截肢患者创面均愈合良好。结论改良TTT通过设计胫骨后内侧骨筋膜皮支的嵌合瓣治疗重度糖尿病足,不仅能有效改善患者足部的症状,促进创面愈合,而且可减少骨搬移区域的并发症,值得推广Objective To explore the feasibility and clinical effect of modified tibial transverse transport(TTT)technique in treatment of severe diabetic foot.Methods The research was carried out from November 2015 to November 2017 at the Department of Hand Microsurgery,Xiangya Hospital of Central South University.Red latex was used to perfuse 10 adult lower limb specimens through femoral artery.The study observed the occurrence rate of osteofascial cutaneous branches from the inner and posterior edge of tibia within 6.0 to 10.0 cm distal from the tibial tubercle,as well as the number,distribution,outer diameter and other indicators of the perforating cutaneous branches and periosteal branches.Combined with findings in the anatomical observation,a chimeric flap with a vessel of posterior medial tibial osteofascial cutaneous branch was designed to improve TTT in the treatment of diabetic foot.From February 2016 to November 2018,12 patients with Wagner’s Grades Ⅲ and Ⅳ diabetic feet were treated.All the patients were treated with a modified TTT,with a piece of designed tibial bone flap at 10.0 cm×2.5 cm in size.After surgery,5 patients with gangrenous toes received various toe stump reconstruction surgery for removal of the external fixator for bone transport.Two patients had arch stone flap reconstructions for the wounds of heel and sole,3 patients had the wounds self-healed,and 2 patients with Wagner’s Grade IV diabetic feet had proximal calf amputations.Postoperative follow-ups were run through visits of outpatient clinic,and meanwhile the preliminary effects of the surgical procedure were observed and summarised.Results Among the 10 specimens,it was found that a total of 11 osteofascial cutaneous branches(2 branches in 1 case and 1 branch in 9 cases)branched out from the posterior edge of tibia within 6-10 cm distal to the tibial tubercle.The distance to the tibial tubercle was 9.23 cm±0.62 cm,with an outer diameter at 1.10 mm±0.10 mm.After penetrating the deep fascia,the osteofascial cutaneous branch further b

关 键 词：糖尿病足 胫骨横向骨搬移 嵌合皮瓣 骨筋膜皮支 并发症 

分 类 号：R587.2[医药卫生—内分泌] R687.3[医药卫生—内科学]