改良皮瓣桥术式在创伤性小腿溃疡治疗中的应用及疗效观察  

Application and curative effect of a modified procedure on flap bridging in treatment of traumatic calf ulcers

作　　者：臧谋圣[1] 刘自立[1] 闫兵勇 王剑利[2] ZANG Mousheng;LIU Zili;YAN Bingyong;WANG Jianli(Department of Orthopaedics,the Second People's Hospital of Hefei,Hefei 230011,China;Institute of Traumatic Orthopaedics of PLA,the 80th Group Army Hospital of PLA,Weifang,Shandong Province 261021,China)

机构地区：[1]合肥市第二人民医院骨科,合肥230011 [2]中国人民解放军陆军第八十集团军医院全军创伤骨科研究所,山东潍坊261021

出　　处：《中华显微外科杂志》2024年第5期549-554,共6页Chinese Journal of Microsurgery

摘　　要：目的探讨一种根据创伤性小腿溃疡分3型诊断的改良皮瓣桥携带游离皮瓣移植修复与二期重建患肢大隐静脉的手术方法, 并观察临床效果。方法 2010年4月-2023年6月, 合肥市第二人民医院骨科应用循证医学研究, 纳入创伤性小腿溃疡患者25例:Ⅰ型缺损型5例、Ⅱ型瘢痕型8例、Ⅲ型骨髓炎型12例;男17例、女8例;年龄22~67岁, 平均44岁;病程3个月~36年;左侧17例、右侧8例。术前下肢功能量表(LEFS)评分为(37.07±18.92)分。改良皮瓣桥术式分为2个阶段实施。第1阶段手术分2个手术小组施行:第1手术组, 即溃疡扩创和皮瓣桥制备组。按分3型诊断采用个体化扩创方式, 彻底清除感染及病变组织, 缺损范围为5 cm×11 cm~14 cm×27 cm;以健侧小腿近端为旋转点, 解剖内侧皮瓣制备皮瓣桥(包含大隐静脉);双下肢并拢固定, Ⅰ型或Ⅲ型骨折未愈合者, 胫骨骨折复位外固定支架固定, 同时与对侧胫骨连接固定。Ⅱ型或Ⅲ型骨折愈合者, 以1枚斯氏针斜穿两侧跟骨固定。第2手术组, 即解剖游离皮瓣组。按受区扩创情况, 选择可以调整设计及解剖的供区皮瓣, 以面积较大、优势静脉血管较粗的股前外侧皮瓣(13例)、胸脐皮瓣(9例)、侧胸皮瓣(3例)为优, 移植皮瓣大小6 cm×12 cm~15 cm×28 cm。供区直接拉拢缝合18例, 中厚皮植皮7例。2组合并移植皮瓣, 游离皮瓣覆盖创面缝合固定, 皮瓣血管蒂的动脉-桥内胫后动脉、优势静脉-桥内大隐静脉、非优势静脉-桥内优势胫后静脉分别吻合, 缝合创口。第2阶段手术:5~6周皮瓣桥断蒂后, 向皮瓣桥近端解剖大隐静脉(长度≥10 cm, 含3~4个静脉瓣)并切断, 断端与患肢近端大隐静脉吻合, 皮瓣桥及胫后血管束还原回植。术后精细管理及随访, 统计LEFS评分。结果 25例均获得门诊随访6~18个月, 平均10.5个月。术后患肢血管CDU均显示重建大隐静脉通畅, 溃疡均治愈, 小腿外形满意Objective To explore a modified flap bridging procedure in primary free flap transfer to reconstruct defects in calf and with secondary reconstruction of the great saphenous vein of the calf according to the diagnoses of 3 types of traumatic calf ulcers,and to observe the clinical effect.Methods A research on evidence-based medicine was applied from April 2010 to June 2023 in the Department of Orthopaedics of the Second People's Hospital of Hefei on 25 patients with calf traumatic ulcers.The traumatic calf ulcers were classified into 3 types:Type I,a defect type(5 patients),Type II,a scar type(8 patients),and TypeⅢ,a osteomyelitis type(12 patients).The age of patients ranged from 22 to 67 years old,with an average of 44 years old.The course of calf traumatic ulcers from 3 months to 36 years,with 17 in left calf and 8 in the right.The preoperative Lower Extremity Function Scale(LEFS)was 37.07 points±18.92 points.The modified flap bridge surgery was planned in 2 stages.The first stage surgery was simultaneously performed by 2 surgical teams,with surgical team 1 carried out ulcer debridement and preparation for a flap bridging surgery.According to the 3 types of diagnosis,the infected and unhealthy tissues were completely removed by individualised debridement,the sizes of defect were 5 cm×11 cm-14 cm×27 cm.Medial flaps were dissected to prepare a flap bridging(including great saphenous vein)with the proximal calf of the healthy side as the rotation point.Both lower legs were then fixed together.For an unhealed Type I or III fracture,the tibial fracture was reduced and fixed with an external fixator and then fixed with the contralateral tibia.For a healed Type II or III fracture,both calcaneus were fixed together with a Steinmann pin in obliquely penetration.The surgical team 2 carried out the task of harvest of a free flap.The flap with both adjustable design and anatomy was selected.The flap donor sites with a larger area and dominant vein were the best:anterolateral thigh flap(13 patients),thoracoumbilical fl

关 键 词：小腿溃疡 皮瓣移植 大隐静脉 皮瓣桥 改良 

分 类 号：R658.3[医药卫生—外科学]