脚踝软组织缺损适合做皮瓣还是植皮 足部大面积皮肤软组织缺损的皮瓣修复临床分析

　　[摘要]目的:比较足部大面积皮肤软组织缺损应用不同类型皮瓣(小腿主干血管逆行皮瓣、皮神经营养血管逆行皮瓣和游离皮瓣)修复的临床效果。方法:57例足部大面积皮肤软组织缺损的患者清创后,应用不同类型的皮瓣进行修复,并比较其成活面积、观察其疗效。其中,小腿主干血管逆行皮瓣14例,面积:7～9cm×11～20cm,平均:8cm×16cm,采用胫后动脉逆行皮瓣3例,腓动脉逆行皮瓣11例;皮神经营养血管逆行皮瓣26例,面积:7～9 cm×9～15cm,平均:8cm×11cm,采用腓肠神经营养血管逆行岛状皮瓣23例,隐神经营养血管逆行岛状皮瓣3例;游离皮瓣17例,面积:9.5～15 cm×12～28cm,平均:12cm×25cm,采用股前外侧皮瓣13例,隐动脉皮瓣3例,胸背动脉皮瓣1例。结果:57例皮瓣中,完全坏死2例,部分坏死7例,其余全部成活。坏死者全部涉及前足皮肤缺损,其中,主干血管逆行皮瓣完全坏死1例,部分坏死2例;皮神经营养血管逆行皮瓣远端部分坏死5例;游离皮瓣完全坏死1例。统计学分析:皮瓣面积按类型比较(ANOVA),P=0.000,差异有非常显著性意义;皮瓣成活率按类型比较(Kruskal-Wallis Test),P=0.455,差异无显著性意义。经3～18个月随访,所有成活皮瓣血运、外形、质地、功能均满意。结论:大部分足部大面积皮肤软组织缺损可选用皮神经营养血管逆行皮瓣进行修复,但如果涉及前足,特别是缺损较大时,选择游离皮瓣更为适宜。
　　[关键词]足部;皮肤缺损;皮瓣
　　[中图分类号]R622[文献标识码]A[文章编号]1008-6455(2010)01-0014-03
　　
　　Clinical analysis of repair of large skin defects in feet with flaps
　　YANG Yun-fa,ZHANG Guang-ming,XU Zhong-he
　　(Department of Orthopedics,Guangzhou First Municipal People,s Hospital,Guangzhou Medical College,Guangzhou 510180,Guangdong,China)
　　
　　Abstract:ObjectiveTo analyze the clinical outcomes of three different type flaps (retrogressive flaps based on trunk vessel in leg, retrogressive cutaneous neurovascular island flaps, and free flaps) for repair of large skin defects in feet. MethodsAfter thorough debridement,57 cases of large skin defects in feet were repaired by three different type flaps, including 14 cases of retrogressive flaps based on trunk vessel in leg with the average survive size of 8cm×16cm (7～9cm×11～20cm): 3 cases of retrogressive flaps based on posterior tibial artery, 11 cases of retrogressive flaps based on peroneal artery; 26 cases of retrogressive cutaneous neurovascular island flaps with the average survive size of 8cm×11cm(7～9cm×9～15cm): 23 cases of distal pedicle sural neurovascular island flaps and 3 cases of distal pedicle saphenous nerve neurovascular island flaps; 17 cases of free skin flaps with the average survive size of 12cm×25cm (9.5～15cm ×12～28cm): 13 cases of lateral thigh flaps,3 cases of arteria saphena flaps,and 1 case of thoracodorsal artery flap; and the clinical outcomes were observed.ResultsAfter 3 to 18 months follow-up, the flaps survived completely reveal sufficient blood supply, good shape, perfect texture and satisfactory outcome excluding 2 cases of complete necrosis (1 case of free skin flap and the other case of retrogressive flaps based on trunk vessel in leg) and 7 cases of distal marginal part necrosis (5 cases of distal pedicle nerve neurovascular island flaps and 2 cases of retrogressive flaps based on trunk vessel in leg). According to flap types, significant difference was between survive size (ANOVA,P=0.000),while no difference between survive ratio (Kruskal-Wallis Test,P=0.455).ConclusionMost skin defects of feet can be effectively repaired by distal pedicle cutaneous neurovascular island flaps, while if the defects encroached in forefeet especially when the defects size are comparatively large,free flaps should be strongly recommended.
　　Key words:feet;skin defects;flaps
　　
　　足部皮肤缺损在临床较为常见,由于其特定的功能和解剖特点,常合并骨、肌腱外露而难于愈合,常需要皮瓣修复[1],尤其是大面积皮肤缺损。能用于修复足部大面积皮肤缺损的皮瓣较多,但无外乎三类,即主干血管逆行皮瓣、皮神经营养血管逆行皮瓣和游离皮瓣,现对其修复效果进行临床对比,分析如下。
　　
　　1资料和方法
　　
　　1.1 一般资料:2002.3～2008.12,我科共收治足部大面积皮肤软组织缺损病例57例,男39例,女18例。年龄6～72岁,平均42.6岁。缺损原因:创伤46例,肿瘤切除后2例,瘢痕清除后3例,慢性溃疡6例。缺损面积:6cm～8cm×10cm～24cm。修复方法:主干血管逆行皮瓣14例,其中胫后动脉逆行皮瓣3例,腓动脉逆行皮瓣11例;非主干血管逆行皮瓣26例,其中腓肠神经营养血管逆行岛状皮瓣23例,隐神经营养血管逆行岛状皮瓣3例;游离皮瓣17例,其中股前外侧皮瓣13例,隐动脉皮瓣3例,胸背动脉皮瓣1例。皮瓣成活面积:7cm～9cm×12cm～28cm。供区处理:自体中厚皮植皮。
　　1.2 手术方法
　　1.2.1 小腿主干血管逆行皮瓣:①彻底清创后,以胫后动脉或腓动脉的体表投影为轴设计皮瓣;②以内踝上或外踝上5～7cm为旋转点,近段可至小腿上1/3,切取顺序应从下界开始,再从后界到前界,最后是上界,于近端结扎切断胫后动脉或腓动脉,注意勿损伤皮支血管和胫神经,防止血管断端撕脱,逆行旋转修复足部创面[2-3];③注意血管蒂长度,要求无张力,不能扭曲,皮下隧道要宽松;④供皮区采用整块中厚皮片植皮,以减少瘢痕增生;⑤皮瓣边缘与正常的组织缝合,以利于皮瓣血循环重建和周围神经末梢长入皮瓣。
　　1.2.2 皮神经营养血管逆行皮瓣:①彻底清创后,以腓肠神经或隐神经体表投影为轴设计皮瓣,于皮下组织内寻找该皮神经及其伴行之静脉和神经营养血管[4-5];②在神经血管束旁开1～2cm处切开深筋膜,于深筋膜下显露腓动脉穿支血管束2～3支,以这些穿支为皮瓣蒂部的旋转轴点,在轴点近端以腓肠神经血管束为中心,保留1～2cm宽之皮肤并在旋转点下方切断皮肤至浅筋膜,切取包含皮下组织并两侧各保留2cm宽的深筋膜共同形成以腓肠神经及其营养血管束为中心,包括深筋膜、浅筋膜的皮瓣蒂;③在蒂的近端依据皮瓣设计,在深筋膜深层游离皮瓣,即使深筋膜保留于皮瓣内,使整个皮瓣于深筋膜下翻起,制成逆行岛状皮瓣;④松止血带,观察皮瓣血运,如皮瓣快速充盈,于远端将静脉结扎;⑤观察血运满意,经切开的皮肤隧道转移至受区。
　　1.2.3 游离皮瓣:①彻底清创后,分别以旋股外侧动脉、隐动脉、胸背动脉为轴设计皮瓣,皮瓣可同时切取股外侧皮神经或隐神经;②以胫前血管、胫后血管与大隐静脉为受区血管行端端或端侧吻合;③吻合股外侧皮神经或隐神经以恢复皮瓣的感觉[6-7];④手术可分两组同时进行以缩短手术时间。
　　1.3 观察指标:术中测量皮瓣大小,术后观察皮瓣成活面积及成活质量。皮瓣坏死小于1/3为部分坏死。比较三类不同皮瓣的成活面积和成活率,成活面积均数比较采用组间单因素方差分析(ANOVA),成活率比较采用组间非参数检验,P