保留腓肠神经的小腿后外侧穿支皮瓣的临床应用

摘要

目的 探讨以腓动脉远端穿支为蒂保留供区腓肠神经,小隐静脉的小腿后、外侧穿支皮瓣的切取方法,评价其修复创面缺损的效果.方法 自2011年5月至2013年9月,采用以腓动脉远端穿支为蒂,保留腓肠神经、小隐静脉在供区创面内,保留腓肠神经营养血管网在小腿后、外侧皮瓣内的方法修复足、踝、跟腱区皮肤缺损12例,其中外伤导致皮肤及软组织缺损6例,糖尿病所致慢性溃疡、伤口不愈合4例,感染导致皮肤坏死2例,创面大小4.0 cm×2.5 cm～8.0 cm×5.0 cm,皮瓣面积9.0 cm×4.0 cm～ 17.0 cm×7.0 cm.术后常规观察皮瓣血运,评价供区肢体肿胀及疼痛情况,后期评价皮瓣外形、质地及感觉功能,6～ 12个月问卷调查患者对皮瓣外形满意度(％),对患足功能行AOFAS评分.结果 12例供区均完整保留腓肠神经及小隐静脉,术后10例皮瓣完全存活,2例皮瓣远端出现各约2 cm的皮肤坏死,经换药在2个月内愈合.9例获得有效随访,时间平均13.7个月,皮瓣外形美观,质地良好,患肢肿胀轻.皮瓣恢复痛觉、触觉、温度觉及单点分辨觉,术后12个月感觉功能评级为S3.患者对皮瓣外形均满意,患足AOFAS评分87 ～ 93,平均值为90.2.结论 以腓动脉远端穿支为蒂的小腿后、外侧皮瓣可以完整保留供区腓肠神经及小隐静脉,减少了供区损伤,且皮瓣血运可靠,临床修复效果满意.%Objective To explore the surgical techniques of preserving sural nerve and lesser saphenous vein while harvesting lower leg posterolateral flap based on distal perforator of the fibular artery,and evaluate the treatment results of repairing foot and ankle defects with the flap.Methods From May 2011 to September 2013,soft tissue defects around the foot and ankle in 12 patients were repaired by transferring fibular artery distal perforator flap.The sural nerve and lesser saphenous vein were left intact in the donor site,while the sural neurovascular network was included in the lower leg posterolateral flap.The defects were caused by trauma in 6 cases,by chronic diabetic ulceration in 4 cases,and by necrosis following infection in 2 cases.The size of the wounds ranged from 4.0 cm × 2.5 cm to 8.0 cm × 5.0 cm.Flaps size ranged from 9.0 cm × 4.0 cm to 17.0 cm × 7.0 cm.Skin grafts were applied to cover the donor sites.Postoperatively,blood supply of the flaps,swelling of the leg,and pain were closely monitored for 10 days.Flap appearance,contour,and sensation were evaluated later.Questionnaire survey of patient satisfaction of the flap and AOFAS scoring were performed 6 to 12 months postoperatively.Results Complete survival was seen in 10 flaps.Two flaps had partial marginal necrosis in the distal portion,which were managed with surgical debridement.The wound healed in two months.Nine patients had more than 12 months' follow-up.The flaps had good appearance and good contours.Swelling of the leg was minimum.Pain,temperature and touch perception of flaps at 12 months postoperatively indicated S3 sensory recovery.Patients were satisfied with the appearance of the flaps.The AOFAS scores were 87 to 93,the mean score being 90.2.Conclusion Posterolateral lower leg flap pedicled on fibular artery distal perforator can be safely raised without severing the sural nerve and lesser saphenous vein,which minimizes donor site morbidity without compromising blood supply of the flap.