Song Yiping, Zhang Fahui, Liu Hongbin
Department of Orthopedics, the 97th Hospital of Chinese PLA, Xuzhou Jiangsu, 221004, P.R. China.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009 Dec;23(12):1435-9.
To explore the clinical outcomes of repairing limb wound with distal based neurocutaneous flap.
From June 2003 to June 2009, 187 cases with wounds in the hand, foot, and distal leg were treated. There were 127 males and 60 females aged 20-70 years old (average 37.5 years old). The wound was caused by traffic accident in 130 cases, crush injury in 38 cases, machinery accident in 16 cases, and explosion injury in 3 cases. Among them, the soft tissue defect was in the dorsal and palmar aspects of the hand in 35 cases, the distal leg in 50 cases, the dorsal aspect of foot in 40 cases, the region around ankle in 27 cases, the tendon area in 11 cases, the medial side of foot in 4 cases, the heel and sole of foot in 5 cases, and the forefoot area in 15 cases. The size of skin soft tissue defect was 5.0 cm x 3.0 cm-17.5 cm x 10.0 cm. Four cases suffered from nonunion of heel and 15 cases suffered from tibia defect (3-7 cm). The course of disease was 3 days-8 years. During operation, 35 cases with wound in the hand were treated with three types of lower rotation point of forearm neurocutaneous flaps with rotation points 0-3 cm above the wrist joint, 66 cases were treated with distal based saphenous nerve and saphenous vein neurovascular flaps, muscle flaps and bone flaps with rotation points 2-5 cm above the medial malleolus, and 86 cases were treated with sural and saphenous flaps, muscle flaps and bone flaps with rotation points 1-5 cm above the external malleolus. The flap was 5 cm x 3 cm-17 cm x 15 cm in size, the muscle flap was 5 cm x 3 cm x 1 cm-10 cm x 6 cm x 2 cm in size, the fibula flap was 4.0 cm x 2.5 cm-10.0 cm x 8.0 cm in size. The ligation of the superficial veins was performed below the rotation point of the flap in 163 cases, and the cutaneous nerve ending anastomosis was performed in 22 cases. The donor site was repaired by split thickness skin grafting from the inner side of the thigh.
Various degree of skin flap swelling occurred, and the swelling extent in the patients receiving the superficial vein ligation was obvious less than that of patients with no ligation. At 4-7 days after operation, 6 cases had necrosis at the edge of flaps and 6 cases had blister, all of them healed after changing dress. The rest skin flaps and skin grafting in the donor site survived uneventfully, and the incision healed by first intention. All the patients were followed up for 2 months to 3 years. The appearance of the flap was satisfactory, the hand function and the foot function of walking and weight-bearing recovered. The two point discrimination of the patients 1 year after cutaneous nerve ending anastomosis was 8-12 mm. The grafted fibula in the patients with bone defect reached union 8-10 months after operation. The appearance and the movement of the donor site were normal.
The new type distal based neurocutaneous flap has such advantages as simple operative procedure, less invasion, high survival rate, and recovery of the sensory function of the hand and the foot. It is suitable to repair the tissue defect in the hand, the foot, and the distal leg.
探讨远端蒂神经皮瓣修复肢体创面的临床效果。
2003年6月至2009年6月，治疗手部、足部及小腿远端创面187例。男127例，女60例，年龄20 - 70岁（平均37.5岁）。致伤原因：交通事故130例，挤压伤38例，机器伤16例，爆炸伤3例。其中，手部背侧及掌侧软组织缺损35例，小腿远端50例，足部背侧40例，踝关节周围27例，肌腱区11例，足内侧4例，足跟及足底5例，前足区15例。皮肤软组织缺损面积为5.0 cm×3.0 cm - 17.5 cm×10.0 cm。足跟不愈合4例，胫骨缺损（3 - 7 cm）15例。病程3天至8年。手术中，手部创面35例采用前臂神经皮瓣下旋转点类型，旋转点位于腕关节上方0 - 3 cm；66例采用远端蒂隐神经隐静脉神经血管瓣、肌瓣及骨瓣，旋转点位于内踝上方2 - 5 cm；86例采用腓肠神经营养血管皮瓣、隐神经营养血管皮瓣、肌瓣及骨瓣，旋转点位于外踝上方1 - 5 cm。皮瓣面积为5 cm×3 cm - 17 cm×15 cm，肌瓣面积为5 cm×3 cm×1 cm - 10 cm×6 cm×2 cm，腓骨瓣面积为4.0 cm×2.5 cm - 10.0 cm×8.0 cm。163例在皮瓣旋转点以下结扎浅静脉，22例进行皮神经断端吻合。供区采用大腿内侧中厚皮片移植修复。
皮瓣均出现不同程度肿胀，浅静脉结扎患者肿胀程度明显轻于未结扎者。术后第4 - 7天，6例皮瓣边缘坏死，6例出现水疱，经换药后均愈合。其余皮瓣及供区植皮均顺利成活，切口一期愈合。所有患者随访2个月至3年。皮瓣外观满意，手部功能及足部行走、负重功能恢复。皮神经断端吻合患者术后1年两点辨别觉为8 - 12 mm。骨缺损患者移植的腓骨术后8 - 10个月达到骨性愈合。供区外观及活动正常。
新型远端蒂神经皮瓣具有手术操作简单、创伤小、成活率高、能恢复手足感觉功能等优点，适合修复手部、足部及小腿远端组织缺损。
