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錯位環扎法治療下肢深靜脈栓塞后小腿潰瘍21例

小腿內側皮瓣修復手部創傷47例

我科自1983年5月～1993年5月，應用小腿內側皮瓣整復手部創傷47例(48側)。隨訪時間1～10年，效果滿意。手術后無1例發生供瓣側下肢功能障礙，皮瓣成活率97.9%。對小腿內側皮瓣應用于手部創傷中的特點作了討論。

REPAIR OF HUGE SKIN DEFECT ON LEG AND FOOT WITH MULTIPLE PEDICLED BLOCKING RANDOMIZED FASCIOCUTANEOUS FLAP

OBJECTIVE In order to increase the survival area of pedicled fasciocutaneous flap, a multiple pedicled blocking randomized fasciocutaneous flap was designed. METHODS From January 1991 to September 1998, this technique was used to repair 33 cases, including 27 males and 6 females and the ages ranged from 6 to 58 years. All of the patients were suffered from traffic accidents. In these cases, 22 cases had skin defects of legs and feet with bone, nerve and tendon exposed, 5 cases had osteomyelitis as well as internal fixaters exposed and the other 6 had deformity from scar. The size of the flap was 25.0 cm x 13.0 cm x 2.4 cm at its maximum and 6.0 cm x 3.5 cm x 1.5 cm at its minimum. Based on the traditional blocking flap, according to the severity of the wound and conditions of the neighboring tissues, a flap having 2 to 4 orthogonal pedicles with a width of 1.5 to 3.0 cm was designed. The medical-graded stainless steel sheet was implanted below the deep fascia, and after blocking for 3 to 6 days, the side pedicles were divided. 6 to 14 days later, one of the two remaining pedicles was divided and was transferred to repair the defect. RESULTS 31 cases were followed up for 6 months to 5 years without any trouble of the joints. The flap had a good external appearance and was high pressure-resistant. CONCLUSION The multiple pedicled blocking randomized fasciocutaneous flap increased the size of the flap and the length to width ratio. It had the following advantages: manage at will, high resistance to infection and a large survival area of flap.

小腿腓腸神經和隱神經營養血管蒂皮瓣修復脛前及足部軟組織缺損

目的 報道小腿腓腸神經、隱神經營養血管蒂皮瓣修復脛前及足部缺損的臨床應用及其療效。 方法 2004年2月～2006年4月，對15例脛前及足部外傷感染后致軟組織缺損壞死骨外露徹底清創后，采用腓腸神經或隱神經營養血管蒂皮瓣修復，脛前軟組織缺損6.5 cm×4.0 cm～16.0 cm×8.0 cm，足部軟組織缺損4.0 cm×2.6 cm～6.0 cm×4.5 cm。皮瓣切取范圍為5.5 cm×4.5 cm～18.0 cm×10.0cm。 結果 術后13例皮瓣Ⅰ期愈合，2例Ⅱ期愈合，經3～12個月隨訪，質地良好，外觀滿意。足背皮瓣中1例邊緣壞死，另1例少許表皮壞死。踝部功能不受影響，皮瓣皮膚感覺僅少部分恢復。 結論 小腿腓腸神經或隱神經營養血管蒂皮瓣是修復脛前及足部軟組織缺損的有效方法，但蒂長血供有限，宜慎用。

Imaging study and clinical application of peroneal perforating chimeric tissue flap

Objective To explore the feasibility of peroneal perforating chimeric tissue flap in repairing the composite defects of calf and heel based on lower limb angiography, and the clinical effect. Methods The digital subtraction angiography images of lower limbs of 50 patients met the selection criteria between May 2011 and October 2014 were used as the research object to observe the course of peroneal artery and its perforating vessels. Based on the observation results, between April 2015 and October 2020, the peroneal perforating chimeric tissue flap was designed to repair 7 cases of composite defects of the calf and heel. There were 5 males and 2 females with an average age of 38 years (range, 25-55 years). The causes of injury included traffic accident in 4 cases, falling from height in 2 cases, and machine strangulation in 1 case. There were 5 cases of calf skin defect and tibial defect. The size of skin defect ranged from 5 cm×3 cm to 11 cm×7 cm, and the length of bone defect was 5-8 cm. There were 2 cases of heel skin defect and calcaneal defect. The sizes of skin defects were 5.0 cm×4.0 cm and 7.5 cm×6.5 cm, and the bone defects were 3.0 cm×2.6 cm and 4.0 cm× 3.0 cm. For the calf defect, the size of skin flap ranged from 6 cm×4 cm to 12 cm×8 cm, and the length of the fibula was the same as that of the tibial defect. For the heel defect, the sizes of the skin flaps were 8.5 cm×5.5 cm and 13.0 cm×5.0 cm, and the lengths of the fibulae were 10 cm and 12 cm. Free transplantation was performed in 5 cases and pedicle transplantation in 2 cases. The wound at donor site was repaired with skin grafting or sutured directly. Results The peroneal artery ran close to the fibula 7.25-8.40 cm below the fibula head and send out 5-7 perforating vessels, with an average of 6.5 vessels. Perforating vessels mainly appeared in four places, which were (9.75±0.91), (13.21±0.74), (18.15±1.22), and (21.40±0.75) cm below the fibular head, with the occurrence rates of 94%, 90%, 96%, and 88%, respectively. Clinical application of 7 cases of peroneal perforating chimeric tissue flap all survived, all wounds healed by first intention. The skin graft at donor site survived and the incision healed by first intention. All patients were followed up 6-36 months, with an average of 12 months. Peroneal perforator chimeric tissue flap had good shape and soft texture. X-ray films showed that the bone graft healed well, and the healing time was 6-11 months (mean, 7 months). No obvious bone resorption was observed during follow-up. Five patients had no pain when walking, and 1 had mild pain with claudication. Postoperative heel ulcers formed in 1 case and healed after wearing custom plantar pressure dispersing shoes. At 6 months after operation, 2 patients were rated as grade Ⅳ and 5 patients as grade Ⅴ according to Holden walking function score. ConclusionThe peroneal perforating vessel distribution is constant and the peroneal perforating chimeric tissue flap is safe and reliable for repairing the composite defects of calf and heel.

小腿踝上穿支蒂螺旋槳皮瓣修復足底黑色素瘤切除后創面

目的總結小腿踝上穿支蒂螺旋槳皮瓣修復足底黑色素瘤切除后創面的療效。方法2016 年 4 月—2018 年 6 月，收治 6 例足底黑色素瘤患者。男 2 例，女 4 例；年齡 32～53 歲，平均 36 歲。病程 1～320 個月，中位病程 58 個月。腫瘤擴大切除后，遺留創面范圍為 5.8 cm×4.5 cm～10.6 cm×8.7 cm，切取小腿踝上穿支蒂螺旋槳皮瓣修復。皮瓣旋轉后大槳無張力修復創面，小槳修復供區創面；皮瓣切取范圍為 8.5 cm×6.8 cm～12.0 cm×10.5 cm。供區經皮瓣修復后 4 例直接拉攏縫合、2 例游離植皮修復。結果術后除 1 例皮瓣部分表皮壞死，其余皮瓣及植皮均順利成活，創面及供區切口均Ⅰ期愈合。患者均獲隨訪，隨訪時間 3～24 個月，平均 18 個月。除 3 例皮瓣臃腫行二期修整外，其余皮瓣外形良好，色澤、質地及彈性佳；足底淺感覺不同程度恢復。末次隨訪時，按美國矯形足踝協會（AOFAS）評分，獲優 4 例、良 1 例、可 1 例，優良率為 83.3%。隨訪期間無腫瘤復發。結論小腿穿支蒂螺旋槳皮瓣質地與足底組織相似，皮瓣易于旋轉，無需犧牲主要血管，適用于修復足底黑色素瘤切除后創面。

高頻彩色多普勒超聲診斷肌疝一例

多個筋膜皮下瓣組合修復小腿大面積皮膚缺損

目的 總結應用多個筋膜皮下瓣組合修復小腿大面積皮膚缺損的手術方法和療效。 方法 2007 年4 月－ 6 月，采用在受區周圍不同方向切取多個大小為7 cm × 3 cm ～ 22 cm × 8 cm 的筋膜皮下瓣，向受區中央翻轉匯合加植皮的方法，修復小腿大面積皮膚缺損2 例。男性患者40 歲，脛腓骨多段開放粉碎性骨折，軟組織嚴重挫傷，足部無血循環；右小腿中下段前內側皮膚缺損達23 cm × 18 cm，骨外露23 cm × 8 cm。女性患者40 歲，左脛腓骨多段開放性骨折，軟組織損傷嚴重，小腿自脛骨結節至內踝上皮膚缺損25 cm × 7 cm。 結果 2 例術后均獲隨訪，隨訪時間分別為6 個月和5 個月。供區創面均Ⅰ期愈合，筋膜皮下瓣及植皮成活，皮膚質地、外觀滿意，關節活動無明顯受限，X 線片見有骨痂形成。 結論 多個筋膜皮下瓣組合修復小腿大面積皮膚缺損，手術操作簡便，成功率高，適用于不能用單一筋膜皮下瓣修復的較大創面

小腿復雜組織缺損的修復

目的 總結小腿復雜組織缺損的特點、修復的最佳時機與方法。 方法 2000 年1 月－ 2007 年12 月，收治小腿復雜組織缺損122 例。男102 例，女20 例；年齡7 ～ 65 歲，中位年齡31.5 歲。重物砸傷57 例，交通事故傷32 例，車輪絞傷3 例，其他傷30 例。缺損位于小腿上段28 例，中段37 例，下段57 例。皮膚缺損范圍為10 cm ×5 cm ～ 20 cm × 11 cm。113 例伴骨、肌腱或鋼板外露。病程4 h ～ 18 個月。術中采用吻合血管皮瓣19 例，帶蒂皮瓣及筋膜皮瓣103 例，切取皮瓣大小為7 cm × 5 cm ～ 20 cm × 7 cm。骨缺損分別采用肢體縮短、髂骨植骨、吻合血管的腓骨及同側腓骨植骨，骨移植長度3 ～ 16 cm。供區均用中厚皮片修復。 結果 術后119 例皮瓣成活，3 例皮瓣壞死，經對癥處理后愈合。供區植皮均成活，切口愈合良好。術后98 例獲隨訪，隨訪時間4 ～ 38 個月。12 例背闊肌皮瓣外觀略顯臃腫，未作處理；其他皮瓣質地良好。獲隨訪的54 例骨缺損患者于術后8 ～ 18 個月達骨性愈合。 結論 小腿復雜組織缺損應根據組織缺損的具體情況，針對性選擇皮瓣、適時對骨缺損進行修復與制動是手術成功的關鍵。

The Repair of Lower Leg, Ankle and Foot Soft Tissue Defects

目的　評價不同皮瓣、肌皮瓣修復小腿及足踝部皮膚軟組織缺損的效果，探討小腿及足踝部皮膚軟組織缺損的理想修復方法。 方法　2002年6月－2010年1月，應用15種皮瓣、肌皮瓣修復128例（138處）小腿及足踝部皮膚軟組織缺損。其中小腿中上段21處，小腿中下段45處，內外踝及足跟部43處，足背及前足29處。主要應用最多的皮瓣有腓腸神經營養血管皮瓣、腓腸肌內外側頭肌皮瓣、腓淺神經營養血管皮瓣和足底內側皮瓣。修復軟組織缺損范圍5 cm×4 cm～23 cm×14 cm。 結果　術后135處創面Ⅰ期愈合，皮瓣完全成活；2處皮瓣部分壞死，經二次手術植皮修復；1例游離股前外側皮瓣修復小腿中下段軟組織缺損，皮瓣完全壞死，后改取對側腓腸神經營養血管交腿皮瓣修復成活。腓腸神經營養血管皮瓣應用例數最多，成活率高，吻合血管的游離皮瓣壞死率較高。術后患者均獲隨訪1～10年，平均23個月，皮瓣均成活良好, 無潰瘍、滲液等。 結論　正確認識并選擇皮瓣、肌皮瓣修復小腿及足踝部皮膚軟組織缺損可提高皮瓣成活率，恢復肢體良好功能，腓腸神經營養血管皮瓣是一種修復小腿及足踝部軟組織缺損的理想皮瓣。