小剂量肝素治疗皮神经营养皮瓣术后静脉危象的探讨

目的:探讨小剂量肝素治疗皮神经营养皮瓣术后静脉危象的临床价值。方法:我院自2010年1月至10月共5例发生皮神经营养皮瓣术后皮瓣出现静脉危象。所有5例患者均在间断拆线的同时应用皮瓣皮下小剂量肝素注射使切缘持续缓慢渗血,并根据血运情况调整肝素使用剂量,观察皮瓣血运恢复情况及存活情况。结果:经小剂量肝素治疗后,5例皮神经营养皮瓣术后皮瓣颜色转红润,静脉危象均逐步缓解,全部皮瓣均成活,伤口无感染,愈合良好。患者对皮瓣外观和功能满意。结论:小剂量肝素皮下注射是一种简易但有效的解决皮神经营养皮瓣术后静脉危象的方法。     

VSD联合带腓肠神经营养血管逆行岛状皮瓣治疗胫骨慢性骨髓炎的术后护理及功能锻炼

目的:观察封闭式负压引流(vacuum sealing drainage,VSD)联合带腓肠神经营养血管逆行岛状皮瓣治疗胫骨慢性骨髓炎的术后护理及功能锻炼的效果.方法:2009年1月-2009年11月,收治28例胫骨慢性骨髓炎患者,采用VSD待创面肉芽组织新鲜、感染控制后,用带腓肠神经营养血管逆行岛状皮辩治疗胫骨慢性骨髓炎,术后予以特殊护理与康复治疗.结果:28例患者术后予以特殊护理与康复治疗,皮瓣顺利成活.28例患者均获随访,随访时间1～10个月.皮辩与周围皮肤色泽相似,无臃肿,两点辨别觉6～8mm.术后能穿鞋正常行走,皮瓣受力处无破溃.结论:VSD联合带腓肠神经营养血管逆行岛状皮瓣治疗胫骨慢性骨髓炎,术后予以特殊护理与康复治疗,疗效满意     

腓肠神经营养血管皮瓣修复跟骨骨折术后皮肤软组织缺损的临床研究

摘要 目的：探讨负压引流技术结合腓肠神经营养皮瓣在跟骨骨折钢板内固定术后皮肤软组织缺损的临床效果。方法：回顾性分析我院骨科2012年5月-2020年5月共31例跟骨骨折术后钢板外露,皮肤软组织缺损住院病人。纳入患者均使用负压引流技术结合腓肠神经营养皮瓣修复技术。创面给予彻底清创后行封闭负压吸引引流术,待创面新鲜后以腓肠神经营养皮瓣修复创面。对术后皮瓣成活情况;Maryland功能评分以及BMRC感觉功能评分进行综合评估。结果：术后2周时,28例皮瓣顺利成活,供区与受区伤口愈合良好,干燥、无渗出。3例术后出现皮瓣肿胀,皮瓣颜色发暗,伤口渗出较多,皮瓣边缘坏死,窦道形成等,给予切开引流、加强换药、敏感抗生素控制感染等治疗后,皮瓣成活。术后随访6-24个月皮瓣外观及功能恢复良好,无创面再坏死,裂开,感染等情况出现。其中2例再次入院行皮瓣整形术。术后6个月时,Maryland功能评分：优：17例;良：11例;优良率为：90.3%。BMRC感觉功能评分：S3-S4：20例;S2：8例;S1：3例。结论：腓肠神经营养皮瓣联合封闭负压吸引技术在跟骨骨折钢板内固定术后皮肤软组织缺损的治疗中能够缩短治疗时间,操作简单,疗效确切,可获得良好的修复效果。     

股前外侧穿支皮瓣与胸腹带蒂皮瓣对手外伤组织缺损修复的应用效果及对创面愈合程度的影响

摘要 目的：探讨股前外侧穿支皮瓣与胸腹带蒂皮瓣对手外伤组织缺损修复的应用效果及对创面愈合程度的影响。方法：选取我院2018年12月到2020年12月共收治的119例手外伤组织缺损患者作为研究对象,随机分为2组,分别为对照组（n=59,应用胸腹带蒂皮瓣修复术）和观察组（n=60,应用股前外侧穿支皮瓣修复术）。对比两组患者治疗优良率,对比两组患者治疗前后手部创面面积、创面愈合程度以及组织愈合时间,对比两组患者治疗后的Jamar握力、TAM和DASH评分情况,对比两组患者的皮瓣成活率、皮瓣危象率和血管吻合时间。结果：通过对比两组患者治疗优良率发现,观察组患者优的人数为21例、良为35例,优良率为93.33%,对照组患者优的人数为16例,良为30例,优良率为77.97%,观察组高于对照组（P＜0.05）;治疗后,与对照组相比,观察组患者的手部创面面积、组织愈合时间和DASH评分显著减少,创面愈合程度以及TAM与Jamar握力显著增加（P＜0.05）;通过对比两组患者的皮瓣成活率、术后皮瓣危象率以及血管吻合时间发现,两组患者的术后皮瓣危象率、血管吻合时间对比无明显差异（P＞0.05）,两组患者的术后皮瓣成活率对比差异显著,观察组明显高于对照组（P＜0.05）。结论：对手外伤组织缺损患者应用股前外侧穿支皮瓣与胸腹带蒂皮瓣修复术均具有明显的修复效果,但是应用股前外侧穿支皮瓣能够提升治疗效果,提升患者创面愈合程度减少愈合时间,提升患者手部运动情况,提升术后皮瓣成活率,值得临床应用推广。     

口腔颌面部肿瘤患者术后缺损的外侧皮瓣修复术与前臂皮瓣修复术对比研究

摘要 目的：探讨口腔颌面部肿瘤患者术后缺损的外侧皮瓣修复术与前臂皮瓣修复术对比。方法：选取遂宁市中心医院（我院）2015年8月到2020年8月共收治的120例口腔颌面部肿瘤患者,所有患者通过肿瘤切除术后均出现组织缺损现象,对所有组织缺损的患者依照不同的皮瓣修复方式分为两组,其中应用外侧皮瓣修复术的68例患者分为外侧皮瓣修复组,应用前臂皮瓣修复术的52例患者分为前臂皮瓣修复组,对比两组的皮瓣修复效果,治疗后的口腔功能恢复情况,瓣成活率、术后皮瓣危象率以及血管吻合时间,并发症情况。结果：外侧皮瓣修复组的总有效率为95.59 %,前臂皮瓣修复组的总有效率为84.62 %,外侧皮瓣修复组明显高于前臂皮瓣修复组（P＜0.05）;外侧皮瓣修复组患者的外形修复、语言功能、咀嚼功能、吞咽功能以及口腔闭合评分明显高于前臂皮瓣修复组（P＜0.05）;两组的皮瓣成功率均比较高对比无明显差异（P＞0.05）,两组的术后皮瓣危象率比较低,对比无明显差异（P＞0.05）,血管吻合时间对比无明显差异（P＞0.05）;对比两组并发症发生情况发现,外侧皮瓣修复组的总并发症发生率为2.94 %,前臂皮瓣修复组并发症发生率为17.31 %,外侧皮瓣修复组明显低于前臂皮瓣修复组（P＜0.05）。结论：对口腔颌面部肿瘤患者术后缺损患者应用外侧皮瓣修复术能够提升患者的皮瓣修复效果,提升患者的口腔功能恢复情况,减少并发症的发生,安全性好,值得临床应用推广。     

游离股前外侧皮瓣修复对急诊肢体复合组织缺损患者近期和远期预后的影响

摘要 目的：探讨与分析游离股前外侧皮瓣修复对急诊肢体复合组织缺损患者近期和远期预后的影响。方法：2015年4月到2021年9月选择在本院急诊的下肢复合组织缺损患者66例作为研究对象,根据1:1随机分配原则把患者分为研究组与对照组各33例。研究组给予游离股前外侧皮瓣修复治疗,对照组给予下肢外侧皮瓣修复治疗,观察与随访患者的近期和远期预后情况。结果：所有患者都顺利完成急诊修复治疗,所有皮瓣都创面都Ⅰ期愈合,研究组的术后住院时间、术后换药次数、术后上皮组织完全覆盖创面时间、术后创面愈合时间少于对照组（P<0.05）。研究组术后3个月的皮瓣血供优良率为100.0 %,高于对照组的84.8 %（P<0.05）。研究组术后3个月的血肿、伤口感染、血管危象、骨髓炎等并发症发生率为3.0 %,低于对照组的27.3 %（P<0.05）。研究组术后12个月的皮瓣保护性感觉率为100.0 %,高于对照组的78.8 %（P<0.05）。结论：游离股前外侧皮瓣修复在急诊肢体复合组织缺损患者的应用能促进患者康复,提高皮瓣血供优良率,还可减少并发症的发生,改善患者远期的皮瓣保护性感觉状况。     

膝内侧游离皮瓣修复足跟软组织缺损的研究与应用

目的:探讨膝内侧游离皮瓣修复足跟皮肤软组织缺损的临床效果.方法:2007-2009应用膝内侧游离皮瓣移植修复足跟皮肤软组织缺损12例.将膝降动脉和其伴行静脉与胫后动静脉吻合,皮瓣大隐静脉与受区大隐静脉吻合,将股内侧皮神经、隐神经与受区腓肠神经或隐神经吻合,使皮瓣具有良好的血运和感觉功能;将缝匠肌腱和股薄肌腱重建跟腱缺损修复跟腱功能.结果:移植皮瓣全部成活,创面一期愈合,经6周-18个月随诊,皮瓣感觉恢复良好,足跟外形及稳定性良好.结论:膝内侧游离皮瓣血管口径粗,蒂长,带有两根知名感觉神经,皮瓣较薄,修复足跟外形美观,耐磨,稳定好,特别是带有缝匠肌腱和股薄肌腱修复跟腱缺损,是足跟部皮肤软组织缺损修复良好供区.     

吻合皮下静脉的带蒂皮瓣修复四肢皮肤软组织缺损的效果分析

摘要 目的：探讨与分析吻合皮下静脉的带蒂皮瓣修复四肢皮肤软组织缺损的效果。方法：选择2018年12月到2021年12月在本院创伤造成的四肢皮肤软组织缺损60例患者作为研究对象,将其随机分为吻合皮下静脉带蒂皮瓣组与传统带蒂皮瓣组各30例。吻合皮下静脉带蒂皮瓣组给予吻合皮下静脉的带蒂皮瓣修复治疗,传统带蒂皮瓣组给予常规直接覆盖创面修复治疗。结果：所有患者都顺利完成手术,吻合皮下静脉带蒂皮瓣组围手术指标时间均较传统带蒂皮瓣组少（P<0.05）。吻合皮下静脉带蒂皮瓣组术后3个月的总有效率为96.7 %,高于传统带蒂皮瓣组的76.7 %（P<0.05）。吻合皮下静脉带蒂皮瓣组术后3个月的并发症发生率较传统带蒂皮瓣组低（P<0.05）。吻合皮下静脉带蒂皮瓣组术后6个月的感觉功能恢复情况好于传统带蒂皮瓣组（P<0.05）。结论：吻合皮下静脉的带蒂皮瓣能促进患者的创面愈合,提高治疗效果,减少并发症,加快恢复患者的四肢皮肤软组织缺损。     

足踝骨肿瘤切除后采用腓肠神经营养血管皮瓣术的修复效果及对运动功能的影响

摘要 目的：探讨足踝骨肿瘤切除后采用腓肠神经营养血管皮瓣术的修复效果及对运动功能的影响。方法：选取我院2013~2019年收治的足踝骨肿瘤切除患者83例,应用随机分组法将其分为研究组41例和对照组42例。对照组患者应用以往清创换药的保守修复方法,研究组患者应用腓肠神经营养血管皮瓣术修复方法,对比两组患者的治疗总有效率与致残率、住院费用、住院时间以及治疗前后运动功能的变化。结果：治疗后,研究组的总有效率为90.24%,显著高于对照组(64.29%,P＜0.05);两组患者住院花费比较差异无统计学意义(P＞0.05);研究组患者的住院天数上明显短于对照组(P＜0.05);研究组患者的致残率为2.44%,明显低于对照组(16.67%,P＜0.05);研究组患者修复后的Fugl-Meyer下肢运动功能评定(Fugl-Meyer assessment,FMA)和Berg平衡量表(Berg Balance Scale,BBS)评分均明显高于对照组(P＜0.05)。结论：腓肠神经营养血管皮瓣术修复术较清创换药的保守修复方法可以更有效修复足踝骨肿瘤广泛切除术后患者足踝部的创伤面,改善患者运动功能,且手术方法相对简单,安全性更高。     

带蒂皮瓣移植在小腿开放性骨折中的临床研究

目的:探讨不同带蒂皮瓣移植术式在小腿开放性骨折中的临床应用效果。方法:35例小腿开放性骨折患者,完善术前准备后,根据小腿皮肤软组织的缺损部位、面积、深度分别选择腓肠神经营养皮(肌)瓣、隐神经营养逆行皮瓣、局部旋转皮(肌)瓣修复创面。结果:所有移植皮瓣中,1处移植失败(坏死面积>1/2),2处皮瓣远端1-2.5cm坏死,经清创换药后愈合,余患者皮瓣均成活。从皮瓣成活的优良率和出血量上对比,三组间无明显差别,从手术时间上对比,局部旋转皮(肌)瓣组优于另两组(P<0.05)。结论:在小腿开放性骨折伴皮肤软组织缺损的治疗中,完善的术前准备及根据皮损形态选择适当的皮瓣是获得满意疗效的基础。     

The simple and effective choice for treatment of chronic calcaneal osteomyelitis: neurocutaneous flaps

The authors describe their experience with the use of distally based saphenous and sural neurofasciocutaneous flaps for the treatment of calcaneal osteomyelitis in nine cases. Aggressive débridement of all nonviable and poorly vascularized tissue and coverage with a distally based neurofasciocutaneous flap were coupled with a thorough antibiotic course in all cases. The deepithelized peripheral parts of all flaps were buried in the bone cavities after bone débridement. Follow-up periods ranged from 15 to 27 months. All flaps survived completely. All of the wounds except one healed completely. These flaps have adequate blood flow for the management of chronic bone infections. They also have many advantages, such as easy quick elevation, short operative time, and acceptable donor-site morbidity. Moreover, patients treated with neurocutaneous flaps do not require debulking procedures or special shoes. Reconstruction with neurocutaneous flaps after radical débridement is a versatile alternative to the use of local or distant muscle flaps and calcanectomy procedures for patients with osteomyelitis of the os calcis.     

Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot

Skin defects over the lower one-fourth of the leg and over the foot are difficult to cover. Two types of pedicled fasciocutaneous flaps used to cover such defects were studied: the lateral supramalleolar flap and the distally based sural neurocutaneous flap. The series consisted of 27 and 36 cases, respectively. The lateral supramalleolar flap was used 27 times: for skin defects over the ankle (4), foot (16), and leg (7). The distally based sural neurocutaneous flap was used 42 times: over the foot (24), ankle (13), and leg (5). Fourteen of these patients were 65 years of age or older, and local vascularity was diminished in 16 cases. The flaps were evaluated clinically twice: in the immediate postoperative period for survival or for partial or total flap necrosis, and again to determine the presence of pain at the donor or recipient sites and the cosmetic appearance. Thirty-nine patients (62 percent) were reviewed subsequently, with a mean follow-up of 5 years for the supramalleolar flap and 2 years for the sural neurocutaneous flap. The results were evaluated for the presence or absence of pain, the appearance of the flap, the disability due to the insensate nature of the flap, and the presence or absence of secondary ulceration. Painful neuromata were noted in three cases with the sural neurocutaneous flap, whereas complete necrosis of the supramalleolar artery flap occurred in three patients. The distally based sural neurocutaneous island flap is very reliable, even in debilitated patients. Though the lateral supramalleolar artery flap offers the possibility of covering the same areas as the sural neurocutaneous flap, it is much less reliable in the presence of diminished local vascularity (18.5 percent failure rate as compared with 4.8 percent for the sural neurocutaneous flap). Because the procedure can cover extensive defects and is easy to perform, the distally based sural neurocutaneous flap was the method of choice for covering skin defects over the foot, heel, ankle, and the lower one-fourth of the leg. The lateral supramalleolar artery flap is indicated only when the sural neurocutaneous flap is contraindicated.     

A new flap design: neural-island flap

This report introduces the "neural-island flap" concept, which represents a consistent and reliable skin flap design supplied only by the intrinsic vasculature of a cutaneous nerve. In this study, the lateral femoral cutaneous nerve was selected as the pedicle of the neural-island flap, and a standard skin flap, which is the territory of the accompanying vessels (i.e., iliac branches of the iliolumbar artery and vein), was elevated on the lower dorsal region of the rats. In a total of 92 Wistar rats, three experiments were performed. In part I (n = 24), the vascular anatomy of the lateral femoral cutaneous nerve was established by the methods of dissection, microangiography, nerve mapping, perfusion with colored latex and India ink, and histologic analysis. In part II (n = 46), the role of the cutaneous nerve in supporting an acutely elevated skin flap was explored by creating five flap groups as follows: group 1, conventional flap (artery, vein, and nerve intact); group 2, neural island flap (only the nerve intact); group 3, neurocutaneous flap (vein and nerve intact); group 4, denervated flap (artery and vein intact); and group 5, skin graft. In part III (n = 22), the role of a preliminary surgical delay procedure to augment the survival of the neural island flap was investigated. Results of the anatomic studies indicated a consistent perineural vasculature by the accompanying iliolumbar artery. Skin flaps survived totally in groups where the artery and vein were intact, whereas mean survival rates for the neural island flap and the neurocutaneous flap were 38.2 +/- 3.1 percent and 44.5 +/- 3.8 percent, respectively (p > 0.05). Results of part III of the experiment demonstrated a significantly higher survival for the delayed neural island flap (94.5 +/- 5.5 percent) compared with the acutely elevated neural island flap (p < 0.05). The perineural and intraneural vessels were found to be greatly dilated after a delay procedure, demonstrated by direct observation, microangiography, histologic analysis, dye injection study, and scanning electron microscopy. On the basis of this promising series of experiments, a clinical technique was developed using the sural neural-island flap. The flap was used to reconstruct lower extremity defects in four cases. A delay procedure was accomplished in the first stage by elevating a fasciocutaneous flap from the midcalf region based on a posterior skin bridge and the sural nerve. After a 2-week delay period, a sural neural-island flap was created based on the nerve and transposed to the defect. Flap survival was complete in all cases, with a satisfactory result. The authors conclude that this report proves for the first time that a robust and reliable skin flap can be created pedicled only by the intrinsic vasculature of a cutaneous nerve, after a proper surgical delay. The so-created neural-island flap design offers two novel advantages: (1) a very narrow pedicle and (2) a pedicle without any restriction to a specific pivot point, in addition to the previously described unique advantages of preservation of a major artery and avoidance of microvascular anastomoses.     

The effect of low-molecular-weight heparin in the survival of a rabbit congested skin flap

Swelling and congestion of flaps are frequently seen postoperatively and can cause unexpected necrosis. According to previous reports, venous thrombosis seems to be a more frequent problem than arterial occlusion in both experimental and clinical surgery. Few satisfactory venous trauma models exist, and reports on experimental venous thrombosis are rare. The object of this study was to create a rabbit venous occlusion flap model and to evaluate the effect of low-molecular-weight heparin on this flap. Eight New Zealand rabbits were used in the pilot study, in which the ideal congested flap was investigated using a flap pedicle based on the central auricular artery with a skin pedicle 0, 1, 2, or 3 cm wide. The flap (3 x 6 cm) was designed on the central part of the left ear, and the central auricular vein and nerve, the former for venous return, were cut out at the base of the flap. The flaps with skin pedicles 0, 1, 2, or 3 cm wide showed mean necrosis length of 60.0, 9.3, 4.2, and 0.0 mm, respectively. The flaps with skin pedicles 0, 1, 2, or 3 cm wide showed mean necrosis of 100, 15.5, 7, and 0 percent, respectively. Therefore, the flap, based on a 1-cm-wide skin pedicle and the central auricular artery, was selected as an optimal congested flap model showing 15.5 percent necrosis. The congested flap was then elevated on the left ear of another 10 rabbits. Subcutaneous low-molecular-weight heparin (320 IU/kg) was administered immediately after surgery to five of the rabbits (the low-molecular-weight heparin group), and the remaining five were used as a control group. Fluorescein was injected 15 minutes after surgery to evaluate the circulatory territory of the flap, and the circulatory territory was measured 5 minutes after injection. The flaps were assessed 7 days after surgery by angiography, histology, and clinical findings. The circulatory territory was significantly greater in the low-molecular-weight heparin group (mean +/- SD, 39.2 +/- 3.0 mm) than the control group (mean +/- SD, 48.0 +/- 1.0 mm) (p < 0.001) assessed 7 days after surgery. The longest flap survival length in group A and group B ranged from 40 to 55 mm (mean +/- SD. 49.4 +/- 5.6 mm) and complete survival (mean +/- SD, 60.0 +/- 0.0 mm). The improvement in survival was statistically significant for group B compared with group A (p < 0.015). Histologic evaluation revealed moderate to severe venous congestion and inflammation in the control group, whereas there were minimal changes in the low-molecular-weight heparin group. Angiography of the flap revealed obvious venous occlusion in the periphery in the control group compared with the low-molecular-weight heparin group. The authors conclude that subcutaneous administration of low-molecular-weight heparin has a great potential to improve the survival length of a congested flap without major complications.     

The role of the large superficial vein in survival of proximally based versus distally based sural veno-neuro-fasciocutaneous flaps in a rabbit model

A sural veno-neuro-fasciocutaneous flap in the New Zealand White rabbit was developed, and the role of the large subcutaneous lesser saphenous vein was investigated in proximally based versus distally based flaps. Retrograde dye injection showed that the lesser saphenous vein in rabbits has many valves with strong resistance against reflux. Twenty rabbits were randomly allocated into four groups of 10 flaps each. Group I consisted of proximally based flaps with the lesser saphenous vein intact (outflow) in the veno-neuro-adipofascial pedicle. Group II also consisted of proximally based flaps but the lesser saphenous vein was ligated at 1 cm proximal to the pedicle. Group III consisted of distally based flaps with the lesser saphenous vein intact (inflow) in the veno-neuro-adipofascial pedicle. Group IV also consisted of distally based flaps, but the lesser saphenous vein was ligated at 1 cm distal to the pedicle. The results showed that the mean flap survival area in group I (88.8 percent) was statistically higher than that in group II (62.6 percent, p < 0.001), and was higher in group IV (55.5 percent) than in group III (22.7 percent, p < 0.01). However, group II and group IV had no significant difference (p > 0.05). This experiment demonstrated that flap viability is determined by its intrinsic vascularization, both arterial and venous. The large superficial subcutaneous vein has a positive role (venous outflow) in proximally based flaps but a negative role (venous inflow) in distally based flaps. If the effect of the large subcutaneous vein is excluded, distally based flaps are not inherently inferior to proximally based flaps.     

超薄前臂皮瓣在鼻部缺损的应用

目的：探讨超薄前臂皮瓣修复鼻部缺损的临床效果,为临床治疗提供依据。方法：回顾性分析我院于2007年1月~2010年12月收治鼻颌面部缺损患者16例,观察患者皮瓣的成活率和并发症发生等情况。结果：超薄前臂皮瓣移植组皮辫成活率为100％,住院天数为（21．5±6．5）d,无并发症发生。16例患者随访6个月~2年,无失访。皮瓣颜色与面部正常皮肤接近,厚度适中,鼻部外形满意。同时前臂切口瘢痕不明显,皮肤感觉无异常。结论：超薄前臂皮瓣在鼻部缺损修复中成活率更高,患者康复快,并发症较少,值得临床推广使用。     

Extending the reach of the heterodigital arterialized flap by vein division and repair

The heterodigital arterialized flap is ideal for nonsensory reconstruction of sizable soft-tissue defects in the proximal fingers, web spaces, and the hand. The inclusion of a dorsal vein augments the venous drainage of this digital island flap and avoids the problem of postoperative venous congestion, which is a common problem in digital island flaps. However, the presence of a dorsal vein pedicle inhibits flap mobility somewhat, and the reach of the flap is mainly limited to adjacent fingers. In situations that demand a transfer from a nonadjacent donor finger or when the reach from the adjacent donor finger is inadequate, the dorsal vein pedicle can be temporarily divided and then anastomosed microsurgically after flap transfer is performed. This enables the reach of the flap to be extended up to two fingers from the donor finger. The authors performed this "partially free" heterodigital arterialized flap in 11 consecutive patients between 1991 and 2001. The average size of the defects was 4.4 x 2.3 cm. All of the flaps survived completely, without any evidence of postoperative flap congestion. Healing of all of the flaps was primary and did not result in any scarring. All of the donor fingers had "normal" two-point discrimination of 3 to 5 mm. All of the donor fingers retained excellent or good total active motion, as graded by the criteria of Strickland and Glogovac.     

带腓肠腱膜的腓肠神经营养皮瓣修复KuwadeⅣ型跟腱缺损

目的:回顾性分析带腓肠肌腱膜的腓肠神经营养皮瓣修复KuwadeⅣ型跟腱缺损的临床病例,探讨其手术注意事项及治疗经验。方法:总结2008年5月-2013年8月收治的KuwadeⅣ型跟腱缺损19例,应用带腓肠肌腱膜的腓肠神经营养皮瓣进行一期修复。7例为新鲜损伤,12例为陈旧性缺损。19例跟腱缺损均伴有皮肤及软组织坏死,皮肤缺损范围为4.0 cm×6.0 cm-6.0cm×12.0 cm,跟腱缺损长度为5-9 cm,术中皮瓣切取范围为6.0 cm×5.5 cm-12.0 cm×8.0cm,腓肠腱膜切取范围5.5 cm×6.0cm-10.0 cm×6.0 cm;供区游离植皮修复。客观性评价指标包括关节跖屈、背伸动度及形态学,主观性评价采用AOFAS评分。结果:术后17例跟腱功能重建良好,2例感染控制不良,跟腱移植体部分坏死。皮瓣完全成活13例,创面Ⅰ期愈合。2例术后6天皮瓣远端表皮坏死,经换药后愈合。2例术后10天皮瓣远端部分坏死,经局部皮瓣移位修复愈合,2例感染控制不良者,皮瓣未愈合,移植跟腱部分坏死,经再次清创后,行阔筋膜条修复术,局部皮瓣移位修复。术后19例均获随访,随访时间6~24个月,平均18个月。术后皮瓣略臃肿,但不影响穿鞋,行走功能恢复良好,术后1年AOFAS评分平均80.31分。结论:带腓肠肌腱膜的腓肠神经营养皮瓣用于治疗KuwadeⅣ型跟腱缺损,可以同时修复皮肤及跟腱缺损,是一种较为理想的一期修复方法。     

Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.