CAJ | 학술논문

目的：探讨不携带大隐静脉的游离膝降动脉穿支皮瓣修复肢体末端组织缺损的疗效及技术要点。方法回顾性分析2010年8月至2014年4月，采用不携带大隐静脉的游离膝降动脉穿支皮瓣修复18例肢体末端组织缺损患者资料，男16例，女2例；年龄7～63岁，平均32.4岁；8例足部、10例手部组织缺损；2例为陈旧性损伤矫形后单纯软组织缺损，16例为开放性损伤并伴软组织感染，其中5例合并骨折或骨缺损；皮肤软组织缺损面积2.0 cm×8.0 cm~9.0 cm×12.0 cm，均采用对侧下肢游离膝降动脉穿支皮瓣/复合皮瓣修复。皮瓣切取时尽量携带股内侧皮神经，术前利用多普勒超声定位皮瓣血管穿支与大隐静脉的体表投影，采用逆向分离法保护穿支切取皮瓣，并将大隐静脉主干及隐神经保留在供区。结果术后18例皮瓣均成活并获3～30（平均10.3）个月随访；切取皮瓣面积2.5 cm×9.0 cm～9.5 cm×13.0 cm，平均5.6 cm×10.8 cm；无一例发生静脉危象。2例采用游离皮-骨瓣移植后的骨缺损区（受区），术后未发生骨髓炎，3个月后骨瓣植入区均骨性愈合；另3例骨折患者采用内固定治疗，术后2～3个月骨折愈合。受区皮瓣两点辨别觉7.0～12.0 mm，10例手部损伤患者臂肩手残疾问卷评分为34～79分，平均51分，8例足部损伤患者日本骨科协会足部疾患评分为61～78分，平均70.5分。供区除5例游离植皮外；13例均直接缝合，其中12例遗留线性瘢痕，1例出现大腿供区切口愈合不良，经3周换药后愈合；皮瓣供区肢体远端无感觉异常或皮疹。膝降动脉皮穿支体表投影点与大隐静脉垂直距离平均为3.7 cm。结论不携带大隐静脉的膝降动脉穿支皮瓣可修复肢体末端组织缺损，供区损伤小、隐蔽，穿支血管变异少，可恢复受区感觉。
목적：탐토불휴대대은정맥적유리슬강동맥천지피판수복지체말단조직결손적료효급기술요점。방법회고성분석2010년8월지2014년4월，채용불휴대대은정맥적유리슬강동맥천지피판수복18례지체말단조직결손환자자료，남16례，녀2례；년령7～63세，평균32.4세；8례족부、10례수부조직결손；2례위진구성손상교형후단순연조직결손，16례위개방성손상병반연조직감염，기중5례합병골절혹골결손；피부연조직결손면적2.0 cm×8.0 cm~9.0 cm×12.0 cm，균채용대측하지유리슬강동맥천지피판/복합피판수복。피판절취시진량휴대고내측피신경，술전이용다보륵초성정위피판혈관천지여대은정맥적체표투영，채용역향분리법보호천지절취피판，병장대은정맥주간급은신경보류재공구。결과술후18례피판균성활병획3～30（평균10.3）개월수방；절취피판면적2.5 cm×9.0 cm～9.5 cm×13.0 cm，평균5.6 cm×10.8 cm；무일례발생정맥위상。2례채용유리피-골판이식후적골결손구（수구），술후미발생골수염，3개월후골판식입구균골성유합；령3례골절환자채용내고정치료，술후2～3개월골절유합。수구피판량점변별각7.0～12.0 mm，10례수부손상환자비견수잔질문권평분위34～79분，평균51분，8례족부손상환자일본골과협회족부질환평분위61～78분，평균70.5분。공구제5례유리식피외；13례균직접봉합，기중12례유류선성반흔，1례출현대퇴공구절구유합불량，경3주환약후유합；피판공구지체원단무감각이상혹피진。슬강동맥피천지체표투영점여대은정맥수직거리평균위3.7 cm。결론불휴대대은정맥적슬강동맥천지피판가수복지체말단조직결손，공구손상소、은폐，천지혈관변이소，가회복수구감각。
Objective To explore the surgical technique and the efficacy of free descending genicular artery perforator flap without saphenous vein for tissue defect. Methods 18 cases of extremity tissue defect were involved in this study from Au?gust 2010 to April 2014, including 16 males and 2 females with an average age of 32.4 years (8 plantar or heel soft tissue defect, 10 back of hand or palm soft tissue defect). 2 old injury cases that had soft tissue defect after scar release were treated by free flaps and the other 16 were open injury with infection, among which 5 cases were combined with fractures or bone defect. Sizes of the skin and soft tissue defect were 2.0 cm × 8.0 cm to 9.0 cm × 12.0 cm. All wounds were treated by free descending genicular artery perforator flap from the contralateral limb. Medial femoral cutaneous nerve was kept in flaps as far as possible. The projection points of descending genicular artery perforator and saphenous vein were detected by Doppler, then the flaps were cut with reverse approach, and saphenous vein and saphenous nerve were preserved. Results All 18 flaps were survived and all cases were fol?lowed up for 3 to 30 months (average, 10.3 months). The flap sizes varied from 2.5 cm×9.0 cm-9.5 cm×13.0 cm. 2 cases with bone defect were healed 3 months later without infection, and the other 3 cases with fractures were healed 2-3 months after operation. The two point’s discrimination distance was 7.0-12.0 mm on the flap. The disabilities of the arm, shoulder, and hand question?naire score averaged 51, and the mean Japanese Orthopaedic Association's foot rating scale was 70.5. Most patients were satisfied with appearance of the recipient and donor sites, among which 5 cases had skin?graft on the donor sites, and the other 12 cases had small scars on the donor sites. Poor healing was detected in 1 case on the thigh which was healed 3 weeks later. There was no par?esthesia and rash on the donor sites. The mean distance between projection points of descending genicular artery perforator and sa?phenous vein was 3.7 cm. Conclusion Free descending genicular artery perforator flap without saphenous vein is an optimal therapy for the extremity tissue defect, which has the advantage of covert donor site, less invasion, less variation of perforator, and could recover the skin sense of recipient site.