膝关节周围严重皮肤软组织缺损的组织瓣修复策略
슬관절주위엄중피부연조직결손적조직판수복책략
Tissue flap repair strategy for severe defects of skin and soft tissue around the knee joints
  • 万方数据
    中华烧伤杂志 중화소상잡지
    Chinese Journal of Burns
    2015年 5期 331-336 ,共6页

    沈余明%马春旭%胡骁骅%王成%张琮

    침여명%마춘욱%호효화%왕성%장종

    外科皮瓣%膝损伤%移植%创面修复 外科皮瓣%膝損傷%移植%創麵脩複
    외과피판%슬손상%이식%창면수복
    Surgical flaps%Knee injuries%Transplantation%Wound repair
    目的 探讨修复膝关节周围严重皮肤软组织缺损的组织瓣选择及方法.方法 2008年6月-2014年12月,笔者单位收治54例膝关节周围严重皮肤软组织缺损患者,均有肌腱、骨外露或坏死或假体外露,其中5例膝关节损伤,行彻底清创或肿瘤切除术后创面面积为5 cm×5 cm～46 cm×22 cm.采用游离背阔肌肌皮瓣修复3例,改良缝匠肌肌皮瓣修复7例,腓肠肌肌皮瓣修复8例,腓肠肌肌瓣修复1例,小腿后侧皮瓣+腓肠肌肌瓣修复2例,股二头肌肌瓣+腓肠肌肌瓣修复1例,股前外侧逆行岛状皮瓣修复13例,股前外侧逆行岛状皮瓣+腓肠肌肌皮瓣修复2例,膝上外侧皮瓣修复2例,股后侧逆行岛状皮瓣修复4例,隐动脉皮瓣修复11例.4例行髌韧带重建.组织瓣面积5 cm×5 cm～38 cm× 19 cm.供瓣区直接拉拢缝合或采用同侧/对侧大腿中厚皮移植修复.结果 本组54例患者采用59个组织瓣修复创面,其中50例患者移植的55个组织瓣全部成活;其余4个组织瓣远端部分坏死,包括隐动脉皮瓣1个、股前外侧逆行岛状皮瓣2个、游离背阔肌肌皮瓣1个.3个远端坏死皮瓣经扩创再植皮修复愈合,1个远端坏死肌皮瓣经腓肠肌肌皮瓣移植修复.随访6 ～36个月,组织瓣外形及质地良好,大部分膝关节功能良好;4例重建髌韧带者膝关节功能恢复良好,5例膝关节损伤者中4例出现膝关节僵硬.结论 修复膝关节周围广泛皮肤软组织缺损首选游离背阔肌肌皮瓣;修复膝前创面首选股前外侧逆行岛状皮瓣,其次是隐动脉皮瓣;修复膝外侧创面主要选择股前外侧逆行岛状皮瓣,较小创面可考虑膝上外侧皮瓣;膝内侧创面首选改良缝匠肌肌皮瓣和隐动脉皮瓣;对膝后侧创面采用股后侧逆行岛状皮瓣或膝上外侧皮瓣;感染重或腔隙大的创面首选腓肠肌肌皮瓣或肌瓣或改良缝匠肌肌皮瓣;需髌韧带重建者首选股前外侧皮瓣或腓肠肌肌皮瓣.
    목적 탐토수복슬관절주위엄중피부연조직결손적조직판선택급방법.방법 2008년6월-2014년12월,필자단위수치54례슬관절주위엄중피부연조직결손환자,균유기건、골외로혹배사혹가체외로,기중5례슬관절손상,행철저청창혹종류절제술후창면면적위5 cm×5 cm～46 cm×22 cm.채용유리배활기기피판수복3례,개량봉장기기피판수복7례,비장기기피판수복8례,비장기기판수복1례,소퇴후측피판+비장기기판수복2례,고이두기기판+비장기기판수복1례,고전외측역행도상피판수복13례,고전외측역행도상피판+비장기기피판수복2례,슬상외측피판수복2례,고후측역행도상피판수복4례,은동맥피판수복11례.4례행빈인대중건.조직판면적5 cm×5 cm～38 cm× 19 cm.공판구직접랍롱봉합혹채용동측/대측대퇴중후피이식수복.결과 본조54례환자채용59개조직판수복창면,기중50례환자이식적55개조직판전부성활;기여4개조직판원단부분배사,포괄은동맥피판1개、고전외측역행도상피판2개、유리배활기기피판1개.3개원단배사피판경확창재식피수복유합,1개원단배사기피판경비장기기피판이식수복.수방6 ～36개월,조직판외형급질지량호,대부분슬관절공능량호;4례중건빈인대자슬관절공능회복량호,5례슬관절손상자중4례출현슬관절강경.결론 수복슬관절주위엄범피부연조직결손수선유리배활기기피판;수복슬전창면수선고전외측역행도상피판,기차시은동맥피판;수복슬외측창면주요선택고전외측역행도상피판,교소창면가고필슬상외측피판;슬내측창면수선개량봉장기기피판화은동맥피판;대슬후측창면채용고후측역행도상피판혹슬상외측피판;감염중혹강극대적창면수선비장기기피판혹기판혹개량봉장기기피판;수빈인대중건자수선고전외측피판혹비장기기피판.
    Objective To explore selection and method of tissue flaps for the repair of severe defects of skin and soft tissue around the knee joints.Methods Fifty-four patients with wounds around the knee joints, all accompanied by exposure or necrosis of tendon or bone and exposure of prosthesis, were hospitalized in our burn center from June 2008 to December 2014.Five of them were with knee joint injury.After thorough debridement or tumor resection, the wound area ranged from 5 cm × 5 cm to 46 cm× 22 cm.Three patients were repaired with free latissimus dorsi myocutaneous flaps, 7 were repaired with modified sartorius myocutaneous flaps, 8 were repaired with gastrocnemius myocutaneous flaps, one was repaired with gastrocnemius muscle flap, two were repaired with posterior leg flaps combined with gastrocnemius muscle flaps, one was repaired with femoral biceps muscle flap combined with gastrocnemius muscle flap, 13 were repaired with reverse anterolateral thigh island flaps, two were repaired with reverse anterolateral thigh island flap combined with gastrocnemius myocutaneous flaps, two were repaired with superior lateral genicular flaps, 4 were repaired with reverse posterior thigh island flaps, 11 were repaired with saphenous artery flaps.Patellar ligament was reconstructed in 4 patients.The tissue flap size ranged from 5 cm × 5 cm to 38 cm × 19 cm.Some donor sites were sutured directly, and the others were closed by split-thickness skin grafting obtained from ipsilateral or contralateral legs.Results Among 59 tissue flaps of 54 patients, 55 tissue flaps of 50 patients survived, while necrosis of the distal part was observed in 4 tissue flaps, including one saphenous artery flap, two reverse anterolateral thigh island flaps, and one free latissimus dorsi myocutaneous flap.Among them, 3 flaps with necrosis at the distal part healed after debridement followed by skin grafting, one myocutaneous flap healed by transplanting gastrocnemius myocutaneous flap.During the followup period of 6 to 36 months, the tissue flaps were in good appearance and texture, and knee joint function was good in most cases.In 4 patients the knee joint function was satisfactory after patellar ligament reconstruction, while stiffness was observed in 4 out of 5 patients with knee joint injury.Conclusions Free latissimus dorsi myocutaneous flaps are preferred to repair extensive defects around the knee joints.Reverse anterolateral thigh island flaps followed by saphenous artery flaps are preferred to repair wounds around the anterior knee.Wounds of the lateral knee are mainly repaired with reverse anterolateral thigh island flaps, and for small wounds the use of the superior lateral genicular flaps may be considered.Wounds of the medial knee can be repaired with modified sartorius myocutaneous flaps or saphenous artery flaps.Wounds of the posterior knee can be repaired with reverse posterior thigh island flaps or superior lateral genicular flaps.Wounds with severe infection or large space can be repaired with gastrocnemius myocutaneous flaps or muscle flaps or modified sartorius myocutaneous flaps.Anterolateral thigh flaps and gastrocnemius myocutaneous flaps are preferred in cases with indication of patellar ligament reconstruction.
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