摘要
目的：探讨并比较儿童及成人腓肠神经营养血管皮瓣的皮瓣成活相关并发症(以下简称并发症)及其影响因素。
方法：回顾性分析2001年4月～2011年3月所行201例远端蒂腓肠神经营养血管皮瓣的临床资料和手术图片。患者年龄3～78岁。导致皮肤软组织缺损的病因：外伤165例；肿瘤4例；不稳定疤痕9例；慢性骨髓炎并溃疡11例,并窦道形成5例；慢性溃疡并截瘫3例,并静脉回流不全3例,并外周动脉疾病1例。创面均合并骨、关节、肌腱和(或)内固定外露。皮瓣切取范围上界为胭窝横纹,下界为旋转点处。旋转点位于外踝尖上4.0～19.0cm,筋膜蒂长2.0～18.0cm,筋膜蒂宽2.5～6.0 cm,皮瓣总长(皮瓣瓣部长加筋膜蒂长)10.0～30.Ocm,皮瓣长宽比(皮瓣总长/筋膜蒂宽)(2.50～7.14)：1,瓣宽(皮瓣瓣部最大宽度)4.0～16.0cm,皮瓣大小5.0cm×4.0cm～20.0cm×15.0cm。53例皮瓣患者年龄<14岁(儿童组),148例皮瓣患者年龄≥14岁(成人组)。根据皮瓣成活情况将皮瓣分为无并发症皮瓣、主要并发症(部分坏死)皮瓣及次要并发症(包括边缘坏死、表皮坏死、伤口裂开)皮瓣三类。小腿后面等分为九个区段。皮瓣并发症可能的影响因素(性别、病因、缺损部位,近端位置、旋转点位置、皮瓣瓣部长和宽、筋膜蒂长和宽、长宽比及皮瓣总长)在儿童组与成人组组内及组间进行分析比较。使用SPSS17.0软件包处理数据。
结果：201例皮瓣中,完全成活148例(73.6%),创面均一期愈合；部分坏死25例(12.4%),12例植皮、4例二期缝合、1例换药、5例另行局部皮瓣覆盖后创面愈合,3例截肢消灭创面；边缘坏死16例(8.0%),5例二期缝合、11例换药后创面愈合；表皮坏死8例(4.0%),创面均自然愈合；伤口裂开4例(2.0%),均二期缝合后创面愈合。术后患者均获随访,随访时间2周至72个月,平均6.2个月。儿童组皮瓣主要并发症率(13.2%)、次要并发症率(17.0%)及总并发症率(30.2%)均稍高于成人组相应指标(12.2%、12.8%及25.0%),但差异均无统计学意义(P>0.05)。儿童组及成人组近端位置位于第八及以上区段皮瓣的总并发症率均高于近端位置位于第七及以下区段皮瓣,差异均有统计学意义(P<0.05)。儿童组瓣宽≥8cm皮瓣的总并发症率(42.4%,14/33)高于瓣宽<8cm皮瓣(10%,2/20)；成人组瓣宽≥10cm皮瓣的总并发症率(34.5%,20/58)高于瓣宽<10cm皮瓣(18.9%,17/90),差异均有统计学意义(P<0.05)。儿童组皮瓣瓣部长和宽、筋膜蒂宽及皮瓣总长：有并发症(包括主要及次要并发症)皮瓣均大于无并发症皮瓣；成人组皮瓣总长有并发症皮瓣大于无并发症皮瓣,差异均有统计学意义(P<0.05)。
结论：(1)儿童与成人的腓肠神经营养血管皮瓣发生并发症(包括主要、次要及总并发症)的可能性无明显差别；(2)儿童及成人腓肠神经营养血管皮瓣在小腿下7/9范围内切取,皮瓣成活均可靠；(3)当儿童瓣部宽度≥8cm或成人瓣部宽度≥10cm时,腓肠神经营养血管皮瓣发生并发症的可能性明显增高。
Objective:To compare the flap-viability-related complications and risk factors of distally based sural neurofasciocutaneous flaps in children and adults.
Methods:The clinical data and pictures of 201 distally based sural neurofasciocutaneous flaps performed from April 2001 to March 2011 were reviewed and analyzed retrospectively. Patients aged from 3 to 78 years were involved in this study. Etiology of 201 defects included: trauma (n=165), soft tissue tumor (n=4), unstable scarring (n=9), chronic osteomyelitis with ulcer (n=11) or sinus (n=5), chronic ulcer with paraplegia (n=3), venous insufficiency (n=3) or peripheral arterial disease (n=1). All the defects were combined with exposure of the bones, joints, tendons, and/or internal fixation hardware. The flaps were harvested between the popliteal fossa crease and the pivot point which was located 4.0-19.0cm above the tip of the lateral malleolus. The adipofascial pedicles were 2.0-18.0cm in length, and 2.5-6.0cm in width; total length (length of adipofascial pedicle plus the length of skin island) was 10.0-30.0cm, and the width of the flap was 4.0-16.0cm, and length to width ratio was (2.5-7.14):1. The dimensions of the flap were 5.0cm×4.0cm-20.0cm×15.0cm. There were 53 patients in Children group (<14 years), and 148 patients in Adult group (≥14 years). According to the flap viability, the outcomes were classified into three types:no complication (complete survival), major complication (partial necrosis), and minor complication (including marginal necrosis, de-epithelialization and wound dehiscence). Posterior aspect of the lower leg was equally divided into 9 zones. The following possible risk factors associated with flap-viability-related complications were analyzed and compared between Children group and Adult group:patients factors (sex, etiology, regions of soft tissue defects), flap factors (position of top-edge, location of pivot point, length to width ratio, length and width of both the skin island and the adipofascial pedicle, and total length of the flap). All the data were statistically analyzed by SPSS 17.0 software.
Results:Out of the 201 flaps,148 flaps were completely survived. Partial necrosis occurred in 25 (12.4%) flaps, of which remaining defects were covered successfully by changing dressings (n=1), skin grafting (n=12), secondary suture (n=4) or transferring other local flaps (n=5), and eliminated by amputation (n=3). Marginal necrosis developed in 16 flaps (8.0%), and residual defects were re-surfaced by changing dressings (n=11) or secondary suture (n=5). De-epithelialization presented in 8 flaps (4.5%), whose remanent defects were re-epithelialized spontaneously without further surgical treatment. Wound dehiscence occurred in 4 flaps (2.0%), and residual defects were re-epithelialized through secondary suture (n=4). Follow-up of all the patients was carried out, with a mean course of 6.2 months (ranged from 2 weeks to 72 months). The appearance of the flaps was satisfied without infection. The major complication (partial necrosis) rate and minor complication (including marginal necrosis and de-epithelialization and wound dehiscence) rate were 13.2% and 17.0% in Children group, and 12.2% and 12.8% in Adult group, respectively. Overall complication rate in Children group (30.2%) was significantly higher than that in Adult group (25.0%) (P>0.05). The overall complication rate of the flaps with the top-edge locating in the 8th or upper zones in both Children group (45.5%,15/33) and Adult group (32.6%,28/86) were significantly higher than those of the flaps with the top-edge locating in the 7th or lower zones in Children group (5%,1/20) and Adult group (14.5%,9/62) (P<0.05), respectively. In Children group, the overall complication rate of the flaps with a width of 8cm or more (42.4%,14/33) was significantly higher than that of the flaps with a width of less than 8cm (10%,2/20) (P<0.05). In Adult group, the overall complication rate of the flaps with a width of 10cm or more (34.5%,20/58) was significantly higher than that of the flaps with a width of less than 10cm (18.9%,17/90) (P<0.05). In Children group, the values (including the width of adipofascial pedicle, the length of skin island, and the width of skin island and the total length of the flap) of the flaps with complications were more than those of the survival flaps (P<0.05). In Adult group, the values of the total length of the flaps with complications were more than those of the survival flaps (P<0.05).
Conclusions:(1) There are no significant differences between children and adults in complications (including major complication, minor complication and overall complication) of distally based sural neurofasciocutaneous flaps; (2) In both children and adults, the flap with top-edge locating in lower 7/9 of the lower leg is safe and reliable; (3) When skin-island width is 8cm or more in children and 10cm or more in adults, possibility of complication present in the flap will rise significantly.
引文
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