腓肠外侧动脉穿支与腓肠外侧皮神经营养血管的解剖研究及临床应用

发布时间：2018-04-15 16:30

  本文选题：腓肠外侧动脉 + 腓肠外侧皮神经营养血管　； 参考：《河北医科大学》2012年硕士论文

【摘要】：目的：本研究在尸体标本解剖的基础上，观察测量腓肠外侧动脉穿支与腓肠外侧皮神经营养血管的解剖位置关系，从而设计一种二者联合为蒂的肌皮瓣，并通过临床应用来观察此联合蒂肌皮瓣的临床效果，以期为临床修复髌前及胫骨上端皮肤及软组织缺损设计一种皮瓣修复的新方法。前人对腓肠神经营养血管及腓肠肌血管的显微解剖、造影和腓肠神经营养皮瓣、腓肠肌肌皮瓣的基础及临床应用研究已有大量文献报道。但是通过临床实践发现，对于髌前及胫骨上端较复杂创面，如伴有骨缺损或骨髓炎，单纯的肌皮瓣所带肌肉多，对供区创伤大，皮瓣外观也很臃肿，在外观及功能上都难以满足膝关节的要求；而筋膜皮瓣则难以填实创面，往往会留下死腔，淤积渗液形成感染灶，导致皮瓣坏死。基于此，我们考虑是否可以将肌肉血管与神经营养血管联合，从而设计出一种联合蒂肌皮瓣来修复髌前及胫骨上端较复杂创面。 方法：选用5具（10侧）成人下肢新鲜标本，由河北医科大学解剖学实验室提供。2例为河北医科大学第三医院介入科提供的正常人下肢数字减影血管造影（DSA）资料。 临床病例5例,为2009年2月至2011年11月期间河北医科大学第三医院手外科住院患者，均为男性，年龄21～47岁，平均32.8±9.6岁。致伤原因：交通事故伤致软组织缺损4例，压砸伤1例。病程36～56d。损伤部位：均为外伤致髌前及胫骨上段皮肤与深部软组织、骨质缺损。创面面积：6cm×9cm～9cm×12cm（Table3）。 1解剖方法：采用分层解剖方法。选择乆窝中点到外踝与跟腱中点的连线，此连线为腓肠神经营养血管轴体表投影线（Fig.1）。沿此线依次切开皮肤及浅筋膜，找到腓肠神经及其营养血管（Fig.2, Fig.3）。沿腓肠外侧皮神经向近端游离至入肌点，切开深筋膜，找到腓肠肌外侧头（Fig.4），再向外牵开腓肠肌外侧头，显露腓肠肌外侧血管神经束（Fig.5），然后向近端解剖乆动静脉（Fig.6），向远端解剖分离腓肠外侧动脉，显露其主要分支（Fig.7, Fig.8）。直视放大镜下分离解剖，观察记录腓肠外侧动脉穿支数目、穿出点、口径及与腓肠外侧皮神经营养血管之间的吻合交通情况。血管口径用游标卡尺测量，血管长度和分布范围用软尺测量。所测数据用SPSS13.0统计学软件进行分析，以均数±标准差(x±s)表示。 2手术方法：术前先用多普勒血流探测仪在距乆皱折以远4～10cm，距后正中线1～4cm范围内探测腓肠外侧动脉的穿支，选择最近端的1支做标记。乆窝中点到外踝与跟腱中点的连线为皮瓣切取轴线。根据受区损伤情况和穿支动脉位置设计皮瓣，切取肌皮瓣大小比受区放大1cm左右。于标记穿支水平上2cm左右，腓肠肌内、外侧头之间找到腓肠外侧动脉，顺此血管纵行分开肌肉，沿途保留1～3支周围留少量肌纤维组织的肌皮穿支，同时根据携带肌肉量保留1～2支肌支血管。当游离出的血管蒂长度达到受区要求后,再切开肌皮瓣四周。皮瓣切取时要确认腓肠外侧动脉穿支、腓肠神经及其营养血管轴都包含在内时方可切取。 结果： 1尸体解剖所见：腓肠外侧皮神经于腓骨头上起自腓总神经，分布于小腿后外侧上2/3部,其营养动脉主要是乆窝外侧皮动脉。腓肠外侧动脉由起始点至外径1mm处长度为163.5±5.0mm，由起始点至入肌点为50.9±2.1mm，由起始点距腓肠外侧皮神经起始点为53.9±2.1mm，其分出点水平距离腓肠外侧皮神经为9.4±1.6mm。腓肠外侧动脉伴行静脉为2支，血管束入肌后行走于腓肠肌外侧头中间，沿肌纤维方向下行，沿途发出3～5支外径0.20～1.80mm肌皮穿支。第一穿支口径为1.16±0.37mm，入肌点距起始点为23.2±4.08mm，入肌点距腓肠外侧皮神经起始点81.8±3.05mm，入肌点距后正中线（乆动脉）9.7±1.77mm。第二穿支口径为0.76±0.21mm，入肌点距起始点为53.4±4.06mm，入肌点距腓肠外侧皮神经起始点108.9±3.81mm，入肌点距后正中线（乆动脉）21.6±3.2mm。第三穿支口径为0.43±0.11mm，入肌点距起始点为120.0±8.67mm，入肌点距腓肠外侧皮神经起始点173.6±4.03mm，，入肌点距后正中线（乆动脉）12.9±3.0mm。第四、五穿支变异较大，本实验数据资料有限，且临床设计此联合蒂肌皮瓣时多以第一、二穿支血管带取肌肉，故未统计在内（Table1,Table2）。 2下肢DSA显示在小腿后区的上2/3段，腓肠外侧动脉发出穿支与腓肠外侧皮神经营养血管轴吻合，构成血管链，参与形成浅、深筋膜血管网。支持解剖实验和术中所见（Fig.10,Fig.11）。 3临床应用：皮瓣4例一期愈合，1例远端部分浅表坏死，经换药逐渐愈合。术后随访2个月～6个月，肌皮瓣质地优良，颜色可，外形好，不臃肿，不需要二次修薄手术。患肢行走及穿裤接近正常，没有发生磨损、溃破现象。供区愈合良好，无明显的功能障碍，临床效果满意（Fig.16）。 结论： 1腓肠外侧动脉入肌后沿途发出3～5支外径0.20～1.80mm肌皮穿支，营养腓肠肌外侧头及周围皮肤，并与腓肠外侧皮神经营养血管参与形成浅、深筋膜血管网。 2联合蒂皮瓣有两套血供，血运丰富，扩大了皮瓣切取面积；同时皮瓣内带有感觉神经，保证了皮瓣感觉，可以修复膝关节周围较复杂皮肤软组织缺损。 3皮瓣蒂部不臃肿，转移方便，不损伤主要血管，创伤小，易于临床推广应用。
[Abstract]:Objective : To study the relationship between the anatomical location of the lateral sural cutaneous flap and the sural cutaneous nerve nutrient vessels on the basis of the anatomy of the body specimen , and to design a new method for the repair of skin and soft tissue defects on the upper end of the patella and tibia .
However , it is difficult to fill the wound surface with fascia flap , which often leaves dead space , which leads to the necrosis of the skin flap . Based on this , we consider whether the muscle blood vessel can be combined with the nerve nutrition blood vessel , so that a combined pedicle skin flap can be designed to repair the complex wound surface at the upper end of the patella and the upper end of the tibia .

Methods : Five ( 10 sides ) adult lower limb fresh specimens were selected from Hebei Medical University ' s Anatomy Laboratory .

5 cases of clinical cases were male , aged 21 - 47 years , average 32.8 卤 9.6 years old in the third hospital of Hebei Medical University between February 2009 and November 2011 . The causes of injury were : 4 cases of soft tissue defect caused by traffic accident , 1 case with crush injury , and 36 - 56d of injury . All cases were trauma - induced pre - patellar and upper tibia and deep soft tissue and bone defect . The wound area was 6 cm 脳 9 cm ~ 9 cm 脳 12 cm ( Table3 ) .

1 Anatomy method : The connection of point to the middle point of the Achilles tendon was selected by the method of stratified dissection . The line was the projection line of sural nerve nutrition vascular axis ( Fig . 1 ) . The skin and superficial fascia were cut in turn along this line to find sural nerve and its nutrient vessels ( Fig . 2 , Fig . 3 ) . At the proximal end of the sural cutaneous nerve , the proximal end of the sural cutaneous nerve was dissociated into the muscle point , the deep fascia was dissected , the lateral head of the muscle was found ( Fig . 4 ) , then the lateral head of the muscle was drawn outward , and then the outer vessel nerve bundle ( Fig . 5 ) was exposed to the proximal end , then the lateral sural artery was dissected to reveal its main branch ( Fig . 7 , Fig . 8 ) . Under the direct - view magnifying glass , dissection was carried out to observe the anastomoses between the number of perforating branches of the external carotid artery , the puncture point , the caliber and the nerve nutrient vessels of the lateral sural cutaneous nerve . The vascular caliber was measured with a vernier caliper , the length of the vessel and the distribution range were measured by a soft rule . The data measured were analyzed by SPSS 13.0 , and expressed by mean 卤 standard deviation ( x 卤 s ) .

2 Operation methods : Doppler blood flow detector was used to detect the perforating branches of the lateral sural artery in the range of 4 锝

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