嵌合型游离股前外侧穿支皮瓣治疗慢性骨髓炎伴四肢软组织缺损的临床研究

发布时间：2018-05-21 05:09

本文选题：游离股前外侧皮瓣 + 穿支　；参考：《浙江大学》2015年硕士论文

【摘要】：背景：高能量损伤导致的软组织骨质损伤严重,治疗过程中经常面临软组织、骨质坏死感染缺损等问题,加上不合适手术等的二次打击和多次彻底的清创,软组织及骨质缺损更加严重。目前国内外治疗方法主要有Papineau技术、ilizarov技术和骨搬运技术、皮瓣覆盖技术、肌皮瓣覆盖技术、带血管游离骨移植技术等,其中Papineau技术、ilizarov技术和骨搬运技术、带血管游离骨移植技术主要用于治疗一小部分软组织骨缺损范围较少或者骨缺损较多的病例,大多数的患者需要皮瓣和肌皮瓣覆盖技术治疗,其中需要用肌皮瓣覆盖技术的又占多数,但肌皮瓣覆盖技术供区损伤较大,且受区臃肿,对于深部不规则骨质缺损填塞效果不确切。近年来随着显微外科的发展,国内外学者的研究主要集中在穿支皮瓣治疗慢性骨髓炎,但不能解决慢性骨髓炎伴软组织缺损遗留深部腔隙的问题。本研究旨在使用穿支肌瓣灵活填塞残腔,同时减少供区损伤及受区臃肿问题,减少并发症,推动穿支皮瓣治疗慢性骨髓炎的发展。目的：探讨嵌合型游离股前外侧穿支皮瓣治疗慢性骨髓炎伴四肢软组织缺损的疗效。方法：2012年6月-2015年6月使用嵌合型游离股前外侧穿支皮瓣治疗慢性骨髓炎伴四肢软组织缺损15例,男11例,女4例,致伤原因：车祸伤6例,砸伤4例,压伤3例,高处坠落伤2例。其中胫骨慢性骨髓炎11例,跟骨慢性骨髓炎2例,桡骨骨髓炎1例,掌骨骨髓炎1例。结果：15例皮瓣,1例出现血管危象,术后第三天出现皮瓣略紫,张力略高,考虑血肿形成,拆除缝线挤压皮瓣有血凝块溢出,予引流换药,皮瓣色泽及张力恢复。2例皮缘部分坏死,给予游离植皮及局部皮瓣转移好转。1例骨髓炎复发,经过两次清创、病灶切除好转。14例感染未复发,其中10例术后自体骨加人工骨植骨愈合,3例未植骨愈合,1例因继发创伤性关节炎性行关节融合愈合。随访6-23月,平均随访13.2月,皮瓣色泽与受区相似,无明显臃肿,外形美观,供区肢体运动功能无明显影响,供区切口线型愈合,瘢痕略有挛缩。结论：嵌合型游离股前外侧皮瓣使皮瓣和肌瓣即相互独立,又通过同一供血动脉相互联系,设计成的穿支肌瓣较肌皮瓣能较好的填塞骨缺损腔隙,满足慢性骨髓炎残留骨缺损腔隙消除的需要,同时供区肌肉损伤减少,功能影响减少。另外供区隐蔽,切口线形愈合,受区不臃肿,符合美学要求,是治疗慢性骨髓炎伴四肢软组织缺损的一个较好的选择。
[Abstract]:Background: the soft tissue bone injury caused by high energy injury is very serious. In the course of treatment, the soft tissue, osteonecrosis, infection and defect are often faced with the problems of secondary attack and multiple thorough debridement. Soft tissue and bone defects are more serious. At present, the main treatment methods at home and abroad include Papineau technique and bone handling technique, flap covering technique, musculocutaneous flap covering technique, vascularized free bone graft technology, etc. Among them, Papineau technique and bone handling technology. The technique of vascularized free bone transplantation is mainly used to treat a small number of cases with less or more bone defects in soft tissue. Most of the patients need flap and myocutaneous flap covering technique to treat them. Most of them need to be covered by myocutaneous flap, but the donor area of myocutaneous flap covering is larger and the area is bloated, so the effect of tamponade on deep irregular bone defect is not accurate. In recent years, with the development of microsurgery, scholars at home and abroad mainly focus on perforating flap in the treatment of chronic osteomyelitis, but it can not solve the problem of deep space left by chronic osteomyelitis with soft tissue defect. The purpose of this study was to use perforator muscle flap to fill the residual cavity flexibly, reduce donor area injury and bloated area, reduce complications, and promote the development of perforator flap in the treatment of chronic osteomyelitis. Objective: to evaluate the efficacy of chimeric free anterolateral femoral perforator flap in the treatment of chronic osteomyelitis with soft tissue defect of extremities. Methods: from June 2012 to June 2015, 15 cases (11 males and 4 females) of chronic osteomyelitis with soft tissue defect of extremities were treated with chimeric free anterolateral femoral perforator flap. The causes of injury were: 6 cases of traffic accident, 4 cases of smashing injury and 3 cases of compression injury. There were 2 cases of falling injury. There were 11 cases of chronic osteomyelitis of tibia, 2 cases of chronic osteomyelitis of calcaneus, 1 case of radial osteomyelitis and 1 case of metacarpal osteomyelitis. Results the vascular crisis was found in 1 case of 15 cases of skin flap. The third day after operation, the flap appeared purple slightly, the tension was slightly higher. Considering the formation of hematoma, there was blood clot overflow in the decompressed suture flap. The color and tension of the flap recovered in 2 cases, the free skin graft and the local flap transfer were given to improve the recurrence of osteomyelitis. After two debridement, the lesion was resected and improved in 14 cases, and the infection did not recur. Among them, 10 cases were healed with autogenous bone and artificial bone graft. 3 cases without graft union and 1 case with secondary traumatic arthritis underwent joint fusion healing. The skin flap was followed up for 6-23 months and followed up for an average of 13.2 months. The color of the flap was similar to that of the recipient area, no obvious bloated appearance, no obvious effect on the motor function of the donor limb, the line healing of the donor incision and a slight contracture of the scar. Conclusion: the interlocking free anterolateral femoral flap makes the flap and muscle flap independent of each other, and through the same blood supply artery, the perforating branch muscle flap is better than the musculocutaneous flap in filling the space of bone defect. It can meet the need of eliminating the lacunae of residual bone defect in chronic osteomyelitis, and reduce the muscle injury and functional impact of donor area. In addition, the donor area is concealed, the incision is linear healing, and the recipient area is not bloated, which meets the aesthetic requirements. It is a better choice for the treatment of chronic osteomyelitis with soft tissue defect of extremities.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

【共引文献】