探讨数字化三维重建技术在隐神经营养血管皮瓣血供可视化研究的可行性及其临床应用效果。

新鲜捐献成人尸体1具，采用改良的明胶-氧化铅灌注方法进行灌注，灌注前和灌注后均用64排螺旋CT进行扫描，利用Mimics 10.01软件，获得血管、肌肉、骨骼以及皮肤的三维解剖结构图像，并对血管进一步分割，构建出单支血管及其分支，并对所构建的三维图像进行单独显示与组合显示，以设计切取隐神经营养血管皮瓣。在上述基础上，选择于2015年12月至2018年1月住院的小腿下段及足踝部皮肤软组织缺损需行隐神经营养血管皮瓣修复手术患者40例，随机分成A、B两组，每组20例，A组术前进行数字化重建，B组术前不予数字化重建。比较2组术后隐神经营养血管皮瓣存活率，手术所需时间，精确性以及皮瓣旋转点到内踝顶点距离。

灌注前数据可轻易重建出骨、肌肉、筋膜与皮肤，灌注后的数据可构建出血管，组合显示后可得到血管在某个局部的具体分布状况，为隐神经营养血管皮瓣的临床个性化设计与基础研究提供准确的血管解剖学基础。A组隐神经营养血管皮瓣经数字化重建后，可显示皮瓣主要血供，并能够清晰显示皮肤、肌肉与血管三维解剖关系；应用软件自带测量工具对血管、皮瓣进行测量，可以准确定位指导手术操作。术中探查血供与重建图像相符，体表定位准确。A组20例皮瓣均成活良好，伤口一期愈合，皮瓣质地良好，局部无瘢痕挛缩；B组20例皮瓣4例患者于术后出现皮瓣远端部分坏死，经二期清创换药和植皮术后愈合。术后随访3～12个月，A组皮瓣质地良好，外形满意，B组有6例皮瓣远端出现质硬瘢痕和轻度挛缩，行走时疼痛，后经手术松解植皮后好转。A组皮瓣成活率(100%)明显高于B组(70%)，差异有统计学意义(P<0.05)；A组手术所需时间[(114.05±10.36) min]明显短于B组[(123.20±11.91) min]，差异有统计学意义(P<0.01)；A组皮瓣切取精确性(0.17±0.03)明显高于B组(0.23±0.02)，差异有统计学意义(P<0.01)；A组皮瓣蒂部旋转点到内踝顶点距离[(4.14±0.38) cm]明显少于B组[(5.96±0.81) cm]，差异有统计学意义(P<0.01)。

数字化三维重建技术为隐神经营养血管皮瓣临床手术的个性化设计提供了一个很好的辅助手段，临床应用修复小腿远端及足踝部软组织缺损效果满意，值得临床推广应用。

To explore the feasibility and effectiveness of the digital three-dimensional reconstruction methods in visualization and clinical application for the saphenous neurocutaneous flap.

One resh cadaver was subjected to spiral CT scanning before and after the radio-opaque material infused by the femoral artery.The bones, muscles, fascia, skin and vessels were reconstructed by the Mimics 10.01, and the single artery and its branches were gained by the subdivision of the vessels. 3D-images were shown respectively and combinedly to design and cut the saphenous neurovascular flap.The study on the basis of above included 40 patients with soft tissue defects of the ankle and foot who underwent soft tissue reconstruction between December 2015 and January 2018. The patients were randomly assigned into two groups (A, B) (n=20 cases), digital reconstruction preoperative was performed in group A, but was not performed in group B. Two groups were compared with postoperative saphenous neurocutaneous flap survival rate, operation time, accuracy and distance of flap rotation to the medial malleolus vertex.

Bones, muscles, fascia and skin were easy to be reconstructed from the data which was scanned before the infusion, and the vessels were easy to be reconstructed from the data after the infusion.The vessels and soft tissue displayed in the software could show detailed distribution of the vessels in one region and this could provide the accurate anatomical basis for the saphenous neurocutaneous flap and the design of the operation.Group A of saphenous neurocutaneous flap after reconstruction of digital and could show flap blood supply and be able to clearly show the skin, muscle, and three-dimensional vascular anatomy; application of software comes with measurement tools to measure the blood vessels, the flap could be accurately positioning the guidance of the surgical procedure. Blood for intraoperative exploration and reconstruction of the image match, accurate positioning of the body surface. All flaps in Group A survived and the recipient site primarily healed, but 4 flaps in Group B had marginal necrosis after the operation. During the 3-12 month follow-up period, all flaps in Group A had good skin quality. In Group B, hard scarring and mild contracture occurred in 6 cases, and the patients experienced pain when walking. The survival rate of the flap in Group A (100%) was significantly higher than that in Group B (70%), the difference was statistically significant (P<0.05). The operation time in Group A[(114.05±10.36) min]was significantly less than that in Group B [(123.20±11.91)min], the difference was statistically significant (P<0.01). The surgical accuracy in Group A(0.17±0.03) was significantly better than that in Group B(0.23±0.02), the difference was statistically significant (P<0.01). The distance of flap rotation to the medial malleolus vertex in Group A[(4.14±0.38) cm] was significantly shorter than that in Group B[(5.96±0.81) cm], the difference was statistically significant (P<0.01).

The method of three-dimensional reconstruction is very good for the design of the operation. The preoperative use of three-dimensional digitalized virtual planning for the saphenous neurocutaneous flap obtains a satisfactory therapeutic effect in repair of soft tissue defects in the ankle and foot.It is worthy of clinical popularization and application.