目的

观察带蒂穿支皮瓣在手部及足踝部肌腱或骨质等深部组织外露创面修复中的应用效果。

方法

2020 年5 月至2023 年4 月，解放军联勤保障部队第九一〇医院烧伤整形科收治符合入选标准的手部及足踝部肌腱或骨质外露创面患者47 例，其中男29 例、女18 例，年龄25～68 岁。创面位于手部20 例（其中3 例各存在2 处手部肌腱外露创面），创面位于足踝部27 例。清创后创面面积为1.0 cm×2.0 cm～12.0 cm×6.0 cm。采用带蒂穿支皮瓣进行修复，皮瓣切取面积为1.2 cm×2.5 cm～13.0 cm×6.5 cm。其中采用指固有动脉穿支皮瓣修复12例，掌背动脉穿支皮瓣修复8例，腓动脉穿支皮瓣修复12例，胫后动脉穿支皮瓣修复12例，第一跖底动脉穿支皮瓣修复3例。皮瓣供区经缝合或皮片移植修复。术后观察皮瓣成活及供区愈合情况。随访观察皮瓣外观、皮瓣供区恢复情况，合并骨折患者观察是否出现骨不连、骨髓炎等并发症，观察术区瘢痕情况。末次随访时采用中华医学会手外科学会上肢部分功能评定试用标准评定手部功能；参照美国矫形足踝协会（AOFAS）评分标准评定足踝部功能。

结果

本组47例患者共采用50个带蒂穿支皮瓣修复创面，其中45个皮瓣完全成活；2个指固有动脉穿支皮瓣、1个胫后动脉穿支皮瓣远端回流欠佳，出现浅表组织坏死，后期经换药愈合；1个胫后动脉穿支皮瓣、1个第一跖底动脉穿支皮瓣远端部分坏死，再次经邻位皮瓣转移修复治愈。18个供区直接拉拢缝合，32个供区行皮片移植修复，均一期愈合。随访6～18个月，皮瓣外观良好，质地、色泽接近周围皮肤，无明显臃肿，仅2例腓动脉穿支皮瓣、2例胫后动脉穿支皮瓣修复患者再次入院行皮瓣修薄术，供区瘢痕增生不明显。手部功能评定优14例、良6例，足踝部功能评定优21例、良6例。合并骨折患者未出现骨不连或骨髓炎等并发症。

结论

采用带蒂穿支皮瓣修复手部及足踝部深部组织外露创面，具有设计灵活、皮瓣组织利用率高、质地与受区相近、术区在同一视野等优点，且外观及功能恢复良好。

Objective

To observe the application efficacy of pedicle perforator flap in the repair of deep tissue exposed wounds such as tendons or bones in the hands， feet， and ankles.

Methods

From May 2020 to April 2023， 47 cases of deep exposed wounds such as tendons or bones in the hands， feet， and ankles who met the inclusion criteria were admitted to the Department of Burns and Plastic Surgery of the 910th Hospital of Joint Service Support Unit of PLA， including 29 males and 18 females， aged 25-68 years.There were 20 cases of hand wounds （3 cases each had 2 wounds with exposed tendons in the hand） and 27 cases of foot and ankle wounds.The wound area after debridement ranged from 1.0 cm×2.0 cm to 12.0 cm×6.0 cm.The pedicle perforator flaps were used for repair， of which proper digital artery perforator flaps were used in 12 cases， metacarpophal dorsal artery perforator flaps were used in 8 cases， peroneal artery perforator flaps were used in 12 cases， posterior tibial artery perforator flaps were used in 12 cases， and the first plantar metatarsal artery perforator flaps were used in 3 cases.The flap incision area ranged from 1.2 cm×2.5 cm to 13.0 cm×6.5 cm.The donor sites of flaps were repaired with sutures or skin grafting.The survival of flaps and wound healing of the donor sites were observed after surgery.During follow-up， the appearance of the flap and the wound recovery of the donor sites were observed， and complications such as bone nonunion and osteomyelitis were observed in the patients with fractures，observed the scar condition of the surgical area.At the last follow-up， the hand function of the patients were evaluated according to the trial standards for evaluation of partial function of upper extremity by the Hand Surgery Society of Chinese Medical Association，and the foot function of the patients were evaluated according to the scoring standards of American Orthopedic Foot and Ankle Society （AOFAS）.

Results

A total of 50 pedicle perforator flaps were used in 47 patients，of which 45 flaps survived completely， 2 proper digital artery perforator flaps and 1 posterior tibial artery perforator flap with poor returnand and superficial tissue necrosis occurred at distal end of flap were healed by dressing change in the later stage， and 1 posterior tibial artery perforator flap and 1 the first plantar metatarsal artery perforator flap were partially necrotic and repaired by adjacent flap metastasis again.Eighteen donor sites were directly sutured， and 32 donor sites were repaired by skin grafting， all the donor sites were healed in one stage.After 6-18 months of follow-up， the appearance of the flaps were good， the texture and color of the flap were similar to those of the surrounding skin，and was not obviously bloated in appearance， only 2 peroneal artery perforator flaps and 2 posterior tibial artery perforator flaps were readmitted to the hospital for flap thinning surgery， and the scar hyperplasia in the donor sites was not obvious.There were 14 cases with excellent hand function and 6 cases with good hand function， the foot and ankle function of the affected limb was evaluated as excellent in 21 cases， good in 6 cases， and no complications such as nonunion or osteomyelitis occurred in patients with fractures.

Conclusion

The pedicle perforator flap using in the repair of deep tissue exposed wounds in the hands， feet and ankles has the advantages of flexible design， high utilization rate of flap tissue， the texture is similar to that of the affected area， and the same field of view in the surgical area， and the appearance and function recover well.