游离腓骨瓣嵌合腓动脉穿支皮瓣的应用解剖及临床研究

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作者签名：导师签名：年月日年月日目录中文摘要--------------------------------------------------------- 1 英文摘要--------------------------------------------------------- 3 第一章成人游离腓骨瓣嵌合腓动脉穿支皮瓣的应用解剖研究1前言-----------------------------------------------------------6 2材料与方法-----------------------------------------------------6 3结果---------------------------------------------------------- 8 4讨论----------------------------------------------------------12 5 结论--------------------------------------------------------- 15 第二章成人游离腓骨瓣嵌合腓动脉穿支皮瓣的临床研究1前言----------------------------------------------------------16 2材料与方法----------------------------------------------------17 3结果----------------------------------------------------------19 4典型病例------------------------------------------------------22 5讨论----------------------------------------------------------31 6 结论--------------------------------------------------------- 36 参考文献--------------------------------------------------------- 36 综述------------------------------------------------------------- 41 攻读硕士学位期间完成发表论文情况--------------------------------- 51 致谢------------------------------------------------------------- 52中文摘要第一章成人游离腓骨瓣嵌合腓动脉穿支皮瓣的应用解剖目的明确腓动脉皮瓣穿支和骨穿支的走行规律、穿支血管数目、区域分布、蒂长、外径及皮肤穿支和骨穿支位置关系，为腓骨瓣嵌合腓动脉穿支皮瓣的临床应用提供解剖学基础。

方法 20例新鲜成人带膝关节的小腿标本，红色乳胶灌注后进行解剖。

将腓骨分为三段，观测各段腓动脉发出的皮穿支及骨穿支的分布、数目、蒂长、外径、走行及两种穿支之间的关系。

结果腓动脉于腓骨头下方7.23±3.76cm处开始贴紧腓骨走行并发出穿支。

小腿中段穿支血管恒定，数目最多,骨、皮穿支均为5.0±1.0支；管径最粗，皮穿支为1.12±0.56mm，骨穿支为0.82±0.44mm；皮穿支血管蒂长6.38±1.72cm。

腓动脉的骨、皮穿支基本在不同位置。

结论腓动脉骨穿支和皮穿支既共主干又适度分离，具有嵌合皮瓣解剖特点。

适合设计腓骨瓣嵌合腓动脉穿支皮瓣。

关键词穿支皮瓣；嵌合皮瓣；腓动脉；小腿；应用解剖第二章成人游离腓骨瓣嵌合腓动脉穿支皮瓣的临床应用目的探讨游离腓骨瓣嵌合腓动脉穿支皮瓣修复长段骨缺损伴或不伴皮肤软组织缺损创面的可行性，并分析其临床疗效。

方法选择2010年6月至2012年10月收治的骨缺损伴或不伴皮肤软组织缺损患者10例，采用游离腓骨瓣嵌合腓动脉穿支皮瓣移植修复，术后随访观察皮瓣外观、骨瓣愈合情况、供区并发症,并将此组患者设为研究组。

回顾性选择2010年6月以前采用传统腓骨皮瓣修复骨缺损伴或不伴皮肤软组织缺损患者10例，设为对照组。

比较两组病例皮瓣的成活情况、皮瓣外观、骨瓣愈合时间以及术后供区的并发症。

结果研究组：术后10例皮瓣全部存活，其中9例一期完全愈合，1例皮瓣边缘部分坏死，换药后愈合，皮瓣外观满意，1例稍臃肿，供区7例直接缝合，仅留线性疤痕，3例予以植皮成活，4例出现轻度的并发症。

骨瓣愈合时间为7.18±1.01个月。

对照组：术后6例皮瓣一期完全愈合，2例皮瓣完全坏死，采用其它皮瓣修复愈合，2例皮瓣部分坏死，换药后愈合，供区7例直接缝合，仅留线性疤痕，3例予以植皮成活，6例出现不同程度的并发症，影响功能。

骨瓣愈合时间为7.05±1.43个月，术后6例出现不同程度的并发症，其中两例出现较严重的并发症，影响功能。

从骨瓣愈合时间、皮瓣坏死率、皮瓣臃肿率、供区并发症四方面将两组病例进行统计分析。

骨瓣愈合时间行T检验，P>0.05，差异无统计学意义。

皮瓣坏死率、皮瓣臃肿率、供区并发症行卡方检验，P<0.05，差异有统计学意义。

结论游离腓骨瓣嵌合腓动脉穿支皮瓣使得骨瓣和皮瓣有效分离，对受区创面的修复更灵活，减少了血管蒂卡压等风险，更有利于皮瓣成活，是临床修复长段骨缺损伴或不伴皮肤软组织缺损的最佳选择之一。

关键词穿支皮瓣；腓骨瓣；嵌合皮瓣；骨缺损AbstractChapter I Applied anatomy of Mosaic of the adult free fibulaflap and the peroneal artery perforator flapObjective To crystallize coursrs ,numbers, distributions, pedicle lengths, externaldiameter and the position of perforators of the peroneal artery flap perforators and bonego line rule, then to provide anatomical basis for the application of Mosaic of the adultfree fibula flap and the peroneal artery flap.Methods Twenty fresh specimens of adult leg with knee joint injected with red latexwere dissected.Fibulas were divided into three sections.Distribution, numbers, pediclelength excernal, diameters,courses and relations of peroneal artery skin perforators andbone perforators in each section were observed,as well as measured and analyzed.Results The peroneal artery began to adhere fibula and give the perforators 7.23 ±3.76 cm under fibular head. The skin perforators and the bone perforators constantlyappeared in the midpiece of legs.In this section, numbers of perforators were the largestwith 5 ± 1 branch respectively; diameters were widest with 1.12 ± 0.56 mm for skinperforators and 0.82±0.44 mm for bone perforators. Skin perforators vascular pediclewas 6.38 ±1.72 cm long. the skin perforators and bone perforators of the peroneal arteryalmost appeared in different position.Conclusions Bone and skin perforators of peroneal artery shared the same trunk andmoderatly separated, characterized by chimeric flap anatomical features,which weresuitable for designning the fibula flap Mosaic of the peroneal artery flap.Key words Perforator flap; Mosaic flap; The peroneal artery; Calf; Applied anatomyChapter II Clinical application of mosaic of the free fibula flap and the peroneal artery perforator flap Objective To explore the feasibility of Mosaic of the free fibula flap and the peroneal artery perforator flap to repair bone defect with or without skin and soft tissue defects, and to analyze its clinical effect.Method10 patients who had Bone defects with or without skin and soft tissue defects had been treated repairs with Mosaic of the free fibula flap and the peroneal artery perforator flap from June 2010 to October 2012. outward appearance ,wound healingand donor site complications of skin flap and bone flap obserred during postoperative follow-up. This group of patients was set to be a study group. 10 patients of bone defects before June 2010, with or without skin and soft tissue defects, who had adopted the traditional fibula flap operation was set to be the control group. Survival flap appearance, bone flap healing time and donor site postoperative complications of the two groups were compared.Results Study Group: 10 cases of flaps all survived, including 9 cases of phase I healing completely, 1 case of skin flap necrosis edges which healed after dressing change with satisfactory skin flap appearance.1 case a bit bloated, linear scar was left with direct suture in 7 cases of direct suture, 3 cases of skin graft survival, 4 cases of mild complications. Bone flap healing time was 7.18 ± 1.01 months. Control group included 6 cases of postoperative flap completely healing, 2 cases of complete skin flap necrosis which healed by using other skin flap to repair of 2 cases of skin flap necrosis and healing after dressing change, 7 cases directly suture with linear scars, 3 cases of skin graft survival, 6 cases different degree of complication with unsatisfactory function. Bone flap healing time was 7.05 ±1.43 months.postoperative complications of different level appeared in two cases, of which severe complications with unsatisfactory function appeared in two cases. Two groups of patients were statistically analyed flom the perspectives of healing time of the bone flap, flap necrosis rate, flap bloating rate , donor site complications .Bone flap healing time was recorded by T test,P value is greater than 0.05, without statistical significance. skin flap necrosis rate and skin flap bloating ratewere tested by chis quare test, P values were less than 0.05, with statistical significance.Conclusions Mosaic of Free fibula flap and the peroneal artery perforators flap separate the bone flap and skin flap is effectively, resulting in more flexible repair, less risk of vascular pedicle pressfitting and more satisfactory flap survival, which becomesone of the best choice for the clinical repair of bone defects with or without skin and soft tissue defect.Postgraduate:XunYunhuaDirected byprofessor:Liu Mingjiang Key words Perforator flap; fibula flap；Mosaic flap; bone defect第一章成人游离腓骨瓣嵌合腓动脉穿支皮瓣的应用解剖1前言骨缺损的修复一直以来被认为是临床上的一大难题，早在1878年Macewen即有1例异体植骨获得成功的报道。