本文選題：腓腸外側(cè)動脈 + 腓腸外側(cè)皮神經(jīng)營養(yǎng)血管�。� 參考：《河北醫(yī)科大學(xué)》2012年碩士論文

【摘要】：目的：本研究在尸體標(biāo)本解剖的基礎(chǔ)上，觀察測量腓腸外側(cè)動脈穿支與腓腸外側(cè)皮神經(jīng)營養(yǎng)血管的解剖位置關(guān)系，從而設(shè)計一種二者聯(lián)合為蒂的肌皮瓣，并通過臨床應(yīng)用來觀察此聯(lián)合蒂肌皮瓣的臨床效果，以期為臨床修復(fù)髕前及脛骨上端皮膚及軟組織缺損設(shè)計一種皮瓣修復(fù)的新方法。前人對腓腸神經(jīng)營養(yǎng)血管及腓腸肌血管的顯微解剖、造影和腓腸神經(jīng)營養(yǎng)皮瓣、腓腸肌肌皮瓣的基礎(chǔ)及臨床應(yīng)用研究已有大量文獻報道。但是通過臨床實踐發(fā)現(xiàn)，對于髕前及脛骨上端較復(fù)雜創(chuàng)面，如伴有骨缺損或骨髓炎，單純的肌皮瓣所帶肌肉多，對供區(qū)創(chuàng)傷大，皮瓣外觀也很臃腫，在外觀及功能上都難以滿足膝關(guān)節(jié)的要求；而筋膜皮瓣則難以填實創(chuàng)面，往往會留下死腔，淤積滲液形成感染灶，導(dǎo)致皮瓣壞死。基于此，我們考慮是否可以將肌肉血管與神經(jīng)營養(yǎng)血管聯(lián)合，從而設(shè)計出一種聯(lián)合蒂肌皮瓣來修復(fù)髕前及脛骨上端較復(fù)雜創(chuàng)面。 方法：選用5具（10側(cè)）成人下肢新鮮標(biāo)本，由河北醫(yī)科大學(xué)解剖學(xué)實驗室提供。2例為河北醫(yī)科大學(xué)第三醫(yī)院介入科提供的正常人下肢數(shù)字減影血管造影（DSA）資料。 臨床病例5例,為2009年2月至2011年11月期間河北醫(yī)科大學(xué)第三醫(yī)院手外科住院患者，均為男性，年齡21～47歲，平均32.8±9.6歲。致傷原因：交通事故傷致軟組織缺損4例，壓砸傷1例。病程36～56d。損傷部位：均為外傷致髕前及脛骨上段皮膚與深部軟組織、骨質(zhì)缺損。創(chuàng)面面積：6cm×9cm～9cm×12cm（Table3）。 1解剖方法：采用分層解剖方法。選擇乆窩中點到外踝與跟腱中點的連線，此連線為腓腸神經(jīng)營養(yǎng)血管軸體表投影線（Fig.1）。沿此線依次切開皮膚及淺筋膜，找到腓腸神經(jīng)及其營養(yǎng)血管（Fig.2, Fig.3）。沿腓腸外側(cè)皮神經(jīng)向近端游離至入肌點，切開深筋膜，找到腓腸肌外側(cè)頭（Fig.4），再向外牽開腓腸肌外側(cè)頭，顯露腓腸肌外側(cè)血管神經(jīng)束（Fig.5），然后向近端解剖乆動靜脈（Fig.6），向遠端解剖分離腓腸外側(cè)動脈，顯露其主要分支（Fig.7, Fig.8）。直視放大鏡下分離解剖，觀察記錄腓腸外側(cè)動脈穿支數(shù)目、穿出點、口徑及與腓腸外側(cè)皮神經(jīng)營養(yǎng)血管之間的吻合交通情況。血管口徑用游標(biāo)卡尺測量，血管長度和分布范圍用軟尺測量。所測數(shù)據(jù)用SPSS13.0統(tǒng)計學(xué)軟件進行分析，以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示。 2手術(shù)方法：術(shù)前先用多普勒血流探測儀在距乆皺折以遠4～10cm，距后正中線1～4cm范圍內(nèi)探測腓腸外側(cè)動脈的穿支，選擇最近端的1支做標(biāo)記。乆窩中點到外踝與跟腱中點的連線為皮瓣切取軸線。根據(jù)受區(qū)損傷情況和穿支動脈位置設(shè)計皮瓣，切取肌皮瓣大小比受區(qū)放大1cm左右。于標(biāo)記穿支水平上2cm左右，腓腸肌內(nèi)、外側(cè)頭之間找到腓腸外側(cè)動脈，順此血管縱行分開肌肉，沿途保留1～3支周圍留少量肌纖維組織的肌皮穿支，同時根據(jù)攜帶肌肉量保留1～2支肌支血管。當(dāng)游離出的血管蒂長度達到受區(qū)要求后,再切開肌皮瓣四周。皮瓣切取時要確認(rèn)腓腸外側(cè)動脈穿支、腓腸神經(jīng)及其營養(yǎng)血管軸都包含在內(nèi)時方可切取。 結(jié)果： 1尸體解剖所見：腓腸外側(cè)皮神經(jīng)于腓骨頭上起自腓總神經(jīng)，分布于小腿后外側(cè)上2/3部,其營養(yǎng)動脈主要是乆窩外側(cè)皮動脈。腓腸外側(cè)動脈由起始點至外徑1mm處長度為163.5±5.0mm，由起始點至入肌點為50.9±2.1mm，由起始點距腓腸外側(cè)皮神經(jīng)起始點為53.9±2.1mm，其分出點水平距離腓腸外側(cè)皮神經(jīng)為9.4±1.6mm。腓腸外側(cè)動脈伴行靜脈為2支，血管束入肌后行走于腓腸肌外側(cè)頭中間，沿肌纖維方向下行，沿途發(fā)出3～5支外徑0.20～1.80mm肌皮穿支。第一穿支口徑為1.16±0.37mm，入肌點距起始點為23.2±4.08mm，入肌點距腓腸外側(cè)皮神經(jīng)起始點81.8±3.05mm，入肌點距后正中線（乆動脈）9.7±1.77mm。第二穿支口徑為0.76±0.21mm，入肌點距起始點為53.4±4.06mm，入肌點距腓腸外側(cè)皮神經(jīng)起始點108.9±3.81mm，入肌點距后正中線（乆動脈）21.6±3.2mm。第三穿支口徑為0.43±0.11mm，入肌點距起始點為120.0±8.67mm，入肌點距腓腸外側(cè)皮神經(jīng)起始點173.6±4.03mm，，入肌點距后正中線（乆動脈）12.9±3.0mm。第四、五穿支變異較大，本實驗數(shù)據(jù)資料有限，且臨床設(shè)計此聯(lián)合蒂肌皮瓣時多以第一、二穿支血管帶取肌肉，故未統(tǒng)計在內(nèi)（Table1,Table2）。 2下肢DSA顯示在小腿后區(qū)的上2/3段，腓腸外側(cè)動脈發(fā)出穿支與腓腸外側(cè)皮神經(jīng)營養(yǎng)血管軸吻合，構(gòu)成血管鏈，參與形成淺、深筋膜血管網(wǎng)。支持解剖實驗和術(shù)中所見（Fig.10,Fig.11）。 3臨床應(yīng)用：皮瓣4例一期愈合，1例遠端部分淺表壞死，經(jīng)換藥逐漸愈合。術(shù)后隨訪2個月～6個月，肌皮瓣質(zhì)地優(yōu)良，顏色可，外形好，不臃腫，不需要二次修薄手術(shù)。患肢行走及穿褲接近正常，沒有發(fā)生磨損、潰破現(xiàn)象。供區(qū)愈合良好，無明顯的功能障礙，臨床效果滿意（Fig.16）。 結(jié)論： 1腓腸外側(cè)動脈入肌后沿途發(fā)出3～5支外徑0.20～1.80mm肌皮穿支，營養(yǎng)腓腸肌外側(cè)頭及周圍皮膚，并與腓腸外側(cè)皮神經(jīng)營養(yǎng)血管參與形成淺、深筋膜血管網(wǎng)。 2聯(lián)合蒂皮瓣有兩套血供，血運豐富，擴大了皮瓣切取面積；同時皮瓣內(nèi)帶有感覺神經(jīng)，保證了皮瓣感覺，可以修復(fù)膝關(guān)節(jié)周圍較復(fù)雜皮膚軟組織缺損。 3皮瓣蒂部不臃腫，轉(zhuǎn)移方便，不損傷主要血管，創(chuàng)傷小，易于臨床推廣應(yīng)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 鹵 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 鹵 standard deviation ( x 鹵 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

本文編號：1754896