目的 探讨穿支螺旋桨皮瓣(PPPF)修复足踝部软组织缺损的临床效果以及术前超声辅助供区穿支定位的作用。方法 2017年1月-2023年6月，漯河医学高等专科学校第二附属医院显微骨科应用PPPF修复26例足踝部中、小面积软组织缺损，其中男17例，女9例，年龄18～68岁，平均46岁。缺损部位:前足3例，中足6例，均合并不同程度的肌腱外露、骨外露;足踝部、足跟部软组织缺损17例，合并不同程度骨外露、踝关节开放12例，跟腱外露5例。软组织缺损面积2。5 cm × 1。5 cm～16。0 cm × 6。5 cm。术前测量创面宽度，HHD在创面近端探测供区穿支，高频CDU再次定位确认穿支发出位置、走行、血流量、管径、2条穿支标记点连线为皮瓣中轴线，利用"提捏法"评估供区可直接闭合或应用接力皮瓣可闭合供区。皮瓣切取面积2。8 cm × 1。5 cm～24。0 cm × 7。5 cm，供区直接闭合22例，接力皮瓣修复4例。皮瓣携带皮神经与受区皮神经缝接4例。合并骨缺损同期行Masquelet技术6例。出院后前2个月间隔1～2周门诊复查1次，骨缺损植骨患者1～2个月复查X线片直至骨缺损骨性愈合。结果 仅1例术后24h出现皮瓣瘀血、肿胀，远端血运差，给予拆除蒂部部分缝线，1周后皮瓣尖端仍出现小面积坏死，经换药后愈合，其余皮瓣未经特殊处理顺利成活。21例得到4个月～3年的随访，皮瓣外形、颜色、质地满意，无溃疡。皮瓣感觉恢复评定按照英国医学研究会(BMRC)评定标准，缝接神经的3例皮瓣感觉恢复至S2级1例，S3级2例;据美国足踝关节协会(AOFAS)踝-后足功能评分结果优16例，良5例。结论 超声辅助下PPPF可有效修复足踝部软组织缺损。
Ultrasonography assistance in reconstruction of soft tissue defect in ankle and foot with perforator pedicled propeller flap:a report of 26 cases
Objective To explore the clinical effect of perforator pedicled propeller flap(PPPF)in recon-struction of soft tissue defect in ankle and foot,as well as the role of preoperative ultrasonography in assistance of the location of perforators in donor site.Methods From January 2017 to June 2023,the Department of Microortho-pedics of the Second Affiliated Hospital of Luohe Medical College of Higher Education applied PPPF to reconstruct small and medium-sized soft tissue defects in the ankle and foot for 26 patients.The patients were 17 males,9 females,aged 18 to 68 years old with 46 years old in average.The defect sites were 3 in forefoot and 6 in midfoot and combined with different degrees of tendon and bone exposure,17 in ankle and heel and combined with various degrees of bone exposure,12 with ankle open injury and 5 with Achilles tendon exposure.The area of soft tissue defects ranged from 2.5 cm×1.5 cm to 16.0 cm × 6.5 cm.The width of injury was measured before surgery,and a HHD was used to detect the perforators proximal to the defect site,and then high-frequency CDU was used to locate and confirm the location of the perforator and its alignment,blood flow and diameter.The line drawn be-tween the 2 perforators was set as the axis of flap.The donor site was assessed by a"pinching and lifting"method to determine a direct closure of donor site or to have it closed by a flap transfer.The sizes of flap were from 2.8 cmx 1.5 cm to 24.0 cm×7.5 cm.Twenty-two donor sites were directly closed and 4 received flap transfers.Four flaps had sutures with the skin nerves in the recipient site.Masquelet technique was performed in 6 patients with bone defects in the surgery.Patients received outpatient reviews with 1-2 weeks of intervals in the first 2 months after surgery,and X-ray reviews per 1-2 months for those with bone implants until bone healing.Results All flaps survived successfully without any special treatment after surgery,except 1 flap that had blood vessel congestion and showed swelling and poor blood supply to the distal flap at 24 hours after surgery.The blood vessel congestion was revised by removal of part of the suture at the tip of flap pedicle.One week later,the tip of the flap remained with a small area of necrosis,which was then healed after dressing changes.A total of 21 patients were included in postoperative follow-up with 4 months to 3 years.All of the flaps had satisfactory appearance,colour and texture,and without any ulceration.Three cases of nerve suture were also included in follow-up.According to the assessment criteria of British Medical Research Council(BMRC),the sensory recovery of the flaps was found of S2 in 1 flap and S3 in 2 flaps.According to the American Orthopaedic Foot and Ankle Society(AOFAS),the ankle-hindfoot function scores,there were excellent in 16 patient and good in 5 patients.Conclusion With the assistance of ultrasound,the PPPF can be effectively used in reconstruction of soft tissue defects in ankle and foot.
Perforator pedicled propeller flapUltrasoundReconstructionAnkle and footMicrosur-gical techniqne
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