1.Department of Burn Surgery, Beijing Jishuitan Hospital, Beijing 100035, China;2.Department of Vascular Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
背景与目的 肢体部位的毁损性创面，常会合并主干血管的损伤，如果处理不当，会导致肢体缺血坏死而截肢的严重后果。为探索此类毁损性创面的诊治方法，本研究分析应用游离皮瓣联合血管重建来修复上肢毁损性创面合并主干血管损伤的临床效果，以期为此类毁损性创面的临床治疗提供参考和借鉴。方法 回顾性分析2017年12月—2022年12月北京积水潭医院收治的上肢毁损性创面合并主干血管损伤，并用游离皮瓣联合血管重建来修复的患者45例，总结血管损伤的评估及处理方法，修复毁损性创面所用游离皮瓣的种类，观察术后重建血管通畅情况和肢体血运情况以及皮瓣存活情况、创面和供瓣区愈合情况。最后一次随访时，根据中华医学会手外科学会上肢部分功能评定试用标准中手部肌腱、神经修复评定标准，评价手部屈、伸功能的肌力和手指感觉功能。结果 45例患者中，男38例，女7例；平均年龄（39.4±15.1）岁。上臂毁损性创面合并肱动脉损伤5例，前臂及腕部毁损性创面合并桡动脉和（或）尺动脉损伤40例。大隐静脉桥接重建肱动脉3例（6.7%），人工血管桥接重建肱动脉2例（4.4%），大隐静脉桥接重建尺动脉1例（2.2%），大隐静脉桥接重建桡动脉35例（77.8%），行血流桥接皮瓣重建桡动脉4例（8.9%）。股前外侧皮瓣移植29例（64.4%），脐旁穿支皮瓣移植12例（26.7%），腹股沟皮瓣移植1例（2.2%），背阔肌肌皮瓣（面积24~10 cm×35~18 cm）移植3例（6.7%）。供瓣区直接缝合封闭24例（53.3%），于附近转移皮瓣覆盖13例（28.9%），取断层皮移植覆盖8例（17.8%）。游离皮瓣存活率为97.8%（44/45），创面I期愈合率为93.3%（42/45）。38例患者获随访3~36个月，皮瓣及患肢血运良好，重建血管通畅率为92.1%（35/38）。最后一次随访时，患者伸拇及伸指功能基本正常；屈拇及屈指肌力评定：Ⅴ级5例（13.2%）、Ⅳ级13例（34.2%）、Ⅲ级16例（42.1%）、Ⅱ级4例（10.5%）；手指感觉功能评定：S4级5例（13.2%）、S3级10例（26.3%）、S2级12例（31.6%）、S1级8例（21.0%）、S0级3例（7.9%）。结论 上肢毁损性创面合并主干血管损伤需及时评估和处理损伤的血管，根据损伤血管的直径可用自体血管或人工血管桥接重建损伤的主干动脉，以避免肢体缺血坏死；重建的血管和毁损性创面需及时应用血循环丰富的组织瓣来覆盖，有条件的话，应优先采用游离皮瓣移植，效果要优于远位带蒂皮瓣移植。
Background and Aims Destructive wounds in the extremities often involve damage to major blood vessels. If not properly managed, they can lead to severe consequences such as limb ischemic necrosis and amputation. In order to explore diagnostic and treatment methods for such destructive wounds, this study was performed on the clinical outcomes of using free flaps combined with vascular reconstruction to repair upper limb destructive wounds combined with major vascular injuries to provide reference and guidance for the clinical treatment of such destructive wounds.Methods A retrospective analysis was conducted on 45 patients with upper limb destructive wounds and significant vascular injuries who underwent repair using free flaps combined with vascular reconstruction at Beijing Jishuitan Hospital from December 2017 to December 2022. The evaluation and treatment methods for vascular injuries, types of free flaps used for wound repair, postoperative vascular patency and limb perfusion, flap survival, and wound and donor site healing were summarized. During the last follow-up, hand muscle and nerve repair assessment criteria from the Hand Surgery Society of the Chinese Medical Association were used to evaluate the muscle strength of hand flexion and extension and finger sensory function.Results Among the 45 patients, there were 38 males and 7 females, with a mean age of (39.4±15.1) years. Five cases involved upper arm destructive wounds combined with brachial artery injuries, and 40 cases involved forearm and wrist destructive wounds combined with radial and/or ulnar artery injuries. The reconstruction methods included significant saphenous vein bridge reconstruction of the brachial artery in 3 cases (6.7%), artificial vascular bridge reconstruction of the brachial artery in 2 cases (4.4%), significant saphenous vein bridge reconstruction of the ulnar artery in 1 case (2.2%), significant saphenous vein bridge reconstruction of the radial artery in 35 cases (77.8%), and blood flow bridge flap reconstruction of the radial artery in 4 cases (8.9%). Anterolateral thigh flaps were used in 29 cases (64.4%), paraumbilical perforator flaps in 12 cases (26.7%), groin flaps in 1 case (2.2%), and latissimus dorsi muscle flaps (with an area of 24-10 cm×35-18 cm) in 3 cases (6.7%). The donor site was directly sutured and closed in 24 cases (53.3%), nearby flaps were transferred for coverage in 13 cases (28.9%), and split-thickness skin grafts were used for coverage in 8 cases (17.8%). The survival rate of free flaps was 97.8% (44/45), and the wound healing rate at stage I was 93.3% (42/45). Thirty-eight patients were followed up for 3-36 months, and the flaps and limb perfusion were satisfactory. The patency rate of reconstructed vessels was 92.1% (35/38). The patient's thumb and finger extension function was normal at the last follow-up. The muscle strength assessment of thumb and finger flexion showed grade Ⅴ in 5 cases (13.2%), grade Ⅳ in 13 cases (34.2%), grade Ⅲ in 16 cases (42.1%), and grade Ⅱ in 4 cases (10.5%). The finger sensory function assessment showed grade S4 in 5 cases (13.2%), grade S3 in 10 cases (26.3%), grade S2 in 12 cases (31.6%), grade S1 in 8 cases (21.0%), and grade S0 in 3 cases (7.9%).Conclusion Prompt evaluation and treatment of vascular injuries are necessary for upper limb destructive wounds combined with major vascular injuries. Autogenous or artificial vascular reconstruction should be performed based on the diameter of the injured vessels to prevent limb ischemic necrosis. Reconstructed vessels and destructive wounds should be covered promptly with tissue flaps rich in blood supply. Free flap transplantation should be prioritized whenever possible as it yields better results than distal pedicle flap transplantation.