Objective: To investigate the clinical effects of retrograde anterolateral thigh perforator flaps assisted with computed tomography angiography (CTA) in repairing skin and soft tissue defects around the knee or in proximal lower leg. Methods: A retrospective cohort study was conducted. From May 2015 to October 2019, 17 patients with skin and soft tissue defects around the knee or in proximal lower leg were admitted to the Department of Orthopedics of Jizhong Energy Xingtai Mig General Hospital, including 12 males and 5 females, aged 16-65 years, with an average age of 35 years. The areas of skin and soft tissue defects after debridement ranged from 6.0 cm×3.0 cm to 15.0 cm×9.0 cm. The retrograde anterolateral thigh perforator flaps were designed according to the origin and distribution of the perforating branches in flaps and the length of the vascular pedicle examined with CTA and the condition of the wound to repair the wounds. The areas of resected flaps ranged from 6.5 cm×3.5 cm to 15.5 cm×9.5 cm. The wounds in donor sites of flaps were sutured directly or covered with medium-thickness skin grafts from healthy upper leg. The sources of the perforating branches in flaps were recorded. The lateral circumflex femoral artery, its branches, and the relative length of the vascular pedicle were compared between preoperative CTA detection and intraoperative observation. The survivals of the flaps were observed. At the last follow-up, the effects of flaps in repairing wounds were evaluated according to evaluation standard of efficacy satisfaction; the motion ranges of flexion and extension of the knee joint were measured, and the knee joint function was evaluated according to the Hohl knee joint function evaluation standard; the sensory function in the flap area was evaluated according to the sensory function evaluation standard formulated by the British Medical Research Council; the wound healing and the occurrence of complication affecting motor function of limb of flap donor sites was observed. Data were statistically analyzed with paired sample t test. Results: The perforating branches in flaps originated from descending branches, oblique branches, and rectus femoris branches of lateral circumflex femoral artery in 7, 6, and 4 patients, respectively. The flaps with blood supply from descending branches, oblique branches, and rectus femoris branches of lateral circumflex femoral artery were type 1, 2, and 3 retrograde anterolateral thigh perforator flaps, respectively. The preoperative CTA examination of lateral circumflex femoral artery and its branches were consistent with those observed during operation. The relative lengths of vascular pedicles of type 1, 2, and 3 retrograde anterolateral thigh perforator flaps calculated after CTA examination were 0.32±0.13, 0.56±0.07, and 0.56±0.15, which were close to 0.35±0.12, 0.52±0.10, and 0.53±0.12 measured and calculated during operation, respectively (t=0.45, 0.80, 0.31, P>0.05). All flaps survived in 17 cases without vascular crisis. At the last follow-up, 16 patients were satisfied with effects of flaps in wound repair, with 1 patient feeling average about the effect; the flexion range of knee joint was 100-120°, and the extension range of knee joint was -2-0°; knee joint function was evaluated as excellent in 9 cases, good in 7 cases, and poor in 1 case; the sensory function of the flap area reached S4 level in 2 cases, S3 level in 8 cases, and S2 level in 7 cases; the wounds in flap donor sites healed well; there was no adverse effect in motor function of limbs. Conclusions: Retrograde anterolateral thigh perforator flap is an effective method for repairing skin and soft tissue defects around the knee or in proximal lower leg. Preoperative CTA examination can fully show the anatomical characteristics of the branches of the lateral circumflex femoral artery and the perforating vessels of each branch, which can guide preoperative flap design and operation, thus shortening operation time and improving flap survival rate, with good clinical effects.
目的： 探讨CT血管造影（CTA）辅助下逆行股前外侧穿支皮瓣修复膝周或小腿近端皮肤及软组织缺损的临床效果。 方法： 采用回顾性队列研究方法。2015年5月—2019年10月，冀中能源邢台矿业集团有限责任公司总医院骨三科收治17例膝周或小腿近端皮肤及软组织缺损患者，其中男12例、女5例；年龄16~65岁，平均35岁；清创后皮肤及软组织缺损面积为6.0 cm×3.0 cm~15.0 cm×9.0 cm。根据术前CTA明确的皮瓣中穿支血管来源与分布及测量的血管蒂长度、创面情况设计逆行股前外侧穿支皮瓣修复创面，皮瓣切取面积为6.5 cm×3.5 cm~15.5 cm×9.5 cm。供瓣区创面直接拉拢缝合或取健侧大腿中厚皮覆盖。记录皮瓣中穿支血管来源，比较术前CTA检查的旋股外侧动脉及其分支、血管蒂相对长度与术中探测结果是否一致，观察皮瓣成活情况。末次随访，根据疗效满意度评价标准评定皮瓣修复创面的效果；测定膝关节屈伸活动度，根据Hohl膝关节功能评定标准评定患者膝关节功能；根据英国医学研究会制订的感觉功能评价标准评定移植皮瓣区域感觉功能；观察供瓣区创面愈合及影响肢体运动功能的并发症发生情况。对数据行配对样本t检验。 结果： 皮瓣中穿支血管来源于旋股外侧动脉降支7例、斜支6例、股直肌支4例，由旋股外侧动脉降支、斜支、股直肌支来源的穿支供血的皮瓣分别为1、2、3型逆行股前外侧穿支皮瓣。术前CTA检查的旋股外侧动脉及其分支与术中探测结果一致。1、2、3型逆行股前外侧穿支皮瓣CTA检查后计算的血管蒂相对长度分别为0.32±0.13、0.56±0.07、0.56±0.15，与术中实际测量后计算的血管蒂相对长度0.35±0.12、0.52±0.10、0.53±0.12相近（t=0.45、0.80、0.31，P>0.05）。17例患者皮瓣全部成活，无血管危象。末次随访，患者对皮瓣修复创面的效果满意度为满意16例、一般1例；膝关节屈曲达100~120°、伸直达-2~0°，膝关节功能评定为优9例、良7例、差1例；移植皮瓣区域感觉功能达到S4级2例、S3级8例、S2级7例；供瓣区创面愈合良好，肢体运动功能无影响。 结论： 逆行股前外侧穿支皮瓣为膝周或小腿近端皮肤及软组织缺损的有效修复方式。术前CTA能够明确旋股外侧动脉分支及各分支穿支血管的解剖特点，指导术前皮瓣设计及手术操作，缩短手术时间，提高皮瓣成活率，临床疗效较佳。.