跟外侧动脉穿支皮瓣的应用解剖

doi:10.13418/j.issn.1001-165x.2018.04.001

摘要/Abstract

摘要：

目的　探讨跟腱区及跟部皮肤软组织的血供解剖学，为跟外侧动脉穿支皮瓣的临床应用提供解剖学基础。方法　16侧经红色乳胶灌注的成人下肢标本，解剖观察跟外侧动脉“垂直段”及其穿支血管的位置、口径、数目及分布规律。结果　位于小腿后骨筋膜鞘深部的腓动脉于外踝尖上(6.6±1.1) cm ( 5.5~9.4 cm) 发出腓动脉前穿支和跟外侧动脉，跟外侧动脉下行穿出分隔小腿后骨筋膜鞘浅、深部之小腿后筋膜隔到达外踝后间隙，于腓骨肌腱与跟腱之间移行，继续绕外踝向前下方分布。小腿下段腓动脉、跟外侧动脉穿支数为(3.6±0.7)支，口径为（0.9±0.29） mm，营养跟腱区及跟部皮肤软组织。结论　研究结果显示跟腱区及跟部皮肤软组织的血供主要来源于腓动脉、跟外侧动脉，为跟外侧动脉的命名、临床应用以及小腿中下段皮瓣的设计和跟部手术提供解剖学基础。

关键词: 外踝后间隙, 　跟外侧动脉, 　穿支皮瓣

Abstract:

Objective　To report the vascular anatomy of the integument in the Achilles tendon area, with an emphasis on the lateral calcaneal artery perforators emerging superficially along the lateral margin of the Achilles tendon.　Methods　16 cadaveric legs were dissected to investigate the perforators arising from the vertical segment of the lateral calcaneal artery(LCA) in terms of number and location relative to the tip of the lateral malleolus, and distribution.　Results　The peroneal artery (PA) ended into the anterior perforating branch and LCA at the level of (6.6±1.1) cm (range 5.5~9.4 cm) above the tip of the lateral malleolus. LCA pierced the fascia separating the deep posterior and superficial posterior compartment of the lower leg, proceeded between the Achilles tendon and peroneal tendons. It followed a curve around the lateral malleolus. Both PA and LCA, especially the LCA, gave off an average of (3.6±0.7) perforators with an average diameter of ( 0.9±0.29) mm that contributed to nourishment of the integument overlying the Achilles tendon. Conclusions　The integument overlying the Achilles tendon derives its blood supply through the perforators of the LCA primarily and that of the PA secondarily. It provides the anatomic basis for appreciating the LCA with regard to its terminology, clinical significance, perforator flap design and hindfoot surgery.

Key words: Lateral retromalleolar space; , Lateral calcaneal artery; , Perforator flap

黄海华,吴泽勇,陈秀凤,李小芳,王绥江. 跟外侧动脉穿支皮瓣的应用解剖[J]. 中国临床解剖学杂志, 2018, 36(4): 361-366.

HUANG Hai-hua, WU Ze-yong, CHEN Xiu-feng, LI Xiao-fang, WANG Sui-jiang. Anatomic basis of the lateral calcaneal artery perforator skin flap[J]. Chinese Journal Of Clinical Anatomy, 2018, 36(4): 361-366.

参考文献

[1] 李匡文, 唐举玉, 刘昌雄, 等. 腓动脉穿支皮瓣的应用解剖[J]. 中国临床解剖学杂志，2011, 29 (4): 382-385.
[2] Zhang FH, Chang SM, Lin SQ, et al. Modified distally based sural neuro-veno-fasciocutaneous flap: anatomical study and clinical applications[J]. Microsurgery，2005, 25(7):543-550.
[3] 张世民, 徐达传, 张发惠, 等. 外踝后穿支皮瓣[J]. 中国临床解剖学杂志, 2005, 23 (4) :345-348.
[4] Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications[J]. Plast Reconstr Surg, 2009, 124(5): 1529-1544.
[5] Wang SJ, Kim YD, Huang HH, et al. Lateral calcaneal artery perforator-based skin flaps for coverage of lower-posterior heel defects[J]. J Plast Reconstr Aesthet Surg, 2015, 68(4): 571-579.
[6] 徐达传, 张世民, 钟世镇. 远端蒂腓肠神经营养血管皮瓣的基础与临床研究进展[J]. 中国临床解剖学杂志, 2005, 23 (4): 343-344.
[7] Beveridge J, Masquelet AC, Romana MC, et al. Anatomic basis of a fascio-cutaneous flap supplied by the perforating branch of the peroneal artery[J]. Surg Radiol Anat, 1988,10(3):195-199.
[8] Chang SM, Li XH, Gu YD. Distally based perforator sural flaps for foot and ankle reconstruction[J]. World J Orthop, 2015, 6(3):322-330.
[9] Bekara F, Herlin C, Somda S, et al. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis[J]. Microsurgery, 2018, 38(1):109-119.
[10]Attinger CE, Evans KK, Bulan E, et al. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization[J]. Plast Reconstr Surg, 2006,117(7 Suppl):261S-293S.
[11]孙超. 前臂皮支链皮瓣的解剖学研究[D]. 广州：南方医科大学, 2012.
[12]Grabb WC, Argenta LC. The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser saphenous vein, and sural nerve skin flap) [J]. Plast Reconstr Surg, 1981, 68(5): 723-730.
[13]Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg[J]. Plast Reconstr Surg, 1992, 89(6): 1115-1121.
[14]高英茂. 人体解剖学名词[M]. 第2版.北京:科学出版社,2014:229-230.
[15]Standring S. Gray's Anatomy[M]. 40th ed. Elsevier: Churchill Livingstone, 2008:1425.
[16]Freemon BJC, Duff S, Allen PE, et al. The extended lateral approach to hindfoot. Anatomical basis and surgical implications[J]. J Bone Joint Surg Br, 1998, 80(1):139-142.
[17]史增元, 尹维刚, 毛海蛟, 等. 足背外侧动脉链岛状皮瓣的应用解剖[J]. 中国临床解剖学杂志, 2012, 30(6): 609-611.
[18]Dziemianczyk-Pakiela D, Groth D, Toloczko-Iwaniuk N,et al. Peroneal artery-vein index as a potential factor of thrombosis occurrence in free osteocutaneous fibula flap[J]. J Craniomaxillofac Surg，2016, 44(9):1314-1319.
[19]Woo KJ, Park JW, Mun GH. The lateral calcaneal artery as an alternative recipient vessel option for heel and lateral foot reconstruction[J]. Microsurgery, 2018, 38(2):164-171.
[20]谢志平, 庄跃宏,郑和平,等. 腓血管蒂腓骨嵌合组织瓣设计的解剖学基础[J]. 中国临床解剖学杂志， 2014, 32 (3): 259-263.
[21]Ishikawa K, Isshiki N, Hoshino K, et al. Distally based lateral calcaneal flap[J]. Ann Plast Surg，1990, 24(1):10-16.
[22]Elsaidy MA, El-Shafey K. The lateral calcaneal artery: Anatomic basis for planning safe surgical approaches[J]. Clin Anat, 2009, 22(7):834-839.
[23]Cho BC, Kim SY, Park JW, et al. Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications[J]. Plast Reconstr Surg, 2001,108(7):1963-1971.
[24]Papadimas D, Paraskeuopoulos T, Anagnostopoulou S. Cutaneous perforators of the peroneal artery: Cadaveric study with implications in the design of the osteocutaneous free fibular flap[J]. Clin Anat, 2009, 22(7):826-833.
[25]Heitmann C, Khan FN, Levin LS. Vasculature of the peroneal artery: an anatomic study focused on the perforator vessels[J]. J Reconstr Microsurg, 2003,19(3):157-162.
[26]黄海华, 王绥江, 吴泽勇, 等. 面动脉穿支蒂螺旋桨皮瓣修复外鼻皮肤软组织缺损之蒂部浅析[J]. 中华显微外科杂志, 2017 ,40(5): 499-502.
[27]Lykoudis EG, Koutsouris M, Lykissas MG. Vascular anatomy of the integument of the lateral lower leg: an anatomical study focused on cutaneous perforators and their clinical importance[J]. Plast Reconstr Surg, 2011,128(1):188-198.
[28]Yoshimura M, Shimada T, Hosokawa M. The vasculature of the peroneal tissue transfer[J].Plast Reconstr Surg, 1990, 85(6): 917-921.
[29]Chen YL, Zheng BG, Zhu JM, et al. Microsurgical anatomy of the lateral skin flap of the leg[J]. Ann Plast Surg, 1985, 15(4): 313-318.
[30]Tang M, Mao Y, Almutairi K, et al. Three-dimensional analysis of perforators of the posterior leg[J]. Plast Reconstr Surg, 2009, 123(6):1729-1738.
[31]Attinger C，Cooper P，Blume P. Vascular anatomy of the foot and ankle[J]. Operative Techniques in Plastic and Reconstructive Surgery, 1997, 4(4):183-198.
[32]Taylor GI, Rozen WM, Whitaker IS. Establishing a perforator flap nomenclature based on anatomical principles[J]. Plast Reconstr Surg, 2012,129(5):877e-879e.