Anastomotic fibular flap excision

It is suitable for long tube backbone and skin defects left after debridement or local scar resection. It is difficult to close the wound by conventional repair method. Treatment of diseases: calf artery injury Indication It is suitable for long tube backbone and skin defects left after debridement or local scar resection. It is difficult to close the wound by conventional repair method. Preoperative preparation 1. Prevention of wound infection is an important guarantee for the success of bone grafting. The anti-infective power of the graft bone is very weak. Once infected, the bone graft is soaked in the pus, necrosis will occur, and failure will occur. The precautionary measures are: the skin should be strictly prepared for the affected area and the donor area; the storage process of the stored bone must have strict sterility requirements; those with bone and soft tissue infection must be cured after 3 to 6 months of infection. Bone graft surgery, otherwise the surgery is easy to stimulate local latent bacteria, so that the infection recurs. Such patients should use antibiotics before surgery, and should use the anti-infective cancellous bone graft or the anastomotic bone graft. 2. The soft tissue around the bone area and the blood supply to the bone should be rich, and the growth force should be strong, so as to ensure the healing process of the bone graft. If the local skin and soft tissues have extensive scars, the blood supply will not be good, and the content after bone transplantation will increase, the skin will be difficult to suture, and infection will occur easily, forming a sinus. Therefore, the scar should be removed before surgery, and the flap should be transplanted to create conditions for the healing of the bone graft. 3. Many patients who need bone grafting have undergone multiple operations or long-term external fixation, resulting in muscle atrophy of the injured limb, decalcification of the bones, varying degrees of joint activity, poor blood circulation and low anti-infectiveness. The tissue growth ability is also poor. External fixation after an indispensable period of bone grafting will result in muscle atrophy and increased joint stiffness. Therefore, a period of functional exercise and physical therapy should be performed before surgery. For patients with non-displaced lower extremity fracture non-union or bone defect, functional exercise can be performed under the protection of stent or external fixation. 4. Preoperative x-ray film to understand the condition of the diseased bone, design the operation according to the condition (including the bone grafting part, the size of the bone graft and the bone grafting method). If the bone graft is to be anastomosed, the full length of the graft bone and the lateral x-ray film should be taken before surgery to select the site and length of the bone graft. 5. Before the bone graft of the anastomotic blood vessel, the ultrasonic artery should be used to detect the presence and blood flow of the main artery in the donor and recipient limbs in order to design the operation. Generally, the branches of the main arteries of the limbs are used for anastomosis, such as the deep femoral artery of the femoral artery, the inner and outer arteries of the circumflex femoral artery. If there are 2 main arteries in the receiving area, such as the ulnar artery, radial artery, anterior and posterior iliac artery, one of the main arteries may be used for anastomosis. The prerequisite must be that another major artery is confirmed by ultrasonic flowmeter or clinical examination. The blood supply is good. The veins in the recipient area are usually treated with superficial veins, such as the cephalic vein, the venous vein, the great crypt, the small saphenous vein and its branches. Therefore, the superficial vein of the recipient area should be examined for damage or inflammation before surgery. Recently used as a puncture, the superficial vein of the infusion cannot be used as a receiving vein. Surgical procedure 1. Position: If the receiving area is the upper limb, the donor area is the contralateral humerus. The patient takes the semi-recumbent position, the upper limb is extended elbow, and the abduction is 90°, which is placed on the small table next to the operating table. If the affected area is the contralateral lower limb, the patient is lying supine, and the limb is straightened; the buttocks of the donor area are 30°45°, the limb is bent and the femoral part is closed; or the semi-recumbent position is taken first, and the humerus is completely free. And then change to a flat position. 2. Incision: With the tibia as the vertical axis, the skin flap is designed according to the skin defect area of the receiving area plus 10% to 15%. The flap is generally fusiform, with the proximal tip at the humeral neck and the distal tip depending on the size of the flap, but no longer than 20 cm. The width of the flap can be up to 5 cm from the longitudinal axis of the flap to the front and back. Therefore, the flap cutting range can reach 10-20 cm2. 3. Separation of the posterior side: The size of the flap is depicted on the skin with gentian violet. The posterior edge of the flap is first cut, from the skin to the deep fascia, from the deep surface of the deep fascia and between the gastrocnemius and the soleus muscle, the flap is separated forward. Care should be taken not to enter the subcutaneous tissue during separation. It must be separated in front of the deep fascia to avoid damage to the blood supply. When separating to the posterior border of the humerus, special attention should be paid to the distal part of the soleus muscle attached to the distal part of the tibia a few mm. There are several perforating branches of the annular artery, which should be carefully protected from the posterior border of the tibia through the deep fascia into the subcutaneous tissue. To avoid damage, otherwise it will cause skin flap necrosis. About 0.5 cm away from the posterior side of the perforating branch, the soleus muscle is longitudinally cut, and the muscle is pulled to the posterior side to reveal the spurs and veins. Along the vascular bundle, it is separated upward to the posterior iliac artery and vein, and is separated downward to enter the flexor longus tendon. According to the length of the transplanted tibia required by the receiving area, the tibia is cut with a wire saw, the tibia is rotated forward, and the flexor longus is cut along the iliac and vein until the distal end of the humerus has been cut, and the plane is ligated and cut off. ,vein. 4. Separation of the anterior side: the incision of the leading edge of the flap is also deep into the deep fascia, from the deep fascia deep and the extensor muscles of the calf, between the long and short tibia, and the posterior separation of the flap to the longissimus dorsi edge. After protecting the common peroneal nerve, the anterior muscle of the tibia was cut in turn, and the muscle fibers of 3 to 4 mm thick were retained on the tibia. Rotate the humerus backwards and cut the interosseous membrane longitudinally. The transplanted humeral segment was pulled outward to see the sacral nerve, and the posterior tibial muscle was cut on the outside, and the muscle fiber attached to the tibia was about 10 mm thick to protect the iliac bone graft and periosteum from the axillary and vein. Support the annular artery. When the posterior tibial muscle is cut, the direction of the agitation and vein should be identified frequently to avoid accidental injury. After the posterior tibial muscle was dissected, the tibial flap was completely free except for the connection with the iliac crest and vein. 5. Stitching: After releasing the pneumatic tourniquet, the flap is gradually changed from pale to ruddy, the skin edge is active, the capillaries are well filled, and the blood and bone marrow cavity are continuously oozing out, suggesting that the bone flap blood supply good. After the operation of the affected area is completed, the proximal spurs and veins can be cut and ligated, and transferred to the receiving area. After the donor site completely stopped bleeding, the fascia, subcutaneous tissue and skin were sutured. Due to the removal of the tibia and part of the muscle, the incision can be directly sutured. If suturing is difficult, it can be transplanted with medium-thickness skin graft to cover the wound.

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