股前外侧皮瓣修复足跟大面积软组织缺损感觉重建的解剖学基础与临床研究
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摘要
足跟承担人体负重、行走和吸收震荡等重要功能，由于其解剖结构和生理功能的特殊，足跟部外伤后大面积软组织缺损是一种非常严重的损伤，治疗难度大，致残率高。随着显微外科技术的不断发展，多种带血管蒂皮辦和游离皮辦、肌皮辦相继应用于临床，足跟部软组织缺损的创面修复难题基本上得到了解决。然而，现有的皮辦缺乏必需的保护性感觉，不耐磨耐压，易引起磨破、烫伤、冻伤和继发溃疡等，且足底没有感觉冲动传入，不能与中枢建立协调反应，负重行走不稳，严重影响足跟的功能。因此，在行足跟部软组织缺损修复的同时，除充分考虑皮辦的血供、质地、厚度外，其感觉重建已受到临床医生的高度重视。
目前，修复足跟部软组织缺损的皮辦很多，各有其优缺点。局部带感觉皮辦切取面积较小，临床应用常常受到限制；带血管蒂小腿逆行岛状皮辦切取面积较大，可修复足跟中等面积软组织缺损，但感觉重建效果不佳，皮辦稳定性亦不满意，修复足跟大面积软组织缺损受到限制；背阔肌皮辦、胸脐皮辦和肩胛皮辦等游离组织辦移植可以修复各种范围的足跟软组织缺损，但此类皮辦最大的缺点是皮辦内没有特定的皮神经，术后皮辦感觉恢复差，且外形臃肿，有“面团感”，稳定性不好。股前外侧皮辦血运丰富、厚薄适中、切取面积大、供区隐蔽，且带有阔筋膜，修复足跟稳定性较好，特别是带有股外侧皮神经，可重建股前外侧皮辦的感觉，因此，被认为是目前修复足跟大面积软组织缺损的最佳皮辦。但是，缝合股外侧皮神经的股前外侧皮辦的感觉恢复亦不理想，到底是什么原因使其感觉恢复不良，如何解决其感觉重建，是目前临床棘手的问题。
本研究旨在从股前外侧皮辦移植修复足跟大面积软组织缺损感觉重建的角度，拟对支配股前外侧皮辦和足跟的皮神经(包括股外侧皮神经、跟内侧神经和跟外侧神经)进行解剖学研究，以了解其正常走行、分布及变异情况和不同平面的外径大小，并于股外侧皮神经、跟内侧神经和跟外侧神经的不同平面取样切片进行组织学观察，了解其截面形态特点、神经纤维束分布规律和神经纤维的数量，探讨影响股前外侧皮辦感觉恢复的形态学因素。然后，依据股外侧皮神经、跟内侧神经和跟外侧神经的解剖和形态学特点及修复足跟部位和范围的不同，改良股前外侧皮辦的设计与切取方法，选择最佳的皮神经、吻合部位和神经缝合方法，并对临床应用病例进行疗效分析，试图寻求解决吻合股外侧皮神经的股前外侧皮辦修复足跟大面积软组织缺损的感觉重建问题。
第一章股外侧皮神经的解剖学研究
目的了解股外侧皮神经在股前外侧区域的走行、分布、不同平面的外径大小及其形态和变异情况，以指导股前外侧皮辦移植时感觉功能的重建。
方法选择成人尸体12具21个下肢，解剖股外侧皮神经，观察其走行、分布、形态及变异情况；分别测量股外侧皮神经主干在腹股沟韧带下缘穿出点及其发出后支、前支平面至髂前上棘的距离、股外侧皮神经于阔筋膜穿出点至髂前上棘的距离、股外侧皮神经主干在腹股沟韧带下缘穿出点及其发出后支、前支后各平面的外径。
结果本组标本股外侧皮神经均自髂前上棘内侧0～5.1cm(平均2.71cm)腹股沟韧带下方穿出后向股前外侧下行，大多数(17／20)于髂前上棘下13.2～21.0cm(平均16.9cm)穿出阔筋膜走行于浅筋膜内；股外侧皮神经分别于髂前上棘下0～16.9 cm(平均4.8cm)和6.7～24.1cm(平均14.2cm)发出后支和前支，中间支为主支，其终支末梢分布于膝关节外上方皮肤。股外侧皮神经可见六种分支类型：普通三支型(9／21)、高位后支型(5／21)、后支缺如型(3／21)、前支缺如型(1／21)、纤细型(主干横径小于1.5mm，占2／21)和缺如型(1／21)。1侧后支缺如型的股前外侧上段皮肤感觉由股神经上部穿支支配，2侧纤细型和1侧缺如型，均由股神经上部发出粗大穿支支配股前外侧中下段皮肤。股外侧皮神经截面多呈扁圆形，其主干在腹股沟韧带下缘穿出点横径平均为2.68mm(1.18～4.52mm)，发出后支后平均为2.18mm(0.80～4.10mm)，发出前支后平均为1.63mm(0.44～2.60mm)。
结论股外侧皮神经解剖较为恒定，其主干及发出前支以近节段外径较为粗大，具备神经吻合的解剖学特点，适合于股前外侧皮辦移植时感觉功能的重建。
第二章跟内侧神经的解剖学研究
目的了解跟内侧神经的来源、发出部位、形态、走行、分布情况及其主干与分支的外径大小，为临床采用跟内侧神经作为受区皮神经重建足跟感觉提供解剖依据。
方法选择成人尸体足标本20个，解剖跟内侧神经，观察其发出部位、来源、形态、走行与分布情况，分别测量并记录跟内侧神经自胫神经发出部位及其属支分支处到内踝尖平面的距离，测量跟内侧神经主干及其主要分支的外径。
结果本组20侧标本中，跟内侧神经的出现率为95％(19／20)；3侧跟内侧神经自胫神经发出后走行于踝管表面，16侧走行于踝管内；跟内侧神经分别于内踝尖水平面上0～12cm(平均在内踝尖平面上3.3cm)自胫神经发出，分别于距内踝尖平面上2.9cm至内踝尖平面下2.3cm(平均在内踝尖平面下0.3cm)发出前支和后支；前支分支支配跟内侧和足跟负重区前部皮肤，后支分支支配跟内侧和足跟负重区中后部皮肤；跟内侧神经主干及其前支、后支形态多类似圆柱形，其主干起始部外径平均为1.58mm(0.78～2.70mm)，前支起始部外径平均为1.13mm(0.50～2.00mm)，后支起始部外径平均为0.90mm(0.30～1.88mm)。
结论跟内侧神经解剖较为恒定、有较粗的外径和较大的截面积、起始部离足跟负重区有一定距离，具备重建足跟特别是足跟负重区感觉所要求的皮神经解剖学特点。
第三章跟外侧神经的解剖学研究
目的了解跟外侧神经的来源、发出部位、形态、走行、分支与分布情况及其外径大小，为临床采用跟外侧神经作为受区皮神经重建足跟感觉提供解剖依据。
方法选择成人尸体标本20个下肢，解剖显露腓肠内侧皮神经与腓肠外侧皮神经的会合部位，直至各支跟外侧神经的终末支；观察各支跟外侧神经的来源、发出部位、形态、走行、分支与分布情况；测量各支跟外侧神经自腓肠神经主干发出平面至外踝尖水平面的垂直距离和各支跟外侧神经起始部的外径。
结果大部分腓肠内、外侧皮神经于外踝尖平面上8.9cm(2.4～21cm)会合成腓肠神经主干，于其后外侧部发出跟外侧神经1～3支；跟外侧神经第一支分别于外踝尖平面至外踝尖平面上7.2cm自腓肠神经主干或腓肠外侧皮神经发出，跟外侧神经第二支分别于外踝尖平面上2.5cm至外踝尖平面下1.7cm自腓肠神经发出，跟外侧神经第三支分别于外踝尖平面至外踝尖平面下1.8cm自腓肠神经发出；各支跟外侧神经发出后均垂直于足底平面向下走行，大多走行于小隐静脉属支表面；跟外侧神经第一支至足跟外侧又发出2～4支分支支配跟外侧皮肤，终支分布于足跟负重区外侧部皮肤；跟外侧神经及其分支多为类似圆柱形态；跟外侧神经第一支、第二支和第三支的外经分别平均为1.62mm、1.10mm和0.85mm；单支型、双支型和三支型中的跟外侧神经第一支外经分别平均为1.53mm、1.72mm和1.59mm。
结论跟外侧神经第一支解剖恒定，外径较为粗大，起始部离足跟外侧缘有一定距离，具备重建足跟特别是跟外侧区感觉所要求的皮神经解剖学特点。
第四章股外侧皮神经和跟内、外侧神经的截面观察与神经纤维计数
目的了解股外侧皮神经和跟内、外侧神经的截面形态、神经纤维束组数量、排列规律、神经纤维密度和神经纤维数量，为临床进行股前外侧皮辦移植修复足跟软组织缺损感觉重建时选择合适的皮神经、吻合部位和吻合方法提供解剖学依据。
方法选择7具成年男性尸体标本，分别于股外侧皮神经髂前上棘下5cm、跟内侧神经和跟外侧神经第一支主干起始段切取神经样本。经固定、梯度脱水、包埋、修块定位和半薄切片后，以甲苯胺蓝染色。以MOTICMED 6.0数码医学图像分析系统摄取图片；取放大40倍显微镜下图片观察神经截面形态、神经纤维束组数目和排列；取放大100倍、200倍或400倍显微镜下图片计数神经纤维和测定神经纤维密度。采用photoshop 7.0选区面积计算软件测量和计算神经纤维束组面积；应用photoshop网格功能测量和计算神经纤维密度。数据处理和统计分析软件采用SPSS11.0版统计软件包，采用完全随机设计多个样本比较的Kruskal-Wallis H检验，P＜0.05被判断为差异有统计学意义。
结果本组7例股外侧皮神经样本中5例为扁圆形，2例为椭圆形，神经纤维束多呈横形排列，外径大多粗细不等，神经束外、束间含有较多脂肪组织。7例跟内侧神经样本中6例为椭圆形，1例为扁圆形，跟内侧神经干内神经纤维含量相对丰富，脂肪组织含量较少，5例神经纤维束外径均匀。7例跟外侧神经第一支样本中亦有6例为椭圆形，神经纤维束在2束以上者呈三角形或多边形排列，5例神经束粗细不均，2例神经纤维束偏于一侧，神经干内有较多脂肪组织。测得股外侧皮神经、跟内侧神经和跟外侧神经第一支的神经束组中位数分别为4束、3束和4束，束组面积中位数分别为114.28um~2、126.92um~2、102.76 um~2，纤维密度中位数分别为11.43束／um~2、6.47束／um~2、10.08束／um~2，神经纤维束中位数分别为987束、862束、570束。经过统计学比较，尚不能说明股外侧皮神经、跟内侧神经和跟外侧神经第一支的神经纤维束组数、总面积、神经纤维密度与神经纤维计数差异有统计学意义。
结论跟内侧神经和跟外侧神经第一支具有与股外侧皮神经较为相似的截面形态特点，股前外侧皮辦移植修复足跟大面积软组织缺损时，适宜选择跟内侧神经或跟外侧神经第一支与股外侧皮神经吻合来重建皮辦感觉。
第五章股前外侧皮辦修复足跟大面积软组织缺损的感觉功能重建
目的探讨股前外侧皮辦移植修复足跟大面积软组织缺损新的感觉重建方法及其临床应用的初步效果。
方法本研究选择2004年10月至2006年9月采用股前外侧皮辦移植修复的足跟大面积软组织缺损病例进行回顾性分析。其中2004年10月至2005年9月连续收治的足跟大面积软组织缺损病例(视为对照组)，按传统的方法设计、切取股前外侧皮辦，将股外侧皮神经与隐神经、腓肠神经或胫神经缝合(端端或端侧吻合)重建皮辦感觉；2005年10月至2006年9月连续收治的足跟大面积软组织缺损病例(视为研究组)，依据本研究前期对股外侧皮神经、跟内侧神经和跟外侧神经的解剖和截面形态研究结果，设计、切取股前外侧皮辦和股外侧皮神经，依据修复部位的不同选择不同的皮神经，依据神经截面形态特点的不同选择不同的吻合部位和缝合方法。术后3个月、6个月、9个月和12个月随访，观察皮辦外形、血运、稳定性和行走能力，测试皮辦的痛觉、触觉、温度觉和两点辨别觉恢复情况。
结果对照组8例和研究组6例股前外侧皮辦全部成活，皮辦血运丰富，没有发生血管危象和感染，修复创面一期愈合，两组病例均恢复负重和行走能力。对照组8例随访6～18个月(平均9个月)，5例皮辦外形好，3例臃肿，皮辦感觉恢复优良率为25％，其中1例因为没有恢复保护性感觉，冬天烤火发生过2次烧伤，2例发生过表浅溃疡。研究组6例随访3～12个月(平均6个月)，5例外形好，1例较为臃肿，皮辦感觉恢复优良率为66.7％，无一例发生溃疡。
结论股前外侧皮辦修复足跟大面积软组织缺损感觉重建时，注意股外侧皮神经的分布及变异情况、选择合适的受区皮神经和吻合部位、依据两侧神经截面的形态特点选择合适的神经缝合方法可以明显改善股前外侧皮辦的感觉功能恢复。
The heel of human body plays an important role in weight loading, ambulation and absorption of vibration. Because of heel's special anatomic structure and physiological function, traumatic soft tissue defects in heel are often repaired by cutaneous flaps. In early days, the survival rates have been paid more attention in the studies of cutaneous flaps transplantation, and we always emphasis on the blood circulation of flaps. With the development of microsurgical technique, the problem of repairing the wound in heel was solved on the whole result from many kinds of island skin flaps with distally-based vessel pedicle and free skin flaps, myocutaneous flaps have been used in repairing clinical cases one by one and the survival rates of flaps have been increased step by step, but the heel repaired without sensory flaps gave rise to many problems, it is likely to be rough and weather-shack, can not resist wearing and withstanding pressure, the worst is it raise the possibility of being worn out, scalded, cold injuried and chronic ulceration, moreover, there is no sensory impulse introduced into the footplate, it can not build up concerted reaction with center, lead to unsteady walking under weight loading, the function of foot can not bring into full play. For this reason, in the case of repairing traumatic soft tissue defects of heel, more and more clinicians think highly of its sensation reconstruction as well as its blood supply, texture and thickness.
Widespread soft tissue defect in heel is a severe injury, it's difficult to cure, lead to high disability frequency if couldn't received rational treatment. The fasiocutaneous flaps nearby are too small to meet requirements. The island flaps of calf with distally-based vessel pedicle can be used to repairing moderate area wounds in heel, but are limited to be used in repairing large area soft tissue defects in heel and the sensory restoration and stability of the flaps are not satisfied. Free flaps or myocutaneous flaps such as latissimus dorsi muscle-skin flap, thoracic umbilical flap and scapular flap can be used to repair all sorts of wounds in heel because of their large dermatomic area, but the greatest disadvantage is there is no specified cutaneous nerve to dominate the flap, sensation always is very poor, and it always appear to be very fat and clumsy, and the flap's doughy sensation lead to poor stability. The anterolateral thigh flap (ALTF) is considered as an ideal free flap for repairing large area soft tissue defects in heel at present, because it has so many advantages such as abundant blood supply, fitting thickness, wide flap territory, covert supply-area, especially of it's lateral femoral cutaneous nerve(LFCN) can be used for sensory reconstruction, and with femoral fascia together can keep the heel's stability. However, whether it's necessary to coapate cutaneous nerve for the sensory recovery is always in debate in home and abroad at present because the sensory recovery of ALTF don't meet the goal though we have coapated LFCN. So, it is necessary to approach the reasons for unsatisfactory sensory restoration of the ALTF even we have coapated its cutaneous nerve, and to improve the modus operandi so as to obtain better postoperative results. In abstract, after coapating the cutaneous nerves, the sensory restoration may come true if nerves can regenerate and pass through the stoma and grow along built-in tubes of endoneural membrane to arrive the neurocutaneou's ends. but there is no neurocutaneous morphology research aim directly at sensation reconstruction of skin flap. What on earth lead to poor sensory recovery of flap? And how to improve the flap's function? All these clinical problems are necessary to resolve as soon as possible.
This anatomic research analyze the dissection of cutaneous nerves including the LFCN, the medial calcaneal nerve(MCN) and the lateral calcaneal nerve(LCN) that dominate the ALTF and heel from the view of sensory reconstruction of ALTFs transplanted for repairing widespread soft tissue defects in heel, to get the message of their number, distribution, variation, and the extemal diameters of different plane, observe the histology of the LFCN, the MCN and the LCN's slices of different planes, get the message of their characteristics of sectional morphous, regularity of nerve fiber bundles and the quantity of nerve fiber. To approach the morphologic facts that influence the sensory recovery of the ALTF, and based on the anatomic and histological characteristics of the LFCN, the MCN and the LCN's dissection and sectional morphology, to improve the method of the ALTF's design, choose suitable cutaneous nerve and rational anastomosis position according to the recipient site and its scope, select suitable suturation means according to the morphological characteristics of nerval section, combined with curative effect's analysis of clinical cases to try to fred a new method to rebuild the sensation of ALTF.
ChapterⅠAn Anatomic Study of the LFCN
Objective To guide sensory reconstruction of ALTF by approaching extemal diameters of the LFCN at different plane and its shape,distribution and variation in the area of anterolateral thigh.
Methods Choose 12 adult cadaver specimens with 21 lower limbs, dissect LFCN to observe its distribution, course and variation. Measure the position where the bole of LFCN appear below the inguinal ligament(IL), the distance between the plane where the bole sent out the posterior branch and the anterior branch and the anterior superior iliac spine(ASIS), and the distance between the position where the LFCN appear from the IL and the ASIS, and the external diameter of the bole of LFCN on the planes of just below the IL and after the bole send out posterior branch and anterior branch.
Results The LFCN passes through under the IL and descends along a line between the ASIS and the lateral border of the patella and sents out the posterior branch 0～16.9 cm (4.8cm on average) below the ASIS and the anterior branch 6.7～24.1cm (14.2cm on average) below the ASIS. The medial and anterior segments descended subcutaneously to the knee. The LFCN was divided into six patterns on the ground of their branches: typeⅠ: common with three branches (9/21), typeⅡ: posterior branches at high position (5/21 ), typeⅢ: posterior branches absent (3/21), typeⅣ: anterior branches absent (1/21), typeⅤ: the diameter of the LFCN is thinner than 1.5mm (2/21), typeⅥ: the LFCN absent (1/21).In one case of posterior branches absent type, the cutaneous sensation of the superior segment of lateral femoral field is dominated by the perforating branches sent out from the superior part of femoral nerve,while in 2 typeⅤcases and 1 type of the LFCN absent, the cutaneous sensation of the midst and inferior segment of lateral femoral field is dominated by the gross perforating branches sent out from the superior part of femoral nerve. The shape of the majority of LFCNs and its anterior and posterior branches are oblate,The diameter of the bole of LFCN at the position where it appears from below the IL is 1.18～4.52mm (2.68mm on average), its diameter after send out the posterior branch is 0.80～4.10mm (2.18mm on average) and after send out the anterior branch it turns to be 0.44～2.60mm (1.63mm on average)
Conclusion The LFCN is an ideal cutaneous nerve to rebuild the ALTF's sensory function because its anatomical position is relatively constant, its external diameter is big and the diameter of the bole of LFCN at the position where it appears from below the IL to the position where the anterior branch appears is so gross that it's anatomic characteristic is very suitable for nerves suturing.
ChapterⅡAn Anatomic Study of the MCN
Objective To approach the origin, position where it is sending out, course and distribution of the MCN and the external diameter of its bole and branches, investigate the possibility of using the MCN for rebuilding sensation as the recipient site's cutaneous nerve in heel.
Methods Choose 20 adult cadavers' lower limbs, dissect the MCNs and their branches, observe their shapes, courses and their distribution, measure the position where it is sending out, the perpendicular distance from the branching location to the tip of medial malleolus and the external diameters of its bole and branches.
Results The frequency of the MCN is 95% (19/20) in this array. Among of them, all the MCN arise from the tibial nerve at 3.3 cm (0～12cm) up the horizontal plane of the tip of medial malleolus, three MCNs go along on the surface of malleolus canal after sending out from the tibial nerves, they send out anterior branches and posterior branches from 2.9cm above the horizontal plane of the tip of medial malleolus to 2.3cm below the horizontal plane(0.3cm below the horizontal plane on average). The anterior branch dominates the cutaneous sensation of the anterior part of the medial calcaneal and calcar pedis' weight loading field, while the posterior branch dominates the cutaneous sensation of the post median part. The shapes of the majority of MCNs and their anterior branches and posterior branches are like circular cylinder, the external diameter of the MCN's initiation is 0.78～2.70mm (1.58mm on average), that of the anterior branch's initiation is 0.50～2.00mm (1.13 mm on average ), that of the posterior branch's initiation is 0.30～1.88mm (0.90 mm on average)
Conclusion The MCN is an ideal cutaneous nerve for sensory reconstruction in heel, especially in its weight loading area because its anatomical position is relatively constant, and its external diameter and section area are suitable, besides these, the initiation of it is not close to the heels' weight loading area.
ChapterⅢAn Anatomic Study of the LCN
Objective To approach the origin, position where it is sending out, course and distribution of the LCN and the external diameters of its trunk and branches, and investigate the possibility of using the LCN for rebuilding sensation as the recipient site's cutaneous nerve in the lateral calcaneal area.
Methods Choose 20 adult cadavers' lower limbs, dissect them and reveal the position where the medial sural cutaneous nerve and the lateral sural cutaneous nerve converge and the tip of lateral malleolus, observe the origin, position where it is sending out, course and distribution of the LCN and the external diameters of its bole and branches, set the horizon through the tip of lateral malleolus as the location sign, measure and record the perpendicular distance from the planes where each LCN to the tip of lateral malleolus'transverse plane and every LCN's external diameters.
Results Majority of medial sural cutaneous nerves and lateral sural cutaneous nerves converge 8.9cm average (2.4～21cm) above the plane of the tip of lateral malleolus to be sural nerve, then it sends out 1～3 LCNs from its lateral part, the first lateral calcaneal nerve(LCN1) sent out from sural nerve or lateral sural cutaneous nerve from the plane of the tip of lateral malleolus to 7.2cm above, the second lateral calcaneal nerve(LCN 2) sent out from sural nerve from 2.5cm above the plane of tip of lateral malleolus to 1.7cm below, the third lateral calcaneal nerve(LCN3) sent out from sural nerve from the plane of the tip of lateral malleolus to 1.8cm below, the shapes of them are almost like circular cylinder. All LCN proceed downward vertical from the trunk of sural nerve, the endings are distributed in the lateral calcaneal area.When near the lateral calcaneal, the LCN1 sents out 2～4 branches to dominate cutaneous sensation of the lateral calcaneal area, the ending is distributed over the lateral part of the lateral calcaneal's weight loading field. The shape of them are almost circular cylinder.The external diameter of the three branches is 1.62mm, 1.10mm and 0.85mm respectively, and the external diameter of the LCN1 in the three types is 1.53mm, 1.72mm and 1.59mm respectively.
Conclusion The LCN1 is an ideal cutaneous nerve for sensory reconstruction in heel, especially in its lateral calcaneal area because its anatomical position is fairly constant, its external diameter is gross, and the initiation is not close to the lateral calcaneal area.
ChapterⅣThe Histomorphological Study of the LFCN, the MCN and the LCN:Observation of Sectional Morphous and Measurement of Nerve Fibre Number
Objective Observe the sectional morphous of the LFCN, the MCN and the LCN, the quantity and distribution of their nerve fiber bundles, quantity and density of their nerve fibers. To provide the anatomic proof for selecting suitable cutaneous nerves, anastomotic position and means of suture to reconstruct the sensation of the ALTF used to repair extensive soft tissue defects in heel.
Methods Choose 7 adult male corpses, take the nerval samples respectively from the LFCN 5cm below the ASIS and the initial segment of the MCN and the LCN1, fixed, dewatered gradiently, embedded, located, and made them into semithin sections, dyed with toluidine blue. Observe the nerves's sectional morphous, the quantity and distribution of their nerve fiber bundles under 40 times amplified, count the quantity of nerve fibers and determine the density of them by amplified 100 times, 200 times and 400 times. The pictures were taken by a medicine figure imaging analysis system named MOTICMED 6.0. Use photoshop 7.0 version precinct software for measuring and calculating the area of the nerve fiber bundles and the photoshop grid function was used to measure the density of the nerve fibers. Data analysis was performed by using Kruskal-Wallis H test, of which several specimens designed completely random. A P value of <0.05 was considered statistically significant.
Results In our cross-section study, among of 7 LFCN samples, 5 were oblate, 2 were ellipse, the majority of nerve bunches lined up transversally and had imcompatible diameters, in addition, there were much adipose tissue lying in and out the nerve fiber bunches. On the contrary, among of 7 MCN samples, only one was oblate, 6 were ellipse, the majority of nerve bunches had similar diameter and disposed concentratedly, there were little adipose tissue while abundant nerve fiber tissue in the trunk of MCN. The majority of LCN (6/7) were ellipse, the majority of nerve bunches (5/7)had imcompatible diameters and disposed with triangle or polygon in those specimens with over two nerve bunches, nerve bunches located at one side of the bole and there were much adipose tissue lying out the nerve fiber bunches in two samples. As to LFCN, MCN and LCN1, the median number of nerve bunches was 4, 3 and 4, respectively. The median number of nerve fibers' area was 114.8 um~2, 126.92um~2 and 102.76 um~2, respectively. The median number of nerve fibers' density was 11.43/ um~2, 6.47/ um~2 and 10.08/ um~2, respectively. The median number of nerve fibers was 987, 862 and 570, respectively.In the arrays, the difference of number, density and area of these nerve fibers in this three cutaneous nerves was considered statistically insignificant.
Conclusion The MCN and the LCN1 are ideal cutaneous nerves to suture with LFCN in the ALTF used to repair widespread soft tissue defects in heel because they have similar histomorphological characteristics with the LFCN.
ChapterⅤInnervation of Free ALTFs for Repairing
Widespreadly Traumatic Soft Tissue Defects in Heel
Objective To explore a new method of innervating ALTFs for repairing widespreadly traumatic soft tissue defects in heel and analyze its initial results of clinical application.
Methods The clinical cases were divided into 2 groups. In control group, eight consecutive ALTFs were transplanted in 8 patients for repairing widespreadly traumatic soft tissue defects in heel from October 2004 to September 2005 in our department, the sensory reconstruction of ALTFs based on traditional method: selecting sural nerve, saphenous nerve or tibial nerve as innervate nerve in the recipient site and simple suturing their nerve membrane in end to end or end to side. In research group, six consecutive ALTFs were transplanted in 6 patients for repairing widespreadly traumatic soft tissue defects in heel from October 2005 to September 2006, the sensory reconstruction of ALTFs included such as design and section of the LFCN, select the cutaneous nerves in recipient sites and anastomotic position as well as suture means based on the research of the anatomic and histomorphological characteristics of LFCN, MCN and LCN. The patients were evaluated at 3, 6, 9 and 12 months on the postoperative follow-up parameters including flap contour, flap stability, locomotor activity, touch sensation, pain sensation, static two-point discrimination, and thermal sensibility.
Results All the free flaps survived in both groups. The flaps have good blood supply, no vassular articulo and infection, all the wounds are primary intention healing. All the 8 cases in the control group follow up 6～18 months (9 months on average), 5 have good shape, 3 are fat and clumsy, the rate of good sensory recovery is 25%, one of which have been burned 2 times owing to poor sensory recovery, another 2 had light ulceration. All the 6 cases in the research group follow up 3～12 months (6 months on average), 5 have good shape, 1 was fat and clumsy, the rate of good sensory recovery is 66.7%, no ulceration happened.
Conclusion When repairing widespread sofl tissue defects in heel, satisfactory sensory function restoration can be obtained by paying attention to the distribution and variety of ALTFs, selecting suitable cutaneous nerves and rational coaptated position as well as suitable suturation means which based on the anatomic and histomorphological characteristics of the LFCN, the MCN and the LCN.
目前，修复足跟部软组织缺损的皮辦很多，各有其优缺点。局部带感觉皮辦切取面积较小，临床应用常常受到限制；带血管蒂小腿逆行岛状皮辦切取面积较大，可修复足跟中等面积软组织缺损，但感觉重建效果不佳，皮辦稳定性亦不满意，修复足跟大面积软组织缺损受到限制；背阔肌皮辦、胸脐皮辦和肩胛皮辦等游离组织辦移植可以修复各种范围的足跟软组织缺损，但此类皮辦最大的缺点是皮辦内没有特定的皮神经，术后皮辦感觉恢复差，且外形臃肿，有“面团感”，稳定性不好。股前外侧皮辦血运丰富、厚薄适中、切取面积大、供区隐蔽，且带有阔筋膜，修复足跟稳定性较好，特别是带有股外侧皮神经，可重建股前外侧皮辦的感觉，因此，被认为是目前修复足跟大面积软组织缺损的最佳皮辦。但是，缝合股外侧皮神经的股前外侧皮辦的感觉恢复亦不理想，到底是什么原因使其感觉恢复不良，如何解决其感觉重建，是目前临床棘手的问题。
本研究旨在从股前外侧皮辦移植修复足跟大面积软组织缺损感觉重建的角度，拟对支配股前外侧皮辦和足跟的皮神经(包括股外侧皮神经、跟内侧神经和跟外侧神经)进行解剖学研究，以了解其正常走行、分布及变异情况和不同平面的外径大小，并于股外侧皮神经、跟内侧神经和跟外侧神经的不同平面取样切片进行组织学观察，了解其截面形态特点、神经纤维束分布规律和神经纤维的数量，探讨影响股前外侧皮辦感觉恢复的形态学因素。然后，依据股外侧皮神经、跟内侧神经和跟外侧神经的解剖和形态学特点及修复足跟部位和范围的不同，改良股前外侧皮辦的设计与切取方法，选择最佳的皮神经、吻合部位和神经缝合方法，并对临床应用病例进行疗效分析，试图寻求解决吻合股外侧皮神经的股前外侧皮辦修复足跟大面积软组织缺损的感觉重建问题。
第一章股外侧皮神经的解剖学研究
目的了解股外侧皮神经在股前外侧区域的走行、分布、不同平面的外径大小及其形态和变异情况，以指导股前外侧皮辦移植时感觉功能的重建。
方法选择成人尸体12具21个下肢，解剖股外侧皮神经，观察其走行、分布、形态及变异情况；分别测量股外侧皮神经主干在腹股沟韧带下缘穿出点及其发出后支、前支平面至髂前上棘的距离、股外侧皮神经于阔筋膜穿出点至髂前上棘的距离、股外侧皮神经主干在腹股沟韧带下缘穿出点及其发出后支、前支后各平面的外径。
结果本组标本股外侧皮神经均自髂前上棘内侧0～5.1cm(平均2.71cm)腹股沟韧带下方穿出后向股前外侧下行，大多数(17／20)于髂前上棘下13.2～21.0cm(平均16.9cm)穿出阔筋膜走行于浅筋膜内；股外侧皮神经分别于髂前上棘下0～16.9 cm(平均4.8cm)和6.7～24.1cm(平均14.2cm)发出后支和前支，中间支为主支，其终支末梢分布于膝关节外上方皮肤。股外侧皮神经可见六种分支类型：普通三支型(9／21)、高位后支型(5／21)、后支缺如型(3／21)、前支缺如型(1／21)、纤细型(主干横径小于1.5mm，占2／21)和缺如型(1／21)。1侧后支缺如型的股前外侧上段皮肤感觉由股神经上部穿支支配，2侧纤细型和1侧缺如型，均由股神经上部发出粗大穿支支配股前外侧中下段皮肤。股外侧皮神经截面多呈扁圆形，其主干在腹股沟韧带下缘穿出点横径平均为2.68mm(1.18～4.52mm)，发出后支后平均为2.18mm(0.80～4.10mm)，发出前支后平均为1.63mm(0.44～2.60mm)。
结论股外侧皮神经解剖较为恒定，其主干及发出前支以近节段外径较为粗大，具备神经吻合的解剖学特点，适合于股前外侧皮辦移植时感觉功能的重建。
第二章跟内侧神经的解剖学研究
目的了解跟内侧神经的来源、发出部位、形态、走行、分布情况及其主干与分支的外径大小，为临床采用跟内侧神经作为受区皮神经重建足跟感觉提供解剖依据。
方法选择成人尸体足标本20个，解剖跟内侧神经，观察其发出部位、来源、形态、走行与分布情况，分别测量并记录跟内侧神经自胫神经发出部位及其属支分支处到内踝尖平面的距离，测量跟内侧神经主干及其主要分支的外径。
结果本组20侧标本中，跟内侧神经的出现率为95％(19／20)；3侧跟内侧神经自胫神经发出后走行于踝管表面，16侧走行于踝管内；跟内侧神经分别于内踝尖水平面上0～12cm(平均在内踝尖平面上3.3cm)自胫神经发出，分别于距内踝尖平面上2.9cm至内踝尖平面下2.3cm(平均在内踝尖平面下0.3cm)发出前支和后支；前支分支支配跟内侧和足跟负重区前部皮肤，后支分支支配跟内侧和足跟负重区中后部皮肤；跟内侧神经主干及其前支、后支形态多类似圆柱形，其主干起始部外径平均为1.58mm(0.78～2.70mm)，前支起始部外径平均为1.13mm(0.50～2.00mm)，后支起始部外径平均为0.90mm(0.30～1.88mm)。
结论跟内侧神经解剖较为恒定、有较粗的外径和较大的截面积、起始部离足跟负重区有一定距离，具备重建足跟特别是足跟负重区感觉所要求的皮神经解剖学特点。
第三章跟外侧神经的解剖学研究
目的了解跟外侧神经的来源、发出部位、形态、走行、分支与分布情况及其外径大小，为临床采用跟外侧神经作为受区皮神经重建足跟感觉提供解剖依据。
方法选择成人尸体标本20个下肢，解剖显露腓肠内侧皮神经与腓肠外侧皮神经的会合部位，直至各支跟外侧神经的终末支；观察各支跟外侧神经的来源、发出部位、形态、走行、分支与分布情况；测量各支跟外侧神经自腓肠神经主干发出平面至外踝尖水平面的垂直距离和各支跟外侧神经起始部的外径。
结果大部分腓肠内、外侧皮神经于外踝尖平面上8.9cm(2.4～21cm)会合成腓肠神经主干，于其后外侧部发出跟外侧神经1～3支；跟外侧神经第一支分别于外踝尖平面至外踝尖平面上7.2cm自腓肠神经主干或腓肠外侧皮神经发出，跟外侧神经第二支分别于外踝尖平面上2.5cm至外踝尖平面下1.7cm自腓肠神经发出，跟外侧神经第三支分别于外踝尖平面至外踝尖平面下1.8cm自腓肠神经发出；各支跟外侧神经发出后均垂直于足底平面向下走行，大多走行于小隐静脉属支表面；跟外侧神经第一支至足跟外侧又发出2～4支分支支配跟外侧皮肤，终支分布于足跟负重区外侧部皮肤；跟外侧神经及其分支多为类似圆柱形态；跟外侧神经第一支、第二支和第三支的外经分别平均为1.62mm、1.10mm和0.85mm；单支型、双支型和三支型中的跟外侧神经第一支外经分别平均为1.53mm、1.72mm和1.59mm。
结论跟外侧神经第一支解剖恒定，外径较为粗大，起始部离足跟外侧缘有一定距离，具备重建足跟特别是跟外侧区感觉所要求的皮神经解剖学特点。
第四章股外侧皮神经和跟内、外侧神经的截面观察与神经纤维计数
目的了解股外侧皮神经和跟内、外侧神经的截面形态、神经纤维束组数量、排列规律、神经纤维密度和神经纤维数量，为临床进行股前外侧皮辦移植修复足跟软组织缺损感觉重建时选择合适的皮神经、吻合部位和吻合方法提供解剖学依据。
方法选择7具成年男性尸体标本，分别于股外侧皮神经髂前上棘下5cm、跟内侧神经和跟外侧神经第一支主干起始段切取神经样本。经固定、梯度脱水、包埋、修块定位和半薄切片后，以甲苯胺蓝染色。以MOTICMED 6.0数码医学图像分析系统摄取图片；取放大40倍显微镜下图片观察神经截面形态、神经纤维束组数目和排列；取放大100倍、200倍或400倍显微镜下图片计数神经纤维和测定神经纤维密度。采用photoshop 7.0选区面积计算软件测量和计算神经纤维束组面积；应用photoshop网格功能测量和计算神经纤维密度。数据处理和统计分析软件采用SPSS11.0版统计软件包，采用完全随机设计多个样本比较的Kruskal-Wallis H检验，P＜0.05被判断为差异有统计学意义。
结果本组7例股外侧皮神经样本中5例为扁圆形，2例为椭圆形，神经纤维束多呈横形排列，外径大多粗细不等，神经束外、束间含有较多脂肪组织。7例跟内侧神经样本中6例为椭圆形，1例为扁圆形，跟内侧神经干内神经纤维含量相对丰富，脂肪组织含量较少，5例神经纤维束外径均匀。7例跟外侧神经第一支样本中亦有6例为椭圆形，神经纤维束在2束以上者呈三角形或多边形排列，5例神经束粗细不均，2例神经纤维束偏于一侧，神经干内有较多脂肪组织。测得股外侧皮神经、跟内侧神经和跟外侧神经第一支的神经束组中位数分别为4束、3束和4束，束组面积中位数分别为114.28um~2、126.92um~2、102.76 um~2，纤维密度中位数分别为11.43束／um~2、6.47束／um~2、10.08束／um~2，神经纤维束中位数分别为987束、862束、570束。经过统计学比较，尚不能说明股外侧皮神经、跟内侧神经和跟外侧神经第一支的神经纤维束组数、总面积、神经纤维密度与神经纤维计数差异有统计学意义。
结论跟内侧神经和跟外侧神经第一支具有与股外侧皮神经较为相似的截面形态特点，股前外侧皮辦移植修复足跟大面积软组织缺损时，适宜选择跟内侧神经或跟外侧神经第一支与股外侧皮神经吻合来重建皮辦感觉。
第五章股前外侧皮辦修复足跟大面积软组织缺损的感觉功能重建
目的探讨股前外侧皮辦移植修复足跟大面积软组织缺损新的感觉重建方法及其临床应用的初步效果。
方法本研究选择2004年10月至2006年9月采用股前外侧皮辦移植修复的足跟大面积软组织缺损病例进行回顾性分析。其中2004年10月至2005年9月连续收治的足跟大面积软组织缺损病例(视为对照组)，按传统的方法设计、切取股前外侧皮辦，将股外侧皮神经与隐神经、腓肠神经或胫神经缝合(端端或端侧吻合)重建皮辦感觉；2005年10月至2006年9月连续收治的足跟大面积软组织缺损病例(视为研究组)，依据本研究前期对股外侧皮神经、跟内侧神经和跟外侧神经的解剖和截面形态研究结果，设计、切取股前外侧皮辦和股外侧皮神经，依据修复部位的不同选择不同的皮神经，依据神经截面形态特点的不同选择不同的吻合部位和缝合方法。术后3个月、6个月、9个月和12个月随访，观察皮辦外形、血运、稳定性和行走能力，测试皮辦的痛觉、触觉、温度觉和两点辨别觉恢复情况。
结果对照组8例和研究组6例股前外侧皮辦全部成活，皮辦血运丰富，没有发生血管危象和感染，修复创面一期愈合，两组病例均恢复负重和行走能力。对照组8例随访6～18个月(平均9个月)，5例皮辦外形好，3例臃肿，皮辦感觉恢复优良率为25％，其中1例因为没有恢复保护性感觉，冬天烤火发生过2次烧伤，2例发生过表浅溃疡。研究组6例随访3～12个月(平均6个月)，5例外形好，1例较为臃肿，皮辦感觉恢复优良率为66.7％，无一例发生溃疡。
结论股前外侧皮辦修复足跟大面积软组织缺损感觉重建时，注意股外侧皮神经的分布及变异情况、选择合适的受区皮神经和吻合部位、依据两侧神经截面的形态特点选择合适的神经缝合方法可以明显改善股前外侧皮辦的感觉功能恢复。
The heel of human body plays an important role in weight loading, ambulation and absorption of vibration. Because of heel's special anatomic structure and physiological function, traumatic soft tissue defects in heel are often repaired by cutaneous flaps. In early days, the survival rates have been paid more attention in the studies of cutaneous flaps transplantation, and we always emphasis on the blood circulation of flaps. With the development of microsurgical technique, the problem of repairing the wound in heel was solved on the whole result from many kinds of island skin flaps with distally-based vessel pedicle and free skin flaps, myocutaneous flaps have been used in repairing clinical cases one by one and the survival rates of flaps have been increased step by step, but the heel repaired without sensory flaps gave rise to many problems, it is likely to be rough and weather-shack, can not resist wearing and withstanding pressure, the worst is it raise the possibility of being worn out, scalded, cold injuried and chronic ulceration, moreover, there is no sensory impulse introduced into the footplate, it can not build up concerted reaction with center, lead to unsteady walking under weight loading, the function of foot can not bring into full play. For this reason, in the case of repairing traumatic soft tissue defects of heel, more and more clinicians think highly of its sensation reconstruction as well as its blood supply, texture and thickness.
Widespread soft tissue defect in heel is a severe injury, it's difficult to cure, lead to high disability frequency if couldn't received rational treatment. The fasiocutaneous flaps nearby are too small to meet requirements. The island flaps of calf with distally-based vessel pedicle can be used to repairing moderate area wounds in heel, but are limited to be used in repairing large area soft tissue defects in heel and the sensory restoration and stability of the flaps are not satisfied. Free flaps or myocutaneous flaps such as latissimus dorsi muscle-skin flap, thoracic umbilical flap and scapular flap can be used to repair all sorts of wounds in heel because of their large dermatomic area, but the greatest disadvantage is there is no specified cutaneous nerve to dominate the flap, sensation always is very poor, and it always appear to be very fat and clumsy, and the flap's doughy sensation lead to poor stability. The anterolateral thigh flap (ALTF) is considered as an ideal free flap for repairing large area soft tissue defects in heel at present, because it has so many advantages such as abundant blood supply, fitting thickness, wide flap territory, covert supply-area, especially of it's lateral femoral cutaneous nerve(LFCN) can be used for sensory reconstruction, and with femoral fascia together can keep the heel's stability. However, whether it's necessary to coapate cutaneous nerve for the sensory recovery is always in debate in home and abroad at present because the sensory recovery of ALTF don't meet the goal though we have coapated LFCN. So, it is necessary to approach the reasons for unsatisfactory sensory restoration of the ALTF even we have coapated its cutaneous nerve, and to improve the modus operandi so as to obtain better postoperative results. In abstract, after coapating the cutaneous nerves, the sensory restoration may come true if nerves can regenerate and pass through the stoma and grow along built-in tubes of endoneural membrane to arrive the neurocutaneou's ends. but there is no neurocutaneous morphology research aim directly at sensation reconstruction of skin flap. What on earth lead to poor sensory recovery of flap? And how to improve the flap's function? All these clinical problems are necessary to resolve as soon as possible.
This anatomic research analyze the dissection of cutaneous nerves including the LFCN, the medial calcaneal nerve(MCN) and the lateral calcaneal nerve(LCN) that dominate the ALTF and heel from the view of sensory reconstruction of ALTFs transplanted for repairing widespread soft tissue defects in heel, to get the message of their number, distribution, variation, and the extemal diameters of different plane, observe the histology of the LFCN, the MCN and the LCN's slices of different planes, get the message of their characteristics of sectional morphous, regularity of nerve fiber bundles and the quantity of nerve fiber. To approach the morphologic facts that influence the sensory recovery of the ALTF, and based on the anatomic and histological characteristics of the LFCN, the MCN and the LCN's dissection and sectional morphology, to improve the method of the ALTF's design, choose suitable cutaneous nerve and rational anastomosis position according to the recipient site and its scope, select suitable suturation means according to the morphological characteristics of nerval section, combined with curative effect's analysis of clinical cases to try to fred a new method to rebuild the sensation of ALTF.
ChapterⅠAn Anatomic Study of the LFCN
Objective To guide sensory reconstruction of ALTF by approaching extemal diameters of the LFCN at different plane and its shape,distribution and variation in the area of anterolateral thigh.
Methods Choose 12 adult cadaver specimens with 21 lower limbs, dissect LFCN to observe its distribution, course and variation. Measure the position where the bole of LFCN appear below the inguinal ligament(IL), the distance between the plane where the bole sent out the posterior branch and the anterior branch and the anterior superior iliac spine(ASIS), and the distance between the position where the LFCN appear from the IL and the ASIS, and the external diameter of the bole of LFCN on the planes of just below the IL and after the bole send out posterior branch and anterior branch.
Results The LFCN passes through under the IL and descends along a line between the ASIS and the lateral border of the patella and sents out the posterior branch 0～16.9 cm (4.8cm on average) below the ASIS and the anterior branch 6.7～24.1cm (14.2cm on average) below the ASIS. The medial and anterior segments descended subcutaneously to the knee. The LFCN was divided into six patterns on the ground of their branches: typeⅠ: common with three branches (9/21), typeⅡ: posterior branches at high position (5/21 ), typeⅢ: posterior branches absent (3/21), typeⅣ: anterior branches absent (1/21), typeⅤ: the diameter of the LFCN is thinner than 1.5mm (2/21), typeⅥ: the LFCN absent (1/21).In one case of posterior branches absent type, the cutaneous sensation of the superior segment of lateral femoral field is dominated by the perforating branches sent out from the superior part of femoral nerve,while in 2 typeⅤcases and 1 type of the LFCN absent, the cutaneous sensation of the midst and inferior segment of lateral femoral field is dominated by the gross perforating branches sent out from the superior part of femoral nerve. The shape of the majority of LFCNs and its anterior and posterior branches are oblate,The diameter of the bole of LFCN at the position where it appears from below the IL is 1.18～4.52mm (2.68mm on average), its diameter after send out the posterior branch is 0.80～4.10mm (2.18mm on average) and after send out the anterior branch it turns to be 0.44～2.60mm (1.63mm on average)
Conclusion The LFCN is an ideal cutaneous nerve to rebuild the ALTF's sensory function because its anatomical position is relatively constant, its external diameter is big and the diameter of the bole of LFCN at the position where it appears from below the IL to the position where the anterior branch appears is so gross that it's anatomic characteristic is very suitable for nerves suturing.
ChapterⅡAn Anatomic Study of the MCN
Objective To approach the origin, position where it is sending out, course and distribution of the MCN and the external diameter of its bole and branches, investigate the possibility of using the MCN for rebuilding sensation as the recipient site's cutaneous nerve in heel.
Methods Choose 20 adult cadavers' lower limbs, dissect the MCNs and their branches, observe their shapes, courses and their distribution, measure the position where it is sending out, the perpendicular distance from the branching location to the tip of medial malleolus and the external diameters of its bole and branches.
Results The frequency of the MCN is 95% (19/20) in this array. Among of them, all the MCN arise from the tibial nerve at 3.3 cm (0～12cm) up the horizontal plane of the tip of medial malleolus, three MCNs go along on the surface of malleolus canal after sending out from the tibial nerves, they send out anterior branches and posterior branches from 2.9cm above the horizontal plane of the tip of medial malleolus to 2.3cm below the horizontal plane(0.3cm below the horizontal plane on average). The anterior branch dominates the cutaneous sensation of the anterior part of the medial calcaneal and calcar pedis' weight loading field, while the posterior branch dominates the cutaneous sensation of the post median part. The shapes of the majority of MCNs and their anterior branches and posterior branches are like circular cylinder, the external diameter of the MCN's initiation is 0.78～2.70mm (1.58mm on average), that of the anterior branch's initiation is 0.50～2.00mm (1.13 mm on average ), that of the posterior branch's initiation is 0.30～1.88mm (0.90 mm on average)
Conclusion The MCN is an ideal cutaneous nerve for sensory reconstruction in heel, especially in its weight loading area because its anatomical position is relatively constant, and its external diameter and section area are suitable, besides these, the initiation of it is not close to the heels' weight loading area.
ChapterⅢAn Anatomic Study of the LCN
Objective To approach the origin, position where it is sending out, course and distribution of the LCN and the external diameters of its trunk and branches, and investigate the possibility of using the LCN for rebuilding sensation as the recipient site's cutaneous nerve in the lateral calcaneal area.
Methods Choose 20 adult cadavers' lower limbs, dissect them and reveal the position where the medial sural cutaneous nerve and the lateral sural cutaneous nerve converge and the tip of lateral malleolus, observe the origin, position where it is sending out, course and distribution of the LCN and the external diameters of its bole and branches, set the horizon through the tip of lateral malleolus as the location sign, measure and record the perpendicular distance from the planes where each LCN to the tip of lateral malleolus'transverse plane and every LCN's external diameters.
Results Majority of medial sural cutaneous nerves and lateral sural cutaneous nerves converge 8.9cm average (2.4～21cm) above the plane of the tip of lateral malleolus to be sural nerve, then it sends out 1～3 LCNs from its lateral part, the first lateral calcaneal nerve(LCN1) sent out from sural nerve or lateral sural cutaneous nerve from the plane of the tip of lateral malleolus to 7.2cm above, the second lateral calcaneal nerve(LCN 2) sent out from sural nerve from 2.5cm above the plane of tip of lateral malleolus to 1.7cm below, the third lateral calcaneal nerve(LCN3) sent out from sural nerve from the plane of the tip of lateral malleolus to 1.8cm below, the shapes of them are almost like circular cylinder. All LCN proceed downward vertical from the trunk of sural nerve, the endings are distributed in the lateral calcaneal area.When near the lateral calcaneal, the LCN1 sents out 2～4 branches to dominate cutaneous sensation of the lateral calcaneal area, the ending is distributed over the lateral part of the lateral calcaneal's weight loading field. The shape of them are almost circular cylinder.The external diameter of the three branches is 1.62mm, 1.10mm and 0.85mm respectively, and the external diameter of the LCN1 in the three types is 1.53mm, 1.72mm and 1.59mm respectively.
Conclusion The LCN1 is an ideal cutaneous nerve for sensory reconstruction in heel, especially in its lateral calcaneal area because its anatomical position is fairly constant, its external diameter is gross, and the initiation is not close to the lateral calcaneal area.
ChapterⅣThe Histomorphological Study of the LFCN, the MCN and the LCN:Observation of Sectional Morphous and Measurement of Nerve Fibre Number
Objective Observe the sectional morphous of the LFCN, the MCN and the LCN, the quantity and distribution of their nerve fiber bundles, quantity and density of their nerve fibers. To provide the anatomic proof for selecting suitable cutaneous nerves, anastomotic position and means of suture to reconstruct the sensation of the ALTF used to repair extensive soft tissue defects in heel.
Methods Choose 7 adult male corpses, take the nerval samples respectively from the LFCN 5cm below the ASIS and the initial segment of the MCN and the LCN1, fixed, dewatered gradiently, embedded, located, and made them into semithin sections, dyed with toluidine blue. Observe the nerves's sectional morphous, the quantity and distribution of their nerve fiber bundles under 40 times amplified, count the quantity of nerve fibers and determine the density of them by amplified 100 times, 200 times and 400 times. The pictures were taken by a medicine figure imaging analysis system named MOTICMED 6.0. Use photoshop 7.0 version precinct software for measuring and calculating the area of the nerve fiber bundles and the photoshop grid function was used to measure the density of the nerve fibers. Data analysis was performed by using Kruskal-Wallis H test, of which several specimens designed completely random. A P value of <0.05 was considered statistically significant.
Results In our cross-section study, among of 7 LFCN samples, 5 were oblate, 2 were ellipse, the majority of nerve bunches lined up transversally and had imcompatible diameters, in addition, there were much adipose tissue lying in and out the nerve fiber bunches. On the contrary, among of 7 MCN samples, only one was oblate, 6 were ellipse, the majority of nerve bunches had similar diameter and disposed concentratedly, there were little adipose tissue while abundant nerve fiber tissue in the trunk of MCN. The majority of LCN (6/7) were ellipse, the majority of nerve bunches (5/7)had imcompatible diameters and disposed with triangle or polygon in those specimens with over two nerve bunches, nerve bunches located at one side of the bole and there were much adipose tissue lying out the nerve fiber bunches in two samples. As to LFCN, MCN and LCN1, the median number of nerve bunches was 4, 3 and 4, respectively. The median number of nerve fibers' area was 114.8 um~2, 126.92um~2 and 102.76 um~2, respectively. The median number of nerve fibers' density was 11.43/ um~2, 6.47/ um~2 and 10.08/ um~2, respectively. The median number of nerve fibers was 987, 862 and 570, respectively.In the arrays, the difference of number, density and area of these nerve fibers in this three cutaneous nerves was considered statistically insignificant.
Conclusion The MCN and the LCN1 are ideal cutaneous nerves to suture with LFCN in the ALTF used to repair widespread soft tissue defects in heel because they have similar histomorphological characteristics with the LFCN.
ChapterⅤInnervation of Free ALTFs for Repairing
Widespreadly Traumatic Soft Tissue Defects in Heel
Objective To explore a new method of innervating ALTFs for repairing widespreadly traumatic soft tissue defects in heel and analyze its initial results of clinical application.
Methods The clinical cases were divided into 2 groups. In control group, eight consecutive ALTFs were transplanted in 8 patients for repairing widespreadly traumatic soft tissue defects in heel from October 2004 to September 2005 in our department, the sensory reconstruction of ALTFs based on traditional method: selecting sural nerve, saphenous nerve or tibial nerve as innervate nerve in the recipient site and simple suturing their nerve membrane in end to end or end to side. In research group, six consecutive ALTFs were transplanted in 6 patients for repairing widespreadly traumatic soft tissue defects in heel from October 2005 to September 2006, the sensory reconstruction of ALTFs included such as design and section of the LFCN, select the cutaneous nerves in recipient sites and anastomotic position as well as suture means based on the research of the anatomic and histomorphological characteristics of LFCN, MCN and LCN. The patients were evaluated at 3, 6, 9 and 12 months on the postoperative follow-up parameters including flap contour, flap stability, locomotor activity, touch sensation, pain sensation, static two-point discrimination, and thermal sensibility.
Results All the free flaps survived in both groups. The flaps have good blood supply, no vassular articulo and infection, all the wounds are primary intention healing. All the 8 cases in the control group follow up 6～18 months (9 months on average), 5 have good shape, 3 are fat and clumsy, the rate of good sensory recovery is 25%, one of which have been burned 2 times owing to poor sensory recovery, another 2 had light ulceration. All the 6 cases in the research group follow up 3～12 months (6 months on average), 5 have good shape, 1 was fat and clumsy, the rate of good sensory recovery is 66.7%, no ulceration happened.
Conclusion When repairing widespread sofl tissue defects in heel, satisfactory sensory function restoration can be obtained by paying attention to the distribution and variety of ALTFs, selecting suitable cutaneous nerves and rational coaptated position as well as suitable suturation means which based on the anatomic and histomorphological characteristics of the LFCN, the MCN and the LCN.
引文
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[1] Chang KN, DeArmond SJ, Buncke HJ. Sensory reinnervation in microsurgical reconstruction of the heel. Plast Reconstr Surg. 1986; 78: 652-664.
[2] Meland NB. Microsurgical reconstruction: The weightbearing surface of the foot. Microsurgery, 1990, 11: 54.
[3] 蔡锦方，孙宝国，潘冀清，等．足跟足底移植皮瓣的感觉功能重建，中华显微外科杂志，1992，15(1)：7-8。
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[1] 洪建军，高伟阳，池永龙，等．足底缺损的修复及感觉重建的随访．中华骨科杂志，2001，21(3)：148-151．
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[4] Chang KN, DeArmond SJ, Buncke HJ. Sensory reinnervation in microsurgical reconstruction of the heel. Plast Reconstr Surg. 1986, 78: 652-664.
[5] 蔡锦方，孙宝国，潘冀清，等．足跟足底移植皮瓣的感觉功能重建．中华显微外科杂志，1992，15(1)：7-8．
[6] Ulusal BG, Lin YT, Ulusal AE, et al. Reconstruction of foot defects with free lateral arm fasciocutaneous flaps: analysis of fifty patients. Microsurgery. 2005, 25(8): 581-588.
[7] Mourougayan V. Medial plantar artery (instep flap) flap. Ann Plast Surg. 2006, 56(2): 160-163.
[8] 唐举玉，李康华，刘俊，等．股前外侧游离皮瓣修复足跟大面积软组织缺损．中华整形外科杂志，2006，22(60)：436-438．
[9] 陆伟，于国中．游离皮瓣感觉恢复的观察与评价．中华显微外科杂志．1993，16(3)：177．
[10] Kuran I, Turgut G, Bas L, et al. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg, 2000, 105: 574.
[11] Sonmez A, Bayramicli M, Sonmez B, et al. Reconstruction of the Weight-Bearing Surface of the Foot with Nonneurosensory Free Flaps. Plast Reconstr Surg, 2003, 111(7): 2230-2236.
[12] Karacalar A, oZbek S, oZcan M. Free rectus abdominis muscle flap with plantar sking a combined method of aesthetic and functional reconstruction of the heel. Scand J Plast Reconstr Surg Hand Surg, 2004, 38(4): 248-249.
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[14] Dellon AL. Discussion: free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg 2002, 109: 2323-2324.
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[16] Boyd JB, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: Are we making sense? Plast Reconstr Surg, 1994, 93: 1350.
[17] Sekido M, Yamamoto Y, Furukawa H, et al. Change of weight-bearing pattern before and after plantar reconstruction with free anterolateral thigh flap. Micosurgery, 2004, 24(4): 289-292.
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