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Der Saphenusperforatorlappen

Saphenous perforator flap

Operative Orthopädie und Traumatologie volume 25, pages 152–161 (2013)Cite this article

Zusammenfassung

Operationsziel

Ersatz von Haut mit Fettgewebe und Faszie vom körperfernen Unterschenkeldrittel bis zur Fußwurzel, gemäß dem Defekt und angepasst an den Verlauf der Blutgefäße für die Haut distal gestielter fasziokutaner Lappen, basierend auf der individuellen Anatomie der distalen Perforatoren der A. tibialis posterior.

Indikationen

Defekte von Haut und Weichgeweben, größte Länge 12 cm, größte Breite 8 cm. Bei ausreichender Durchblutung des Fußes durch die A. tibialis posterior, unabhängig vom Alter und von Vorerkrankungen, bei Osteomyelitis, Endoprothesen, Frakturen und bei freiliegenden Sehnen.

Kontraindikationen

Gründe, die gegen einen Eingriff von 1–2 h sprechen; Notwendigkeit eines gefäßchirurgischen Eingriffs oder Thrombose der tiefen Beinvenen; Decollement oder Narben um die distalen Perforatoren der A. tibialis posterior; lokale Entzündungen oder Nekrosen, die nicht im Gesunden ausgeschnitten werden können.

Operationstechnik

Radikales Debridement. Lappenpräparation ohne Blutleere oder Blutsperre. Mikrodissektion unter Prismenlupenvergrößerung. Planung durch Zeichnung auf der Haut: Drehpunkt ~ 10 cm (6–14 cm) proximal der Innenknöchelspitze; Basis ~ 5 cm breit, vordere Grenze über Verlauf des N. saphenus und dem der V. saphena magna und hintere Grenze am Rand der Achillessehne; Stiel bis zu 15 cm lang über dem Septum zwischen M. flexor digitorum longus und M. soleus, am Vorderrand N. saphenus und V. saphena magna; fingerbreiter Hautstreifen über dem adipofaszialen Stiel, Hauthalbinsel in der Form des Defekts 1–2 cm größer und mit einem 1–2 cm breiten adipofaszialen Saum. Anpassung der Planung und der Hebung des Lappens an die individuelle Lage des distalen Perforators der A. tibialis posterior nahe dem Drehpunkt. Rücklagerung und Verzögerung der Verlagerung, wenn die Trennung von mehr als einem Perforator körpernah des Drehpunkts die Durchblutung sichtbar mindert. Keine Tunnelung des Stiels.

Weiterbehandlung

Protokollierte Kontrolle der Durchblutung. Antibiotische Behandlung gemäß Testung. Bei ödematöser Schwellung und bei Änderung der Farbe der Hauthalbinsel unverzüglich Entfernung von Fäden, Ansetzten von Blutegeln und operative Revision in Narkose.

Ergebnisse

Retrospektive, nichtkontrollierte Studien über 70 distale Saphenusperforatorlappen, operiert im Zeitraum von 1995 bis 2011. Defekte 62-mal bei Osteomyelitis, 3-mal bei Endoprothesen, 3-mal bei Frakturen und 2-mal bei freiliegenden Sehnen. 1995 bis 2006: 44/50 (88 %) Lappen heilten vollständig oder zu 3/4 ohne weitere Lappenplastik. 2007 bis 2011: 13/20 (65 %) Lappen heilten vollständig, 6/20 (30 %) zu 3/4 ohne weitere Lappenplastik; Verlust eines Lappens (5 %).

Abstract

Objective

Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery.

Indications

Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated.

Contraindications

For patients, in whom a 1–2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised.

Surgical technique

Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~ 10 cm (6–14 cm) proximal of the tip of the medial malleolus; base ~ 5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No “tunnelling “of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary by “artificial skin”. A gap in the bandage over the skin island allows for observation.

Postoperative management

Protocol of controls of vascularization: color and time for revascularization; antibiotic treatment according to bacteriological testing. In case of edema or discoloration of the flap: immediate removal of sutures, administration of leeches, operative revision. Split skin graft 1 week after flap transposition, if the skin had been temporary substituted.

Results

Retrospective uncontrolled study with over 70 saphenous perforator flaps from 1995–2011. Full soft tissue defects 62 times with osteomyelitis, 3 times with endoprothesis, 3 times with fractures, 2 times with exposed tendons. From 1995–2006, 44/50 (88 %) flaps healed completely or at least to 3/4 without the necessity of further flaps; from 2007–2011, 13/20 (65 %) flaps healed completely and 6/20 (30 %) flaps healed at least to 3/4 without the necessity of further flaps, loss of one flap (5 %).

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Danksagung

Die Autoren danken Herrn Dr. med. G. Walter, Chefarzt der Abteilung für Septische Chirurgie der Berufsgenossenschaftlichen Unfallklinik Frankfurt für die Zusammenarbeit.

Interessenkonflikt

Der korrespondierende Autor gibt für sich und seine Koautoren an, dass kein Interessenkonflikt besteht.

Author information

Affiliations

  1. Abteilung für Handchirurgie und wiederherstellende Plastische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland

    R. Winkel, M. Schlageter & G. Hanebuth

  2. University of Northern Norway, Tromsö, Tromsö, Norwegen

    N. Tajsic & H. Husum

  3. Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Deutschland

    R. Hoffmann

Authors
  1. R. Winkel
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  2. N. Tajsic
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  3. H. Husum
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  4. M. Schlageter
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  5. G. Hanebuth
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  6. R. Hoffmann
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Corresponding author

Correspondence to R. Winkel.

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Winkel, R., Tajsic, N., Husum, H. et al. Der Saphenusperforatorlappen. Oper Orthop Traumatol 25, 152–161 (2013). https://doi.org/10.1007/s00064-012-0198-z

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Schlüsselwörter

  • Untere Extremitäten
  • Sprunggelenk
  • Saphenusperforatorlappen
  • Weichgewebeverletzungen
  • Operative Technik

Keywords

  • Lower extremity
  • Ankle
  • Saphenous perforator flap
  • Soft tissue injuries
  • Surgical technique