摘要目的:探讨拱顶石皮瓣（KF）修复四肢长骨骨折内固定术后软组织缺损并钢板外露的临床疗效。方法:2019年10月-2023年8月,共11例四肢长骨骨折内固定术后钢板外露患者在新疆医科大学第一附属医院显微外科应用KF修复创面，钢板外露创面3例位于胫骨,5例位于腓骨,2例位于肱骨,1例位于尺骨。钢板外露原因包括缝合张力过大、局部感染严重、软组织损伤严重、低蛋白血症、糖尿病、长期吸烟和小腿深静脉血栓合并小腿肿胀，钢板外露后软组织缺损面积为8.0 cm×3.0 cm～20.0 cm×4.0 cm，设计KF的面积为12.0 cm×8.0 cm～24.0 cm×12.0 cm。应用KF类型为Ⅱ A型7例、Ⅲ型3例、Ⅳ型1例；所有患者定期门诊随访,观察皮瓣外观和术后并发症,皮瓣外观使用温哥华瘢痕量表(VSS)、瘢痕外观评估和评定量表(SCAR)进行评分和分析。结果:术后随访3~48(15.91±10.23)个月,10例患者未出现皮瓣坏死、感染、伤口裂开和静脉（或淋巴）回流障碍等并发症,仅1例术后2个月再次出现钢板外露,待骨折愈合后拆除钢板并修复创面,所有患者KF移植区域的颜色、质地与周围正常皮肤相近,感觉恢复良好；末次随访VSS评分为(2.72±0.66)分,SCAR评分为(4.90±0.66)分,修复结果满意。结论:KF作为一个多穿支蒂皮瓣，可以有效利用局部软组织移行潜力转移修复钢板外露所导致的软组织缺损,避免使用复杂的带血管蒂的组织瓣及游离皮瓣,并可有效控制感染。

abstractsObjective:To explore the clinical efficacy of Keystone flap (KF) in reconstruction of soft tissue defect with plate exposure after internal fixation of long bone fractures of four limbs.Methods:From October 2019 to August 2023, a total of 11 patients with exposed plates after internal fixation of limb fractures were treated by KF to reconstruct the soft tissue defects in the Department of Microsurgery of the First Affiliated Hospital of Xinjiang Medical University. Of the exposed internal fixation plates, 3 were located in the tibia, 5 in the fibula, 2 in the humerus and 1 in the ulna. Causes of exposure of internal fixation plate included excessive tension of suture, severe local infection, severe soft tissue injury, hypoalbuminemia, diabetes, and long-term smoking and calf deep vein thrombosis with swelling calf. The areas of soft tissue defect after the plate exposure were measured 8.0 cm×3.0 cm-20.0 cm×4.0 cm in size. The sizes of KF were 12.0 cm×8.0 cm-24.0 cm×12.0 cm. Seven patients were treated with type ⅡA KF, 3 with type Ⅲ KF and 1 with type IV KF. All patients were included in the postoperative follow-up by visiting of outpatient clinics to observe the appearance of the flaps and postoperative complications. Appearances of the flaps were assessed and analysed according to Vancouver Scar Scale (VSS) and Scar Cosmesis Assessment and Rating (SCAR).Results:During the 3~48(15.91±10.23) months of follow-up, no complication such as flap necrosis, infection, wound split and disorder of venous-lymphatic drainage occurred in 10 patients. One patient had the plate re-exposure at 2 months after surgery, and the wound was repaired after the fracture had healed and removal of the plate. The colour and texture of the transferred KFs were similar to those of the surrounding normal skin in all patients, with good sensation recovery. At the final follow-up, the VSS score achieved at 2.72 points ± 0.66 points and the SCAR score at 4.90 points ± 0.66 points. The outcomes of the surgery were satisfactory.Conclusion:As a multi-perforator pedicled flap, the KF can effectively utilise the migration potential of local soft tissue to repair soft tissue defects caused by the exposed plates, avoid the use of complex vascularised tissue flaps and free flaps, while effectively controls infection.