穿支皮瓣联合足趾移植术修复拇指毁损伴手部软组织缺损的临床疗效

杨涛; 陈佳; 成贝贝; 汪帅; 江小萌; 宋力; 周明武; 李士民

doi:10.3760/cma.j.cn501120-20200727-00360

穿支皮瓣联合足趾移植术修复拇指毁损伴手部软组织缺损的临床疗效

doi: 10.3760/cma.j.cn501120-20200727-00360

解放军联勤保障部队第988医院创伤显微外科，郑州　　450042

基金项目:

河南省医学科技攻关计划联合共建项目 LHGJ20200793

详细信息

通讯作者:
李士民，Email：lsm8123@163.com

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出版历程
- 收稿日期: 2020-07-27

Clinical effect of perforator flap combined with toe transplantation for repairing thumb damage with soft tissue defect of hand

Department of Trauma and Microsurgery, the 988th Hospital of Joint Logistic Support Force of PLA, Zhengzhou 450042, China

Funds:

Joint Construction Project of Henan Medical Science and Technology Research Plan LHGJ20200793

More Information

Corresponding author: Li Shimin, Email: lsm8123@163.com

摘要

摘要: 目的探讨穿支皮瓣联合足趾移植术修复拇指毁损伴手部软组织缺损的临床疗效。方法采用回顾性观察性研究方法。2014年5月—2019年6月，解放军联勤保障部队第988医院收治8例拇指毁损伴手部软组织缺损患者，其中男6例、女2例，年龄25~46岁；患者拇指毁损分度中Ⅱ度3例、Ⅲ度1例、Ⅳ度4例，对毁损拇指均行穿支皮瓣联合足趾移植术进行修复。6例患者手部软组织缺损采用游离股前外侧穿支皮瓣修复，2例采用游离腹壁下动脉穿支瓣修复；Ⅱ度毁损拇指采用第1足趾移植联合穿支皮瓣修复，Ⅲ或Ⅳ度毁损拇指采用第2足趾移植联合穿支皮瓣修复。术后观察再造拇指及其皮瓣的血运、成活情况及供区的伤口愈合情况。随访10~18个月，观察患指外观、感觉恢复以及足部行走功能情况；末次随访时对拇指功能再造进行评价。结果再造拇指及其皮瓣血运、存活情况均良好。供区伤口愈合良好。随访可见再造拇指及皮瓣外观良好，指腹痛觉、触觉恢复良好；足部行走功能无明显影响。末次随访时，患者拇指再造功能评价为优4例、良3例、可1例。结论穿支皮瓣联合足趾移植术的修复方法，可在Ⅰ期完成伴手部皮肤软组织缺损的拇指毁损的针对性修复，最大限度减小足部供区损伤，缩短早期康复病程，是治疗复杂拇指毁损的理想方法之一。
- 拇指 /
- 外科皮瓣 /
- 再造 /
- 修复
Abstract: Objective To investigate the clinical effect of perforator flap combined with toe transplantation for repairing thumb damage with soft tissue defect of hand. Methods The retrospective observational study method was used. From May 2014 to June 2019, 8 patients with thumb damage and soft tissue defect of hand were admitted to the 988th Hospital of Joint Logistic Support Force of PLA, including 6 males and 2 females, aged from 25 to 46 years. Among them, thumb damage in 3 cases were degree Ⅱ, 1 case was degree Ⅲ, and 4 cases were degree Ⅳ. All thumb damage were repaired with perforator flap combined with toe transplantation. The skin and soft tissue defects of hand were repaired by free anterolateral thigh perforator flap in 6 cases and free deep inferior epigastric perforator flap in 2 cases. The thumb damage of degree Ⅱ was repaired by the first toe transplantation combined with perforator flap, and thumb damage of degree Ⅲ or Ⅳ was repaired by the second toe transplantation combined with perforator flap. The survival and blood supply of reconstructed thumbs and flaps, and wound healing of donor sites were observed after surgery. All the patients were followed up for 10 to 18 months, the appearance of the reconstructed thumbs, sensory recovery, and foot walking function were observed. At the final follow-up, the functional reconstruction of the thumb was evaluated. Results All the blood supply and survival of the reconstructed thumbs and flaps were good, and all the wounds of donor sites healed well. During the follow-up, the appearances of the reconstructed thumb and flap were good, the sensation of pain and touch of the finger pulp recovered well, and no significant impact on foot walking function was observed. At the final follow-up, the function of reconstructed thumb was evaluated as excellent in 4 cases, good in 3 cases, and fair in 1 case. Conclusions The repair method of perforator flap combined with toe transplantation technique can complete the targeted repair of thumb damage with skin and soft tissue defect of hand in one stage, minimizing the foot donor site injury and shortening the course of disease and early rehabilitation, which is one of the ideal methods for the treatment of complex thumb damage.
- Thumb /
- Surgical flaps /
- Reconstruction /
- Repair
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老年烧伤患者往往预后不佳。预后营养指数（PNI）可预测围手术期营养状态及预后。韩国国家医疗中心麻醉与疼痛科Hee Yeong Kim教授团队和韩国蔚山大学医学院Asan医学中心麻醉与疼痛科Young-Kug Kim教授团队近期在《Burns & Trauma》发文《The prognostic nutritional index on postoperative day one is associated with one-year mortality after burn surgery in elderly patients》，该文通过回顾性纳入年龄≥65岁的烧伤患者，采用10×血清白蛋白水平（g/dL）+0.005×总淋巴细胞计数（/mm³）计算PNI。采用Cox回归、受试者操作特征（ROC）曲线、Kaplan-Meier生存分析评价影响患者术后1年病死率的危险因素。结果显示，189例老年烧伤患者术后1年死亡数为71例（37.6%）。患者术后1年病死率的危险因素包括术后第1天的PNI（危险比=0.872，95%置信区间=0.812~0.936，P<0.001）、序贯性器官衰竭评估评分（危险比=1.112，95%置信区间=1.005~1.230，P=0.040）、美国麻醉师协会生理状况分级（危险比=2.064，95%置信区间=1.211~3.517，P=0.008）、烧伤总体表面积（危险比=1.017，95%置信区间=1.003~1.032，P=0.015）和术前血清肌酐水平（危险比=1.386，95%置信区间=1.058~1.816，P=0.018）。预测烧伤术后1年病死率的PNI的ROC曲线下面积为0.774（最佳阀值=25.5）。PNI≤25.5患者的1年生存率（32.1%）明显低于PNI>25.5的患者（75.9%，P<0.001）。由此可见，老年烧伤患者术后第1天的PNI与其术后1年的病死率相关，表明识别低PNI老年烧伤患者可降低手术后的病死率。

杨敏，编译自《Burns & Trauma》，2021，9：tkaa043；韩春茂，审校

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1 第1足趾联合游离腹壁下动脉穿支（DIEP）皮瓣修复例1患者热压伤拇指毁损伴手部软组织缺损。1A.右手拇指热压伤外观，可见指体皮肤软组织皮革样烧伤；1B.受区彻底清创后为右手拇指Ⅱ度毁损，仅残留近节指骨，屈伸指肌腱均无活性并已去除，同时伴有虎口、大鱼际皮肤缺损；1C.第1足趾的切取，暴露并携带有效趾背静脉回流系统、第1跖背动脉及腓侧趾固有神经；1D、1E.游离DIEP皮瓣的切取与游离，暴露腹直肌及前鞘，游离DIEP皮瓣，并携带腹壁浅静脉留待吻合；1F.血管吻合并通血后再造拇指外观；1G.术后12个月随访，患手可握笔写字；1H.术后12个月随访，足部供区外观，伤口愈合好

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2 第2足趾联合游离股前外侧穿支（ALTP）皮瓣修复例2患者绞伤拇指毁损伴手部软组织缺损。2A.左手拇指毁损伤外观，Ⅳ度毁损，伴大鱼际及虎口皮肤缺损；2B.第2足趾的切取，暴露并携带有效趾背静脉回流系统、第1跖背动脉及双侧趾固有神经，于第2跖骨干中段截骨；2C.将第2足趾游离切取完毕后调整骨质长度留待固定；2D.根据皮肤缺损情况，设计游离ALTP皮瓣；2E.切取携带旋股外侧动脉降支主干及穿支，留待吻合；2F.血管吻合并通血后再造拇指外观；2G.术后10个月随访外观，能完成抓捏动作；2H.术后10个月随访足部供区外观，伤口愈合好，无𧿹外翻畸形

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