游离𧿹甲皮瓣联合第2趾复合组织瓣用于电烧伤后毁损性拇指再造的临床效果

邢培朋; 母心灵; 夏成德; 史继静; 薛继东; 杨高远; 张建; 狄海萍

doi:10.3760/cma.j.cn501120-20210621-00222

游离𧿹甲皮瓣联合第2趾复合组织瓣用于电烧伤后毁损性拇指再造的临床效果

doi: 10.3760/cma.j.cn501120-20210621-00222

郑州市第一人民医院烧伤科，郑州　　450004

基金项目:

河南省医学科技攻关计划联合共建项目 LHGJ20191000, LHGJ20200698

详细信息

通讯作者:
狄海萍，Email：308591645@qq.com

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出版历程
- 收稿日期: 2021-06-21

Clinical effects of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns

Department of Burns, Zhengzhou First People's Hospital, Zhengzhou 450004, China

Funds:

Joint Construction Project of Henan Medical Science and Technology Research Plan LHGJ20191000, LHGJ20200698

More Information

Corresponding author: Di Haiping, Email: 308591645@qq.com

摘要

摘要: 目的探讨游离𧿹甲皮瓣联合第2趾复合组织瓣用于电烧伤后毁损性拇指再造的临床效果。方法采用回顾性观察性研究方法。2018年5月—2021年4月，郑州市第一人民医院收治了12例符合入选标准的电烧伤致拇指毁损男性患者，年龄27~58岁，彻底清创后拇指缺损分度为Ⅲ度者10例、Ⅳ度者2例。采用游离𧿹甲皮瓣联合携带皮岛的第2趾趾骨、关节、肌腱等复合组织瓣再造拇指，𧿹甲皮瓣供区Ⅰ期覆盖人工真皮并行持续负压封闭引流、Ⅱ期移植腹股沟区中厚皮片覆盖，第2趾供区应用髂骨条填塞固定。再造术后1周观察再造拇指成活情况，皮片移植术后2周观察𧿹甲皮瓣供区皮片成活情况，再造术后6周复查X线观察再造拇指指骨及供足第2趾趾骨骨痂形成情况。随访时观察再造拇指外形，评估感觉功能；按照中华医学会手外科学会上肢部分功能评定试用标准评定再造拇指功能；观察供足𧿹趾及第2趾的趾间关节是否僵硬、足部供区瘢痕增生情况及供足站立、行走功能是否受限。结果再造术后1周，患者再造拇指均成活。皮片移植术后2周，11例患者𧿹甲皮瓣供区皮片全部成活；1例患者𧿹甲皮瓣供区皮片部分坏死，换药10 d后创面完全愈合。再造术后6周，10例患者再造拇指指骨及供足第2趾趾骨骨痂形成，拔除其克氏针；2例患者再造拇指指骨骨痂形成欠佳，延迟2周拔除其克氏针。随访6~24个月，患者再造拇指外形与健侧拇指接近，指腹两点辨别觉距离为7~11 mm，功能评定：优4例、良6例、可2例；供足𧿹趾及第2趾的趾间关节僵硬，足部供区均遗留轻度瘢痕增生，供足站立及行走功能均未明显受限。结论游离𧿹甲皮瓣联合第2趾复合组织瓣可用于电烧伤后毁损性拇指再造，该方法应用重建代替修复的理念封闭创面，可恢复毁损拇指的外形及功能，且未对供足造成较大的损伤。
- 烧伤，电 /
- 拇指 /
- 外科皮瓣 /
- 游离组织瓣
Abstract: Objective To explore the clinical effects of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns. Methods A retrospective observational study was conducted. From May 2018 to April 2021, 12 male patients with thumb destructive defects caused by electrical burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, aged 27 to 58 years, including 10 cases with degree Ⅲ thumb defect and 2 cases with degree Ⅳ thumb defect after thorough debridement. The thumb was reconstructed with free hallux-nail flap combined with composite tissue flap of the second phalangeal bone, joint, and tendon with skin island. The donor site of hallux-nail flap was covered with artificial dermis in the first stage and performed with continuous vacuum sealing drainage, and covered with medium-thickness skin graft from the groin site in the second stage. The donor site in the second toe was filled and fixed with iliac bone strips. The survival of reconstructed thumb was observed 1 week after the reconstruction surgery, the survival of skin graft in the donor site of hallux-nail flap was observed 2 weeks after skin grafting, and the callus formation of the reconstructed thumb phalanx and the second toe of the donor foot was observed by X-ray 6 weeks after the reconstruction surgery. During the follow-up, the shape of reconstructed thumb was observed and the sensory function was evaluated; the function of reconstructed thumb was evaluated with trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association; whether the interphalangeal joints of the hallux and the second toe were stiff, the scar hyperplasia of the foot donor site, and whether the walking and standing functions of the donor feet were limited were observed. Results One week after the reconstruction surgery, all the reconstructed thumbs of the patients survived. Two weeks after skin grafting, the skin grafts in the donor site of hallux-nail flap of 11 patients survived, while the skin graft in the donor site of hallux-nail flap of 1 patient was partially necrotic, which was healed completely after 10 days' dressing change. Six weeks after the reconstruction surgery, callus formation was observed in the reconstructed thumb and the second toe of the donor foot of 10 patients, the Kirschner wires were removed; while callus formation of the reconstructed thumb was poor in 2 patients, and the Kirschner wires were removed after 2 weeks of delay. During the follow-up of 6 to 24 months, the shape of reconstructed thumb was similar to that of the healthy thumb, the discrimination distance between the two points of the reconstructed thumb was 7 to 11 mm, and the functional evaluation results were excellent in 4 cases, good in 6 cases, and fair in 2 cases. The interphalangeal joints of the hallux and the second toe of the donor foot were stiff, mild scar hyperplasia was left in the donor site of foot, and the standing and walking functions of the donor foot were not significantly limited. Conclusions The application of free hallux-nail flap combined with the second toe composite tissue flap in the reconstruction of damaged thumb after electrical burns adopts the concept of reconstruction instead of repair to close the wound. It can restore the shape and function of the damaged thumb without causing great damage to the donor foot.
- Burns, electric /
- Thumb /
- Surgical flaps /
- Free tissue flaps
邢培朋、母心灵、夏成德、狄海萍：手术设计和操作、论文撰写；史继静、薛继东、杨高远、张建：患者管理、手术操作

所有作者均声明不存在利益冲突

目前，对增生性瘢痕形成的机制仍然知之甚少。与正常皮肤相比，瘢痕组织中存在的大多数类型的细胞基因表达有明显差异。Fb在基因表达方面表现出最突出的改变，显示出独特的纤维化特征。通过比较小鼠Fb在瘢痕发展过程中上调的基因和成熟的人类肥厚性瘢痕中高表达的基因，该研究团队观察到一组丝氨酸蛋白酶——二肽基肽酶4（DPP4）和尿激酶参与了瘢痕形成。进一步分析研究显示，DPP4和尿激酶在TGF-β₁介导的肌Fb分化和ECM成分过表达中发挥了作用。在瘢痕形成期间，局部外用DPP4和尿激酶的抑制剂，尤其是使用尿激酶抑制剂BC-11后，可以显著抑制小鼠和人的皮肤纤维化和瘢痕形成。此外，该研究团队还构建了增生性瘢痕的遗传图谱，并提出有关增生性瘢痕形成机制的见解。总之，该研究团队认为使用丝氨酸蛋白酶抑制剂可以治疗皮肤纤维化。

张凡，编译自《Nat Commun》,2021,12(1):6242；肖健，审校

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1 游离左足𧿹甲皮瓣联合第2趾复合组织瓣用于左手电烧伤后毁损性拇指再造。1A.高压电烧伤后左手拇指坏死；1B.彻底清创后拇指创面情况；1C.设计左足𧿹甲皮瓣及携带部分皮岛的第2趾复合组织瓣背侧观；1D.切取后的𧿹甲皮瓣联合第2趾复合组织瓣；1E.将𧿹甲皮瓣包绕第2趾复合组织，并应用克氏针固定；1F、1G.分别为拇指再造术后即刻背侧观、掌侧观；1H.𧿹趾供区移植中厚皮片后；1I.再造术后6个月，左手拇指与对侧拇指外形相近、无臃肿；1J.术后6个月，左足𧿹趾供区愈合，遗留轻度瘢痕增生

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