Comparative study of the effects between second toe tibial dorsal artery flap and second toe tibial plantar proper artery flap in repairing finger skin and soft tissue defects
-
摘要:
目的 对比第2趾胫侧趾背动脉皮瓣（简称趾背动脉皮瓣）与第2趾胫侧趾底固有动脉皮瓣（简称趾底动脉皮瓣）修复手指皮肤软组织缺损的疗效。 方法 采用回顾性队列研究方法。2019年1月—2020年6月，苏州瑞华骨科医院收治27例符合入选标准的手指末端皮肤软组织缺损患者，其中男21例、女6例，年龄19~59（37±10）岁，清创后缺损面积1.5 cm×1.2 cm~2.6 cm×1.8 cm。根据对缺损手指采用的皮瓣修复方式，将患者分为趾背动脉皮瓣组（12例）和趾底动脉皮瓣组（15例）。趾背动脉皮瓣切取面积为1.5 cm×1.2 cm~2.5 cm×1.6 cm，趾底动脉皮瓣切取面积为1.7 cm×1.3 cm~2.6 cm×1.8 cm，对皮瓣供区创面行同侧小腿内侧全厚皮片移植，将皮片供区创面直接缝合。记录患者皮瓣动脉口径、皮瓣切取时间及术后2周皮瓣成活情况与随访时间。末次随访时，记录患者皮瓣移植处两点辨别觉距离、指关节总主动活动度（TAM）及皮瓣供区创面愈合情况，采用温哥华瘢痕量表（VSS）对第2趾供区与手指受区瘢痕情况进行评分，采用Michigan手概况问卷（MHQ）中的外观与自我满意度2个子量表对患指进行评价。对数据行独立样本t检验或Fisher确切概率法检验。 结果 趾背动脉皮瓣组患者皮瓣动脉口径为0.35~0.80（0.56±0.14）mm、皮瓣切取时间为（14.0±2.7）min，均明显短于趾底动脉皮瓣组的0.80~1.35（1.02±0.16）mm、（19.7±3.4）min（t值分别为7.81、4.79，P<0.01）。术后2周，2组患者受区皮瓣均成活。末次随访时，2组患者皮瓣供区创面均愈合良好。2组患者术后随访时间及末次随访时的皮瓣移植处两点辨别觉距离、指关节TAM、第2趾供区和手指受区瘢痕的VSS评分及患指MHQ中外观与自我满意度评分比较，差异均无统计学意义（P>0.05）。 结论 相较于趾底动脉皮瓣，趾背动脉皮瓣解剖层次浅，手术切取皮瓣时间短，能够保留趾底固有动脉与趾底固有神经，减少供区的损伤。 Abstract:Objective To compare the effects between second toe tibial dorsal artery flap (2-TDAF) and second toe tibial plantar proper artery flap (2-TPPAF) in repairing finger skin and soft tissue defects. Methods A retrospective cohort study was conducted. From January 2019 to June 2020, 27 patients with skin and soft tissue defects at the fingertips with area of 1.5 cm×1.2 cm-2.6 cm×1.8 cm after debridement who met the inclusion criteria were admitted to Suzhou Ruihua Orthopaedic Hospital, including 21 males and 6 females, aged 19-59 (37±10) years. According to flap repair methods used in the defective fingers, the patients were divided into 2-TDAF group (12 cases) and 2-TPPAF group (15 cases). The area of 2-TDAF ranged from 1.5 cm×1.2 cm to 2.5 cm×1.6 cm, and the area of 2-TPPAF ranged from 1.7 cm×1.3 cm to 2.6 cm×1.8 cm. Full-thickness skin grafts from the medial side of the ipsilateral leg were grafted to the wounds in donor sites, and the wounds in donor sites of skin grafts were directly sutured. Flap arterial diameter, flap excision time, flap survival situation of patients in 2 weeks after operation, and follow-up time were recorded. At the last follow-up, the two-point discrimination distance of flap graft site, total action motion (TAM) of the finger joints, and wound healing of the flap donor site were recorded; the Vancouver scar scale (VSS) was used to score the scar in donor area of the second toe and the recipient area of fingers; the appearance and self-satisfaction subscales of the Michigan hand outcomes questionnaire (MHQ) were used to evaluate the affected finger. Data were statistically analyzed with independent sample t test or Fisher's exact probability test. Results The flap artery diameter of patients in 2-TDAF group was 0.35-0.80 (0.56±0.14) mm and the flap cutting time was (14.0±2.7) min, which were significantly shorter than 0.80-1.35 (1.02±0.16) mm and (19.7±3.4) min in 2-TPPAF group (with t values of 7.81 and 4.79, respectively, P<0.01). The flaps of patients in the 2 groups in recipient areas survived well in 2 weeks after operation, and the wounds in donor areas of flaps of patients in the 2 groups healed well at the last follow-up. There was no statistically significant difference in the postoperative follow-up time, and two-point discrimination distance of flap graft site, TAM of the finger joints, VSS score of scar in the second toe donor site and the finger recipient site, and the appearance and self-satisfaction of MHQ scores of the affected finger at the last follow-up (P>0.05). Conclusions Compared with 2-TPPAF, 2-TDAF has a shallower anatomical layer and shorter time for surgical flap removal, which can preserve the proper arteries and nerves at the base of the toes and reduce the damage to the donor site. -
Key words:
- Surgical flaps /
- Fingers /
- Skin /
- Soft tissue injuries /
- Dorsal toe artery /
- Wound repair
-
参考文献
(32) [1] 王兵, 马炬雷, 张蛟, 等. 以趾背动脉为蒂的(拇)甲皮瓣修复拇指甲床合并指背皮肤缺损[J].中华手外科杂志,2019,35(6):470-471. DOI: 10.3760/cma.j.issn.1005-054X.2019.06.028. [2] 常树森, 金文虎, 魏在荣, 等. 患指锯齿状指固有动脉神经蒂皮瓣联合双皮下蒂V-Y推进皮瓣修复同指指端皮肤软组织缺损[J].中华烧伤杂志,2016,32(4):204-207. DOI: 10.3760/cma.j.issn.1009-2587.2016.04.004. [3] Diaz-AbeleJ, HayakawaT, BuchelE, et al. Anastomosis to the common and proper digital vessels in free flap soft tissue reconstruction of the hand[J]. Microsurgery, 2018,38(1):21-25. DOI: 10.1002/micr.30066. [4] 王辉, 杨晓溪, 王斌, 等. 吻合静脉的带蒂指动脉背侧支岛状皮瓣修复同指指端或指腹缺损的效果[J].中华烧伤杂志,2020,36(11):1065-1069. DOI: 10.3760/cma.j.cn501120-20191113-00427. [5] BalanJR. Free toe pulp flap for finger pulp and volar defect reconstruction[J]. Indian J Plast Surg, 2016,49(2):178-184. DOI: 10.4103/0970-0358.191319. [6] KwonHJ, YoonS, HanHH, et al. Partial second-toe pulp free flap for fingertip reconstruction: experience and surgical tips to minimize complications[J]. Microsurgery, 2021,41(7):629-636. DOI: 10.1002/micr.30804. [7] 梁鹏飞, 张丕红, 张明华, 等. 手指Ⅳ度烧伤创面的修复方法与临床效果[J].中华烧伤杂志,2021,37(7):614-621. DOI: 10.3760/cma.j.cn501120-20210114-00020. [8] ChungKC, PillsburyMS, WaltersMR, et al. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire[J]. J Hand Surg Am, 1998,23(4):575-587. DOI: 10.1016/S0363-5023(98)80042-7. [9] 李木卫, 吴巩, 黄少耿, 等. 第1跖背动脉-第2趾胫侧动脉一蒂串联皮瓣修复同手指两处软组织缺损[J].中华显微外科杂志,2021,44(4):374-377. DOI: 10.3760/cma.j.cn441206-20210222-00052. [10] ElliotD, AdaniR, Hyun WooS, et al. Repair of soft tissue defects in finger, thumb and forearm: less invasive methods with similar outcomes[J]. J Hand Surg Eur Vol, 2018,43(10):1019-1029. DOI: 10.1177/1753193418805698. [11] 褚庭纲, 陈庭祥, 王安远, 等. 第二趾胫侧趾底动脉岛状皮瓣修复腓侧皮瓣供区[J].中华整形外科杂志,2018,34(10):841-844. DOI: 10.3760/cma.j.issn.1009-4598.2018.10.013. [12] 李祥军, 巨积辉, 刘海亮, 等. 游离第二趾胫侧血流桥接皮瓣修复伴指动脉缺损的手指创面[J].中华手外科杂志,2017,33(5):355-357. DOI: 10.3760/cma.j.issn.1005-054X.2017.05.015. [13] HeB, LiuJ, PangV, et al. Anatomical and clinical comparison of small free flaps for repairing finger skin defects[J]. Ann Plast Surg, 2019,83(6):664-669. DOI: 10.1097/SAP.0000000000001933. [14] 王辉, 杨晓溪, 刘冰冰, 等. 手部三种近位带蒂皮瓣接力修复手指指端脱套伤及供区软组织缺损的效果[J].中华烧伤杂志,2021,37(1):64-69. DOI: 10.3760/cma.j.cn501120-20200103-00001. [15] YinY, TaoX, LiY, et al. Cosmetic and functional results of a newly reconstructed thumb by combining the phalanx of second toe and the great toenail flap transplantation[J]. J Orthop Surg Res, 2020,15(1):458. DOI: 10.1186/s13018-020-01986-y. [16] DellonAL, KallmanCH. Evaluation of functional sensation in the hand[J]. J Hand Surg Am, 1983,8(6):865-870. DOI: 10.1016/s0363-5023(83)80083-5. [17] 谢广中, 苗存良, 王光耀, 等. 第二足趾动脉的应用解剖及临床应用[J].中华显微外科杂志,2008,31(6):452-454. DOI: 10.3760/cma.j.issn.1001-2036.2008.06.021. [18] LiuCJ, LiuL, LiuGL, et al. Repair of thumb defect by using the toenail flap: biomechanical analysis of donor foot-a retrospective cohort study[J]. J Orthop Surg Res, 2019,14(1):287. DOI: 10.1186/s13018-019-1330-7. [19] KhoongYM, HuangX, GuS, et al. Imaging for thinned perforator flap harvest: current status and future perspectives[J/OL]. Burns Trauma, 2021,9:tkab042[2022-06-30]. https://pubmed.ncbi.nlm.nih.gov/34926708/. DOI: 10.1093/burnst/tkab042. [20] GilbertA. Composite tissue transfers from the foot: anatomic basis and surgical technique[G].St Louis:Mosby,1976:230-232. [21] 周健, 魏在荣, 孙广峰, 等. 游离第3足趾胫侧微型皮瓣修复手指末节指腹皮肤软组织缺损[J].中华烧伤杂志,2019,35(3):205-208. DOI: 10.3760/cma.j.issn.1009-2587.2019.03.008. [22] 李祥军, 巨积辉, 王友兵, 等. 甲皮瓣联合趾侧方皮瓣修复指端复合组织缺损[J].中国美容整形外科杂志,2016,27(1):34-36. DOI: 10.3969/j.issn.1673-7040.2016.01.013. [23] 肖湘君, 刘鸣江, 廖辉文, 等. 游离𧿹趾甲皮瓣嵌合第2趾骨复合组织瓣再造拇指的显微外科解剖[J].中国临床解剖学杂志,2017,35(3):245-248. DOI: 10.13418/j.issn.1001-165x.2017.03.002. [24] 周望高, 余少校, 李东扬, 等. 带趾骨背侧骨质的第2趾甲皮瓣修复手指甲床缺损[J].中华显微外科杂志,2021,44(1):16-19. DOI: 10.3760/cma.j.441206-20191220-00387. [25] 徐磊, 巨积辉, 侯瑞兴, 等. 双足第二趾胫侧皮肤两点分辨觉的比较研究及其临床意义[J].中华手外科杂志,2016,32(6):460-462. DOI: 10.3760/cma.j.issn.1005-054X.2016.06.027. [26] 王晓松, 巨积辉, 吕文涛, 等. 带趾底固有神经和带趾背神经的第二趾胫侧皮瓣修复指端缺损的疗效对比[J].中华手外科杂志,2020,36(3):168-172. DOI: 10.3760/cma.j.cn311653-20191004-00277. [27] 杨延军, 黄伟宏, 钟小妮, 等. 第2趾胫侧皮瓣修复手指末节皮肤软组织缺损[J].中华显微外科杂志,2014,37(4):402-404. DOI: 10.3760/cma.j.issn.1001-2036.2014.04.029. [28] 蒋国栋, 巨积辉, 吕文涛, 等. 吻合趾背神经的第二足趾胫侧皮瓣修复指端缺损[J].中华整形外科杂志,2018,34(7):515-519. DOI: 10.3760/cma.j.issn.1009-4598.2018.07.005. [29] 唐林峰, 巨积辉, 刘跃飞, 等. 趾底固有动脉弓上动脉岛状皮瓣塑形再造指的解剖学及临床研究[J].中华手外科杂志,2016,32(6):468-469. DOI: 10.3760/cma.j.issn.1005-054X.2016.06.031. [30] 李雷, 巨积辉, 崔龙杰, 等. 拇趾甲皮瓣与第2足趾侧方皮瓣同蒂修复电烧伤后拇指缺如[J].中华烧伤杂志,2015,31(2):137-139. DOI: 10.3760/cma.j.issn.1009-2587.2015.02.015. [31] 钟怡鸣, 孙焕伟, 张洪权, 等. 改良游离第一趾蹼皮瓣移植修复手部指蹼皮肤缺损[J].中华手外科杂志,2019,35(2):122-124. DOI: 10.3760/cma.j.issn.1005-054X.2019.02.015. [32] 杨涛,陈佳,成贝贝,等.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[J].中华烧伤杂志,2021,37(9):875-879. DOI: 10.3760/cma.j.cn501120-20200727-00360. -
1 第2趾胫侧趾背动脉皮瓣和第2趾胫侧趾底固有动脉皮瓣设计切取示意图
注：1指第2趾胫侧趾底固有动脉，2指第2趾胫侧趾底固有神经，3指第2趾胫侧趾背动脉，4指第2趾胫侧趾背神经，黑色虚线为皮瓣大致切取范围；第2趾胫侧趾背动脉皮瓣切取第2趾胫侧趾背动脉及第2趾胫侧趾背神经，保留第2趾胫侧趾底固有动脉及趾底固有神经；第2趾胫侧趾底固有动脉皮瓣切取第2趾胫侧趾底固有动脉及趾背神经，保留第2趾胫侧趾底固有神经
2 采用第2趾胫侧趾背动脉皮瓣修复例1患者铁块压伤致右示指指腹皮肤软组织缺损创面的效果。2A.清创后右示指皮肤软组织缺损情况；2B.术中左足第2趾胫侧趾背动脉皮瓣的设计；2C.分离趾背动脉与趾背神经术中；2D.术中测量切取皮瓣的动脉口径为0.40 mm；2E.术后即刻皮瓣外观；2F.术后13 d皮瓣成活，外形稍臃肿，无色素沉着；2G.术后7个月随访，受伤示指关节活动度良好，屈伸无受限；2H.术后7个月随访，供区创面愈合良好，可见轻度瘢痕增生
3 采用第2趾胫侧趾底固有动脉皮瓣修复例2患者机器挤压致左示指指腹皮肤软组织缺损创面的效果。3A.清创后左示指皮肤软组织缺损情况；3B.术中左足第2趾胫侧趾底固有动脉皮瓣的设计；3C.分离并切取趾底固有动脉术中；3D.术后即刻皮瓣外观；3E.术后12 d皮瓣成活，外形无臃肿，部分色素沉着；3F.术后7个月随访，移植皮瓣中可见部分色素沉着；3G.术后7个月随访，左示指关节活动度良好，屈伸不受限；3H.术后7个月随访，供区创面愈合良好，可见轻度瘢痕增生
表1 2组手指皮肤软组织缺损患者一般资料比较
组别 例数 性别（例） 年龄（岁， 缺损手指（个） 致伤原因（例） 男 女 拇指 示指 中指 环指 小指 重物砸伤 机器夹伤 切割伤 趾背动脉皮瓣组 12 10 2 37±10 1 6 1 3 1 8 3 1 趾底动脉皮瓣组 15 11 4 36±10 1 6 4 2 2 9 5 1 t值 — 0.20 — — P值 0.500 0.844 0.121 0.892 注：趾背动脉皮瓣指第2趾胫侧趾背动脉皮瓣，趾底动脉皮瓣指第2趾胫侧趾底固有动脉皮瓣；“—”表示无此统计量值 
下载: 导出CSV
表2 2组手指皮肤软组织缺损患者术后随访时间及末次随访时的指关节总主动活动度与皮瓣移植处两点辨别觉距离比较（
组别 例数 随访时间（个月） 指关节总主动活动度（°） 皮瓣移植处两点辨别觉距离（mm） 趾背动脉皮瓣组 12 10.1±2.6 241±12 12.4±2.0 趾底动脉皮瓣组 15 11.2±2.5 237±12 12.6±2.2 t值 1.15 0.79 0.22 P值 0.261 0.435 0.825 注：趾背动脉皮瓣指第2趾胫侧趾背动脉皮瓣，趾底动脉皮瓣指第2趾胫侧趾底固有动脉皮瓣
下载: 导出CSV
表3 2组手指皮肤软组织缺损患者末次随访时第2趾供区和手指受区瘢痕的VSS评分及患指MHQ中的外观与自我满意度评分比较(分，
组别 例数 第2趾供区VSS评分 手指受区VSS评分 患指MHQ中外观评分 患指MHQ中自我满意度评分 趾背动脉皮瓣组 12 5.5±1.0 6.8±1.1 16.6±1.8 4.8±1.0 趾底动脉皮瓣组 15 5.7±1.2 6.9±1.1 16.0±2.0 5.0±1.3 t值 0.38 0.44 0.90 0.55 P值 0.708 0.665 0.375 0.586 注：VSS为温哥华瘢痕量表，MHQ为Michigan手概况问卷，趾背动脉皮瓣指第2趾胫侧趾背动脉皮瓣，趾底动脉皮瓣指第2趾胫侧趾底固有动脉皮瓣
下载: 导出CSV
-
图(4) / 表(3)
计量
- 文章访问数: 1029
- HTML全文浏览量: 142
- PDF下载量: 24
- 被引次数: 0
